Claire Burke Draucker, RN, PhD, CS

For additional information on domestic violence, see Culturally Competent Assessment for Family Violence, which can be purchased online.

Objectives

1. Describe the incidence and prevalence of intimate partner abuse, child abuse and elder abuse.

2. Explain overt and subtle signs and symptoms of abuse of women, children and elderly.

3. Explore the future directions which must be taken by nurses who are interested in combating domestic violence on individual, regional, state and national levels.

Introduction

Domestic violence is recognized globally as a critical public health problem and a human rights violation that robs victims of "full and equal participation in all spheres of life" (United Nations, 1995, p. 3). Women and children worldwide are especially vulnerable to aggression, violence, and abuse by family members, caretakers, and intimates. Domestic violence has been defined as:

Physical, sexual, or emotional/psychological violence directed toward men, women, children, or elders occurring in current or past familial or intimate relations whether the individuals are cohabiting or not and including violence directed toward dating partners. (AACN, 2001, p. 1)

Domestic violence is best understood within a cultural context (Campbell, Moracco, & Saltzman, 2000; Hoff, 2001). For example, The Beijing Declaration and Platform for Action, resulting from the 1995 Fourth World Conference on Women stressed, "Violence against women ... derives essentially from cultural patterns, particularly the harmful effects of certain traditional practices and all acts of extremism linked to race, sex, language or religion that perpetuate women’s lower status..." (United Nations, 1995, p. 7). Campbell et al. (2000) argued that violence research demands a cultural competency that extends beyond cultural sensitivity to include an in-depth appreciation of group norms, beliefs, and life ways. Cultural competency is reflected by the acknowledgment that violence occurs in a gendered sociocultural context, an understanding of the relationship between colonial practices and violence and oppression, an awareness of cultural practices and attitudes that support, as well as deter, domestic violence, advocacy for cross-cultural research, and a commitment to oppose oppression experienced by minority groups and those marginalized by their society (e.g., women of color, migrant women, immigrant women, and lesbian women) (Campbell,Campbell, 1996; Campbell et al., 2000, Hoff, 2001).

Domestic violence is associated with varied and significant health-related consequences. In addition to immediate physical injuries stemming from an assault and acute psychological distress related to victimization, domestic violence is associated with long-term psychological, physical, social, and economic effects. Nurses and other health care providers play a key role in domestic violence identification and intervention and have been visible advocates for the prevention of domestic violence throughout the world. Many health care professionals have had personal experiences with domestic violence and are forced to confront their own concerns related to violence as they attempt to help others.

This article will provide an overview of the three major types of domestic violence: intimate partner abuse, child abuse, elder abuse. The scope, history, and health consequences of each type of violence will be described.

Spouse/partner abuse

Walker (1999) argued that "the single most powerful risk marker for becoming a victim of violence is to be a woman" (p. 23). While strangers or acquaintances commit the majority of the assaults against men, women are much more likely to be raped, assaulted, or murdered by romantic/intimate partners (Mahoney, Williams, & West, 2001).

Unlike street violence, domestic partner violence occurs in the context of "shared" lives.

Intimate partner abuse includes abuse by current or former spouses or romantic or co- habitating partners. Partner abuse does not typically involve a single violent assault; it is a cyclic, progressive process in which violence is used to control one’s partner. Most violence against women by male partners is best described as battering - that is, "a pattern of behaviors through which one person continually reinforces a power imbalance over another in an intimate/romantic relationship context" (Mahoney et al., 2001, p. 145). Intimate partner abuse includes a variety of abusive and coercive behaviors that may be of a physical, psychological, sexual, or economic nature (Ganley, 1998). It is estimated, for example, that 40 to 45% of battered women also experience forced sex by male partners (Campbell, 1998).

Unlike street violence, domestic partner violence occurs in the context of "shared" lives. In addition to affective ties, the victim and the perpetrator share, or have once shared, a residence, financial obligations and resources, children, and/or friends. The abuse often occurs in the context of an on-going or recently severed relationship; perpetrators may therefore have on-going access to the victim. Because intimate partner violence is considered a "family concern," it is often taken less seriously than stranger or street violence. Victims often experience social and economic barriers to ending the relationship (Ganley, 1998).

Scope

Many health care professionals have experienced domestic violence in their personal lives.

