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“You're Not a Victim of Domestic Violence, Are You?” Provider–Patient Communication about Domestic Violence

Karin V. Rhodes, MD, MS; Richard M. Frankel, PhD; Naomi Levinthal, MA; Elizabeth Prenoveau, BA; Jeannine Bailey, MA; and Wendy Levinson, MD
[+] Article, Author, and Disclosure Information

From School of Social Policy & Practice, University of Pennsylvania, Philadelphia, Pennsylvania; Indiana University School of Medicine, Regenstrief Institute, and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana; The University of Chicago, Chicago, Illinois; and The University of Toronto, Toronto, Ontario, Canada.

Acknowledgment: The authors thank Mindy Drum, PhD; David Howes, MD; Laura McCloskey, PhD; Melissa Dichter, MSW; and Joanna Bisgaier, BA, for instrumental support and insightful feedback. They also thank the many helpful internal and external reviewers, and the faculty, residents, staff, and patients of the University of Chicago Emergency Medicine Program.

Grant Support: By the Agency for Healthcare Research and Quality (grant RO1 HS 11096-03). Dr. Rhodes is also supported by grant K23 MH64572 from the National Institute of Mental Health.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Karin V. Rhodes, MD, MS, Division of Health Care Policy Research, Department of Emergency Medicine, School of Social Policy & Practice, University of Pennsylvania, 3815 Walnut Street, Room 201, Philadelphia, PA 19104; e-mail, kvr@sp2.upenn.edu.

Current Author Addresses: Dr. Rhodes: Division of Health Care Policy Research, Department of Emergency Medicine, School of Social Policy & Practice, University of Pennsylvania, 3815 Walnut Street, Room 201, Philadelphia, PA 19104.

Dr. Frankel: Indiana University School of Medicine, Indianapolis, IN 46202.

Ms. Levinthal and Ms. Prenoveau: University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637.

Ms. Bailey: 1655 North Burlington Street, #1, Chicago, IL 60614.

Dr. Levinson: University of Toronto, 190 Elizabeth Street, #3-805, Toronto, Ontario M5G 2C4, Canada.

Author Contributions: Conception and design: K.V. Rhodes, R.M. Frankel, W. Levinson.

Analysis and interpretation of the data: K.V. Rhodes, N. Levinthal, R.M. Frankel, E. Prenoveau, W. Levinson.

Drafting of the article: K.V. Rhodes, R.M. Frankel, N. Levinthal, E. Prenoveau.

Critical revision of the article for important intellectual content: K.V. Rhodes, R.M. Frankel, N. Levinthal, W. Levinson.

Final approval of the article: K.V. Rhodes, R.M. Frankel, J. Bailey, W. Levinson.

Provision of study materials or patients: K.V. Rhodes.

Obtaining of funding: K.V. Rhodes, W. Levinson.

Administrative, technical, or logistic support: K.V. Rhodes, E. Prenoveau, J. Bailey.

Collection and assembly of data: K.V. Rhodes, R.M. Frankel, E. Prenoveau, J. Bailey.

Ann Intern Med. 2007;147(9):620-627. doi:10.7326/0003-4819-147-9-200711060-00006
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From June 2001 to December 2002, we conducted a randomized, controlled trial of a self-administered computer-based health risk assessment tool, which generated health recommendations for patients and alerted physicians to a variety of potential health risks, including domestic violence. The trial took place at 2 socioeconomically diverse emergency departments: an urban academic medical center that serves a predominately publicly insured, inner-city, African-American population, and a suburban community hospital that serves a predominately privately insured, white population. Inclusion criteria were sequential female patients 18 to 65 years of age who were triaged as medically nonemergent and could give consent. The emergency providers (40 attending physicians, 46 residents, and 4 nurse practitioners) involved in the study were aware that the intent was to increase detection of domestic violence. Before the start of data collection, providers received a 1-hour lecture and a 30-minute video and instruction guide about assessing safety and documenting and providing referrals related to domestic violence (9).

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Figure 1.
Study flow diagram.

ED = emergency department.

Grahic Jump Location




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Domestic violence in India
Posted on November 10, 2007
Akashdeep Singh
Christian Medical College and Hospital Ludhiana,India
Conflict of Interest: None Declared

