The American Medical Association's Diagnostic and Treatment Guidelines on Domestic Violence state that, “Family violence usually results from the abuse of power or the domination and victimization of a physically less powerful person by a physically more powerful person.”¹ 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 psychologic 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. It should be noted that, although the most familiar constellation for partner violence is one in which the (current or ex-) husband or boyfriend is the perpetrator and the wife or girlfriend is the victim, partner abuse also occurs in homosexual relationships and in heterosexual relationships in which men are the victims. Unless specifically mentioned, the remarks in this article are true for situations in which men and women are the abusers.

Etiology

Although victimization is often dismissed as “human nature” (and therefore nonpreventable or remediable), cross-cultural research demonstrates that this is not the case.² Societies exist in which violence is rare and violence against women virtually nonexistent. Low-violence cultures share certain key characteristics that include strong sanctions against interpersonal violence, community support for victims, flexible gender roles for women and men, equality of decision-making and resources in the family, a cultural ethos that condemns violence as a means of resolving conflict, and female power and autonomy outside the home.² Table 1 lists factors that increase the likelihood that abuse and neglect may occur. 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.

Medical Management Guidelines

General principles for the medical response to all forms of family violence are summarized in Table 2. Clinical interventions specific to the problems of partner violence are discussed below in the context of two case presentations. Medical complications of partner abuse are listed in Table 3.

Illustrative Cases

The following two cases, drawn from the clinical experiences of the authors, illustrate techniques for the diagnosis and management of patients experiencing interpersonal violence in partnered relationships. The discussion that follows each case is designed to assist family physicians with practical approaches to preventing violence and promoting victim safety.

CASE 1

An 18-year-old woman presented to her family physician for an initial obstetric examination, accompanied by her 27-year-old boyfriend. Initial history revealed that she was a gravida 1, para 0, at 16 weeks of gestation and living in a mobile home with her partner. She was strongly considering giving up the baby for adoption because of “financial and other” reasons. Answers to screening violence history questions (Table 4)¹ indicated that she had been beaten by her father from preschool age until she was 13 years of age; her parents then divorced. The patient stated that her present partner had “slapped her around” on several occasions and that once she was “accidentally dragged by his truck” during an argument. He had slammed the driver's door, started the truck and put it in gear, reportedly without realizing that her dress was caught in the car door. On further questioning the patient stated that she was not happy in this relationship and in fact did not feel safe. However, she stated that she “had no place else to go”and expressed optimism about the future because her partner had begun to attend church and stated that he wanted to be a good father.

DISCUSSION

Battering is frequent during pregnancy^3–5 and is more common if, as in this case, the pregnancy is unintended.⁶ Battering can result in pregnancy complications, delayed entry into prenatal care^7,8 and unintended, rapid-repeat pregnancy in adolescent mothers.⁹ Simple screening questions, administered in a private setting, often identify pregnant women who are being abused.⁷ Furthermore, because battering may begin late in pregnancy, a discussion of personal safety should be included at multiple times during the course of obstetric care.

This patient is a survivor of an abusive childhood. She lives with a partner who controls her behavior and who is on occasion physically abusive to her. She is also financially dependent on him. Her vulnerability is further increased, physically and psychologically, by her unplanned pregnancy and her lack of family or other emotional support.

Because battering usually does not abate during pregnancy, the physician can best intervene by providing her with information regarding the potential danger of her situation and by assisting her in safety planning, including a facilitated referral to a shelter for battered women.¹⁰ One useful technique is for the physician to contact the shelter while the patient is in the examination room or a private office. The physician can then hand the telephone to the patient and leave the room, allowing the patient to talk to a counselor in private. Thus, the patient's autonomy and privacy are respected, but an additional barrier to seeking help is removed.

The physician should inquire about the presence of firearms in the home or in the possession of the battering partner. This step is crucial in preventing serious injury and homicide.^11–13 Statistics from the Federal Bureau of Investigation indicate that over one half of female murder victims are killed by firearms in the hands of a current male partner or ex-husband.

It is also crucial that, throughout the course of the pregnancy, the physician avoid communicating to the patient that she is in any way responsible for, or deserving of, the abuse.¹⁴ For example, asking her why she is still living with her partner may be interpreted as a judgment of her failure to end the relationship. Furthermore, as most men who batter will from time to time express goodwill or intent to change, it may be helpful to ask the patient if her partner has previously made promises of improved behavior and inquire if he has kept such promises. The physician may wish to review the elements of abuse outlined in Table 5 with the patient and ask about her partner's behaviors. This table illustrates the many faces of abuse and may help her visualize and assess her risk in light of the overall circumstances, rather than focusing on her partner's latest promises. She may be unaware that the main issues in abusive relationships are power and control.

