What is Futures Without Violence?
For more than 30 years, FUTURES has been providing groundbreaking programs, policies, and campaigns that empower individuals and organizations working to end violence against women and children around the world. Striving to reach new audiences and transform social norms, we train professionals such as doctors, nurses, judges, and athletic coaches on improving responses to violence and abuse. We also work with advocates, policy makers, and others to build sustainable community leadership and educate people everywhere about the importance of respect and healthy relationships. Our vision is a future without violence that provides education, safety, justice, and hope.
Learn more here: www.futureswithoutviolence.org
What is the National Health Resource Center on Domestic Violence?
For more than two decades, the National Health Resource Center on Domestic Violence (a project of FUTURES) has supported health care professionals, domestic violence experts, survivors, and policy makers at all levels as they improve health care’s response to domestic violence. The center offers personalized, expert technical assistance via email, fax, phone, postal mail and face-to-face at professional conferences and meetings around the nation. Contact us at firstname.lastname@example.org or call 415-678-5500.
What is domestic violence?
Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It includes physical violence, sexual violence, psychological violence, and emotional abuse. The frequency and severity of domestic violence can vary dramatically; however, the one constant component of domestic violence is one partner’s consistent efforts to maintain power and control over the other.
Learn more about the dynamics, signs, and prevalence of domestic violence here: http://www.ncadv.org/learn-more/what-is-domestic-violence
What is sexual violence (also referred to as sexual assault)?
Sexual violence is defined by the Center for Disease Control as: A sexual act committed against someone without that person’s freely given consent. Sexual violence is divided into the following types:
-Completed or attempted forced penetration of a victim
-Completed or attempted alcohol/drug-facilitated penetration of a victim
-Completed or attempted forced acts in which a victim is made to penetrate a perpetrator or someone else
-Completed or attempted alcohol/drug-facilitated acts in which a victim is made to penetrate a perpetrator or someone else
-Non-physically forced penetration which occurs after a person is pressured verbally or through intimidation or misuse of authority to consent or acquiesce
-Unwanted sexual contact
-Non-contact unwanted sexual experiences
What is intimate partner violence (IPV)?
The U.S. Centers for Disease Control and Prevention defines IPV as physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner.
What is trauma?
Trauma is a normal reaction to an abnormal situation. “Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”
Read more here: http://www.integration.samhsa.gov/clinical-practice/trauma
What is trauma-informed care?
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines a trauma-informed approach to care as:
“A program, organization, or system that:
- Realizes the widespread impact of trauma and understands potential paths for recovery;
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
- Seeks to actively resist re-traumatization.
A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing.”
Learn more here: https://www.samhsa.gov/nctic/trauma-interventions
What is vicarious trauma?
Vicarious trauma happens when we accumulate and carry the stories of trauma—including images, sounds, resonant details—we have heard, which then come to inform our worldview.
Learn more here: http://www.joyfulheartfoundation.org/learn/vicarious-trauma
What is universal education?
Universal education is the clinical strategy used to educate all patients on healthy and unhealthy relationships, and the health consequences of IPV. This approach differs from screening in that it advocates for all patients to be given information on the health impact of IPV, regardless of whether or not they disclose current or past experiences of violence, thus reaching more patients who may choose not to disclose for a variety of reasons, while also promoting prevention. Universal education should also be coupled with direct inquiry and an offer for a warm referral and available resources for IPV.
Read more about our evidence-based clinical intervention.
See our CUES intervention graphic as a visual reminder of the steps of the intervention, which can be posted in your staff break room.
What is a warm referral?
A warm referral, as referred to in the CUES intervention, is a supported referral to DV/SA advocacy services from a health provider, in which the provider is able to offer a patient access to an onsite DV/SA advocate; offer use of the clinic’s phone to call a local resource; or offer the name and phone number so they can reach out independently, etc. Complement a warm referral with a brochure or safety card from a local DV/SA agency, if it is safe for the patient to take home. Ideally, the provider has an established relationship with the DV/SA advocacy program and is familiar with the staff and services available, thus increasing the likelihood of the patient following through with the connection.