Findings from the National Violence Against Women Survey, a telephone survey of a national random sample of 8,000 U.S. men and 8,000 U.S. women, indicated that approximately 22.1 % of the surveyed women were physically assaulted by a current or former spouse, co-habitating partner, boyfriend or girlfriend, or date in their lifetime; 1.3 % of the surveyed women reported such violence during the previous year. Based on these findings and U. S. Census data, the researchers estimated that approximately 1.3 million women are physically assaulted annually by an intimate partner or ex-partner. In addition, 7.7 % of the surveyed women were raped by a current or former intimate partner at some time; 0.2 % experienced such violence in the preceding 12 months. It is estimated, therefore, that over 200,000 women are raped each year in the United States by an intimate partner (Tjaden & Thoennes, 2000a).

Many health care professionals have experienced domestic violence in their personal lives. Ellis (1999) surveyed 40 registered nurses employed in a large emergency department and found that 57.5% reported a personal experience with domestic violence. While 35% reported having been hit, kicked, or punched, only 25% of this group identified these experiences as abuse. In a survey of 275 nurses in perinatal practice, 31% reported abuse of themselves or their family members (Moore, Zaccaro, & Parsons, 1998).

Significant controversy exists about the prevalence and the nature of female violence against male partners. Some experts maintain that women are as violent as are men to their partners, whereas others maintain that female to male violence differs significantly in both frequency and severity, and is often used in self-defense (Tjaden & Thoennes, 2000b). Results of the National Violence Against Women Survey support the latter view. Whereas 22.1 % of the women surveyed had been physically assaulted by a current or former partner at some time, only 7.4 % of the men had experienced similar violence. Women were thus more than 2.9 times as likely as men to report abuse by a partner of the opposite sex. Survey results also indicated that the frequency of victimization was greater for women (7.1 incidents vs 4.7 incidents), as was the duration of the violence (3.8 years vs 3.3 years). The female victims also experienced significantly more life threats (33 % vs 26 %) and fear of bodily injury (45 % vs 20 %). The authors concluded that male and female violence in relationships is asymmetrical as women experience male-perpetrated violence more frequently, and the abuse is more repetitious and physically injurious.

History

According to English common law, women were viewed as chattel - first as property of their fathers, and then of their husbands. When a woman married, her legal existence was consolidated into that of her husband; she was considered to be under his protection and influence and could not inherit property (Schornstein, 1997). Physical violence was used frequently by husbands against wives. According to the "rule of thumb" law, a man could beat his wife with a rod no bigger than his thumb (Barnett, Miller-Perrin, & Perrin,1997).

Schornstein (1997) provided several examples of 19^th century U. S. court rulings that reflected the principles of English common law and upheld the right of a husband to physically discipline his wife. In 1864, the Supreme Court of North Carolina ruled in State v. Black that a husband could not be convicted of battering his wife unless he inflicted a permanent injury, used excessive violence, or exhibited malignity or vindictiveness. In 1868, the Supreme Court of South Carolina in State v. Rhodes refused to hold a husband criminally responsible for having beaten his wife with a small stick.

In the late 1800s, legal reform related to domestic violence began in the United States (Barnett et al., 1997). In the 1870s, Alabama and Massachusetts introduced the first legislation making it illegal to beat one’s wife. Several other states followed with similar legislation. Few arrests were made, however, and district attorneys were unlikely to prosecute. In 1882, the state of Maryland passed legislation that outlawed wife beating and made it a crime punishable by 40 lashes or a year in jail (Schornstein, 1997).

Grassroots feminists brought the problem of violence against women to public attention in the U.S. in the l960s and 1970s and began to establish a number of community-based programs for battered women. Haven House in Pasadena, California, the first shelter for battered women and their children, was opened in 1964. Organizations such as the National Organization of Women and the National Coalition Against Domestic Violence pushed for social services and legislative reform to better protect battered women (Barnett et al., 1997).

In 1979, Lenore Walker published The Battered Woman , an influential book that defined the battered women’s syndrome (BWS). The major components of BWS are the post-traumatic stress symptoms and learned helplessness that develop when the woman’s attempt to end the abuse proves futile. Walker’s work was significant as the symptoms experienced by battered women were identified as responses to on-going abuse, challenging the traditional assumption that a woman’s psychological vulnerability causes or contributes to, rather than results from, her battering.

