Profiling Domestic ViolenceWHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Scientific investigation of the problem of domestic violence is a relatively recent endeavor. It is only within the past 30 years that violence against women has been acknowledged nationally and internationally as a threat to the health and rights of women as well as to national development. Many who live with violence day in and day out assume that it is an intrinsic part of the human condition. But this is not so. Violence can be prevented. Violence can be turned around. Governments, communities and individuals can make a difference. We have some of the tools and knowledge to make a difference -- the same tools that have successfully been used to tackle other health problems. Public health has made some remarkable achievements in recent decades, particularly with regard to reducing rates of many childhood diseases. However, saving our children from these diseases only to let them fall victim to violence or lose them later to acts of violence between intimate partners, to the savagery of war and conflict, or to self-inflicted injuries of suicide, would be a failure of public health. Domestic violence not only poses a direct thereat to women's health, but also has adverse consequences for other aspects of women's health and well-being and for the survival and well-being of children.
The purpose of this document is to understand our role in the prevention of violence worldwide. While public health does not offer all the answers to this complex problem, we hope this helps to shape the global response to violence and to make the world a safer and healthier place for all. The goal of the article is to raise awareness about the problem of violence globally, and to make the case that violence is preventable and that public health has a crucial role to play in addressing its causes and consequences. It also suggests the recommendations for action at local, national, and international levels. This chapter illuminates the different faces of violence, from the "invisible" suffering of society's most vulnerable individuals to the all-too-visible tragedy of societies.
Social and Economic Effects:
The societal and economical effects of intimate partner violence are profound. The costs of intimate partner violence against women exceed an estimated $ 5.8 billion. These costs include nearly $ 4.1 billion in the direct costs of medical care and mental healthcare. These considerable expenses result in significantly higher costs to health insurance plans for intimate partner violence victims than for the general female enrollee. Services for victims of intimate partner violence are lacking. More than 30% of women requesting refuge in battered women's shelters are turned away for lack of space, and many have little to no economic resources for independent living. These women, especially those with children, often are left homeless or return to their violent homes. This also is true for adolescents, elderly victims, or women with substance abuse issues. A system that is prepared to assist and advocate for both the victim and the physician is needed.
A wide range of studies from both industrialized and developing countries have produced a remarkably consistent list of events that are said to trigger partner violence. These include: not obeying the man; arguing back; not having food ready on time; not caring adequately for the children or home; questioning the man about money or girlfriends; going somewhere without man's permission; refusing the man sex; the man suspecting the woman of infidelity. All age groups are affected by intimate partner violence and domestic violence. 4% of intimate partner homicide cases occur in adolescents and are reported as early as age 12 years. Peak rates occur among those aged between 20-39 years. 6% of partner homicides occur in women older than 65 years. Among all pregnant women, 0.9-21% experience domestic violence.
In victims of abuse, posttraumatic stress disorder often is associated with depression, anxiety disorders, substance abuse, and suicide. Research confirms the long-term physical and psychological consequences of ongoing or past violence. The stress of living in ongoing abusive relationship contributes to chronic headaches; chronic pelvic pain; sleep and appetite disturbances; sexual dysfunction; abdominal problems; palpitations; chronic viginitis; and mental health problems such as feeling of inadequacy and self-blame; depression; mood and anxiety disorders, suicidal ideation and suicide. 30% of female intimate partner violence victims have injuries that require significant medical attention. 37% of women seen in hospital emergency departments are thought to be victims of intimate partner violence or domestic violence, although it is well established that only a fraction of the cases seen there are recognized or documented as such. Injuries are often severe and most commonly involve the head, face, breasts, or abdomen.
