In Birdy's Eyes:

Domestic Violence

-Birdy

The Exact Definition: Assaultive behavior intended to punish, dominate, or control another in an intimate family relationship; physicians are often best able to identify situations of domestic violence and assist victims to implement preventive interventions.



KEY ISSUES:

The cycle of violence: A repeating pattern of violence characterized by increasing tension, culminating in violent action, and followed by remorse

Family violence: Violence against a family member, typically to assert domination, control actions, or punish, which occurs as a pattern of behavior, not as a single, isolated act; also called battering, marital violence, domestic violence, relationship violence, child abuse, or elder abuse

Funneling: An interviewing technique for assessing violence in a patient’s relationship, beginning with broad questions of relationship conflict and gradually narrowing to focus on specific violent actions

Hands-off violence: Indirect attacks meant to terrorize or control a victim; may include property or pet destruction, threats, intimidating behavior, verbal abuse, stalking, and monitoring

Hands-on violence: Direct attacks upon the victim’s body, including physical and sexual violence; comprises a continuum of acts ranging from seemingly minor to obviously severe

Lethality: The potential, given the particular dynamics of violence in a relationship, for one or both partners to be killed

Safety planning: The development of a specific set of actions and strategies to enable a victim either to avoid violence altogether or, once violence has begun, to escape and minimize damage and injury

The Causes and The Symptoms:

Domestic or family violence is the intentional use of violence against a family member. The purpose of the violence is to assert domination, to control the victim’s actions, or to punish the victim for some actions. Family violence generally occurs as a pattern of behavior over time rather than as a single, isolated act.
Forms of family violence include child physical abuse, child sexual abuse, spousal or partner abuse, and elder abuse. These forms of violence are related, in that they occur within the context of the family unit. Therefore, the victims and perpetrators know one another, are related to one another, may live together, and may love one another. These various forms of violence also differ insofar as victims may be children, adults, or frail, elderly adults. The needs of victims differ with age and independence, but there are also many similarities between the different types of violence. One such similarity is the relationship between the offender and the victim. Specifically, victims of abuse are always less powerful than abusers. Power includes the ability to exert physical and psychological control over situations. For example, a child abuser has the ability to lock a child in a bathroom or to abandon him or her in a remote area in order to control access to authorities. A spouse abuser has the ability to physically injure a spouse, disconnect the phone, and keep the victim from leaving for help. An elder abuser can exert similar control. Such differences in power between victims and offenders are seen as a primary cause of abuse; that is, people batter others because they can.

Families that are violent are often isolated. The members usually keep to themselves and have few or no friends or relatives with whom they are involved, even if they live in a city. This social isolation prevents victims from seeking help from others and allows the abuser to establish rules for the relationship without answering to anyone for these actions. Abuse continues and worsens because the violence occurs in private, with few consequences for the abuser.

Victims of all forms of family violence share common experiences. In addition to physical violence, victims are also attacked psychologically, being told they are worthless and responsible for the abuse that they receive. Because they are socially isolated, victims do not have an opportunity to take social roles where they can experience success, recognition, or love. As a result, victims often have low self-esteem and truly believe that they cause the violence. Without the experience of being worthwhile, victims often become severely depressed and anxious, and they experience more stress-related illnesses such as headaches, fatigue, or gastrointestinal problems.

Child and partner abuse are linked in several ways. About half of the men who batter their wives also batter their children. Further, women who are battered are more likely to abuse their children than are non-battered women. Even if a child of a spouse-abusing father is not battered, living in a violent home and observing the father’s violence has negative effects. Such children often experience low self-esteem, aggression toward other children, and school problems. Moreover, abused children are more likely to commit violent offenses as adults. Children, especially males, who have observed violence between parents are at increased risk of assaulting their partners as adults. Adult sexual offenders have an increased likelihood of having been sexually abused as children. Yet, while these and other problems are reported more frequently by adults who were abused as children than by adults who were not, many former victims do not become violent. The most common outcomes of childhood abuse in adults are emotional problems. Although much less is known about the relationship between child abuse and future elder abuse, many elder abusers did suffer abuse as children. While most people who have been abused do not themselves become abusers, this inter-generational effect remains a cause for concern.