In 1982, the U.S. Commission on Civil Rights published a report entitled Under the Rule of Thumb: Battered Women and the Administration of Justice evaluating the treatment of victims of domestic violence by the criminal justice system and social service agencies. The report concluded that police officers, prosecutors, and judges provided little relief for victims of domestic violence because they considered domestic violence a private matter rather than a crime (Schornstein, 1997).

The former US Surgeon General, Everett Koop, designated the battering of women as a significant health problem and convened The Surgeon General’s Workshop on Violence and Public Health in 1985 (USDHHS, 1986). The 150 attendees were advocates, practitioners, educators, and researchers concerned with violence against women. Mandatory training and examination of health professionals in the essentials of domestic violence intervention was a major recommendation from the workshop (Hoff, 2001).

In 1994, Congress passed the Violence Against Women Act (VAWA) as a part of the Violent Crime Control and Law Enforcement Act. The VAWA is a "group of individually conceived legislative pieces that were joined together to create a package of federal laws and grant programs specifically addressing domestic violence, sexual assault, and stalking" (Valente, Hart, Zeya, & Malefyt, 2001, p. 285). The VAWA was the first federal law to criminalize domestic violence. The legislation authorized grants to states, Native American tribunals, and local governments to improve criminal justice response to domestic violence. It included new federal statutes for interstate domestic violence, introduced a civil rights cause of action, funded a wide assortment of programs, initiated new federally-funded research on domestic violence, and created a national domestic violence hotline (Schornstein, 1997). In 1995, the Violence Against Women Office of the Office of Justice Programs was created to implement the VAWA (U. S. Department of Justice, 2001).

Since the 1970s, nursing has been involved in efforts to combat the problem of intimate partner abuse.

The Violence Against Women Act of 2000, which was amended to the Victims of Trafficking and Violence Provention Act of 2000, reauthorized critical grant programs, established new programs, and strengthened federal laws related to domestic violence, sexual assault, and stalking. VAWA 2000 provides coverage for dating violence, supervised visitation centers, civil legal assistance and judicial education, and increased protection for battered immigrant women (U.S. Department of Justice, 2000).

Since the 1970s, nursing has been involved in efforts to combat the problem of intimate partner abuse. Nurses were strongly represented at the Surgeon General’s 1985 workshop. The Nursing Network on Violence Against Women International (NNVAWI), which aims to "end violence against women, empower battered women, and change the health care system to be more responsive to the needs of abused women and their children" (Campbell & Parker, 1999, p. 541) was founded in 1986. In 1997, the Public Health Service Office on Women’s Health coordinated a National Nursing Task Force on Violence Against Women with members representing 30 national nursing organizations. The group’s work resulted in national policy recommendations that were presented during the National Nursing Summit on Violence Against Women (U.S. Public Health Service, 2001). Several nursing organizations have issued position statements acknowledging violence recognition, prevention, and intervention as health care priorities (the American Association of Colleges of Nursing, 2001; the American Nurses’ Association, 1991; the National Black Nurses’ Association, Inc., 1994; the American College of Nurse-Midwives, 1997; the Emergency Nurses Association, 1998). During the 1990s, there has been a proliferation of programs in hospitals and community-based health centers that provide specialized domestic violence prevention and intervention programs for battered women and their children (Sheridan, 1998).

Health Consequences

The physical consequences of battering range from minor injuries to permanent disability, disfigurement, and death. The National Violence Against Women Survey found that 30.2 % of the women injured during their most recent physical assault and 35.6 % of the women injured during their most recent rape received some type of medical treatment . Women who are assaulted or raped by a current or former partner are at the greatest risk for injury (Tjaden & Thoennes, 2000a). Nurse researchers have documented that 22 % to 35 % of women who seek treatment at hospital emergency departments do so for injuries related to domestic violence (Campbell, Pliska, Taylor, & Sheridan, 1994).

