Elaine J. Alpert, MD, MPH
Potential Financial Conflicts of Interest: None disclosed.
Current Author Address: Elaine J. Alpert, MD, MPH, Boston University School of Public Health, 715 Albany Street, T-2W, Boston, MA 02118-2526; e-mail, email@example.com.
Alpert E.; Addressing Domestic Violence: The (Long) Road Ahead. Ann Intern Med. 2007;147:666-667. doi: 10.7326/0003-4819-147-9-200711060-00011
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Published: Ann Intern Med. 2007;147(9):666-667.
Domestic violence is pervasive in U.S. society, with adverse and often devastating lifelong effects on the health and well-being of individuals, families, and communities. It was virtually unrecognized as a health care issue until just 3 decades ago; since then, advances in education, practice, and research have added the words “domestic violence” to the medical lexicon. Such progress notwithstanding, the article by Rhodes and colleagues (1) in this issue reminds us of the (long) road ahead.
What has changed over 30 years? Aren't we doing better than before? Is the glass at least half full? Indeed, most medical schools and many residency programs now offer at least nominal domestic violence education to trainees. Curricular principles (2) and core competencies (3) have been developed and disseminated. Questions related to violence and abuse are found infrequently, but at least predictably, on licensing and certification examinations. We have made some progress.
Christian Medical College and Hospital, LDH, Pb, In
November 6, 2007
Abuse and Domestic Violence In Elderly And Female Patients
We recently admitted a 60 year old female patient in an unconscious state. Her son had brought her to casualty dept. but he did not offer any history as to help us know what was wrong with her. Once the patient regained consciousness after two days, she told us that she had consumed fifty tablets of alprazolam in an attempt to end her life. On detailed history taking (after taking her into confidence), she revealed that her son used to mistreat her and often beat her up. More than often the elderly suffer from abuse but the form of abuse may not be obvious when they visit the hospital with medical complaints. Domestic violence is prevalent all over the globe, in every community. Only the form in which it presents is different. A United States Department of Justice survey of 50,000 households in 1992 and 1993 estimated that over 1 million women and 150,000 men are victims each year of physical abuse or sexual assault by their partner . Sixteen percent of couples reported episodes of physical violence in the previous year [4,5]. Abuse of the elderly can be in the form of humiliation, intimidation, constant threatening by care takers, inflicting of physical pain or injury, in the form of slapping, bruising, restraining or nonconsensual sexual contact of any kind , misappropriation of funds that belong to the elderly, or they may not be taken care of and denied of shelter and food and may also be deserted. In these situations the elderly may threaten their own life and take on the course of "˜chronic suicide'. Female patients are more prone to domestic violence. Especially when they are pregnant or carry an unwanted pregnancy [6,7,8] or when the woman is a single, divorced, or separated. Research has shown that abuse is also common among patients on alcohol or drugs or who smoke cigarettes. Poverty has been shown to be more prevalent among the abused [9,10,11,12,13]. Patients who experienced sexual and physical abuse during childhood are at increased risk of abuse when they grow up to adulthood. Domestic violence should be thought of while seeing a female patient in casualty room, with complaints of headache, fatigue syndrome. Other things that should raise suspicion are very early or late antenatal checkups, repeated abortions, abdominal pain. Elderly presenting with injuries should also be investigated for abuse. [1,2]. Likewise history and examination suggestive of substance abuse , anxiety, depression, morbid obesity, should alert the doctor to look for possibilities of abuse.
1 . Elliott L; Nerney M; Jones T; Friedmann PD Barriers to screening for domestic violence J Gen Intern Med 2002 Feb;17(2):112-6.
2 Rodriguez MA; Bauer HM; McLoughlin E; Grumbach K Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999 Aug 4;282(5):468-74.
3 Bachman, R, Saltzman, LE. Violence against women: Estimates from the redesigned survey. Bureau of Justice Statistics special report, Publication no. NCJ-154348. U.S. Department of Justice, Washington, DC 1995.
4 Straus, MA, Gelles, RJ, Steinmetz, SK. Behind closed doors: A survey of family violence in America. Doubleday, New York 1980.
5 - Straus, MA, Gelles, RJ. Physical violence in American families. Transaction Publishers, New Brunswick, NJ 1990.
6 Hillard PJ Physical abuse in pregnancy. Obstet Gynecol 1985 Aug;66(2):185-90
7 Stewart DE Incidence of postpartum abuse in women with a history of abuse during pregnancy. CMAJ 1994 Dec 1;151(11):1601-4.
