Identifying domestic violence: cross sectional study in primary care
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7332.274 (Published 02 February 2002) Cite this as: BMJ 2002;324:274All rapid responses
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EDITOR
Richardson et al found that only 7% of domestic violence (DV) cases
were documented in the medical records of women. 1 Various reports claimed
that the prevalence for DV varies between 20 to 50%. 2
One of the authors (JTK) reviewed all outpatient records between 1999
-2000 of 1,598 general population subjects in a psychiatric sub-study of
Northern Finland Birth Cohort 1966. 3 There were over 4,000 patient
records in 16 different health care settings. Only 43 subjects had no
patient records. Of the subjects 659 were married, 302 cohabitant and 162
divorced, 411 were unmarried and 13 widowed. Among these 823 male and 775
females only 24 consultations contained some remarks about DV; 91% were
about male against female DV. This was an extremely low number (1.5% of
all subjects, or 2.8% of females on whom DV predominantly focused on).
Seven of these 22 notes mentioned that a violent spouse also abused
alcohol. There were nine remarks about a violent father and three about a
violent mother of patient, but surprisingly none of these were patients
whose own partner was violent.
There was at least a 10-fold difference between reported prevalence
of DV 2 and our findings from patient records, and about a 2-fold
difference compared with findings of Richardson. 1 Physicians might try to
protect victims of DV by not mentioning DV in patient records, but
Richardson et al found that doctors and nurses rarely ask about DV. 1
We need training and clear instructions for health care personnel to
uncover and handle this stigmatised private secret. They ought to focus on
asking direct questions about abuse, assessing and providing safety. 2 The
uncovering of the situation may even represent life danger for patients.
The staff should realize that violence is never acceptable and it is
criminal also at home. Violence will not vanish by itself from intimate
relationships without interference. Violence easily tends to get worse in
a vicious circle: aggression –> perpetrators make it up to victim –>
forgiving –> tension increasing –> aggression. Feelings of shame and
guilt enfold the victim in social isolation and prevent searching for
help. The staff should also remember children, who are usually more aware
of the situation than the parents realize, and also urge for help. The
present lack of evidence of effectiveness of interventions indicates the
need for further intervention studies.
Reference List
1. Richardson J, Coid J, Petruckevitch A, Chung WS, Moorey S, Feder
G. Identifying domestic violence: cross sectional study in primary care.
BMJ 2002;324:274. (2 February.)
2. Jewkes R. Preventing domestic violence. BMJ 2002;324:253-4. (2
February.)
3. Rantakallio P. The longitudinal study of the northern Finland
birth cohort of 1966. Paediatr Perinat Epidemiol 1988;2:59-88.
Competing interests: No competing interests
Dear Editor,
Richardson's identification of risk factors for domestic violence
against women is helpful but the failure to distinguish between pregnancy
outcome in the year prior to the survey is especially unfortunate as a
history of abortion has been found to be an especially valuable indicator
of risk for domestic violence.
Women who report a history of abortion are over twice as likely to
report violent acts committed by their partner in the last year compared
those who do not report a history of abortion (OR=2.27; 95% CI = 1.53 to
3.36).(1) They are also fourteen times more likely to be victims of
homicide compared to those who carry to term.(2)
Pregnancy may expose women to abuse if a male partner is unwilling to
accept or tolerate the birth of a child. Verbal or physical abuse may be
used to compel them to submit to an unwanted abortion.(3) According to one
study of battered women, the target of battery during their pregnancies
shifted from their face and breasts to their pregnant abdomen,(4) which
suggests hostility toward the woman's fertility. This problem may be
widespread since numerous studies show that pregnant women are at higher
risk of being abused (5, 6), a finding supported by Richardson's data.
Coerced abortions can clearly be a form of and result of abuse.
Following a coerced abortion, a woman's reactions of grief and depression
may trigger repeated acts of violence on the part of the male who may
interpret her withdrawal as rejection and repudiation. Furthermore, even
voluntary abortions may contribute to domestic violence if there are post-
abortion psychological reactions—on either the part of the woman or man.