Many batterers who eventually stop using physical violence substitute psychologic abuse and intimidation.¹⁵ Thus, it may further help the patient to understand that even in relationships in which the physical violence has ceased, a climate of fear may persist to a level where the formerly battered partner continues to comply with the requests of the dominant partner out of fear that the physical violence will resume.

When discussing postpartum contraception with women living in an abusive partnership, it is important for the physician to bear in mind that such relationships often include forced or coercive intercourse. The family physician should ask the patient about unwanted sexual contact, even if the patient is married or living with an intimate partner. Some abusers sabotage contraceptive efforts (i.e., steal oral contraceptives or refuse to use condoms) in order to maintain control in the relationship. If the patient does not leave the abusive partner, these issues must be discussed. A non-coitus–dependent contraceptive method, such as progesterone implants (Norplant), may be the best option.⁹

This abusive relationship was detected through the routine application of questions screening for violence risk in intimate partnerships (Table 4).¹ Other signs that often indicate a need to further assess the risk of abuse include excessive work loss, sleep disturbances, substance abuse, somatization or “bad nerves,” sexual dysfunction, depression, frequent injuries or being “accident prone.”¹⁶ In this case, it is extremely important to review any records received from emergency departments, urgent care facilities and any obstetric colleagues (e.g., cross-coverage providers) during the remainder of her pregnancy and postpartum period. It is imperative to discuss events noted in these records with the patient and to assess any discrepancy between an injury and its reported causative mechanism, because injuries related to battering are often attributed to falling on the stairs or some other household accident. In such cases, the patient should be asked to describe the accident in more detail, or the physician should ask about precipitating factors (e.g. “were you pushed?”). Ancillary tests should be obtained as indicated for the specific injury or infection. The physician should be especially alert for pregnancy complications and sexually transmitted infections, including human immunodeficiency virus infection.

Factors that specifically relate to partner abuse include the following: (1) a power differential in the relationship in which one partner is financially or emotionally dependent on the other; (2) a temporary or permanent disability (including pregnancy); (3) a force orientation—a belief on the part of the perpetrator that violence is an acceptable solution to conflicts and problems, and (4) a personal or family history of abuse. It may be useful to ask the patient how her partner manages frustration or stress. Does he blame others (including her) or does he take responsibility for his mistakes? Does he use aggression (including threats or put-downs) to resolve conflicts in the relationship?

CASE 2

A 45-year-old man presented to his physician with a complaint of worsening depression. The patient had been taking antidepressant medications for many years, was receiving ongoing psychotherapy from a clinical social worker and attending Alcoholics Anonymous meetings. The patient complained of insomnia, loss of appetite and thoughts of guilt and suicide since his spouse had “kicked him out.” He was especially concerned because she has multiple sclerosis, relies on him for some physical assistance and, in his opinion, should not be left alone. Further discussion revealed that during an argument, he verbally threatened to harm her, then threw a large lamp at her (although he missed and did not actually hit her). She called the police, had him removed from the home and told him she would soon be filing for divorce.

DISCUSSION

A positive outcome is possible for this couple because of the confluence of several helpful events and interventions. The patient had previously received treatment for alcoholism, had not resumed drinking and was under care for depression. Furthermore, his wife had worked as a teacher before her illness, was receiving retirement benefits and was not financially dependent on him. Perhaps most significantly, she called the police during the first violent episode rather than excuse her husband's actions and allow a pattern of threats and intimidation to become established. She also received a prompt response and support from the police and the courts.

The patient's depression worsened during the court proceedings, eventually requiring inpatient psychiatric treatment for suicide prevention. During the course of his therapy, he received psychologic support for his stressful personal situation, but his behavior toward his wife was not excused in any way by his treating physicians. Eventually, this couple began marital therapy together, after the goals of establishing a non-violent and equitable relationship were defined.

