Renee Mallett - Hello, my name is Renee Mallett, I am a healthcare attorney. Prior to law school, I was actually a registered nurse and practiced in the Emergency Department and Intensive Care Unit. Right out of law school I was hired directly by a hospital CEO. He asked myself, a nurse practitioner, a few physicians and other healthcare administrators to come up with a community-wide protocol and a hospital policy to address any patients or victims that represents with any sort of violence. Hence the victims could be victims that suffered child abuse, domestic violence, sexual assault, rape, et cetera. I'm coming to you today to share that experience and to walk you through a situation in which you may have a client that presents with any form of violence.

This course will allow you to provide counsel to any client whether they're in the early stages of identifying they have experienced abuse or have endured abuse and violence for a period of time. You will be able to counsel them on the appropriate steps depending on what their stage of readiness is.

So let's begin. Imagine this scenario, your law firm saw how the shelter in place orders during the beginning of the COVID-19 pandemic fueled an increase in episodes of domestic violence, now broadly defined as intimate partner violence. Your law firm wants every attorney to attend a one hour continuing legal education course on representing victims of intimate partner violence because attorneys are asked to provide legal counsel and support to victims of intimate partner violence.

Your firm wants to ensure that all attorneys are prepared to counsel clients who walk in to discuss the beginning stages of intimate partner violence or long-term abuse. While not every client may be prepared to leave their abuser, key guidance and resources can be provided. Leaving an abuser is complex, complicated, and the most dangerous time for a victim as the abuse is about power, dominance and control. The violence may escalate when your clients prepare to leave his or her abusers, particularly if children are involved. Should the violence escalate prior to clients being able to leave the abuser or escalate when they are attempting to separate from the abusers, you will be prepared to assess your client's danger, the abuser's homicidal risk factors and secure a protection order when applicable.

Further, your firm would like you to become knowledgeable about when and how clients may utilize healthcare professionals to provide therapeutic counseling or if severe psychological or sexual abuse has occurred, how physicians and nurses may assist with legal representation by properly collecting key forensic evidence and documenting violent episodes in the client's medical records. Where do you begin? Let's address these issues one at a time.

Domestic violence, intimate partner violence, let's give you the background.First before you can counsel clients on responding to domestic violence it's important to understand what it is.

Domestic violence sometimes referred to as family violence, interpersonal violence, or intimate partner violence is a pattern of assaultive and coercive behaviors including physical, sexual and psychological aggression and attacks, as well as stalking and economic coercion that adults or adolescents use against their intimate partners. Physical abuse or violence and emotional or psychological abuse includes intentional acts or coercive tactics that cause trauma to another person.

Trauma is characterized by feelings of intense fear, helplessness, loss of control and threats of being completely destroyed or obliterated. The violence can happen all the time or only occasionally. Partners may be married or not. They may be heterosexual or same-sex couples. They may be living together, separated or dating. It crosses the boundaries of all ages, socioeconomic statuses, religions, races, ethnicities, and nationalities.

Intimate partner violence is a crime, usually a misdemeanor or a felony and in most states it includes physical assault, which is hitting, pushing, shoving. Sexual violence, which is unwanted or for sexual activity and stalking, in which physical evidence via photos, witnessed abuse, emails, texts, email, and other forms of written communication or evidence that can make it easier to approve. Emotional, psychological, spiritual and financial abuses are more difficult to approach in a court, but its important to note they are forms of violence.

Next let's cover some key definitions. These definitions are provided by the Centers for Disease Control and Prevention, CDC when collecting prevalence data on the rate of intimate partner violence. Please see your state specific laws on domestic or intimate partner violence for definitions. Should your state not have a specific definition the following definitions from the National Center for Injury Prevention of the CDC will be utilized in this course.

What is an intimate partner? An intimate partner is a person with whom one has a close personal relationship that may be characterized by the partners emotional connectedness, regular contact ongoing physical contact and sexual behavior, identify as a couple and familiarity and knowledge about each other's life. This relationship need not involve all of these dimensions.

Typically an intimate partner relationship includes current or former spouses such as married spouses, common law spouses, civil unions spouses, domestic partners. Intimate partner relationships could include current or former boyfriend or girlfriend's, dating partners or ongoing sexual partners. Now let's discuss the definition for physical violence.

