Reflection Complete this week’s assigned readings, chapters 86 & 87. After completing the readings, post a short reflection, approximately 1 paragraph or n

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Reflection Complete this week’s assigned readings, chapters 86 & 87. After completing the readings, post a short reflection, approximately 1 paragraph or no more than 250 words, discussing your thoughts and opinions about one or several of the specific topics covered in the textbook readings pertaining to politics in associations and interest groups. Identify which one MSN Essential most relates to your selected topic in your discussion.

chapters 86 & 87 attached C H A P T E R 8 6


Family and Sexual Violence

Nursing and U.S. Policy

Kathryn Laughon, Angela Frederick Amar

“If the numbers we see in domestic violence were applied to terrorism or gang violence, the entire

country would be up in arms, and it would be the lead story on the news every night.”

Rep. Mark Green, Wisconsin

Our society is steeped in violence. In the most recent national statistics, more than 26 per 1000

people aged 12 years or older will be the victims of a violent crime (Truman, Langton, & Planty,

2013). Most of our violence prevention strategies prepare potential victims to ward off violent

attacks from strangers; yet, someone known to the victim perpetrates most violence against women,

children, and older adults. The intimate nature of this violence, often perpetrated behind closed

doors, has made these forms of violence less visible. However, the toll of violence on individuals

and societies is substantial. The World Health Organization has framed violence as a significant

public health problem (Truman, Langton, & Planty, 2013). A public health approach suggests an

interdisciplinary, science-based approach with an emphasis on prevention. Effective strategies draw

on resources in many fields, including nursing, medicine, criminal justice, epidemiology, and other

social scientists.

The purpose of this chapter is to provide an overview of state, federal, and health sector policies

regarding violence against women in the United States, briefly discuss policies related to violence

against children and older adults, and outline the resulting implications for nurses and directions

for future work.


Intimate Partner and Sexual Violence Against Women

Intimate partner violence (IPV) is physical, sexual, or psychological harm inflicted by a current or

former partner (same sex or not) or a current or former spouse (Black et al., 2011). Almost one third

of American women experience being hit, slapped, or pushed by an intimate partner, and nearly a

quarter will experience serious forms of IPV during their lifetimes. Additionally, nearly one in five

women will experience a completed or attempted rape in their lifetimes. Men experience IPV and

rape as well, although at far lower rates than do women. About a quarter of men will experience

IPV (about 12% serious forms of violence) and nearly 1.5% a completed or attempted rape.

Although more than half of women reporting rape report that the assailant was an intimate partner

and 40% that the assailant was an acquaintance, men report that half of rapes were by

acquaintances and 15% by strangers; the number raped by an intimate partner was too small to


The health effects of IPV and sexual violence are substantial and cost as much as $8.3 billion in

health care and mental health services for victims (Max et al., 2004). Violence is associated with a

wide range of health problems, including chronic pain recurring central nervous system symptoms,

vaginal and sexually transmitted infections and other gynecological symptoms, and diagnosed

gastrointestinal symptoms and disorders (Black et al., 2011). Mental health symptoms include

depression, anxiety, posttraumatic stress disorder, and alcohol and drug use (Black et al., 2011;

Campbell, 2002).


State Laws Regarding Intimate Partner and Sexual


State laws address a number of issues important for nurses to understand. Most often, crime of IPV

and sexual violence are addressed through state laws. Most, although not all, states have laws

specifically providing enhanced penalties for assault and battery that occurs between intimate

partners. (It worth noting that most laws refer to domestic violence or family abuse rather than

IPV.) For example, at least 23 states have some form of mandatory arrest for IPV (Hirschel, 2008).

Research findings are mixed on whether mandatory arrest laws reduce reassault (Felson,

Ackerman, & Gallagher, 2005; Hirschel et al., 2007), although findings from at least one study

suggest that the overwhelming majority of victims support mandatory arrest laws (Barata &

Schneider, 2004). Additionally, states may have enhanced penalties, such as escalating third

offenses to felonies.

