Domestic Violence David Stanford, M.D. Some facts on domestic violence. 95% of the victims are women. There have been some studies that show that husbands and wives are equally violent and that study showing that both men and women are equally violent really has a lot of flaws. (1) It did not look at the issue of self-defense. (2) It did not look at the extent and the effects of violence on the victim. There are dramatic differences there and also it does not fit with the fact that 80% of all violent crimes in this country are committed by men. Conservative figures show 3-4 million American women are battered by their husband or partner. These reported studies are probably 2-3 times lower than what are really occurring. It occurs in all races and economic groups. Lower socioeconomic women frequently seek help in public assisted programs such as shelters, Emergency Rooms. 32% are victimized again within six months. This is a recurring chronic problem. Wife beating results in more injuries requiring medical treatment than rape, auto accidents and muggings combined. It is about 3 times more frequent than auto accidents. Greater than 1 million women seek medical treatment for injuries from battering and 20-80% of the women presenting with an injury to the Emergency Room are the result of abuse. The figure that is most widely accepted is about 25% and about 50% of serious traumas. There are barriers. One of the barriers is lack of knowledge and training. Women are labeled as neurotic, hypochondriacal and in fact, if you look at charts and Emergency Room charts and you see where somebody was labeled neurotic or hypochondriacal, the incidence of domestic violence is very, very high in that group of women. ACOG called for several changes several years ago. One was to include it in the medical student and resident curriculum. Include it in our examinations. They encourage advocacy programs and they also recommend including it in the review of systems. It is something that needs to be asked about in every contact in a medical setting with a woman. The other issue is lack of resources. More money is spent on animal shelters in this country than on women's shelters. Most women's shelters in this country are full. They turn people away on a regular basis. What are some of the social misconceptions? One is that domestic violence is rare. Is that violence does not occur in normal relationships. There are misconceptions that abuse and the abused are very stereotypic. In fact, oftentimes the abusers appear as very comforting individuals. One other misconception is that battered women are masochistic, poor minorities without religion. Mentally ill, uneducated. They also batter. They are beyond help. They just keep going back to the same old thing. The battering men are less successful, substance abusers, mentally ill, always violent. They stop when they get married. They are beyond help, stressed out. They just cannot quite cope. The issue here is that we view, as a society, domestic violence as a family matter and in our country we do not intervene in the family very easily. Women are often times encouraged to go work out the problems when they do talk about it and unfortunately, without assistance, they can't do that in many cases. Battered women oftentimes are considered responsible for the abuse. They provoke, they enjoy it. They are not willing to change it. There are many barriers that are set up for women so that they cannot leave. The greatest risk factor of a victim who is killed is when she tries to leave the relationship. They are blamed frequently as being codependent. A codependency is defined as a painful pattern of dependency on compulsive behaviors and approval seeking in order to gain safety, identity and self-worth. This implies that the woman is responsible for the abuse. Codependency implies that a woman is staying in this relationship for some type of secondary gain because she had some problem early on in life. She actually seeks out an abusive partner to fulfill this unfulfilled need. The issue is not that. The issue is that men have been able to abuse and justify their abuse as being appropriate. There have been no consequences for it. It is an issue of control and it is an issue of power and society allows this to persist and that is why we have the problem of abuse. It is not because a woman does not want to leave the relationship. There are other barriers for recognition as well. A study looking at an HMO and a group of primary care providers in California found that there were several areas that were barriers for them. It was hard for them to confront people that were like them. It is real easy to confront someone of a different color, someone of a different socioeconomic level. It is very hard to confront someone about issues like this who are just like you. The other issue that came up. When you look at studies, the incidence of abuse that occurs in the families of a nurse, a woman who becomes a nurse or a man that becomes a nurse, is upwards to 50%. Many times they go into these helping professions because of some of the problems and issues in their background. What they did in this study is they looked at the men and 14% of the male physicians said that they had been in abusive situations as a child or that their parents had an