Case Scenario

A 27-year-old woman from Central America, 15 weeks pregnant, came to my office with bruises on her face. It seemed obvious to me that someone had attacked her. When I asked her what happened, she admitted that her partner had beaten her. The patient did not want to press charges because this man was her only source of support. (On an earlier day, one of the office assistants had seen that man, drunk in public.) I discussed a plan of action with her should he attempt to hurt her again, and I urged her to meet with our social worker. Still, I didn't feel that this was adequate intervention. What more can I do to help such a patient, if she refuses to take action herself?

Commentary

Domestic violence in the United States is a problem of enormous proportions and represents a significant health concern.¹ It results in more injuries requiring medical attention than rape, accidents, and muggings combined.² Many terms have been used to describe domestic violence, such as spouse abuse, partner abuse, and spousal assault. The most recent and all-encompassing definition of domestic violence is this: violence between adults who are intimate, regardless of their marital status, living arrangements, or sexual orientation. These violent acts might be considered relatively minor, such as pushing or slapping, or major, such as beating, raping, or killing.³

Although formal statistics on domestic violence were rare until recently, media awareness and contemporary research have provided some startling statistics. Nonfatal partner assaults occur in nearly 17 percent of U.S. homes, resulting in an estimated 2,000,000 women who are severely injured by their male partners each year. Approximately 9 percent of homicides in the United States are domestic in origin.² The greatest risk appears to be for unmarried, separated, or divorced women. In contrast, the overall rate of violence inflicted by husbands on their wives appears to be declining.

It is important to note that there is usually a predictable cycle of violence. Typically, it begins with an escalation of abusive behavior in which the abusing partner criticizes and threatens the victim. During this time, the abuser is likely to be moody and withdrawn. In turn, the victim may be especially acquiescent in an attempt to placate the abuser. As the cycle continues, the violence eruption phase occurs, characterized by severe violence and humiliation. Next, during the de-escalation stage, the abuser becomes apologetic and penitent. During this “honeymoon” period, the victim is likely to feel hopeful about the relationship's future and will often stop legal proceedings that he or she may have just initiated. In general, the pattern of abuse rarely stops without professional intervention or death of the victim. In fact, once domestic violence begins in a relationship, the frequency and severity of beatings almost always increase.^1–3

Interventions can be difficult, especially when the victim is unwilling to pursue criminal charges or take other action against the perpetrator. In this case scenario, the woman indicated that she did not want to press charges because her partner was her only source of support. We don't know whether she is referring to financial or emotional support, but both reasons are often given by women in similar situations. Other common reasons cited for victims' reluctance to report their attackers are fear of reprisal from the perpetrator, difficulty obtaining safe housing, emotional ties to the children of the abuser, and religious or cultural influences.⁴ In addition, a feeling of isolation from family members and the perception that no help is available are also cited by victims.

The significance of this victim's disclosure of abuse to the physician should be underscored. Her disclosure provides an important opportunity for the physician because he or she may be the first person to whom the patient has talked about the abuse. Based on the physician's response and receptiveness, the victim may or may not choose to tell others. The physician should be careful not to make decisions for the victim. Ethically, this would infringe on the patient's autonomy and dignity. In addition, reestablishing a person's sense of efficacy and control is particularly important in cases involving domestic violence.

The physician in this case acted appropriately in developing a plan of action should the patient's partner hurt her again. Usually, the initial concern is for the safety of the victim and of any children in the household. With this in mind, crisis intervention techniques should be implemented. If the victim returns home, as is implied in this case, it is important that she put together an emergency kit of necessary items so she would be able to quickly leave the home and survive on her own. The kit should include such items as an extra set of keys, emergency telephone numbers, money, credit cards and blank checks, medical cards, Public Aid identification, and essential papers (for example, birth certificates, marriage license). Identifying in advance a safe place to go for the night in case the violence escalates is important. It is often helpful to leave a packed suitcase with a friend to assist in a rapid escape from the abuse.

