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Domestic Violence Back to Course Index

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DOMESTIC VIOLENCE

 

 

 

 

INTRODUCTION

 

 

Domestic Violence is an inclusive term gathering into itself several other related terms such as domestic abuse, spousal abuse, battering, family violence, dating abuse, and Intimate Partner Abuse (IPA).  The definition of domestic violence is:  A pattern of abusive behaviors including a wide range of physical, sexual, and psychological maltreatment used by one person in an intimate relationship against another to establish power unfairly or maintain that persons misuse of power, control, and authority.  It is typically  viewed as a pattern of antisocial behaviors that can take many forms, including physical aggression or assault (hitting, kicking, biting, shoving, restraining, slapping, throwing objects, battery), or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic deprivation.  Domestic violence and abuse are not limited to obvious physical violence.  It can also mean endangerment, criminal coercion, kidnapping, unlawful imprisonment, trespassing, harassment, and stalking.

  

The awareness, perception, definition, documentation and treatment of domestic violence differ (slightly) from region-to-region in the United States.  For example, studies indicate that it is tolerated more in the South than in other regions. Also, the laws pertaining to domestic violence vary by country. While it is generally outlawed in the Western World, this is not the case in some Middle East countries. For instance, some Arab countries allow a man to physically discipline his wife and children.  The social acceptability of domestic violence also differs by country. While in most developed countries domestic violence is considered unacceptable by most people, in many areas of the world the views are different: according to recent studies, the percentage of adult women think that a husband is justified in hitting or beating his wife under certain circumstances is over 70% in Afghanistan, Jordan, and in the Central African Republic. Refusing to submit to a husband’s wishes is a common reason given for justification of violence.               

 

Domestic violence is largely thought to be male against female; however, the term includes any intimate relationship husband against wife, wife against husband, brother against brother, uncle against nephew, grandchild against grandparent, and roommate against roommate. Wikipedia, The Free Encyclopedia states that domestic violence occurs when a family member, partner or ex-partner attempts to physically or psychologically dominate another. The encyclopedia goes on to say that domestic violence often refers to violence between spouses, or spousal abuse but can also include cohabitants and non-married intimate partners. Domestic violence occurs in all cultures; people of all races, ethnicities, religions, sexes and classes can be perpetrators of domestic violence. Domestic violence is perpetrated by both men and women.

 

Also from Wikipedia, domestic violence can be criminal and includes physical assault (hitting, pushing, shoving, etc.), sexual abuse (unwanted or forced sexual activity), and stalking. Although emotional, psychological and financial abuse is not generally criminal behaviors in some legal systems, they are forms of abuse and can lead to criminal violence. There are a number of dimensions including:

 

  • Mode: physical, psychological, sexual and/or social.      
  • Frequency: on/off, occasional and chronic.
  • Severity: in terms of both psychological or physical harm and the need for treatment. Injuries may vary from mild to moderate to severe up to homicide.
  • Transitory or permanent

 

An important component of domestic violence, often ignored is the realm of passive abuse, leading to violence. Passive abuse is covert, subtle and veiled. This includes victimization, ambiguity, and neglect, spiritual and intellectual abuse.

 

Recent attention to domestic violence began in the women’s movement, particularly feminism and women’s rights, in the 1970s, as concern about wives being beaten by their husbands gained attention. Estimates are that only about a third of cases of domestic violence are actually reported in the United States. According to the Centers for Disease Control, domestic violence is a serious, preventable public health problem affecting more than 30 million Americans. Popular emphasis has tended to be on women as the victims of domestic violence. However, with the rise of the men’s movement, and particularly men’s rights, there is now advocacy for men victimized by women. In a special report on violence related injuries by the US Department of justice (in August 1997) hospital emergency room visits pertaining to domestic violence indicated that physically abused men represent just under one-sixth of the total patients admitted to the hospital reporting domestic violence as the cause of their injuries. The report highlights that significantly more men than women did not disclose the identity of their attacker.  In significant numbers, males are the batterers and females are the sufferers of domestic violence.  However, that is not always the case.  Fewer men report incidents.