In its various forms, family violence is a public health epidemic in the United States. Once thought to be rare, family violence occurs with high frequency in the general population. Although exact figures are lacking and domestic violence tends to be under-reported, it is estimated that each year 1.9 million children are physically abused, 250,000 children are sexually molested, 1.6 million women are assaulted by their male partners, and between 500,000 and 2.5 million elders are abused. Rates of violence directed toward unmarried heterosexual women, married heterosexual women, and members of homosexual male and female couples tend to be similar. No one is immune: Victims come from all social classes, races, and religions. Partner violence directed toward heterosexual men, however, is rare and usually occurs in relationships in which the male hits first.

Because family violence is so pervasive, physicians encounter many victims. One out of every three to five women visiting emergency rooms is seeking medical care for injuries related to partner violence. In primary care clinics, including family medicine, internal medicine, and obstetrics and gynecology, one out of every four female patients reports violence in the past year, and two out of five report violence at some time in their lives. It is therefore reasonable to expect all physicians and other health care professionals working in primary care and emergency rooms to provide services for victims of family violence.
Family violence typically consists of a pattern of behavior occurring over time and involving both hands-on and hands-off violence. Hands-on violence consists of direct attacks against the victim’s body. Such acts range from pushing, shoving, and restraining to slapping, punching, kicking, clubbing, choking, burning, stabbing, or shooting. Hands-on violence also includes sexual assault, ranging from forced fondling of breasts, buttocks, and genitals; to forced touching of the abuser; to forced intercourse with the abuser or with other people.

Hands-off violence includes physical violence that is not directed at the victim’s body but is intended to display destructive power and assert domination and control. Examples include breaking through windows or locked doors, punching holes through walls, smashing objects, destroying personal property, and harming or killing pet animals. The victim is often blamed for this destruction and forced to clean up the mess. Hands-off violence also includes psychological control, coercion, and terror. This includes name calling, threats of violence or abandonment, gestures suggesting the possibility of violence, monitoring of the victim’s whereabouts, controlling of resources (such as money, transportation, and property), forced viewing of pornography, sexual exposure, or threatening to contest child custody. These psychological tactics may occur simultaneously with physical assaults or may occur separately. Whatever the pattern of psychological and physical tactics, abusers exert extreme control over their partners.

Neglect the failure of one person to provide for the basic needs of another dependent person is another form of hands-off abuse. Neglect may involve failure to provide food, clothing, health care, or shelter. Children, older adults, and developmentally delayed or physically handicapped people are particularly vulnerable to neglect.

Family violence differs in two respects from violence directed at strangers. First, the offender and victim are related and may love each other, live together, share property, have children, and share friends and relatives. Hence, unlike victims of stranger violence, victims of family violence cannot quickly or easily sever ties with or avoid seeing their assailants. Second, family violence often increases slowly in intensity, progressing until victims feel immobilized, unworthy, and responsible for the violence that is directed toward them. Victims may also feel substantial and well-grounded fear about leaving their abusers or seeking legal help, because they have been threatened or assaulted in the past and may encounter significant difficulty obtaining help to escape. In the case of children, the frail and elderly, or people with disabilities, dependency upon the caregiver and cognitive limitations make escape from an abuser difficult. Remaining in the relationship increases the risk of continued victimization. Understanding this unique context of the violent family can help physicians and other health care providers understand why battered victims often have difficulty admitting abuse or leaving the abuser.

Family violence follows a characteristic cycle. This cycle of violence begins with escalating tension and anger in the abuser. Victims describe a feeling of “walking on eggs.” Next comes an outburst of violence. Outbursts of violence sometimes coincide with episodes of alcohol and drug abuse. Following the outburst, the abuser may feel remorse and expect forgiveness. The abuser often demands reconciliation, including sexual interaction. After a period of calm, the abuser again becomes increasingly tense and angry. This cycle generally repeats, with violence becoming increasingly severe. In partner abuse, victims are at greatest risk when there is a transition in the relationship such as pregnancy, divorce, or separation. In the case of elder abuse, risk increases as the elder becomes increasingly dependent on the primary caregiver, who may be inexperienced or unwilling to provide needed assistance. Without active intervention, the abuser rarely stops spontaneously and often becomes more violent.

Specific Treatment and Therapy For the Abuser:

Physicians play an important role in stopping family violence by first identifying people who are victims of violence, then taking steps to intervene and help. Physicians use different techniques with each age group because children, adults, and older adults each have special needs and varying abilities to help themselves. This section will first consider the physician’s role with children and will then examine the physician’s role with adults and older adults.