How often should I screen and offer universal education on IPV?
It’s important to talk to all patients at least once a year or with each new partner about healthy relationships, ones that aren’t, and how it affects their health. Ensure that screening questions are accompanied with a discussion about the health impact of IPV and available resources. Because of the higher prevalence of abuse during pregnancy, check in with pregnant women about how their relationship is going at least once a trimester and postnatal.
Should I screen and offer universal education to just women or to all patients?
Everyone deserves to have respectful and caring relationships and anyone can be a victim of intimate partner and sexual violence. LGBTQ people experience IPV at rates similar to or higher than heterosexual women–another reason to talk to all patients about the health impact of IPV and available resources. All patients can benefit from universal education about the health impact of healthy and unhealthy relationships. Because the majority of IPV survivors are women, most health centers begin by offering universal education and screening to just women later expanding to all patients once the practice has been solidified.
What screening tool is best to use in our EHR?
We support a universal education approach–talking to all patients about the health impact of IPV, in addition to asking direct questions about current and past experiences of IPV. Universal education also provides patients with resources of where to get help if they need it, and offering brief counseling and a warm referral to a DV/SA advocate in the event of a disclosure. Universal education can be combined with screening tools that are integrated into the electronic health records (EHRs). The US Preventive Services Taskforce also recommends a number of screening tools, including Hurt, Insult, Threaten, Scream (HITS) (English and Spanish versions); Slapped, Threatened, and Throw (STaT); and Humiliation, Afraid, Rape, Kick (HARK).
What is a safety card?
The Health Resource Center on Domestic Violence, a project of Futures Without Violence offers a number of multilingual, low-literacy patient education safety cards that provide information on healthy and unhealthy relationships, their impact on health and list national referrals for support. The evidence-based safety card tool was developed to help clinicians and DV/SA advocates open conversations about DV/SA and healthy relationships with their clients. They are typically a 4-5 panel double-sided tool that folds into a 2.5 x 3 inch card (business-card sized). The Health Resource Center on Domestic Violence offers a number of setting-specific and population-specific safety cards.
How can I protect survivor privacy and still promote improved health?
Federal legislation and state and local statutes are crucial to establishing a comprehensive baseline of regulations and protections for the use and disclosure of sensitive electronic information. Health information technology (HIT) developers and vendors also have a role in building the software and hardware necessary to deal with the information in an appropriate fashion.
Below are guiding principles that should be applied by clinicians, administrators, policy makers and developers when designing, building or regulating health information systems that will hold or exchange sensitive health information. These principles build on past work to protect information collected in paper health records, and expand the consideration to electronic health records and health information exchanges.
What are the health care reporting requirements for IPV in my state, tribe, or U.S. territory?
Domestic Violence and Sexual Assault (DV/SA) programs: What are they and where can I find one?
Many DV/SA partners are equipped to provide supportive services such as translation, transportation, and legal support which mirror the enabling services offered by health centers. DV/SA programs exist in many communities in which health centers are located and DV/SA advocates can offer a range of support to survivors identified in health centers. Such confidential patient support may include information on healthy and unhealthy relationships; emotional support; emergency and long-term safety planning; and supports related to other social determinants of health including housing, food insecurity, and employment as well as court and legal advocacy. Some advocates staff crisis hotlines, run support groups or provide in-person counseling, and some agencies have programs for adolescents and children. In some instances, a community may only have one such program available to support DV/SA survivors and their families. However, other communities may operate both a domestic violence program and a distinct sexual assault program.
The National Hotline on Domestic Violence can help identify local programs and offer safety planning assistance to survivors, concerned family members, or professionals working with clients who need help. The Hotline is staffed by DV/SA advocates available to talk 24/7 at 1-800-799-SAFE (7233) in over 170 languages and online: www.thehotline.org. All calls are confidential and anonymous.