 

 Domestic violence has been an increasing health concern in America for the past 25 years; consequently, communities are developing strategies to slow the violence and provide more protective mechanisms for women, men, and children who are battered.  Researchers estimate that approximately 90 percent of the violence is against females and that over 3 million experience some form of violence each year. Also, most have been attacked by a family member or a person they are acquainted with. However, domestic violence is a family problem that devastates every sector of society, overwhelming our courts and hospitals, spilling over into our streets, and filling our morgues. We must all be a part of the solution if we are to address the deadly toll this epidemic is taking. Every community is touched, yet the pervasive problem of domestic violence continues to be a problem that most individuals struggles with at the time of witnessing an event that seems as though it is pushing the envelope of just an argument.  When do you call the police?  When do you get involved?  Do you look away?

 

Domestic violence was one of the leading causes of injury to women at the start of the 21st century and continues to the present time.  It results in more injuries than muggings, stranger rapes, and auto accidents combined.  Researchers estimate that some form of domestic violence occurs in approximately one-third of marriages in the United States and has a significant impact on the health care cost as the victims spend nearly 125,000 days in hospitals, make 40,000 emergency room visits, and 70,000 trips to the doctor every year.   Also, about one-half of homeless women and their children are fleeing from domestic violence situations.  Also, over 4 million children witness or are involved in acts of domestic violence every year.  The risk of psychological and behavioral problems increases dramatically for these children and they are more likely to attempt suicide and/or abuse alcohol, tobacco and other drugs.  They start their early life with a significant handicap (due to no fault of their own) and frequently never completely overcome it.  In essence, it’s a heavy load on children who either witness domestic violence or are victims themselves.

 

 RECENT STATISTICS AND A GROWING PROBLEM

 

 Researchers predict that over five million Americans will be victims of domestic violence per annum.  Almost one in three women will be assaulted by their partner, at least once.  Even with those daunting figures, experts agree that the actual numbers are higher because many feel too ashamed or fearful of their perpetrator to report the incident.  According to the American Psychological Association Task Force on Violence and the Family, this type of violence is the leading cause of injury to women age 15 to 44 in the US, and represents a national epidemic of violence in the home. 

 

Although much can be predicted about the pattern after abuse has begun, little can predetermine with validity who will abuse.  Race and or socio-economic levels are not significant risk factors meaning that domestic violence occurs across all racial and socio-economic levels.  African-American women experience more domestic violence than White women in the age group of 20-24. However, Black and White women experience the same level of victimization in all other age categories.  Hispanic women are less likely to be victimized than non-Hispanic women in every age group.

 

Research suggests a high correlation between aggression and the use of alcohol and other drugs.  Not necessarily in that there is a correlation that suggests alcohol and other drugs cause abuse, but rather their presence can exacerbate the level of violence.  Alcohol and other drug use lower inhibitions, affect judgment, and often increase emotions.

 

HISTORY

 

Researchers have found that over 40% of battering men came from male dominated homes where the male was either violent or controlling or both. Typically, family members were afraid of the dominant male because of threats or frequent violence acts generally directed at his mate or the children.  Although men are more likely to be victims of violent crime overall, a recent study by the U.S. Department of Justice reports that “intimate partner violence is primarily a crime against women.  Of those victimized by an intimate partner, approximately 90% are women and 10% are men. In other words, women are considerably more likely than men to be victimized by an intimate partner.  Even when men are victimized, 10% are assaulted by another man. In contrast, only 2% of women who are victimized are assaulted by another woman.  With these statistics, it is important to note that women are more likely to report violent incidents.  Only about half of domestic violence incidents are reported to police.  There is growing skepticism regarding the quality of police response which is grounded in reality.  For example, a recent study by the D.C. Metropolitan Police Department concluded that only 17% of the victims were asked about a restraining order, and 83% were provided no printed information with contact information or resources which is a department standard.  This may or may not be indicative of service across the country, but it is an alarming discovery. As noted previously, Domestic abuse occurs when one person in a relationship or marriage tries to dominate and/or control the other person. The abuser may use fear, guilt, shame, or intimidation to gain an advantage over the victim.  He or she may threaten the victim or their family (including their children).  When abuse turns violent (physical attacks) it is called domestic violence. Victims of domestic abuse/violence may be men or women, although women are more commonly victimized.  Domestic abuse/violence occurs among heterosexual couples as well as in same-sex relationships. Domestic abuse/violence does not discriminate except for gender (women are predominately the victims).  Also, it occurs across all ages, ethnic backgrounds, and social/economic levels.

