Causes and Symptoms
Domestic or family violence is the intentional use of violence against a family member. The purpose of the violence is to assert domination, to control the victim’s actions, or to punish the victim for some actions. Family violence generally occurs as a pattern of behavior over time rather than as a single, isolated act.
Forms of family violence include sexual or physical abuse of a child, an intimate partner, or an elderly family member. These forms of violence are related in that they occur within the context of the family unit. The victims and perpetrators know one another, are often related to one another and live together, and may have strong emotional feelings for one another. The needs of victims differ with age and independence, however, but there are many similarities between different types of violence. One such similarity is the relationship between the offender and the victim. Specifically, victims of abuse are always less powerful because of their age, position in the family unit, or through the abuser completely controlling every facet of the victim's life. Power is also seen in the abuser applying physical and/or psychological control over victim. For example, a child abuser may lock a child in a bathroom or abandon the child in a remote area. A intimate partner abuser may physically injure, isolate socially by disconnecting the phone (whether a landline or cellular service) or by dictating with whom the victim can talk or have contact, or may isolate geographically by moving away from friends, family, and work. An elder abuser can exert similar control.
Families that experience violence are often socially isolated and have little to no contact with others outside the family or home. The family members tend to keep to themselves and have few or no friends or relatives with whom they regularly interact. Social isolation prevents victims from seeking help and allows the abuser to exert more control and establish rules for the relationship. Abuse continues and worsens because the violence occurs in private with few consequences for the abuser.
Victims of all forms of family violence share common experiences. In addition to physical violence, victims are also attacked psychologically and experience loss of self-esteem when they are told they are worthless and responsible for the abuse they receive. Also, due to social isolation, victims have little opportunity to experience success, recognition, or love and often become depressed or anxious, and they experience more stress-related illnesses such as headaches, fatigue, or gastrointestinal problems.
Child and intimate partner abuse are linked in several ways. About half of the men who batter their wives also batter their children. Furthermore, women who are battered are more likely to abuse their children than are nonbattered women. Even if a child of a spouse-abusing father is not battered, living in a violent home and observing the father’s violence has negative effects. Such children often experience low self-esteem, aggression toward other children, and school problems. Moreover, abused children are more likely to commit violent offenses as adults. Children, especially males, who have observed violence between parents are at increased risk of assaulting their partners as adults. Adult sexual offenders have an increased likelihood of having been sexually abused as children. Yet, while these and other problems are reported more frequently by adults who were abused as children than by adults who were not, many former victims do not become violent. The most common outcomes of childhood abuse in adults are emotional problems. Although much less is known about the relationship between child abuse and future elder abuse, many elder abusers did suffer abuse as children. While most people who have been abused do not themselves become abusers, this intergenerational effect remains a cause for concern.
In its various forms, family violence is a public health issue. Once thought to be rare, family violence occurs with high frequency in the general population. Exact figures are lacking and domestic violence tends to be underreported; however, it is estimated that millions of people are abused each year. Rates of violence directed toward unmarried heterosexual women, married heterosexual women, and members of homosexual male and female couples tend to be similar. No one is immune: victims come from all social classes, races, and religions. Intimate partner violence directed toward heterosexual men, however, is rare and usually occurs in relationships in which the male hits first.
Because family violence is so pervasive, physicians encounter many victims. One out of every three to five women visiting emergency rooms is seeking medical care for injuries related to partner violence. In primary care clinics, including family medicine, internal medicine, and obstetrics and gynecology, one out of every four female patients reports violence in the past year, and two out of five report violence at some time in their lives.
Family violence typically consists of a pattern of behavior occurring over time and involving both hands-on and hands-off violence. Hands-on violence consists of direct attacks against the victim’s body. Attacks are often in the form of pushing, shoving, and restraining as well as slapping, punching, kicking, clubbing, choking, burning, stabbing, or shooting. Hands-on violence also includes sexual assault.
Hands-off violence includes physical violence that is not directed at the victim’s body but is intended to display destructive power and to assert domination and control. Examples include breaking through windows or locked doors, punching holes through walls, smashing objects, destroying personal property, and harming or killing pet animals. The victim is often blamed for this destruction and forced to clean up the mess. Hands-off violence also includes psychological control, coercion, and terror such as name calling, threats of violence or abandonment, gestures suggesting the possibility of violence, monitoring of the victim’s whereabouts, controlling resources (such as money, transportation, and property), or threatening to contest child custody. These psychological tactics may occur simultaneously with physical assaults or separately. Whatever the pattern of psychological and physical tactics, abusers exert extreme control over their partners.
