Nursing and U.S. Policy – Family and Sexual Violence Essay Papers Notes

Nursing and U.S. Policy – Family and Sexual Violence Essay Papers Notes

Complete this week’s assigned readings given belowAfter completing the readings, post a short reflection, approximately 1 paragraph in length, discussing your thoughts and/or professional concerns about one or several of the specific topics covered in the textbook readings. pertaining to politics in associations and interest groups. Identify which one MSN Essential most relates to your selected topic in your discussion.


Family and Sexual Violence

Nursing and U.S. Policy

“If the numbers we see in domestic violence were applied to terrorism or gang violence, the entire country would be up in arms, and it would be the lead story on the news every night.”


Our society is steeped in violence. In the most recent national statistics, more than 26 per 1000 people aged 12 years or older will be the victims of a violent crime (Truman, Langton, & Planty, 2013). Most of our violence prevention strategies prepare potential victims to ward off violent attacks from strangers; yet, someone known to the victim perpetrates most violence against women, children, and older adults. The intimate nature of this violence, often perpetrated behind closed doors, has made these forms of violence less visible. However, the toll of violence on individuals and societies is substantial. The World Health Organization has framed violence as a significant public health problem (Truman, Langton, & Planty, 2013). A public health approach suggests an interdisciplinary, science-based approach with an emphasis on prevention. Effective strategies draw on resources in many fields, including nursing, medicine, criminal justice, epidemiology, and other social scientists.

The purpose of this chapter is to provide an overview of state, federal, and health sector policies regarding violence against women in the United States, briefly discuss policies related to violence against children and older adults, and outline the resulting implications for nurses and directions for future work.

Intimate Partner and Sexual Violence Against Women

Intimate partner violence (IPV) is physical, sexual, or psychological harm inflicted by a current or former partner (same sex or not) or a current or former spouse (Black et al., 2011). Almost one third of American women experience being hit, slapped, or pushed by an intimate partner, and nearly a quarter will experience serious forms of IPV during their lifetimes. Additionally, nearly one in five women will experience a completed or attempted rape in their lifetimes. Men experience IPV and rape as well, although at far lower rates than do women. About a quarter of men will experience IPV (about 12% serious forms of violence) and nearly 1.5% a completed or attempted rape. Although more than half of women reporting rape report that the assailant was an intimate partner and 40% that the assailant was an acquaintance, men report that half of rapes were by acquaintances and 15% by strangers; the number raped by an intimate partner was too small to estimate. Nursing and U.S. Policy – Family and Sexual Violence Essay Papers Notes.

The health effects of IPV and sexual violence are substantial and cost as much as $8.3 billion in health care and mental health services for victims (Max et al., 2004). Violence is associated with a wide range of health problems, including chronic pain recurring central nervous system symptoms, vaginal and sexually transmitted infections and other gynecological symptoms, and diagnosed gastrointestinal symptoms and disorders (Black et al., 2011). Mental health symptoms include depression, anxiety, posttraumatic stress disorder, and alcohol and drug use (Black et al., 2011; Campbell, 2002).

State Laws Regarding Intimate Partner and Sexual Violence

State laws address a number of issues important for nurses to understand. Most often, crime of IPV and sexual violence are addressed through state laws. Most, although not all, states have laws specifically providing enhanced penalties for assault and battery that occurs between intimate partners. (It worth noting that most laws refer to domestic violence or family abuse rather than IPV.) For example, at least 23 states have some form of mandatory arrest for IPV (Hirschel, 2008). Research findings are mixed on whether mandatory arrest laws reduce reassault (Felson, Ackerman, & Gallagher, 2005; Hirschel et al., 2007), although findings from at least one study suggest that the overwhelming majority of victims support mandatory arrest laws (Barata & Schneider, 2004). Additionally, states may have enhanced penalties, such as escalating third offenses to felonies.

Until 1975, all states provided what is called the marital rape exemption under which it was legally impossible to commit rape against one’s wife. Beginning in the mid-1970s, based in part on nursing research, these laws began to change (Campbell & Alford, 1989). Although all states now recognize marital rape as a crime, in some states it is still treated differently from rape by a nonspouse (Prachar, 2010).

Nonlethal strangulation of women is a significant but often overlooked threat to public safety. Most (80%) strangulations of women are committed by intimate partners (Shields et al., 2010). They can result in significant physical health problems for victims (Taliaferro et al., 2009) and substantially increase risk of later lethal violence (Glass et al., 2008). These cases can be difficult to charge and prosecute commensurate with the severity of the crime (Laughon, Glass, & Worrell, 2009); therefore, a growing number of states have strengthened laws related to strangulation.

All states provide for civil protective orders in cases where victims have a reasonable fear of violence from an assailant (Carroll, 2007). States vary widely, however, in who is eligible to obtain an order and how the orders are obtained. For example, in some states minors or dating partners may not be able to obtain orders of protection. Most states provide for civil protection orders against assailants who are accused of sexual assault, but the procedures may be different from those for protective orders against intimate partners. Studies of the effectiveness of these orders are mixed (Logan & Walker, 2009; Prachar, 2010).

In addition to these criminal justice remedies, state laws may address other issues related to IPV and sexual violence. As of 2010, 26 states had established intimate partner fatality review teams (Durborow et al., 2010). Fatality review teams use a multidisciplinary, public health approach to reviewing fatalities and identifying risk factors (Websdale, 1999). A handful of states require health care providers to report domestic violence against competent adults. It is important to understand that in most states, IPV and sexual assault are not mandatory reports unless there are other factors present.

Federal Laws Related to Intimate Partner and Sexual Violence

There are two significant federal laws that address violence against women. The Family Violence Prevention and Services Act was first authorized in 1984. It was most recently authorized through 2015 (Public Law [PL] 111-320 42 U.S.C. 10401, et seq.). It is the primary federal funding source for domestic violence shelters and service programs in the United States. It also funds the work of state coalitions on domestic violence, community-based violence prevention efforts, and a number of smaller training and assistance programs.

The Violence against Women Act (VAWA) was first authorized in 1994 (Title IV, sec. 40001-40703 of the Violent Crime Control and Law Enforcement Act of 1994, HR 3355, signed as PL 103-322). As states began creating the protective order and criminal statutes discussed earlier, the limitations of this patchwork of remedies became apparent.


The VAWA was therefore created to address the gaps in state laws; create federal laws against domestic violence, including protection for immigrant women and enhanced gun control provisions; and fund a variety of violence-related training and other local programs (Valente et al., 2009). The law originally included a provision making crime motivated by gender a civil rights offense. This provision was, however, found unconstitutional in 2000 (Brzonkala v. Morrison, 2000).

The VAWA represented a significant turning point in public policy related to violence against women. Previously, women who received a protective order might find that violations that occurred in other states could not be enforced. The full faith and credit provision of the VAWA requires that protective orders be recognized and enforced across jurisdictional, state, and tribal boundaries within the United States. Likewise, by creating federal crimes of domestic violence and stalking, criminal acts that cross jurisdictional boundaries can now be more easily charged and prosecuted. Under the VAWA, it is illegal for individuals subject to certain types of protective orders or convicted of even misdemeanor domestic violence offenses to possess a firearm. Given that risk of intimate partner homicide increases dramatically when firearms are available to the assailant, this represents an important safeguard for women (Campbell et al., 2003). The VAWA addressed the significant hardships faced by both legal and illegal immigrant women experiencing abuse from their partners. The VAWA additionally funds a wide range of victim advocacy and training programs, with the goal of ensuring that victims of violence receive consistent, competent services in all communities.