 

Heterosexual males (in relationships) are the most frequent domestic violence offenders.  However, researchers have found that women are equally likely to hit or physically harm a partner.  Also, an average man is larger and more capable of defending himself against physical assaults; consequently they do not have the same reaction to violence directed at them.  It is equally wrong regardless of who does the abusing, as no one should have to tolerate being abused by another person. In any case, the female is more likely to sustain a serious injury than the male counterpart.  Also a man’s reaction to a woman’s violence is usually less emotionally than a woman’s reaction to a man’s violent acts. The man’s reaction is usually categorized in the annoyance, anger and self-righteousness categories whereas the reaction for women is more traumatic, often involving varying amounts of fear or terror. When a 200-lb man hits a 120lb woman, the impact is going to be greater for her than if the roles were reversed due to physical size, training and mind-set.  If either the man or women hits a young child the results can be devastating.

 

MYTH 

 

Despite a common myth, domestic violence is not due to the abusers loss of control over his emotions and behavior. Researchers have concluded that their violence is a deliberate choice made by the abuser in order to control the victim.  Some of the more obvious observations to support this conclusion are:

 

  • The perpetrator does not batter other individuals-the supervisor who treats him unfairly or the restaurant server who spills food.  He waits until there are no witnesses and abuses the person he says he loves.
  • In most cases, the perpetrator can stop when the police arrive at the scene.  It’s amazing how quickly he can regain his composure and look calm, cool and collected and she is the one who may look hysterical.  If he were truly “out of control” he would not be able to stop himself when it is to his advantage to do so.
  • The incident generally escalates from pushing and shoving to hitting in places where the bruises and marks don’t show. An out of control perpetrator would not be able to direct or limit where he kicks or punches the victim.

 

 

LEGAL CONSIDERATIONS

 

In most states, only the physical acts of domestic violence are actionable under law.  This is generally interpreted as the use of physical force or threats to control or intimidate a victim.  Certainly there are many relationships between people that are dysfunctional in which one or both people are emotionally abusive to the other. But if there’s no battering (threat of violence or overwhelming control of that person’s life) then we’re simply talking about a bad relationship in which either party can choose to remove themselves; and not one in which a person feels threatened of serious harm if they leave. Another legal issue to consider is the mandatory arrest policies in which police are required to make an arrest if there is probable cause that a person has committed domestic violence. Passage of these laws was advocated by domestic violence experts to address the inadequate response to domestic violence victims by law enforcement. When officers arrive at the scene of a domestic violence crime, they often cite evidence that both partners have engaged in some aggressive behavior, and arrest both. This “dual arrest” strategy fails to take into account which of two people is primarily responsible for the aggression and which one is responding out of self-defense, and can have devastating effects, particularly if there are children involved in the relationship. To counteract this problem, some departmental or statewide policies now provide guidelines for an officer to determine who the primary aggressor is in a violent incident. For example, the California Commission on Peace Officer Standards and Training publishes a guidebook for officers responding to domestic violence, discouraging “dual arrests” and outlining several factors to consider when determining who is the primary aggressor in a domestic violence situation. The primary aggressor is defined as “the person determined to be the most significant, rather than the first, aggressor.” Factors to consider include the history of domestic violence between the people involved, the threats and fear level of each person, and whether either person acted in self defense. These are appropriate considerations when determining who the primary aggressor is, and therefore which of the two parties should be arrested.

 

TYPES OF DOMESTIC VIOLENCE

 

 Acts of domestic violence generally fall into one or more of the following categories:        

 

 Physical battering includes bodily attacks or aggressive behavior. This type of behavior is what most people think of when they hear the term domestic violence.  Physical violence ranges from pushing or shoving to bruising (while restraining) to punching, kicking, biting to serious injury up to and including death.  Most experts agree that without some type of intervention physical violence escalates with time.  It starts with a relatively minor incident, which is excused as trivial such as pushing someone or throwing keys, and then escalates over time into more frequent and serious attacks.

 Psychological or emotional abuse is deliberate undermining of someone’s sense of safety and well-being.  This type of abuse includes repeated criticisms, humiliation, name-calling, extreme jealousy, harassment, threats of suicide, and isolation from friends and family.  Isolation occurs to undermine the support system and reduce the negative feedback about the relationship someone might receive from family and friends. 