Neglect—the failure of one person to provide for the basic needs of another dependent person—is another form of hands-off abuse. Neglect may involve failure to provide food, clothing, health care, shelter, or emotional support. Children, older adults, and developmentally delayed or physically disabled people are particularly vulnerable to neglect.
Family violence differs in two respects from violence directed at strangers. First, the offender and victim are related and may love each other, live together, share property, have children, and share friends and relatives. Unlike victims of stranger violence, victims of family violence cannot quickly or easily sever ties with or avoid seeing their assailants. Second, family violence often increases slowly in intensity, progressing until victims feel immobilized, unworthy, and responsible for the violence that is directed toward them. Victims may also fear leaving their abusers or seeking legal help because they have been threatened or assaulted in the past and may encounter significant difficulty obtaining help to escape. In the case of children, the frail and elderly, or people with disabilities, dependency upon the caregiver and cognitive limitations make escape from an abuser difficult. Remaining in the relationship increases the risk of continued victimization. Understanding this unique context of the violent family can help physicians and other health care providers understand why battered victims often have difficulty admitting abuse or leaving the abuser.
Family violence follows a characteristic cycle. This cycle of violence begins with escalating tension and anger in the abuser. Victims describe a feeling of “walking on eggshells.” Next comes an outburst of violence that often coincides with episodes of alcohol and drug abuse. Research has shown that the presence of drug or alcohol addictions in the home increases the likelihood of family violence. In 2010, Addiction Treatment magazine reported that 80 percent or more of all cases of domestic violence are somehow connected to the use of drugs or alcohol. The US Department of Justice (DOJ) has reported that 61 percent of domestic violence offenders are addicted to drugs or alcohol. Schneider and Irons found that 75 percent of women living with addicts have been threatened with violence, while 45 percent have been physically or sexually assaulted by their partners. Following the outburst, the abuser may feel and express remorse and expect forgiveness. The abuser often demands reconciliation that often involves sexual interaction. After a period of calm, the abuser again becomes increasingly tense and angry. This cycle generally repeats, with violence becoming increasingly severe. In intimate partner abuse, victims are at greatest risk when there is a transition in the relationship such as pregnancy, divorce, or separation. In the case of elder abuse, risk increases as the elder becomes increasingly dependent on the primary caregiver who may be inexperienced or unwilling to provide needed assistance. Without active intervention, the abuser rarely stops and often becomes more violent.
Treatment and Therapy
Physicians and health care professionals are in a position to play a significant role in identifying and intervening in family violence. First, family members who are victims of violence must be identified, and then steps to intervene and help must be taken. Physicians use different techniques with each age group because children, adults, and older adults each have special needs and varying abilities to help themselves.
Because children and adolescents are not usually forthcoming about physical or sexual abuse, physicians must use several strategies to identify victims. One such strategy bis to screen for abuse during regular checkups by asking children if anyone has hurt them, touched them in private places, or scared them. Adolescents can be provided with information on sexual abuse and date rape then asked whether they have ever experienced either.
Another strategy many physicians use to identify children who are victims of family violence is to remain alert for general signs of distress that present when a child or youth lives in a violent or tumultuous situation. Depression, anxiety, low self-esteem, hyperactivity, disruptive behaviors, aggressiveness toward other children, and lack of friends are all signs of distress that is potentially caused by family violence.
More obvious signs and symptoms of physical and sexual abuse in children are bruises that look like a handprint, a belt mark, or a rope burn. X-rays are able to show a history of broken bones that may be suspicious in nature. Intentional burns from hot water, fire, or cigarettes often have a characteristic pattern. Sexually transmitted diseases in a child's genital, anal, or oral cavities would also point to sexual abuse.