Battered woman syndrome is based on the ongoing failure to identify the etiology of acute injuries and co-existing emotional distress. Over time this leads to somatization with the development of medically unexplained symptoms. Screening all patients, not just those in whom abuse is suspected, is the key to improving the overall health status of women. More than 70% of abused women have never discussed abuse with their physicians. Because of the prevalence of violence, being female is a significant enough risk factor to warrant universal screening of all women for intimate partner violence and domestic violence at periodic intervals, such as annual examinations and new patient visits. The goals of identifying an abused woman are to prevent further abuse and improve her health status by expanding the focus of partner violence and abuse from crisis intervention to crisis prevention, managing long-term health issues, and ultimately preventing abuse.
1. Child Abuse and Children of Violent Families:
Child abuse has for a long time been recorded in literature, art and science in many parts of the world. Reports of infanticide, mutilation, abandonment and other forms of violence against children date back to ancient civilizations. The term "battered child syndrome" was coined by Kempe et al in 1962, to characterize the clinical manifestations of serious physical abuse in young children. Now, four decades later, there is clear evidence that child abuse is a global problem. It occurs in a variety of forms and is deeply rooted in cultural, economic and social practices. Solving this global problem, however, requires a much better understanding of its occurrence in a range of settings, as well as of its causes and consequences in these settings. The International Society for the Prevention of Child Abuse and Neglect recently compared definitions of abuse from 58 countries and found some commonality in what was considered abusive. In 1999, the WHO Consultation on Child Abuse Prevention drafted the following definition:
"Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power." This definition covers a broad spectrum of abuse.
Violence between intimate partners may be the most important risk factor for child abuse. Child abuse occurs in 33-37% of families in which there is abuse of adults and at a rate that is 15 times higher than in families without intimate partner violence. There is 60% overlap between violence against children and violence against women in the same family, and as the frequency of violence against the woman increases, the odds of her child being abused also increases. Children and adolescents from violent homes demonstrate more psychological morbidity compared with children in non-violent homes. This is manifested as behavioral, emotional, social, and cognitive problems and expressed as aggression, anxiety, depression, and poor social interactions and school performance. Sleep disturbances, enuresis, and separation anxiety are seen in younger children. Eating disorders, manipulative behavior, problems with abandonment and control, pregnancy, suicidal or homicidal thoughts, and drug and alcohol abuse are seen in older children and adolescents who have witnessed abuse. Female children who are exposed to violence in the home are at increased risk for becoming future victims; male children are at increased risk of becoming perpetrators of interpersonal violence. Each of these responses is a function of role-modeling and learned behavior. Children in violent homes need as much care and attention as the abused woman.
Adolescents are a high risk for intimate partner violence and domestic violence. This population is at risk for physical and sexual abuse from parents, family members, and dating partners. More than 30% of female adolescents report partner violence in their heterosexual relationships. Both adolescent abuse and adolescent pregnancy are associated with childhood physical and sexual abuse, earlier onset of sexual activity, and unwanted sexual experiences. It is important to identify and address dating and family violence and to provide prevention efforts and education to assist the adolescent in recognizing and avoiding future violence. Prevention efforts and education are important for both female and male adolescent populations.
Patterns of behaviors, including violence, change over the course of a person's life. The period of adolescence and young adulthood is a time when violence, as well as other types of behaviors, is often given heightened expression. Understanding when and under what conditions violent behavior typically occurs as a person develops can help in formulating interventions and policies for prevention that target the most critical age groups. Peer influences during adolescence are generally considered positive and important in shaping interpersonal relationships, but they can also have negative effects. Having delinquent friends, for instance, is associated with violence in young people. The communities in which young people live are an important influence on their families, the nature of their peer-groups, and the way they may be exposed to situations that lead to violence. The presence of gangs, guns and drugs in a locality is a potent mixture, increasing the likelihood of violence. In the United States, for example, the presence together in neighborhoods of these three items would appear to be an important factor in explaining why the juvenile arrest rate for homicide more than doubled between 1994 and 2004 (from 5.4 per 100,000 to 14.5 per 100,000).
