Medicine and Society Curriculum Contents

Section One: Approaching the Victim of Partner Abuse

One in ten women in the U.S. has been the victim of major domestic violence. Health care providers interact with victims of partner abuse every day. Studies have found that anywhere between 4 and 30 percent (depending on location, time, and other factors) of all women treated at emergency rooms are seeking treatment for injuries due to partner abuse.¹

Not all battered women seeking treatment end up at the emergency room, however. Some of these women go to their primary care physicians for treatment. One study conducted at an internal medicine practice revealed that 12 percent of the women seeking treatment were in battering relationships at the time, and as many as three times that number have a past history of partner abuse.^2,3

Detection of abuse is not always easy. Patients don’t often report the true cause of their injuries, and doctors may not ask. Battered women may not speak about their abuse for various reasons. Many women worry that their partners will learn of their disclosure and retaliate. Some may feel too ashamed or embarrassed to discuss the abuse. Others might believe that abuse is normal or that they somehow deserve it, or that health care professionals would not be supportive or understanding.⁴

Many health care professionals have never received any education about partner abuse and do not know what to look for. When they do suspect violence, many do not know what to do next. With the current pressure on medical personnel to provide speedy treatment, taking time to ask a patient about abuse may seem impractical.

Violence against an intimate partner rarely occurs in isolation. The abuse tends to continue and escalate, so a minor injury is often a red flag that more severe injuries are imminent. The abusive partner may be victimizing others, particularly children or animals in the household. Since health care professionals are often the first to come in contact with battered women, they are in a unique and critical position to provide aid. Along with other professionals in the community, they can begin the process of addressing violence in the home.

Signs of Abuse: What Physicians Should Look For

Battered women tend to have different injuries than the general emergency room population. They are more likely to sustain injuries to the face, head, neck, thorax, and abdomen than nonabused women.⁵ Facial contusion is the most common injury among battered women.

In taking a medical history, look for evasiveness or inconsistent explanations about injuries.⁶ Often there is an inexplicable delay between the occurrence of the injury and the date treatment is sought. Other things to look for include “vague complaints of pain without physiological cause” and a medical history of repeated “accidents.”⁷

Women with a history of repeated emergency room visits deserve special attention. Researchers have found that victims of partner abuse are more likely to use emergency rooms and outpatient services than nonvictims.⁷ Suspicion is also warranted if an injured woman’s partner is hovering over her or answering the health care provider’s questions for her.

Battered women report that their partners exercise excessive control over every aspect of their lives, often intimidating and threatening them.³ They live with a constant fear of assault. Frequently, their partners become so accusatory of their actions with others that the women eventually cut off contact with their friends and families in order to avoid conflict with their partners. They often experience extreme social isolation. Any or all of these characteristics should alert health care professionals to the possibility of partner abuse.

Battered women are more likely to attempt suicide, abuse alcohol and/or drugs, and be diagnosed with psychiatric illnesses.⁷ Alcohol abuse by the partner increases the likelihood of violence.

Intervention

1. Ensure Privacy
The patient’s history should be taken in a private area where no one can hear or read the questions and responses.^6,8 The woman’s partner, if present, should be asked to wait in the waiting room.

2. Provide a Safe Environment
It is important to make patients feel they are in a safe environment. This can be accomplished through buttons, posters, pamphlets, etc., that address domestic violence.⁸ In a Minnesota study, residents wore buttons that read, “It’s okay to talk to me about family violence and abuse,” and elicited significantly more conversations about abuse with their patients.⁹ Placing information in women’s restrooms is a good way to reach abused women when they are not in the presence of their partners.

A complete line of domestic violence awareness products is available from the Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103-5133; (415) 252-8900; fax: (415) 252-8991.

3. Ask About Violence
The most important step for the health care professional is to ask about violence. Several studies found that including a single question about domestic violence in the medical interview significantly increases detection rates.^2,10,11 Contrary to what physicians may imagine, researchers found that women did not mind being asked about domestic violence, and that some even seemed relieved. Direct questioning about partner abuse should be a routine aspect of all medical interviewing, not just when partner abuse is suspected.

4. Be Supportive
Let the patient know that you are concerned for her safety and that she does not deserve to be abused.⁸ Assure her that the abuse is not her fault, and that you’d like to help her. Make sure that she is currently safe at home or has someone safe with whom she can stay.

5. Conduct a Thorough Physical Examination
Women who present with injuries should be thoroughly examined to determine if they have previous injuries. Injuries in different stages of healing typically indicate violence.⁶ Be particularly vigilant for injuries to the head, neck, breasts, and genitals.^5,6,8

6. Document Injuries
Thoroughly document all of the patient’s injuries, either through photographs or sketches.^6,8 Have the patient sign the documentation once it is completed. This evidence may be the only way a woman can legally prove her abuse and may help protect herself or her children against future injury.