Until 1975, all states provided what is called the marital rape exemption under which it was

legally impossible to commit rape against one’s wife. Beginning in the mid-1970s, based in part on

nursing research, these laws began to change (Campbell & Alford, 1989). Although all states now

recognize marital rape as a crime, in some states it is still treated differently from rape by a

nonspouse (Prachar, 2010).

Nonlethal strangulation of women is a significant but often overlooked threat to public safety.

Most (80%) strangulations of women are committed by intimate partners (Shields et al., 2010). They

can result in significant physical health problems for victims (Taliaferro et al., 2009) and

substantially increase risk of later lethal violence (Glass et al., 2008). These cases can be difficult to

charge and prosecute commensurate with the severity of the crime (Laughon, Glass, & Worrell,

2009); therefore, a growing number of states have strengthened laws related to strangulation.

All states provide for civil protective orders in cases where victims have a reasonable fear of

violence from an assailant (Carroll, 2007). States vary widely, however, in who is eligible to obtain

an order and how the orders are obtained. For example, in some states minors or dating partners

may not be able to obtain orders of protection. Most states provide for civil protection orders

against assailants who are accused of sexual assault, but the procedures may be different from those

for protective orders against intimate partners. Studies of the effectiveness of these orders are mixed

(Logan & Walker, 2009; Prachar, 2010).

In addition to these criminal justice remedies, state laws may address other issues related to IPV

and sexual violence. As of 2010, 26 states had established intimate partner fatality review teams

(Durborow et al., 2010). Fatality review teams use a multidisciplinary, public health approach to

reviewing fatalities and identifying risk factors (Websdale, 1999). A handful of states require health

care providers to report domestic violence against competent adults. It is important to understand

that in most states, IPV and sexual assault are not mandatory reports unless there are other factors



Federal Laws Related to Intimate Partner and Sexual


There are two significant federal laws that address violence against women. The Family Violence

Prevention and Services Act was first authorized in 1984. It was most recently authorized through

2015 (Public Law [PL] 111-320 42 U.S.C. 10401, et seq.). It is the primary federal funding source for

domestic violence shelters and service programs in the United States. It also funds the work of state

coalitions on domestic violence, community-based violence prevention efforts, and a number of

smaller training and assistance programs.

The Violence against Women Act (VAWA) was first authorized in 1994 (Title IV, sec. 40001-40703

of the Violent Crime Control and Law Enforcement Act of 1994, HR 3355, signed as PL 103-322). As

states began creating the protective order and criminal statutes discussed earlier, the limitations of

this patchwork of remedies became apparent. The VAWA was therefore created to address the gaps

in state laws; create federal laws against domestic violence, including protection for immigrant

women and enhanced gun control provisions; and fund a variety of violence-related training and

other local programs (Valente et al., 2009). The law originally included a provision making crime

motivated by gender a civil rights offense. This provision was, however, found unconstitutional in

2000 (Brzonkala v. Morrison, 2000).

The VAWA represented a significant turning point in public policy related to violence against

women. Previously, women who received a protective order might find that violations that

occurred in other states could not be enforced. The full faith and credit provision of the VAWA

requires that protective orders be recognized and enforced across jurisdictional, state, and tribal

boundaries within the United States. Likewise, by creating federal crimes of domestic violence and

stalking, criminal acts that cross jurisdictional boundaries can now be more easily charged and

prosecuted. Under the VAWA, it is illegal for individuals subject to certain types of protective

orders or convicted of even misdemeanor domestic violence offenses to possess a firearm. Given

that risk of intimate partner homicide increases dramatically when firearms are available to the

assailant, this represents an important safeguard for women (Campbell et al., 2003). The VAWA

addressed the significant hardships faced by both legal and illegal immigrant women experiencing

abuse from their partners. The VAWA additionally funds a wide range of victim advocacy and

training programs, with the goal of ensuring that victims of violence receive consistent, competent

services in all communities.

Each subsequent renewal of the VAWA has strengthened these provisions. The latest renewal in

2013 expanded its definitions to explicitly include gay, lesbian, and transgender victims; expanded

the safeguards available to women assaulted in tribal territories; expanded housing provisions to

prohibit discrimination against victims of IPV in all forms of subsidized public housing;

strengthened protections for immigrant women; and, for the first time, specifically addressed

violence on college campuses (Violence against Women Act, 2013).