Physical violence is defined as the intentional use of physical force with the potential for causing death, disability, injury or harm. Physical violence includes but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, hair-pulling, slapping, punching, hitting, burning, or use of a weapon such as a gun, knife or other object and use of restraints or one's body size/ strength against another person. Physical violence also includes coercing other people to commit any of the above acts.

Sometimes there's also sexual violence. Sexual violence is defined as a sexual act that is committed or attempted by another person without freely given consent of the victim or against someone who is unable to consent or refuse. It includes force or alcohol drug facilitated penetration of a victim. Forced or alcohol drug facilitated incidents in which the victim was made to penetrate a perpetrator or someone else. Sexual violence also includes non-physically pressured unwanted penetration, intentional sexual touching, or non-contact acts of a sexual nature. Sexual violence can also incur when a perpetrator forces or coerces a victim to engage in sexual acts with a third party.

Many states have defined stalking as intimate partner violence. Stalking is a pattern of repeated unwanted attention and contact that causes fear or concern for one's own safety or the safety of someone else such as a family member or close friend. Stalking acts by a perpetrator can include, but are not limited to, repeated and unwanted phone calls, voice messages, text messages, and hangups, repeated and unwanted emails, instant messages or messages through websites and other social media such as Facebook. Leaving cards, letters, flowers or presents when the victim does not want them. Watching or following a victim from a distance. Spying with a listening device, camera or global positioning system. Approaching or showing up at the victim's home, place of work, school or church. Leaving strange or potentially threatening items for the victim to find. Sneaking into the victim's home or car and doing things to scare the victim. Damaging the victims personal property, pets, or belongings. Making threats to physically harm the victim.

Let's move into psychological aggression, which is the use of verbal and nonverbal communication with the intent to harm another person mentally or emotionally and or to exert control over another person. Psychological aggression can include, but is not limited to expressive aggression, which is name calling humiliating, degrading, acting angry in a way that seems dangerous. Psychological aggression is also coercive control, learning access to transportation, money, friends, and family. Excessive monitoring of a person's whereabouts and communications. Monitoring or interfering with electronic communication without permission. Making threats to harm self or making threats to harm a loved one or possessions. Psychological aggression includes the threats of physical or sexual violence such as I'll kill you, I'll beat you up if you don't have sex with me or such as taking a knife or a weapon or a gun and brandishing it with the intent to harm another individual. Threats of physical or sexual violence can be used by words, gestures, weapons, to communicate the intent to cause death, disability, injury, or physical harm. Threats also include the use of words, gestures, weapons to communicate the intent to compel a person to engage in sex, a sexual act or sexual contact when the person is either unwilling or unable to provide consent. Psychological aggression is the control of one's reproductive or sexual health such as refusal to use birth control, cohorts pregnancy, or a termination of that pregnancy. Exploitation of the victims vulnerability such as their immigration status, disability, undisclosed sexual orientation.

An example of this could be telling the victim, if you call the police I could get you deported. And lastly gaslighting, which is commonly referred to as mind games. Presenting false information to the victim with intent of making them doubt their own memory and perception. A violent episode is defined as a single act or series of acts of violence that are perceived to be connected to each other and that may persist over a period of minutes, hours or days.

A violent episode may involve a single or multiple types of violence, such as physical violence, sexual violence, stalking and or psychological aggression. Patterns of violence are defined as the way the violence is distributed over time in terms of frequency, severity, or type of violent episode such as the physical violence, sexual violence stalking and or psychological aggression. Let's move on to the prevalence of intimate partner violence in the United States.

In 2016, the National Network to End Domestic Violence reported in a single day the United States domestic violence shelters and programs serve 72,245 victims and answered 20,352 crisis hotline calls. The latest data from the 2011 National Intimate Partner and Sexual Violence Surveys conducted by the CDC indicate that over 10 million women and men in United States experienced physical violence each year by a present or former intimate partner.