Domestic violence injuries frequently include lacerations, bruises and contusions, musculoskeletal damage (broken bones, tendon & ligament injuries), neurological problems (hearing and vision loss, impaired concentration), and, in the case of sexual assault, vaginal and anal tears (Warshaw, 1998). Stress-related consequences of battering may include persistent headaches, chronic irritable bowel syndrome, chronic pain, and eating disorders (Campbell, 1998; Warshaw, 1998). Sexual violence may result in increased risk for a number of genito-urinary problems, including pelvic inflammatory disease, sexually-transmitted diseases, bladder infections, sexual dysfunction, pelvic pain, and urinary tract infections. Battering during pregnancy is also considered a major health risk, and may result in miscarriages, placental separation, antepartum hemorrhage, fetal fracture, rupture of the uterus, and preterm labor (Warshaw, 1998). Battering during pregnancy has been associated with low birth weight infants, perhaps through the influence of factors such as smoking, low weight gain, and substance abuse (Campbell et al., 2000). Mental health effects most frequently associated with battering include depressive symptoms, post traumatic stress disorder, substance abuse, and suicidality (Campbell, 1998; Warshaw, 1998). The most grim consequence of domestic violence is death; the majority of women who are killed in the United States are killed by a current or former intimate partner (Campbell, 1998).

Childhood abuse, like partner abuse, is a significant health issue across the globe.

Child Abuse

Childhood abuse, like partner abuse, is a significant health issue across the globe. Childhood abuse may be physical, sexual, or psychological in nature, or may involve psychological or physical neglect. Definitions of childhood abuse and maltreatment vary widely. Legal definitions of childhood abuse, for example, differ from state to state. While all state statutes acknowledge that physical abuse includes non-accidental physical injury that results in harm or substantial risk of harm, some statutes specify the types of acts (e.g., striking with an object) or overt consequences (e.g., visible bruises) that constitute physical abuse (Barnett et al., 1997). Considerable disagreement exists both among the public and child development professionals as to what separates "normal" corporal punishment (e.g., spanking) from abuse. Spanking, paddling, and slapping children as a form of discipline is a common practice in the United States and such behaviors are typically not labeled as abusive by most adults. On the other hand, some experts have argued that spanking is always harmful because it legitimizes violence and may engender other forms of interpersonal aggression (e.g., sibling abuse, violence outside the home) (Straus, 1994). As Kolko (1996) argued, "The task of determining when parental behaviors are excessive, unwarranted, dangerous, and ultimately abuse remains a complex one" (p. 22).

Definitions of childhood sexual abuse are dependent upon historical, cultural, and social contexts and vary widely. Emotional abuse and child neglect are perhaps the most prevalent forms of childhood maltreatment, and the most difficult to define. Bernstein and Fink (1998) have identified some common definitions of child abuse and neglect found in the childhood trauma literature:

Emotional abuse refers to verbal assaults on a child’s sense of worth or well-being, or any humiliating, demeaning, or threatening behavior directed toward a child by an older person. Physical abuse refers to bodily assaults on a child by an older person that pose a risk of, or result in, injury. Sexual abuse refers to sexual contact or conduct between a child and older person; explicit coercion is a frequent but not essential feature of these experiences. Emotional neglect refers to the failure of caretakers to provide a child’s basic psychological and emotional needs, such as love, encouragement, belonging, and support. Physical neglect refers to failure of caregivers to provide a child’s basic needs, including food, shelter, safety, and supervision. (p. 2)

The Third National Incidence Study of Child Abuse and Neglect (NIS-3), conducted by the National Center on Child Abuse and Neglect, was mandated by Congress to provide official estimates of these phenomenon in the United States. The NIS-3 follows the NIS-1, published in 1981, and the NIS-2, published in 1986. The findings of the NIS-3 are based on a nationally representative sample of over 5,600 professionals in 842 agencies in 42 counties, and reflect the number of abuse and neglect cases investigated by child protective services or served by community agencies. Data were collected in 1993 and compared to data collected in the NIS-2 survey. The NIS-3 used two standards. Children who had already experienced harm from abuse or neglect were considered abused by the Harm Standard; children who experienced abuse or neglect that put them at risk for harm were considered abused by Endangerment Standard. Using the Harm Standard, survey findings suggest that in 1993, 1,553,800 children were abused or neglected; this estimate raises to 2,815,600 under the Endangerment Standard. Outlined in Table 1 are the number of children estimated to have been sexually or physically abused and physically or emotionally neglected. The authors of the survey concluded, "The findings of the Third National Incidence Study of Child Abuse and Neglect (NIS-3) show a sharp increase in the scope of the problem, whether maltreatment is defined using the Harm Standard or the Endangerment Standard" (Sedlak & Broadhurst, 1996, p. 7).