Sexual violence is unwanted or coerced sexual contact of any kind.  Married or not, a person has the right to say no.

 

Intimidation is defined in this context as the act of deterring or making someone fearful by threats of violence to manipulate or control behavior.  The abuser inhibits the victims behavior by threatening to hurt or kill them or their friends and family, including blackmail and threats to abduct children.  This category often includes physical violence against property such as breaking into an individual’s home and wrecking it or displaying weapons in such a way that a threat is implied.

 

 Parallel violence is when an abuser acts against another person the intended victim cares about or a pet in order to control the partner.

 

Economic abuse is often used to control a victim’s ability to leave a relationship.  It involves restricting access to money or to other financial resources.  Keeping a partners income or preventing them from earning income is included in this type of abuse. 

 

PSYCHOLOGICAL PROFILE OF AN ABUSER

 

 Some of the psychological/personality characteristics common in abusers (in addition to their propensity to use physical violence) are:

 Dominance or type A personality: Most perpetrators have a domineering personality with a strong need to be in charge of those around them. They like to tell people what to do and when to do it and for their orders to be followed.  They have a tendency to direct most family activities.

 Humiliation tendencies: A perpetrator will do almost anything to embarrass a victim.  His objective is to make the victim feel bad or feel defective in some manner. The abusers objective is to make the victim believe they are worthless and of no value to anyone else.  Also, the victim’s self-esteem is eroded through insults, name-calling, shaming, and put-downs.

 Isolationism: This trait is used to increase the victims dependence on the perpetrator. The perpetrator will limit transportation, money and other items to isolate a victim from family and friends.  In severe cases this may extend to work and school activities.

 Threats: Threats are used to keep a victim from leaving or to scare them into dropping charges. The threats are generally related to the physical realm and may include a threat to harm children, other family members or pets. He may also threaten to harm himself.

 Intimidation: A perpetrator may use threatening looks or gestures, damage personal property, drive-bys, injure your pets or display guns to scare a victim into submission. The message is that if you don’t obey, there will be violent consequences.

 Denial and blame: Perpetrators blame their violent behavior on a bad childhood, trouble at work, bad neighborhood, a bad day, family or anything else that will shift the responsibility for the abuse to someone or something else. The perpetrator will also minimize his role or deny that it occurred. He will commonly shift the responsibility for his violence onto you as if somehow it’s your fault.

 

SYMPTOMS OF ABUSE/VIOLENCE

 

Emotional Abuse

       Put-downs (erodes victims self esteem)

       Name Calling/personal insults

       Playing the psycho game (make someone think they are going crazy)

       Humiliation (public reprimand; exploit/exaggerate any mistake in public)

       Causing guilt (false accusations)

 

Economic Abuse

       Limit job opportunities (outside the home)

       Denying a person money or access to money

       Limit how much a person can spend (allowance)

       Taking the other persons money

 

Coercion and Threats

       Making or carrying out threats to do something to hurt the other person.

       Threatening to leave the other person, to commit suicide, report the other person to law enforcement

       Making the other person do illegal things

 

Intimidation

       Making the other person afraid by using looks, gestures, or actions

       Smashing things

       Abusing pets

       Displaying weapons

 

Using Children

       Making the other person feel guilty about the children

       Using visitation to harass the other person

       Threatening to take the children away

 

Abusing Privileges

       Treating the other person like a slave

       Making all the decisions  

 

DYNAMICS OF DOMESTIC VIOLENCE RELATIONSHIPS

 

Many theories have been developed to explain ongoing violence in intimate relationships.  Some have named family dysfunction, inadequate communication skills, stress, chemical dependency, and financial distress as theories.  These problems may be associated with domestic violence but they are not the cause.  Removing the factors that perpetuate anger will not end violence.  Domestic violence is about power and control.  Power and control over one or a select few.  Power and control is the primary factor in this kind of conduct.  The violence begins and continues because it is an effective method for gaining and keeping control over another person, frequently with few negative consequences.