3. Abuse during Pregnancy:
Violence also occurs during pregnancy, with consequences not only for the woman but also for the developing fetus. In the United States, estimates of abuse during pregnancy range from 3% to 11% among adult women and up to 38% among low-income teenage mothers. Violence during pregnancy has been associated with: miscarriage; late entry into prenatal care; stillbirth; premature labor and birth; fetal injury; low-birth weight which is major cause of infant death in the developing world. Evidence suggests that the severity and frequency of violence can escalate during pregnancy, and even become more prevalent in the postpartum period. Pregnancy complications, such as poor maternal weight gain, infection, anemia, and second- and third-trimester bleeding, occur more commonly among pregnant women who are battered than among those who are not battered. Regular contact with medical providers increases the likelihood of disclosure; therefore, pregnancy offers a unique opportunity to screen and identify partner and family violence. Screening all patients at various times during the pregnancy is important because some women do not disclose abuse the first time they are asked. Screening should occur at the first prenatal visit, at least once per trimester, and at the postpartum check up.
Partner violence also has many links with the growing AIDS epidemic. In six countries in Africa for instance, fear of ostracism and consequent violence in the home was an important reason for pregnant women refusing an HIV test, or else not returning for their results. Similarly, in a recent study of HIV transmission between heterosexuals in rural Uganda, women who reported being forced to have sex against their will in the previous year had an eight-fold increased risk of becoming infected with HIV.
4. Women with Disabilities:
These women are vulnerable to neglect or exploitation and can experience physical, sexual or emotional abuse. The abuse can include withholding of necessary assistive devices, care or treatment. Most often the abuse is by male known to the victim, particularly in sexual abuse. Under-reporting is likely caused by fear and dependency on the abuser. Women with physical disabilities are more at risk for abuse by attendants or healthcare providers and more likely to experience a longer duration of abuse. It has been estimated that more than 30% of women with developmental disabilities have been sexually abused in their lifetimes. Women with Down syndrome are particularly vulnerable because of their passive, obedient, and affectionate behavior. For additional information on this population refer to the "Access to Reproductive Health Care for Women With Disabilities" chapter.
5. Immigrant Women:
In many places, there are customs other than child marriage that result in sexual violence towards women. Immigrant and refugee women are susceptible to violence and abuse because of isolation and manipulation by their partners, language and cultural differences, and lack of awareness of their rights, legal and social resources. Immigrants often do not trust advocates from outside their communities and my fear the police and deportation based on experiences in their countries of origin. These women are under great pressure to maintain cohesive family structures, no matter what the cost, and comply with their abusers' demands and behaviors. Furthermore, in some ethnic groups, traditional practices of abuse and violence are cultural norms (eg. wife beating, honor killings). Thus, the prevalence of abuse in these populations may be greater than 50%. Because of the increasing number of women of many cultures who appear for care, it is important for physicians to maintain cultural sensitivity and awareness. They are able to seek shelter, health care, and advocacy, as well as apply for residency without the batterer's sponsorship. State benefits are available under various aid programs, including those for children. Many immigrant women are unaware of these opportunities. Provision of this information by physicians to this population can be very valuable.
6. Lesbian, Gay, Bisexual and Transgender Communities:
In 2,000, there were approximately 4,400 documented cases of lesbian, gay, bisexual and transgender partner abuse, with a prevalence rate of between 20% and 35%, similar to that among heterosexual couples. The processes of power and control, the cyclicity, and the severity of physical, sexual, and emotional violence in the lesbian, gay, bisexual, and transgender communities are the same as in partner abuse in all other populations. Often these individuals are stigmatized and isolated from main-stream society by their sexual orientation or gender identity. Myths in mainstream society contribute to a lack of both understanding and acknowledgement of intimate partner violence in these communities. The legal, law enforcement, and advocacy response systems can be insensitive to abuse of lesbian, gay, bisexual, and transgender individuals, incorrectly assuming that intimate partner violence does not occur in these populations. Thus, these women may have limited access to violence prevention and advocacy programs or to protective services that are otherwise provided by the law. Several states define domestic violence in ways that exclude individuals in same sex relationships from access to protective orders. Counseling, therapy and support group initiatives have been found to be helpful following sexual assaults, especially where there may be complicating factors related to violence itself or the process of recovery. There is some evidence that a brief cognitive-behavioral program administered shortly after assault can hasten the rate of improvement of psychological damage arising from trauma.