Table 1

Estimated incidence of child abuse in the US in 1993 from the Third National Incidence Study of Child Abuse and Neglect (Sedlak & Broadhurst, 1996)

Harm Standard			Endangerment Standard
Sexually abused	217,700	83%*		300,200	125%*
Physically neglected	338,900	102%*		1,335,100	163%*
Emotionally neglected	212,800	333%*		585,100	188%*
Physically abused	381,700	42%*		614,100	97%*
Total abused or neglected	1,553,800	67%*		2,815, 600	98%*

*Increase over NIS-2 estimates in 1986

Official estimates such as those derived from the NIS-3 survey are based on only those children who come to the attention of authorities or helping professionals. The actual incidence of abuse and neglect of children in the U.S. is likely to be much higher. Participants in the National Violence Against Women Survey, for example, were asked a series of behaviorally specific questions about a range of physical assaults committed by adult caretakers. More than half of the respondents had experienced at least one physical assault by a caretaker (Tjaden & Thoennes, 2000a). In a national U. S. telephone survey of 2,626 adults, 27 % of the women and 16 % of the men reported experiencing sexual abuse during their childhood (Finkelhor, Hotaling, Lewis, & Smith, 1990).

Throughout history, parents and other caretakers have maltreated children.

History

Throughout history, parents and other caretakers have maltreated children. Many societies practice infanticide and the abandonment of unwanted children. Industrialized societies have used children for dangerous and exhausting work (Barnett et al., 1997). Girls around the world are especially at risk for sexual abuse, child marriage, child prostitution and pornography, and female genital mutilation (Kendall-Tackett, 2001).

In the U. S., children have historically been considered property of their parents and without legal rights. In 1874, the first U.S. child abuse case was tried in New York; it resulted in a conviction of a woman for assault and battery on her 8 year-old stepdaughter, Mary Ellen (Barnett et al., 1997). Mary Ellen had been beaten daily, starved, and prohibited from leaving the house. This case attracted considerable public attention and led to the founding of the Society for the Prevention of Cruelty to Children (SPCC).

In the early 1900s, state legislatures began to enact statutes criminalizing the abuse and neglect of children and providing protective measures for mistreated children. Between 1899 and 1920, almost all states in the United States instituted statewide juvenile court systems (Bulkley, Feller, Stern, & Roe, 1996). In the 1900s, several child protective organizations were founded, including the National Committee to Prevent Child Abuse, the Family Resource Coalition, the Children’s Defense Fund, the National Center for Missing and Exploited Children, and the Child Welfare League of America (Barnett et al., 1997).

In 1962, C. Henry Kempe, a pediatrician at the University of Colorado, and his colleagues identified the "battered child syndrome" - a constellation of physical and psychological symptoms resulting from physical child abuse (Kempe, Silverman, & Stele, 1962). Kempe’s work resulted in increased recognition and reporting of childhood physical abuse by health professionals and mobilized advocacy for greater government intervention for child welfare. In 1974, Congress enacted the Child Abuse Prevention and Treatment Act (CAPTA), providing federal funds for states that passed legislation requiring the reporting of child abuse by certain professionals (e.g., teachers, health care professionals). It also established the National Center for Child Abuse and Neglect (Barnett et al., 1997). The 1980s and 1990s saw a proliferation of health-system and community-based interventions for the prevention and treatment of physical child abuse (Barnett et al., 1997).

The third "discovery" of childhood sexual abuse occurred during the 1970s with the advent of the women’s movement. Along with issues of rape and wife battering, activists and survivors brought childhood sexual abuse into public awareness.

Historically, professionals and the public did not consider sexual abuse to be a prevalent or traumatic experience in the lives of children. Herman (1981) identified three "discoveries" of incest. In the first "discovery," Freud initially reported that female patients in psychoanalysis frequently described incestuous childhood experiences, and that these experiences were the root cause of adult hysteria. He later repudiated this claim in the service of protecting the culture of the patriarchal family and suggested instead that the women’s claims were incestuous fantasies rather than actual childhood events. Following this repudiation, the reality and prevalence of childhood sexual abuse were again denied. In the 1940s, incest was "discovered" again by social scientists conducting large scale surveys of sexual practices, such as the early Kinsey studies. Despite the fact that the prevalence of childhood sexual abuse was substantiated in these studies, Herman suggested that the reality of the experience was minimized. Because the researchers were attempting to encourage enlightenment and tolerance of sexual attitudes, they failed to highlight the victimizing nature of the experiences. The third "discovery" of childhood sexual abuse occurred during the 1970s with the advent of the women’s movement. Along with issues of rape and wife battering, activists and survivors brought childhood sexual abuse into public awareness. In the 1980s and 1990s, there was a proliferation of scholarly, clinical, and self-help literature on the topic.

