Elaine J. Alpert

Violence in intimate relationships and the practicing internist : new disease or new agenda ?

Clinical manifestations, suggested diagnostic strategies, obstacles to leaving the abusive relationship, and the barriers that patients face in obtaining and that physicians face in providing optimal care in situations of domestic violence are discussed. Physicians can play a pivotal role in primary prevention, early intervention, and follow-up care during and after an episode of intimate partner violence. Clinical competence in the treatment and prevention of family violence is an important component of the new agenda for health care, particularly in generalist fields such as general internal medicine. Core competence in screening, recognizing, and treating the short- and long-term manifestations of violence in intimate relationships is increasingly expected as the standard of care for internists and other generalist and specialist physicians. Yet, most practicing physicians have received no education or training in this area during medical school, residency training, or continuing education [1-4]. The objectives of this paper are the following: 1) to help physicians better recognize and understand the spectrum of clinical manifestations of intimate partner violence; 2) to introduce and reinforce the concept of routine periodic inquiry regarding current, past, or potential victimization as a component of standard patient care in generalist and subspecialist practice; 3) to discuss the range of difficulties that battered women face in leaving abusive relationships and in accessing and interacting with the health care system; 4) to discuss the logistic and attitudinal barriers that physicians face when confronting issues of violence and abuse in their practice settings; 5) to summarize for practicing physicians the skills that can be used in the care of patients who may be at risk for or suffering the effects of intimate partner violence; and 6) to enable physicians to gain a new understanding of violence in the context of the life cycle of the patient as a member of a family and community and of the medical, social, and cultural contexts of violence as learned behavior in our society. Background and Definitions Relationship violence can be defined as intentional violent or controlling behavior in the context of an intimate relationship [5]. Although most victims of domestic violence are women in heterosexual relationships [6], the incidence and prevalence of domestic violence appear to be similar in male and female homosexual relationships [7, 8]. This finding underscores the predominant constructs of power and control in this syndrome as opposed to gender. Thus, violence throughout the human life cycle, expressed as child abuse and neglect, dating violence, domestic violence, elder abuse, and abuse of the disabled can be viewed as learned behavior manifested to assert power and maintain control. Domestic violence encompasses not only physical injury but also threats, sexual abuse, emotional and psychological torment, economic control, and progressive social isolation [9]. In fact, physical violence usually occurs in the setting of a prodrome of nonassaultive behaviors, which can occur in any combination over a varying time course. Risk Factors and Clinical Characteristics It is widely acknowledged that domestic violence is prevalent in all racial, educational, geographic, and socioeconomic segments of society. Various clinical and demographic characteristics of women who are currently being physically abused have been elucidated in the study by McCauley and colleagues in this issue of Annals [10]. In addition to acute physical trauma, domestic violence is associated with many physical and psychological sequelae, including multiple somatic symptoms [11]; chronic abdominal pain [12]; chronic headaches [13]; pelvic pain [14, 15]; and anxiety, depression, post-traumatic stress syndromes, and other psychiatric disorders [16]. Alcohol and drug addiction, musculoskeletal symptoms, and eating disorders are other health-related sequelae of short- and long-term abuse [17]. Physical violence seems to be particularly common during pregnancy, with prevalence estimates ranging from 16% to 37% [18-20]. Obstacles to Leaving an Abusive Relationship Many battered women endure a pattern of progressively escalating violence over months to years but remain in the abusive relationship. Understanding why battered women do not just leave is key to the delivery of compassionate and effective care. See related articles on pp 737-46, 782-94, 800-2, and 804-5. Fear Battered women harbor legitimate fear for the physical safety of themselves and dependent family members. Indeed, such women are well aware that leaving does not necessarily mean safety. It is not uncommon for a battered woman to report threats of harm or even death against herself, her children, or other family members should she attempt to leave. In fact, because the most dangerous time for a battered woman is when she does attempt to leave, safety planning is a key element in the care of such patients. Financial Constraints Battered women often lack access to the economic resources necessary to gain and maintain independence. In addition to the increased prevalence of violence seen in poorer women [10], battered women are often denied access to liquid assets available to their partners such as bank accounts, credit cards, and cash. It is thus nearly impossible for such women to secure independent credit, establish a new apartment or other living arrangement, or simply afford the bus or taxi fare that is often