 

Much can be predicted about the pattern that exists within the abusive relationship.  Batterers typically externalize blame, explaining their violence is due to stress, the partner’s behavior, alcohol, etc.  Poor self-esteem, feeling inadequate and feeling powerless in the world are frequent attributes of those that abuse.  They take these feelings of inadequacy and lack of power over the outside world out on those that are on the inside and intimate.  Often, their chief source of identity and ego gratification depends on their being able to exert control over their partner.

 

Often blame is placed on those who stay in abusive relationships.  On the surface the situation seems obvious.  However the barriers to leaving an abusive relationship are plentiful.  Survivors of abuse typically experience shame, guilt, embarrassment, and isolation. How many men want to admit they are being physically abused?  How many would make jokes about a man explaining he was forced to have unwanted sex?  Homelessness in women is a leading outcome of leaving violent marriages.  The threat of losing children is a terrifying nightmare.  At the very least, leaving means a loss of income, the difficulties associated with single parenting, frequently harassment at work.  Friends and family will not always believe the victim. 

 

There is also the very real emotional pull that comes from the fact that most violent relationships are not violent at all times.  The human spirit is full of hope.  Abusers can be every bit as loving as they can be cruel.  One of the most important points to remember is that leaving is dangerous. 

 

Violent relationships frequently develop into cycles of violence.  The cycle can be described as:

 

 

 

 

 

 

The cycle begins with Phase One:  Escalating or Tension Building.  In this phase the batterer is in a low stage of anger.  They degrade, humiliate, and verbally harass the victim.  They are easily irritated and agitated.  Often a husband will have a growing fear that his wife will leave and he has an increased degree of surveillance of her behavior and a higher degree of jealousy.  There is a definite increase in stress and anxiety.  The victim does everything they can to keep the peace. They often place blame on outside stressors.  Characteristics/interactions of this phase include:

  Abuser begins to get irritable and begins verbal attacks; generally is in continuous hostile/anger mood

  Abuse may begin; may initially be minor; may include threats to victim, other family members, friends and others; may include threat to commit harm self)

  There is generally a breakdown of effective communication;  loss of trust; may become protective of joint property and joint financial resources

  Abuser may attempt to limit victims outside contacts with family and friends

  Victim feels the need to keep the abuser calm

  Victim feels they are walking on egg shells

  Tension increases to the critical/explosive stage

 

The second is Phase Two:  Acute battering.  In this phase there is a violent discharge of tension or rage.  The batterer appears to have impaired awareness and lacks control.  Often batterers in treatment say, “she knew just what to do to push my buttons; she did it on purpose”.  This can be explained by the victim in this phase as they often feel a passive acceptance and a belief that it’s futile to try to escape.  In some instances they know if they get through the incident the next phase will come.  The victim is isolated, depressed and often suffers from an emotional collapse after the violence.   The characteristics/interactions of this phase include:

 

  Abuser physically and emotionally attacks victim; may attack other family members of friends; may inflict physical and/or emotional harm to the victim.

   Abuser may appear to lose awareness of his surroundings and loss of control of his actions (researchers have concluded that most abuser know what they are doing at all times).

   Alcohol and or other drugs may increase risk of severe injury

   Abuser will generally isolate the victim and limit their communication

   Abuser may restrain victim

   Abuser may leave scene with children (victim is emotionally stressed by absence of children and fear that they may be harmed)

   Police are generally involved; parties are generally separated until they regain their composure and request reconciliation 

   Restraining/protective court orders may be required

   

The third is Phase Three:  The Honeymoon Phase.  The batterer loves and asks for forgiveness.  They promise never again.  They are dependent on the victim’s acceptance and validation.  The victim experiences guilt and responsibility for the batterer.  They have hope that this is the last time until the behaviors begin again in phase one.  The characteristics/interactions of this phase include:

 

  Abuser acts as if the incident never happened

 Abuser may apologize and be very remorseful (generally temporary); promises that it will never happen again; attempts to explain away the incident

  Abuser may shower victim with gifts and affection

  Victim may hope that abuse is over

 

The cycle can happen sever times in an abusive relationship.  Each stage lasts a different amount of time in each relationship.  The cycle can take anywhere from a few hours to a year or more to complete.  It is important to remember that not all domestic violence relationships fit the cycle.