Family physicians can play a crucial role in referring batterers to appropriate services for behavior modification interventions and treatment of comorbidities, such as depression and alcoholism. If the abusive patient's wife or partner is also a patient in the physician's practice, asking that person questions about her experiences of violence and providing information about safety planning and resources may be lifesaving.^10,17

Studies have not identified any consistent psychiatric diagnoses among batterers, but abusive men share some common characteristics such as 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), and drug and alcohol abuse (which are not causative but are often associated).¹⁸ Some but not all batterers meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM–IV) for personality disorders or depression.¹⁹

Men who have alcoholism combined with a major depressive disorder or antisocial personality disorder are more likely to commit domestic violence than men with either of these conditions alone.²⁰ Most researchers believe that abusive behavior is the result of multiple factors, including individual characteristics, a family history of violence, the culturally rooted belief that violence is an acceptable means of solving problems and that violence toward women is acceptable or tolerated.^21,22 The patient in this case did not hold these beliefs and was eventually able to participate successfully in couples' therapy.

Batterers are often difficult to identify because they rarely present with symptoms that suggest problems with violence; however, they may seek care for injuries received from a violent episode where the victim's attempts at self-defense result in injuries to the batterer (e.g., hand fractures, bites, lacerations, eye injuries).

Family physicians can also screen for violent behavior by asking direct questions²³ or by inquiring about related beliefs and behaviors while conducting a routine patient history. One such approach is the funneling technique (Table 6), which begins with less threatening questions and progresses to questions about more serious violence, depending on the patient's responses. Batterers often minimize or deny their abuse by using euphemisms for violence such as “not getting along,” “loss of temper,” “fighting” and “self-defense,” when in fact they are referring to their own violent actions.¹⁵ Therefore, questioning does not always result in identification of battering behavior. Nevertheless, this approach allows the physician to broach the subject, and further questioning about what the patient means by a specific term may sometimes provide the opportunity for the patient to disclose abusive actions and seek help.

Patients who batter should be advised that their behavior is illegal and should be given information about treatment programs. Family physicians should bear in mind that the usefulness of batterer treatment programs remains controversial.²⁴ Many perpetrators do not change their beliefs or behavior, and the immediate goal is protection of the battered patient and dependents (children and elderly relatives) from further harm. Early referral to community resources (e.g., safe houses and legal aid) and follow-up until the situation is resolved can be crucial. Encouraging the battered victim to call the police or involve sympathetic family members or friends may help alleviate the isolation that often accompanies domestic violence and also help prevent retaliation.

In this case, the patient's wife was able to make use of multiple sources of support to remain safe in her own home during her partner's arrest, brief incarceration and treatment. She was also fortunate in that he recognized his behavior as problematic and genuinely wished to change. Most situations involving partner violence are not as amenable to a positive outcome. In many cases, the victimized partner remains in danger for years. Couples' therapy should not be attempted until it is clear that the violence has stopped and the perpetrator has undergone successful treatment.¹⁵ Physicians may inadvertently collude with the batterer by encouraging a premature reunion of the couple.

The simultaneous actions of medical, mental health and law enforcement personnel, plus the determination of this couple, resulted in a positive outcome. Nonetheless, family physicians should remain aware that, without adequate community support from the police and courts, outcomes such as this one are rare.

All intervention should be conducted in a supportive atmosphere with confidentiality assured. The physician should ask the patient if it is safe to take home written materials that pertain to domestic violence. If not, important telephone numbers can be offered on plain stationery or a prescription sheet. As part of a safety plan, the physician should arrange for a safe way to follow-up with the patient by telephone. For example, if a call from the medical office might arouse the suspicions of the batterer, the physician and patient could agree in advance to say that the call was from a local business. Physicians may wish to ask the patient ahead of time for the name of a friend who can be contacted as a way of reaching the patient, if necessary. The patient should be asked if the physician can call the police if he or she is unable to contact the patient and believes the patient might be in immediate danger.

Prevention

Occasional conflict is a universal feature of intimate relationships. However, coercion, violence and unwanted sexual activity are not a normal part of marriage or other relationships and must not be tolerated. Many alternatives exist for handling conflict that do not involve violence, intimidation or domination of one person by the other. 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.

In contrast, perpetrators are often articulate, interesting community figures who present themselves more favorably.¹⁷ In order to deal most effectively with the problem of partner abuse and to maintain a balanced perspective, family physicians must remain aware that appearances can be deceiving. Incorporating routine screening for violence risk into clinical practice may minimize the risk that a physician will fall prey to unconscious stereotypes about abused persons.

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. Resources are listed in Table 7.

Final Comment

Family physicians can prevent suffering, serious injury and death by remaining alert to the possibility of interpersonal violence and victimization when evaluating health risks during routine practice. Early intervention, including timely legal involvement and emergency service provision, in a context of community support, may prevent further violence and later sequelae. In addition, efforts by family physicians and other concerned persons to increase societal awareness of the problem of violence, to 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.