If either or both partners experience grief, resentment, anger, substance
abuse, self-punishing or self-destructive behaviors, this may aggravate
the frequency and intensity of subsequent domestic conflicts.(3)
This hypothesis is supported by clinical experience with abused women
as well as the results of a survey of 260 post-abortive women of whom 53
percent agreed with the statement that after their abortion "I started
losing my temper more easily," and 48 percent agreed that "I became more
violent when angered." In this same sample, 56 percent reported
experiencing suicidal feelings, with 28 percent actually attempting
suicide one or more times. Approximately 37 percent described themselves
as "self-destructive" with another 13 percent "unsure," that is unwilling
to rule out that they had become self-destructive.(3)
Further analyses of this data revealed that increased post-abortion
levels of self-hatred, hatred of the male, and hatred of men in general,
were all significantly correlated to each other. In addition, suicidal
tendencies and self-destructive behavior were statistically associated
with shorter tempers and increased levels of anger and violence (p<
.00001). In turn, short tempers and self-destructive behavior were also
significantly associated with feeling less in touch with one's emotions,
feeling unable to grieve, faking displays of happiness, and feeling less
control over one's life.
In summary, women who are angry and self-destructive following an
abortion may be less inclined to avoid violent confrontations. In
addition, the association between abortion and abuse may indicate that a
substantial number of women may be submitting to unwanted abortions in the
face of abuse and coercive pressure.
Research on domestic violence would be improved by closer attention
to these associations. In the meantime, screening for domestic violence
would be improved by examining pregnancy histories. An additional benefit
from such screening is that abortion is also associated with higher rates
of suicide, substance abuse, and depression and is therefore a useful
marker for identifying women who may benefit from intervention counseling.
NOTES
1. Russo NF, Denious JE. Violence in the lives of women having
abortions: implications for practice and public policy. Professional
Psychology: Research and Practice 2001; 32:142-150.
2. Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E.
Pregnancy-associated deaths in Finland 1987-1994 -- definition problems
and benefits of record linkage. Acta Obset Gynecol Scand 1997;76:651-657.
3. Burke T, Reardon DC. Forbidden Grief: The Unspoken Pain of
Abortion. Springfield, IL: Acorn Books, 2002.
4. Hilberman E, Munson K. Sixty battered women. Victimology 1977-78; 2:460
-470.
5. Gazmararian JA, Adams MM, Saltzman LE, Johnson CH, Bruce FC, Marks
JS, Zahniser SC The relationship between pregnancy intendedness and
physical violence in mothers of newborns. The PRAMS Working Group. Obstet
Gynecol 1995 Jun;85(6):1031-8.
6. Amaro H, Fried LE, Cabral H, Zuckerman. Violence during pregnancy
and substance use. Am J Public Health 1990 May;80(5):575-9.
Competing interests: No competing interests
Editor - The two studies recently published in the BMJ on domestic
violence highlighted the lack of routine involvement of primary care
practitioners when confronted with female victims (even in the case of
physical injury)1, as well as the difficulties in screening this
phenomenon in general practice2. These two studies are of great importance
since European data on domestic violence have remained rare and scarce.
Richardson et al. concluded that the introduction of screening for
domestic violence in healthcare settings is "premature" because of its
"limited acceptability" (20% would "mind being asked by their GP" about
it) while Bradley et al. observed that only 7% of women "would mind such
routine inquiry by their doctor". Unlike the first author, we find this
rate of spontaneous acceptability extremely high, and favourable for the
adoption of this type of screening, regarding a practice which does not
yet exist in fact and is therefore not integrated by women. After all,
other types of screening - such as those for breast, cervix or prostate
cancer - were probably not greeted with greater enthusiasm! Particularly
as other authors report good sensitivity and good specificity from primary
care questionnaires, at least regarding severe intimate partner violence3.
