Domestic ViolenceKay M. Mitchell, M.D., FACP Domestic violence is a common but often poorly recognized source of medical morbidity. In Florida, a person is killed by a family member every 36 hours. More than 119,930 incidents of domestic violence were reported to the FDLE in 1994. Domestic violence costs employers 3-5 billion dollars annually due to worker absenteeism and medical expenses. It is important for physicians to realize the true extent of abuse in their practices, and to develop screening mechanisms to identify victims and perpetrators. It is also important to recognize the physical and psychological signs of abuse and to be aware of community resources for counseling. Who is most likely to be affected by domestic violence? In most heterosexual relationships the majority of victims are female and the majority of batterers are male. Battering may also occur in homosexual male and female relationships. Domestic violence crosses racial, religious and chronological lines. The occupations of the victim may be as diverse as the perpetrator ranging from physicians to attorneys, and sports heroes to housewives. Domestic violence is thought be more common among the immigrant population. Past and current victims of domestic violence are overrepresented in the welfare population. Statistics Regarding ViolenceThe American Medical Association estimates that almost 4 million women are assaulted by "significant others" each year. One of every three women are likely to be abused or assaulted by a partner during their adult life. According to a report from the U.S. House Select Committee on Aging suggested between 1 and 2 million elderly are mistreated annually. At least 1 million incidents of physical, emotional, and/or sexual maltreatment occur to children each year.
Dynamics Of Domestic ViolenceBattering is a learned response and often the byproduct of an abusive upbringing. Perpetrators learn that they can achieve what they want through the use of force. Batterers seek to maintain power, control, and domination. Women between the ages of 17-28, women who abuse drugs or alcohol or whose partners do drugs or alcohol are at risk. Women that are single, divorced or separated are at risk, as are women planning to end a relationship. Women whose partners are excessively jealous, accusing or possessive are at risk. Pregnant women are also at a greater risk (see Dr. Lyon's article on abuse of pregnant women). Most battered women deal with the abuse in stages. Initially, they are in denial and refuse to admit there is a problem. Next, the victim may experience guilt in which she acknowledges there is a problem and considers herself responsible for the batterer's behavior. Then she reaches enlightenment, and realizes that she is not responsible for the abuse. She usually stays with the abuser at this point to try and work things out. The final stage is responsibility where the victim realizes the batterer is not going to change and she leaves the relationship. Role Of The PhysicianWhat is our role as physicians in this tragedy of our society? We should learn how to recognize abuse, learn to screen for abuse, know how to intervene and know what the laws pertinent to abuse are in Florida. Development of screening questions in your usual office setting will help you to identify abuse. If you provide your patients with a health history form in your office, always ask the questions: Has your spouse or intimate partner mistreated you? Have your children been mistreated? These questions can open the door for the patient to talk about the issue of abuse. Other screening questions include:
These questions should not be asked in front of the partner. During physical exams always question injuries and trauma, particularly if the reason is not plausible. If patients come in with repeated injuries in the same areas, suspect abuse as a reason. If at anytime you suspect abuse, ask your patient about it. If they deny it, provide them with outside "help lines" to call or give them a safety plan. Many times the abused will speak, if they can remain anonymous. When the physician feels that abuse is possibly present, the patient's physical finding must be well documented in the medical record. A detailed description of injuries, including the type, number, size, location, stages of healing, color, resolution, possible causes, and explanations should be given. Body diagrams are useful in charting the location of injuries. Color photographs should be made as soon as the injuries are found before any treatment. It is helpful to position a ruler near the injury to illustrate its size. Appropriate treatment should be administered and appropriate authorities notified. There is no statute which directly requires a physician to report domestic violence. Domestic violence is defined (FS 741.28) as any assault, aggravated assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family member or household member by another who is or was residing in the same single dwelling unit. The State of Florida requires that any person who has knowledge of or suspects that an elderly person or child has been abused, neglected or exploited must report this immediately to the abuse hotline at 1-800-962-2873. Florida Statute 790.24 requires any physician, nurse, or employee knowingly treating any person suffering from a gunshot wound or other wound indicating violence or receiving a request for such treatment, shall report the same immediately to the sheriff's department of the county in which said treatment is administered or request therefore received. Any person willfully failing to report such treatment or request therefor is guilty of a class A misdemeanor, punishable as provided in Florida Statute 775.082 or 775.083. There are many agencies within the counties of Florida. It is very important that physicians become aware of these agencies and shelters, so that safe haven information can be given to patients. It is also important that appropriate counseling referrals be given to address psychological needs of the abused and battered. SummaryDomestic violence is an unfortunate cause of morbidity. What is more unfortunate is that the role of domestic battery as the source of this morbidity is often missed. It is our role in the health care community to be aware of this and know where to turn to help our patients. References Florida Coalition Against Domestic Violence brochure Hyman A, Schillinger D, Lo B. Laws Mandating Reporting of Domestic Violence. JAMA. 1995; 273(22):1781-1787. Bullock K. Domestic Violence: Not just a Women's Issue. Consultant. 1996; 5:897. State of Florida Statutes, Chapter 14, Statutes 741.28, 790.24, 775.082, and 775.083. Multidsiciplinary Responses to Domestic Violence. ABA Commission on Domestic Violence, American Bar Association.<http://www.abanet.org/domviol/mrdv/home.html> The Commission on Domestic Violence. American Bar Association.<http:// www.abanet.org/domviol/> Jacksonville Medicine / May, 1999What's New
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