Scope of a Hidden Problem

When a patient comes to your office do you ask her about her bruises? Do you encourage her to tell you more about how she got her injuries? Should you? And what would you do if you discovered that her injuries were the result of domestic violence?

"Domestic abuse," "domestic violence," and "partner violence" are all terms describing a pattern of assaultive and coercive behaviors within dating, intimate, or cohabiting relationships, or even relationships that have ended. The common thread in cases of domestic violence is a pattern of controlling behaviors meant to intimidate or dominate the victim, behaviors that may include actual or threatened physical injury, sexual assault, psychological abuse, economic control, and progressive social isolation.

Every year, one to two million women in the U.S. are victims of partner abuse. According to some studies, 30% of women have suffered domestic violence, and one in seven seen in general internal medicine clinics has recently experienced domestic violence. A 1995 JAMA

study found that one in nine women, currently in a relationship, who seeks care in emergency facilities has suffered abuse that prompted that visit regardless of the stated reason for coming. That study also found that 54% of all women seen in emergency facilities have been in a violence or abusive relationship.

Domestic violence occurs in every age group, race, culture, and social class, and in all types of relationships, including lesbian and gay couples. Occasionally it is the woman who abuses a male partner. The victim and perpetrator can be dating or cohabiting, and may be married, separated, or divorced. Most victims are women in heterosexual relationships and women who are young, unmarried, and of lower socioeconomic status appear to have higher rates of victimization.

Partner abuse has complex individual, social, and cultural underpinnings. Effective intervention requires knowing more than simply how to diagnose and treat the associated medical problems. Communicating with empathy and compassion is crucial, as is being mindful of patients’ and caregivers’ emotional needs and physical safety.

Source: Hippocrates. March 2000. Vol. 14, No. 3

Myth #1 — Battering is rare.

FACT: Battering is extremely common. The FBI estimates that a woman is battered every 9 seconds in the United States. A 1993 study found that 1 out of 20 women had experienced domestic violence in the previous year, and 1 out of 5 women had experienced it in their adult lives.

Myth #2 — Domestic violence occurs only in poor, undereducated, dysfunctional, or minority families. It could never happen to anyone you know.

FACT: Domestic violence crosses all age, ethnic, socioeconomic, religious, and educational boundaries. There is no "typical" violent family. There are doctors, ministers, psychologists, police, attorneys, judges, and other professionals who beat their wives. At least one third of all married women have been physically abused by their husbands or ex-husbands.

Myth #3 — Battering is about couples getting into a brawl on Saturday night, pushing each other around, and totally disrupting the neighborhood.

FACT: While physical abuse is common, women are also abused emotionally, sexually, and psychologically. Domestic violence is not "mutual assault" or two people yelling, scratching, and pulling each other’s hair. It is one partner beating, intimidating, and terrorizing the other. It’s one person dominating and controlling the other.

Myth #4 — The problem is not simply woman abuse, but spouse abuse. Women are just as violent as men.

FACT: In approximately 95% of domestic assaults, the man is the perpetrator. Women are 13 times more likely to be the victim in cases of spousal abuse. Sixty percent of men who were killed by their wives were killed as they were assaulting or threatening to injure or kill the woman. This fact may make us uncomfortable.

To end domestic violence, we must examine the historic and legal permission men have been given to be violent in general, and to be violent towards their wives and children specifically. There are rare cases where a woman batters a man. Survivors of abuse in such relationships must hear that their abuse is just as valid and serious. Battering also occurs in lesbian and may male relationships. Domestic violence throughout life is experienced as child abuse neglect, dating violence, spouse abuse, elder abuse, and abuse of the disabled. The National Domestic Violence Hotline states that violence is unacceptable in all intimate relationships and provides services to any person who has been victimized.

Myth #5 — Where there is violence in the family, all family members are at fault to a certain extent, and therefore all must change for the violence to stop.

FACT: Only the perpetrator has the ability to stop the violence. Battering is an attitude and chosen behavior. Many battered women try to change their own behavior and their children’s hoping that this will stop the abuse. This does not work. Changes in family members’ behavior will not cause or influence the batterer to be non-violent.

Myth #6 — Domestic violence is usually a one-time isolated incident where the abuser simply lost control.