Why do doctors find it so difficult to recognise marital violence, even in
the case of visible physical violence? A study carried out in 2000, among
235 general practitioners in the Paris area showed that in only 7.7% of
the cases of domestic violence finally recognised as such had the doctor
taken the initiative of raising the question of domestic violence. It also
showed that the vast majority do not know how to cope with this problem:
75.6% did not know of any structure or other professional liable to help
their patient, 60.3% declared themselves insufficiently trained to detect
and provide follow-up for domestic violence, 47% judged themselves unable
to do so, and 21% declared having too little time to raise this question.
In view of this situation, a multilingual internet site have been created
in 2001 with the support of the Daphne initiative of the European Union,
to provide health professionals with information and recommendations to
detect and provide follow-up for female victims of domestic violence
(www.sivic.org). As an extension, a European surveillance network of
primary care practices in the case of domestic violence - the "Vigil"
network - now brings together both health professionals (general
practitioners, emergency services, gynaecologists) and associations which
help female victims, in 8 European countries: Belgium, Denmark, France,
Ireland, Italy, Portugal, United Kingdom and Spain. Regarding each case
recognized by them, the volunteer doctors are questioned as to how the
violence was detected, their intervention and the difficulties
encountered. The female victims are also questioned as to their contacts
with health professionals (or as to why there were none) and as to the
proposals made by them.
1 Richardson J, Coid J, Petruckevitch A, Chung WS, Moorey S, Feder
G. Identifying domestic violence: cross sectional study in primary care.
BMJ 2002; 324: 274.
2 Bradley F, Smith M, Long J, O'Dowd T. Reported frequency of domestic
violence: cross sectional survey of women attending general practice. BMJ
2002; 324: 271.
3 McNutt LA, Carlson BE, Rose IM, Robinson DA. Partner violence
intervention in the busy primary care environment. Am J Prev Med 2002; 22:
84-91.
Competing interests: No competing interests
Editor
In response to Richardson et al(1) and Bradley et al (2) we would
like to highlight related outcomes of the Queensland Health Domestic
Violence Initiative (3) that incorporated screening for domestic violence
into routine history taking protocols, as a component of core clinical
practice. The provider asks the client 2-3 additional questions related to
domestic violence during the client history taking procedure. This small
change has resulted in significant improvement in detection and provision
of health services and information to women who experience domestic
violence.
Respondents in the Richardson and Bradley studies completed a self-
report questionnaire but many had never been asked directly about DV in a
screening process. Only 12% of women in the Bradley study reported that
their doctor had ever asked about domestic violence. In our study, 83% of
women presenting to antenatal or gynaecology outpatient services were
screened, with approximately 6.5% disclosing some form of domestic
violence. Of those women who screened positive for domestic violence 10%
accepted an offer of immediate help. Screening for domestic violence was
overwhelmingly perceived by clients as a good idea, with 97% of surveyed
women supporting screening. This is higher that the reported 77% (Bradley)
and 80% (Richardson) of women in favour of screening. Richardson presented
a somewhat negative view of screening by reporting that "at least 20% of
women objected to screening" rather than focusing on the 80% who found it
acceptable. More accurate conclusions may be drawn from research that
reports on the views of women who have experienced personalised DV
screening to determine the extent of acceptability.
Richardson reports that 42% of women would find it easier to discuss
domestic violence issues with a female doctor. Issues of gender, power
relations and interpersonal sensitivity must be considered when sreeening
for domestic violence. Neither Richardson or Bradley identified if certain
contexts were described in the questionnaire items when investigating
women's attitudes to screening. For example, it may be that women's
attitudes to DV screening alter if the questions were asked in private
with no family member present, if they were asked by a female health
professional, if women perceived the health professional to be genuinely
concerned about them, and if they were offered access to information and
referral. Such issues need to be considered when investigating service
user attitudes to DV.
The studies also report a low rate of documentation of DV where, for
example, only 17% of cases in the Richardson paper were documented. The
results of our work identified the benefits of fast, simple, but routine
screening can be effective with documented compliance of around 88% and
97% acceptability to women.
1 Richardson J, Coid J, Petruckevitch A, Chung W, Moorey S, Feder G.
Identifying domestic violence: A cross sectional study in primary care.