Health Policies Related to Intimate Partner and Sexual


As discussed earlier, the health consequences of violence are significant for women. Additionally,

women who have experienced violence have significantly higher health care costs than women

without a victimization history (Bonomi et al., 2009; National Center for Injury Prevention and

Control, 2003). There is now a consensus that these health care settings offer a unique opportunity

to identify and support women living with the effects of violence (Family Violence Prevention

Fund, 2002; World Health Organization [WHO], 2013). The U.S. Preventative Services Taskforce

recommends “clinicians screen women of childbearing age for IPV such as domestic violence, and

provide or refer women who screen positive to intervention services.” The Institute of Medicine

identified screening and brief counseling for interpersonal violence as an essential and evidencebased

practice necessary to ensure the well-being of women (National Research Council, 2011). A

wide variety of medical and nursing professional organizations also recommend routine screening

for violence (Amar et al., 2013). Significant evidence now exists for safety planning strategies to

prevent homicide for women in abusive relationships. The Danger Assessment Instrument, for

example, has been shown to have good predictive value and can assist women with making a

realistic appraisal of their likelihood of experiencing lethal violence (Campbell, Webster, & Glass,

2008). Health care institutions should also have the appropriate capacity to provide care to women

in the acute period after a physical or sexual assault (WHO, 2013).

Nurses and other health professionals have a role to play in community responses to violence.

Many localities have created sexual assault response teams. These interdisciplinary teams work to

ensure consistent, trauma-informed, and effective care for victims of sexual assault. Despite scant

research on the effectiveness of these teams, they are a promising practice (Greeson & Campbell,

2013). Likewise, intimate partner/domestic violence fatality review teams review cases of intimate

partner homicide with a public health approach. As with sexual assault response teams, there are

little data on the effectiveness of these teams that have also been labeled a promising practice

(Wilson & Websdale, 2006).


Child Maltreatment

Child maltreatment includes physical, sexual, and emotional abuse, as well as neglect. Actual

prevalence of maltreatment is unknown, but there are more than 3 million referrals for more than 6

million children to child protective agencies annually, with nearly a quarter of these cases

substantiated. An estimated 1570 children nationally died from abuse or neglect in 2011

(Administration on Children, Youth, and Families Children’s Bureau, 2011; U.S. Government

Accountability Office, 2011), a number that is believed to be undercounted. The estimated annual

cost of child abuse and neglect in the United States for 2008 was $124 billion (Fang et al. 2012). Child

maltreatment results in lifelong adverse physical and mental health consequences such as

posttraumatic stress disorder, increased risk of chronic disease, lasting impacts or disability from

physical injury, and reduced health-related quality of life (Corso et al. 2008).


State and Federal Policies Related to Child Maltreatment

Because minors are considered to need additional protection as a result of their age, states not only

have laws making the acts of abuse and neglect criminal offenses but also have laws requiring that

certain adults must report suspected maltreatment to appropriate authorities. In some states, all

adults are mandated reporters. In most states, specific professionals, teachers, health care

professionals, social workers, law enforcement personnel, and others are mandated reporters (Child

Welfare Information Gateway, 2011). At the federal level, the Child Abuse Prevention and

Treatment Act (CAPTA) provides funding to states to support prevention, assessment,

investigation, prosecution, and treatment activities related to child maltreatment and funding for

research activities (Child Welfare Information Gateway, 2011, 2013).


Health Policies Related to Child Maltreatment

Children’s Advocacy Centers coordinate investigation and intervention services for maltreated

children by bringing together social work, legal, health care, and other professionals and agencies in

a multidisciplinary team to create a child-focused approach to child abuse cases. Home visitation is

another strategy that shows promise for improving child health and preventing child maltreatment

(Avellar & Supplee, 2013).