Because children do not usually tell a physician directly if they are being abused physically or sexually, physicians use several strategies to identify child and adolescent victims. Physicians screen for abuse during regular checkups by asking children if anyone has hurt them, touched them in private places, or scared them. To accomplish this screening with five-year-old patients having routine checkups, physicians may teach their young patients about private areas of the body; let them know that they can tell a parent, teacher, or doctor if anyone ever touches them in private places; and ask the patients if anyone has ever touched them in a way that they did not like. For fifteen-year-old patients, physicians may screen potential victims by providing information on sexual abuse and date rape, then asking the patients whether they have ever experienced either.

A second strategy that physicians use to identify children who are victims of family violence is to remain alert for general signs of distress that may indicate a child or youth lives in a violent situation. General signs of distress in children, which may be caused by family violence or by other stressors, include depression, anxiety, low self-esteem, hyperactivity, disruptive behaviors, aggressiveness toward other children, and lack of friends.

In addition to general signs of distress, there are certain specific signs and symptoms of physical and sexual abuse in children which indicate that the child has probably been exposed to violence. For example, a bruise that looks like a hand-print, belt mark, or rope burn would indicate abuse. X rays can show a history of broken bones that are suspicious. Intentional burns from hot water, fire, or cigarettes often have a characteristic pattern. Sexually transmitted diseases in the genital, anal, or oral cavity of a child who is aged fourteen or under would suggest sexual abuse.

A physician observing specific signs of abuse or violence in a child, or even suspecting physical or sexual abuse, has an ethical and legal obligation to provide this information to state child protective services. Every state has laws that require physicians to report suspected child abuse. Physicians do not need to find proof of abuse before filing a report. In fact, the physician should never attempt to prove abuse or interview the child in detail because this can interfere with interviews conducted by experts in law, psychology, and the medicine of child abuse. When children are in immediate danger, they may be hospitalized so that they may receive a thorough medical and psychological evaluation while also being removed from the dangerous situation. In addition to filing a report, the physician records all observations in the child’s medical file. This record includes anything that the child or parents said, drawings or photographs of the injury, the physician’s professional opinion regarding exposure to violence, and a description of the child abuse report.

The physician’s final step is to offer support to the child’s family. Families of child victims often have multiple problems, including violence between adults, drug and alcohol abuse, economic problems, and social isolation. Appropriate interventions for promoting safety include foster care for children, court-ordered counseling for one or both parents, and in-home education in parenting skills. The physician’s goal, however, is to maintain a nonjudgmental manner while encouraging parental involvement.
Physicians also play a key role in helping victims of partner violence. Like children and adolescents, adult victims will usually not disclose violence; therefore, physicians should screen for partner violence and ask about partner violence whenever they notice specific signs of abuse or general signs of distress. Physicians screen for current and past violence during routine patient visits, such as during initial appointments; school, athletic, and work physicals; premarital exams; obstetrical visits; and regular checkups. General signs of distress include depression, anxiety disorders, low self-esteem, suicidal idealization, drug and alcohol abuse, stress illnesses (headache, stomach problems, chronic pain), or patient comments about a partner being jealous, angry, controlling, or irritable. Specific signs of violence include physical injury consistent with assault, including that requiring emergency treatment.

When a victim reports partner violence, there are several steps that a physician can take to help. Communicating belief and support is the first step. Sometimes abuse is extreme and patient reports may seem incredible. The physician validates the victim’s experience by expressing belief in the story and exonerating the patient of blame. The physician can begin this process by making eye contact and telling the victim, “You have a right to be safe and respected” and “No one should be treated this way.”
Another step is helping the patient assess danger. This is done by asking about types and severity of violent acts, duration and frequency of violence, and injuries received. Specific factors that seem to increase the risk of death in violent relationships include the abuser’s use of drugs and alcohol, threats to kill the victim, and the victim’s suicidal idealization or attempts. Finally, the physician should ask if the victim feels safe returning home. With this information, the physician can help the patient assess lethal potential and begin to make appropriate safety plans.

Another step is helping the patient identify resources and make a safety plan. The physician begins this process by simply expressing concern for the victim’s safety and providing information about local resources such as mandatory arrest laws, legal advocacy services, and shelters. For patients planning to return to an abusive relationship, the physician should encourage a detailed safety plan by helping the patient identify safe havens with family members, friends, or a shelter; assess escape routes from the residence; make specific plans for dangerous situations or when violence recurs; and gather copies of important papers, money, and extra clothing in a safe place in or out of the home against the event of a quick exit. Before the patient leaves, the physician should give the patient a follow-up appointment within two weeks. This provides the victim with a specific, known resource. Follow-up visits should continue until the victim has developed other supportive resources.