BMJ 2002;324:274
2 Bradley F, Smith M, Long J, O'Dowd T. Reported frequency of
domestic violence: Cross sectional survey of women attending general
practice. BMJ 2002;324:271
3. Webster J, Stratigos S, Grimes K. Women's responses to screening
for domestic violence in health care settings. Midwifery 2001;17:289-294
Competing interests: No competing interests
I concur with Dr. Ashworth, and am disappointed that your recent
coverage of domestic violence has been used as yet another stick to beat
down on men. The clear implication being that men are the oppressors and
women suffer. Whilst this is sadly often true, it is far from being the
whole picture.
The 1996 British Crime Survey (BCS) asked a representative sample of
16,500 adults in England and Wales directly about their experiences of
crime – whether or not it was reported to the police. It included a
computer-assisted self-interviewing (CASI) questionnaire, designed to give
the most reliable findings to date on the extent of domestic violence in
England and Wales. The results published in January 1999 found 4.2% of
women and 4.2% of men said they had been physically assaulted by a current
or former partner in the last year.
Many studies have found similar results. The work of Murray Straus,
a good example of which can be found at
http://www.vix.com/menmag/straus21.htm, is particularly authoritative.
Indeed when one considers that most violence against children is probably
committed by women, in terms of gender it is women who are the most likely
perpetrators of domestic violence.
Does this manner of presentation matter? I think it does. On a
personal level it leads to the situation I encountered not too long ago in
our local police station. A man with quite severe injuries following an
attack by his former (female) partner, found himself in the cells for
breach of the peace. On a broader level in adds to the negative image of
men so widespread in parts of our popular culture. This does nothing to
help the forging of a masculine identity in certain vulnerable young men,
which is cited I believe correctly by Jewkes (1) as a risk factor for
violence.
Why I wonder is domestic violence so often portrayed in such a
partisan and unscientific way?
1 Preventing domestic violence. Rachel Jewkes
BMJ 2002; 324: 253-254
Competing interests: No competing interests
Sir, I read with interest the paper by Richardson et al. (1) It is
heartening that this important problem is being researched in Britain. The
authors deserve credit for tackling an uncomfortable subject. However,
there is no indication in this paper whether the women who reported
domestic violence were still in the intimate relationship or not. While
former partners in abusive relationships have the potential for continuing
abuse this is considerably less than those who may be trapped in an
ongoing abusive relationship. This is also pertinent to the vexed question
of screening women for domestic violence. Questioning women about domestic
violence, one would imagine, aims to identify those patients who are
trapped in an abusive relationship and would possibly benefit from
interventions.
The finding that a fifth of the sample objected to routine
questioning about domestic violence is surprising. The way the question is
asked is important, I find the following question useful and inoffensive
“We know that violence at home is a problem for many women, is there
anyone who is making you feel unsafe in anyway?” I accept that this is
personal anecdote and that I work in a very different environment to
primary care.
The response rate is low, and as the authors acknowledge, this may
bias in the results in unpredictable ways.
The definition of domestic violence in the scientific literature is
very variable.(2)This limits the comparability of many studies. Estimates
of prevalence in different populations are extremely variable, but it is
difficult to see whether these differences are real or due to definitions.
There are, however, a number of validated measures of domestic violence
that have published (3-5)and perhaps these could have been used. Failing
that a questionnaire from another community or primary care survey could
have been used to at least try and get some comparability.
(1) Richardson J, Coid J, Petruckevitch A, Chung W, Moorey S, Feder
G. Identifying domestic violence: cross sectional study in primary care.
British Medical Journal 2002; 324:274-277.
(2) Hegarty K, Roberts G. How common is domestic violence against
women? The definition of partner abuse in prevalence studies. Australian
& New Zealand Journal of Public Health 1998; 22(1):49-54.
(3) Straus M, Hamby S, Boney-McCoy S, Sugarman D. The revised
conflict tactics scale CTS2. Journal of Family Issues 1996; 17(3):283-316.
(4) Attala JM, Hudson WW, McSweeney M. A partial validation of two
short-form partner abuse scales. Women & Health 1994; 21(2-3):125-139.