8 Gazmararian JA; Lazorick S; Spitz AM; Ballard TJ; Saltzman LE; Marks JS Prevalence of violence against pregnant women. JAMA 1996 Jun 26;275(24):1915-20.
9. McCauley, J, Kern, DE, Kolodner, K, et al. The "battering syndrome": Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123:737.
10. Flitcraft, A, Hadley, S, et al. Diagnostic and treatment guidelines on domestic violence. American Medical Association, Chicago 1992.
11. Kyriacou, DN, Anglin, D, Taliaferro, E, et al. Risk factors for injury to women from domestic violence against women. N Engl J Med 1999; 341:1892.
12. Grisso, JA, Schwarz, DF, Hirschinger, N, et al. Violent injuries among women in an urban area. N Engl J Med 1999; 341:1899.
13. Gerber, MR, Ganz, ML, Lichter, E, et al. Adverse health behaviors and the detection of partner violence by clinicians. Arch Intern Med 2005; 165:1016.
14. Hegarty, K, Gunn, J, Chondros, P, Small, R. Association between depression and abuse by partners of women attending general practice: descriptive, cross sectional survey. BMJ 2004; 328:621.
15. Campbell, J, Jones, AS, Dienemann, J, et al. Intimate partner violence and physical health consequences. Arch Intern Med 2002; 162:1157.
November 10, 2007
Intertwined Roles of Healthcare and Society in Domestic Violence
Alpert EJ and Rhodes KV et al have addressed the issue of domestic violence and have suggested that the building blocks of an effective health care response to domestic violence are in place. (1, 2) While it is clear that any form of domestic violence is unacceptable, it is unclear how much of impact healthcare providers alone would make in abuse screening and identification. The practice of medicine is getting increasingly fragmented with numerous physicians involved and each encounter constrained in time. Hospitals and physicians today pay attention to two aspects of patient care- what you get reimbursed for and on what aspects your performance metrics is judged. Unfortunately, on neither count would domestic violence screening qualify, as it would not only be time-consuming but there is no financial reward for the same. Also, the United States Preventive Services Task Force found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse. (3) The limitations of evidence-based medicine are known and abuse screening is a situation where clinical judgment, humanity and common sense trumps evidence. (4) All these mean that there is little incentive for healthcare system to try and screen for domestic violence on every clinical encounter.
The larger issue though is how society wants to deal with this issue. Do family members, friends and neighbors not have a duty to report suspected domestic violence to the relevant law enforcement agencies? Their relationships with the victims of domestic violence should make them interested parties, as their loved ones would benefit. Additionally, they certainly have a much better chance of knowing about domestic violence and abuse than healthcare providers. If domestic violence is underreported, it is because society does not care enough about it. This callousness also extends to the healthcare system. The good news is that society today cares a little more than it did thirty years ago, and therefore strides have been made in domestic violence reporting. However, unless society wants to really address the issue further on a larger scale, progress will be very slow. The medical community has a definite and significant role, but their commitment to the cause will mirror society's attitude to domestic violence and abuse.
1. Alpert EJ Addressing Domestic Violence: The (Long) Road Ahead. Ann Intern Med. 2007 Nov 6; 147(9):666-667
2. Rhodes KV, Frankel RM, Levinthal N, Prenoveau E, Bailey J, Levinson W. "You're not a victim of domestic violence, are you?" Provider"“patient communication about domestic violence. Ann Intern Med. 2007; 147:620-7.
3. Neilson HD, Nygren P, McInerney Y, Klein J, U.S. Preventive Services Task Force. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U. S. Preventive Services Task Force. Ann Intern Med. 2004; 140:387-96.
