Domestic Violence

Dr. Hanan Abbas

Lecturer of family medicine
 Interpersonal violence and abuse, especially
between relatives and domestic partners, are
leading causes of morbidity and mortality.

 Many victims of abuse hesitate to seek help,

while those who batter are often difficult to
identify.
 Evaluating injury patterns, understanding
factors that increase the risk for violence and
making use of specific interview questions and
techniques will aid family physicians in the
difficult task of assessing and managing
patients living in abusive partnership.
 ?How extensive is the problem
 Domestic violence is the single largest cause
of injury to women between the ages of 15 and
44 in the United States, more than car
accidents, and rapes combined. Each year
between 2 million and 4 million women are
battered, and 2,000 of these battered women
will die of their injuries. Violence against men
by women is also a problem, according to the
August 2000 Annals of Emergency Medicine.
 Who definition of violence
 The intentional use of physical force or power,
threatened or actual, against oneself, another
person, or against a group or community, that
either results in injury, death, psychological
harm, maldevelopment or deprivation.

 “Domestic violence” refers to all aspects of

family violence (child abuse, spouse abuse,
and elder abuse).
 Goal of the Abuse
 Power and control by the perpetuator.
 Dominance is always reinforced by sexual and
physical violence
 Ongoing ego battering erodes the victim’s self
image.
 She becomes to believe that she is somehow to
blame for the violence she suffers and she is
worthless, incapable of survival without her
abuser------ learned helplessness.
 Prevalence

 Nearly ¼ of the women are abused by their

partner in USA.
 In 2000, the rate of violent death in low to
middle income countries was 32.1 /100.000.
 Death represents the “tip of the iceberg”.
 Estimates of non fatal violence:

In national surveys the percentage of women

who reported ever being physically assaulted
by their intimate partner was 34.4 % in Egypt.
 Mortality/Morbidity
A home in which anyone has been hit or hurt
in a family fight is 4.4 times more likely to be
the scene of a homicide than is a violence-free
home.
 A force orientation--a belief on the part of the
perpetrator that violence is an acceptable
solution to conflicts and problems.
 Cycle of violence

 Honey moon phase

 Tension building phase

 Violent phase
 Pathophysiology
 The patient may be amenable to intervention
during both the tension-building and battering
phases. During the reconciliation phase, the
battered person typically is showered with
expressions of love and apology and with
assurances that the abuse will never happen
again. Given the dynamics of this stage, the
patient is much less willing to seek or receive
help.
 Friends and family of victims, as well as
experts, frequently ask victims of domestic
violence why they stay in such apparently
horrible situations.
 A non-exhaustive list of reasons includes love,
hope, dependence, fear, and learned
helplessness.
 Spectrum of domestic violence

 Using coercion and threatens.

 Using intimidation
 Using emotional abuse
 Using isolation
 Minimizing, denying & blaming.
 Using children.
 Using male privilege
 Using economic abuse
 TheAmerican Medical Association's
Diagnostic and Treatment Guidelines on
Domestic Violence state that:
 "Familyviolence usually results from the
abuse of power or the domination and
victimization of a physically less powerful
person by a physically more powerful person."
 Other factors that create or maintain a power
differential, such as unequal financial
resources, family connections or health status,
can also foster situations in which the more
powerful person exerts inappropriate control
or intimidation over the less powerful person.
Any misuse of power, especially that which
involves physical violence or psychological
intimidation, constitutes abuse.
A perpetrator is a person who performs or
permits the actions that constitute abuse or
neglect.
 The term "batterer" refers more specifically to
a perpetrator who engages in physical
violence.
Factors Increasing Risk for Violence
 substance abuse
 External stressors
 Poverty or financial difficulties
 Losses
 Family disruption
 Work stress
 Life cycle changes
 Rigid or conflicted family roles or rules
 Past history of abusive relationships

 Mental or physical disability in family

 Social isolation
 These risk factors for abuse do not constitute

"excuses" for violent behavior. They are

presented as guidelines for early recognition

and intervention by health professionals.

Elements of the Medical Management
of Abuse
 Be alert to signs of abuse or neglect.
 Conduct a thorough evaluation and search for
injuries.
 Document historical and physical findings in
the medical record.
 Provide support for patient and family, when
possible.
 Provide close follow-up.

 Keep in mind and manage counter transference

and other emotional responses
 Believe the victim (take all reports of violence
and abuse seriously).
 Maintain patient confidentiality.