FACT: Battering is a pattern, a reign of force and terror. Once violence begins in a relationship, it gets worse and more frequent over a period of time. Battering is not just one physical attack. It is a number of tactics (intimidation, threats, economic deprivation, psychological and sexual abuse) used repeatedly. Physical violence is just one of these tactics. Experts have compared methods used by batterers to those used by terrorists to brainwash hostages. This is called the "Stockholm Syndrome."

Myth #7 — Battered women always stay in abusive relationships.

FACT: Many battered women leave their abusers permanently, and despite many obstacles, succeed in building a life free of violence. Almost all battered women leave at least once. The perpetrator dramatically escalates his violence when a woman leaves (or tries to), because it is necessary for him to reassert control and ownership. Battered women are often very active on their own behalf. Their efforts often fail because the batterer continues to assault, and society refuses to provide needed protection and resources.

Myth #8 — Feminist propaganda says the abuser is never punished, but the community does place responsibility for violence where it belongs — on the criminal.

FACT: Most people blame the victim of battering for the crime, some without realizing it. They expect the woman to stop the violence, and repeatedly analyze her motivations for not leaving, rather than scrutinizing why the barterer keeps beating her, and why the community allows it.

Myth #9 — Drinking causes battering.

FACT: One of the myths about abuse is that it is caused by alcohol, drugs, unemployment, or the stress of day-to-day living. Although these are often factors, they can more accurately be viewed as triggers, not as causes. Many men experiencing these issues do not batter,

whereas a man who has violently attacked his wife may blame his actions on any number of incidents, even a trivial or invented one. A person who is potentially violent may drink in order to give himself an excuse for violent actions. Some men who batter when drinking later stop drinking but continue to batter, switching to some other excuse.

Myth #10 — Stress causes domestic violence.

FACT: Many people who are under extreme stress do not assault their partners. Assailants who are stressed at work do not attack their co-workers or bosses. Just as with drinking, abusers often use stress as an excuse for their violence.

Myth #11 — Men who batter do so because they cannot control themselves or because they have "poor impulse control".

FACT: Men who batter are usually not violent toward anyone but their wives/partners or their children. They can control themselves sufficiently enough to pick a safe target. Men often beat women on parts of their bodies where bruises will not show. Many assaults are planned and can last for hours.

Myth #12 — If a battered woman really wanted to leave, she could just call the police.

FACT: Police traditionally have been reluctant to respond to domestic assaults, or to intervene in what they think is a private matter. They temporarily separate the couple, leaving the woman vulnerable to further violence. Laws have been improved, but considerable change is still needed in law enforcement and the court system.

Myth #13 — If a battered woman really wanted to leave, she could easily get help from her minister or other clergy.

FACT: Some priests, clergy, and rabbis have been extremely supportive of battered women. Others ignore the abuse, are unsupportive, or actively support the assailant’s control of his partner, basing their defense on a man’s religious right as head of the household.

Myth #14 — Batterers are often good fathers and should have joint custody of their children.

FACT: Nearly 90% of children who grow up in abusive homes witness their father assault their mother. Forty to sixty percent of batterers also abuse their children. Nearly 50% of abusive husbands batter their pregnant wives with blows to the pregnant abdomen, resulting miscarriage, premature delivery, or fetal injury.

Myth #15 — If a battered woman really wanted to leave, she could just pack up and go some place.

FACT: Battered women considering leaving their assailants are faced with the very real possibility of severe physical injury or even death. Batterers deliberately isolate their partners and deprive them of money, opportunities for acquiring education, job skills, or work. This combined with unequal opportunities for women in general and lack of affordable childcare, make it excruciatingly difficult for women to leave.

Behavioral Characteristics of Abusers

This is a list of behaviors seen in people who beat their intimate partners. The last four signs are almost always seen only if the person is a batterer. If the person has several of the other behaviors (say three or more) there is a strong potential for physical violence; the more signs the person has, the more likely the person is a batterer. In some cases, a batterer may have only a couple of behaviors that the woman can recognize, but they are very exaggerated (e.g., extreme jealousy over ridiculous things). At first the batterer will try to explain his behavior as signs of his love and concern, and the woman may be flattered; as time goes on, the behaviors become more severe in order to dominate the woman.