7. Elder Abuse:
Concern over the mistreatment of older people has been heightened by the realization that in the coming decades, in both developing and developed countries, there will be a dramatic increase in the population in the older age segment. Mistreatment of older people referred to as "elder abuse" was first described in British scientific journals in 1975 under the term "granny battering". As a social and political issue, though, it was the United States Congress that first seized on the problem, followed later by researchers and government actions were reported from Australia, Canada, China, Hong Kong, Norway, Sweden and the United States; and in the following decade from Argentina, Brazil, Chile, India, Israel, Japan, South Africa, the United Kingdom and other European countries. The National Elder Abuse Incidence Study estimates that approximately 450,000 older individuals in domestic settings are abused or neglected annually. Women make up 58% of victims of elder abuse. It is estimated that only 1 out of 14 elder abuse cases is reported to a public agency. Under-reporting of elder family abuse may be related to the setting in which the abuse occurs and the relationship between the victim and the abuser. In almost 90% of incidents with a known perpetrator, the abuser is a family member, usually an adult child or spouse. Physicians or other healthcare providers who provide acute or chronic medical care to older adults may see these individuals on a regular basis and have unique opportunities for screening and assessment. Incorporating screening related to elder abuse and neglect into these encounters will increase identification of abuse. Physicians should assess patients for elder abuse and respond to patients who are victims of elder abuse as they would to domestic violence in general.
Legal Issues & Reporting:
A basic understanding of legal measures and considerations can enhance a physician's ability to counsel and assist women in violent relationships. Because there is significant variation among state laws in terms of the requirements for healthcare providers, familiarity with local news and politics is critical. Healthcare providers can contact their state medical society for up-to-date information about these laws.
All states require physicians to report suspected child abuse. Almost all states require physicians to report injuries sustained by a gun, knife, or other deadly weapon. State laws generally provide physicians with immunity from civil or criminal liability if good faith is used when filing a report of suspected or confirmed domestic violence. Breaches in privacy and confidentiality expose a victim to further physical and emotional consequences and various forms of social discrimination. Violence may escalate if the perpetrator learns that a report has been filed and retaliates, especially if the woman leaves the relationship. Recommendations have been made for the use and disclosure of health information for victims of intimate partner violence and domestic violence based on respecting autonomy and confidentiality to assure victims' safety and quality of care and to protect their rights to social programs.
There is often a culture of silence around the topic of domestic violence, which makes the collection of data on this sensitive topic particularly challenging. Even women who want to speak about their experience with domestic violence may find it difficult because of feelings of shame or fear. Women are not the only ones to suffer health-related repercussions from domestic violence. Starting from conception, children of mothers who have experienced violence are at disproportionate risk for poor health outcomes. The decision to take action can be a long and difficult process and can include many attempts to leave a violent relationship before it is left permanently. Therefore, to assume that a patient can leave without consequences suggests that the woman has more control than is apparent and implies that she is part of the problem. It ignores the possibility of long-term psychological sequelae from childhood or adolescent abuse and the cumulative effects that past or present abuse can have on a woman. It ignores the dynamics of violence, the true perpetrator, and the criminal nature of partner and family abuse.Once an abuse is identified in the family, the role of the obstetrician and gynecologist is to bring this to the attention of those who will provide family case management. Actively making referrals to such resources is essential, because the abused woman may not be willing or able to do so on her own, especially if she fears retaliation or loss of child custody. Conversely, some battered women seek help through their children.
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