A physician observing specific signs of abuse or violence in a child, or even suspecting physical or sexual abuse, has an ethical and legal obligation to provide this information to state child protective services. Every state in the United States has laws that require physicians to report suspected child abuse. Physicians do not need to find proof of abuse before filing a report. In fact, the physician should never attempt to prove abuse or interview the child in detail because this can interfere with interviews conducted by experts in law, psychology, and the medicine of child abuse. When children are in immediate danger, they may be hospitalized in order to receive a thorough medical and psychological evaluation while also being removed from the dangerous situation. In addition to filing a report, the physician records all observations in the child’s medical file. This record includes anything that the child or parents have said, drawings or photographs of the injury, the physician’s professional opinion regarding exposure to violence, and a description of the child abuse report.
The physician’s final step is to offer support to the child’s family. Families of child victims often have multiple problems, including violence between adults, drug and alcohol abuse, economic problems, and social isolation. Appropriate interventions for promoting safety include foster care for children, court-ordered counseling for one or both parents, and in-home education in parenting skills. The physician’s goal, however, is to maintain a nonjudgmental manner while encouraging parental involvement.
Physicians also play a key role in helping victims of intimate partner violence. Like children and adolescents, adult victims are often hesitant to disclose exposure to violence; therefore, physicians should ask about intimate partner violence whenever they notice specific signs of abuse or general signs of distress. Physicians screen for current and past violence during routine patient visits, such as during initial appointments; school, athletic, and work physicals; premarital exams; obstetrical visits; and regular checkups. General signs of distress include depression, anxiety disorders, low self-esteem, suicidal ideation, drug and alcohol abuse, stress illnesses (headache, stomach problems, chronic pain), or patient comments about a partner being jealous, angry, controlling, or irritable. Specific signs of violence include physical injury consistent with assault, including that requiring emergency treatment.
When a victim reports intimate partner violence, there are several steps that a physician can take to help. Communicating belief and support is the first step. Sometimes abuse is extreme and patient reports may seem incredible. The physician should validate the victim’s experience by expressing such statements as, “You have a right to be safe and respected” and, “No one should be treated this way.”
Another step is helping the patient assess danger. This is done by asking about the types and severity of violent acts, the duration and frequency of violence, and the injuries received. Specific factors that seem to increase the risk of death in violent relationships include the abuser’s use of drugs and alcohol, threats to kill the victim, and the victim’s suicidal ideation or attempts. Finally, the physician should ask if the victim feels safe returning home. With this information, the physician can help the patient assess lethal potential and begin to make appropriate safety plans.
Another step is helping the patient identify resources and make a safety plan by providing information about local resources such as mandatory arrest laws, legal advocacy services, and shelters. For patients planning to return to an abusive relationship, the physician should encourage a detailed safety plan by helping the patient identify safe havens with family members, friends, or a shelter; assess escape routes from the residence; make specific plans for dangerous situations or when violence recurs; and gather copies of important papers, money, and extra clothing in a safe place in or out of the home to help ensure a quick exit. Before the patient leaves, the physician should give the patient a follow-up appointment within two weeks. This provides the victim with a specific, known resource. Follow-up visits should continue until the victim has developed other supportive resources.
The physician’s final step is documentation in the patient’s medical file. This written note includes the victim’s report of violence, the physician’s own observations of injuries and behavior, assessment of danger, safety planning, and follow-up. This record can be helpful in the event of criminal or civil action taken by the victim against the offender. The medical file and all communications with the patient are kept strictly confidential. Confronting the offender about the abuse can place the victim at risk of further, more severe violence. Improper disclosure can also result in loss of the patient’s trust, precluding further opportunities for help.
Physicians also play an important role in helping adults who are older, developmentally delayed, or physically disabled. People in all three groups experience a high rate of family violence. Each group presents unique challenges for the physician. One common element among all three groups is that the victims may be somewhat dependent upon other adults to meet their basic needs. Because of this dependence, abuse may sometimes take the form of failing to provide basic needs such as adequate food or medical care. In many states, adults who are developmentally delayed are covered by mandatory child abuse reporting laws.
The signs and symptoms of the abuse of elders are similar to those of the other forms of family violence. These include physical injuries consistent with assault as well as signs of distress or neglect, including self-neglect. Elder abuse victims are often reluctant to reveal abuse because of fear of retaliation, abandonment, or institutionalization. Therefore, a key to intervention is coordinating with appropriate social service and allied health agencies to support an elder adequately, either at home or in a care center. Such agencies include aging councils, visiting nurses, home health aides, and respite or adult day care centers. Counseling and assistance for caregivers are also important parts of intervention.
Many states require physicians to report suspected elder abuse. Because many elder abuse victims are mentally competent, however, it is important that they be made part of the decision-making and reporting process. Such collaboration puts needed control in the elder’s hands and therefore facilitates healing. Many other aspects of intervention described for partner abuse apply to working with elders, including providing emotional support, assessing danger, safety planning, and documentation.
In addition to helping the victims of acute, ongoing family violence, physicians have an important role in helping survivors of past family violence. People who have survived family violence may continue to experience negative effects similar to those experienced by acute victims. Physicians can identify survivors of family violence by screening for past violence during routine exams. A careful history can determine whether the patient has been suffering medical or psychological problems related to the violence. Finally, the physician should identify local resources for the patient, including a mutual help group and a therapist.
Physicians can also help prevent family violence. One avenue of prevention is through the education of patients by discussing partner violence with patients at key life transitions, such as during adolescence when youths begin dating, prior to marriage, during pregnancy, and during divorce or separation. A second avenue of prevention is the making of medical clinic waiting rooms and examination rooms into education centers by displaying educational posters and providing pamphlets.
Perspective and Prospects
Despite its frequency, family violence has not always been viewed as a problem. In the nineteenth century, for example, it was legal in the United States for a husband to beat his wife and for parents to use physical punishment with their children. Although the formation of the New York Society for the Prevention of Cruelty to Children in 1874 signaled rising concern about child maltreatment, the extent of the problem was underestimated. As recently as 1960, family violence was viewed as a rare, aberrant phenomenon, and women who were victims of violence were often seen as partially responsible because of “masochistic tendencies.” Several factors combined to turn the tide during the next thirty years. Medical research published in the early 1960s began documenting the severity of the problem of child abuse. By 1968, every state in the United States had passed a law requiring that physicians report suspected child abuse, and many states had established child protective services to investigate and protect vulnerable children.
Progress in the battle against intimate partner violence was slower. The women’s movement brought new attention and a feminist perspective to the widespread and serious nature of intimate partner violence. This growing awareness provided the impetus during the 1970s and 1980s for reform in the criminal justice system, scientific research, the continued growth of women’s shelters, and the development of treatment programs for offenders.
The medical profession’s response to intimate partner abuse followed these changes. In 1986, US Surgeon General C. Everett Koop declared family violence to be a public health problem and called upon physicians to learn to identify and intervene with victims. In 1992, the American Medical Association (AMA) echoed the surgeon general and stated that physicians have an ethical obligation to identify and assist victims of partner violence, and it established standards and protocols for identifying and helping victims of all types of family violence.
Family violence has at various times been considered as a social problem, a legal problem, a political problem, and a medical problem. Because of this shifting understanding and because of the grassroots political origins of the child and intimate partner violence movements, some may question why physicians should be involved. There are three compelling reasons.
First, there is a medical need: Family violence is one of the most common causes of injury, illness, and death for women and children. Victims seeking treatment for acute injuries make up a sizable portion of emergency room visits. Even in outpatient clinics, women report high rates of recent and ongoing violence and injury from partners. In addition to physical injuries, many victims experience stress-related medical problems for which they seek medical care. Among obstetrical patients who are battered, there is a risk of injury to both the woman and her unborn child. Hence, physicians working in clinics and emergency rooms will see many people who are victims.
Second, physicians have a stake in breaking the cycle of violence because they are interested in injury prevention and health promotion. When a physician treats a child or adult victim for physical or psychological injury but does not identify root causes, the victim will return to a dangerous situation. Prevention of future injury requires the proper diagnosis of root causes rather than the mere treatment of symptoms.
Third, physicians have a stake in the treatment of domestic violence because it is a professional and ethical obligation. Two principles of medical ethics apply. First, a physician’s actions should benefit the patient. Physicians can benefit patients who are suffering the effects of family violence only if they correctly recognize the root cause and intervene in a sensitive and professional manner. Physicians are also mandated to do no harm to their patients. A physician who fails to recognize and treat domestic violence will harm the patient by providing inappropriate advice and treatment.
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