|
Domestic Violence and Primary Care
Katherine Mathews, MD, Departments of Pediatrics and Neurology,
University of Iowa Hospitals and Clinics
Summer 2000
I recently had the opportunity to listen to the tape of a 911 dispatcher talking to a young girl
calling for help because her father was beating her mother. The terror and pain in her voice left
no question in my mind that violence in the home is an issue of vital importance to anyone who is
concerned about the physical and psychological welfare of children.
The term "domestic violence" is used here to mean violent or threatening behavior between
intimate adults. It can include physical, emotional, or sexual assault. Ninety-five percent of
victims of domestic violence are women. Such violence is common. Surveys in a variety of settings
show that acute or recent domestic violence affects from a tenth to a third of all American
households. These numbers are at least doubled if one examines an American woman’s lifetime
risk of being the victim of domestic violence. Every year about 2 million women in this country are
assaulted and seriously hurt by their domestic partner.
|
Child abuse and domestic violence
in the United States
Of the 22.3 million children in the U.S. between the ages of 12-17:
- 1.8 million (8%) were victims of serious sexual assault
- 3.9 million (17.5%) were victims of serious physical assault
- 9.0 million (40%) witnessed serious violence
National Conference of
State Legislatures
12-2-99
|
Domestic violence crosses socioeconomic lines. A pilot study of domestic violence
screening in a community pediatric setting found no significant differences in incidence
between women with private insurance and women with families using Medicaid. High
socioeconomic status does not protect against violent behavior in the home. Similarly,
studies done in Iowa as well as in other areas of the country show that domestic
violence affects families in both urban and rural areas. Research also shows that
neither an abused nor an abusive adult can be identified by appearance, or by how they
interact socially outside the home.
Impact of domestic violence on children
The millions of children growing up in households
affected by domestic violence are at risk for both physical and
psychological injury. A growing body
|
of evidence
demonstrates that the damage to the wellbeing of these children may begin in childhood,
but it persists throughout their lives.
A high correlation exists between domestic violence and violence directed toward the children.
About 30-60% of the families that experience domestic violence will also experience child abuse.
Screening for domestic violence often uncovers previously unreported child abuse. Screening
mothers of abused children reveals a high rate of domestic violence.
-
Domestic violence can also affect the unborn fetus; pregnancy is a high-risk time for women
whose partners are abusive.
-
Children who witness domestic violence learn to respond to conflict with violent behavior.
Children growing up in abusive homes are more likely than peers to be abusive and violent
themselves.
-
Domestic violence is kept secret. Most children have no one to talk to about the problem.
Domestic violence may interfere with a child’s ability to form close relationships with
others. It is isolating.
-
An abused adult may feel trapped and impotent. Often, abused adults lack the emotional
resources or social supports necessary to provide the parenting their children need. If they
use drugs or alcohol, or have other maladaptive behaviors, this can further erode their ability
to give support and guidance to children in the home.
|
AMA Facts:
Family Violence
Child abuse occurs in all types of families, in all socioeconomic settings, and
to children of all ages.
Risk factors for abuse include marital problems, substance abuse, unemployment,
and financial burdens.
Domestic violence is a leading indicator that child abuse is happening in the home.
30% of American women are physically abused by husband or boyfriend.
33% of abused women grew up in a household where their mother was abused.
Child abuse and domestic violence account for 1/3 of the $450 billion spent in the US on
crime each year.
In 1997, 3.1 million cases of child abuse were reported, and 1,215 children
died of abuse.
Child fatalities related to abuse have increased by 39% since 1985.
American Medical Association
|
Role of the health care provider
Physicians in a wide range of specialties are recognizing that domestic violence is a
serious public health problem. Many professional medical organizations, including the
AAP, AAFP, and the AMA, have developed policy statements that deal with the medical
identification of and response to domestic violence. Domestic violence is recognized as
an issue with significant medical consequences, including death.
As a health care provider, you can take several steps to address the problem of domestic
violence in your own practice.
1. Examine your own biases and beliefs:
- Do you believe that people who are abused by their partners probably deserve it?
- Do you believe that people who are abused "drive their partners to it" or in some way provoke assault?
-
Do you feel that physical or psychological violence is appropriate in any other
setting in our society?
- Do you know anyone who has been the victim of domestic violence? What was your response?
2. Learn how to talk with families about violence in the home.
Talk with patients in
a private setting. Introduce the topic by noting that violence is recognized as a risk factor for a
variety of health problems. Screening questions may include the following:
1. Do you feel safe in your home?
2. Does your partner ever hurt you or
threaten to hurt you?
3. Are you afraid of your partner?
|
Remember that the medical record is a relatively public document, and that both parents have the
legal right to read their child’s chart. Because of the risk to the victim who reports violence
in the home, charting should be done cautiously. In some settings a separate screening form may be
developed that does not need to be released with the rest of the record. [See also
"Families and Domestic Violence: Guidelines to Follow."]
3. Integrate assessment for domestic violence into routine history taking and into health
maintenance for children. The AAP Task Force on Violence recommends routinely assessing
for domestic violence, from infancy through late adolescence. This indicates to the patient that
you recognize domestic violence as a health care concern, and that you are willing to talk about
it.
In addition, situations that should prompt specific questions about domestic violence in the home
include:
- Suspected or confirmed child abuse.
-
A child who is visiting your office too often as the result of minor medical concerns or
stress-related illnesses, such as chronic headaches or stomachaches.
-
Frequent visits to the emergency room, particularly at night or during hours that both parents
are home. The ER may provide a safe setting where an abused parent can escape a dangerous
situation. It may also be viewed as a relatively anonymous way for a family to get medical
care when they are struggling with the stress and stigma of domestic violence.
4. If you suspect or know that domestic violence is occurring, schedule follow-up care.
Your office may be one of the few safe places for an adult who is being abused. Your non-judgmental
concern may provide the support needed for intervention to begin.
5. Know the resources in your county or community. One reason physicians don’t
ask about domestic violence is their lack of knowledge about how to respond if abuse is revealed.
Learn about the resources in your community:
- Assistance for the victim, such as local phone numbers for battered women’s shelters
- Restraint and education of the abusive partner
- Counseling for family members, including children
In Iowa, you can call the statewide hotline for victims of domestic violence at
1-800-942-0333.
This hotline is answered 24 hours a day, 7 days a week by trained staff with expertise in domestic
violence. They offer phone counseling and referral to domestic violence services around the state.
[See also "Iowa Referral Resources."]
6. If resources in your community are inadequate, advocate for change.
7. Encourage and support the education of other health care providers in your community.
The entire health care community needs to be sensitive to the issue of domestic violence and its
effect on children in the home. The health care community needs to encourage training for
providers in screening, assessment, and intervention related to domestic abuse.
Domestic violence has a physical and psychological impact on all members of a family. Children in
homes where domestic violence occurs are at risk for injury. They may experience psychological
problems, and may display violent behavior themselves. Health care providers who are committed to
preventive health care are in a unique position to help break the cycle of violence. Asking
questions, being supportive, acknowledging that domestic violence is a common problem, and
referring the victim to help can significantly affect outcomes.
|
