33 Intimate Partner and Sexual Violence

Maryann B. Wilbur

Abigail E. Dennis

INTIMATE PARTNER VIOLENCE AND RELATED BEHAVIORS

Definitions

• Intimate partner violence (IPV): a pattern of assaultive and/or coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, intimidation, and reproductive coercion

• Domestic violence (DV): an older and very similar term referring to assaultive and/or coercive behavior within a shared household; IPV and DV strongly overlap

• Population-specific violence: includes different forms of population-specific violence affecting particularly vulnerable patients, such as child abuse, adolescent abuse, elder abuse, and patterns of behavior affecting vulnerable or marginalized populations

Background

• Affects individuals of all ages, races, and educational and economic backgrounds

• Occurs in both heterosexual and homosexual relationships; however, the most common presentation is a heterosexual relationship with a female victim

• Can be thought of as part of a larger disempowerment syndrome and is seen more often in women affected by low socioeconomic status, sexually transmitted infections, and unintended pregnancy

• Long-standing abusive relationships tend to develop a cycle in which a violent episode is followed by a period of reconciliation and apology.

• Escape from the relationship may be difficult because of fear, shame, powerlessness, and social isolation. Over time, the degree of violence may escalate.

P.440

Statistics

• The majority (85%) of individuals affected by IPV are women.

• In primary care practices, nearly 25% of women endorse current or previous IPV.

• Approximately 25% of women in the United States will be abused by a current or former partner sometime during their lifetime.

• IPV is the single most common cause of injury to women in the United States; more than 30% of all women's emergency room visits can be attributed to IPV.

• Fifty-four percent of IPV is reported to police; only 24% of sexual assaults are reported.

• One third of female homicides in the United States are IPV-related.

• Women are more likely to be injured, raped, or killed by a current or former male partner than by all other types of assailants combined.

Intimate Partner Violence and Pregnancy

• According to the Centers for Disease Control and Prevention (CDC), 4% to 8% of pregnant women report abuse during pregnancy.

• One in six abused women reports her partner was first abusive in pregnancy.

• Abuse often escalates during the course of the pregnancy and postpartum.

• IPV can result in poor pregnancy outcomes, such as miscarriage, preterm labor, low birth weight, and fetal injury or death.

• Women with an unintended pregnancy have a threefold higher risk of abuse than those women whose pregnancy was planned.

• Pregnant women have a threefold higher risk of being victims of attempted or completed homicide, and IPV- related homicide is the number one cause of death in pregnancy.

Reproductive Coercion

• Defined as “explicit male behavior to promote pregnancy unwanted by the woman and can include ‘birth control sabotage' and/or ‘pregnancy coercion,' such as telling a woman not to use contraception and threatening to leave her if she doesn't get pregnant.”

• More broadly, clinicians will encounter a spectrum of coercive behaviors that aim to influence women's reproductive choices.

• Strongly correlated with the following demographics:

• Ethnic and/or racial minority

• Low educational achievement

• Lack of employment

• Low socioeconomic status

• History of sexually transmitted infection (STI)

• History of unwanted pregnancy

• Increasing age difference between the individual and her partner

• Current unwanted pregnancy

• Reproductive coercion represents another form of controlling behavior within a relationship displaying power differentials.

Evaluation and Management

Screening

• Regular screening for IPV is the most important thing clinicians can do and routine surveillance has been recommended by the U.S. Department of Health and Human

Services, the Institute of Medicine, and the American College of Obstetricians and Gynecologists (ACOG).

• Routine IPV screening significantly increases detection. In a study of trauma victims, the institution of a screening protocol increased detection from 5.6% to 30%.

• The opinion published by ACOG supports specifically asking women about their abuse history and recommends screening at the following patient encounters:

• New patient visits

• Annual visits

• Problem visits where unintended pregnancy or STI is diagnosed

• First prenatal visit

• Once during each trimester in pregnancy

• Postpartum visit

• Guidelines for screening

• Setting is very important. A patient must feel that she is in a safe and comfortable environment. Ideally, screening should be done without a partner, children, or other relatives present. Be aware that the aggressor often accompanies the woman to the appointment and wants to remain in the room to monitor what is said.

• Ensure patient confidentiality.