There is also a national helpline for Native American communities, the StrongHearts Native Helpline, 1-844-7NATIVE (1-844-762-8483) Monday through Friday, from 9 am to 5:30 pm CST. The StrongHearts Native Helpline is a culturally-appropriate, confidential service for Native Americans affected by domestic violence and dating violence.
Additionally, RAINN (Rape, Abuse & Incest National Network) is the nation’s largest anti-sexual violence organization. RAINN created and operates the National Sexual Assault Hotline (800.656.HOPE) and www.rainn.org (with a live chat) in partnership with more than 1,000 local sexual assault service providers across the country.
What is the Domestic Violence Resource Network (DVRN)?
The Domestic Violence Resource Network (DVRN) is funded by the U.S. Department of Health and Human Services and funds a network of organizations working to improve the country’s response to domestic violence. In addition to funding two national resource centers, National Resource Center on Domestic Violence and National Indigenous Women’s Resource Center, the DVRN also funds three culturally- specific resource centers. These include:
- Casa de Esperanza, the national resource center for working with Latin@ communities. Casa de Esperanza offers a webinar series on topics such as “Trauma Informed and Culturally Specific Practice with Latin@ Survivors” and “Safety Planning for Immigrant Survivors of Domestic and Sexual Violence.”
- Asian & Pacific Islander Institute on Gender-Based Violence, which offers training and technical assistance for survivors in Asian & Pacific Islander communities. Their resource library has culturally-specific materials available for various forms of gender-based violence that are prevalent in Asian & Pacific Islander communities.
- Ujima, the National Center on Violence Against Women in the Black Community, which offers training and technical assistance and educational resources for prevention and responding to domestic, sexual, and community violence in the Black community.
Five special issue resource centers:
- Battered Women’s Justice Project Criminal and Civil Justice Center
- National Clearinghouse for the Defense of Battered Women
- National Council of Juvenile and Family Court Judges
- National Health Resource Center on Domestic Violence
- National Center on Domestic Violence, Trauma, & Mental Health
In addition, the DVRN supports the National Domestic Violence Hotline, and the National LGBTQ Institute on Intimate Partner Violence.
Do you provide training onsite?
As a national program, we are unable to provide onsite trainings, but contact us at email@example.com to see how we can best support your training needs. The Health Resource Center on Domestic Violence offers a number of training curricula and other tools to facilitate trainings in addition to hosting a biennial annual National Conference on Health and Domestic Violence and an ongoing webinar series, where you can learn more about promising practices and research in the field.
What resources do you have for American Indian/Alaska Native (AI/AN) communities?
The National Health Resource Center on Domestic Violence offers a number of resources tailored specifically for American Indian and Alaska Native (AI/AN) communities, including safety cards, posters, and a Promising Practices Report. Learn more about our work with AI/AN communities, and order hard copies and download PDFs of our materials. See also www.niwrc.org, the National Indigenous Women’s Resource Center (NIWRC) to enhance safety of Native women and their children.
There is also a national helpline specifically for Native American survivors of domestic violence or dating violence, the StrongHearts Native Helpline, 1-844-7NATIVE (1-844-762-8483) Monday through Friday, from 9 am to 5:30 pm CST.
What resources do you have for Lesbian, Gay, Bisexual, Trans and Queer (LGBTQ) and Gender-non-conforming (GNC) communities?
The National Health Resource Center on Domestic Violence offers a number of resources tailored specifically for LGBTQ/GNC communities, including safety cards and posters. Learn more about our resources for working with LGBTQ/GNC communities, and order materials.
What languages are your materials in, and what culturally-specific resources do you offer?
The National Health Resource Center on Domestic Violence has developed materials to meet the unique needs of all individuals and families. Culturally-specific resources include patient safety cards, posters, fact sheets and reports, and some are multi-lingual. For example:
- American Indian/Alaska Native safety cards (3 versions), posters, a care giver/parent brochure, fact sheet, and promising practices report. See also the FAQ entry for resources for American Indian/Alaska Native (AI/AN) communities.