The sexual abuse of children also began to receive legislative attention in the U. S. in the 1970s. In 1978, the Protection of Children Against Sexual Exploitation Act was passed. In 1986, the Child Sexual Abuse and Pornography Act made it a federal crime to sexually exploit children or to permit a child to engage in pornography (Barnett et al., 1997).

Health Consequences

Child abuse can have significant psychological and physical consequences for children, as well as long-term effects that may extend into adulthood. Barnett and colleagues (1997) identified the most frequently reported effects of physical abuse on children. Physical consequences may include bruises; head, chest, and abdominal injuries; burns and fractures. Abused children often exhibit a number of cognitive difficulties, including deficits in verbal, reading, math, and perceptual-motor skills; poor school achievement; and impaired memory. Behavioral problems, such as aggression, noncompliance, and antisocial behaviors, have also been associated with abuse, as have a variety of emotional difficulties, including depression, low self-esteem, and increased daily stress. Long-term effects in adults may include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems, including suicidality, anxiety, hostility, dissociation, and interpersonal difficulties. Experts stress, however, that physical child abuse does not affect individuals in consistent and predictable ways. The negative effects, in fact, can be mitigated by a number of factors, especially by the presence of supportive adults in the child’s life (Barnett et al., 1997).

Barnett and colleagues (1997) have summarized the most frequented substantiated effects of child sexual abuse as well. Physical consequences of child sexual abuse often include genital bruising, bleeding, pain, and itching; enuresis; encopresis; and a variety of stress-related symptoms, including sleep and eating disturbances, stomachaches, and headaches. Short-term effects of child sexual abuse include emotional problems, such as anxiety, depression, aggression, and low self-esteem, as well as a variety of behavioral and learning difficulties. Long-term effects exhibited by adult survivors of child sexual abuse include emotional difficulties, such as depression, anxiety, and posttraumatic stress symptoms; interpersonal and sexual problems; and certain behavior problems, such as eating and substance abuse disorders. As with physical abuse, individual responses to child sexual abuse are highly individualized and can be mediated by a number of factors, including the victim’s subjective perception of the events and available social support (Barnett et al., 1997).

A myriad of effects have also been associated with childhood neglect. Childhood neglect may result in social difficulties, including impairment of parent-child interactions and problematic peer interactions; intellectual deficits; and a variety of emotional and behavior problems, including low self-esteem, ineffective coping, aggression, and negative affect. The physical consequences of child neglect include failure to thrive and death. The effects of psychological maltreatment have not been studied extensively, but seem to include a variety of negative effects, including difficulties in interpersonal adjustment, intellectual deficits, and affective-behavioral problems(Barnett et al., 1997).

Experts suggest that domestic elder abuse is perhaps the most underreported crime.

Elder Abuse

The U.S. Administration on Aging reports that there are 43 million Americans over the age of 60, and 3 million who are 85 or older. Due to improved health and standards of living, it is predicted that by the year 2030, more than 85 million Americans will be over 60 and more than 8 million will be over the age of 85 (Administration on Aging, 2001). While other issues affecting the elderly, such as retirement security and affordable long-term care, have received national attention, the abuse and neglect of the elderly has historically been ignored (National Center on Elder Abuse, 2001). Elder abuse has traditionally been associated with street crimes, abuse in nursing homes, and financial fraud (Quinn & Tomita, 1997). Only recently has elder abuse by family members and intimates attracted scholarly attention, public outrage, and public funding for prevention and education.

Experts suggest that domestic elder abuse is perhaps the most underreported crime. Older adults may be especially reluctant to report abuse because they are ashamed to admit that their spouse or children have mistreated them, fear retaliation, or dread being institutionalized if they are removed from the care of the abuser (Payne, 2000, Quinn & Tomita, 1997). In addition, cognitive and physical impairments may make it impossible for some elderly individuals to report their abuse. Unlike children who must attend school, abused elders may remain isolated in their homes.