necessary to flee the batterer. Social Isolation Battered women tend to become progressively isolated from friends, family, and community as they try to conform to rigid rules of behavior within the household. The batterer often restricts or denies the victim access to friends, family, the telephone, and even commonly available media such as radio and television. As a result, the battered woman becomes progressively isolated and dependent on the batterer as her sole source of social and emotional support. Feelings of Failure Battered women frequently express emotions such as shame, humiliation, low self-esteem, and feelings that she somehow caused her partner to be abusive and thus deserves to be abused. Such profound feelings of failure are too commonly reinforced by both explicit and implicit messages, by individuals and groups, of the responsibility of the battered woman not only to stay in the relationship but also to try to make it better. Thus, the woman not only feels ashamed of her situation but also of her inability to change it. Recurring feelings of shame, worthlessness, and helplessness often accompany reactive chronic depressive symptoms. Promises of Change Episodes of violence are typically followed by a honeymoon period of variable length. During the honeymoon phase, the batterer often behaves in a manner that is construed as loving, tender, apologetic, and remorseful and that is accompanied by promises that he will change his behavior. These seemingly tranquil periods are typically followed by an increase in tension, culminating in a subsequent violent episode [21]. Despite the predictable nature of this cycle of violence, loving and tender behavior between abusive episodes can serve as a powerful force that often influences the battered woman to remain with her abuser, in the hope that the violence will ultimately abate. Unresponsive Support Network Domestic violence is endemic in society and until recent years was statutorily legal, affording women little protection under the law. Although abuse prevention laws have been enacted in all 50 states, intervention programs and legal protections for battered women and their children remain less than adequate. More importantly, community-based primary prevention and education programs, the most essential cornerstones of a comprehensive, effective, and long-term solution to violence in our society, are being de-emphasized, down-sized, or even dismantled in the current economic and political environment. Further-more, through frequent and graphic news and entertainment media offerings, U.S. society has been desensitized to the horrific effects of abuse. A culture in which violence is normalized, bought, sold, and even admired cannot effectively respond to the multifaceted problem of violence because it is constrained in its ability to support effective community, state-wide, and national responses. Obstacles Patients Face in Approaching Physicians about Violence and Abuse Although the general public is now beginning to expect that physicians know about domestic violence, most patients do not believe their physician knows about the issue, would know what to do, or even cares about domestic violence. Many patients are reluctant to disclose, especially initially, because of shame, fear of loss of confidentiality, or fear of reprisals from the batterer, especially if the abuser uses the same physician or health care facility. Some patients also feel they are not allowed to bring up an issue, particularly one that is not strictly medical, unless directly asked. As a corollary, subtle and usually unintentional victim-blaming statements, minimization, and denial on the part of some health care providers could reinforce the patients sense of shame, humiliation, and responsibility about the violence and can prevent some patients from seeking help in the health care setting. Finally, some patients fear a denial or revocation of health, disability, or life insurance benefits if their abuse is discovered. Although most battered patients do not volunteer a history of violence to the physician unless directly asked, the rate of disclosure increases substantially when routine inquiry is instituted in an empathic, confidential, and non-judgmental manner [22-24]. However, physicians typically fail to ask about violence and victimization during the medical encounter [25-27]. Thus, it is imperative that routine confidential i

Family Violence and Public Health Education A Call For Action

The public health approach has advanced our understanding of family violence and our capacity to develop, implement, and disseminate successful intervention and prevention strategies. To ensure successful public health responses to family violence, emerging public health professionals must be trained to become competent in the field. Boston University School of Public Health has developed a course to help build a critical mass of practitioners. This article describes the content and initial experience with the course, the use of teaching assistants as partners in the educational process, and recommendations for future initiatives in training public health and other health professionals.

“Challenges and Strategies” and “Evidence-Based Care” Excerpts From Day 1 Plenary Sessions

National experts discuss challenges and strategies for improving health cares response to domestic violence and moving toward evidence-based health care for domestic violence. Comments address ethical and legal issues, system incentives, public health and prevention, the need for evidence-based care, designing an effective research agenda, and outcome measurement.