The ethical principle of non-malfeasance--do no harm--also directs
physicians to diagnose domestic violence.
When a diagnosis of abuse is missed, treatment is likely to be
inappropriate and potentially harmful. For instance, diagnosing
pain medications or mild tranquilizers these are contraindicated for
abuse victims because they are at an increased risk for suicide and drug
or alcohol abuse.
Failing to diagnose abuse may further the victim's sense of entrapment.
Inability to find help often causes victims to feel that there is no
escape from the violence. Failure to diagnose domestic violence
increases the patient's health risks.
The solutions to domestic violence extend into social, legal and
political realms, but the medical profession can provide a number of
important interventions. The most important contribution a
physician can make to ending the cycle of abuse and protecting the
health and welfare of a victim is in identifying and acknowledging the
abuse. This simple intervention can initiate the process whereby
the victim may seek the necessary assistance to find safety.
Other important responsibilities of health care professionals include:
providing sensitive support, clear documentation of the abuse, providing
information about options and resources, making necessary referrals
(with the patient’s consent).
DEFINITION OF DOMESTIC VIOLENCE
The Florida Statutes define domestic violence as "assault, battery,
sexual assault, sexual battery, aggravated assault, aggravated battery,
stalking and aggravated stalking or any criminal offense resulting in
physical injury or death of one family or household member by another."
Each state may define it differently, but in essence, the meaning is the
In the Florida Statutes,
"Family or household member" means: spouse, former spouse, persons
related by blood or marriage, persons who are presently residing
together, as if a family, persons who have resided together in the past,
as if a family, and persons who have a child in common regardless of
whether they have been married or have resided together at any time."
Persons in other states should review their State's statutes for a
PATTERNS OF DOMESTIC VIOLENCE
Domestic violence is not an isolated
individual event, but rather a pattern of perpetrator behaviors used
against a victim. It includes physical assaults, sexual assaults,
and psychological assaults such as threats of violence and harm, attacks
against property or pets or other acts of intimidation, emotional abuse,
isolation, use of children , and use of economics.
Domestic violence is
purposeful, coercive behavior. The abuse is directed at achieving
compliance from or control over the victim. The pattern is not
random or "out of control" behavior. Perpetrators who minimize or
excuse their behavior by claiming they "lost it" or "were out of
control" have actually made specific choices. For example, they
may be violent only toward their victim even though they may be in
conflict with other people such as their boss or other family members.
Some will break only the victim's possessions and not their own.
Some will hit only in private. Such decision-making indicates they
are actually in control of their abusive behaviors.
CAUSES OF DOMESTIC VIOLENCE
Domestic violence is learned behavior. It is learned
through observation and reinforcement. Like other forms of
aggression, domestic violence is not caused by mental illness or
genetics. It is a behavior that is learned over time through multiple
observations and interactions with individuals and institutions.
It is learned through direct observation (e,g., the male child
witnessing the abuse of his mother by his father or from the
proliferation of images of violence against women in the media).
It is also learned through the reinforcement of the perpetrators'
experiences (e.g., perpetrators receiving peer support or not being held
responsible, arrested, prosecuted, or sentenced appropriately for their
violence). Domestic violence is repeated because it works. Thus,
the pattern of behavior is reinforced.
Domestic violence is not
caused by alcohol and other drugs. Many people use or abuse drugs
without ever battering their partners. While research studies have
found high correlations between aggression and the consumption of
various substances, there is no data clearly proving a cause-and-effect
Domestic violence is not caused by anger.
Many abuse episodes occur when the perpetrator is not angry and is, in
fact, calm. The role of anger in domestic violence is complex and
cannot be simplistically reduced to one of cause-and-effect.
Domestic violence is not caused by stress.
Life is filled with many different sources of stress and people respond
to stress in a wide variety of ways. People choose ways to reduce
stress according to what they have learned about strategies that have
worked for them in the past.