         

 

CHARACTERISTICS OF ABUSERS

 

Most authorities on the subject of domestic violence agree that it is an issue of power and control rather than simply anger.  Batterers can be characterized as using violence as a strategy to gain power and control over others.  The following list defines qualities that are many experts have compiled that are frequently, but not always, present in batterers:

       Male

       Dependent, inadequate personalities

       Violent family of origin

       History of violence

       Abusive of alcohol or other drugs

       Easily frustrated

       Poor control of impulses

       Rigid beliefs

       Mood swings

 

 

Risk Factors for Abuse

 

Abuse occurs in all socioeconomic groups, all genders, all religions, all races, all educational backgrounds, all ages, and all sexual orientations. In a national survey of over 6,000 American families, 50% of the men who frequently assaulted their wives also frequently abused their children (Straus, M.A. & Gelles, R.J., Physical Violence in American Families, 1990).  The following factors are areas of increased risk for abuse:

 

 Female between the ages of 19 to 29

 Pregnancy

 Individuals who come from abusive homes or have had previously abusive relationships

 Women who are single and under 35 are more likely to report the abuse

 

Barriers to Leaving a Violent Relationship

 

The most crucial reason to stay is leaving is dangerous.  The most dangerous time in a violent relationship is when the victim is attempting to end the relationship.  Men and women alike are frequently embarrassed to admit they have been physically abused.  Often leaving means continued and escalated harassment.  In an attempt to control the individual leaving, threats are frequently made concerning finances and child custody.

 

There is also a mixed emotion for love and hope along with the manipulation, intimidation and fear.  Often the abusers will threaten to hurt themselves or other loved ones if the victim does not stay.

 

Support systems often become weaker once the threat is increased and pointed at them, as well.  A friend who offers a friend a safe place to stay can become threatened and scared.  Clergy and secular counselors are often trained to see only the goal of saving the marriage.  Financial institutes do not want to get involved in family issues.

 

 

Preparing Health Care Professionals to Screen for Domestic Violence

 

Less than 10% of primary care physicians screen for domestic violence on a routine basis during regular office visits.  In emergency rooms, less than 3% of female patients disclosed or were screened for domestic violence by a nurse or physician, yet an estimated 17% to 27% of the injuries that bring women to the emergency room were caused by their partner. Using protocols to identify and treat those in the population that is at increased risk of domestic violence and any others who meet certain criteria increases the identification rate to 30%.  The National Institute of Justice and the Centers for Disease Control indicated that women make almost 700,000 health care visits due to injuries resulting from physical assault, and that most of these are inflicted by intimate partners.  All women and men who present with injure and implausible explanations should be evaluated with abuse in mind.

 

Injuries are not the only symptom of domestic violence.  Many chronic health care problems, such as alcoholism and other substance abuse issues, depression, and other mental health problems are also caused by this type of violence. 

 

According to The Family Violence Prevention Fund all females over the age of 14 should be asked questions concerning the topic of domestic violence.  There publication has a set of clinical guidelines for routine screening for domestic violence in health care settings.  They recommend these guidelines be utilized in all primary care, urgent care, obstetrics/gynecology, family planning, mental health, and residential settings.  Screening should be a part of all initial intake forms, including prenatal visits.  The number one most prevalent time in a woman’s life to be battered is during pregnancy.

 

The following is a checklist that could be utilized as a tool for health care providers:

 

Does your partner:

 

___Put you down, embarrass or make fun of you in front of others?

 

___Make fun of your goals or discourage you?

 

___ Intimidate or attempt to control you?

 

___ Tell you that you are nothing without them?

 

___Attempt to make all of the decisions?

 

___Treat you rough-grab, push, pinch, shove or hit you?

 

___Make you feel bad about yourself?

 

___Call you several times a night or show up to make sure you are where

       you said you would be?

 

___Blame you for how they feel or act?

 

___Blame alcohol or other drugs for how they act?

 

___Pressure you sexually?

 

___Are you ever afraid of them?

 

___Are you afraid they will hurt themselves or someone else if you leave the  

      relationship?

 

___Do you find yourself attempting not to make them angry at all costs?

 

  

To ensure the effectiveness of the screening, health care providers should be educated about the dynamics of domestic violence, the safety and autonomy of abused patients, and the cultural aspects of this type of violence.  These screeners should be trained in asking about abuse and in intervening with abuse victims.  This screening should be conducted in a private setting and under the best of circumstances should be done in person.  A nonjudgmental approach is essential.