• Begin with an objective statement that demonstrates that your screening is universal and necessary to provide comprehensive health care. This type of introduction increases the detection rate and helps the patient feel that she has not been singled out.

• Never ask what the patient did wrong or why she remains with her partner. Avoid judgment or value-laden terms, such as “abused” and “battered.”

• Choose quick screening questions that feel comfortable and make screening routine. Several useful questionnaires have been developed to address abuse:

ξ Family Violence Prevention Fund questions (Table 33-1)

ξ The Structured Analysis Family Evaluation questions (Table 33-2)

ξ The three-question Abuse Assessment Screen (Table 33-3)

• Be patient.

• Leave the conversation open and make sure patients are aware that they can discuss any issues at future visits. This supportive environment where information is available regarding options or resources could prompt patients to seek help in the future.

Diagnosing Intimate Partner Violence

• Women affected by IPV will often have numerous office or emergency room visits for injury. There may be an inconsistent explanation for the injuries or a delay in seeking treatment. The injuries classically involve multiple sites, such as three or more body parts; affect the head, back, breast, and abdomen (whereas accidental injuries are more likely to be peripheral); and are in various stages of healing.

Patients who are abused tend to report somatic complaints, such as fatigue, headache, and abdominal pain. They are also more likely to suffer from eating disorders, gastrointestinal complaints, psychiatric disorders, and substance abuse.

P.442

TABLE 33-1 Screening Questions from the Family Violence Prevention Fund

Sample Intimate Partner Violence Screening Questions

While providing privacy, screen for intimate partner violence during new patient visits, annual examinations, initial prenatal visits, each trimester of pregnancy, and the postpartum checkup.

Framing Statement

“We've started talking to all of our patients about safe and healthy relationships because it can have such a large impact on your health."^a

Confidentiality

“Before we get started, I want you to know that everything here is confidential, meaning that I won't talk to anyone else about what is said unless you tell me that... (insert the laws in your state about what is necessary to disclose)."^a

Sample Questions

“Has your current partner ever threatened you or made you feel afraid?” (Threatened to hurt you or your children if you did or did not do something, controlled who you talked to or where you went, or gone into rages)^b

“Has your partner ever hit, choked, or physically hurt you?” (“Hurt” includes being hit, slapped, kicked, bitten, pushed, or shoved.)^b

For women of reproductive age:

“Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?”^a

“Does your partner support your decision about when or if you want to become pregnant?”^a

“Has your partner ever tampered with your birth control or tried to get you pregnant when you didn't want to be?”^a

For women with disabilities:

“Has your partner prevented you from using a wheelchair, cane, respirator, or other assistive device?”^c

“Has your partner refused to help you with an important personal need such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink or threatened not to help you with these personal needs?”^{c a}Modified and reprinted from Family Violence Prevention Fund.

^bModified and reprinted from Family Violence Prevention Fund. National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. San Francisco, CA: Family Violence Prevention Fund, 2004.

http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf. Accessed October 12, 2011, with permission.

^cModified and reprinted from Center for Research on Women with Disabilities. Development of the abuse assessment screen-disability (AAS-D). In Violence against Women with Physical Disabilities: Final Report Submitted to the Centers for Disease Control and Prevention. Houston, TX: Baylor College of Medicine, 2002:II-1-II-16. http://www.bcm.edu/crowd/index.cfm?pmid=2137. Accessed October 18, 2011, with permission.

P.443

TABLE 33-2 Structured Analysis Family Evaluation Questionnaire

ξ Stress/safety: Do you feel safe in your relationship?

ξ Afraid/abused: Have you ever been in a relationship in which you were threatened, hurt, or afraid? ξ Friends/family: Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?

ξ Emergency plan: Do you have a safe place to go and the resources you need in an emergency?

Based on Neufeld B. SAFE questions: overcoming barriers to the detection of domestic violence. Am Fam Physician 1996;53:2575-2582.

• Gynecologic and obstetric clues to the presence of abuse include increased prevalence of sexually transmitted disease, chronic pelvic pain, premenstrual syndrome, unintended pregnancy, and late prenatal care (Table 33-4).

Assessment of Risk

• In the case that the patient reveals that she has been affected by IPV, the clinician should attempt to elicit the degree of risk to the patient.

• How were you hurt?

• Has this happened before?

• When did it first happen?

