Publication of the BOOK – “MEDICAL ASPECTS OF DOMESTIC VIOLENCE”

We prepared and published a book: “Medical Aspects of Domestic Violence”.

Health care professionals are often a first point of contact for women suffering from the effects of domestic violence (DV). These practitioners need guidance to develop a pragmatic and sensitive approach to recognize signs of domestic violence and care for victims.

Domestic violence is a global problem that occurs regardless the culture, ethnicity, orientation, or socioeconomic class. The Family Violence Prevention Fund (FVPF) defines it as “a pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks as well as economic coercion. that adults or adolescents use against their intimate partners”.

In 95 % of cases, women are the victims and their batterers are men. DV also occurs in homosexual relationships and by women against men. According to a recent report by the Agency for Healthcare Research and Quality, 5 to 15 percent of all women seen in health care settings have a recent history of domestic violence, which also causes an estimated 73.000 hospitalizations and 1.500 deaths among women each year. In addition to causing the injuries sustained during violent episodes, domestic violence is linked to numerous lifelong physical and psycological effects for those who experience intimate partner violence.

DV is a pattern of abuse, including:

• physical abuse (slapping, hitting, kicking, burning, threatening with a weapon (gun, knife, other weapons), destroying objects or mutilating pets).
• sexual abuse (forcing the woman to sex, rape).
• psychological abuse (insults and abusive nicknames, humiliation, isolation, threats, accusations of infidelity, depriving of sleep, demonstration of power…)
• economic abuse (withholding money, lying about money, stealing money from the victim, spending all the money for himself, gambling…)

The „goal“ of violence is to get and maintain power and control over the victim. The physical abuse strengthens the non-physical abuse by showing: „this is what I’ll do to you if you oppose my orders“. Thus it is not always „necessary“ to use physical abuse, as non-physical violence has the same effect on the victims and is much more difficult to „prove“. However, severe the physical consequences of violence, most women find the psychological consequences to be even more long-term and devastating.

According to a recent review of 50 studies from around the world about 10 % to 50 % of women have experienced some act of physical violence by an intimate partner at some point of their lives. This and an earlier World Bank review highlight some of the characteristics that often accompany violence in intimate relationships:

• Physical violence is almost always accompanied by psychological abuse and in many cases by sexual abuse.
• Most women who suffer any physical aggression by a partner generally experience multiple acts over time.
• DV cuts across socio-economic classes, religious and ethnic lines.
• Men who batter their partners, exhibit profound controlling behaviour.

There are risk factors, such as alcohol and drug abuse, poverty and childhood witnessing of or experiencing violence, that contribute to the incidence and severity of violence against women. Overall, however, it is a multicausal problem, influenced by social, economic, psychological, legal, cultural and biological factors, as illustrated in the figure below.

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Any woman can be a victim.

Risk factors for DV:

• Single
• Recently separated or divorced
• Ages 17-28
• Alcohol or drug abuse by the woman or her partner
• Pregnancy

There is no typical abuser.

Common characteristics:

• Maintain different private and public images
  -violent at home
  -normal behavior at work
• Deny or minimize their abusive actions.

Reasons include:

• Fear
• Economic constraints
• Social isolation
• Low self-esteem
• Believing the abuser’s promises of change
• Lack of intervention by anyone who could help

Women who are abused have poorer mental and physical health, more injuries and a greater need for medical resources than non-abused women. Health outcomes of DV have been associated with reproductive health risks and problems, chronic ailments, psychological consequences, injury and death (Fi. 2).

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It’s important to mention that in approximately 70 % of the wife abuse cases children are also victims of abuse. The children of battered women are heavily affected, either by direct violence or by witnessing the violence against their mothers. That’s why it is of high importance to consider the needs and safety of the children when dealing with violence against women. These children are more likely to suffer from learning, emotional and behavioral problems. Also they are at increased risk of becoming abusers and of being abused later in life.

Women who experience intimate partner abuse are three times more likely to have gynecological problems than are non-abused women. These problems include: chronic pelvic pain, vaginal bleeding or discharge, vaginal infection, painful menstruation, sexual dysfunction, pelvic inflammatory disease, painful intercourse, urinary tract infection, infertility.

Sexual abuse can cause physical and mental trauma. In addition to damage to the urethra, vagina and anus, abuse can result in STIs, including HIV.

Abuse limits women’s sexual and reproductive autonomy. Women who have been sexually abused are much more likely than non-abused women to use family planning clandestinely, to have had their partner stop them from used family planning and to have a partner refuse to use a condom to prevent disease.