 

As a medical professional it is important for you to know how to build rapport and ask the appropriate questions. 

 

Questions can be in the form of general framing questions such as:

 Violence against women is becoming such a prevalent problem in our society that I have begun to include it in all of my assessments.  Can you tell me about your experiences?

 I’m concerned about how your injuries were caused.  Are you comfortable telling me how they occurred?

 

Questions can be direct such as:

 Does your partner threaten you, attempt to control you, push or hit you?

 Are you or have you ever been concerned for your safety?

   

If, as a medical professional, you are concerned for a patient who is not currently admitting to abuse or is not ready to leave the relationship you can refer them to counseling and or give them telephone numbers to shelters and protective agencies.  Sometimes discussing the safety of children and pets motivates them to get the help they need.

 

 

 

Battering in Special Populations

 

Teen relationships follow the same pattern and have the same under current, as do the relationships of adults.  Young individuals are often struggling with self-esteem, gender roles, sexual activities they are comfortable with and those they are not.  Even in the best of relationships this is a time when individuals do not have assurance in who they are and what they want or need.  Self-esteem can often easily be manipulated, isolation from family is often already occurring as the teen develops independence.  Many times when a boyfriend displays extreme possessiveness it is taken as he must really love and care about me.

 

The elderly represent a population that often does not have a voice to defend themselves with.  Special consideration should be given to screening for abuse in this population.

 

Understanding cultural issues are paramount in investigating domestic violence.  Understanding how and why domestic violence occurs is impossible without taking into account the varying religious and cultural beliefs and practices.  In many countries, society is permissive of violence.  Popular songs, movies, even the nightly news and literature all normalize violence as a common, almost every day experience.

 

The patriarchal structure of the family is traditional in many countries with the husband’s authority unquestioned.  Often in many cultures there is a major emphasis on compliance and not speaking out.  Laws in many cultures are designed to protect the male, head of the household’s right to make decisions about the family.  A female who stands up to her husband or protests a beating causes the family, and herself, shame and embarrassment. 

 

A few fundamental religions and cults promote keeping women and children in line with advice from the pulpit to beat unruly wives and children. 

 

Because America is a melting pot of cultures it is necessary to keep these statistics and cultural aspects in mind.  It is important to recognize that these situations are, by families of these cultures standards, not considered wrong.  If you question a female from that culture if someone has done something out of line the answer will be no.  They will often not report violence, as they do not see it as a reportable concern.

 

To intervene successfully in all these cultures, it will be necessary to change both men’s and women’s socialization patterns and establish a new definition of authority.

 

 

Impact of Domestic Violence 

 

Every American suffers from the effects of domestic violence.  Although women are who you predominately think of when discussing domestic violence, men are also frequently victims.  Conservative estimates are that between 3.3 and 4.3 million children every year witness domestic violence, with devastating results.  Pets are also frequently abused as part of the pattern.

 

An estimated three to five billion dollars every year are lost due to this problem.  Lost wages, lower productivity, sick day usage, medical expenses and legal expenses combine to drain the national economy (Hollingworth, Domestic Violence, 2002). 

 

When discussing domestic violence the issue of homelessness is brought to the surface.  Statistic figures indicate that domestic violence is a factor in approximately 50% of homeless women and children.  For women alone, estimates range from 17 to 24%. 

 

Legal and Social Resources

 

There are many options to give those in need.  As a health care provider it is essential you are prepared with the resources and suggestions. 

 

If a person is not prepared to immediately leave an abusive relationship, it is critical that they develop safety plans.  While in a violent relationship, a victim needs to be prepared to leave if physically threatened.  If it is a safe to do so, they should be prepared to call for help, by phone or by yelling.  If a confrontation is occurring, advise is given to stay close to an exit, avoid being in the bathroom, kitchen, or near any weapons.  The potential target of violence should consider in advance what the safe ways to quickly exit the house are.  They need to determine which doors, windows, stairways, etc. are quickest and safest to use, and where they will be when they have exited.  In some cases it is a good idea to get spare keys to their vehicles made and placed in an accessible place.  Keys are often taken from them in an argument.

