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Domestic Violence

Background

The medical literature defines domestic violence in different ways. In this article, domestic violence refers to the victimization of a person with whom the abuser has or has had an intimate, romantic, or spousal relationship. Domestic violence encompasses violence against both men and women and includes violence in gay and lesbian relationships.

Domestic violence consists of a pattern of coercive behaviors used by a competent adult or adolescent to establish and maintain power and control over another competent adult or adolescent. These behaviors, which can occur alone or in combination, sporadically or continually, include physical violence, psychological abuse, stalking, and nonconsensual sexual behavior. Each incident builds upon previous episodes, thus setting the stage for future violence.

Forms of physical violence include assault with weapons, pushing, shoving, slapping, punching, choking, kicking, holding, and binding. Two forms of physical violence have been posited: occasional outbursts of bidirectional violence (ie, mutual combat) and frank terrorism, of which the “patriarchal” form has been the most researched.

Psychological abuse includes threats of physical harm to the victim or others, intimidation, coercion, degradation and humiliation, false accusations, and ridicule.

Intimate partner stalking may occur during a relationship or after a relationship has ended. Of women who are stalked by an intimate partner, 81% are also physically assaulted. A new development is psychological abuse (generally threats) expressed through the Internet, so-called cyberstalking.

Sexual abuse may include nonconsensual or painful sexual acts (often unprotected against pregnancy or disease).

Domestic violence may be associated with physical or social isolation (eg, denying communication with friends or relatives, or making it so difficult that the victim stops attempting communication) and deprivation (eg, abandonment in dangerous places, refusing help when sick or injured, prohibiting access to money or other basic necessities).

Domestic violence is not a new epidemic—it spans history and cultures. The Common Law of England permitted a man to beat his wife, provided the diameter of the stick so used was not wider than the diameter of his thumb, hence, the term “Rule of Thumb.”

Domestic violence exacts a multitude of costs. Annual economic costs (in 2003 dollars) was estimated at $8.3 billion, including $6.2 billion for physical assault, $461 million for stalking, $460 million for rape, and $1.2 billion for lives lost. The Centers for Disease Control and Prevention (CDC) reports that victims of severe domestic violence annually miss 8 million days of paid work—the equivalent of 32,000 full-time jobs, and approximately 5.6 million days of household productivity.

The magnitude of the current problem may be further appreciated by examining the burden placed on law enforcement. Police in the United States spend approximately a third of their time responding to domestic violence calls. Of women presenting to the emergency department (ED), research suggests that between 4 and 15% are there because of problems related to domestic violence. Calls to the police and visits to the ED sometimes are used by victims of domestic violence to strategically manage the episode by de-escalating the violence.

When victims of domestic violence (male and female) were asked where they would go for assistance, they responded as follows:

Would seek help from the police – 31.2%

Did not know – 27.7%

Would go to a hospital – 14.7%

Would approach a family member – 10.7%

Would go to a shelter – 10.7%

Would forego assistance and simply retaliate – 3.1%

Women who are abused seek medical attention moreso than those who are not victimized. A study in the Northwest found that 95% of women with diagnosed domestic violence sought care 5 or more times per year and that 27% sought medical care more than 20 times per year. Often, these women go to the ED.

Victims of acute domestic violence are those patients in the ED whose complaints directly relate to an incident of abuse. Two to 4% of women who present for treatment of injuries, excluding those sustained in motor vehicle collisions (MVCs), are victims of domestic violence.

Of women in violent relationships, 77% who present to the ED do so for reasons other than trauma. The percentage of women with domestic violence–related symptoms who present to an ED with any complaint ranges from 22-35%, including patients requesting nontrauma, prenatal, or psychiatric care.

Abused patients who present for other medical problems resulting from a violent milieu are said to suffer from chronic domestic violence. This term applies to those patients who are victims of violence at the hands of a partner and who seek medical care for symptoms related, directly or indirectly, to the stress of the relationship.

Women report to the police only 20% of all rapes, 25% of all physical assaults, and 50% of all stalkings perpetrated by intimate partners. Even fewer men who are victims of such crimes at the hands of an intimate partner report them to law enforcement. Thus, the emergency clinician is often the first professional from whom an abused person seeks help. In fact, more than 85% of Americans indicated they could tell a physician if they had been a victim or perpetrator of family violence, slightly more than those who would tell their priest, pastor, or rabbi and considerably more than those who would tell a police officer.

Yet, if a request for help is not explicit, the opportunity to intervene in domestic violence often is not addressed. The following elements may deter interceding in domestic violence:

Social factors, such as implicit and explicit social norms, societal tolerance of violence, and desensitization through exposure

Personal factors, such as sex bias, personal history of abuse, idealized concepts of family life, concerns over privacy, and perceived powerlessness

Professional factors, such as time constraints, inadequate skills, professional detachment, and professional relationships with abusers or victims

Institutional and legal factors such as inadequate or unclear policies and fear of legal reprisal

Additional barriers including blaming the victim, disapproving of her or his decisions and circumstances, questioning patients in an inappropriate manner, and failing to query middle-class or affluent patients in the mistaken belief that such individuals are not victims of domestic violence

If the emergency clinician is to recognize occult domestic violence and correctly interpret its associated behavior, a high index of suspicion is necessary, and battering must be entertained in the differential diagnosis of a wide variety of presenting complaints. In this regard, much improvement is needed. An accurate diagnosis of battering is estimated in less than 1 of 25 women. Data from another study documented that 23% of women presented 6-10 times and another 20% sought medical attention on 11 occasions before a diagnosis of abuse finally was made.

Why would domestic violence consistently be unrecognized over so many ED visits? The most significant reason for missing the diagnosis of domestic violence simply may be failure to ask. Limiting inquiry about domestic violence to patients with specific complaints fails to identify many victims of abuse.

The largest ED-based study to date (n = 4501) discovered that 6 diagnoses were more common in women in physically abusive relationships compared with women not in such relationships. However, the low sensitivity and positive predictive value of these diagnoses made the findings clinically useless in detecting most women in violent relationships—those who do not present with injuries resulting from acute battering.

The US Preventive Services Task Force states that it cannot, at this time, determine the balance between the benefits and the harms of screening for family and intimate partner violence among children, women, and older adults. However, given the substantial percentage of patients seeking care in the ED who are abused by their partners, considering a context of violence in assessing all types of ED patients would seem prudent. Patients may be males or females from any socioeconomic group, and their injuries may or may not be related to trauma. Moreover, the incidence and prevalence of domestic violence, coupled with its morbidity and potential mortality, strongly militate in favor of routinely screening most adult or adolescent emergent patients.

Recognition of domestic violence and employment of appropriate management strategies may well have even broader implications. Domestic violence fits within a spectrum of family violence that also includes elder abuse, child sexual abuse, and child abuse and neglect.

These forms of violence share many similar root causes, thus interventions directed at one may positively influence other forms of violence as well.

The practitioner in the emergency department is on the front line of interpersonal violence and is thus in a unique and vital position to initiate the process that may stop the cycle of violence in all of its familial expressions.

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