Anna Schwartz, M.D. and Miriam Rabkin, M.D., M.P.H.
Domestic violence is a significant public health problem in the United States. Millions of women are victims of battering in the U.S. each year, and as many as one in four women seen in the primary care setting has been abused at some point in her life. Battering is the most common cause of nonfatal injury to young women, and 30 to 40 percent of female homicide victims are killed by current or former partners., Though the vast majority (more than 90 percent) of domestic violence cases involve women victims and male batterers, physical abuse of men by female partners does occur, and battering also occurs in same-sex relationships. No racial or ethnic differences have been consistently observed among victims of domestic violence. Although the psychosocial stresses associated with poverty appear to be a risk factor across cultures and countries, battering occurs in all socioeconomic groups.
The terms "domestic violence," "intimate violence," "abuse" and "battering" are often used interchangeably. However, the term "battering" connotes more than incidents of physical aggression. Batterers may use physical and sexual assault, threats, intimidation, and economic deprivation to exercise coercive control over their partners. Violence between partners may be an isolated incident in some couples, and a single violent incident may be enough to establish an atmosphere of threat and danger in a relationship, but survey data suggest that two-thirds of battered women suffer repeated assaults. It is important to understand this context of abuse when interviewing and counseling domestic violence victims.
Battered women frequently seek medical care, more often for vague physical complaints and psychiatric symptoms than for acute injuries. While it is difficult to determine the exact prevalence of domestic violence due to profound underreporting, experts estimate that battered women account for 22 to 35 percent of women seeking medical care for any reason in emergency rooms, and 14 to 25 percent of women seen in internal medicine clinics. Battered women also account for a significant proportion of women seen in psychiatric and ob-gyn settings. Physicians should maintain a high degree of suspicion for domestic violence in patients with unexplained physical symptoms, particularly gastrointestinal complaints, sleep or appetite disturbance, headaches, sexual dysfunction, pelvic pain, dyspareunia or urinary tract symptoms. The American Medical Association recommends routine inquiry about domestic violence for all female patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings, irrespective of their chief complaint.
Despite the high prevalence of domestic violence in health care settings, physicians are notoriously poor at diagnosing such abuse. There are many barriers to talking about the subject on the part of both patients and physicians. Women rarely volunteer the fact that they are battering victims. Battered women may feel ashamed, may believe that doctors cannot or do not want to help, may feel protective of their partner, or may fear that reporting the abuse will put them at risk for more violence. Factors that prevent physicians from asking about domestic violence include lack of training and ignorance of the prevalence of domestic violence. Doctors may also believe that identifying and intervening in domestic violence cases is not part of their role, may be uncomfortable with the feelings evoked by hearing about abuse, may be concerned about the time involved in addressing the subject, or may feel helpless or unsure of how to intervene.
The ethical principles of beneficence and nonmaleficence, however, require physicians to diagnose and intervene in cases of domestic violence.4 Potential consequences of not diagnosing domestic violence include the labeling of battered women as "somatizers," or the performance of unnecessary diagnostic tests. More importantly, clinicians who miss this diagnosis are missing the opportunity to intervene in potentially life-saving ways. One survey of women killed by intimates noted that 40 percent had presented to an emergency department with an injury-related complaint in the year prior to her death.
New York Presbyterian Hospital has a robust system for the care of victims of domestic violence. The Domestic and Other Violence Emergencies (DOVE) program is available to patients and providers 24 hours a day. Given these resources, our focus is on the identification and referral of battered patients, rather than on their management, although both are discussed in this chapter.
The following guidelines may facilitate the interviewing of battered women. The patient should be interviewed alone, never in the presence of her partner, family or friends; the presence of others might cause the patient to feel ashamed or to fear reprisal from her partner. Framing questions in a way that normalizes the answers is an extremely important maneuver. Experts recommend statements like: "Because violence is so common in women’s lives, I ask every woman in my practice about domestic violence," or "Because violence is so common in our society, I have started to ask all of my patients if they are being hurt or threatened by anyone." Women should be specifically asked about domestic violence, using tools such as the SAFE questionnaire (Table 1). They should be told that questions about abuse are routine, that any discussion of abuse is confidential, and that no information about it will be revealed to any third party without their explicit consent (some states do have laws mandating reporting of domestic violence, but New York is not one of them). The physician should be nonjudgmental, and should universalize and validate the woman’s experience, for example by telling her that she is not alone, that abuse is common, that she does not deserve such treatment, and that help is available for her.7
Table 1: SAFE questionnaire
Do you feel safe in your relationship? What happens when you and your partner disagree?
