Domestic Violence: Explore the Issue

HEALTH CARE PROVIDERS AND FORENSIC MEDICAL INSTITUTES

Health care systems can be an important part of a coordinated, community-wide effort to combat domestic violence. Many battered women do not contact advocacy organizations, shelters, police or prosecutors, or do not do so until the abuse has become quite serious and life-threatening. Women often continue, however, to seek emergency and routine medical care for themselves and their children. Health care professionals can thus provide needed assistance to women who may not seek other types of help, or may be able to intervene earlier than can advocates or agencies.

Doctors and other health care providers can assist victims of domestic violence in many ways. Health care workers can assist victims of violence by (1) avoiding victim-blaming behavior that can reinforce a victim’s isolation and undermine her self-confidence, (2) conducting both individualized and general screening (i.e., watching for signs of abuse in individual patients and asking all patients about violence in their lives), (3) documenting injuries and details of the abuse, (4) referring patients to resources in the community, and (5) maintaining patient privacy and confidentiality. From World Health Organization, Violence Against Women: What Health Workers Can Do . In addition, doctors are often respected members of the community; their involvement in efforts to end domestic violence can contribute significantly to raising awareness about the issue and to efforts to eliminate the abuse.

Health care providers in all settings can be important links in the response to domestic violence. Women who do not seek medical assistance for themselves may continue to seek medical assistance for their children. In fact, this assistance may be required more frequently for children of domestic violence victims because of the health effects of abuse on children. Mental health professionals may see women suffering from anxiety, post-traumatic stress disorder, and depression, all of which might be linked to domestic violence.

The Family Violence Prevention Fund (FVPF), a U.S.-based NGO, provides a Fact Sheet containing additional information on the health care system’s response to domestic violence, an online newsletter, Health Alert on current issues, and information packets on health care issues that can be ordered on-line.

Forensic Medical System

In the CEE/CIS region, access to court systems either requires or heavily depends on formal forensic medical certificates to prove domestic violence. Generally, according to this system, forensic doctors examine a woman and document her injuries with a certificate. The certificate indicates the seriousness of the injury and the category of assault violated by the injury. From Cheryl Thomas, Domestic Violence, in 1 Women and International Human Rights Law 219, 225 (Kelly D. Askin & Dorean M. Koenig eds., 1999). One of the many problems associated with forensic medical systems is that since the institutions exist for the purpose of providing documentation for court proceedings, their primary focus is not the best medical care and treatment of domestic violence victims. Women seeking treatment for their injuries may be confused and misled by the process and may never receive adequate medical care. Domestic violence advocates should be aware of the hurdles presented to domestic violence victims by the forensic medical system.

Confidentiality

Critical to any health care response is confidentiality. Inappropriate disclosure of information concerning domestic abuse may endanger or victimize patients further. Battered women may fear retaliation and are in the best position to determine when it is safe for them to leave. Health care providers, like advocates, must ensure that women know that the information they share will be kept safe.

Although documentation of the abuse is important, any policy regarding documentation should be accompanied by protocols that ensure that this information is kept confidential. In developing the protocol, it is important to assess who currently accesses or has opportunities to access patient medical information. The protocol should define who should have access to what patient information, under what conditions they may have access to this information, when patients should be able to limit further dissemination of their medical information, and when spouses may have access to patient information.

Confidentiality concerns may require changes to the way in which the hospital or other care facility communicates with the patient. Each patient should be given the option to communicate by alternative means or locations, such as directing correspondence to an alternate address or communicating only by mail.

The FVPF’s Health Privacy Principles for Protecting Victims of Domestic Violence (2000), provides an excellent overview of the questions that should be asked in designing a privacy policy that adequately respects patients’ autonomy and need for confidentiality while understanding that sharing of patient information is sometimes needed to ensure proper treatment. The Toolkit to End Violence Against Women, created by the National Advisory Council on Violence Against Women and the United States Department of Justice’s Violence Against Women Office, offers a health care chapter , available in text and PDF formats, detailing additional strategies advocates can use to improve the health care system’s response to domestic violence.