Each subsequent renewal of the VAWA has strengthened these provisions. The latest renewal in 2013 expanded its definitions to explicitly include gay, lesbian, and transgender victims; expanded the safeguards available to women assaulted in tribal territories; expanded housing provisions to prohibit discrimination against victims of IPV in all forms of subsidized public housing; strengthened protections for immigrant women; and, for the first time, specifically addressed violence on college campuses (Violence against Women Act, 2013).

Health Policies Related to Intimate Partner and Sexual Violence

As discussed earlier, the health consequences of violence are significant for women. Additionally, women who have experienced violence have significantly higher health care costs than women without a victimization history (Bonomi et al., 2009; National Center for Injury Prevention and Control, 2003). There is now a consensus that these health care settings offer a unique opportunity to identify and support women living with the effects of violence (Family Violence Prevention Fund, 2002; World Health Organization [WHO], 2013). The U.S. Preventative Services Taskforce recommends “clinicians screen women of childbearing age for IPV such as domestic violence, and provide or refer women who screen positive to intervention services.” The Institute of Medicine identified screening and brief counseling for interpersonal violence as an essential and evidence-based practice necessary to ensure the well-being of women (National Research Council, 2011). A wide variety of medical and nursing professional organizations also recommend routine screening for violence (Amar et al., 2013). Significant evidence now exists for safety planning strategies to prevent homicide for women in abusive relationships. The Danger Assessment Instrument, for example, has been shown to have good predictive value and can assist women with making a realistic appraisal of their likelihood of experiencing lethal violence (Campbell, Webster, & Glass, 2008). Health care institutions should also have the appropriate capacity to provide care to women in the acute period after a physical or sexual assault (WHO, 2013).

Nurses and other health professionals have a role to play in community responses to violence. Many localities have created sexual assault response teams. These interdisciplinary teams work to ensure consistent, trauma-informed, and effective care for victims of sexual assault. Despite scant research on the effectiveness of these teams, they are a promising practice (Greeson & Campbell, 2013). Likewise, intimate partner/domestic violence fatality review teams review cases of intimate partner homicide with a public health approach. As with sexual assault response teams, there are little data on the effectiveness of these teams that have also been labeled a promising practice (Wilson & Websdale, 2006).

Child Maltreatment

Child maltreatment includes physical, sexual, and emotional abuse, as well as neglect. Actual prevalence of maltreatment is unknown, but there are more than 3 million referrals for more than 6 million children to child protective agencies annually, with nearly a quarter of these cases substantiated. An estimated 1570 children nationally died from abuse or neglect in 2011 (Administration on Children, Youth, and Families Children’s Bureau, 2011; U.S. Government Accountability Office, 2011), a number that is believed to be undercounted. The estimated annual cost of child abuse and neglect in the United States for 2008 was $124 billion (Fang et al. 2012). Child maltreatment results in lifelong adverse physical and mental health consequences such as posttraumatic stress disorder, increased risk of chronic disease, lasting impacts or disability from physical injury, and reduced health-related quality of life (Corso et al. 2008).

State and Federal Policies Related to Child Maltreatment

Because minors are considered to need additional protection as a result of their age, states not only have laws making the acts of abuse and neglect criminal offenses but also have laws requiring that certain adults must report suspected maltreatment to appropriate authorities. In some states, all adults are mandated reporters. In most states, specific professionals, teachers, health care professionals, social workers, law enforcement personnel, and others are mandated reporters (Child Welfare Information Gateway, 2011). At the federal level, the Child Abuse Prevention and Treatment Act (CAPTA) provides funding to states to support prevention, assessment, investigation, prosecution, and treatment activities related to child maltreatment and funding for research activities (Child Welfare Information Gateway, 2011, 2013).

Health Policies Related to Child Maltreatment

Children’s Advocacy Centers coordinate investigation and intervention services for maltreated children by bringing together social work, legal, health care, and other professionals and agencies in a multidisciplinary team to create a child-focused approach to child abuse cases. Home visitation is another strategy that shows promise for improving child health and preventing child maltreatment (Avellar & Supplee, 2013).

Older Adult Maltreatment

Best estimates indicate that 1 to 2 million Americans over the age of 65 years are abused, neglected, or exploited, most often by caregivers (National Center on Elder Abuse, 2005). Precise numbers are not available, attributable to differences in definitions of abuse, lack of a comprehensive national data system, and different state system reporting and data collection. Further, only a small fraction of abuse comes to the attention of Adult Protective Services (Dong & Simon, 2011). The U.S. aging population is rapidly increasing with projections for individuals 65 years and older to increase from 40.2 million in 2010 to 54.8 million in 2020 and to 72.1 million in 2030 (Dong & Simon, 2011). Legislation has been effective in bringing about reform.

State and Federal Legislation Related to Older Adult Maltreatment

As with child maltreatment, state laws provide for criminal charges related to the abuse of older adults (the definition of which varies from state to state, but may be as young as 55 years of age). Most (but not all) states define certain individuals as mandated reporters of abuse of older adults as well. At the federal level, the Older American Act of 2006 developed and maintains the National Center on Elder Abuse, which provides funding for prevention activities, research, data collection, and long-term planning for elder justice. The Elder Justice Act (EJA) of 2010, which was part of the Patient


Protection and Affordable Care Act (2010), is the first comprehensive strategy to address older adult abuse, neglect, and exploitation. It is important to note that the authorized funding has not been appropriated at this time and that the EJA is set to expire in 2014. Funding for older adult maltreatment is significantly less than for other types of violence and a national database has yet to be established.

Health Care Policies Related to Older Adult Maltreatment

Recent efforts have focused on using the primary care setting to identify and respond to older adult abuse (Perel-Levin, 2008). Case management strategies can be effective in providing consistency in monitoring of adult patient and caregiver behavior (Choi & Mayer, 2000). Research on effective intervention strategies in this area lags behind that of other areas of violence and is an area where nursing can make an impact.

Opportunity for Nursing

Nurses have the skills and education to take a leadership role in addressing violence and abuse on multiple levels, as providers, researchers, policy analysts, educators, and advocates. Efforts to address violence against children, women, and older adults have met with impressive successes over the past decades. These forms of violence, seen as largely justifiable and perhaps even necessary in the past, are now recognized as both crimes and important public health problems. The evidence base for interventions to prevent these forms of violence, end them when they start, and mitigate the related health consequences is growing. It is clear, however, that we still have important gaps in our understanding of both effective violence interventions and policies. Although we work to address these gaps in knowledge, we can continue to move forward on numerous fronts. Educators should ensure that curriculums at all levels include content on violence and abuse. Given the high rates and significant health effects of violence, all nurses should have basic clinical knowledge of how to assess for, competently respond to, and appropriately refer all patients with a history of violence or abuse. Nurses can serve as powerful advocates for victims of violence, ensuring that state and federal laws meet the highest standards.

Violence and crime unite two powerful systems, health care and criminal justice, and involve multiple professionals including physicians, nurses, social services, police, lawyers, and judges. Prevention and intervention strategies require efforts at the individual, community, institutional, and public policy levels. Nurses can have a significant voice in ensuring the best possible prevention and advocacy services at the local, state, and federal levels. Nursing research and the testimony of nurses has been foundational for federal and state laws and resulting public policy related to violence.

Discussion Questions

  1. Consider the differences in the treatment of violence across states and what federal pro­visions might be advantageous to address the discrepancies.
  2. How might nursing research help to fill the gaps in the knowledge?
  3. It is apparent in the chapter that different strategies exist for violence against women, child maltreatment, and older adult abuse. Could the same strategies work across populations and abuse types? What might be the advantages/disadvantages to having similar strategies?


Administration on Children, Youth, and Families Children’s Bureau. Child abuse and neglect fatalities 2011: Statistics and interventions. U.S. Department of Health and Human Services, Administration for Children and Families: Washington, DC; 2011.

Amar A, Laughon K, Sharps P, Campbell J. Screening and counseling for violence against women in primary care settings. Nursing Outlook. 2013;61(3):187–191.

Avellar SA, Supplee LH. Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics. 2013;132(10, Suppl. 2):S90–S99.

Barata PC, Schneider F. Battered women add their voices to the debate about the merits of mandatory arrest. Women’s Studies Quarterly. 2004;32(3–4):148.

Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, et al. The national intimate partner and sexual violence survey (NISVS):


2010 summary report. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention: Atlanta, GA; 2011.

Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Services Research. 2009;44(3):1052–1067.

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

Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359(9314):1331–1336.

Campbell JC, Alford P. The dark consequences of marital rape. American Journal of Nursing. 1989;89(7):946–949.

Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, et al. Risk factors for femicide in abusive relationships: Results from a multisite case control study. American Journal of Public Health. 2003;93(7):1089–1097.

Campbell JC, Webster DW, Glass N. The danger assessment: Validation of a lethality risk assessment instrument for intimate partner femicide. Journal of Interpersonal Violence. 2008;24(4):653–674.

Carroll CA. Sexual assault civil protection orders (CPOs) by state. American Bar Association Commission on Domestic and Sexual Violence: Washington, DC; 2007.

Child Welfare Information Gateway. About CAPTA: A legislative history. U.S. Department of Health and Human Services, Children’s Bureau: Washington, DC; 2011.

Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. U.S. Department of Health and Human Services.: Washington, DC; 2013 [Retrieved from]

Choi NG, Mayer J. Elder abuse, neglect, and exploitation: Risk factors and prevention strategies. Journal of Gerontological Social Work. 2000;33(2):5–25.

Corso PS, Edwards VJ, Fang X, Mercy JA. Health-related quality of life among adults who experienced maltreatment during childhood. American Journal of Public. 2008;98(6):1094–1100.

Dong XQ, Simon MA. Enhancing national policy and programs to address elder abuse. JAMA: The Journal of the American Medical Association. 2011;305(23):2460–2461.

Durborow N, Lizdas KC, O’Flaherty A, Marjavi A. Compendium of state statutes and policies on domestic violence and health care. Family Violence Prevention Fund: San Francisco, CA; 2010.

Family Violence Prevention Fund. National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. Author: San Francisco; 2002.

Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect. 2012;36(2):156–165.

Felson RB, Ackerman JM, Gallagher CA. Police intervention and the repeat of domestic assault. Criminology. 2005;43(3):563–588.

Glass N, Laughon K, Campbell J, Block CR, Hanson G, et al. Non-fatal strangulation is an important risk factor for homicide for women. Journal of Emergency Medicine. 2008;35(3):329–335.

Greeson MR, Campbell R. Sexual assault response teams (SARTs): An empirical review of their effectiveness and challenges to successful implementation. Trauma, Violence and Abuse. 2013;14(2):83–95.

Hirschel D. Domestic violence cases: What research shows about arrest and dual arrest rates. National Institute for Justice: Washington, DC; 2008.

Hirschel D, Buzawa E, Pattavina A, Faggiani D. Domestic violence and mandatory arrest laws: To what extent do they influence police arrest decisions? Journal of Criminal Law & Criminology. 2007;98(1):255–298.

Laughon K, Glass N, Worrell C. Review and analysis of laws related to strangulation in 50 states. Evaluation Review. 2009;33(4):358–369.

Logan T, Walker R. Civil protective order outcomes: Violations and perceptions of effectiveness. Journal of Interpersonal Violence. 2009;24(4):675–692.

Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll of intimate partner violence against women in the United States. Violence and Victims. 2004;19(3):259–272.

National Center on Elder Abuse. Fact sheet: Elder abuse prevalence and incidence. National Center on Elder Abuse: Washington, DC; 2005.

National Center for Injury Prevention and Control. Costs of intimate partner violence against women in the United States. Centers for Disease Control and Prevention: Atlanta; 2003.

National Research Council. Clinical preventive services for women: Closing the gaps. The National Academies Press: Washington, DC; 2011.

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

Perel-Levin S. Discussing screening for elder abuse at primary health care level. World Health Organization: Geneva; 2008.

Prachar M. The marital rape exemption: A violation of a woman’s right of privacy. Golden Gate University Law Review. 2010;11:717.

Shields LB, Corey TS, Weakley-Jones B, Steward D. Living victims of strangulation: A 10-year review of cases in a metropolitan community. American Journal of Forensic Medicine and Pathology. 2010;31:320–325.

Taliaferro E, Hawley D, McClane G, Strack GB. Strangulation in intimate partner violence. Mitchell C, Anglin D. Intimate partner violence: A health-based perspective. Oxford University Press: New York; 2009.

Truman J, Langton L, Planty M. Criminal victimization, 2012 No. NCJ 243389. US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics: Washington, DC; 2013.

U.S. Government Accountability Office. Child maltreatment: Strengthening national data on child fatalities could aid in prevention (GAO-11-599). U.S. Government Accountability Office: Washington, DC; 2011.

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Online Resources

Child Welfare Information Gateway.

Futures without Violence.

National Center of Elder Abuse.

Rape, Abuse, and Incest National Network.


Human Trafficking

The Need for Nursing Advocacy

Barbara Glickstein

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

Harriet Ross Tubman, nurse abolitionist

Human trafficking is a serious crime of forced labor or enslavement. As defined under U.S. federal law, victims of human trafficking include children involved in the sex trade, adults age 18 years or over who are coerced or deceived into commercial sex acts, and anyone forced into different forms of labor or services, such as domestic workers held in a home or farm workers forced to labor against their will. A victim does not have to be physically transported from one location to another for the crime to fall under the definition of human trafficking (U.S. Department of State, 2013a).

Trafficking not only violates human rights but also contributes to harmful social, health, and economic conditions for the persons who are trafficked. Persons who are trafficked can experience intense psychological trauma, infectious disease (most notably HIV/AIDS), extensive physical injury, drug addiction, unwanted pregnancy, and malnutrition. Human trafficking also poses a significant public health problem.

Victim identification is the critical first step in stopping this crime. Nurses are well placed in every community to identify trafficking victims. They also bring a public health lens to this human rights issue, which contributes to their having a better understanding of the complexity of the issues a survivor faces. Nurses can focus on developing and implementing a victim-centered approach. The U.S. Department of Homeland Security Blue Campaign defines a victim-centered approach to combating human trafficking as one that places equal value on the identification and stabilization of victims, with the investigation and prosecution of traffickers (U.S. Department Homeland Security, 2013).

Encountering the Victims of Human Trafficking

Many nurses have treated victims of human trafficking without realizing it. Encountering modern-day slavery can provoke a strong visceral response, often followed by the urge to distance oneself. These feelings make it hard to imagine what you, one nurse, could possibly do to stop it. However, nurses are uniquely situated to make a difference.

Nurses should ask themselves one question: “What role can nurses have in stopping human trafficking?” (See Box 87-1.)

Box 87-1

What Can You Do About Human Trafficking?

  • Be well informed. Start with investigating what policy and protocols are in place at your health institution and if the issue of human trafficking is being addressed in the nursing curriculum in courses at your university or college.
  • If there are no policies in place, start an interdisciplinary task force to develop policies and pursue a plan to implement them.
  • Assess and educate community stakeholders, such as shelters, victim-assistance agencies, advocacy groups, and law enforcement agencies, and collaborate with them.
  • Become familiar with services and hotlines so that you can refer people who have been trafficked. Build a resource list, and keep it current. Access to reporting at the national level includes the National Human Trafficking Resource Center (NHTRC). The NHTRC is a national, toll-free hotline that operates 24 hours a day, 7 days a week, 365 days a year. The NHTRC can be reached by calling 1-888-3737-888 or text BeFree (233733).
  • Bring the issue of human trafficking to the public’s attention in their local communities through public speaking in schools, places of worship, and social action groups. Use both traditional media and social media to launch campaigns and increase pressure on local authorities to act to stop human trafficking.

Advancing Policy in the Workplace

Does your place of employment have a policy on nursing’s role in human trafficking? Does it have an action plan or protocol to follow when a person who is trafficked is identified? Networks of health care providers, law enforcement, lawyers, and nongovernmental organizations are developing evidence-based multisectored policies and protocols on how to proceed when a person has been identified as being trafficked. If your place of work does not have a policy, you can take the lead and get this process in motion to ensure that people who have been trafficked are given proper care, treated with respect, protected from harm, and directed to social and legal services. Resources that can provide support to develop a protocol are the Polaris Project (2014), which offers training and technical assistance, and the International Organization for Migration handbook on Caring for Trafficked Persons (International Organization on Migration, 2009).

Role of Professional Nursing Associations

Historically, nursing organizations have played a critical role in developing and advancing policies on human rights issues. The International Council of Nurses’ (ICN) Code of Ethics for Nurses position statement, Nurses and Human Rights, requires nurses to safeguard and promote human rights (ICN, 2006a, 2006b). This statement as well as other ICN advocacy and lobbying position statements cover a wide range of health issues where nurses must act to enforce human rights and to promote and protect health as a fundamental human right and a social goal (ICN, 2010).

In 2008, the New York State Nurses Association (NYSNA) invited me to deliver an address entitled Nurses Working to Stop Human Trafficking at their annual convention. The NYSNA board’s response was immediate. They drafted and submitted an action proposal on human trafficking to the American Nurses Association (ANA), which was passed by the ANA House of Delegates in 2008. The resolution states that it will advocate legislation to reduce the incidence of human trafficking and will work to ensure that nurses know how to identify and assist victims. This is a commendable action by the ANA to educate nurses nationally and support stronger enforcement of the federal laws (American Nurses Association [ANA], 2008).

Investigate to see whether your state nurses’ association and specialty nursing association has a position statement on nurses’ role in human trafficking. You can be the person who takes the lead on this initiative if nothing exists to date. A good place to start would be to identify one or two state nurses’ associations that have already developed a policy and ask for guidance from them on strategy and language for your state nurses’ association.

Advocating for State Legislation and Policy on Human Trafficking

Nurses can become part of a national network of health providers and advocacy groups challenging the lack of services available to victims of human trafficking by advocating for the allocation of resources on both the federal level and state level to address this void. They can also use their influence and leadership to advocate for better enforcement of existing antitrafficking laws in their state.

In 2000, the federal law Victims of Trafficking and Violence Protection Act (TVPA) was enacted, making human trafficking a federal crime. The TVPA includes a provision that each state could pass their own legislation to strengthen the work of the federal government and coordinate a partnership with local and federal law enforcement. The Federal Bureau of Investigation (FBI) and agents of Immigration and Customs Enforcement (ICE), a division under Homeland Security, are the main federal agencies involved in investigating human trafficking cases. Because states are enacting legislation and strengthening laws to prosecute traffickers and training law enforcement, we have an increase in investigating human trafficking. To date, not every one of the 50 states has done so. The website of the Center for Women Policy Studies (2014), an advocacy organization, provides an interactive map to learn about individual states and their statutes on human trafficking. If your state has legislation and an interagency antitrafficking task force working on a comprehensive plan to provide services for persons who have been trafficked, ask if there is a nurse on the task force. Once identified, ask how you can help. If there is no nurse on the task force, work toward getting a nurse appointed, or nominate yourself. If your state is one of the remaining states without antitrafficking laws, identify local and national advocacy organizations working toward this goal and work with them to pass this legislation. Contact and engage your state nurses’ association to lobby to pass these comprehensive laws.

Advancing Policy Through Media and Technology

The media, both traditional media and digital media, is the single most powerful tool to educate, effect social change, and influence policies. Like most Americans, nurses’ knowledge about human trafficking has been shaped by the media. A study by researchers Johnston, Friedman, and Scaefer (2012) evaluated print and broadcast media reports on human trafficking beginning in 2008 through 2012. They found that stories on the crime of sex trafficking dominated the coverage, while stories of survivors or the impact on public policy were less common. Dramatization of human trafficking appears more frequently in story lines on popular crime series on television and in movie plots in theaters. The news media have been the primary source of national policy and legislative issues about human trafficking.

Coverage of the issue about the health of the victims and the public health implications of human trafficking has been missing. A recent study on the dominant issues covered in the media on the issue of sex trafficking reported that only 1% of the news coverage addressed the issue of public health. When nurses become educated on the health implications of human trafficking they can become resources for the media’s coverage on trafficking and shape the public’s understanding of human trafficking beyond the issue that it is a crime. When the public is aware of the indicators of human trafficking and whom to contact if they see such indi­cators, victims can more readily be identified and helped.

Technologies are now being used for antitrafficking efforts. The Global Human Trafficking Hotline Network shares and analyzes data from hotlines to find and help victims and identify trafficking locations. One of them, the National Human Trafficking Resource Center (NHTRC) in the United States, answers calls from anywhere in the country and has started accepting text messages. Texting can be a safer form of connect­ing with victims and those seeking to report suspected human trafficking activities. When a text is received, a live, trained specialist receives the text and responds immediately. Texting provides secrecy that phone lines cannot provide if the person reporting feels threatened by others near them (Polaris Project, 2014).

Trafficking as a Global Public Health Issue

There are more than 13 million nurses worldwide providing up to 80% of the health services in most countries (ICN, 2010). In every community where a nurse provides care, there are people who are vulnerable and could be targeted by traffickers. For nurses, trafficking in persons can be best understood as a very serious health risk, because trafficking, like other forms of violence, is associated with physical and psychological harm (International


Organization on Migration, 2009). It has serious public health implications related to the spread of infectious diseases such as tuberculosis, HIV, and other sexually transmitted infections. Victims of trafficking are highly prone to social, economic, and legal issues that further put them at risk for a variety of mental health issues, including substance abuse, addiction, posttraumatic stress disorder, anxiety, depression, and even suicide (Hynes & Raymond, 2002). Common abuses experienced by trafficked persons include rape, torture, and other forms of physical, sexual, and psychological violence (Zimmerman et al., 2008). Paradoxically, these victims who desperately require health services are less likely to have access as a result of discrimination, social stigma, fear of law enforcement, and other factors. Nurses can contribute their expertise by conducting research on human trafficking as a global public health issue.

Nurses are also at risk for being trafficked. As poorer nations prepare nurses for export to other countries, questionable recruiting practices have led some migrating nurses to be threatened with criminal charges and deportation when they object to exploitative working conditions. Raising nurses’ awareness about human trafficking can lower their own risk.

The World of the Victims

Without recruiters and criminals, human trafficking would not exist. Poverty, unemployment, economic collapse, war, natural disasters, and the lack of a promising future are compelling factors that facilitate the ease with which traffickers recruit people, but they are not the cause of trafficking. Traffickers take advantage of poverty, unemployment, and the desire to emigrate to recruit people and traffic them into dangerous situations. Tragically, recruiters often know their victims. A common way that many victims are recruited is through a friend or acquaintance (e.g., a cousin, neighbor, or boyfriend) or by an individual recommended to them by someone they trusted.

Finally, traffickers can be anyone. Traffickers brazenly operate in our neighborhoods. They advertise in our newspapers and on Craigslist. They are men and women of all ages. They run legal employment agencies. They are diplomats who often get diplomatic immunity when caught, and they work in all types of professions (General Accounting Office [GAO], 2008). They act alone or they may be members of international crime rings (Table 87-1).

TABLE 87-1

Myths and Facts of Human Trafficking

The U.S. Department of Homeland Security’s antitrafficking plan, called the Blue Campaign, provides a list of six myths and misconceptions about human trafficking:

Myth #1

Human trafficking does not occur in the United States. It only happens in other countries.


Human trafficking exists in every country, including the United States. It exists nationwide, in cities, suburbs, and rural towns, and possibly in your own community.

Myth #2

Human trafficking victims are only foreign-born individuals and those who are poor.


Human trafficking victims can be any age, race, gender, or nationality: young children, teenagers, women, men, runaways, U.S. citizens, and foreign-born individuals. They may come from all socioeconomic groups.

Myth #3

Human trafficking is only sex trafficking.


You may have heard about sex trafficking, but forced labor is also a significant and prevalent type of human trafficking. Victims are found in legitimate and illegitimate labor industries, including sweatshops, massage parlors, agriculture, restaurants, hotels, and domestic services. Note that sex trafficking and forced labor are both forms of human trafficking, involving exploitation of a person.

Myth #4

Individuals must be forced or coerced into commercial sex acts to be a victim of human trafficking.


According to U.S. federal law, any minor under the age of 18 years who is induced to perform commercial sex acts is a victim of human trafficking, regardless of whether he or she is forced or coerced.

Myth #5

Human trafficking and human smuggling are the same.


Human trafficking is not the same as smuggling. “Trafficking” is exploitation-based and does not require movement across borders. “Smuggling” is movement-based and involves moving a person across a country’s border with that person’s consent, in violation of immigration laws.

Although human smuggling is very different from human trafficking, human smuggling can turn into trafficking if the smuggler uses force, fraud, or coercion to hold people against their will for the purposes of labor or sexual exploitation. Under federal law, every minor induced to engage in commercial sex is a victim of human trafficking.

Myth #6

All human trafficking victims attempt to seek help when in public.


Human trafficking is often a hidden crime. Victims may be afraid to come forward and get help; they may be forced or coerced through threats or violence; they may fear retribution from traffickers, including danger to their families; and they may not be in possession or have control of their identification documents.

Retrieved from

International Policy

The first international statement to use the term human rights was the Universal Declaration of Human Rights (UDHR), adopted by the United Nations General Assembly in Paris in 1948. The UDHR states that human rights are rights inherent to all human beings, whatever our nationality, place of residence, sex, national or ethnic origin, color, religion, language, or any other status. Among several protections covered by the UDHR, Article 4 of the UDHR states: “No one shall be held in slavery or servitude: slavery and the slave trade shall be prohibited in all their forms.” The UDHR made history and is used by human rights activists globally (General Assembly of the United Nations, 1948).

The first international legal instrument to address human trafficking as a crime and to define trafficking was passed in 2000, when the United Nations Office on Drugs and Crime (2000) passed the Protocol to Prevent, Suppress, and Punish Trafficking in Persons. As of 2009, 136 Member States have signed the Protocol. It defines trafficking in persons as follows:


The recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs. (United Nations, 2000)


This International Protocol established the standard approach for governments developing policies on trafficking: the 3P Paradigm—prevention, prosecution, and protection of victims.

In 2007, the United Nations Global Initiative to Fight Human Trafficking (UN.GIFT) was established to coordinate global efforts to adopt the Protocol. In addition to working with governments, the UN.GIFT works with businesses, academia, civil society, and the media to develop effective tools to fight human trafficking (United Nations Office on Drugs and Crime [UNODC], 2009).


U.S. Response to Human Trafficking

The U.S. Department of State began monitoring trafficking in persons in 1994, when the issue began to be covered in the Department’s Annual Country Reports on Human Rights Practices. During the Clinton administration, the United States passed the TVPA of 2000. This Act established the standard for federal policy on trafficking, and responses to the Act were all based on the 3P Paradigm.

More recently, advocacy organizations globally are launching campaigns that focus on the demand side of slavery as a means of stopping this crime. These laws would take the focus off the women and children in prostitution and put it on the end user or customer. Another demand-reduction strategy is an education and awareness campaign that is aimed at boys and young men and focuses on the negative consequences of purchasing sex: from public and private health problems such as the spread of HIV and other sexually transmitted infections to the grim facts about who runs the sex trade and how customers are helping traffickers flourish and hurting those who have been trafficked.

The 2013 Trafficking in Persons (TIP) report (U.S. Department of State, 2013b) outlines major forms of human trafficking including forced labor, bonded labor, debt bondage among migrant laborers, involuntary domestic servitude, forced child labor, child soldiers, sex trafficking, and child sex trafficking and related abuses. The 2013 report focuses on victim identification as a top priority in the global movement to combat trafficking in persons. It details training and techniques that make identification efforts successful, and areas that need further focus such as culturally sensitive health services for all victims and better understanding in identifying boys, men, and lesbian, gay, bisexual, and transgender people who are trafficked. The 2013 TIP report stated that 47,000 victims of human trafficking were identified globally in 2013, a small percentage of the estimated 27 million women, men, and children being trafficked at any time. Global convictions of human traffickers increased by almost 20% from 2012 with 4746 convictions in 2013.

In January 2014, the White House released the 5-year federal strategic action plan Coordination, Collaboration, Capacity: Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States, 2013-2017. The Plan is a collaborative project involving 15 agencies across the federal government and nonprofits. This strategic plan includes significant input from survivors of trafficking. Development of the Plan was a collaborative, multiphase effort across a number of federal agencies, led by co-chairs from the U.S. Departments of Justice, Health and Human Services, and Homeland Security.

The Plan outlines a strategic coordinated effort with specific goals, objectives, and action items to better identify and provide services to victims of trafficking in the United States.


Although there is much work that needs to be done to understand and end human trafficking, great progress has been made since 2000. The international community has taken decisive action to end human trafficking. Greater research related to trafficking is a prerequisite for ending the abuse. Lack of data and failure to grasp the complexities that underlie human trafficking worldwide must be addressed. The media treatment of trafficking does not present the true dimensions of the problem, and we should work toward better reporting to help shatter the myths about human trafficking. Nongovernment agencies and advocacy groups dedicated to creating public awareness campaigns and developing victim services programs should be supported by volunteering your nursing expertise, time, and resources. Whether nurses are engaged in clinical care, advocacy, policy, or program activities, they can monitor human trafficking and have an impact on preventing it. Most activists agree that to stop human trafficking, global awareness of the problem must increase. Nurses can add their voices through advocacy and help build the global capacity needed to stop human trafficking.


Discussion Questions

  1. There is a clear need to develop, implement, and evaluate high-quality education and training programs that focus on human trafficking for nurses and other health care providers. How can you contribute to this unmet need?
  2. What skills do you already have as a nurse when it comes to working with a patient who has experienced violence and trauma that can inform your work going forward advancing the health care needs of people who have been victims of human trafficking?
  3. Consider researching a current news item on human trafficking and conduct a media analysis of how human trafficking is reported. Is this news item a blame narrative? Is the language sensitive to the victim or exploitive? Does it provide a health lens or public health lens? If not, consider a response pointing these issues out with a letter to the editor. Be sure to identify yourself as a registered nurse.