 

Belongings are not a factor in the face of violence.  Getting to a safe place is far more important.  In the event of ongoing abuse, if safe, advice can be given to keep a bag of clothing and essentials at the residence of a friend.  Neighbors need to be identified who are aware of the violence and they should be encouraged to call the police if they hear a disturbance.  Development of a code to be used with children, friends, and a neighbor when help is needed is advised. 

 

If a person is already preparing to leave a violent relationship, additional elements of a safety plan can be considered.  A separate savings account with a safe address is sometimes recommended, when safe.  Money, spare keys, important documents, and extra clothing can be left with a friend so that leaving can occur quickly.  Arrangements for where a victim will stay can be made in advance.  Arrangements for pets in danger can also be made.  A calling card and the number of the closest emergency shelter should be kept on hand at all times.  The most dangerous period of time is when someone is leaving a violent relationship. 

 

Upon leaving a dangerous relationship, additional locks, different routes to and from work, sometimes informing employers is necessary and an unlisted phone number should be obtained.  A safety plan for the children when the parent is not with them needs to be developed.  Day care centers and schools need to be clearly informed about who can and cannot pick up the children.  If the person has obtained a restraining order, they should keep a copy on their person at all times.  All threatening phone messages should be documented, tapes of threats should be retained, and all instances of violating a protective order should be reported. 

 

There are many domestic violence programs that can offer assistance and help in obtaining a civil protection order and for referral to a lawyer who can be helpful in pursuing criminal prosecution.  Laws vary widely in different cities, counties, and states.  In most jurisdictions, judges can issue protective orders, order abusers to leave the home, award temporary custody and order temporary child support.  Unfortunately, a court order offers little protection against a determined abuser. 

 

In the past, police have traditionally regarded domestic violence as a family dispute in which they did not get involved beyond stopping the immediate incident.  The system is changing and frequently both parties are arrested and left to the court system to untangle.  In many areas, arrest of the alleged batterer is mandatory.  Even if victims withdraw charges due to fear or emotional confusion, the perpetrator of the violence will still be prosecuted.  Victims are not able to drop charges. 

 

Many communities generally offer some sort of shelter and services for battered women and their children.  The addresses and telephone numbers of shelters are kept as secret as possible.  Under most circumstances the police have these numbers and can make a referral.

 

Most court systems recommend domestic violence counseling.  Individual therapy for victims generally focuses on assisting them to look at and correct distorted thinking and to deal with the terror of long-term abuse, anger and anxiety that they experience.  Many victims love their abusers.  This is a time of confusion and loneliness.  Building rapport, establishing a support system for the survivor, helping them to recognize and correct the distorted belief systems are critical components of treatment. Many will fall into similar types of relationships without personal growth.  Violence, feelings of guilt, the inability to make decisions for them are normal, what is strange and different is a healthy relationship.  Helping them explore their history of relationship patterns can enable them to seek out positive relationships the next time.  Individuals need to deal with any family of origin issues and any reasons they stayed in the abusive relationship so that they do not repeat the same decisions in future relationships. 

 

Group therapy can be very effective with this issue.  This therapeutic mode of treatment allows individuals to build a support network and hear the stories of others in similar situations.  As they offer support to others, as well, they become more confident in their abilities.  They begin to recognize that they were not responsible for their partners behavior.  Well, if she wasn’t pretty enough, together enough, a good enough mother, a good enough cook; then no one could be for him Group therapy is also helpful to show the effects of domestic violence on children.

 

As a professional it is important for you to have your resources handy.  Each local area has hotline numbers and resources specific to that location.

 

 

The following are national resource numbers:

 

National Domestic Violence Hotline: 1-800-799-SAFE 

National Resource Center on Domestic Violence:  1-800-537-2238

Battered Womens Justice Project:  1-800-903-0111

Resource Center on Domestic Violence/Child Protection and Custody: 800-527-3223

Health Resource Center on Domestic Violence:  1-888-792-2873

Family Violence Prevention Fund:  415-252-8089

 

 

Websites for further help:

 

http://www.nationalcouncilfvd.org

www.fvpf.org/health

National Coalition Against Domestic Violence

Bureau of Statistics

Violence Against Women Online Resources

NOW Legal Defense and Education Fund

 

 Resources by Mail:

 American Bar Association Commission on Domestic Violence: 

740 15th Street, NW, 9th Floor

Washington, DC  20005-1022

 

 

 

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