Appendix 60 - Domestic Violence

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


According to the Surgeon General, "Domestic violence may touch as many as one fourth of all American families."[698]

Every roof is agreeable to the eye, until it is lifted; then we find tragedy and moaning women, and hard-eyed husbands - Emerson

Domestic violence is a pervasive and entrenched problem in the United States. Battering is thought to be the single most common cause of injury to women - more common than automobile accidents, muggings, and rapes combined. Several studies have shown that between 1 in 5 to 1 in every 3 women showing up in emergency departments are there for symptoms related to ongoing abuse in a relationship.[699] As one researcher wrote in JAMA, "It's more prevalent than we ever dreamed."[700]

While most physicians wouldn't consider discharging a patient from the hospital with a life-threatening condition, data from emergency room records show that the majority of women who are victims of domestic violence are discharged without any arrangements for their safety.[701] In a survey of Massachusetts emergency departments, 23% were found never to allow battered women to stay overnight even if they have no other safe place to go.[702]

In a study of the interactions between physicians and their battered patients in a large urban hospital emergency department, the physicians failed to determine the women's relationship to her assailant in three out of four interactions. "Hit by a lead pipe," "blow to head by stick with nail in it," "hit on left wrist with jackhammer" were all recorded as mechanisms of injury. Clearly missing from these statements was who hit her.

Another study found that in 90% of interactions with a victim of domestic violence, the physician failed to obtain a psychosocial history, failed to ask about a history of sexual or physical abuse, failed to ask about a woman's living arrangements, and failed to address the woman's safety. From an article in JAMA, "As a profession, we have not produced a sterling record of success in this arena. We must overcome our own denial and apathy."[703]

Pandora's Box

"'It's striking that physicians almost never ask their patients about violence,' says Mark Rosenberg, director of the CDC Division of Injury Control...." According to a JAMA editorial, physicians only identify about 4-5% of domestic violence victims.[704] One doctor quipped, "The only physicians who ask about violence are psychiatrists and they're only interested if it occurs in a dream."[705]*

* It's no joke. Psychiatry's position on domestic violence has been historically abominable. An example from the Archives of General Psychiatry: "[W]e see the husband's aggressive behavior as filling masochistic needs of the [sexually frigid] wife and to be necessary for the wife's equilibrium."[707]

In survey after survey, physicians found exploring domestic violence in a clinical setting analogous to "opening Pandora's box." An article in JAMA explains why this is the perfect victim-blaming metaphor:

According to Greek mythology, Pandora was the first woman. Her creation was part of Zeus' revenge against Prometheus for providing mankind with fire. She single-handedly opened a box and unleashed the spites of aging, labor, sickness, insanity, passion, and vice into the world.[706]

 

Other reasons for not addressing violence in the home were given. Over half of the physicians, "revealed concern regarding offending the patient...." Physicians described it as, "sort of a sensitive private area;" "I don't want to be nosing around into somebody's business...." The time element, however, was the, "most persuasive and driving fear."

The majority of physicians (71%) identified the time constraints of a busy primary care practice as the major deterrent for asking about violence in the home.... 'You don't open a Pandora's box for the same reason you don't generally ask people, "Do you have sexual problems?" Not because it is not important, but because you don't have time to do that. You literally don't have time to deal with all this.'[708]

Also, physicians felt their attempts at intervention were useless. "I can't give this woman a job," one physician answered, "I can't hold her hand."[709]

 


 

[698] Novello, AC, et al. JAMA 267(1992):3132.

[699] Randell, T. "Domestic Violence Intervention Calls for More Than Treating Injuries." Journal of the American Medical Association 264(1990):939-940.

[700] "Domestic Violence Begets Other Problems of Which Physicians Must be Aware to be Effective." Journal of the American Medical Association 264(1990):940-943.

[701] Randell, T. "Domestic Violence Intervention Calls for More Than Treating Injuries." Journal of the American Medical Association 264(1990):939-940.

[702] Isaac and Sanchez. "Battered Women." Annals of Emergency Medicine 23(1994):857.

[703] Novello, AC, et al. Journal of the American Medical Association 267(1992):3132.

[704] Abbot, J, et al. "Domestic Violence Against Women." Journal of the American Medical Association 273(1995):1763-1765.

[705] Randell, T. "Domestic Violence Intervantion Calls for More Than Treating Injuries." Journal of the American Medical Association 264(1990):939-940.

[706] Sugg, NK. "Primary Care Physicians' Response to Domestic Violence." Journal of the American Medical Association 267(1992):3157-3160.

[707] Snell, JE, et al. "The Wifebeater's Wife." 11(1964): 107-112) 1964.

[708] Sugg, NK. "Primary Care Physicians' Response to Domestic Violence." Journal of the American Medical Association 267(1992):3157-3160.

[709] Ibid.

 


 

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