Older Adult Maltreatment

Best estimates indicate that 1 to 2 million Americans over the age of 65 years are abused, neglected,

or exploited, most often by caregivers (National Center on Elder Abuse, 2005). Precise numbers are

not available, attributable to differences in definitions of abuse, lack of a comprehensive national

data system, and different state system reporting and data collection. Further, only a small fraction

of abuse comes to the attention of Adult Protective Services (Dong & Simon, 2011). The U.S. aging

population is rapidly increasing with projections for individuals 65 years and older to increase from

40.2 million in 2010 to 54.8 million in 2020 and to 72.1 million in 2030 (Dong & Simon, 2011).

Legislation has been effective in bringing about reform.


State and Federal Legislation Related to Older Adult


As with child maltreatment, state laws provide for criminal charges related to the abuse of older

adults (the definition of which varies from state to state, but may be as young as 55 years of age).

Most (but not all) states define certain individuals as mandated reporters of abuse of older adults as

well. At the federal level, the Older American Act of 2006 developed and maintains the National

Center on Elder Abuse, which provides funding for prevention activities, research, data collection,

and long-term planning for elder justice. The Elder Justice Act (EJA) of 2010, which was part of the

Patient Protection and Affordable Care Act (2010), is the first comprehensive strategy to address

older adult abuse, neglect, and exploitation. It is important to note that the authorized funding has

not been appropriated at this time and that the EJA is set to expire in 2014. Funding for older adult

maltreatment is significantly less than for other types of violence and a national database has yet to

be established.


Health Care Policies Related to Older Adult


Recent efforts have focused on using the primary care setting to identify and respond to older adult

abuse (Perel-Levin, 2008). Case management strategies can be effective in providing consistency in

monitoring of adult patient and caregiver behavior (Choi & Mayer, 2000). Research on effective

intervention strategies in this area lags behind that of other areas of violence and is an area where

nursing can make an impact.


Opportunity for Nursing

Nurses have the skills and education to take a leadership role in addressing violence and abuse on

multiple levels, as providers, researchers, policy analysts, educators, and advocates. Efforts to

address violence against children, women, and older adults have met with impressive successes

over the past decades. These forms of violence, seen as largely justifiable and perhaps even

necessary in the past, are now recognized as both crimes and important public health problems. The

evidence base for interventions to prevent these forms of violence, end them when they start, and

mitigate the related health consequences is growing. It is clear, however, that we still have

important gaps in our understanding of both effective violence interventions and policies. Although

we work to address these gaps in knowledge, we can continue to move forward on numerous

fronts. Educators should ensure that curriculums at all levels include content on violence and

abuse. Given the high rates and significant health effects of violence, all nurses should have basic

clinical knowledge of how to assess for, competently respond to, and appropriately refer all patients

with a history of violence or abuse. Nurses can serve as powerful advocates for victims of violence,

ensuring that state and federal laws meet the highest standards.

Violence and crime unite two powerful systems, health care and criminal justice, and involve

multiple professionals including physicians, nurses, social services, police, lawyers, and judges.

Prevention and intervention strategies require efforts at the individual, community, institutional,

and public policy levels. Nurses can have a significant voice in ensuring the best possible

prevention and advocacy services at the local, state, and federal levels. Nursing research and the

testimony of nurses has been foundational for federal and state laws and resulting public policy

related to violence.


Discussion Questions

1. Consider the differences in the treatment of violence across states and what federal provisions

might be advantageous to address the discrepancies.

2. How might nursing research help to fill the gaps in the knowledge?

3. It is apparent in the chapter that different strategies exist for violence against women, child

maltreatment, and older adult abuse. Could the same strategies work across populations and abuse

types? What might be the advantages/disadvantages to having similar strategies?



Administration on Children, Youth, and Families Children’s Bureau. Child abuse and neglect

fatalities 2011: Statistics and interventions. U.S. Department of Health and Human Services,

Administration for Children and Families: Washington, DC; 2011.

Amar A, Laughon K, Sharps P, Campbell J. Screening and counseling for violence against

women in primary care settings. Nursing Outlook. 2013;61(3):187–191.

Avellar SA, Supplee LH. Effectiveness of home visiting in improving child health and

reducing child maltreatment. Pediatrics. 2013;132(10, Suppl. 2):S90–S99.