Over one in five women, 22.3% and nearly one in seven men which is 14% have experienced extreme physical violence by an intimate partner in their lifetime. This translates to 29 million US women and 16 million US men. Data also suggest that nearly one in 11 women, 8.8% have been raped by an existing or former intimate partner at some point in their lives. Approximately 9.2% of women and 2.5% of men have been stalked by an intimate partner in their lifetime. Data from US crime reports suggest that 16% about one in six of homicide victims are killed by an intimate partner. The reports found that nearly half of female homicide victims are killed by a current or former male intimate partner. Intimate partner violence begins early and continues throughout lifetime. When intimate partner violence starts in adolescents, it is called teen dating violence.

About 11 million women and 5 million men who recounted suffering sexual violence, physical violence, and stalking by an intimate partner all before the age of 18. Childhood exposure to intimate violence is associated with the intergenerational spread of all forms of violence as the child grows into adulthood and has a family of his or her own.

A study done by a researcher at the University of North Texas found that males who witnessed violence and or experience abuse in childhood are more likely to commit intimate violence later in their lives than those who have neither witnessed violence nor been abused as children. Offenders of teen dating violence have a history of witnessing parental intimate violence.

Next let's discuss the Violence Against Women Act. In 1994 a landmark piece of legislation was passed called the Violence Against Women Act. This federal law sought to improve criminal justice and community-based responses to domestic violence, dating violence, sexual assault, and stalking to include protection orders. For survivors living in federally assisted housing, provide options to relocate to new safe housing through emergency transfers and related vouchers or to terminate their leases early. Assist survivors who are homeless, expand eligibility for unemployment insurance and device protection from employment discrimination based on victimization. Provide focus education relevant to economic abuse and security for victims. Increase investment in rape prevention and education programs and youth programs that promote healthy with men and boys to reduce gender based violence. Reduce domestic violence homicides in closing the gap in domestic violence related firearm laws. Increase avenues to justice focusing on victim autonomy and safety beyond the criminal justice system, as well as funding access to Violence Against Women Act legal services. Increase access for immigrant survivors. Next we're gonna talk about the patterns and severity of violence. Understanding the patterns of violence and the tactics abusers use on their victims will assist you in counseling clients that present for assistance. Moreover, should you have to prepare a protection order for a client you will need to articulate and document the abuser's pattern and severity of violence and the tactics utilized.

The scope and breadth of violence varies in relationships however three aspects remain consistent, isolation, intimidation, and coercive control. Intimate violence victims are often trapped as the violence increases in regularity and severity over time. And victims may demonstrate symptoms associated with post-traumatic stress disorder or PTSD. The goal of intervention is to return control and decision-making to victims thus increasing their ability to stay safe. The power and control wheel diagram depicts the most common tactics abusers use to control and dominate their intimate partners that is why the words power and control are at the center of the wheel.

An abuser systematically uses threats, intimidation, and coercion to instill fear in his or her partner. These behaviors are the spokes of the wheel and reflect the daily experience of victims. Physical and sexual violence holds it all together, this violence is the rim of the wheel. It is what the abuser will use to reinforce the tactics on the spokes and make them effective. It is noted battering in same sex intimate relationship has many of the same characteristics in heterosexual relationships. Resources that describe same sex domestic violence have been developed by specialists at the Northwest Network by trans, lesbian and gay survivors. The power and control wheel I've provided is for heterosexual relationships, typically when the batterer is the man in the relationship.

As we look at the wheel and look at the spokes specifically the tactics that the male abuser may use, you can use this in writing your protection order. He may use coercion and threats, intimidation, using emotional abuse, using isolation, minimizing, denying, and blaming using children, using his male privilege, using economic abuse. In the spokes when we talk about the tactics provided are key elements of each tactic for you to reflect and study.

Let's shift into some screening tools and questions. The U.S. Preventive Services Task Force recommends the following screening tools to determine if an individual is in an abusive violent relationship. These tools and questionnaires may assist you in documenting and fully understanding the depth and severity of the violence your client has encountered. Further these tools may assist you in preparing the protection order your client may need against their abuser.

Let's start with the first screening tool which is called the HITS. Stands for hurt, insult, threaten, scream. Does your partner physically hurt you? Does he or she insult you or talk down to you? Does he or she threaten you with harm? Does he or she scream and curse at you often? The second tool is called the STaT tool, which means slapped, threatened and thrown. Have you ever been in a relationship where your partner has pushed or slapped you? Have you ever been in a relationship where your partner threatened you with violence? Have you ever been in a relationship where your partner has thrown, broken or punched things? Let's move to the HARK screening tool which stands for humiliation, afraid, rape and kick. Humiliation, within the last year have you been humiliated or emotionally abused in other ways by your partner or your ex partner? Afraid, within the last year have you been afraid of your partner or ex partner? Rape, within the last year have you been raped or forced to have any kind of sexual activity by your partner or ex partner? Kick, within the last year have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex partner?