American Nurses Association [ANA]. RN delegates to ANA biennial meeting take action to work toward greater nurse retention, address public health issues. [Retrieved from]; 2008.

Center for Women Policy Studies. U.S. policy advocacy to combat trafficking (US PACT). Center for Women Policy Studies: Washington, DC; 2014 [Retrieved from]

General Accounting Office [GAO]. Human rights: U.S. government’s efforts to address alleged abuse of household workers by foreign diplomats with immunity could be strengthened. [Retrieved from]; 2008.

General Assembly of the United Nations. Universal declaration of human rights. [Retrieved from]; 1948.

Hynes P, Raymond JG. Put in harm’s way: The neglected health consequences of sex trafficking in the United States. Stillman J, Bhattacharjee A. Policing the national body: Sex, race and criminalization. South End Press: Cambridge, MA; 2002.

International Council of Nurses [ICN]. ICN code of ethics for nurses. [Retrieved from]; 2006.

International Council of Nurses [ICN]. Nurses and human rights. [Retrieved from] ments/C06_Nurse_Retention_Migration.pdf; 2006.

International Council of Nurses [ICN]. About ICN. [Retrieved from]; 2010.

International Organization on Migration. Caring for trafficked persons. International Organization for Migration: Geneva, Switzerland; 2009 [Retrieved from]

Johnston A, Friedman B, Shafer A. News framing of the problem of sex trafficking: Whose problem? What remedy? Feminist Media Studies. 2012 [Retrieved from]

Polaris Project. Tools for service providers and law enforcement. [Retrieved from]; 2014.

United Nations [UN]. Protocol to prevent, suppress, and punish trafficking in persons, especially women and children, supplementing the United Nations Convention Against Transnational Organized Crime. [Retrieved from] 2/convention_%20traff_eng.pdf; 2000.

United Nations Office on Drugs and Crime [UNODC]. Global report on trafficking in persons. [Retrieved from]; 2009.

U.S. Department Homeland Security. Blue campaign. [Retrieved from]; 2013.

U.S. Department of State. Trafficking in persons report. [Retrieved from]; 2013.

U.S. Department of State. Federal strategic action plan on services for victims of human trafficking in the United States 2013–2017. [Retrieved from]; 2013.

Victims of Trafficking and Violence Protection Act [TVPA] of 2000, 22 U.S.C. § 7102(8).

Zimmerman C, Hossain M, Yun K, Gajdadziev V, Guzun N. The health of trafficked women: A survey of women entering post trafficking services in Europe. American Journal of Public Health. 2008;98(1):55–59.

Online Resources

General HEAL Trafficking Listserv.

HEAL Trafficking.

Health Professional Education, Advocacy, Linkage.

Because Human Trafficking is a Health Issue.

The purpose of the HEAL Trafficking Listserv is to discuss issues at the intersection of health and human trafficking. Although we recognize the value of learning about the breadth of antitrafficking efforts, please reserve nonhealth-related conversations for another forum. Please do not solicit funding on this Listserv and at no time discuss any protected health information, including identity, about any potential victim.

[To post to this group, send an e-mail to]

[Visit this group at]

[For more options, visit]


Polaris Project.

U.S. Department of State Office to Monitor and Combat Human Trafficking.


Breastfeeding Advocacy in the United States

Diane L. Spatz, Elizabeth B. Froh

“Formula feeding is the longest lasting uncontrolled experiment lacking informed consent in the history of medicine.”

Frank Oski, MD

Lactivism is a term used to describe breastfeeding advocacy. Lactivists are those who support breastfeeding, advocate for the rights of breastfeeding mothers, ensure that breastfeeding mothers are not discriminated against, and aim to inform the public regarding the health benefits of breastfeeding. Lactivism occurs in many ways, and recently media attention has focused on human milk and breastfeeding. A woman breastfeeding her toddler was on the cover of Time magazine, adults in China are paying lactating women for their maternal breast milk, and the United States recently adapted federal legislation to protect the rights of breastfeeding women in the workplace. Additionally, American media continues to provide attention to stories surrounding wet nursing, informal milk sharing, and nurse-ins. At a nurse-in, mothers gather in public places to breastfeed their children.

Why Advocate for Breastfeeding?

Human milk is the preferred form of nutrition for all infants. The health benefits of human milk are so significant that virtually every professional organization including the American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding for the first 6 months after birth followed by supplementary foods and continued breastfeeding for 1 to 2 years or more as desirable by mother and child (American Academy of Pediatrics, 2012) (Figure 89-1). Although exclusive breastfeeding for the first 6 months is the recommended gold standard, few infants in the United States receive this dietary recommendation (16.4%). Why do suboptimal breastfeeding practices continue in the United States? What has led to the need for lactivism in the United States?

FIGURE 89-1 The International Breastfeeding Symbol. (Copyright © 2015 by

The Historic Decline in Breastfeeding in the United States

Until the mid-1800s, almost all infants in the United States were breastfed. In the 1890s and early 1900s, a shift began that transformed the culture to one in which bottle feeding became the norm. In the 1900s, infant formula manufacturers advertised their products in women’s magazines and mothers had increasing doubts about being able to breastfeed successfully (meaning the woman reached her personal breastfeeding goal). As childbirth moved from the home into the hospital, medical practice began to interfere with establishment of lactation and breastfeeding. By 1948, only 38% of infants were receiving exclusive human milk feeds at 1 week of age, and by 1957, only 21% of infants were exclusively breastfed at the time of hospital discharge after birth (Apple, 1994).

The U.S. federal government has tracked breastfeeding trends only since 1999. Before this, the earliest, and now the longest, ongoing survey of breastfeeding initiation rates in the United States was produced by the baby formula industry (the Ross Mothers Survey). According to the Centers for


Disease Control and Prevention, breastfeeding initiation (defined as one instance of direct breastfeeding or pumping) and duration rates have risen since 1999; however, the increases have been modest. In 1999, approximately 68% of U.S. women initiated breastfeeding, and in 2011, 79.2% of women initiated breastfeeding, only an 11.2% increase. For infants born in 2011, only 18.8% of infants received human milk exclusively for 6 months, with any breastfeeding at 6 months increasing from 32.6% in 1999 to 44.3% in 2008 to 49.4% in 2011 (Centers for Disease Control and Prevention [CDC], 2009, 2011, 2014).

Culture of Breastfeeding

The culture of breastfeeding in the United States has eroded over the past 100 years, and, despite the fact that more women now try breastfeeding, preference for both formula and bottle feeding persists. The United States remains a formula feeding society.

A sociocultural issue that appears to underlie resistance to breastfeeding is the dual roles female breasts have. Wolf (2008) wrote a commentary on why public breastfeeding remains so controversial in the United States. Wolf asserted that American culture focuses on female breasts for their sexual appeal, not for their primary function, which is to provide nourishment. The view that breastfeeding should be a private act, like sex, can make it challenging for some women to feel comfortable breastfeeding or pumping outside their homes (Wolf, 2008). As an exemplar, in 2009 Berjuan Toys introduced the first breastfeeding toy for children, the Breast Milk Baby (The Breast Milk Baby, 2011). Children wear a vest over their chests that comes with a doll; the vest has two appliques of flowers located at the nipple line. When the doll is brought to a flower applique on the vest, it makes a soft sucking noise. After some time, the doll will stop and begin to cry, signaling the child to stop and burp the doll. Available in the United States this toy fostered strong negative media attention with many people seeing the doll as inappropriate for children (The Breast Milk Baby, 2011).