It is important to hold individuals responsible for
the choices they make regarding how they reduce stress, especially when
those choices involve violence or other illegal behaviors. A
robbery or mugging by a stranger is not excused simply because the
perpetrator claims he is stressed. Similarly, the perpetrator of
domestic violence cannot be excused simply because he is stressed.
Since domestic violence is a variety of tactics repeated over time for
the purpose of controlling the victim, specific stresses are less
meaningful in explaining a longitudinal pattern of abusive control.
Domestic violence is not caused by the
victim's behavior or by the relationship. Focusing on the
relationship or the victim's behavior as an explanation for domestic
violence removes the perpetrator's responsibility for the violence and
supports his minimization, denial, blaming, and rationalization for the
BARRIERS TO INTERVENTION IN DOMESTIC
Studies have indicated that physicians
persist in believing several societal myths, the most harmful being:
domestic violence is rare,
domestic violence does not occur in relationships that
domestic violence is a private matter that should be
resolved without outside
battered women are responsible for their abuse.
In one study of a group of primary care
physicians in an effort to determine why doctors avoid confronting
abuse, more than one-third of the doctors compared dealing with abuse to
opening a ‘can of worms’ or opening ‘Pandora's box.’ The evils
they feared unleashing were expressed as: too close for comfort, fear of
offending, powerlessness, loss of control, tyranny of time (Sugg & Inui,
Too close for comfort :
Almost 40 percent of the doctors in the survey
identified with their patients and assumed that patients with
backgrounds similar to their own (white, middle-class) could not be at
risk for violence. Spouse abuse is found at all socioeconomic and
educational levels and in all ethnic and occupational groups.
Fear of offending :
More than half the doctors in the study feared
offending their patients by raising the subject of abuse, although they
did raise the subject more often with women in lower socioeconomic
levels. They also felt uncomfortable about dealing with private,
intimate matters such as sexual preference, sexual behavior or abuse.
Also contributing the their reluctance is the fact that women are often
very ambivalent about disclosing abuse and will sometimes later deny
that abuse occurred. In addition, physicians realize they cannot
report abuse of an adult to third parties without the consent of the
Powerlessness and Loss
Half the doctors did not know what to do about
the abuse, as there are no straightforward solutions. Sixty-one
percent of them had no training on the subject in medical school.
Also, doctors quite naturally want to "fix" whatever is ailing a
patient, and they realize that domestic violence is not so easily
Tyranny of Time:
Seventy-one percent of the doctors said that
they do not have enough time to deal with the issue of abuse so they
avoid raising the issue. They also believe that domestic violence
is not prevalent enough to be worthy of their time.
OF DOMESTIC VIOLENCE VICTIMS IN THE HEALTH CARE SETTING
There are a variety of ways in which battered
women may present to the health care setting and a variety of reasons
for which they may seek care. Clinical manifestations of abuse
include acute injuries, medical problems, complications of pregnancy and
psychiatric symptoms, as well as chronic problems related to the stress
of living with ongoing abuse and danger. Some symptoms are readily
identified as being due to domestic violence. Others are less
obvious and will only be addressed if clinicians routinely ask all women
patients about the presence of domestic violence in their lives.
Injuries range from contusions, sprains, minor
lacerations, fractures, abdominal injuries, and gun shot wounds.
Injuries may result from being punched, hit, kicked, choked, burned, or
stabbed; being thrown down stairs, against walls or out of
buildings; being hit or run over by a car.
The most common site of injuries are: the head, face, neck, and areas
that are usually covered by clothing, such as the chest, breasts and
abdomen. Maxillofacial trauma is common; including eye and ear
trauma, hearing loss, soft tissue injuries, fractures of the mandible,
nasal bones, and orbits. Injury to multiple sites is also a
frequent indication of domestic violence. Other indicators of
abuse include injuries which do not fit the provided explanation;
injuries in various states of healing; injuries with delayed
presentations, such as fading bruises or partially healed lacerations,
and complaints of injury without physical evidence of trauma.