(5) Hudson WW, McIntosh S. The assessment of spouse abuse: two
quantifiable dimensions. Journal of Marriage and the Family 1981; 43:873-
888.
Competing interests: No competing interests
Though the title of Richardson et al's paper "Identifying domestic
violence: cross sectional study in primary care" is not gender specific,
its method and conclusions are. Research such as this will inevitably
serve political as well as scientific interests. The lack of gender
specificity in the title gives the (false) impression that this study was
a cross sectional study of the population when it actually excluded around
half of potential participants (men). It is unclear whether or not women
in gay relationships were included.
Did the authors (and peer reviewers)assume naievely that women are never
the perpetrators of domestic violence or is this a more sinister use of
"evidence"?
Domestic abuse is a widespread and terrible evil but we should ensure that
science leads politics rather than vice versa.
Competing interests:
I am BMA representative on Mens Health Forum Scotland. I am married to the
1984 Scottish Women's Tae Kwon Do Champion who has never subjected me to
any form of abuse!
Competing interests: No competing interests
Response to responses
Editor
Ashworth and Horner question the exclusion of men from our sample of
patients. We chose to focus on women who are abused by men not because we
think that violence by women against men does not occur. As Horner points
out, the overall incidence of domestic violence reported in the community
sample of the British Crime Survey was similar for men and women. What he
fails to say is that the context and severity of violence against women
and the consequent fear and physical and mental health sequelae make
domestic violence against women by men a much larger problem in public
health terms.(1) Violence against male partners in heterosexual and
homosexual relationships needs investigation, but this was not the focus
of our study.
Boyle suggests that it would be useful to distinguish women who are
still in an abusive relationship from those who are not. We agree,
although we chose to report experience of domestic violence in the past
year because women are still at increased risk of abuse after leaving a
violent relationship. We also agree with Boyle that prevalence studies
should use validated measures of abuse; our questions were derived from
the violence, injury and controlling behaviours assessment indices
developed and validated by Dobash and colleagues (2) and were used in a
comparable primary care study by Bradley.(3)
Reardon emphasises the important link between pregnancy and
experience of abuse that we identified in our study. We agree that it
might be useful to explore in more detail associations between pregnancy
outcome and subsequent violence. Our sample included women who had a
termination of pregnancy in the previous twelve months but we did not
identify them in our questionnaire. Undergoing a termination of pregnancy
is distressing for many women. But we do not accept that “post-abortion
psychological reactions on the part of women” make them more susceptible
to partner violence, because that type of explanation shifts the
responsibility for the violence away from the perpetrator.
Finally, Webster and Chauvin question the implications of our finding
that one fifth of women patients would mind being asked by health
professionals about threats orviolence by a partner or previous partner if
they were attending primary care for another reason. We agree that this
proportion might be lower if a screening programme was in place. In any
case, a minority objecting to screening should not stop a screening
programme from being established, if a programme is otherwise justified.
Currently there is insufficient evidence that a screening programme in
health care settings for domestic violence is effective and safe.
Gene Feder
professor of primary care research and development
Jo Richardson
research fellow
Department of General Practice and Primary Care, Barts and the
London, Queen Mary’s
School of Medicine and Dentistry, Mile End Road, London E1 4NS
Jeremy Coid
professor of forensic psychiatry
Department of Forensic Psychiatry,
Barts and the London,
Queen Mary’s School of Medicine and Dentistry,
St Bartholomew’s Hospital,
London EC1 7BE
(1) Taft A, Hegarty K, Flood M. Are men and women equally violent to
intimate partners? Aust N Z J Public Health 2001;25:498-500.
(2) Dobash R, Dobash R, Cavanagh K, Lewis R. Research evaluation of
programmes for violent men. 1996; Edinburgh:The Scottish Office Central
Research Unit.
(3) Bradley F, Smith M, Long J, O'Dowd T. Reported frequency of domestic
violence: cross sectional survey of women attending general practice. BMJ
2002; 324: 271-274.
Competing interests: No competing interests