Because of these conflicting views, breastfeeding mothers have met with discrimination in public areas, stores, and restaurants. At a Toys “R” Us store in Times Square in New York, an employee asked a mother to move to a basement to breastfeed because there were children present. This resulted in a nurse-in at the Times Square location in 2006 (New York Civil Liberties Union, 2006). In 2004, Lori Charkoudian was asked by a Starbucks store employee in Silver Spring, Maryland, to cover up or use the women’s restroom when she attempted to breastfeed her 15-month-old daughter. This also led to a nurse-in involving 30 mothers and their babies as well as family members and friends (Helderman, 2004). Similarly, a mother was ticketed for breastfeeding her son in Colorado at a beach, despite the fact that Colorado passed a law protecting breastfeeding in 2004 (The Denver Channel News, 2005). Table 89-1 provides a sum­mary of breastfeeding incidents and lactivism events.

TABLE 89-1

Summary of U.S. Breastfeeding Incidents and Related Activities

Description of Breastfeeding Incident Response Source
Brooke Ryan was asked to cover the head of her infant while breastfeeding by a waitress and manager of an Applebee’s restaurant in Lexington, Kentucky, in 2007. Both employees claimed that other customers were complaining about her breastfeeding in the restaurant. A nurse-in was held on September 8, 2007. Jonathan R. Weatherby, Jr., Associate General Counsel for Applebee’s attorney, wrote, “We regret that Ms. Ryan left without being served and would like the opportunity to personally invite her to return … we are also considering keeping blankets in the restaurants for use by breast-feeding mothers that may not have them readily available as a result of this incident.”
Danielle Glanvill was harassed twice by a female security guard for breastfeeding in the children’s section of a New York library in 2009. A written apology was granted, and the security guard was transferred to another branch.
A mother was asked to cover up while breastfeeding at a Denny’s restaurant in North Carolina. A nurse-in was held in protest on February 22, 2009.
Emily Gillette was asked to leave her Freedom Airlines flight if she would not cover her breasts while feeding her child. News of the event spurred public nurse-ins at airports around the country, and Gillette filed a complaint with the Vermont Human Rights Commission.
A lifeguard told Laurie Waldherr to leave a public pool in Washington state when she was breastfeeding at the pool’s edge for risk of bodily fluids getting into the pool. Waldherr sued the city and reached a settlement out of court.
Julie Wheelan was asked to leave a shopping mall food court in Providence, Rhode Island, by a security guard when she was breastfeeding. Wheelan suggested that the guard call the police, as she knew she was protected by law to breastfeed her child.
Dorian Ryan was ticketed for indecent exposure on July 14, 2005, at the Carter Lake Swimming beach in Larimer County, Colorado. Ryan requested an apology, and Colorado lawmakers agreed. A law passed that gives women the right to breastfeed anywhere they are allowed to be in public.
Lori Charkoudian was asked by a Silver Spring, Maryland, Starbucks store employee to cover up or use the women’s restroom when she attempted to breastfeed her 15-month-old daughter in 2004. A nurse-in was held in protest. A Starbucks spokesperson wrote, “We will instruct our Maryland store partners to inform any concerned customer that by Maryland law, mothers have the right to breastfeed in public and to suggest to the customer that they either avert their eyes or move to a different location within the store.”
Chelsi Meyerson was harassed for breastfeeding her infant at the Times Square, New York, Toys “R” Us store. An employee asked her to move to the basement to breastfeed. Chelsi refused. Four other female employees also pressed her to move to the basement. A nurse-in was held at Toys “R” Us in Times Square on September 21, 2006. The New York Civil Liberties Union informed Toys “R” Us that it had violated civil rights law when employees told Meyerson she was not allowed to breastfeed in the store and that her breastfeeding was inappropriate because there were children around. Toys “R” Us has apologized to Meyerson and informed stores of its nursing policy, which specifies that nursing women may breastfeed their children in the place “of their choice” at Toys “R” Us stores.
Cheryl Cruz was asked to cover up when breastfeeding at Universal Studios in Florida. Cruz was permitted to breastfeed. A spokesman for the park said, “We’re going to have the specific team members involved in this incident apologize to her, and we’re going to make sure that our team members know how to proceed in these kinds of situations, moving forward.”
Lori Rueger asked if she could breastfeed her baby in a Victoria’s Secret dressing room in Charleston, South Carolina. An employee told her no, it was against store policy, and suggested she go to the mall bathroom. Anthony Hebron, spokesperson for The Limited Brands in Columbus, Ohio, said, “There was an unfortunate misunderstanding in the incident involving us, but you know what, if it’s brought forth even greater things, that’s fine.”
Heather Silvis was confronted in 2008 by a Walmart employee when she attempted to breastfeed. Her shopping cart and infant were taken from her and moved to a dressing room. Two years earlier, Governor Mark Sanford signed an act protecting and promoting breastfeeding throughout the state. Walmart store management apologized to Silvis.

Action to Support Breastfeeding

Efforts to improve breastfeeding rates have included federal and state legislation, changes in workplace policies, and individual activism to draw attention to discrimination against breastfeeding mothers.

Federal Efforts

The U.S. federal government has attempted to address the need for changing breastfeeding outcomes in the United States. The U.S. national health



goals, Healthy People 2020, include objectives aimed at improving breastfeeding (CDC, 2009, 2011, 2014) (Table 89-2).

TABLE 89-2

Summary of Healthy People 2020 Goals

Healthy People 2020 Goals Results
81.9% breastfeeding initiation 17 states have met this objective
60.6% breastfeeding at 6 months 7 states have met this objective
34.1% breastfeeding at 12 months 8 states have met this objective
46.2% exclusive breastfeeding through 3 months 14 states have met this objective
25.5% exclusive breastfeeding through 6 months 6 states have met this objective
To increase the percentage of employers who have worksite lactation programs to 38% 7%
To decrease the percentage of breastfed newborns who receive formula supplementation within the first 2 days of life to 14.2% 19.4%
To increase the percentage of live births that occur in facilities that provide recommended care for lactating mothers and their babies to 8.1% 7.79%


Workplace support for breastfeeding is critical. Breastfeeding mothers need support from supervisors and co-workers and need education regarding the benefits of continued breastfeeding. Co-workers can also benefit from education about the needs of breastfeeding employees. Mothers need time and a place to breastfeed or use a breast pump while at work. Unfortunately, without regulations and policies, it is unlikely that most employers will adopt these practices. For example, Heather Burgbacher, a school teacher from Colorado, was told her contract would not be renewed after she complained about the school’s failure to accommodate her need to pump while at work (under the Colorado Nursing Mothers Act of 2008). The American Civil Liberties Union (ACLU) and the ACLU of Colorado reached a settlement in 2012 in which the


school agreed to make policy changes for employees and provided monetary compensation to Burgbacher. This was the first public settlement brought under the Colorado Nursing Mothers Act (American Civil Liberties Union, 2012).

The Health Resources and Services Administration developed the Business Case for Breastfeeding program in 2008. It includes easy steps to support breastfeeding employees, an employee’s guide to breastfeeding and working, an outreach marketing guide, and a tool kit. Representative Carolyn Maloney (D-NY) introduced the Breastfeeding Promotion Act of 2007 to amend the Civil Rights Act of 1964 to protect breastfeeding by new mothers, to provide performance standards for breast pumps, and to provide tax incentives for employers to encourage breastfeeding.