abusive relationship and 31% of the women had said that they had been exposed to that as a child. So, stirring up some of those old feelings is often very difficult. Fear of offending the patient. It is dealing with a private matter and they don't want to do that. Defending the batterer. You don't want to be accusing somebody and 55% of the physicians said that they were afraid of offending the patient. Powerlessness. Fifty percent of the physicians felt powerlessness when it came to dealing with these patients. Loss of control. Forty two percent said they just felt there was no control here. Seventy-one percent said time was a factor. Time clearly should not be a factor. It should be a part of any medical evaluation. What about the cycle of battering? There are lots of different cycles that we hear about and this is just one cycle. One is the buildup where the tension starts to build up. There is minor battering, pushing, verbal abuse, arguments. The victim attempts to calm the person down. They start to rationalize some outside causes. But those coping mechanisms start to weaken and she cannot hold him off. He cannot stop as his buildup occurs and it is almost like an explosion. A blowup. That is when the acute battering incident occurs. The tension kind of goes beyond the point of no return. Uncontrollable release of tension. They are going to teach you a lesson. And that is when that viciousness starts to occur. Then there is a lot of rationalization. These rationalizations start to occur at that time. Then they also try to minimize the injury. The victim isolates, withdraws. Goes and actually gets into a corner. Goes into another room. The victim then feels listless, no energy, defeated, beat down, literally, as well as figuratively. This is when the police are usually called and this can last between two hours and 24 hours. The honeymoon period. The period of kindness, contrite feelings, loving behavior. This is really when that victimization becomes complete. Bringing flowers, bringing gifts. Vows to give up drinking. Any contributing behavior, it fosters false hope. It sets up glimpses of the man she married. This develops a real symbiotic dependent relationship that is based on rationalization and the belief that they can lick this problem together. Well, this isn't a problem they have together. This is a problem of power and no power. It isn't a problem that they have together. It is really selling yourself for a brief sense of bliss. This really completes that victimization and then the cycle repeats itself again and again and again. What about men who batter? There is no typical behavior. There is no one socioeconomic status, there is no one racial group, all personalities, family backgrounds, professions - physicians, attorneys, garbage men, ministers, teachers, police officers, sports heroes. Anybody can batter. It is a learned behavior. It is a behavior of choice. It is a decision that someone makes. It is not a mental illness and until recently, there really were no consequences for this behavior. Eighty to 90% of the men who batter do not have a criminal record. They are very law abiding citizens outside of the home. Only 5-10% have ever committed a violent act against another person. This is the extreme expression and belief in male dominance. It is the use of force to maintain power and control over a relationship and a partner. One of the areas that often comes up is that of chemical dependency. It is often used as an excuse and it is often used as a treatment to prevent domestic violence and neither one of those really are true. Battering is a socially learned behavior just as chemical dependency has a component of it that is a socially learned behavior as well. It is not a result of substance abuse or mental illness. Alcohol is used as an excuse and there may be a disinhibition theory that alcohol may make the incidence more severe and cause greater injury. This also includes drugs like PCP, amphetamines and cocaine which also could escalate that potential for making the violence more severe but there still is a decision made to act out on that behavior. The concurrent data from alcohol show that there is an association of alcohol and domestic violence. A study by Walker looked at four consecutive incidences of domestic violence within the same couple. Sixty seven percent of the time when they looked at all of those incidences, alcohol was involved. But only in 20% of the time was alcohol involved in all four incidences. Now, 7-14% of battered women use alcohol which is pretty much the national average anyway. There is no more than that you would expect to find in any other group of women who may abuse alcohol. It may be used to help them cope. There is no doubt about that and it may oftentimes be used by the victimizer to justify his abuse. "You drink too much. That is why I did this." There are some common characteristics between alcohol abuse and drug abuse and domestic violence. One is that both are passed on generation to generation. Treatment issues. Alcohol treatment does not cure domestic violence. It is something that when women or families come in and they say that he is going to alcohol treatment and that everything will be okay; this is not going to be the case. Treating one aspect of the illness or the problem may