• How badly have you been hurt in the past?

• Have you ever needed to go to the emergency room for treatment?

• Have you ever been threatened with a weapon, or has a weapon ever been used on you?

• Have you ever tried to get a restraining order against a partner?

• Have your children ever seen or heard you being threatened or hurt?

• Do you know how you can get help for yourself if you are hurt or afraid?

• Is the violence getting worse?

• Are there threats of suicide or homicide?

• Is there a weapon in the home?

TABLE 33-3 Abuse Assessment Screen

• Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?

• Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?

• Within the last year, has anyone forced you to have sexual activities?

Based on McFarlane J, Parker B, Soeken K, et al. Assessing for abuse during pregnancy. JAMA 1992;267:3176-3178.

P.444

TABLE 33-4 Gynecologic and Obstetric Clues to Presence of Abuse

Chronic pelvic pain

Severe premenstrual syndrome

Multiple or recurrent sexually transmitted infections or recurrent vaginitis

Medical noncompliance

Sexual dysfunction

Abdominal pain

Unintended pregnancy

Late registration for prenatal care, no prenatal care

Noncompliance and missed appointment

Fetal or maternal injury (violence is often directed toward the woman's abdomen during pregnancy)

Spontaneous abortion or stillbirth

Vaginal bleeding in the second or third trimester

Preterm labor

Infection

Anemia

Poor weight gain

Low-birth-weight infants

Interventions

• Most victims of abuse are not ready to leave their abusers. They may rely on their abuser for financial support and shelter or may have a fear of repercussions.

• Empowerment of the patient is the first step. Provide support and do not attempt to make decisions for the patient.

• Use resources such as social workers and violence prevention programs. Provide the patient with phone numbers of resource agencies and offer to let the patient establish first contact while she is still in your office.

• Discuss the gravity of the situation and assess immediate safety needs.

• Reinforce that the patient is not to blame. Emphasize that she did nothing to justify this behavior.

• Treat the patient's injuries and screen for suicidal tendencies, depression, and substance abuse.

• When applicable, discuss court restraining orders and laws against stalking with the help of legal and social work resources.

• Review an exit plan or exit drill (Table 33-5). Do not force a woman to leave before she is ready; leaving is associated with increased physical aggression and resources need to be in place to minimize risk to the woman and her children during this critically vulnerable transition.

• Abusive partners often monitor cell phone usage; therefore, offering a separate cell phone specifically to assess safety has been suggested to facilitate a woman leaving an unsafe situation.

• Provide ongoing support, and offer referrals for counseling.

• Provide documentation, including direct quotations and photographs.

TABLE 33-5 Exit Plan for Domestic Violence Intervention

The following exit plan has been proposed for a woman who feels that she or her children are in danger from her partner:

1. Have a change of clothes packed for herself and her children, including toiletries, necessary medications, and an extra set of house and car keys. These can be placed in a suitcase and stored with a friend or neighbor.

2. Cash, a checkbook, and savings account information may also be kept with a friend or neighbor.

3. Have available identification papers, such as birth certificates, social security cards, voter registration card, utility bills, and a driver's license because children will need to be enrolled in school and financial assistance may be sought. If available, also take financial records, such as mortgage papers, rent receipts, or an automobile title.

4. Take something of special interest to each child, such as a book or toy.

5. Have a plan of exactly where to go, regardless of the time of day or night. This may be a friend or relative's home or a shelter for women and children.

6. Have a separate phone available to make emergency phone calls.

Modified from Helton A. Battering during pregnancy. Am J Nurs 1986;86:910-913.

• Report abuse in indicated situations. If the patient is a minor, an elder, or disabled, clinicians are mandated to report abuse. Most states do not require mandatory reporting of IPV in adults who do not meet these criteria.

Special Populations

Elder Abuse

• A form of abuse, neglect, and/or violence, typically at the hands of adult family members or caregivers, affecting as many as 2 million Americans.

• Providers should apply the same criteria in assessing older individuals as they would in assessing a younger woman for DV.

• Elder abuse must be reported to the state elder abuse hotline.

Disabled Women

• Girls or women with physical, cognitive, or emotional disabilities are all at particular risk of IPV and sexual abuse and should be screened at each visit.

• Abuse of disabled persons must be reported to the Disabled Persons Protection Commission.

Women with Undocumented Immigrant Status

• Women with undocumented immigrant status are also particularly vulnerable and may find themselves in a situation where they are being threatened with deportation as a means of coercion. Such a woman should be reassured that this behavior is illegal under United States law. If it can be justified on humanitarian

P.446 grounds, a nonimmigrant visa will allow her to remain in the United States and she should be given resources for contacting a community attorney familiar with this process.

Sex Workers

• Women who trade sex for money and/or drugs are significantly more likely to become victims of coercive behavior and sexual abuse. Clinicians must remain cognizant of the vulnerability of this population and should screen at every encounter. Patients in this category should also be assured that illegal activity on their part should not prevent them from reporting violence to the authorities.

SEXUAL VIOLENCE

Definitions

• Sexual violence: all forms of sexual activity where consent is not given (e.g., assault, sexual harassment, threats, sex trafficking, female circumcision)

• Sexual assault: any sexual act performed on one person by another without consent

• Rape: a legal (not medical) term and should be used minimally, if at all, in medical records

Background

• Sexual assault is the fastest growing violent crime in America.

• Nine in 10 sexual assault victims are women.

• One in 6 women will be sexually assaulted in her lifetime.

• Seventy-three percent of sexual assault victims know their offender.

• Approximately 1 in 6 sexual assaults is reported to the police. Approximately 6% of the accused spend a day in jail.

Evaluation and Management

• A comprehensive workup should be done in a manner that is sensitive to the patient's acute mental and physical state and with an awareness that the collection of forensic evidence needs to be done in a specific, time-sensitive fashion. When possible, one should use a coordinated community response plan, with referral to a medical center that can perform a sexual assault forensic exam. This may not be possible in cases of severe trauma, and life-threatening emergencies should obviously be prioritized.

• When evaluating a patient who has had a recent sexual assault, multiple issues should be addressed.

ξ Medical: injuries, STI exposure, pregnancy

ξ Emotional: crisis intervention, counseling referrals

ξ Forensics: documentation, proper collection and handling of evidence, court appearances

Coordinated Community Response Plan

• Rape crisis centers/hotlines: These centers have trained crisis counselors/advocates who provide free 24­hour counseling, referral, and victim support services.

• Sexual assault response teams (SARTs): These are multidisciplinary teams composed of law enforcement agents, medical providers, sexual assault advocates, social workers, etc. who work together to streamline care/minimize trauma to victims and to optimize collection of evidence.

P.447

• Sexual assault forensic examiner (SAFE) or sexual assault nurse examiner (SANE): These professionals have been specially trained to care for sexual assault victims.

• They are specifically trained in forensic evaluation/precise collection of evidence, minimizing barriers to support in the legal system and providing prompt and compassionate care to patients. All efforts should be made to use these professionals and when possible, physical exams should be deferred until a forensic examiner is present so as not to interfere with evidence collection.

Sexual Assault Evidence Collection Kit

• Walks a provider through the steps of obtaining informed consent and then performing a targeted history and physical exam with emphasis on appropriate collection of forensic evidence

• The Federal Violence Against Women Act (passed in 2005, in effect since 2009) allows for victims of sexual assault to obtain a forensic exam free of charge even if they have chosen not to report the assault to law enforcement (i.e., “Jane Doe rape kits”).

Patient History

• A chaperone of the same gender as the patient should be present at all times for the history and examination.

• Take a targeted sexual and gynecologic history, including last menstrual period (LMP), contraceptive use, and last consensual intercourse. Information about past sexual history may damage a victim's credibility in court.

• Ask about injuries; this will help tailor the examination.

• Ask specifically about the nature of the violation. Elicit specifics regarding oral, vaginal, or rectal penetration as well as condom use.

• Ask what the patient has done since the event (e.g., showering, bathing, douching, voiding, defecating, changing clothes).

• Do not impose interpretation on the description—document the patient's exact description of the event. Avoid inflammatory language. Be objective and avoid passing judgment.

Physical Examination

• If possible, this exam should be performed by a trained examiner (e.g., SANE or SAFE).

• Obtain informed consent to proceed with the examination. This should be done for legal purposes and may help the victim regain autonomy.

• Perform the exam with a chaperone of the same gender as the patient.