And let's talk about the Danger Assessment Tool that was developed in 1988 by Dr.Jacquelyn Campbell. The Danger Assessment Tool is used by many law enforcement personnel when invited at a victim's home. Many police departments have trained officers in conducting what is called a Lethality Assessment using the Danger Assessment Tool. Questions include, has the abuser threatened to kill you, your children, your relatives or him or herself? Has the abuser expressed ideas, dreams or fantasies about killing you, the children, your relatives or him or herself? Has the abuser made more than one threat? Is it daily, monthly? What are the threats? Is there availability of weapons or has there been use of weapons in the past such as the gun or knives? Has the abuser ever used his or her hands or an object to choke or strangulate or suffocate you? Does the abuser have a history of arson or threats of arson? Does the abuser express ownership of you? You can never leave me if I can't have you no one else can, death before divorce. Has there been separation violence meaning violence when you attempt to leave the relationship or when you suggest that the relationship should end? Does the abuser depend heavily on you, idolize you put you above everyone else or isolate you from all aspects of community life? Has the abuser stalked you, taken you hostage or abducted you, held you or taken you against your will? Is the abuser depressed, seeing little hope for life? Has there been an increase in the abuser's violence or risk behavior? Has the abuser physically abused you while you were pregnant? Does the abuser frequently use alcohol or drugs to include narcotics and opioids? Prior threats to kill expressing ideas or having fantasies to kill, access to guns or knives, attempts of choking, strangulation or suffocation, history or attempts of arson and depression and frequent use of alcohol or drugs are all indicators of homicide by the abuser. Women who have been strangled are seven times more likely to be killed by their partner. Pregnancy increases the risks of serious assault or homicide. Domestic violence often escalates from verbal, emotional abuse to physical abuse during pregnancy.

It is noted the Family Justice Centers are a coordinated approach that consists of police officers, prosecutors, community-based advocates, specialized attorneys and healthcare professionals to provide coordinated services to victims of family violence. The core concept is to provide one place where victims can go to talk to an advocate, plan for their safety, talk to a police officer, meet with a prosecutor, receive medical assistance, receive information about a shelter and get help with transportation.

At present there are currently 30 operational centers in the United States with an additional three international centers. The first Family Justice Centers model was in 2002 and is based in San Diego, California. The Danger Assessment Tool is completed for every new client at intake.

Now that you have the screening assessment tools and the Danger Assessment tools let's talk about protection orders. We know leaving an abusive partner is complex and complicated and is the most dangerous time for a victim as the abuse is about power, dominance and control. When a victim exits the situation they are seizing control. The loss of control is a threat to the abusive partners power. In turn this causes the abusive partner to retaliate in a very destructive sometimes life-threatening way. What is a protection order? Protection orders sometimes called PO's are court ordered injunctions aimed at limiting or prohibiting contact between an alleged perpetrator and survivor of intimate partner violence. The goal of the protection order is to prevent further violence from occurring.

A restraining order is a legal order issued by a court which requires one person to stop harming, harassing or coming in contact with another person. It is also sometimes called a protection order, an injunction, an Order of Protection or some other similar name. Although the process varies considerably by state, it typically begins with a petition to immediately issue a temporary or ex parte order until a hearing can be scheduled for a judge to hear from both parties and evaluate whether issuing a permanent order is justified and what the terms should be. In a review of available research protection orders are associated with lower risk of subsequent violence towards the survivor.

Further research suggests that having a protection order significantly increases feelings of wellbeing amongst survivors of intimate partner violence, making protection orders a potentially important tool in supporting survivors. Research also indicates that when battered women receive advocacy services and protection orders, it is more likely their abusers would be found guilty of their violence offense.

What does the protection order protect against? Each state law will determine what the protection order may specify. A judge may issue one or more of the following provisions. Cease abuse, the protection order will instruct the abuser to stop abusing, hurting, stalking or threatening your client.

Stay away, the order will instruct the abuser to stay away from your client, their home and place the work and or school if children are involved and the order protects them.

No contact, to stop all forms of contact by the abuser to your client, such as phone, text messages, emails, voicemails, facts, written notes, delivery of flower or gifts or any contact via a third person.

Financial support, the judge may order the abusers to pay your client temporary child support continue to make the mortgage payment on a home owned by your client and the abuser. Exclusive order use, the judge can order your clients sole use of the family home or car.

Restitution, to pay for your client's medical or dental costs or property damage caused by the abuser. In relinquishment of firearms, the judge can issue an order making the abuser to turn over any guns, rifles, or hunting knives he or she owns to a local law enforcement.

Treatment, the judge may order an abuser to attend anger management classes, batterers' treatment programs, or if there are any chemical dependency issues to obtain addiction services, alcohol and drug counseling, appear for random drug screens.

Custody, visitation, and child support. Many courts allow the judge to make a temporary decision about the care and safety of your client's children in that you can ask for supervised visitations or specify a safe around arrangement for transferring children to and from your client and the abuser. Let's talk about preparing the protection order. The previously discussed screening tools and the power and control wheel will assist you as legal counsel in describing the severity and pattern of violence.

Instruct your client to keep a journal of specific abusive episodes. For example, I was harassed, I was abused, I was stalked. When did it occur? Where did it occur? What was said? Details of what happened, witnesses, and the collection of damaged property, voicemails, emails, texts, social media posts, and photographs.

The Safety Net DocuSAFE app can be downloaded on a smartphone or a computer to log these details or you can simply have your client create an incident log. What happens if the abuser violates the protection order? There are a few options you can offer your client depending on the violation. You may elect to contact the police or the court for enforcement of the protection order. The police will evaluate the evidence presented and may elect to arrest the abuser or take another action such as enforcing a stay away, no contact, cease abuse, or exclusive use order.

Dependent on the type and number of violations the violation may need to be reported to the court. Repeated violations may result in a misdemeanor or felony criminal conviction or punishment. The court will enforce violations for failing to pay child support and other financial support or failing to attend a treatment program. You may file a motion for contempt explaining how the abuser has violated the protection order.

The court will likely hold a hearing to hear evidence supporting the motion. Depending on the nature of the violence the judge will determine if a fine, civil contempt, jail time or both in the case of criminal contempt may be imposed. The judge may elect to extend or modify the original protection order.

Let's talk about the association of firearms and protection orders. Women are at an increased risk for homicide when their violent intimate partner has access to firearms. Federal law makes it unlawful for certain categories of persons to ship, transport, receive or possess firearms. The law includes individuals subject to a court order, such as a protection order, restraining the person from harassing, stalking or threatening an intimate partner or child of the intimate partner and persons who have been convicted of a misdemeanor or felony crime of domestic violence or intimate partner violence.

In 2016, the US Supreme Court upheld a lower court's decision that firearms may be removed from the possession of someone found guilty of a misdemeanor of domestic abuse. State laws often emulate federal law and in some cases enact policies that further limit access or allow police officers to remove firearms from convicted abusers.

Next we're gonna talk about the concurrence of child maltreatment in intimate partner violence situations. To further emphasize why domestic violence or intimate partner violence is a public health issue child maltreatment can jointly present with intimate partner violence. Child maltreatment is an umbrella term covering all forms of child abuse and child neglect. Studies using national data demonstrate more than a third, 33.9% of children who have witnessed partner violence also were victims of maltreatment in the past year. Over half, 56.8% of children exposed to partner violence also experienced maltreatment in their lives.

Let's talk about the Child Abuse Prevention and Treatment Act. This is a landmark federal law tackling child abuse and neglect, in which it was originally enacted on January 31st, 1974. The Child Abuse Prevention and Treatment Act sets forth a federal definition of child abuse and neglect as any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation or an act or failure to act which presents an imminent risk of serious harm.

Check your state law for a definition of child maltreatment or abuse. The Child Abuse Prevention and Treatment Act was most recently amended by the Victims of Child Abuse Act Reauthorization Act of 2018 to provide immunity for civil and criminal liability for individuals such as healthcare professionals, school nurses who make good faith, child abuse and neglect reports who provide medical evaluation or consultation or who offer legal intervention pursuant to a good faith report of child abuse or neglect.

Each state has mandatory reporting laws which refer to the legal requirements to report to authorities including local, county and state agencies such as the Child or Adult Protective Services or local law enforcement, child abuse and neglect divisions. Individuals reporting in good faith, such as healthcare professionals are granted immunity from civil and criminal liability to include actions taken by their professional licensure boards.

Next we will transition into a short conversation about child custody with intimate partner violence. Many victims of intimate partner violence are afraid to leave their abuser because children are involved. Victims fear their children will be taken away and placed in foster care or in the custody of their abuser.

Although more than 22 states and the District of Columbia have statutes mandating a presumption against sole or joint physical or legal custody to a perpetrator of domestic violence. Research indicates that the presumption can be undermined in states that also have a competing friendly parent statute or joint custody presumption. Let's talk about factors determining child custody. The judge will evaluate what is in the best interest of the child or children.

Check with your state law to determine which factors will be assessed in determining custody but usually they involve the physical, emotional, social, medical, moral, and educational needs of the child. The home environment offered by your client and the perpetrator, the interpersonal relationship that exists between the child and each parent, the preferences of the child if the child is mature and of a certain age to provide his or her preference, the mental stability of each parent, past and present behavioral health issues such as mental health and chemical dependency issues which includes drug and alcohol abuse and addiction, history of domestic violence and other violent episodes, history of child maltreatment and the overall safety of the child.

Temporary custody via protection order and supervised visitations. Many states allow your client to request temporary custody of their children via a protection order. With the temporary custody request you may also want to appeal for supervised visitation and exchange. Supervised visitation and exchange seeks to minimize the risks for survivors and their children by creating a safe place for the non-custodial parent child interaction monitored by a third party. Flory and his authors and researchers found that participation in a supervised visitation program resulted in a 50% reduction in verbal and physical aggression between the custodial and non-custodial parents.

Additionally parents referred to a supervised services were significantly less likely to use corporal punishment after participation in the program indicating a potential increase in positive parenting behaviors. Why do victims stay with their abuser? Aside from this danger and the above fears discussed there are many reasons why victims stay in abusive relationships. You may have an individual seeking consultation with you about leaving their abusive partner, but never hear from them again or they may vacillate about having to leave this abusive relationship. Do not be discouraged if you do not hear from a potential client for a long period of time. The advice you provided was likely still helpful.

Per the National Domestic Violence Hotline, the most prevalent reasons why a victim stays in a relationship is the following. Believing abuse is a normal behavior. A victim may have grown up in an unhealthy abusive home and may not know what a healthy relationship looks like. Fear of being exposed. If someone is in a LGBTQ relationship and has not yet come out their partner may threaten to reveal their secret.

Embarrassment or shame, it is often difficult for someone to admit that they have been abused. They may feel that they have done something wrong by becoming involved with an abusive partner. Low self-esteem. When abusive partner constantly put someone down and blames them for the abuse it can be easy for the victim to believe those statements and think that the abuse is their fault.

Love, frequently the victim feels love for the abusive partner. Abusive people can often be charming especially at the beginning of a relationship and the victim may hope that their partner may return to be that person. Culture, religious reasons. Traditional gender roles supported by someone's culture or religion may influence them to stay rather than to end the relationship for fear of bringing shame upon their family. Language barriers, immigration status. If a person is undocumented they may fear that reporting the abuse will affect their immigration status.

Also if their first language is not English it can be difficult for them to express the depth of their situation to others. Lack of money and resources. Financial abuse is common and a victim may be financially dependent on their abusive partner. Without money access to resources or even a place to go it can seem impossible for them to leave the relationship.

Dependency, when someone is physically dependent on their abusive partner they can feel that their well-being is connected to that relationship. This often is referred to as trauma bonding and is natural for an individual to look to the other partner for survival. And the last part of this course we're gonna talk about healthcare assistance for victims of intimate partner violence.

Your client may need a range of healthcare services from mental health, counseling to heal from the sustained trauma they have endured to physical health should they experience a violent episode such as physical or sexual violence. Moreover, when a victim is seen by a healthcare professionals, the above screening tools more likely will be utilized. Thus the healthcare professionals are obligated to document the abuse and trauma the victim has suffered and their medical record. When the victim is ready and is safe for them to leave their abuser the victim's medical record may be utilized to secure a protection order or for other legal remedies.

Let's delve into healthcare resources that are available. The first is the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act imposes requirements on healthcare providers to implement interpersonal and domestic violence screening and counseling for women and their care. Health plans cannot deny coverage to individuals because they've experienced intimate personal violence, or for any preexisting condition that is known as a guaranteed issue.

Some of the preexisting conditions could be the injuries they have sustained from the violence. Survivors can assess affordable coverage that is not tied to their abuser and coverage addresses situations unique to survivors, such as gaps in coverage due to circumstances entirely out of their control. The Institute of Medicine conducted a scientific review and provided recommendations on specific preventative measures that meet the women's unique health needs and help and keep them healthy.

Here are eight additional preventative health benefits for women under the Affordable Care Act. Well women visits, gestational diabetes screening, HPV, DNA testing, sexually transmitted infection counseling, HIV screening, and counseling, contraception and contraceptive counseling, breastfeeding support supplies and counseling and interpersonal and domestic violence screening and counseling. Screening is effective in the early detection and effectiveness of interventions to increase the safety of abuse women. Professional counseling may provide your client with the support and strength to leave an abusive relationship.

Let's talk about the second healthcare services offered to victims which is mandatory reporting requirements, confidentiality and consent for photo and the collection of forensic evidence. Thus healthcare professionals will also aid your client that has experienced intimate partner violence in the collection and preservation of evidence.

Adult victims. Reporting requirements necessitate that healthcare providers who suspect or identify that a patient is abused must document or write that assessment in the patient's medical record. Patients who identified that they have been abused can use the information recorded in the medical record to seek civil or criminal remedies. Only the abused adult patient can assess the danger and relative risk of reporting versus non-reporting the violence they have experienced.

Adult patients 18 years and older will have to consent to the medical forensic examination and any video or photo documentation. They may consent only to the examination or the collection of the evidence or to only photographs of their body, but they may decline to have photos taken of their genitalia or other private parts. It is noted evidence should be collected within 72 hours after the violent episode to preserve the evidence and perform forensic test. An adult may not agree to talk to law enforcement after the examination or days after the event, the adult patient may decline to participate and assist law enforcement in investigating.

Next let's talk about how healthcare professionals can aid the minor victim or any child abuse situation. Child abuse includes all forms of abuse such as sexual abuse, emotional, physical, and neglect cases are always reportable in every state by a healthcare professional. Typically hospitals and health systems, school nurses are required to report all forms of abuse or suspected abuse of patients 17 years of age or younger to the Department of Children's Services. For sexual abuse and assault patients 17 years or younger the sexual assault evidence collection kit and toxicology samples for sexual assault will be given to law enforcement and may be tested at a state crime lab.

It is noted teen dating violence does occur so you may encounter an adolescent client. A minor patient does not need the consent of their parents or guardian to be examined or evidence collected. In many states minors can consent for treatment involving sexual assault, rape sexually transmitted infections and if they are suicidal. Let's talk about confidentiality. You can explain the limits of confidentiality to your client.

For adults the healthcare professional will keep the disclosure confidential unless they have been informed that the harm has occurred to your children, or if you intend to harm yourself or someone else. For adolescents and children the healthcare professional will keep the contents of the medical record confidential Unless your client tells them that somebody is harming you, or you tend to harm yourself or someone else. Depending on the age of your client there are instances where healthcare professionals may need to report sexual conduct or other conduct.

Consent for photographs or videos. Typically healthcare professionals will have your adult client sign a distinct consent form in order to photograph or video record evidence of the abuse. You may need to explain the terms and conditions of the consent form to your client prior to signing. Your adult client has several choices about handling of evidence in their case and you should counsel him or her on each option to help them make the best choice for their individual circumstances. Your client may elect to have their injuries recorded or photographed to preserve the violent episode in their medical record but not submit as evidence to be collected and sent to the state forensic lab. Further your adult client may also elect not to notify law enforcement but you should be prepared to explain why having their injuries photographed or recorded could help them achieve certain legal outcomes. The filing guidance applies to victims who are minors or adults when they have consented.