7. Network With Other Professionals
Social workers, battered women’s shelter staff, the police, and child advocates must be contacted.^6,12 The social work and nursing staffs will help you do this. A multidisciplinary team ensures that no matter which professional has initial contact with a victim of partner abuse, there will be an established network available to aid the victim through the entire process.

If there is any question of animal abuse in the home, contact a humane officer who can be reached through the local humane society or, in some cases, the local animal control agency. In turn, humane officers are often the first to detect child or partner abuse.

8. Keep the Patient in Control
Battered women are so used to being controlled by their partners that an overly controlling physician will only make the situation worse.⁸ While it is crucial to provide an abused woman with the information and resources she needs, she alone can make the decision as to whether (and when) to leave her partner. Expect a battered woman to return to her partner several times before she finally leaves. It will be frustrating and may make you feel helpless, but your support can make a world of difference. As one researcher once said, “Leaving is a process, not an event.”⁸

9. Examine Your Own Feelings
Your beliefs about domestic violence will directly influence how you respond to patients.¹³ Make sure you are aware of your prejudices and can recognize them when they surface in patient interactions. Reading about domestic violence, talking with colleagues, and talking with abuse survivors will help.

An excellent, comprehensive physician’s desk reference to domestic violence intervention, The Physician’s Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse…Another Way to Save a Life, is available from Volcano Press, P.O. Box 270-37, Volcano, CA 95689-0270; (800) 879-9636; fax: (209) 296-4995.

Domestic Violence Education in the Medical Curriculum

If you would like to add more instruction on dealing with domestic violence to your medical school curriculum, here are several steps you can take:^13-16

1. Make sure that questions about domestic violence are included in standard interview training.
2. To become more comfortable in patient interviews, engage in role-plays and participate in video and in-person observation.
3. Have domestic violence survivors and professionals from community groups talk to your class about domestic violence.
4. Visit battered women’s shelters, advocacy centers, or domestic violence court cases.
5. Conduct research on domestic violence.
6. Explore your feelings about domestic violence.

Medical students should be exposed to the following American Medical Association publications:

• Flitcraft A, Hadley SM, Hendricks-Matthews MK, McLeer SV, Warshaw C. Diagnostic and treatment guidelines on domestic violence. Chicago, IL: American Medical Association.
• AMA Council on Ethical and Judicial Affairs. Physicians and domestic violence: ethical considerations. JAMA 1992;267:3190-3.

It is also crucial that current faculty receive domestic violence training. The following resources address faculty and curricular development:

• Albright CL. Resources for faculty development in family violence. Acad Med 1997;72:1:S93-9.
• Proceedings of the AAMC’s consensus conference on the education of medical students about family violence. Acad Med 1995;70:961-1001.

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References
1. Wilt S, Olson S. Prevalence of domestic violence in the United States. J Amer Med Women Assoc 1996;51:77-82.
2. Freund KM, Bak SM, Blackhall L. Identifying domestic violence in primary care practice. J Gen Intern Med 1996;11:44-6.
3. Elliott BA, Johnson MMP. Domestic violence in a primary care setting. Arch Fam Med 1995;4:113-9.
4. Gerbert B, Johnston K, Caspers N, Bleecker T, Woods A, Rosenbaum A. Experiences of battered women in health care settings: a qualitative study. Women Health 1996;24:1-17.
5. Muelleman RL, Lenaghan PA, Pakieser RA. Battered women: injury locations and types. Ann Emerg Med 1996;28:486-92.
6. McCoy M. Domestic violence: clues to victimization. Ann Emerg Med 1996;27:764-5.
7. Roberts GL, Lawrence JM, O’Toole BI, Raphael B. Domestic violence in the emergency department: I: two case-control studies of victims. Gen Hosp Psychiatry 1997;19:5-11.
8. Chescheir N. Violence against women: response from clinicians. Ann Emerg Med 1996;27:766-8.
9. Bolin L, Elliott B. Physician detection of family violence: do buttons worn by doctors generate conversations about domestic abuse? Minn Med 1996;79:42-5.
10. Olson L, Anctil C, Fullerton L, Brillman J, Arbuckle J, Sklar D. Increasing emergency physician recognition of domestic violence. Ann Emerg Med 1996;27:741-6.
11. McLeer SV, Anwar R. A study of battered women presenting in an emergency department. Am J Public Health 1989;79:65-6.
12. Albright CL. Resources for faculty development in family violence. Acad Med 1997;72:S93-9.
13. Warshaw C. Intimate partner abuse: developing a framework for change in medical education. Acad Med 1997;72:S26-37.
14. Congdon TW. A medical student’s perspective on education about domestic violence. Acad Med 1997;72:S7-9.
15. Alpert EJ. Making a place for teaching about family violence in medical school. Acad Med 1995;70:974-8.
16. Pinn VW, Chunko MT. The diverse faces of violence: minority women and domestic violence. Acad Med 1997;72:S65-71.

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