Elder abuse has been particularly difficult to define. There is considerable disagreement over what constitutes abuse and the age at which one becomes elderly. Some experts believe the term elder abuse should be limited to physical or psychological abuse of impaired and dependent seniors; others believe that failure to provide appropriate care also constitutes abuse. The National Center on Elder Abuse (2001) defines domestic elder abuse as "any of several forms of maltreatment of an older person by someone who has a special relation with the elder (e.g., a spouse, a sibling, a child, a friend, or a caregiver in the older person’s home or in the home of the caregiver)" ( p. 1). Elder abuse includes physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation. As with child abuse, legal definitions of elder abuse vary from state to state.

Scope

The National Elder Abuse Incidence Study (NEAIS), conducted by the National Center on Elder Abuse, collected data on domestic elder abuse, neglect, and self-neglect through a nationally representative sample of 20 counties in 15 states (National Center on Elder Abuse, 1998). Data were collected from local Adult Protective Services agencies and from professionals in community agencies who had frequent contact with the elderly. The methodology was designed to be consistent with the National Incidence Studies conducted by the National Center on Child Abuse and Neglect. Based on the NEAIS findings and U. S. Census data, it is estimated that a total of 449,924 persons aged 60 and over experienced abuse and/or neglect in domestic settings in 1996. 70,942 of these cases (16 %) were reported to and substantiated by APS agencies; 378,982 (84%) were not. The researchers also found that females are abused more frequently than males, and that elders over 80 are at the greatest risk for abuse and neglect. In 90 % of the incidents of elder abuse and neglect by a known perpetrator, the perpetrator is a family member; two-thirds of the perpetrators are adult children or spouses.

Pillemer and Finkelhor (1988) conducted a large scale, random sample telephone survey of elder abuse and neglect. They interviewed 2,020 Boston area residents over the age of 65 and found that 3.2 % (N = 63) of the respondents reported being maltreated. Forty respondents (2 %) had experienced physical abuse, 26 (1.1 %) chronic verbal aggression, and 7 (0.4 %) neglect. Thirty-five of the perpetrators were spouses, 10 were sons, 5 were daughters, and 11 were other persons (e.g, grandchildren, siblings.) On the basis of these survey findings, the authors estimate that only 1 in 14 cases of elder abuse is reported to the authorities.

History

Elder abuse first came to public attention in the 1960s when it was discussed in British medical journals under the misguided label of "granny bashing." In 1979, The Battered Elder Syndrome was published by Block and Sinnot (1979), bringing the problem of elder abuse to the attention of health professionals and human service scholars.

In the late 1960s, the U. S. Department of Social and Rehabilitation Services began funding National Protective Services. The first congressional hearing on elder abuse was held in 1979 by the House Select Committee on Aging. In 1981, the National Center for Adult Abuse was established. By 1982, every state developed an adult protection program and 42 states had adopted a mandatory elder abuse reporting law (Payne, 2000).

In 1987, amendments to the Older Americans Act (OAA) mandated that states provide outreach services to identify elder abuse cases, devise procedures to process elder abuse reports, and conduct public education. Title VII, a subsequent amendment to the OAA, included provisions for long term care ombudsmen, legal assistance, and services to prevent abuse. Through Title IV of the OAA, the Administration on Aging (AoA) provided funding for research and service delivery projects. The AoA also funded a national resource center and a national survey on the incidence of elder abuse, neglect, and exploitation (Nerenberg, 1997). Several national advocacy groups, such as the American Association of Retired Persons, the Older Woman’s League, and the National Organization of Women, have held forums, assembled committees, and organized congressional hearings to address the problem of elder abuse. Recently, health-care system and community-based services for abused and neglected elders have begun to be developed (Barnett et al., 1997; Vinton, 2001).

Health Consequences

Like other forms of domestic violence, elder abuse is associated with a myriad of physical consequences. Quinn and Tomita (1997) listed a number of physical effects that are indicators of elder abuse, including scratches, cuts, and bruises; sprains and dislocations; pressure sores, fractures, and detached retinas. Signs and symptoms of possible sexual abuse include genital or urinary irritation, injury or scarring, and intense fear in reaction to an invasive pelvic procedure. Signs and symptoms of possible physical neglect include poor hygiene (body odor, matted hair, unexplained rashes), hypothermia, untreated sores, failure to thrive, malnutrition and dehydration. The psychological consequences of elder abuse have not been systematically researched.