4. Lachs MS Screening for family violence: what's an evidence-based doctor to do? Ann Intern Med. 2004 Mar 2; 140(5):399-400
Christian Medical College and Hospital Ludhiana,India
November 11, 2007
Husband Battering: The Silent Crisis
The first reaction upon hearing about the topic of battered men, for many people, is that of incredulity. Battered husbands are a topic for jokes (such as the cartoon image of a woman chasing her husband with a rolling-pin). One researcher noted that wives were the perpetrators in 73% of the depictions of domestic violence in newspaper comics.1 Battered husbands have historically been either ignored or subjected to ridicule and abuse. In 18th-century France, a battered husband "was made to wear an outlandish outfit and ride backwards around the village on a donkey" 2 Even those of us who like to consider ourselves liberated and open-minded often have a difficult time even imagining that husband battering could take place. Although feminism has opened many of our eyes about the existence of domestic violence, and newspaper reports often include incidents of abuse of wives, the abuse of husbands is a rarely discussed phenomenon. One reason researchers and others had not chosen to investigate husband battering is because it was thought to be a fairly rare occurrence. Police reports seemed to bear this out, with in some cases a ratio of 12 to 14.5 female victims to every one male victim.3 But another reason is that because women were seen as weaker and more helpless than men due to sex roles, and men on the other hand were seen as more sturdy and self-reliant, the study of abused husbands seemed relatively unimportant. In 1974, a study was done which compared male and female domestic violence. In that study, it was found that 47% of husbands had used physical violence on their wives, and 33% of wives had used violence on their husbands.4 Half of the respondents in this study were selected from either cases of domestic violence reported to the police, or those identified by the social service agency. Also in 1974, a study was released showing that the number of murders of women by men (17.5% of total homicides) was about the same as the number of murders of men by women (16.4% of total homicides).4 This study, however, showed that men were three times as likely to assault women as vice-versa. In a study of spousal homicide in the period from 1976 to 1985, it was found that there was an overall ratio of 1.3:1.0 of murdered wives to murdered husbands, and that "Black husbands were at greater risk of spouse homicide victimization than Black wives or White spouses of either sex" 6 . Nonfatal violence committed by women against men is less likely to be reported to the police than is violence by men against women; thus, women assaulters who come to the attention of the police are likely to be those who have produced a fatal result. In 1977, Suzanne Steinmetz released results from several studies showing that the percentage of wives who have used physical violence is higher than the percentage of husbands, and that the wives' average violence score tended to be higher, although men were somewhat more likely to cause greater injury. She also found that women were as likely as men to initiate physical violence, and that they had similar motives for their violent acts. 3 In, a telephone survey was conducted in which subjects were asked about their experiences of domestic violence 15.5% of the men and 11.3% of the women reported having hit their spouse; 18.6% of the men and 12.7% of the women reported having been hit by their spouse.7 The total family violence scores seemed to be about even between husbands and wives, and that wives tended to be more abusive in almost all categories except pushing and shoving. The idea of women being violent is a hard thing for many people to believe. It goes against the stereotype of the passive and helpless female. This, in spite of the fact that women are known to be more likely than men to commit child abuse and child murder Daly & Wilson 1988 report 54% of parent-child murders where the child is under 17 were committed by the mother in Canada between 1974 and 1983, for instance.8 The Statistical Abstract of the United States 1987 reports that of reported child maltreatment cases between 1980 and 1984 between 57.0% and 61.4% of these were perpetrated by the mother. So domestic violence is an issue framed in the media and in the political arena as one of male perpetrators and female victims. The terms "wife beating" and "battered women" have become political expressions, rather than descriptions of reality. And because the issue of domestic violence has been substantially taken out of the arena of serious sociological study, and thrust into the political arena, the definitions of spousal abuse, and the proposed remedies to spousal abuse, will be political ones -- not necessarily ones which reflect the reality of the existing problems. "Husband abuse should not be viewed as merely the opposite side of the coin to wife abuse. Both are part of the same problem, which should be described as one _person_ abusing another _person_. The problem must be faced and dealt with not in terms of sex but in terms of humanity"
1. Saenger, G. "Male and female relation in the American comic strips" in The funnies: An American idiom M. White & R.H. Abel editors, The Free Press, Glencoe IL, 1963, p. 219-223
2. Steinmetz, Suzanne K. and Lucca, Joseph S. "Husband Battering" in Handbook of Family Violence Van Hasselt, Vincent B. et al. editors, Plenum Press, New York 1988, p. 233-246
3. Steinmetz, Suzanne K. "The Battered Husband Syndrome" Victimology 2, 1977-1978, p. 499
4. Gelles, R.J. The violent home: A study of physical aggression between husbands and wives Sage, Beverly Hills CA, 1974
5. Curtis, L.A. Criminal violence: National patterns and behavior Lexington Books, Lexington MA, 1974
6. Mercy, J.A. & Saltzman, L.E. "Fatal violence among spouses in the United States, 1976-85" American Journal of Public Health 79(5): 595-9 May 1989
7. Nisonoff, L. & Bitman, I "Spouse Abuse: Incidence and Relationship to Selected Demographic Variables" Victimology 4, 1979, pp. 131-140
8. Daly, M. & Wilson, M. "Parent-Offspring Homicides in Canada, 1974-1983" Science v. 242, pp. 519-524, 1988
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