Wife abuse, along with its resultant negative health consequences, is becoming increasingly recognized as a pervasive public health problem within both developed and developing countries, including India.1 The prevalence of wife abuse within India vary widely (from about 20% to 75%, with differences in study methods being at least in part responsible for the diverse estimates) 2-3 Numerous factors operating at various levels play important roles in the aetiology of such violence. One such level is the "˜macrosystem', defined as the set of commonly accepted cultural values, beliefs, and practices that permeate a society; yet another level is that of the "˜individual', defined as personality factors and events that occur within a person's lifetime that help to shape an individual's responses to situations and stresses. All countries and societies, including India, have macrosystem-level norms embedded in the culture that may exacerbate gender-based violence. Traditional rigid gender roles are one such cultural norm within various areas of India that may increase the likelihood of violence against women. These roles are defined in such a manner that sons are more likely than daughters to be of benefit to their parents, both financially and in other ways. For example, in northern India, many women marry since, traditionally, there are few lifestyle options for women outside of marriage.4 At the time of marriage, the bride is expected to bring a "˜dowry' (i.e. a gift of cash or possessions from her natal family) into the family of her husband; thus, the groom's parents gain wealth while the bride's parents lose wealth.5 Although dowry demands have been outlawed by the Indian government, these laws are seldom enforced and the practice of dowry is still widespread.6 In recent years, the amount of dowry deemed appropriate has increased dramatically in some areas, so that the bride's family is not always able to provide a dowry large enough to satisfy the groom's family. In this situation, the groom's family may make additional, and repeated, dowry demands. Not meeting such demands places the bride at risk of "˜dowry death'; either due to homicide (i.e. the bride is killed by the groom and/or his family) or suicide (i.e. the bride kills herself to escape the constant harassment by the groom and his family).7 If such a dowry death occurs, the young widower is free to remarry and to obtain another dowry, further enhancing his family's wealth. Moreover, after marriage and throughout adulthood, traditional gender roles within India assure that sons continue to be more valuable than daughters to their parents. For example, the husband and his wife traditionally reside with the husband's parents, enabling the younger generation to care for the older generation as they age. In contrast, a married daughter traditionally resides with her husband's parents in a home that is often far from her own parents; thus, there may be few opportunities for married women to visit their parents, let alone to assure their well-being. Given that sons are greater assets to their parents than daughters, it is not surprising that many Indian couples prefer to have male children. Unfortunately, this strong preference for sons has been implicated as underlying both female infanticide (i.e. the killing of female infants by their parents), a relatively common practice within India in the past, and more recently, female feticide (i.e. the selective abortion of female fetuses based on amniocentesis findings).8-10 In light of these aforementioned cultural practices, it is not surprising that every Indian census has registered more males than females in the population, especially in the more traditional northern states. Furthermore, the primary factor implicated for this sex difference in the population is the higher death rate (from infancy through young adulthood) of females compared to males. Other macrosystem-level cultural norms within India that have been implicated as enhancing gender-based violence are attitudes concerning male superiority to women and male domination of women. These are well described within a famous Indian text (namely, Manusmriti or Manu's code), in which it is written that females must be subservient to males throughout their lifetimes: in childhood, to their fathers; in young adulthood, to their husbands; and in old age (and presuming the deaths of their husbands), to their sons.6 Women are viewed as living almost exclusively for the males in their lives,7 with one of the most dramatic cultural practices illustrating this attitude being the practice of sati"”self-immolation of a widow on her husband's funeral pyre.11 Although sati has been declared illegal by the Indian government, there have been a few contemporary cases reported. Furthermore, the widows involved in these recent sati cases have been viewed by the populace at large with reverence, and, in one situation, the funeral pyre was later turned into a religious shrine.12 This cultural attitude concerning male superiority is so strong that many in India believe that husbands are entitled to control their wives, even by means of physical chastisement.13 For example, in recent research conducted within northern India, the majority of study participants (including males and females, and Muslims and Hindus) reported that husbands were justified in beating wives who were disobedient of their husbands' wishes.14


1 World Bank. Investing in Health: World Development Report. New York: Oxford University Press, 1993

2. Martin SL, Tsui AO, Maitra K, Marinshaw R. Domestic violence in northern India. Am J Epidemiol 1999;150:417"“26

3. Martin SL, Kilgallen B, Tsui AO, Maitra K, Singh KK, Kupper LL. Sexual behaviors and reproductive health outcomes: Associations with wife abuse in India. JAMA 1999;282:1967"“72

4. Miller BD. Wife beating in India: Variations on a theme. In: Counts DA, Brown JK, Campbell JC (eds). To Have and To Hit: Cultural Perspectives on Wife Beating. 2nd Edn. Urbana IL: University of Illinois Press, 1999, pp. 203"“15

5. Ulrich YC. Cross-cultural perspective on violence against women. Response (Nursing Network on Violence Against Women) 1989;12:21"“23

6. Vaz L, Kanekar S. Predicted and recommended behavior of a woman as a function of her inferred helplessness in the dowry and wife-beating predicaments. J Appl Soc Psychol 1990;20:751"“70

7. Bordewich FM. Dowry murders: A bride whose family can't reward the groom may pay with her life. Atlantic Monthly 1986,July:21"“27

8. Ramanamma A, Bambawale U. The mania for sons: An analysis of social values in South Asia. Soc Sci Med 1980;14B:107"“10.

9. Jeffery R, Jeffery P, Lyon A. Female infanticide and amniocentesis. Soc Sci Med 1984:19:1207"“12.

10. Sudha S, Rajan SI. Female demographic disadvantage in India 1981"“ 1991: Sex selective abortions and female infanticide. Development and Change: Special Issue on Gendered Poverty and Well-being 1999;30:585"“618.

11. Freed RS, Freed SA. Beliefs and practices resulting in female deaths and fewer females than males in India. Population and Environment: A Journal of Interdisciplinary Studies 1989;10:144"“61.

12. Baxi U. The Crisis of the Indian legal system: Alternatives in Development: Law. New Delhi: Vikas Publishing House Pvt. Ltd, 1982.

13. Jejeebhoy SJ, Cook RJ. State accountability for wife-beating: the Indian challenge. Lancet 1997;349:110"“12

14. Jejeebhoy SJ. Associations between wife-beating and fetal and infant death: Impressions from a survey in rural India. Stud Fam Plann 1998; 29:300"“08

Conflict of Interest:

None declared

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