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Section 16
Cultural Factors of the Detection and Disclosure
of Spousal or Partner Abuse

Question 16 | Test | Table of Contents

Detection of Spousal or Partner Abuse

Here’s what the latest statistics tell us about this frightening phenomenon:
1. Just under 45% of young couples experienced violence in a relationship either before or during college.
2. Relationship violence seems to peak prior to college for most kids with 53% of women and 27% of men reporting victimization.
3. Emotional violence was the most common type of violence at all ages but is more common in high school.
4. Both sexual and emotional violence increase in college, if not addressed properly.

How can you detect if someone is being abused? Here are the signs, according to Dr. Sylvia Gearing:
Isolation: Abusive partners prefer that their victim remain isolated and unable to turn to others. In addition, victims isolate themselves from friends and family.
Increasing Anxiety and Depression: Domestic abuse victims show signs of anxiety and depression such as agitation, sadness, withdrawal, low energy, emotional mood swings, tearfulness and a decline in functioning at school.
Avoiding the Truth: People who are being abused are shell-shocked. They are literally frozen by the stress. Many kids from good homes are naive about what abuse is, normalize the actions of the abusive partner and make excuses for the abuser until it is too late.
Social Shedding: Victims of emotional of sexual abuse by a partner seem to shed their former relationships—best friends, family connections, socializing patterns. They stop responding to others and deny they are being harassed.
Progressive Pain: Look for signs of increasing disconnection from others, less responsiveness and avoidant behavior. They are locked in a cage of agony and don’t know how to ask for help.

Detecting Intimate Partner Violence
Published research indicates that nearly one-third of women reported that they were presently experiencing some form of intimate partner violence (IPV) when they were asked about these occurrences during an ED visit. When questioned about their past, nearly 50% of women reported being victims of IPV. In addition, other research has demonstrated that 56% of victimized female patients presenting to the ED also report perpetration behaviors. Studies that have focused on detecting perpetrators of IPV in the ED suggest that screening is effective, but few of these individuals are actually identified in medical settings despite frequently being in attendance.

Testing a Shorter Screening Tool for IPV
The gold standard for detecting perpetrators of IPV in the ED has historically been the 25-question Physical Abuse of Partner Scale (PAPS). Although the PAPS is an effective, validated questionnaire, the length of time needed to administer it is not practical for a short visit in the ED. In the February 2012 Journal of Emergency Medicine, my colleagues and I had a study published in which we developed a shorter IPV screening alternative to the PAPS.

We developed the PErpetration RaPid Scale (PERPS) by validating a shortened version of the PAPS consisting of three questions:
1. Have you ever forced your partner to have sex or hurt your partner during sex?
2. Have you ever pushed or shoved or poked your partner violently?
3. Have you ever hit or punched your partner’s arms, body, head, or face?

Unlike the PAPS, which uses a Likert scale for its 25 questions, PERPS has the potential to be administered more quickly because it uses only "yes/no" questions. To validate PERPS, we asked 214 patients presenting to a busy ED to complete both PERPS and PAPS screens. A positive PERPS result occurred when any of the three questions was answered with a "yes." We found that the PERPS positively predicted IPV perpetration with high accuracy when compared with the PAPS. PERPS had a sensitivity of 66%, specificity of 93%, negative predictive value of 87%, positive predictive value of 78%, and an accuracy of 85%. Importantly, PERPS took less than 1 minute for ED patients to complete, and clinicians weren’t required to perform calculations to evaluate responses.

Applications to Practice
Some patients will not answer questions on PERPS or PAPS screens honestly because they fear the potential consequences. Emergency physicians should understand that the goal of IPV interventions in the ED should be to educate patients on the problems associated with IPV and refer them for assistance. Our study showed that the ED appeared to be an ideal place for PERPS screening. It can hopefully be used at an early stage of IPV when the cycle of violence can be broken.

When it’s determined that patients are a perpetrator of IPV, it’s important to discuss the ramifications of this vio­lence and offer education about programs that can help. IPV education can also be provided with videos played on televisions in the ED waiting area. Computer-based edu­cational programs can be developed to enable patients to complete PERPS screenings on a touchscreen computer. Considering the chaos of busy EDs and the fact that pro­viders are often time constrained, a self-administered com­puter option of PERPS screens might prove to be ideal for IPV perpetration screening.

Cross-cultural factors in disclosure of intimate partner violence: an integrated review
Intimate partner violence (IPV) is widespread and prevalent in women regardless of their race, colour, socioeconomic status or the country in which they live. Intimate partner violence is a serious, worldwide, public and social health issue (Tjaden & Thoennes 1998, Abbott & Williamson 1999, Heise et al. 1999, Garcia-Moreno et al. 2005). Worldwide an estimated one in three women has experienced some form of abuse (Heise et al. 1999), and in the United States of America (USA) it is estimated that annually, 1Æ5 million women are physically assaulted by an intimate partner (Tjaden & Thoennes 2000). It is also estimated that over 30% of women who are murdered in the USA are killed by either a spouse or ex-spouse (Center for Disease Control 2000), making IPV both a serious public health concern (Garcia-Moreno et al. 2006) and a serious crime.

According to Garcia-Moreno et al. (2005), a cross-cultural review of over 50 population-based studies performed in 35 countries prior to 1999 indicated that between 10% and 52% of women around the world reported physical abuse, sexual abuse or both, by an intimate partner at some point in their lives. In a qualitative study, Nicolaidis et al. (2003) found that some women who survived attempted homicide had no memory of having ever discussed their lives being in danger with healthcare providers and/or counselors. In addition, the violence perpetrated against women worldwide has an enormous impact on all those women, family and children who witness the violence (Garcia-Moreno et al. 2005).

Intimate partner violence was once considered solely a private matter. According to Richie (2006) only recently has violence against women been acknowledged as a social problem, meriting attention from society and placing it on political agendas. The women’s movement in the 1970s initiated the disclosure of IPV and shed light on violence against women (Davis & Srinivasan 1995, Tjaden & Thoennes 1998, Kilpatrick 2004, Tjaden 2004). However, it was not until 30 years later, through the hard work of many, especially researchers and political activists, that violence against women was acknowledged at the governmental level. New policies and laws protecting women against violence slowly began to be enacted in several countries. The USA enacted its first law in 1994, The Violence Against Women Act. Guatemala and El Salvador enacted laws in their countries in 1996, called Intrafamily Violence and Prevent, Punish and Eradicate Intrafamily Violence respectively. China passed a Domestic Violence Ordinance law in 1997. Colombia enacted a penal code, Intrafamily Violence, in 2000 and Japan passed a law in 2001, The Prevention of Spousal Violence and the Protection of the Victims (Annual Review Law Harvard n.d.). Mexico’s national law, enacted in 2007, is recognized as the first federal measure to address violence against women and domestic abuse (International Herald Tribune 2007).

According to Klevens (2007), most of the literature examining violence against women has focused on white women. Tjaden and Thoennes (2000) suggested that more work is needed to support estimates of IPV prevalence among diverse groups and issues of disclosure may or may not be attributed to social, demographic and environmental factors or their ethnicity/race.

Throughout the literature, the term, IPV is used interchangeably with the terms domestic violence, partner violence, battered women, gender violence, violence against women and spousal abuse (Institute of Medicine 2002). Recent literature has indicated the need for a more consistent definition of the types of violence, particularly violence against women (Mitchell & Lacour 2001). Most recently, the Centers for Disease Control and Prevention (2006) has used the term intimate partner violence. Although both men and women experience IPV, women experience it at a much higher rate (U.S. Department of Justice 2006). Nurses worldwide continue to face challenges in providing care to abused women using appropriate strategies.

The experiences of women in IPV cross-culturally may be similar; however, in specific groups of women they are very different. Moreover, little is known based on race, culture, country of origin or factors influencing disclosure of abuse by women in IPV. Table 1 summarizes the studies by specific ethnicity/race and factors identified within each group. Women from different cultures identified fear as a common factor, with the exception of South Asian women (Gill 2004), immigrants from Mexico (Belknap & Sayeed 2003) and Vietnamese women (Shiu-Thornton et al. 2005). In two separate studies, women from the Japanese culture described fear and shame as two of the many factors interfering with disclosure of abuse (Yoshihama 2002, Nemoto et al. 2006).

Six studies were conducted with Asian women. One of these included South Asian women living in the United
Kingdom (UK) (Gill 2004) and showed that laws relating to immigrants were a factor interfering with disclosure of abuse. This factor was not identified in any of the other five studies with population samples of Asian women. It may be attributed to the women survivors being from the Indian subcontinent, but now living in East London, where the study was conducted (Gill 2004). Conversely, shame was a factor found in all six studies with Asian women participants (Gharaibeh & Al-Ma’aitah 2002, Yoshihama 2002, Gill 2004, Shiu-Thornton et al. 2005, Yuen-Tsang & Sung 2005, Nemoto et al. 2006).

Fox et al. (2007) found that black African women in Johannesburg suffered in silence within their culture. However, in two separate studies conducted in the USA, AfricanAmerican women survivors of IPV did not identify a culture of silence as a factor (Nash 2005, Morrison et al. 2006).

Women from cultures in which there is not generally disclosure were Jordanian (Gharaibeh & Al-Ma’aitah 2002, Latina (Crandall et al. 2005) and Vietnamese (Shiu-Thornton et al. 2005). Belknap and Sayeed (2003) found that immigrant women attributed non-disclosure to the perception that providers were not listening. Similar experiences were found in one other study with women participants in Melbourne, Australia, who described providers as not interested (Hegarty & Taft 2001). There were no studies found on MexicanAmerican women related to this issue.

Sources:
Cross-cultural factors in disclosure of intimate partner violence: an integrated review
Nora Montalvo-Liendo

Dr. Sylvia Gearing
How to Detect Domestic Violence

Detecting Intimate Partner Violence More Quickly
Amy A. Ernst, M.D.

Personal Reflection Exercise #7
The preceding section was about cultural factors of the detection and disclosure of spousal abuse. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 16
According to Dr. Sylvia Gearing, what are four signs that a therapist can look for to detect if someone is being abused?
To select and enter your answer go to Test.

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