The physician’s final step is documentation in the patient’s medical file. This written note includes the victim’s report of violence, the physician’s own observations of injuries and behavior, assessment of danger, safety planning, and follow-up. This record can be helpful in the event of criminal or civil action taken by the victim against the offender. The medical file and all communications with the patient are kept strictly confidential. Confronting the offender about the abuse can place the victim at risk of further, more severe violence. Improper disclosure can also result in loss of the patient’s trust, precluding further opportunities for help.

There are several things that a physician should never do when working with a patient-victim. The physician should not encourage a patient to leave a violent relationship as a first or primary choice. Leaving an abuser is the most dangerous time for victims and should be attempted only with adequate planning and resources. The physician should not recommend couples counseling. Couples counseling endangers victims by raising the victim’s expectation that issues can be discussed safely. The abuser often batters the victim after disclosure of sensitive information. Finally, the physician should not overlook violence if the violence appears to be “minor.” Seemingly minor acts of aggression can be highly injurious.
Physicians also play an important role in helping adults who are older, developmentally delayed, or physically disabled. People in all three groups experience a high rate of family violence. Each group presents unique challenges for the physician. One common element among all three groups is that the victims may be somewhat dependent upon other adults to meet their basic needs. Because of this dependence, abuse may sometimes take the form of failing to provide basic needs such as adequate food or medical care. In many states, adults who are developmentally delayed are covered by mandatory child abuse reporting laws.

The signs and symptoms of the abuse of elders are similar to those of the other forms of family violence. These include physical injuries consistent with assault, signs of distress, and neglect, including self-neglect. Elder abuse victims are often reluctant to reveal abuse because of fear of retaliation, abandonment, or institutionalization. Therefore, a key to intervention is coordinating with appropriate social service and allied health agencies to support an elder adequately, either at home or in a care center. Such agencies include aging councils, visiting nurses, home health aides, and respite or adult day care centers. Counseling and assistance for caregivers are also important parts of intervention.

Many states require physicians to report suspected elder abuse. Because many elder abuse victims are mentally competent, however, it is important that they be made part of the decision-making and reporting process. Such collaboration puts needed control in the elder’s hands and therefore facilitates healing. Many other aspects of intervention described for partner abuse apply to working with elders, including providing emotional support, assessing danger, safety planning, and documentation.

In addition to helping the victims of acute, ongoing family violence, physicians have an important role to play in helping survivors of past family violence. People who have survived family violence may continue to experience negative effects similar to those experienced by acute victims. Physicians can identify survivors of family violence by screening for past violence during routine exams. A careful history can determine whether the patient has been suffering medical or psychological problems related to the violence. Finally, the physician should identify local resources for the patient, including a mutual help group and a therapist.

Physicians can also help prevent family violence. One avenue of prevention is through education of patients by discussing partner violence with patients at key life transitions, such as during adolescence when youths begin dating, prior to marriage, during pregnancy, and during divorce or separation. A second avenue of prevention is making medical clinic waiting rooms and examination rooms into education centers by displaying educational posters and providing pamphlets.

Perspective and Prospects:

Despite its frequency, family violence has not always been viewed as a problem. In the 1800’s, it was legal in the United States for a man to beat his wife, or for parents to use brutal physical punishment with children. Although the formation of the New York Society for the Prevention of Cruelty to Children in 1874 signaled rising concern about child maltreatment, the extent of the problem was underestimated. As recently as 1960, family violence was viewed as a rare, aberrant phenomenon, and women who were victims of violence were often seen as partially responsible because of “masochistic tendencies.” Several factors combined to turn the tide during the next thirty years. Medical research published in the early 1960’s began documenting the severity of the problem of child abuse. By 1968, every state in the United States had passed a law requiring that physicians report suspected child abuse, and many states had established child protective services to investigate and protect vulnerable children.

Progress in the battle against partner violence was slower. The battered woman's movement brought new attention and a feminist understanding to the widespread and serious nature of partner violence. This growing awareness provided the impetus, during the 1970’s and 1980’s, for reform in the criminal justice system, scientific research, continued growth of woman's shelters, and the development of treatment programs for offenders.