Injuries to the extremities, such as fractures, sprains and lacerations
are more likely to be accidental than those to the head, neck, and
torso, but they too can result from battering.
Acute injuries may be the most obvious
manifestation of domestic violence, but it is often the long-term
medical and psychological consequences of battering that are the most
debilitating over time.
Pain is a common presenting symptom.
Headaches, chest pain, back pain, pelvic pain or abdominal pain may also
be symptoms of domestic violence as well as functional GI complaints.
Symptoms related to stress, anxiety or depression may also be signs of
domestic abuse. They may present with exacerbation of chronic
medical conditions such as diabetes, hypertension, or heart disease as
they may be prevented from obtaining or taking their medications or from
seeking medical care. Abuse may also expose women to serious
illness. Between 67% and 83% of HIV positive women in one clinic were or
had been in abusive relationships with men who refused to use barrier
Many women are battered during pregnancy,
which is associated with complications such as placental separation,
ante-partum hemorrhage, fetal fracture, rupture of the uterus, and
pre-term. Women may present with psychiatric manifestations of
abuse. The prevalence of abuse among women patients is even higher
in psychiatric settings than in other medical settings. In one
study, 64% of women in an inpatient psychiatric unit had experienced
physical abuse and 50% of psychiatric outpatients. Rates of suicide
attempts are higher in battered women.
While a number of studies have found significant correlations between
substance abuse and battering for both victims and perpetrators, it is
clear that substance abuse does not cause domestic violence. The
use of alcohol and drugs by battered women does seem to increase
dramatically after physical abuse begins. Up to 50% of alcoholism
in women may be precipitated by abuse.
HEALTHCARE PROVIDERS TO DOMESTIC VIOLENCE
by health care providers for domestic violence include:
Routinely inquiring about abuse
Documenting the abuse
Discussing options and resources
Providing advocacy and referral
Treating medical and mental health problems
Providing for follow-up care
Asking about abuse helps to break the
isolation a battered woman may experience and lets her know resources
are available if and when she can use them. Provision of optimal
care warrants that health care providers routinely ask all women
patients about domestic violence. Routine inquiry may allow for
intervention before injury or illness occur, and will discover patients
who are currently being battered and provide the opportunity to reduce
A. What to Ask
Many women will readily talk about the
violence they are experiencing if they feel safe and supported.
Because they may not define themselves as battered, the practitioner
should ask direct, specific questions. For example, asking "Has
your partner ever punched or kicked you?" will be more effective than
asking, "Are you being battered?"
B. How to Ask
in a way that lets the victim know that the provider takes this issue
seriously, that the victim is not alone, that the healthcare worker is
comfortable hearing about abuse, and that help is available.
Example: "We know domestic violence is a very common problem.
About 25% of women in this country are abused by their partners.
Has that ever happened to you?"
In some clinical settings, it may be more appropriate to ask indirect
questions before going on to direct questions. Example: "Have you
been under any stress lately? Are you having any problems with
your partner? Do you ever argue or fight? Do the fights ever
become physical? Are you ever afraid? Have you ever gotten
Safety issues :
The clinician's primary concern should be with
the patient's safety and privacy. Do not inquire about abuse in
the presence of any person who accompanies the patient, (including
another woman). Appearances can be deceptive--do not assume that
the person who accompanies the patient has her best interest in mind.
Some abusers threaten and intimidate health care personnel, (attempting
to keep them from seeing the patient alone).
Others are verbally or physically assaultive
to their partners in the health care setting itself Clinical staff and
security staff should be prepared and have a plan for separating the
woman from the abuser in a way that increases her safety and makes it
clear to the assailant that abusive behavior is not acceptable.