- Lesbian Gay Bisexual Transgender Queer (LGTBQ) and Gender-Nonconforming (GNC) safety cards (English and Spanish) and a poster. See also the FAQ entry for resources for LGBTQ and GNC communities.
- General health safety card in five languages commonly spoken in Hawaii (Chinese, Chuukese, Hawaiian, Marshallese, and Tagalog).
- Spanish language safety cards, posters, and brochures.
- General health safety card in Tagalog for a national audience, as well as a guide for organizing a community-based response to domestic violence, using the Filipino community as a model.
- General health safety cards in Arabic and Farsi.
- General health safety card, reproductive health safety card, adolescent health, and LGBQ safety cards in Armenian, Chinese, and Korean.
- Safety card for high school and college-aged Muslims.
See all culturally-specific tools here.
What resources do you have for rural or remote communities?
Rural and remote communities have unique needs related to distance, isolation, inclement weather, and access to services and emergency responses, among others. A 2011 study published in the Journal of Women’s Health found that 22.5% of women in small rural areas and 17.9% in isolated areas reported being victims of intimate partner violence, compared to a national average of 16.1%.* Futures Without Violence contributed to the Violence and Abuse in Rural America Guide that addresses the wide range of abuses that may take place in rural communities. FUTURES also offers an archived webinar: Collaborating to Address Trafficking in Rural Communities: Lessons from the Field, and the manual, Building the Rhythm of Change: Developing Leadership and Improving Services Within the Battered Rural Immigrant Women’s Community. View additional resources for American Indian/Alaska Native communities and a partnership model for rural areas.
For information on trafficking in rural communities and how health settings can respond, see this article from the Rural Health Information Hub.
*Peek-Asa, C., Wallis, A., Harland, K., Beyer, K., Dickey, P., & Saftlas, A. (2011). Rural Disparity in Domestic Violence Prevalence and Access to Resources. Journal of Women’s Health, 20(11), 1743-1749. doi:10.1089/jwh.2011.2891
What does it mean to be a survivor of domestic violence/sexual assault?
The terms ‘victim’ or ‘survivor’ may be used to refer to a person who has experienced or is experiencing domestic violence/sexual assault (DV/SA). Some organizations or individuals use the terms interchangeably while others feel that the terms ‘victim’ and ‘survivor’ have very different connotations. It is important for providers to let individuals label their own experience and to mirror this language. We largely use the term survivor in this toolkit.
Where can I find more information on programs addressing human trafficking and its health impact, as well as intervention and support strategies?
Human trafficking has severe adverse effects on the health, well-being, and human rights of millions of vulnerable adults and young people in the U.S. and globally. Learn more about FUTURES’ programs, policies, and initiatives working to prevent and respond to human trafficking.
Learn more about trafficking among American Indian women and girls in Minnesota in the Shattered Hearts report from the Minnesota Indian Women’s Resource Center. View this webinar for more information on addressing trafficking in rural communities.
Watch this Frontline documentary, Trafficked in America, to learn more about a case of labor trafficking on an egg farm in Ohio.
Health professionals can play a significant role in early intervention of human trafficking and reducing the profound suffering it causes. The U.S. Department of Health and Human Services SOAR training program helps health care and social service providers identify and respond to survivors of human trafficking. HEAL Trafficking also takes a public health perspective to ending trafficking and provides trainings for healthcare professionals on addressing and responding to survivors of trafficking.
FUTURES also has resources that address human trafficking:
- The adolescent health safety card and the reproductive health safety card integrate information on trafficking
- Webinar: “Collaborating with Community-based Organizations and Faith-based Communities to Address Trafficking”
- Webinar: “Legal Aspects of Human Trafficking for Health Providers”
- Webinar: “Collaborating to Address the Needs of Trafficked Survivors with Disabilities”
Reach out to the National Human Trafficking Hotline if you or someone you know is a victim of human trafficking and also for more information on the prevalence of trafficking and how to get involved.