Studies show that physical abuse occurs in approximately 4 to 15 percent of pregnancies in the USA, UK, Canada, Sweden, South Africa and Nicaragua. Abuse during pregnancy may be a more significant risk factor for pregnancy complications than other conditions for which pregnant women are routinely screened, such as hypertension and diabetes. Abuse during pregnancy has been linked with delays in obtaining prenatal care, increased smoking and drug/alcohol abuse, poor maternal weight gain and depression. Abuse of pregnant women is associated with unsafe abortion, miscarriage, stillbirth, low birth weight and neonatal mortality. Although it is difficult to determine a causal relationship between abuse and these adverse outcomes, a recent meta-analysis of 14 studies indicates a significant association between low birth weight and abuse during pregnancy. Research has found a four-fold increase in low birth weight among infants born to women who had been physically abused in pregnancy. Abuse may directly influence birth weight through, for example, blows to the abdomen precipitating premature labor. Indirectly, abuse is associated with factors also known to contribute to low birth weight, for example, smoking, alcohol and substance abuse, STIs, elevated stress level, poor nutrition.

Reproductive health
Risks and consequences of violence against women

• Men who are physically abusive are also more likely to have multiple sexual partners, and to coerce their partners into sex, thereby exposing them to sexually transmitted infections (STI), including HIV.
• Women in abusive relationships are less able to refuse forced sex, use contraception, or negotiate condom use, thereby increasing their risk of unwanted pregnancies and STI/HIV.
• Sexual and physical violence increase women’s risk for many reproductive health problems, such as chronic pelvic pain, vaginal discharge, sexual dysfunction, and premenstrual problems, as well as pregnancy loss from abortion or miscarriage, and low birth weight in infants.
• Fear, geographical isolation, and lack of economic resources may prevent women from seeking reproductive health services – prenatal care, gynecological and contraceptive services, STI/HIV screening and care – and to adequately care for their children.
• Witnessing or experiencing violence against women during childhood has been associated with risk-taking behavior during adolescence and adulthood: early sexual initiation, adolescent pregnancy, multiple partners, substance abuse, trading sex, and not using condoms or other forms of contraception.

Based on information from Population Reports (Heise, Ellsberg, and Gottemoeller 1999)

Health care providers can play a crucial role in detecting, referring and caring for women living with violence. Abused women often seek health care, even when they don’t disclose the violent event.

Health care providers have the opportunity and the obligation to identify cases of abuse. For many women a visit to a health clinic for reproductive or child health services may be their only contact with the health care system. The health care sector can capitalize on this opportunity by ensuring a supportive and safe environment for clients, helping women receive the care they need.

The acronym RADAR, developed by Massachusetts Medical Society, summarizes the steps physicians should take in diagnosing and treating victims of DV:

R – Routinely ask about domestic violence
A – Ask direct questions
D – Document findings
A – Assess patient’s safety
R – Refer to appropriate resources

Asking women about abuse in a direct interview can be an effective way to identify survivors of abuse. Nonetheless, few health practitioners routinely ask about abuse. In some programs, screening of all women may be impractical and even unethical if not done appropriately and confidentially. Screening of specific groups, such as women seeking prenatal care or other health services, may be feasible.

Clues from the history:

• Inconsistent explanation for injuries
• Delay in treatment for injuries
• Frequent ER or office visits
• Termination of medical visits
• Somatic complaints: headaches, fatigue, insomnia, chronic abdominal pain
• Associated disorders: eating disorders, substance abuse, anxiety, depression
• Gynecologic presentations: STDs including HIV, unintended pregnancy, chronic pelvic pain, sexual dysfunction.
• Obstetric presentations: late prenatal care
• Learning problems in children

Clues from the physical exam:

• Demeanor: flat affect, avoiding eye contact, fearful, evasive, hostile
• Injuries on the central part of the body, head and neck.
• Injuries to the forearms – occur when victim tries to defend herself
• Bruises of different ages

Clues from the partner’s behavior:

• Overly solicitous
• Answers questions addressed to the woman
• Refuses to leave the exam room

Screening for DV should be a routine part of the medical history.

Providers must ensure a safe, confidential environment and establish a relationship of trust and respect for their clients prior to asking about abuse. Client waiting areas can offer educational materials, including posters on the walls and informational brochures, to let clients know that abuse can be discussed safely at the facility. Providers must be careful not to place clients at increased risk by violating their confidentiality. It is the provider’s role to empathize and validate clients’ experiences and to support their autonomy in deciding what to do about their situations (Figure 3).

     
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• Have you ever felt hurt emotionally or psychologically by your partner?
• Has your partner ever caused physical harm to you?
• Have you ever been forced to have sexual contact?
• Were you ever touched in a way that made you feel uncomfortable when you were a child?

The act of asking questions about violence can let women know that providers consider violence to be an important medical problem and not the client’s fault. Even if an abused woman doesn’t disclose the violence on a first visit, asking about it shows that the clinician cares and may encourage her to talk about it on a later visit.