Barata PC, Schneider F. Battered women add their voices to the debate about the merits of

mandatory arrest. Women’s Studies Quarterly. 2004;32(3–4):148.

Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, et al. The national intimate partner

and sexual violence survey (NISVS): 2010 summary report. National Center for Injury

Prevention and Control, Centers for Disease Control and Prevention: Atlanta, GA; 2011.

Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs

associated with physical and nonphysical-only intimate partner violence. Health Services

Research. 2009;44(3):1052–1067.

Brzonkala v. Morrison, 529 U.S. 598, 627. 2000.

Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359(9314):1331–


Campbell JC, Alford P. The dark consequences of marital rape. American Journal of Nursing.


Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, et al. Risk factors for

femicide in abusive relationships: Results from a multisite case control study. American

Journal of Public Health. 2003;93(7):1089–1097.

Campbell JC, Webster DW, Glass N. The danger assessment: Validation of a lethality risk

assessment instrument for intimate partner femicide. Journal of Interpersonal Violence.


Carroll CA. Sexual assault civil protection orders (CPOs) by state. American Bar Association

Commission on Domestic and Sexual Violence: Washington, DC; 2007.

Child Welfare Information Gateway. About CAPTA: A legislative history. U.S. Department of

Health and Human Services, Children’s Bureau: Washington, DC; 2011.

Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. U.S.

Department of Health and Human Services.: Washington, DC; 2013 [Retrieved from]

Choi NG, Mayer J. Elder abuse, neglect, and exploitation: Risk factors and prevention

strategies. Journal of Gerontological Social Work. 2000;33(2):5–25.

Corso PS, Edwards VJ, Fang X, Mercy JA. Health-related quality of life among adults who

experienced maltreatment during childhood. American Journal of Public. 2008;98(6):1094–


Dong XQ, Simon MA. Enhancing national policy and programs to address elder abuse. JAMA:

The Journal of the American Medical Association. 2011;305(23):2460–2461.

Durborow N, Lizdas KC, O’Flaherty A, Marjavi A. Compendium of state statutes and policies on

domestic violence and health care. Family Violence Prevention Fund: San Francisco, CA; 2010.

Family Violence Prevention Fund. National consensus guidelines on identifying and responding to

domestic violence victimization in health care settings. Author: San Francisco; 2002.

Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the

United States and implications for prevention. Child Abuse & Neglect. 2012;36(2):156–165.

Felson RB, Ackerman JM, Gallagher CA. Police intervention and the repeat of domestic

assault. Criminology. 2005;43(3):563–588.

Glass N, Laughon K, Campbell J, Block CR, Hanson G, et al. Non-fatal strangulation is an

important risk factor for homicide for women. Journal of Emergency Medicine. 2008;35(3):329–


Greeson MR, Campbell R. Sexual assault response teams (SARTs): An empirical review of

their effectiveness and challenges to successful implementation. Trauma, Violence and Abuse.



Hirschel D. Domestic violence cases: What research shows about arrest and dual arrest rates.

National Institute for Justice: Washington, DC; 2008.

Hirschel D, Buzawa E, Pattavina A, Faggiani D. Domestic violence and mandatory arrest laws:

To what extent do they influence police arrest decisions? Journal of Criminal Law &

Criminology. 2007;98(1):255–298.

Laughon K, Glass N, Worrell C. Review and analysis of laws related to strangulation in 50

states. Evaluation Review. 2009;33(4):358–369.

Logan T, Walker R. Civil protective order outcomes: Violations and perceptions of

effectiveness. Journal of Interpersonal Violence. 2009;24(4):675–692.

Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll of intimate

partner violence against women in the United States. Violence and Victims. 2004;19(3):259–


National Center on Elder Abuse. Fact sheet: Elder abuse prevalence and incidence. National Center

on Elder Abuse: Washington, DC; 2005.

National Center for Injury Prevention and Control. Costs of intimate partner violence against

women in the United States. Centers for Disease Control and Prevention: Atlanta; 2003.

National Research Council. Clinical preventive services for women: Closing the gaps. The National

Academies Press: Washington, DC; 2011.

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. 2010.