 Refer patient to appropriate community

resources.
 Common Medical Complications of
Partner Violence
 Acute
Contusions, lacerations, fractures
Blunt abdominal trauma
Closed head injury, concussion
Vaginal trauma (some requiring surgical
repair)
STDs, including hepatitis B and HIV
Obstetric complications (preterm labor,
stillbirth, low-birth-weight infant, miscarriage)
Depression, PTSD, suicide
 Chronic
Increased use of the medical system, including
number of surgeries
Chronic pain syndromes (headache, back pain,
pelvic pain, etc.)
Chronic gastrointestinal disorders
Negative health behaviors (drug use, eating
disorders, sexual risk-taking).
Depression, chronic anxiety, PTSD,
relationship/sexual difficulties, somatization
disorders, suicide.
 Interviewing Patients for Partner
Abuse Risk
 Does your partner physically hurt you or threaten
you?
Have you ever been in a relationship where you were
hurt or threatened?
Are you (or have you been) treated badly in other
ways?
Has your partner ever destroyed things you cared
about or stolen your things?
Has your partner ever threatened or abused your
children?
Has your partner ever forced you to have sex when
you didn't want to?
 We all get into arguments--what happens when you
and you partner fight at home?
Do you ever feel afraid of your partner?
Has your partner ever prevented you from leaving the
house, getting a job, seeking friends or continuing
your education?
How does your partner act when he has been drinking
or using other drugs?
Are there guns (or other weapons) in your home?
Has your partner ever threatened to use them?
 Power and Control Issues in Partner
Violence
Physical Abuse
 Punching
 Grabbing
 Beating
 Pulling hair
 Slapping
 Biting
 Twisting arms
 Kicking
 Using a weapon against partner
 Throwing partner down
 Choking
 Hitting
 Pushing
 Power and Control

 Threats

 Making and/or carrying out threats to do

something to hurt partner emotionally.
 Threatening to commit suicide

 Threatening to take away the children.

 Threatening to report partner to a

governmental agency, or betraying other
important secrets.
 Emotional abuse

 Puttingpartner down.
 Making partner think she is crazy.

 Making partner feel bad about self.

 Playing "mind games" .

 Using male privilege

 Treating partner like a servant

 Acting like the "master of the castle"
 Making all the "big" decisions
 Isolation

 Controlling what partner does

 Controlling who partner talks to
 Controlling who partner sees
 Controlling where partner goes
 Sexual abuse
 Making partner do sex against her will
 Treating partner like a sex object
 Using the children

 Making partner feel guilty about the children

 Using the children to give messages
 Economic abuse

 Trying to keep partner from getting a job

 Taking partner's money

 Making partner ask for money

 Giving partner an "allowance

 Intimidation--putting partner in fear
 Looks, actions, gestures and a loud voice
 Destroying partner's property

 Smashing things

 Killing, hurting or threatening pets

 Studies have not identified any consistent
psychiatric diagnoses among batterers, but
abusive men share some common
characteristics such as
 1 rigid sex-role stereotypes,

 low self-esteem,

 depression,

 a high need for power and control,

 a tendency to minimize and deny their

problems or the extent of their violence,
a tendency to blame others for their behavior,
 violence in the family of origin (particularly
witnessing parental violence),
 drug abuse (which are not causative but are
often associated).
 All intervention should be conducted in a
supportive atmosphere with confidentiality
assured.
 Any discrepancy between an injury and its
reported mechanism should be investigated.
 Prevention of abuse and neglect depends on
the early recognition of risk and on timely,
appropriate response.
 Physicians frequently report that dealing with
domestic violence is a frustrating experience.
 Persons who have been abused are often not
"ideal" patients--they miss appointments,
request tranquilizers, offer vague somatic
complaints, do not follow through with
treatment and often do not leave their
batterers.
 Domestic violence is a criminal offense.
Patient education about these straightforward
facts, during office visits or through written
materials and timely referral, can be lifesaving.
 Family physician should highlight the
unacceptability of interpersonal violence as a
means of resolving conflict and to provide
alternative strategies for dealing with
frustration in family relationships may
eventually decrease the incidence of domestic
abuse and its medical complications
 Management
 Emergency Department Care:
 The emergency care of a victim of
domestic violence is simultaneously
straightforward and challenging.
 Responsibilities when treating such patients, in
addition to lifesaving interventions, include the
following:
– Provide a safe environment.
– Inquire about domestic violence and/or
recognize abuse from information obtained
during the history and physical.
– Establish the diagnosis of domestic
violence.
– Acknowledge the abuse and reassure
the patient that she or he is not at fault.
– Evaluate emotional status and treat the
emotional injury.
– Diagnose and treat physical injuries
and other medical or surgical problems.
– Clearly document the history, physical
findings, and interventions in the medical
record.
– Determine the risks to the victim and any
children and assess safety and available
options.
– Counsel the patient that violence may
escalate.
– Determine the need for legal information or
intervention and report abuse when
appropriate or mandated.
– Develop a follow-up plan.
– Offer referral to shelter, legal services, and
counseling, facilitating such referrals with
the consent of the patient.
Thank you