Support and Affirmation

Health care providers should avoid victim-blaming behavior that can reinforce a victim’s isolation and undermine her self-confidence. Training health care workers on domestic violence issues, the health effects of domestic violence, and the ways in which health care providers can contribute to efforts to end domestic violence can be a highly effective advocacy strategy. Training can help sensitize doctors and counter prevailing myths about domestic violence. For example, doctors may be skeptical about the veracity of women’s accounts of violence. According to research in Poland, forensic doctors may consider it their duty to determine whether a woman’s injuries were caused by an assault or were self-inflicted. From MAHR, A Report on Domestic Violence in Poland 36 (2002).

Screening and Referral

One of the principal ways in which the medical community can more effectively respond to domestic violence is through screening. Women who do not seek assistance through other sources may still be seen by emergency medical personnel or general health care providers. These providers see injuries that may indicate domestic violence, particularly injuries that are inconsistent with the cause offered by the patient.

Health care providers may see other indications of violence, particularly evidence that the patient’s intimate partner is controlling. The patient may allow her husband or partner to speak for her; her partner may insist on accompanying her at all times and on answering all questions. The patient may miss appointments (perhaps due to lack of transportation or telephone), or indicate an inability to obtain medication.

Routine screening questions can be included in the written or oral questions asked of all patients. These questions do not need to be extensive or intrusive; one question might be, for example: “Are you currently in a relationship in which you are being hurt, threatened, or made to feel afraid?” It is useful to frame these questions with a sentence that indicates that all patients are asked about violence. This may help to counter a patient’s fear that she is being singled out or has somehow indicated that she experiences violence in her life. In addition, these questions also help to raise awareness of and to destigmatize the issue of domestic violence.

If health care providers see signs of abuse, or if the patient answers yes to routine screening questions, they can ask additional questions to determine if there is a pattern of violence in the patient’s life. It is critical that this discussion take place in private.

Health care providers can also do a basic lethality assessment by asking whether weapons were involved in the incident that caused the injury, whether her partner has threatened to kill her or commit suicide, whether the abuse is getting worse, and whether she feels that she is in immediate danger.

If a health care provider determines that violence may be an issue for the patient, she can offer to direct the patient to additional resources. Helping to make the patient aware of the existence of such resources, or even to articulate domestic violence as a concern, can provide the woman with the some of the support and information she may need in making informed decisions.

The World Health Organization, in its Violence Against Women: What Health Workers Can Do , also recommends that doctors should not prescribe mood altering drugs, since these may reduce a woman’s ability to protect herself in the case of an attack.

Adapted from Elaine J. Alpert & Cheryl L. Albright, Domestic Violence , 14 Hippocrates (2000); Janet Nudelman & Helen Rodriguez Trias, Building Bridges Between Domestic Violence Advocates and Health Care Providers (1999).

The FVPF offers comprehensive model screening guidelines and useful recommendations on how screening should occur in different kinds of health care contexts in its publication, Preventing Domestic Violence: Clinical Guidelines on Routine Screening (1999).

The SANE-SART programs (Sexual Abuse Nurse Examiners and Sexual Abuse Response Teams), described more fully in the section on sexual assault, provide useful models for working with and treating sexual abuse survivors in a health care setting.

Documentation

Documenting injuries may be critical to later efforts to obtain relief through the legal system. Evidence establishing a pattern of violence can be critical in civil protection order proceedings, criminal prosecutions, and child-custody disputes. Evidence can consist of notes in the patient’s medical file, sketches or drawings, and photos.

Consistent documentation of injuries and health problems related to domestic violence can also have considerable health benefits for the patient. Documentation allows the health care provider to take into account the health effects of abuse over time, and can help ensure that patients receive continuous care even if they later see a different doctor. Finally, documentation can be used to establish the prevalence and importance of the problem, which can then be used to apply for grants to help address the specific needs of battered women.