Legislation to protect the rights of working mothers was included in the passage of the U.S. Patient Protection and Affordable Care Act, Section 4207: Reasonable Break Time for Nursing Mothers, in March of 2010 under President Obama. This Act falls under Section 7 of the Fair Labor and Standard Act (FLSA) and requires employers to provide reasonable unpaid break time and a non-bathroom location (shielded from view and free from intrusion by co-workers and the public) for an employee to express milk for her child for up to 1 year after the child’s birth. To be eligible one must be an employee covered by FLSA and employed by a business with 2 or more employees and (1) does $500,000 in annual sales or business, or (2) is a hospital, care facility, school/preschool, or government agency. Employers with fewer than 50 employees are exempt if they claim undue hardship.

Increasing breastfeeding promotion among minorities is a national priority. The U.S. Department of Health and Human Services, Office on Women’s Health sponsors the campaign It’s Only Natural. This campaign is offers support to African-American women and families to better understand the benefits of breastfeeding for the family (U.S. Department of Health and Human Services, 2013).

State Efforts

Forty-nine states (West Virginia excluded) have enacted legislation to protect breastfeeding (CDC, 2014; National Conference of State Legislatures, 2011). However, the legislation varies significantly from state to state. In some states, breastfeeding is exempted from public indecency laws, and in others, breastfeeding is protected by allowing a mother to breastfeed in any private or public location (Chang & Spatz, 2006). Unfortunately, many women are not aware of their state laws and rights. Chang and Spatz (2006) advocate that nurses inform childbearing women of their rights and provide them with patient family education sheets (including both federal and state-specific legislation) before discharge from the birth hospital. These information sheets should also be available in primary care offices and urgent care facilities.


Breastfeeding Advocacy Organizations

Much breastfeeding advocacy has occurred at the grassroots level led by organizations such as La Leche League. La Leche League was established in 1958 to provide mother-to-mother support and advocacy for breastfeeding. The National Alliance for Breastfeeding Advocacy was formed as the precursor to the U.S. Breastfeeding Committee (USBC). This committee is multidisciplinary and addresses the need for nationwide advocacy as it aims to move the breastfeeding agenda forward. The USBC was incorporated in Florida in 2000. Its mission is to improve the nation’s health by working collaboratively to protect, promote, and support breastfeeding with a focus on collaboration, leadership, and advocacy (U.S. Breastfeeding Committee, 2003, 2005, 2008). USBC members consist of 46 nonprofit organizations, 8 regional breastfeeding coalitions and 7 governmental agencies that all have vested interests in breastfeeding advocacy.

Hospital Policies

Few U.S. hospitals provide evidence-based lactation care. To change infant feeding practices, the World Health Organization and UNICEF sponsored the Baby-Friendly Hospital Initiative (BFHI), is a global program designed to support and encourage hospitals to enact the most beneficial infant feeding practices. The BFHI recognizes hospitals that have achieved optimal infant feeding goals (Baby-Friendly USA, 2013). Only 172 U.S. hospitals are designated as “baby-friendly,” facilities, although there are more than 19,000 worldwide. Fewer than 7% of all U.S. births occur in baby-friendly facilities (Baby-Friendly USA, 2013). If hospital policies do not support, protect, and advocate for breastfeeding at all times, it is unlikely that women will be successful in their breastfeeding efforts. The BFHI is a designation available to birth hospitals only. Children and their mothers also may receive care at nonbirth hospitals (e.g., a children’s hospital or an adult hospital where the mother is receiving care). These hospital personnel need to be aware of the need for breastfeeding education and advocacy. Spatz (2005a, 2005b) described the need for education of nurses and physicians, hospital-wide systems for managing breast milk, and the need for evidence-based standards of care.

The Need for Breastfeeding Advocacy Education

When the lack of hospital policies supporting breastfeeding and the lack of breastfeeding education received by health care providers is considered, the need for breastfeeding education becomes apparent. A model for integration of breastfeeding content into baccalaureate nursing curricula was developed that could be used for all health care disciplines (Spatz, Pugh, & American Academy of Nursing Expert Panel on Breastfeeding, 2007). A seminar course for undergraduate nursing students at the University of Pennsylvania serves as an example. Nursing students receive 28 hours of didactic and 14 hours of clinical experience related to current research topics in breastfeeding. In the CDC Guide to Strategies to Support Breastfeeding Mothers and Babies, step two on professional education features this course as an exemplary model for educating nurses ( A solid foundation in the science of breastfeeding makes nurses better prepared to serve as breastfeeding advocates.

One nurse can make a big difference in breastfeeding outcomes. In a hospital, nurses can pro­vide education and support for new mothers and can also be effective in community advocacy efforts (Spatz & Sternberg, 2005). Since 1995, more than 300 students at the University of Pennsylvania have served as change agents in promoting breastfeeding. One student, who was motivated because her mother attempted breastfeeding her younger sibling born with spina bifida, wrote an article for the National Spina Bifida Association; this led to a second one published in a professional journal (Hurtekant & Spatz, 2007). Other students have targeted those not even planning to have children yet, such as presenting educational programs to their fraternity or sorority, athletic teams, and other organized groups (on and off campus). This type of advocacy work is vital because women make the decision on how they will feed their babies often before they are pregnant based on factors in their environment throughout their lifetime. Nurses are in ideal positions to influence breastfeeding in their clinical roles and as advocates in the workplace, community, and legislatures.

Discussion Questions

  1. Do you know your state’s policies and legislation related to breastfeeding? Who would you contact on the state level if you had concerns regarding a violation of a person’s rights related to breastfeeding?
  2. Consider your school, college, or university. Are there any existing policies to promote and protect breastfeeding women and their families?
  3. Working with your peers, brainstorm an advocacy project that you could implement in your community to promote or support breastfeeding. Nursing and U.S. Policy – Family and Sexual Violence Essay Papers Notes


American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):827–841.

American Civil Liberties Union [ACLU]. ACLU settles lawsuit vindicating the rights of Colorado mothers to pump breast milk in the workplace. [Retrieved September 30, 2013, from]; 2012.

Apple R. The medicalization of infant feeding in the United States and New Zealand: Two countries, one experience. Journal of Human Lactation. 1994;10(1):31–37.

Baby-Friendly USA. Find facilities. [Retrieved from]; 2013.

The Breast Milk Baby. Berjuan Toys brings the breast milk baby doll to the U.S. retailers. [Retrieved from]; 2011.

Centers for Disease Control and Prevention [CDC]. Healthy people 2020. [Retrieved from]; 2009.

Centers for Disease Control and Prevention [CDC]. Vital signs. [Retrieved from]; 2011.

Centers for Disease Control and Prevention [CDC]. Breastfeeding report card—United States, 2012. [Retrieved from]; 2014.

Chang K, Spatz DL. The family & breastfeeding laws: What nurses need to know. American Journal of Maternal Child Nursing. 2006;31(4):224–230.

The Denver Channel News. Mother ticketed for breast-feeding son in public wants apology. The Denver Channel News. 2005 [Retrieved from]

Helderman RS. Md. mom says no to coverup at Starbucks. The Washington Post. 2004 [Retrieved from]

Hurtekant KM, Spatz DL. Special considerations for breastfeeding the infant with spina bifida. Journal of Perinatal and Neonatal Nursing. 2007;21(1):69–75.

National Conference of State Legislatures. Breastfeeding laws. [Retrieved from]; 2011.

New York Civil Liberties Union. Mother’s gather at Toys-R-Us for “nurse In” celebrating right to breastfeed in public. The New York Civil Liberties Union. 2006 [Retrieved from]

Spatz DL. Breastfeeding education and training at a children’s hospital. Journal of Perinatal Education. 2005;14(1):30–38.

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Nursing and U.S. Policy – Family and Sexual Violence Essay Papers Notes

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