Have you or your children ever been physically threatened or abused? Have you ever been forced to have sexual intercourse?
Are your friends or family aware of what is happening? Would they support and help you?
Are you in danger now, and would you like to go to a shelter or talk with someone? Do you have a place where you and your children could go in an emergency?
Although it is vital to communicate to the woman that you, the physician, do not condone violence and are concerned about her safety, it is also important to avoid taking a stance as to whether or not she should leave her partner. Women in abusive relationships may feel it is difficult or impossible to leave for a variety of reasons. They may be financially dependent on their partners, who may not have allowed them to work or may have complete control of family finances. If the couple has children, women may not want to break up the family, or may feel they have nowhere to take the children if they leave home. Battered women may feel at increased risk if they try to leave, especially if their partners have threatened to harm or kill them, or kill themselves, if escape is attempted. Emotional ambivalence about abusive partners often plays a large role as well, with loving, affectionate or protective feelings existing side by side with anger, fear or hatred. Studies of abusive relationships have described a cycle of abuse in which battering incidents are often followed by remorse and pleas for forgiveness by batterers. During such "honeymoon" periods, women may have second thoughts about leaving or pressing charges against their partners. Insisting that a woman leave her partner or communicating that she is crazy if she does not do so, is likely to be experienced by the patient as unempathic, critical and unhelpful.
Having identified a battered patient, the next step is to contact the DOVE program and/or the AIM social workers at once (see Table 3). While it is important to maintain an empathic attitude towards the complexities of battered women’s situations, it is also crucial to assess the degree of danger before the woman leaves your office. The following questions should be covered, by the clinician or by the DOVE team.
Table 2: Domestic and Other Violence Emergencies (DOVE) services at NYPH
Obtain order of protection
Shelter placement/housing assistance
Assistance with the police/District Attorney
Access to free legal services
Lock change services
Assessment of needs of other family members
Assistance with filing for crime victim’s compensation
Counseling, support groups, psychiatric consultation
Linkages to other hospital and community services
A safety plan should be discussed with the woman. She may recognize signs of escalating anger and potential for violence in her partner, and may be able to formulate a strategy for escape at such times, if she is not ready to permanently leave. Ask if she has a place to go at such times, or if she knows how to access a battered women’s shelter. She may want to keep money, keys and ID hidden in a safe place for use in case of a quick get-away. If there are children in the home, she should teach them how to call or go for help, or dial 911 in case of violence.
Documentation in the medical record is important, both for patient care and for potential use in legal cases. The patient’s account of the abuse should be recorded verbatim, with quotation marks, rather than writing a summary comment such as "patient has been abused." A written description of injuries should be made, using a drawing or body chart. If the woman has physical evidence of injury such as bruises, abrasions, etc., these should be photographed (with the woman’s permission) and included in her chart.
Community resources for battered women should be discussed with the patient, and she should be given written information. Referrals can be made (see Table 3) for counseling and support groups, battered women’s shelters, legal assistance (eg: help in filing for a court order of protection or pressing criminal charges), or financial assistance (eg: applying for public assistance). Although battered women may frequently have symptoms of anxiety or depression, psychiatric referral should be made in conjunction with referrals to agencies or services for battered women, and it should be explained to the patient that the psychiatric symptoms are likely a result of living in an abusive relationship, not vice versa. In making referrals, it is important to remember that it may take some time for the woman to feel ready to make any change or to seek help, and to try not to feel discouraged or impatient if she does not follow through immediately.
Table 3: Domestic Violence Information and Referral Services
At Columbia-Presbyterian Medical Center:
The DOVE social worker and volunteer patient advocates are available from 9 to 5; at other times, call the social work supervisor in the ER (305-6204)
beepers # 2140
New York City:
Hotline, full range of services, including counseling and advocacy
Hotline, small women’s shelter, counseling, support groups, advocacy
Counseling, support groups
New York StateDomestic Violence Hotline
NationalCoalition Against Domestic Violence
We thank George Lewert and Maria Mercurio for helpful comments and suggestions.