The medical profession’s response to partner abuse followed these changes. In 1986, Surgeon General C. Everett Koop declared family violence to be a public health problem and called upon physicians to learn to identify and intervene with victims. In 1992, the American Medical Association (AMA) echoed the surgeon general and stated that physicians have an ethical obligation to identify and assist victims of partner violence, and it established standards and protocols for identifying and helping victims of family violence. Because partner and elder abuse have been recognized only recently by the medical community, many physicians are just beginning to learn about their essential role.

Family violence has at various times been considered as a social problem, a legal problem, a political problem, and a medical problem. Because of this shifting understanding and because of the grassroots political origins of the child and partner violence movements, some may question why physicians should be involved. There are three compelling reasons.

First, there is a medical need: Family violence is one of the most common causes of injury, illness, and death for women and children. Victims seeking treatment for acute injuries make up a sizable portion of emergency room visits. Even in outpatient clinics, women report high rates of recent and ongoing violence and injury from partners. In addition to physical injuries, many victims experience stress-related medical problems for which they seek medical care. Among obstetrical patients who are battered, there is a risk of injury to both the woman and her unborn child. Hence, physicians working in clinics and emergency rooms will see many people who are victims.

Second, physicians have a stake in breaking the cycle of violence because they are interested in injury prevention and health promotion. When a physician treats a child or adult victim for physical or psychological injury but does not identify root causes, the victim will return to a dangerous situation. Prevention of future injury requires proper diagnosis of root causes, rather than mere treatment of symptoms.

Third, physicians have a stake in treatment of partner violence because it is a professional and ethical obligation. Two principles of medical ethics apply. First, a physician’s actions should benefit the patient. Physicians can benefit patients who are suffering the effects of family violence only if they correctly recognize the root cause and intervene in a sensitive and professional manner. Physicians should also “do no harm.” A physician who fails to recognize and treat partner violence will harm the patient by providing inappropriate advice and treatment.

For Further Information:

Bancroft, Lundy, and Jay G. Silverman. The Batterer as Parent: Addressing the Impact of Domestic Violence on Family Dynamics. Thousand Oaks, Calif.: Sage Publications, 2002. Examines how partner abuse affects each relationship in a family and explains how children’s emotional recovery is inextricably linked to the healing and empowerment of their mothers.

Barnett, Ola, Cindy L. Miller-Perrin, and Robin D. Perrin. Family Violence Across the Lifespan: An Introduction. 2d ed. Thousand Oaks, Calif.: Sage Publications, 2005. Provides information about the different ways that domestic violence, and the warning signs associated with it, may be recognized at various stages in the life spans of individuals and families.

Dutton, Donald G. The Abusive Personality: Violence and Control in Intimate Relationships. Rev. ed. New York: The Guilford Press, 2003. Dutton, a psychologist, began as a disciple of social learning theory and eventually came to understand that theory alone was inadequate to explain the multifaceted origins of spousal abuse.

Island, David, and Patrick Letellier. Men Who Beat the Men Who Love Them: Battered Gay Men and Domestic Violence. New York: Haworth Press, 1991. The first published book that tackles the issue of gay male partner violence. The authors write in a lively, straightforward manner that is easy to understand. Proposes novel ways of thinking about partner violence.

Kakar, Suman. Domestic Abuse. San Francisco: Austin & Infield, 2002. Offers theoretical and analytical explanations for domestic violence and includes detailed discussion of violence against children, youth, and the elderly.

Levine, Murray, and Adeline Levine. Helping Children: A Social History. New York: Oxford University Press, 1992. The Levines provide an excellent history of child maltreatment in the United States, as well as the various legal, social, and medical strategies that have been used to help abused children.

National Coalition Against Domestic Violence. www.ncadv.org. A website that defines domestic violence and offers information on community responses, getting help, and public policy.

Raphael, Jody. Saving Bernice: Battered Women, Welfare, and Poverty. Boston: Northeastern University Press, 2000. Raphael uses the case study of one welfare mother and survivor of domestic violence to exemplify the broader issues connecting domestic violence and poverty. In interviews taped during 1995-1999, Bernice, a mother of two and on welfare for eight years, recounts the trauma of abuse, harassment, and stalking by her former partner.

Wilson, K. J. When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Violence. Alameda, Calif.: Hunter House, 1997. Wilson seeks to share her wealth of knowledge stemming from experience as the current training director at the Austin Center for Battered Women, as an educator, and as a survivor of domestic abuse.

-Birdy