Let the woman know that the information she
gives you is confidential and, within the confines of the law, and most
importantly, will not be revealed to the batterer or anyone else without
her consent. As an example of ‘within the confines of the law,’
the state of Florida requires that domestic violence be reported to law
enforcement when the patient has an injury which appears to have been
caused by a gun, knife, firearm, or other deadly weapon. This can
vary from state to state, so those living in states other than Florida
should review the statutes within their states.
the patient says that abuse is not occurring, let her know your concerns
and be sure to provide her with a referral sheet of where she can obtain
assistance, (should she change her story). Encourage her to return
if she has problems in the future and document your concerns in the
Immediate Safety Needs:
Once a woman acknowledges that she is being abused,
there are several issues to address before proceeding to a more detailed
history and physical examination. Let her know that the violence
perpetrated against her is not her fault and that you are glad that she
confided in you.
Her immediate safety needs must be addressed.
Does she want you to call security or the police? Does she want to
keep hidden and then find a shelter? Does she have an order of
protection and does she want the abuser arrested if he shows up?
Does she need someone to pick up her children?
of Present Illness:
If a patient is being seen for an injury or
other symptoms related to an acute battering event, ask in detail about
what happened. Record the chief complaint and detail the
descriptions of the abuse, including the perpetrator, his or her
relationship and the time, date, and location of the abuse. Use
the victim's own words in quotes whenever possible. For example,
"My husband hit me with a bat" is better than "Patient has been
battered." Ask about previous abusive episodes.
and Preservation of Evidence:
Before performing the physical examination,
the woman should be asked to disrobe completely and put on a hospital
gown so that all injuries can be seen. The process of examination
and evidence collection should be explained in detail. Inform her
of each step you are about to take so that the exam itself does not
become another traumatic experience. It is important to express
compassion, maintain eye contact and convey respect to the patient.
Perform a thorough physical exam including
neurologic exam and mental status exam if indicated. Be sure to
palpate for areas of tenderness which may be manifestations of injuries
not yet visible, such as scalp hematomas and deep bruises.
Evaluate and describe
Include in your description the type of injuries, the
number, size, and location using a body map. Indicate the degrees of
resolution, possible causes, and explanations given. Be specific,
(e.g., contusions and lacerations to the throat will support allegations
of attempted strangling).
If the patient indicates there has been a recent sexual assault, assess
for evidence of forced sexual activity, including injuries to the
genitalia and restraint marks on the skin. Assess for emotional
trauma and lack of barrier protection (e.g., STDS,
contraception/pregnancy status, exposure to HIV).
Record non-bodily evidence of torn clothing and broken jewelry.
Preserve as evidence bloodied clothing, foreign objects or objects used
as weapons. Get permission from the patient to preserve these
items after explaining that evidence may be necessary for legal
documentation now or in the future. Have her sign a release of
information form and explain the conditions under which the evidence can
be released (with her consent or by a court order). Place the
evidence in a sealed paper bag. Each wet or bloodstained item
should be placed in a separate bag. The patient's name, medical
record number, date and time of evidence collection, as well as a
listing of the contents, should be attached to the individual bags.
In cases where you are concerned that abuse may be
occurring, but the woman denies it, be sure to note in the chart whether
the injuries are compatible with her explanation. This may help
clarify the situation at a future visit as well as provide documentation
in the event that she decides to pursue legal action.
If the woman expresses suicidal ideation,
obtain an emergency psychiatric evaluation. She should also be evaluated
for homicidal ideation. Check with your legal counsel for the law
in your state pertaining to patient/provider confidentiality when
homicide or suicide is a distinct possibility. Most women who kill their
partners have been severely abused for long periods of time and see no
other way out. They kill in self defense or to prevent the murder
or serious injury of themselves or their children.
Photographs are particularly valuable as evidence. The health care
provider should ask the patient for permission and obtain written
consent to take photographs. Explain that the photos will become
part of her medical record and can only be released to the police or
prosecutor with her written permission or by court order. Let her
know that if a case should be filed against the assailant at some point
in the future, photographs will be very useful evidence.