• The patient should undress with a sheet beneath her to capture any debris or evidence. Collect appropriate clothing from the patient and give it to the proper personnel.

• Perform a full skin examination and evaluate all orifices for evidence of laceration, bruising, bite marks, or use of foreign objects. A Wood lamp and colposcope can be used to identify semen and subtle signs of trauma. Toluidine blue will stain underlying tissue if skin is broken. Perform an overall general examination for any other injuries, such as abdominal trauma or broken bones.

• Document the patient's emotional state. Be thorough and systematic, and record all evidence of injury; use drawings and photographs as needed.

Laboratory Testing

• Radiographic imaging, if necessary, should be obtained.

• Gonorrhea and chlamydia tests from any sites of contact

• Wet prep to look for Trichomonas

P.448

• Pregnancy test

• Baseline HIV counseling and testing

• Baseline specimens for hepatitis B and C and syphilis

• Drug screening for the “date rape drugs” flunitrazepam (Rohypnol) and gammahydroxy butyrate (GHB) if indicated

Treatment

• T reat traumatic injuries as indicated.

• T reat presumptively for STIs. Recommendations, per CDC guidelines, are as follows:

• Gonorrhea: ceftriaxone 250 mg intramuscularly

• Chlamydia: azithromycin, 1 g orally, or doxycycline, 100 mg twice daily for 1 week

• Gonorrhea and chlamydia (pregnancy/allergy): erythromycin 1.5 g orally then 500 mg 4?Zday for 1 week

• T richomoniasis: metronidazole, 2 g orally (consider an antiemetic for side effects)

• Provide hepatitis B vaccine if the victim has not received it already.

• In high-risk populations, consider the following additional prophylaxis:

• Herpes: acyclovir 3 g orally

• Syphilis: penicillin G 2.4 million units

• Offer antiretroviral therapy against HIV if Contact hospital and clinic social workers to facilitate this process.

• Follow-up in 1 to 2 weeks for psychosocial evaluation

Sexual Abuse in Children

Background

• Contact or interaction between a child and an adult in which the child is being used for sexual stimulation of that adult or another person. Abuse may also be committed by another minor either when that person is significantly older than the victim or when the abuser is in a position of power or control over the child. Sexual abuse also encompasses nonsexual contact, such as pornography or exhibitionism.

P.449

• The majority of childhood sexual abuse occurs between ages 6 and 14 years and especially between ages 12 and 14 years. The perpetrator is usually a relative or an acquaintance.

Evaluation and Management

• Children suspected of being victims of abuse or assault should be evaluated by professionals trained in conducting interviews, documenting questions and responses, and collecting forensic evidence. Centers designed for a multidisciplinary approach are ideal for these evaluations. The process is the same as outlined earlier, with the following considerations:

• History: Take time to establish rapport with the child. Information should be recorded in the child's own words; for young children with limited verbal skills, techniques such as play interviews or drawings have been used to promote communication. Note the child's composure, behavior, and mental state, as well as interactions with parents and other people. Ask about recent changes in sleep (night terrors) and behaviors.

• Examination: The examination should be complete, extending from head to toe, allowing the child to become accustomed to the touch of the evaluator and establishing trust. Physical or laboratory findings of trauma are rare. Some signs, however, can be used as diagnostic clues for childhood sexual abuse, especially if the abuse is recent or repetitive. Sexual abuse should be considered in any child with trauma or lacerations involving the posterior hymen or in cases of a vaginal foreign body. Have a low threshold for performing an exam under anesthesia.

• Mandatory reporting: All suspected victims of child abuse should be referred to child protective services (CPS). Until the question of protection can be assured, providing temporary placement for the child is advisable.

• Psychosocial support: A trained therapist should be available to assist both victim and family with the evaluation process, medical treatment, and encounters with CPS and law enforcement agencies.

Sexual Abuse in Adolescents

• More than 75% of assaults are committed by an acquaintance of the victim. These include date rape, statutory rape, and incest.

• Teenagers are still learning to establish social boundaries, and they bring various expectations to dating situations. Some adolescents believe that violence is acceptable in some social situations. Furthermore, adolescents may use alcohol and illicit drugs, which alter judgment. A history of nonvoluntary sexual activity has been associated with early initiation of voluntary sexual activity, unintended pregnancy, and poor use of contraceptives.

• As part of routine screening, all teenagers should be asked direct questions regarding their sexual experiences and any incidence of coercion. This is an opportunity to identify adolescent victims and initiate discussion of contraception and STIs. The following sensitive screening question has been suggested by adolescent specialists: “Have you ever had sex when you didn't want to?”

• Providers can offer education, counseling referrals, community resource information, and prevention messages. Some teenage empowerment messages include the following:

• You have the right to say no to sexual activity.

• You have the right to set sexual limits and insist that your partner honor them.

• Be assertive. Stay sober. Recognize and avoid situations that may put you at risk.

P.450

• Never leave a party with someone you don’t know well.

• No one should ever be forced or pressured into engaging in any unwanted sexual behavior.

Human T rafficking

• Definition: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

• Estimates are difficult, but approximately 15,000 individuals are trafficked into the United States annually; 80% of these individuals are female.

• The following are examples of indicators that a patient is the victim of human trafficking:

• Lack of any official identification papers or cards

• Vague answers about their situation

• Inconsistencies to their stories

• Avoiding eye contact

• No control of their money

• Patient and clinician resources are available at the National Human Trafficking Resource Center (NHTRC) hotline: 1-888-373-7888.

Female Genital Mutilation

• Female genital mutilation (FGM), female genital cutting (FGC), and female circumcision are terms that are often used interchangeably to describe the alteration of female genitalia for nontherapeutic reasons, usually without analgesia or aseptic technique.

• It represents a form of violence against girls and women.

• FGM is usually grouped into types I, II, III, and IV.

• Sequelae of FGM include hemorrhage, infection, menstrual abnormalities, fistulae, sexual dysfunction, and depression/anxiety.

• FGM is not an indication for a cesarean delivery.

• FGM is a cultural not a religious practice.

SUGGESTED READINGS

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 507: human trafficking. Obstet Gynecol 2011;118(3):767-770.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 518: intimate partner violence. Obstet Gynecol 2012;119(2, pt 1):412-417.

American College of Obstetricians and Gynecologists. Female Circumcision/Female Genital Mutilation: Clinical Management of Circumcised Women. Washington DC: American College of Obstetricians and Gynecologists, 1999.

Eisenstat SA, Bancroft L. Domestic violence. JAMA 1999;341(12):886-892.

Kilpatrick DG, Edmonds CN, Seymour A. Rape in America: A Report to the Nation. Arlington, VA: National Victim Center and Medical University of South Carolina, 1992.

Miller E, Decker MR, McCauley HL, et al. Pregnancy coercion, intimate partner violence and intended pregnancy. Contraception 2010;81:316-322.

Rickert VI, Wiemann CM, Harrykissoon SD, et al. The relationship among demographics, reproductive characteristics, and intimate partner violence. Am J Obstet Gynecol 2002; 187(4):1002-1007.

Roberts TA, Auinger P, Klein JD. Intimate partner abuse and the reproductive health of sexually active female adolescents. J Adol Health 2005;36:380-385.

P.451

World Health Organization. Eliminating Female Genital Mutilation: An Interagency Statement. Geneva, Switzerland: World Health Organization, 2008.

Zeitler MS, Paine AD, Breitbart V, et al. Attitudes about intimate partner violence screening among an ethnically diverse sample of young women. J Adolesc Health 2004;39(1):119.e1-119.e8.

WEBSITES

• National Domestic Violence hotline 1-800-799-SAFE (7233)

• The National Domestic Violence: www.ndvh.org

• Rape, Abuse & Incest National Network (RAINN) hotline 1-800-656-HOPE (4673)

• The National Coalition Against Domestic Violence: www.ncadv.org

• The U.S. Department of Justice: www.usdoj.gov,www.ndvh.org

• National Human Trafficking Resources Center (NHTRC) hotline: 1-888-373-7888

• Futures Without Violence (previously known as Family Violence Prevention Fund): www.futureswithoutviolence.org

• National Coalition Against Domestic Violence: www.ncadv.org

• National Network to End Domestic Violence: www.nnedv.org

• National Resource Center on Domestic Violence: www.nrcdv.org

• Office on Violence Against Women (U.S. Department of Justice): www.usdoj.gov/ovw