Summary

Despite the fact that intimate partner abuse, child abuse, and elder abuse have captured the attention of the public, social science researchers, health care professionals, and policymakers worldwide, domestic violence continues to be a prevalent problem that brings suffering to millions and enormous costs to all societies. Mahoney and colleagues (2001), for example, argue:

Even after 25 years of research and advocacy, intimate violence against women remains at epidemic proportions, affecting women of all age groups and all walks of life; from preteen girls to elder women, and women of all races, cultures, sexual orientations, and physical abilities. (p. 143)

Despite the fact that intimate partner abuse, child abuse, and elder abuse have captured the attention of the public, social science researchers, health care professionals, and policymakers worldwide, domestic violence continues to be a prevalent problem that brings suffering to millions and enormous costs to all societies.

Nurses and other health care professionals have responded to the problem of domestic violence by engaging in increasingly sophisticated research, designing prevention and intervention programs, and advocating for social change. While we celebrate the strides made in tackling the problem of domestic violence, we must ask why, despite such concerted efforts to address the problem, domestic violence remains a "plague in our land" (American Academy of Nursing, 1995).

Conclusion

Future directions for nurses committed to combating domestic violence must occur on several levels. Domestic violence is rooted in complex sociological and economic factors including poverty, sexism, racism, ageism, substance abuse, family breakdown, violence in the media and the ready availability of handguns. Nurses must advocate for policy that enhances economic opportunities and the redistribution of power in our society, as well as support state and national legislation that will fund domestic violence programs, prevent insurance discrimination against victims of domestic violence, enhance immigration protections for abused women, ensure the rights of women and children affected by welfare reform, and enhance protections for older and disabled women who are abused. Nurses have become increasingly vocal in support of legislation for handgun control and the abolishing of dangerous ammunition.

On the practice level, nurses in all settings must consider routine screening for abuse as a standard of care. While universal health care screening for domestic violence is recommended by most health care organizations, it is most successfully implemented in facilities that have a formal institution-wide commitment to the practice and comprehensive protocols that outline intervention, as well as assessment, strategies. With input from stakeholders, nurses should continue to support, design, and evaluate prevention and intervention programs that are multi-disciplinary, innovative, and culturally specific. Coordinated response programs, that are collaborative community-wide endeavors involving multiple agencies charged with domestic violence prevention and intervention, seem to hold the most promise. As child abuse is "the gateway to many other social and maladaptive problems" (Thomas, 1995, p. 60), nurses and other health care professionals should become involved in community-based family support initiatives, family skills training programs, and family preservation services. School-based programs that identify and intervene with children at risk and that teach skill-building and conflict resolution skills are also essential.

Several experts have suggested that domestic violence services have been ineffective because they are not culturally specific (Koss & Hoffman, 2000; Thomas, 1995). Programs often do not provide culturally competent counselors, use the target language of the groups served, or respect the traditional healing practices of the community (Koss & Hoffman, 2000). Nurses have begun to describe culturally specific clinical interventions. For example, information is available on providing health care for battered women who are African American (Campbell & Gary, 1998), Native American (Bohn, 1998), and Hispanic (Torres, 1998). The special needs of immigrant women (Das Dasgupta, 1998), migrant farm worker women (Rodriguez, 1999), rural women (Fishwick, 1998), and lesbian women (Renzetti, 1998) have also been addressed. Future directions must involve utilizing such information in practice settings and expanding our knowledge base related to the needs of ethnic groups and other marginalized populations.

Finally, nurses must care for themselves. Nurses and other professionals who have experienced domestic violence must be supported in their efforts to find understanding, safety, peace, and healing in their own lives.

Author

Claire Burke Draucker, RN, PhD, CS
cdraucke@kent.edu

Claire Burke Draucker, RN, PhD, CS is a Professor and Director of the Graduate Program in Psychiatric Mental Health Nursing in the College of Nursing at Kent State University. She is a licensed psychologist in the State of Ohio and a Certified Clinical Specialist in Psychiatric Mental Health Nursing. Dr. Draucker has conducted studies on early family experiences and later victimization in the lives of women, the healing processes of women and men who were sexually abused as children, and women’s responses to sexual violence by male intimates. She is the author of Counseling Adult Survivors of Childhood Sexual Abuse (Sage).

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