Adapted from William J. Rudman, Coding and Documentation of Domestic Violence (2000). The United States Department of Justice’s National Institute of Justice offers specific advice on documenting domestic violence in PDF and text formats.

Mandatory Reporting

Both in the United States and in certain CEE/CIS countries, health care workers may be subject to mandatory reporting laws. Although these laws vary substantially, they generally require health care providers to report to law enforcement officers injuries suspected to arise from domestic violence or any other crime.

Advocates of mandatory reporting legislation maintain that such laws improve data collection on domestic violence, enhance the care provided to victims, and assist the legal community in holding batterers accountable. They argue that health care professionals are not sufficiently trained to provide patients with the information and support they need, and thus that it is better to connect patients with specialized services. Mandatory reporting laws also relieve the victim of the burden of filing a report with the police.

Opponents of mandatory reporting legislation argue that these laws place women in danger of retaliation, and that women who fear retaliatory violence against themselves or their children, or who for any other reason do not want to report the violence, may forego necessary medical care. Concealing the cause of the injuries may also impede proper treatment. Advocates in Moldova, for example, expressed concern that because doctors are required to report all cases of domestic violence to the police, women who do not want the police to intervene may conceal the real cause of their injuries. From MAHR, Domestic Violence in Moldova 14 (2000). In Azerbaijan, doctors must inform police of reports of rape or face criminal proceedings. From International Helsinki Federation for Human Rights, Women 2000: An Investigation into the Status of Women’s Rights in Central and South-Eastern Europe and the Newly Independent States 59 (2000).

Batterers may also prevent women from seeking medical care, knowing that the doctor would be required to report suspicions of abuse. Victims may have been told by their abusers that they would lose custody of their children if the abuse is reported. Opponents also maintain that mandatory reporting laws undermine patient autonomy by denying women the ability to make their own decisions about the safest and most appropriate courses of aciton.

Many also argue that these laws conflict with patient privacy rights. Medical privacy policies are a central issue to the health care system’s response to domestic violence because they affect a patient’s willingness to disclose information about abuse to a provider. For example, doctors in Armenia strongly expressed the belief that when women conceal the cause of their injuries, the doctors have no right to investigate further. From MAHR, Domestic Violence in Armenia 19 (2000).

Adapted from Sherry Currens, “Kentucky Coalition’s Concerns About Mandatory Reporting,” Violence Against Women 24-2 (Joan Zorza ed., 2002); Travis A. Fritsch & Kathy W. Frederich, “Mandatory Reporting of Domestic Violence and Coordination with Child Protective Services,” Violence Against Women 24-4 (Joan Zorza ed., 2002);

Janet Nudelman & Helen Rodriguez Trias, Building Bridges Between Domestic Violence Advocates and Health Care Providers (1999).

Creating a Health Care Response

Health care institutions can use many different models to develop institutional responses to domestic violence. Some locations have trained advocates available to provide assistance and advice. One advantage of having specialized staff is that these staff are better equipped to provide advice and support. At the same time, it is useful to train all staff on the basics of domestic violence so everyone is prepared to make necessary referrals to specialized staff.

Other programs train staff to provide such support to patients as it is needed. One program in San Francisco trains all staff members, including janitorial staff, on issues of domestic violence so that “anyone who might come into contact with a battered woman [will] know how to talk to her sensitively about her concerns, situation, and options.” This comprehensive training enabled a member of the janitorial staff to identify a domestic violence issue that others missed; the staff member noticed that a woman was crying herself to sleep every night, and asked her why she was crying. From Janet Nudelman & Helen Rodriguez Trias, Building Bridges Between Domestic Violence Advocates and Health Care Providers (1999).

The development of domestic violence programs in a health care context should be guided by the following key questions: