The goal of the enclosed course is to provide basic instruction on intimate partner violence, including identification, screening, and referral of persons with a history of being, or at risk of becoming, victims or perpetrators of intimate partner violence.

1. Estimate the number of women who are likely to be victims of intimate partner violence (IPV).
2. Define dating violence and the connection with risk factors & health problems.
3. Outline the anatomy and progress of an abusive relationship and correlate with Dr. Lenore Walker’s “Three Phase Theory” of domestic violence.
4. Provide information concerning characteristics of victims and perpetrators of violence.
5. Enumerate important screening procedures the health professional can use to determine if a patient is affected by intimate partner violence.
6. List screening procedures the health professional can use to determine if a patient may be a perpetrator of domestic violence.
7. Identify important advocacy and support organizations available to the domestic violence victim/perpetrator.
8. List some preventive and treatment measures that can be used for abusive families.

Intimate partner violence (including domestic and dating violence) is increasingly recognized as a serious and widespread public health crisis that affects individuals of all ethnic and socioeconomic backgrounds. Domestic violence, now referred to as intimate partner violence (IPV), has been defined as a pattern of coercive control consisting of physical, psychological and/or sexual assaults against current or former intimate partners. Batterers also commonly use economic abuse, isolation, and intimidation to exert power over their partners. The heart of the problem is always an imbalance of power. The abuser learns that coercion “works,” that it’s effective in controlling the relationship and in reinforcing the power imbalance.

This course often refers to the battering of women, since 85% of serious domestic assault victims are women, according to the U.S. Department of Justice, Bureau of Justice Statistics. However, it can also occur by women against men, and between same sex partners.

Millions of women are battered each year by their partners – one every 15 seconds. It is so common that it is now the leading cause of injury to American women, accounting for more hospital emergency room visits than auto accidents, muggings, and rapes combined.

One in three women will be subjected to IPV at some point in life, and as many as 20% of pregnant women are abused by their partners (or, in pregnant adolescents), making IPV more common than preeclampsia and gestational diabetes. Pregnancy itself (particularly if unplanned), prior abuse, and delayed prenatal care are risk factors for IPV. Adverse outcomes associated with IPV before or during pregnancy include urinary tract infections, vaginal bleeding, preterm labor, and substance abuse.

Domestic violence accounts for more than 30% of female homicide cases. A surprising gallery of famous women reportedly touched by domestic abuse includes: Tina Turner, Daryl Hannah, Roseanne, Madonna, and the late Nicole Brown Simpson.

Nurses and other healthcare providers are strongly encouraged to recognize, treat, and prevent this “silent epidemic” that rages throughout our society. We are in a unique position to address this public health problem. Yet domestic vio lence remains extensively under--detected.

Although battered women seek medical care frequently, as few as one in 20 are accurately identified by the practitioners to whom they turn for help. As many as 50% of victims murdered by a spouse or lover were seen in a hospital emergency department, but not screened for domestic violence, before they were killed. Research shows this is largely due to lack of knowledge and training, and that battered women expect healthcare providers to initiate discussions about abuse. However, IPV is rarely detected or disclosed without inquiry by the clinician in routine and repeat screenings.

Clients need to know that it is appropriate to disclose IPV in health care settings. The lack of effective communication on safety assessment, referrals, and follow-up for IPV can also present a problem.

“I used to go without medical treatment... I’d wait until it wasn’t a choice anymore. And I’d wind up having to go to the emergency room.” or “Somebody would find out something was happening in my house, like a social worker, a doctor, a nurse or whatever, I would stop going there and go somewhere else.”

And the lack of an emotional connection with the clinician can be another issue to address. Describing an ED visit, one woman commented: “He checked me, he didn’t ask any questions, nothing, and they took x-rays and pulled out of there... Maybe I was hoping... that they would talk to me? I mean, they checked me out... but I didn’t feel like... emotionally? Like maybe talk, some kind of comfort?”

Benefits of Disclosure: Making Changes, Improving Self-Esteem, Building Relationships With improved awareness and appropriate intervention, attention is directed to how health- care professionals can best respond to breaking the cycle. We need to inquire routinely about domestic/family violence, provide sensitive and nonjudgmental support, address patient safety, document the abuse, provide information about resources and options, and offer referrals.

Such familiarity can also occur in the ED setting, as in one case where the abused woman accepted advice from a nurse who had treated her a few weeks earlier for IPV-related injuries. When the participant returned to the ED with more injuries, the nurse recognized her:

“And I started crying, and she said, ‘Two weeks ago you were here, now you’re back here again today and it’s for the same thing. Your face isn’t all bruised up like it was two weeks ago, but you’re hurtin’. What’s goin’ on?’ I broke down and told her...She was like, ‘Well, you don’t need to be in a relationship like that.” The woman acted on referrals and left her abusive partner as a result of this encounter.

Instead of an immediate end to the abuse, these patient-clinician encounters resulted in a shift in the participant’s self-esteem, perception of the violent relationship, or awareness of alternatives, eventually empowering her to seek help for the abuse on her own. For example, clinicians’ assurances that relationship violence was unacceptable resonated. One woman reported her primary care doctor’s sympathetic insistence that the batterer’s behavior was wrong set the stage for her to take action: “She was like, ‘No... no one who loves you will put their hands on you.’ You know, it’s not right. ‘That’s not real love.’... After [he broke] the wrist, I said, ‘No more.’”

With the continued heightened awareness of acts of violence, many state boards of nursing require courses on intimate partner violence. This requirement is designed to curb the problem of violence by providing information that will help you identify the perpetrators of violence and assist you and others to avoid it.

In a classic study psychologist Lenore Walker, Ed.D., ABPP, completed extensive research on more than 1,000 battered women, as well as a smaller group of abused men. She found a pattern and labeled it the “Three Phase Theory” of family violence.

1. Tension-Building Phase: Tension is a normal factor in everyone’s life and indeed, in all relationships. However, for a variety of reasons, some people react to tensions violently. Once violence occurs within a relationship, it compounds the normal tensions.

During the tension-building phase of a violent relationship, the woman will sense her partner’s increasing tension. She may or may not know what is wrong. The man often is edgy, lashes out in anger and challenges her, tells her she is stupid, incompetent and unconcerned about his welfare. In a violent relationship, the woman generally lets the batterer know she accepts his blame of her. She tries hard not to make any “mistakes” that may upset him. She takes the responsibility for making him feel better and thus begins to set herself up to feel guilt when he eventually explodes in spite of her best efforts to calm and please him.

During the increasing tension, the woman is rarely angry even at the most unreasonable demands or blame. Rather, she internalizes her appropriate anger at the man’s unfairness, and instead feels depression, anxiety, and a sense of helplessness. She may suffer physical symptoms related to her emotional distress, such as headaches, upset stomach, difficulty sleeping, weakness and fatigue. These problems increase the woman’s sense of worthlessness and loss of control and make her more vulnerable to the man’s criticisms.

The woman may often deny her fear in an attempt to minimize the seriousness of the threat, believing she can control the situation. Even if she acknowledges her fear and danger, she often may not seek help. She usually feels ashamed of her failure to please her partner and believes, often correctly, that if other people know about the violence they will blame her for it.

As the tension in the relationship increases, seemingly minor episodes of violence, such as pinching, tripping, slapping, or shoving occur. The batterer knows his behavior is inappropriate, and he fears the woman will leave him. The fear of rejection and loss only serve to increase his rage at the woman and his intense need to control her.

2. Acute Battering Incident Phase: The tension-building phase ends in an explosion of violence. The incident that sets off the man’s violence is often trivial or unknown, leaving the woman desperately confused and feeling very helpless. The woman may or may not fight back. She often attempts to escape the violence, or calls for help. If she cannot escape the beatings, she may make herself feel as if the beatings are happening in a dream. She may not be aware how badly she is hurt.

Following the battering, the woman is in a state of physical and psychological shock. She may be passive and withdrawn, or incoherent. She may not appreciate the seriousness of her injuries and may resist getting treatment. The man may discount the episode, and he usually underestimates the woman’s injuries. He may refuse to summon medical help even when her injuries are obviously life-threatening.

3. Loving Reconciliation Phase: Loving reconciliation may begin within a period of a few hours to several days following the acute battering incident. Both the man and the woman have a profound sense of relief the incident “is over.” While the woman may be initially angry with the man, he begins an intense campaign to “win her back.” Just as his tension and violence were overdone, his apologies, gifts and gestures of love may also be excessive. He showers her with love and praise that helps to repair her shattered self-esteem. It is nearly impossible for her to leave him during this phase as he is meeting her desperate need to see herself as a competent and lovable woman.

It is during this phase that the woman’s feelings of power and her romantic ideals are nurtured. She believes that this gentle, loving person is her “real” man. She believes if only she can find the key, she can control him and prevent further violent episodes. No matter how often it has happened, somehow this episode seems different and she really believes it will never happen again. During the loving reconciliation, a strong bond develops between the couple, isolating both of them from reality and from anyone who might try to intervene in their destructive relationship. Anyone who has attempted to support the woman and urged her out of the violent relationship may now be seen as “the enemy” trying to separate the loving couple.

Loving reconciliation is a period of intense pleasure and reassurance for the couple. It convinces them there is nothing wrong with their relationship and discourages them from seeking assistance from other people or agencies. It is also isolating and provides them a time of being alone. When the violence recurs, the woman finds she has fewer and fewer places to turn for support.

Loving reconciliation also becomes a kind of reward for the violence. Psychologists have found that any behavior followed by a positive reward will occur more frequently. The more often the periods of uncomfortable tension that end in a violent explosion are followed by loving closeness, the less likely the couple will seek alternatives for handling tension and stress. To end the episodes of violence, this cycle must be broken and new alternatives for handling their tension must be developed by the couples that are caught up in the battering relationship.

Violence between partners may be triggered by numerous factors. Some of these triggering factors are:

1. Stress situations such as job loss, financial problems, pregnancy or role changes.
2. Frustrations: Underachieving or not achieving goals.
3. Alcohol and/or other substance abuses.
4. Abuse-prone attitudes and beliefs: “Show the woman who’s boss,” or “I wouldn’t hit her if she didn’t deserve it.”
5. Childhood experiences of abuse and/or parental violence.
6. Psychological or physical disorders.

For many years, intimate partner violence was largely viewed as simply a “family problem.” In numerous instances the police, courts and hospitals, as well as most social service organizations, were hesitant to intervene. However, as a result of the growing issue with violence in general, persons from these agencies and other community groups have become more outspoken and active in the causes of violence within the home.

Just what kind of man is the person who abuses women? Research reveals that batterers come from every walk of life. They are as varied as the circumstances in which they live. Batterers are usually men who were physically or psychologically abused in their homes when they were children. Often they grew up in homes where episodes of violence were common, and their father either beat or completely dominated their mother.

Batterers are also manipulative and often will exhibit a dual personality that is convincingly charming one minute and violent or aggressive the next. The batterer’s victim will never know which behavior he will exhibit the next moment, hour, day or week. To protect herself she must be constantly on the alert to ensure he is kept calm.

The majority of battering men will refuse to admit they have a problem. This is true in the sense that what they are seeking is control of the woman, and they want their control to be absolute and complete. Often because of his larger size, the batterer is in little danger of physical harm from his victim. Frequently if the battered woman attempts to protect herself by fighting him, he will become more enraged and the battering more intense. The batterer will not usually volunteer himself for help and treatment until after the woman has left him and the battering environment and sought help on her own. When the victim is unwilling or unable to leave and seek help, the batterer really has no incentive to change his behavior.

The abuser will often refuse to take responsibility for his destructive behavior. He may use excuses such as, “I was drunk,” “I didn’t know what I was doing,” or “It just happened.” He may, in fact, believe his abuse and violence are justified; in any case, the assaults will continue to occur.

domestic/family violence, what are some of the signs to confirm your suspicions? You should be especially suspicious if the woman is frequently absent from work or social activities. If she reappears wearing long sleeves in warm weather, sunglasses indoors, scarves around her throat, or in extremely heavy makeup, this should raise questions in your mind.

If the woman is often absent from work or otherwise is homebound as a result of a high incidence of sickness, surgeries or other ailments, you should suspect she is a victim of battering. Suspect abuse if she is unable to hide blackened eyes, broken limbs or bruises; and when asked about them, says she was in an accident or experienced a fall, is really clumsy or some other excuse. If she seems to be excessively private, avoids old friends, or if her personality suddenly changes drastically, it is not unreasonable for you to suspect she is a battered woman.

Whenever you suspect battering and the woman victim either will not or cannot admit she is in danger, keep in mind she is suffering from a learned helplessness. Often, her state of mind is such that she believes she must rely totally on the batterer to survive. She is also worried about her health and well- being because she is aware of the fact he might harm her if she attempts to leave. If children are involved, she will also be concerned about their welfare. This is your opportunity to share some kindness with her and respect whatever she decides to do. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.

Children who witness domestic violence are themselves victims of abuse. Unless directly abused, they are often overlooked and do not receive adequate services. The children of battered women must contend with the same myths and untruths about battering which confront their mothers. They must also deal with adult prejudice which tells them, “It’s not so bad...don’t worry. Everything will be all right.” Meanwhile, everything they feel and have experienced is bad.

Many parents minimize or deny the presence of children while the mothers are being assaulted. However, interviews with children of battered women reveal they have seen and heard, and can give detailed accounts of violent behavior that their mother or father never realized they had witnessed. Events can be witnessed in many ways, not just by sight. Children may hear their mother’s screams and crying; the abuser’s threats; sounds of fists hitting flesh, glass breaking, and wood splintering; cursing and degrading language. Children also witness the consequences of the abuse after it has occurred – their mother’s bruises and torn clothes, holes in walls, broken furniture, their mother’s tears. They sense the tension in the house, and in their mother.

Many fathers inadvertently injure their children while throwing furniture or other household objects when abusing their partners. The youngest -children sustain the most serious injuries, such as concussions, or broken shoulders and ribs. These children also suffer poor health, low self-esteem, poor impulse control, sleeping difficulties, and feelings of powerlessness. They are at high risk for alcohol and drug use, sexual acting out, running away from home, isolation, loneliness, fear and suicide. Who will speak for them?

All individuals with evidence of trauma need to be questioned directly about the potential for domestic abuse using a structured, nonjudgmental, confidential interview conducted in privacy and safety. Current recommendations include routine screening of all female patients over age 14.

In addition to the obvious signs listed below, be alert to the presentation of stress-related complaints such as headaches, or stress-enhanced conditions such as chronic upper respiratory problems or bronchitis.

Physical Abuse: Trauma/pattern of injury inconsistent with event history; delay in presentation.

Emotional or Sexual Abuse: Adults frequently present with complaints associated with longterm stress and chronic anxiety. Children or adolescents may present with behavioral problems. The elderly may present as withdrawn or fearful of authority.

Neglect: Lack of attention to person or environment.

Patterned Injuries: Central injuries to the face, head, neck, breasts, abdomen, and genitals are prevalent in contrast to accidental injuries affecting the periphery or extremities. A pattern of multiple non-life threatening injuries at varying stages of healing is highly suspicious. In children and the elderly, spiral fractures may be indicative of abuse.

Pregnancy: Escalation of domestic violence is seen in pregnant women with up to 35% of obstetric patients suffering some type of physical assault.

Screen for batterers, too: The batterer may be our patient in some circumstances, and treating contributing factors can help stop abuse. A batterer may suffer from depression, chemical dependency, or post-traumatic stress disorder, for example. Past head injuries have also been associated with pathological jealousy and violence. Empathy, rather than a confrontational approach, may make the batterer more amenable to treatment.

• Recognize potential victims; take your time to establish rapport, and ask direct questions about domestic battering. Simple and specific is best.
• Implement your agency’s DV protocol if domestic violence is suspected.
• Triage for immediacy of need for treatment
• If injuries do not require immediate trauma or surgical care, take history from patient alone in private room
• If injuries require immediate trauma or surgical care, call security, local police, or both if partner seems disruptive or dangerous
• Contact victim’s advocacy representative and offer services to client as available

If any of the clinical signs are evident, and there are negative responses to the screening questions, it is appropriate to ask additional questions to prompt information such as:

• Sometimes when I see an injury like yours, it is because someone hit them. Did that happen to you?
• I don’t know if this is a problem for you, but many women I see are dealing with an abusive relationship, so I’ve started asking about domestic violence routinely.

The violence your patient is experiencing will not simply go away no matter how often she wishes or prays it will. Neither will it simply get better. Once it has started, it will recur more often and each time it will get progressively worse. It does not matter how much she loves her partner. She must know that she is in danger of losing her life and needs to take steps to assure her own safety.

If she wants protection, she must take the first step. There are many people and places she can call, so she must gather her courage and make a call for help. She can call a friend, family, or the police. She can also call her church, a physician, or a counselor. There are also women’s centers, shelters and family crisis centers. They are always open and she will be able to reach them by phone. Family crisis centers have hotlines and are open 24 hours a day, every day. In spite of what she may have been told, these shelters and family crisis centers do not act to break up families. Rather, they work to save lives and often provide counseling services to the batterer as well as the victim, or have information to direct them to sources of assistance. If she is unable to find the family crisis center, call the police, sheriff, district attorney, public library, or Salvation Army. The Salvation Army has kind and caring people who will help without regard to color, religion or ethnic background. They will put her in touch with people who offer exactly the assistance needed. She must not stop until help is obtained. Her very life depends on it.

Groundbreaking legislation to combat the global crisis of violence against women and girls was introduced in the United States Senate on October 31, 2007 by Senators and Richard Lugar (R-IN) and Joseph Biden (D-DE). The International Violence Against Women Act (IVAWA) would, for the first time, systematically integrate efforts to end gender-based violence into foreign assistance programs, applying the force of U.S. diplomacy and foreign aid totaling $1 billion over five years to prevent the abuse and exploitation that affects up to one in three women worldwide. The International Violence Against Women Act marshals together, for the first time, coordinated American resources and leadership to address this global issue. Empowered and educated women are the key to breaking these cycles.

It aims to prevent domestic and sexual violence, including “honor” killings, bride burnings, genital cutting, mass rapes in war, and more. I-VAWA would integrate training to change attitudes that condone violence against women and girls into humanitarian assistance programs, and train lawyers and police to deal with domestic violence cases. It also bolsters women’s organizations overseas that are already working to end violence against women in their countries. The legislation would decrease potential sexual exploitation and abuse by U.S. humanitarian workers, military personnel, military contractors and police involved in peacekeeping operations by creating training programs to prevent such abuse and a complaints mechanism for reporting problems.

“Every day around the world, women and girls suffer brutal domestic violence, rape, honor killings, bride burnings, violence as a weapon of war, and other atrocities,” said Family Violence Prevention Fund President Esta Soler. “Violence against women is a devastating problem, from Africa and the Middle East, to South and Central America, to right here in the United States. I-VAWA is critically important legislation that can help stop the violence women and girls experience each day.”

Dating violence is defined as the physical, sexual, or psychological/emotional violence within a dating relationship. Each year, 1 in 11 adolescents reports being a victim of physical dating violence, according to the CDC. Many of these cases can be prevented by helping adolescents develop skills for healthy relationships with others.

Adolescents and adults are often unaware how regularly dating violence occurs.

• 1 in 11 adolescents reports being a victim of physical dating violence.
• 1 in 4 adolescents reports verbal, physical, emotional, or sexual violence each year.
• 1 in 5 adolescents reports being a victim of emotional violence.
• 1 in 5 high school girls has been physically or sexually abused by a dating partner.
• Dating violence occurs more frequently among black students (13.9%) than among Hispanic (9.3%) or white (7.0%) students (CDC 2006).

Adolescents and adults often don’t make the link between dating violence and poor health.

• 70% of girls and 52% of boys who are abused report an injury from a violent relationship.
• 8% of boys and 9% of girls have been to an emergency room for an injury received from a dating partner.
• Victims of dating violence are not only at increased risk for injury, they are also more likely to engage in binge drinking, suicide attempts, physical fights, and currently sexual activity (CDC 2006).
• Rates of drug, alcohol, and tobacco use are more than twice as high in girls who report physical or sexual dating violence than in girls who report no violence.
• Dating violence is associated with unhealthy sexual behaviors that can lead to unintended pregnancy, sexually-transmitted diseases, and HIV infections.
• Abusive dating experiences during adolescence may disrupt normal development of self-esteem and body image.
• Adolescents in abusive relationships often carry these unhealthy patterns of violence into future relationships.

Dating violence can be prevented. Adolescence has been characterized as a “window of opportunity” - a time for adolescents to prepare for future relationships by learning healthy relationship skills such as negation, compromise, and conflict resolution. That’s why adults need to talk to adolescents now about the importance of choosing respect and developing healthy relationships.

• Several studies suggest that adolescents do not see the negative consequences of dating violence and violence in their friends’ lives.
• 31% of adolescents report having at least one friend who is in a violent relationship
• Acceptance of dating violence among friends is one of the strongest links to future involvement in dating violence.
• Adolescents often believe that unhealthy relationships are the norm. Many relationships seen on TV, in the movies, and in magazines are unrealistic or unhealthy examples of relationships.
• Qualities like respect, good communication and honesty are absolute requirements for a healthy relationship. Adolescents that do not have this part down before they begin to date may have trouble forming healthy, nonviolent relationships with others.

Choose Respect is a nationwide effort to prevent dating violence before it starts. It encourages adolescents to form healthy relationships with others - before they even start to date.

For the past eight years Sally has been a hardworking, reliable employee. She is pleasant with patients and coworkers and rarely makes a mistake. Recently, Sally is distracted, jumpy and has been making careless errors. Last Friday she called in sick for the fifth time in three weeks. When asked about these performance issues, Sally nervously discloses that there are problems at home but swears that they won’t affect work again. As she fights back tears, it’s obvious that she is both uncomfortable discussing the issue and also fearful that she’ll lose her job. As you look at her, you find yourself wondering if her heavier than usual makeup is covering a bruise on her cheek?

Later, when you see her anxiously looking at a person sitting in a parked car across the street, you realize that these ‘problems at home’ have just entered your workplace. What now? You’re worried about this dedicated employee, but you’ve got patients and a shift to supervise.

Domestic violence occurs more often than any other crime in the US, affecting almost one in three adult women of all ages, races, education levels and socioeconomic groups. While men or women may be victims, 90-95% of domestic violence victims are female (US Bureau of Justice Statistics).

Domestic violence is an abuse of power and control that may include: physical abuse, emotional abuse, intimidation, threats, financial control, social isolation, or sexual abuse.

While victims and their children bear the heaviest personal costs, the effects of intimate partner violence are seen throughout our community.

Take a deep breath, and think long and hard about these things:

• In our workplaces, lost productivity and earnings due to intimate partner violence account for almost $1.8 billion each year. Children exposed to violence in the home, may have difficulty in school, in their social relationships and with physical or emotional health.
• Battered women account for 22-35% of women seeking care for any reason from emergency departments. Health care costs attributed to intimate partner violence exceed $4.1 billion each year for direct medical and mental health services, much of which is paid for by employer health plans.
• Domestic violence seriously impacts homelessness and poverty rates; 50% of all homeless women and children are on the streets because of violence in the home.
• The most appalling cost of domestic violence is that so many members of our community live each day in fear and desperation - fear that they will be intimidated, threatened or attacked within their own home by a person who claims to love them.

In summary, according to the National Coalition Against Domestic Violence, battering is a pattern of behavior used to establish power and control over another person with whom an intimate relationship is or has been shared through fear and intimidation, often including the threat or use of violence. Battering happens when one person believes that they are entitled to control another. Domestic violence may include not only the intimate partner relationships of spousal, live-in partners, and dating relationships, but also familial, elder, and child abuse may be present in a violent home.

Abuse generally falls into one or more of the following categories: physical battering, sexual assault, and emotional or psychological abuse, and generally escalates over a period of time. In all cultures, batterers are most commonly male, but men may also be victims of domestic violence as perpetrated by their female partners. Children witnessing domestic violence and living in an environment where violence occurs may experience some of the same trauma as abused children.

Rural and urban women of all religious, ethnic, socio-economic, and educational backgrounds, and of varying ages, physical abilities, and lifestyles can be affected by domestic violence. There is not a typical woman who will be battered - the risk factor is being born female.

Older battered women are a nearly invisible, yet a tragically sizable population, and they are uniquely vulnerable to domestic violence. Older women are more likely to be bound by traditional and cultural ideology that prevents them from leaving an abusive spouse or from seeing themselves as a victim. Older women are very often financially dependent on their abusive spouse and do not have access to the financial resources they need to leave an abusive relationship.

Many older women find themselves isolated from their family, friends, and community, due to their spouses’ neglect and abuse. This is especially true because older women suffer greater rates of chronic illness, which makes them dependent upon their spouses or caregivers and thus, reluctant or unable to report abuse.

Rural battered women face lack of resources, isolation, small town politics, few if any support agencies, and poor or little transportation and communication systems in addition to the other complications of intimate partner violence that is intensified by the rural lifestyle. The act of leaving the home, place, land, and animals that could depend on her may be emotionally wrenching leaving the battered rural woman surrounded by walls of guilt and self-abasement.

The statistics are shocking and none of us are immune to domestic violence. However, there is help and many resources to

- Domestic Violence is Not just a Private Issue - It Impacts All of Us. -