All photographs or videos should be taken by a forensically trained nursing or medical staff or law enforcement photographer or videographer. If a law enforcement photographer is still not available, photos should be taken by a trained forensic staff member or forensic nurse. Close-up photographs should be taken of the individual space and trauma areas with a measuring device to document the size of the injury, such as the size of the cut bruise or scratch. The photographs or video should be identified such as labeled with the individuals name, hospital, or facility number such as the medical record number and date. It is recommended that photographs of the genitalia should be taken with a trained forensic staff member or forensic nurse.

Forensic trained hospital medical staff is responsible for photo documentation of any evidence of trauma including photographs of the genitalia. Two sets of photographs are recommended. Both sets remain with the medical record unless a law enforcement agency requests the trauma photos for their files. Once that should be given to the local law enforcement agency with a proper release form. Multiple photos should be taken of injuries to provide details of the mechanisms of injury and scope of the injury. A full facial photo must be taken for identification purposes. If your client requests copies of the photos a third set should be made, the person should be advised to store the photos in a safe place such as a relatives home or given to you as legal counsel.

Medical forensic examinations. The U.S. Department of Justice specifically the Office on Violence Against Women endeavors to aid communities' ineffective response to sexual violence victims to include intimate partner violence victims that experience sexual violence from their partner. The medical forensic examination is a best practice approach intended to address victims healthcare needs and promote their safety and healing.

This examination and its accompanying protocol was built upon state national and international resources as well as research related to community response to child and adult sexual abuse and the collection of forensic evidence. The forensic evidence collected during the examination, information collected during the health and medical history, documentation of the examination findings and forensic samples can facilitate case investigation and prosecution of perpetrators of sexual violence.

With effective nursing, medical forensic care and collection of evidence as objectives the Office of violence Against Women's released the national protocol for sexual assault and medical forensic examination for adults and adolescents in 2004, and a second edition has been released in 2013. You can find this protocol on the internet. Likewise in 2016, the Office of Violence Against Women released the national protocol for sexual abuse, medical forensic examinations pediatric, which focuses on prepubescent children.

In conclusion, intimate partner violence and child abuse are prevalent and are public health issues in which legal counsel can advocate and guide their clients. Intimate partner violence can impact child, adolescent and adult victims in any economic class and any part of our country. Your client may be in the discovery stage of understanding the nature of the abuse they have sustained. Determining next steps to take, what resources are available and when it is the right time to safely leave the abuser.

It may take your client a period of time to fully understand the impact of violence they have endured. The fact that this violence has upon their children and to align the appropriate resources needed. Attorneys can guide their clients to seek the assistance of healthcare professionals, to ensure their clients receive preventative and restorative care services, as well as urgent and emergent services should they experience an acute violent episode. As legal counsel you can impact the lives of many victims and aid them in securing a violent free home.

There are many intimate partner violence resources available. I've included at the end of this there are Ted talks on domestic violence. How childhood trauma affects the health across a lifetime by Dr. Nadine Burke Harris. What adverse childhood experiences are by the CDC. The State of Washington has a Housing First program in which it has shown that if victims are provided stable housing they are more likely to leave their abuser. Also the CDC has a teen violence Dating Matters Toolkit that's available for guidance. Also the Center for Disease Control, the CDC, has a toolkit on preventing intimate partner violence and also their surveillance violence definition is included in this resource toolkit. I've also provided the Danger Assessment Tool in which it's meant to be used with a calendar to enhance the accuracy of the victims recall of events. All this information is included in the resource section. You have links to all these resources that you can fully download these available tools to help you in guiding in your client.

I thank you today for participating in this crucial course to assist in any victim as they prepare to leave their abuser or perhaps to seek resources to end the abuse and hopefully stay in a violent free home. For those of you who also want to make a difference you're welcome to partner with your local hospital and healthcare system to see if they need any assistance in enhancing their protocol and or devising a community protocol to aid any victim that reaches out for assistance whether it's immediate assistance or long-term assistance for victims of intimate partner violence. Many state health departments and also the attorney generals of each state has resources available along with a domestic violence coalition that's either community-based or state initiated.

I thank you for taking today's course and all the best in counseling your client on this very difficult topic.