even make it worse because it fosters a sense of hope. "He is out of alcohol treatment and everything is fine now so I will go back into the relationship." Whoever does the assessment needs to take a look at both issues. Types of abuse. Physical abuse with the pushing, shoving, hitting, choking, use of weapons. Emotional and psychological violence. Name calling. Public embarrassment. Sabotaging efforts to get ahead in the world. Threats. Destruction of personal property. Tearing up their clothes. Sexual violence. Rape. Forced sex. Withholding sex. Economic and financial violence. Forbidding women to go to work. Trying to get them fired from work. Of women who seek shelter, 50% are battered weekly. Twenty five percent of those are battered monthly, 60% are hit with a fist or some other type of an object, 50% of them are threatened for their life, 40-60% are choked and kicked, 25-40% are threatened with a gun or a knife and 25% are sexually assaulted. The next step of violence is killing. Thirty percent of female homicide victims are killed by their partner. Four women a day are killed by their current or past husband or boyfriend. The ultimate expression of the need to control a woman's behavior is killing them. Frequently a homicide occurs when they are separated or taking action to leave the relationship. Women don't leave because they are going to get killed. They are afraid to leave. Other studies found that 85-90% of the time the police were called at least once and that 50% of the time the police had been called to that place five times before that woman was killed. Suicides, and this is another one where the victims kill, only they kill themselves, are preceded by domestic violence in 20% of white women and 50% of black women. Children: A study of 900 children in a battered women's shelter found that 70% of the children were victims of abuse by the perpetrator. Fifty percent of these children were victims of sexual abuse and 5% had been hospitalized because of abuse. Only 20% of those cases had been identified previously by child protective services. In 25% of the cases, both parents were abusing the children. Ninety percent of the kids knew their mother was being abused by the spouse or their partner. A mother is 8 times more likely to abuse their child if they are currently being abused so the children suffer as well. Among mothers who abuse children, battering is the most common factor. Seventy percent of those boys who witnessed abuse growing up will become batterers themselves. Being a woman, though, is the only identifiable risk factor for being battered. Women who grow up in homes where battering occurs are at no greater risk than any other woman but the fact that they are a woman puts them at greater risk. 68% of boys 11-20 who murder, kill the man abusing their mother. There are some emotional effects that can occur on children who witness domestic violence and it is very similar to being victimized themselves. Having your mother, your parent abused, there is so much from a psychiatric standpoint. They really haven't differentiated from their parent so the abuse of the mother is actually even abusing themselves. It is the same type of thing. It is interpreted the same way. They take responsibility for the abuse. All the relationship to pregnancy. An OB/GYN is oftentimes the first line of defense for about 70% of women between the ages of 18 and 55. There clearly is increased battering during pregnancy. A phone survey noted a 68% greater chance of abuse in the last year if they were pregnant. Pregnancy creates tension in a relationship. They are not meeting the needs of those men on a daily basis. There is also the fear and stress of an extra burden of a child within the home. 21% of pregnant women seen in the Emergency Room are battered. There is a two times increase in miscarriage rate and may be a factor in preterm labor. Factors that come into play. It is like appendicitis or chemical dependency. There are a lot of things that will raise that red flag about. Threatened abortions, miscarriages, premature contractions, sexually transmitted diseases, low birthweight infants, unexplained fetal injuries at birth. There are anomalies where you will have limb defects because of a broken limb, compromising the blood supply because of a kick or a hit to the abdomen. Abruptio placentae. If you have injuries that are more proximal versus distal. People who fall don't end up with a huge bruise on the side of their face because they fell. You hit your arm first usually. Proximal injuries are a sign that you need to look for. Responsibility. Be aware of referral sources. Tell them what their options are. Understand the law. Know what your state's laws are because it can help that woman understand how you can help her. You want to determine safety. The danger assessment questionnaire. Those kinds of things can be helpful but the primary goal is safety for her. Continue to maintain prenatal care. These women have higher risk pregnancies. They are often showing up for appointments for the first prenatal visit late. They often don't keep their appointments. They don't want to come in with a black eye. Make sure to maintain prenatal care. Decrease current exposure by giving them as many options. Help them network with those community resources.