What is the health impact of IPV?
IPV has serious implications for health and wellbeing of its survivors. As the leading cause of female homicides and injury-related deaths during pregnancy, IPV also accounts for a significant proportion of injuries and emergency room visits for women. IPV is a significant yet preventable public health problem that affects millions of people regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background. Individuals who are subjected to IPV may have lifelong consequences, including emotional trauma, lasting physical impairment, chronic health problems, and even death. Women who have been victimized by an intimate partner and children raised in violent households are more likely to experience a wide array of physical and mental health conditions including frequent headaches, gastrointestinal problems, depression, anxiety, sleep problems, and Post Traumatic Stress Disorder (PTSD). Despite these alarming facts, a critical gap remains in the delivery of comprehensive health care to women. For more information, visit https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html
What are strangulation and traumatic brain injury (TBI) and how do they relate to violence, abuse and fatality risk?
Traumatic Brain Injuries (TBIs) are a common form of physical violence that are often repeated. The Centers for Disease Control (CDC) defines a traumatic brain injury (TBI) as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. Studies show a range of 40%-91% of women experiencing intimate partner violence (IPV) have incurred a TBI due to a physical assault. Strangulation is one of the most common forms of TBI that survivors of violence and abuse experience, and more than two-thirds of survivors are strangled at least once, with the average being 5.3 times per victim
Other common forms of TBI that survivors experience are blunt force blows to the head that can cause concussions, such as being slammed against a wall, or being shaken so hard that the brain hits the wall of the skull. Non-fatal strangulation is an important risk factor for homicide of women. Visit the Training Institute on Strangulation Prevention for more information on the health impact of strangulation.
While immediate TBI physical repercussions may not always be obvious, TBI can cut off oxygen to the brain hours or days following an injury, and victims can die from TBI hours or days after the assault. That’s why it’s important for both domestic violence advocates and health care providers to talk to their clients and patients about any form of head injuries they may have experienced. Health care providers can ask patients about recent or past head injuries, and advocates can add questions to their intakes form to assess for TBIs. Advocates can also keep in mind while safety planning the potential cognitive and behavioral impact that TBIs can have. The “HELPS” Screening Tool for Traumatic Brain Injury is a helpful screening tool to assess for TBIs, which is designed for professionals who are not TBI experts. The “HELPS” tool also describes potential cognitive, behavioral, and physical symptoms of TBIs, as well as recommendations for working with women who have TBIs. The Danger Assessment Tool helps to determine the level of danger an abused woman has of being killed by her intimate partner. It is free, available to the public, and is available in English, Spanish, Portuguese, and French Canadian.
The Ohio Domestic Violence Network (ODVN) developed educational resources for survivors and advocates on TBIs and strangulation. The Has Your Head Been Hurt educational card provides information on injuries related to TBIs and strangulation, links to emotional and cognitive symptoms, and highlights the warning signs of life-threatening injuries. The Invisible Injuries Booklet is a companion tool for the Has Your Head Been Hurt card, to assist domestic violence programs in accommodating the needs of survivors who have experienced head injuries and to identify possible follow-up care or evaluation. ODVN’s work on TBIs and intersections with domestic violence was featured in this report from the U.S. Government Accountability Office, which led to the U.S. Department of Health & Human Services to agree to coordinate among its agencies to better address TBIs related to domestic violence.
 Jacquelyn C. Campbell, PhD, RN, FAAN,1 Jocelyn C. Anderson, PhD, RN,1,2 Akosoa McFadgion, PhD, MSW, Jessica Gill, PhD, RN,4 Elizabeth Zink, MS, RN,Michelle Patch, MSN, APRN-CNS, ACNS-BC,Gloria Callwood, PhD, RN, FAAN,5 and Doris Campbell, PhD, ARNP, FAAN, The Effects of IPV and Probable Traumatic Injury on Central Nervous Symptoms. Journal of Women’s Health (2018) https://www.liebertpub.com/doi/abs/10.1089/jwh.2016.6311?src=recsys&
 Chrisler JC, Ferguson S. Violence Against Women as a Public Health Issue. Annals of New York Academy of Sciences. 2006;1087:235-249.