1. JEALOUSY: At the beginning of a relationship, an abuser will always say that his jealousy is a sign of love; jealousy has nothing to do with love, it’s a sign of insecu- rity and possessiveness. He will question the woman about who she talks to, accuse her of flirting or be jealous of time she spends with family, friends or children. As jealousy progresses, he may call her frequently during the day or drop by unexpect- edly. He may refuse to let her work for fear she’ll meet someone else, or even check her car mileage or ask friends to watch her.
2. CONTROLLING BEHAVIOR: At first, the batterer will explain his behavior in terms of his concern for the woman’s safety, her need to use her time well, or her need to make good decisions. He will be angry if the woman is "late" coming back from the store or an appointment; he will question her closely about where she went, who she talked to. As this behavior worsens, he may not let the woman make per- sonal decisions about the house, her clothing, about going to the church; he may keep all the money or even make her ask permission to leave the house or room.
3. QUICK INVOLVEMENT: Many battered women dated or knew their abuser for less than six months before they were engaged or living together. He comes on like a whirlwind claiming "love at first sight," and he will tell the woman flattering things such as "you’re the only person I could ever talk to," "I’ve never felt loved like this by anyone." He needs someone desperately, and he’ll pressure the woman to commit to him.
4. UNREALISTIC EXPECTATIONS : He is very dependent on the woman for all his needs; he expects her to be a perfect wife, mother, lover, friend. He will say things like "if you love me, I’m all you need— you’re all I need." She is supposed to take care of everything for him emotionally and physically.
5. ISOLATION: The man tries to cut the woman off from all resources. If she has men friends, she is a "whore," if she has women friends, she is a "lesbian;" if she is close to her family, she is "tied to the apron strings." He accuses people who are her supporters of "causing trouble;" he may want to live in the country without a phone, he may not let her use the car, or he may try to keep her from working or going to school.
6. BLAMES OTHERS FOR HIS PROBLEMS: If he is chronically unemployed, someone is always doing him wrong, or "they" are out to get him. He may make mistakes and then blame the woman for upsetting him and keeping him from concen- trating or doing his job. He will tell the woman she is at fault for all that goes wrong.
7. BLAMES OTHERS FOR HIS FEELINGS: He will tell the woman "you make me mad," "you’re hurting me by not doing what I ask," "I can’t help being angry." He really makes decisions about what he thinks and how he feels, but will use words to manipulate the woman.
8. HYPERSENSITIVITY: The man is easily insulted, he claims his feelings are hurt when he’s really very mad, or he takes the slightest setback as a personal attack. He will rant and rave about the injustice of things that have happened to him—things that are just part of living, like being asked to work overtime, getting a traffic ticket, being asked to help with chores, etc.
9. CRUELTY TO ANIMALS AND CHILDREN: This is a man who punishes ani- mals brutally or is insensitive to their pain or suffering; he may expect children to be capable of doing things far beyond their ability (whips a two-year-old for wetting a diaper) or may tease children or young brothers/sisters until they cry (60 percent of the men who beat women they are with also beat their children). He may not want children to eat at the table or he may expect them to stay in their room all evening when he is at home.
10. "PLAYFUL" USE OF FORCE DURING SEX: This man may like to throw the woman down and hold her down during sex. He may want to act out fantasies during sex where the woman is helpless. He’s letting her know that the idea of "rape" excites him. He may show little concern about whether the woman wants to have sex and use sulking or anger to manipulate her into compliance. He may start having sex with the woman while she is sleeping, or demand sex when she is ill or tired.
11. VERBAL ABUSE: In addition to saying things that are meant to be cruel and hurt- ful, this can be seen by the man degrading the woman, cursing her, running down any of her accomplishments. The man will tell her that she’s stupid and unable to function without him. This may involve waking her up to verbally abuse her or not letting her go to sleep.
12. RIGID SEX ROLES: The man expects a woman to serve him; he’ll say she must stay at home, that she must obey him in all things—even things that are criminal in nature. The abuser will see woman as inferior to man, stupid, unable to be a whole person outside of a relationship.
13. DR. JEKYLL AND MR. HYDE: Many women are confused by their abuser’s "sudden" changes in mood—they’ll describe that one minute he’s nice and the next minute he explodes or one minute he’s happy and the next minute he’s sad. This does not indicate some mental problem or that he’s crazy. Explosiveness and mood swings are typical of men who beat their partners, and these behaviors are related to other characteristics such as hypersensitivity. Explosiveness and mood swings are simply two of the control tactics used by batterers.
14. PAST BATTERING: The man may say he has hit women in the past, but claims they made him do it. The woman may hear from relatives or ex-spouses that the man is abusive. A batterer will beat any woman he is with; situational circumstances do not make a person an abuser.
15. THREAT OF VIOLENCE: This would include any threat of physical force meant to control a woman: "I’ll slap your mouth off," "I’ll kill you," "I’ll break your neck." Most men do not threaten their mates, but a batterer will try to excuse this behavior by saying "everybody talks like that."
16. BREAKING OR STRIKING OBJECTS: This behavior is used as a punishment- (breaking loved possessions) but is mostly used to terrorize the woman into submis- sion. The man may beat on a coffee table with his fist, throw objects around or near the woman. Again, this is a very unusual behavior; only very immature people beat on objects in the presence of other people in order to threaten them.
17. USE OF FORCE DURING AN ARGUMENT: This may involve a man holding a woman down, physically restraining her from leaving the room, and pushing or shoving. The man may hold the woman against a wall and say "you’re going to listen to me."

Source: New Mexico Coalition Against Domestic Violence

Domestic violence is a significant, underlying cause of poor health and is well-documented as a serious public health issue. Domestic violence can take many forms. It can include physical, sexual, economic, emotional, social and/or psychological abuse. In addition to being at increased risk for physical harm, victims of all forms of domestic violence are at risk for other complications which eventually lead to the need for medical care and other services.

The following definition of domestic violence is generally accepted by social scientists:

"Domestic violence is a pattern of coercive behavior which can include physical, sexual, economic, emotional and/or psychological abuse exerted by an intimate partner over another with the goal of establishing and maintaining power and control."

Although the vast majority of reported victims of domestic violence are female, providers should seek to identify and screen all potential victims regardless of their gender, age or other demographic characteristics, the gender of their partner(s) or the relationship between the potential victim and abuser. Domestic violence occurs in all communities and can be found in all types of relationships.

There are numerous complications of domestic violence of which a medical professional should be aware.

Other outcomes of domestic violence that can affect physical health and well-being of individuals, their children and others close to them can include loss of housing, withdrawal of financial support, isolation or loss of contact with and support from family and friends, custody retaliation and withholding access to health care or medications.

Diagnosis of domestic violence is challenging because victims can present with a variety of symptoms and physical findings. Studies show that individuals often hope to be asked whether they have been abused and, if asked in a caring and sensitive fashion, will often discuss their history of abuse.

Assessing risk of domestic violence is a requirement in some settings, for example, hospitals, local departments of social services, etc. The need for healthcare professionals to recognize and treat family violence has been formally noted by the American Academy of Family Physicians, the American Medical Association, the American College of Obstetrics and Gynecology, and the American College of Nurse Midwives. In contrast to official recommendations, studies show that domestic violence assessment is still not a routine medical practice.

Additionally, health care providers do not generally recognize men as being subject to domestic violence, even when confronted by evidence of physical or sexual assault. Further, health care providers generally do not consider the possibility of domestic violence among gay or lesbian relationships or with people who are of transgender experience or who are bisexual. More often, injuries are incorrectly assumed to be the result of "lifestyle choices."

Domestic violence risk assessment is a standard of care and should be discussed in general intake procedures in all health and human service settings, including counseling and testing sites.

All discussions related to domestic violence screening should be held in private. In no instance should domestic violence discussions occur in the presence of a parent, guardian, adult or child who accompanies the individual seeking health care. Any individual escorting the person may be the perpetrator of domestic violence or may be an individual whose presence inhibits the person seeking help from discussing domestic violence with the provider. Accompanying individuals should simply be told that the provider needs to meet alone with each person and they should be asked to remain in the waiting area. In addition, if a language interpreter is necessary, such services must be provided by a professional or a party unknown to the person seeking health care.

Discussion of domestic violence concerns should be introduced during patient intake, medi

cal history or health assessment in a general fashion using simple statements such as:

Additional questions should be used to further assess the extent to which an individual may be subjected to various forms of abuse. Such questions may include:

0Pushed, grabbed, slapped, choked or kicked you?

0Forced you to have sex or made you do sexual things you didn’t want to?