It is not enough to simply wait for women to disclose violence on their own. Experience has shown that many women are willing to talk about violence, but it is usually necessary for health personnel to take the initiative. Women are waiting for someone to knock on their door…

Personal reasons:

• Not emotionally ready
• Blames herself
• Is ashamed
• Thinks it won’t happen again
• Afraid of consequences
• Thinks there are no alternatives
• Not aware of community resources

Doctor-patient reasons:

• Not enough trust in the relationship
• Inappropriate setting
• Inappropriate questioning

Careful documentation of a woman’s symptoms or injuries, as well as of her history of abuse are helpful for future medical follow-up. Documentation is also important in the event that she decides to press charges against the abuser or to seek custody of the children. Documentation should be as thorough as possible and clearly state the identity of the offender and his relationship to the victim. Photographs of injuries will be a big help too.

DV can result in severe physical injure and death. The time-period of separation and divorce is the most dangerous phase for abused women, and the risk to get killed is five times higher during these periods.

Most severe and most lethal assaults inflicted on women are connected with the following risk factors:

• Threats to kill the partner and/or the children
• Use of weapons or threats to use weapons
• Serious injuries
• Frequent violence
• Drug/alcohol abuse
• Separation/divorce
• Suicide attempts or threats

It is difficult and dangerous to quit a violent relationship. If the risk of further violence is high and the options to escape are poor, victims tend to stay in the relationship in order to avoid more severe and possibly life threatening violence. This phenomenon has been described by psychologists as „Stockholm Syndrome“.

The questions below can be used to identify risk factors:

• Have the assaults become more frequent or severe?
• Has the perpetrator ever used or threatened to use weapons?
• Are there weapons at home?
• Has the victim ever been chocked by the perpetrator?
• Does he use alcohol or drugs?
• Does he abuse while he is drunk?
• Has he threatened to kill the victim/the children?
• Is the victim afraid that the perpetrator might seriously injure or kill her or the children?
• Is the perpetrator very jealous?
• Does he follow the victim, control her?
• Is the victim suicidal?
• Has the victim separated from the perpetrator or is she considering separation?

If several of these questions are answered with „yes“, the victim is at high risk. In any case safety planning should take place at the interview.

Health care providers can help women protect themselves from intimate partner violence, even if the women may not be ready to leave home or report abusive partners to authorities. When clients have a personal safety plan, they are better able to deal with violent situations. Providers can review these points below to help each woman develop her own personal safety plan:

• Identify one or more neighbors you can tell about the violence, and ask them to seek help if they hear a disturbance in your home.
• If an argument seems unavoidable, try to have it in a room or an area that you can leave easily.
• Stay away from any room where weapons might be available.
• Practice how to get out of your home safely, identify which doors, windows, elevator, or stairwell would be best.
• Have a packed bag ready, containing spare keys, money, important documents, and clothes. Keep it at the home of a relative or friend, in case you need to leave your own home in a hurry.
• Devise a code word to use with your children, family, friends, and neighbors when you need emergency help or want them to call the police.
• Decide where you will go, if you have to leave home, and have a plan to get there.
• Use your instincts and judgment. If the situation is dangerous, consider giving the abuser what he is demanding to calm him down. You have the right to protect yourself and your children.
• Remember: you do not deserve to be hit or threatened.

Find out whether the woman feels that she or her children are in immediate danger. If so, help her consider various courses of action. Is there a friend or relative who can help her? If there is a women’s shelter or crisis center in the area, offer to make the contact for her.

Women who suffer intimate partner violence often have specific reproductive health care needs, including STI testing and treatment, and special concerns about keeping their contraceptive use secret. Women who have been raped may need emergency contraception and prophylactic antibiotics.

Unless clearly necessary, clinicians should avoid prescribing tranquilizers and mood – altering drugs to women who are living with an abusive partner since these may impair their ability to predict and react to their partners’ attacks.

The needs of victims generally extend beyond what the health sector alone is able to provide.

Health care providers can help women by referring them to available local resources.

In Georgia Advice Center for Women „Sakhli“ was created in 1997. Their activities include:

• Rendering psycho-social consultation and rehabilitation to DV victims
• Legal consultations
• Carrying out research work and disseminating information on DV.
• Raising public awareness on DV
• Lobbying the issue in relevant structures in order to promote legislative reforms.

Their work principles are:

• Free of charge services
• Confidentiality
• Religious and political tolerance.

Besides, there is Crisis Center (National Anti-Violence Service for Women and children protection), which offers victims of DV shelter as well as gives them psychological, social and legal consultations. Here works Hotline, which is not only for victims, but also for their friends and relatives.

Patricia O’Campo of The John Hopkins School of Hygiene and Public Health notes that, “It is time that we stop thinking about violence as a woman’s problem”. Certainly, the prevalence, response and prevention of violence against women might be affected by changes in a variety of public policy areas, including but not limited to child welfare and custody, gun control, criminal justice, welfare regulation, abuse reporting requirements and the level of funding for relevant research and social services. At the individual level, there are additional approaches available to health care providers and researchers.

The health care sector can have a significant impact on reducing the health problems related to abuse. Health care providers must be well trained in how to ask about and respond to abuse, and be prepared to help survivors of abuse with treatment and referral. They also must learn to work with agencies in other sectors.

Coordinated efforts and the development of effective referral networks and information systems can maximize scarce resources.