Abbott J, Johnson R, Koxiol-McLain J, Lowenstein SR. Domestic Violence Against Women: Incidence and Prevalence in an Emergency Department Population. JAMA. 1995;273(22):1763-1767.
Coker AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 2002;23(4):260–268.
Frye V. Examining Homicide’s Contribution to Pregnancy-Associated Deaths. JAMA. 2001;285(11):1510-1511.
Golding JM. Intimate Partner Violence as a Risk Factor for Mental Disorders: A Meta-Analysis. Journal of Family Violence. 1999;14(2):99-132.
McLeer SV, Anwar RA, Herman S, Maquiling K. Education is not Enough: A Systems Failure in Protecting Battered Women. Annals of Emergency Medicine. 1989;18:651-653.
Stark E, Flitcraft A, Frazier RJ. Medicine and Patriarchal Violence: The Social Construction of a “Private” Event. International Journal of Health Services. 1979;9(3):461-493.
Stark E, Flitcraft A. Killing the Beast Within: Woman Battering and Female Suicidality. International Journal of Health Services. 1995;25(1):43-64.
 Nancy Glass, PhD, MPH, RN, Kathryn Laughon, PhD, RN, Jacquelyn Campbell, PhD, RN, Carolyn Rebecca Block, PhD, Ginger Hanson, MS, Phyllis W. Sharps, PhD, RN, and Ellen Taliaferro, MD, FACEP, J Emerg Med. 2008 Oct; 35(3): 329–335. Published online 2007 Oct 25. Non-fatal strangulation is an important risk factor for homicide of women
 Training Institute on Strangulation Prevention. (2017). Health Issues Result from Strangulation – Training Institute on Strangulation Prevention. [online] Available at: http://www.strangulationtraininginstitute.com/health-issues-result-from-strangulation
What is the impact of the COVID-19 public health emergency on survivors of domestic violence, sexual assault, and human trafficking?
COVID-19 has had tremendous impacts on people surviving violence and those who are most vulnerable to abuse and exploitation. With stay at home orders in place across much of the U.S., survivors are now likely to be stuck at home with the person(s) causing them harm and now have less access to support networks. This isolation, along with increased stress and financial instability, put survivors more at risk for violence in their homes.[i] Additionally, high unemployment rates can impact survivors’ financial independence, which in turn can make them more dependent on the person(s) causing them harm and make them more vulnerable to exploitation. Communities of color and LGBTQ communities are particularly vulnerable to exploitation, especially during COVID-19.[ii]
Black and brown communities have been disproportionately impacted by COVID-19.[iii] Deaths among black communities nationally is almost twice the percentage of the national population they represent.[iv] This can both be attributed to higher rates of lower-paying and less secure jobs due to systemic inequities, and also social determinants of health, which has led to higher rates of chronic health issues in black communities.[v] For survivors of color, these systemic inequities and increased likelihood of underlying health conditions can further exacerbate the impact of COVID-19.
[i] Campbell A. M. (2020). An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives. Forensic Science International: Reports, 2, 100089. https://doi.org/10.1016/j.fsir.2020.100089
[ii] “COVID-19 May Increase Human Trafficking in Vulnerable Communities.” Polaris Project, 7 Apr. 2020, polarisproject.org/blog/2020/04/covid-19-may-increase-human-trafficking-in-vulnerable-communities/.
[iii] Godoy, Maria, and Daniel Wood. “What Do Coronavirus Racial Disparities Look Like State By State?” NPR, NPR, 30 May 2020, www.npr.org/sections/health-shots/2020/05/30/865413079/what-do-coronavirus-racial-disparities-look-like-state-by-state.