0Threatened to hurt you, your children or someone close to you?

0Stalked, followed or monitored you?

When an individual informs the provider of a domestic violence concern, provider support of the individual’s decision to discuss domestic violence is important. There are many ways that providers can express support and concern. Support and concern can be expressed as follows:

Any time a risk of domestic violence is determined, providers should ensure that referrals are provided for domestic violence support services and a more comprehensive assessment of risks and needed services. Community resources can include licensed domestic violence service providers, a domestic violence hot line, licensed domestic violence programs (both residential and non-residential), support groups for victims of domestic violence, general social services, law enforcement agencies, emergency medical care and providers of legal assistance. Health and human service providers should have available a list of referral sources and telephone numbers for this purpose.

In summary, asking individuals about domestic violence can:

Source: New York State Department of Health

W hat To Do If a Suspected Victim Denies Abuse

A victim of domestic violence may choose not to disclose information about an abusive relationship during a patient interview. Physicians need to accept the patient’s response and right of self-determination and to emphasize that such questions are asked routinely because of the prevalence of domestic violence. Physicians can let the patient know that they are available as a resource for her or for someone who might be abused. Physicians need to recognize that the victim may have been subjected to years of demeaning verbal abuse and that they may be the first to tell her that no one deserves to be beaten. She may be considering the information that she is being given but may not be ready to disclose abuse.

What To Do If the Patient Discloses Abuse

Affirmative answers to domestic violence screening questions should elicit a well-rehearsed response by the healthcare support staff. Of immediate concern to both the patient and the staff is an assessment of whether the patient is in immediate danger. For example, if the perpetrator is armed with a weapon and is exhibiting aggressive behavior in the waiting room, then local police as well as hospital security officers must be summoned. If the pattern of abuse has recently escalated from verbal to physical, the patient’s safety is also at increased risk. Other family members or family pets may have been threatened or harmed. The office staff must be trained to summon help in such situations.

After immediate danger to the patient has been ruled out, a medical assessment of the patient’s injuries should be completed and other safety concerns should be addressed. For example, Will the patient be able to return for follow-up appointments? Does she have access to any community support resources? Has she told her family about the abuse? Does she have a friend whom she can call, day or night, for help? Has she spoken to an advocate from her local domestic violence agency about shelter or obtaining a restraining (protective) order? If she has left the abusive relationship, is she being stalked? Has the perpetrator made homicidal or suicidal threats as consequences to her leaving? Are her children safe? A safety planning checklist for victims of domestic violence is provided below:

Safety Planning Checklist For Victims of Domestic Violence

During a violent argument

4 Move to a space where you are least likely to be injured.

4 Avoid the kitchen, bathroom, garage, and rooms without an outside door.

Plan ahead

4 Keep emergency numbers posted.

4 Work out a signal with a neighbor to call for help.

4 Plan with your children. Work out a code word or signal and teach them how to call 911.

4 Practice ways to get out safely.

4 Park your car so that you are not blocked in.

4 Make an extra set of car keys and keep your gas tank full.

4 Even if you don’t think there will be a next time, plan three places you can go to be safe.

4 Find out about legal options and protective orders before you need them.

4 Open your own savings account at a separate bank.

Put things in their place

4 Keep extra cash and clothes where you can access them safely (at a friend’s home, at your workplace).

4 Make copies of important documents and keep them somewhere safe.

If you have a protective order

4 Keep a copy with you at all times.

4 Give copies to your children’s school or daycare facility and to your employer.

4 Report all violations to the police.

4 Change the locks.

4 Install additional locks.

4 Plan escape routes.

4 Get caller ID.

4 Work out a signal with a neighbor to call for help.

4 Notify police so they know your situation.

Safety at work

4 Use voice mail or have someone screen your calls.

4 Notify security or your supervisor.

4 Make a safety plan with coworkers to deal with your particular situation.

4 Connect with old friends. Join a support group.

4 Call the local domestic violence hotline.

4 The use of alcohol or drugs reduces awareness and the ability to act quickly to protect yourself and your children. Batterers often use alcohol or drugs as an excuse for their violent behavior.

Break the silence

4 Tell your family members, friends, neighbors, coworkers, and physician about the abuse. Remember that isolation increases your risk.

Source: Postgraduate Medicine. Vol. 108, No. 2, August 2000