Perel-Levin S. Discussing screening for elder abuse at primary health care level. World Health

Organization: Geneva; 2008.

Prachar M. The marital rape exemption: A violation of a woman’s right of privacy. Golden Gate

University Law Review. 2010;11:717.

Shields LB, Corey TS, Weakley-Jones B, Steward D. Living victims of strangulation: A 10-year

review of cases in a metropolitan community. American Journal of Forensic Medicine and

Pathology. 2010;31:320–325.

Taliaferro E, Hawley D, McClane G, Strack GB. Strangulation in intimate partner violence.

Mitchell C, Anglin D. Intimate partner violence: A health-based perspective. Oxford University

Press: New York; 2009.

Truman J, Langton L, Planty M. Criminal victimization, 2012 No. NCJ 243389. US Department of

Justice, Office of Justice Programs, Bureau of Justice Statistics: Washington, DC; 2013.

U.S. Government Accountability Office. Child maltreatment: Strengthening national data on child

fatalities could aid in prevention (GAO-11-599). U.S. Government Accountability Office:

Washington, DC; 2011.

Valente RL, Hart BJ, Zeya S, Malefyt M. The violence against women act of 1994: The federal

commitment to ending domestic violence, sexual assault, stalking, and gender-based crimes

of violence. Renzetti CM, Edelson JL, Bergen RL. Sourcebook on violence against women. 1st ed.

Sage: Thousand Oaks, CA; 2009.

Violence against Women Act, Public Law 113–4.

Violence Against Women Reauthorization Act of 2013. 2013.

Websdale N. Understanding domestic homicide. Northeastern University Press: Boston, MA;


Wilson JS, Websdale N. Domestic violence fatality review teams: an interprofessional model

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Online Resources

Child Welfare Information Gateway.

Futures without Violence.

National Center of Elder Abuse.

Rape, Abuse, and Incest National Network.



C H A P T E R 8 7


Human Trafficking

The Need for Nursing Advocacy

Barbara Glickstein

“I freed a thousand slaves. I could have freed a thousand more if only they knew they were slaves.”

Harriet Ross Tubman, nurse abolitionist

Human trafficking is a serious crime of forced labor or enslavement. As defined under U.S. federal

law, victims of human trafficking include children involved in the sex trade, adults age 18 years or

over who are coerced or deceived into commercial sex acts, and anyone forced into different forms

of labor or services, such as domestic workers held in a home or farm workers forced to labor

against their will. A victim does not have to be physically transported from one location to another

for the crime to fall under the definition of human trafficking (U.S. Department of State, 2013a).

Trafficking not only violates human rights but also contributes to harmful social, health, and

economic conditions for the persons who are trafficked. Persons who are trafficked can experience

intense psychological trauma, infectious disease (most notably HIV/AIDS), extensive physical

injury, drug addiction, unwanted pregnancy, and malnutrition. Human trafficking also poses a

significant public health problem.

Victim identification is the critical first step in stopping this crime. Nurses are well placed in

every community to identify trafficking victims. They also bring a public health lens to this human

rights issue, which contributes to their having a better understanding of the complexity of the issues

a survivor faces. Nurses can focus on developing and implementing a victim-centered approach.

The U.S. Department of Homeland Security Blue Campaign defines a victim-centered approach to

combating human trafficking as one that places equal value on the identification and stabilization of

victims, with the investigation and prosecution of traffickers (U.S. Department Homeland Security,



Encountering the Victims of Human Trafficking

Many nurses have treated victims of human trafficking without realizing it. Encountering modernday

slavery can provoke a strong visceral response, often followed by the urge to distance oneself.

These feelings make it hard to imagine what you, one nurse, could possibly do to stop it. However,

nurses are uniquely situated to make a difference.

Nurses should ask themselves one question: “What role can nurses have in stopping human

trafficking?” (See Box 87-1.)

Box 87-1

What Can You Do About Human Trafficking?

• Be well informed. Start with investigating what policy and protocols are in place at your health

institution and if the issue of human trafficking is being addressed in the nursing curriculum in

courses at your university or college.

• If there are no policies in place, start an interdisciplinary task force to develop policies and pursue

a …

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