Physicians should not negatively judge patients for choosing to return to abusive relationships—most women leave and return several times before finally leaving the relationship for good. Furthermore, it is important for the physician and the victim to be aware of the risks of leaving. For example, 70 percent of domestic assaults occur after the abused partner has tried to leave.^1,2

Empowering the victim with nonjudgmental support is critical. Empathic statements defining her injuries as abuse and acknowledging that domestic violence is unacceptable can validate the victim's experience. In addition to providing information about an emergency kit, setting up an action plan might include contacting the local social services office and eliciting a social worker's assistance, with which a more specific plan can be developed. It is often helpful to refer the victim to appropriate resources involving social services, domestic violence hotlines, and domestic violence self-help groups, because they will be most aware of the appropriate interventions. Information regarding emergency housing, which can be provided by these social service organizations, may be of great assistance.^1–3

The legal process should be discussed with the patient as well.¹ The physician should inform the patient that he or she is legally and professionally required to report certain types of abuse, primarily child abuse and elder abuse. The physician should consult local state statutes for specific requirements. In addition, the physician should define ways in which the legal system protects victims of domestic violence. For example, some states have provided additional protection by increasing sentences for aggravated battery to a pregnant woman.

Despite the patient's reluctance to press charges, the physician may emphasize the potential health risks to her fetus and encourage the patient to contact the police. Even if the patient persists in not wanting to involve the police, the physician should emphasize the importance of documenting the abuse in case the patient wishes to press charges at a later date. Clearly documenting medical injuries with x-rays and photographs can be helpful in establishing physical evidence of abuse. Steps in obtaining orders of protection and filing a police report should also be reviewed with the patient.¹

In the case scenario described here, the fetus presents an additional concern to the physician. An increase in the frequency and severity of domestic violence usually occurs during pregnancy, with the abuse often resulting in miscarriage or premature birth. Unfortunately, the information provided in the scenario fails to mention either the timing or frequency of the abuse. This information would be useful because, if the cycle of violence is in the de-escalation phase, the woman may have verbally minimized the brutality of the abuse. In addition to the obvious facial injuries, the woman may have sustained injuries to her breasts, abdomen, and genital area—locations often targeted by abusers. A complete physical examination should be conducted, including a pelvic examination, to determine the presence of vaginal bleeding and trauma to the fetus.

Substance abuse is both a risk factor for, and an effect of, domestic violence. In this vignette, an office assistant had observed the victim's partner being publicly intoxicated. Therefore, another possible intervention is substance abuse treatment for the partner. This intervention would consist of a coordinated plan with the victim, the abuser, and social services that would allow for the abuser to get regular substance treatment and follow-up attention. Given both her pregnancy and the likelihood that she is in pain following the beating, it is particularly worthwhile to determine the victim's own alcohol and drug use. Depressive symptoms and suicidality should be formally assessed since they are associated with domestic abuse.⁵ Additional psychiatric and social services should be planned for as needed.

Specially designed treatment programs for victims and batterers are becoming more common and are being used as referral sources for civil and criminal courts.¹ Having social service personnel on board who are aware of local resources can be critical in rapid intervention and prevention of future harm.

It is also helpful for mental health and family practice professionals to recognize that almost every state has a crime victim compensation program created by statute. Under these laws, abused partners are entitled to receive reimbursement for mental health counseling, medical costs, and lost wages related to physical injury resulting from domestic violence. These programs are funded through the Federal Victims of Crime Act (42 U.S.C. 112 et seq).² It is noteworthy that the act prohibits discrimination based on national origin and will compensate the victim even if she continues to live with the offender. More information can be obtained about this act at the Web site of the Department of Justice, Office for Victims of Violent Crimes (www.ojp.usdoj.gov/ovc).

The physician caring for this young pregnant woman should be commended for being willing to get involved in a difficult case. Having a supportive attitude and discussing an action plan with the patient will likely encourage the victim to return to this physician when further episodes of abuse occur.