It is advisable to have the patient return for
more photos in a few days after bruises and swelling become more
apparent. Polaroid photos are preferred because they can be
attached to the medical record at the time of the patient's visit, thus
decreasing the chance they will be misplaced. A pre-printed
or hand-drawn body map can be very useful to document injuries which may
not show up well in photographs. X-rays showing old injuries can support
a past history of abuse.
IF A VICTIM CHOOSES NOT TO LEAVE THE
It can be very frustrating to anyone who works
with victims of domestic violence when the victim returns to the abusive
situation. It should be understood that most of the time, leaving
the situation is a process. One of the biggest reasons for
remaining in the relationship is the hope that the abusive partner will
change. The women are in committed relationships and have often
built their lives around the relationship, and they hope change will
occur. It is noteworthy that the most likely predictor of whether
a battered woman will permanently separate from her abuser is whether
she has the economic resources to survive without him.
Therefore, it is extremely important that
battered women obtain support awards in protection orders and are
referred to battered women's programs where they can learn about other
economic supports, job training and employment opportunities.
discussion of domestic violence would be complete without addressing the
problem of child abuse. Partner abuse and child abuse frequently
co-exist. Several studies have shown that between 45 and 70
percent of men who battered a wife or girlfriend also abused a child.
(Jones, 1994). The true incidence of child abuse is unknown, but
it is conservatively estimated that over 1,000,000 children nationwide
are abused and/or neglected annually.
PATTERNS OF MALTREATMENT
Analysis of official reports of abuse and
neglect shows that physical abuse occurs in all age groups but the
highest proportion was in age group 12 to 17 years. The incidence
of physical neglect was highest in the youngest age group, birth to 2
years. Maltreatment occurs equally in male and female children.
Report analysis showed that Caucasians constituted about two-thirds of
the total reported cases for all forms of maltreatment and blacks about
one-fifth. In cases of physical abuse and neglect, whites
outnumbered blacks by about 6 to I (Star, 1987).
Although child abuse occurs in all
socioeconomic strata, an association was shown between income and
maltreatment. Seventy-nine (79) percent of physical abuse cases
occurred in homes with income under $15,000 as compared with 2.7 percent
in homes with income of $25,000 or more. Ninety-one (91) percent
of physical neglect cases had incomes of less than $15,000 (Star, 1987).
The vast majority of perpetrators are natural parents (85%). The
female is more likely to maltreat the children than is the male.
Females were the perpetrators in 66 percent of physical abuse cases and
83 percent of physical neglect cases (Star, 1987).
PHYSICAL AND MEDICAL INDICATORS OF
ABUSE AND NEGLECT
Intentionally inflicted injuries can often be
differentiated from accidental injuries. A synopsis of physical
and medical indicators of abuse and neglect is attached. The
health care provider should document injuries and collect evidence in a
manner similar to that of adult victims of abuse.
MANDATORY REPORTING OF SUSPECTED CHILD
ABUSE / NEGLECT
Each state has mandatory reporting law which
require health care providers to report suspected child abuse or
PHYSICAL AND MEDICAL INDICATORS OF
ABUSE AND NEGLECT
Surface Skin Marks:
The location of the injury is a significant
criterion which can aid identification of its origin. Injuries
to the thighs, calves, genitals, buttocks, cheeks, earlobes, lips,
neck and back are more likely a result of abuse than injuries to the
elbows, knees, shins and hands, which are frequently incurred
accidentally. Bruises over the bony parts of the child's body (e.g.,
chin and forehead) are common sites for falling injuries.
Bruises to any infant should be particularly suspect given the
infant's limited mobility and opportunity for self harm.
B. Objects Causing Skin
The shape of a surface skin
mark or pattern of skin marks provide other clues to origin.
Bruises which have distinct configurations or which resemble
instruments should be immediately suspect. Samples of objects
which cause distinct surface skin marks include: