Domestic Violence

Domestic violence, also known as partner abuse, spouse abuse, or battering, occurs when one person uses force to inflict injury, either emotional or physical, upon another person they have, or had, a relationship with. It occurs between spouses and partners, parents and children, children and grandparents, and brothers and sisters. Victims can any age, race, or gender.

Domestic violence is the single largest cause of injury to women between the ages of 15 and 44 in the United States, more than muggings, car accidents, and rapes combined. Each year between 2 million and 4 million women are battered, and 2,000 of these battered women will die of their injuries. Violence against men by women is also a problem, according to the August 2000 Annals of Emergency Medicine. In a study of an inner city hospital, men reported slightly more physical violence than women (20 percent of men and 19 percent of women), although women reported significantly more past and present nonphysical violence than men.

Violence against women is an urgent public health problem with devastating consequences for women, children, and families. According to the U. S. Department of Justice, an intimate person - a husband, ex-husband, boyfriend, or ex-boyfriend - commits 29 percent of all violence against women by a single offender.

Nearly 18 percent of women surveyed, or 17.7 million American women, have been raped or been a victim of attempted rape during their lifetime, according to a collaborative study on violence jointly funded by the Department of Health and Human Services and the Department of Justice.

Research shows that approximately 900,000 parents are beaten or abused by their children each year. The National Elder Abuse Incidence study found that approximately 551,011 elder persons were abused or neglected in a 1-year period (1996). Approximately 2 million children in the United States are seriously abused by their parents, guardians, or others each year, and more than 1,000 children die as a result of their injuries. Recent studies suggest that approximately 20 percent of children will be sexually abused in some way, usually by someone they know, before they become adults. (See ACEP's Feature Column on "How to Protect Children from Abuse")

There is no typical victim. Domestic violence occurs among all ages, races, and socioeconomic classes. It occurs in families of all educational backgrounds. Individuals may be living together or separated, divorced or prohibited from contact by temporary or permanent restraining orders.

Despite the magnitude of the problem, identifying domestic violence victims is still a complex task. It is difficult to determine whether someone fell or was pushed, and emergency physicians are working to improve the identification of domestic violence when it occurs. ACEP encourages emergency personnel to screen patients for domestic violence and appropriately refer those patients who indicate domestic violence may be a problem in their lives.

The first thing a physician can do is recognize the signs of violence. These vary depending upon the type of abuse and the victim's position in the family. Medical findings such as these should prompt direct questioning about domestic violence:

• Central pattern of injuries.

• Contusions or injuries in the head, neck or chest.

• Injuries that suggest a defensive posture.

• Types or extent of injury that are inconsistent with the patient's explanation.

• Substantial delay between when the injury occurred and when the patient sought treatment.

• Injuries during pregnancy.

• Pattern of repeated visits to the emergency department.

• Evidence of alcohol or drug abuse.

• Arriving in the emergency department as a result of a suicide attempt or rape.

Physicians also can gain clues from observing a patient and his or her partner. For example, a battered patient may seem evasive, embarrassed, or inappropriately unconcerned with his or her injuries while the partner may be overly solicitous and answer questions for the patient. A partner of the victim may be openly hostile, defensive or aggressive, setting up communication barriers between emergency personnel and the patient.

Some physicians need to become familiar with the emotional, psychological, and social issues that can predispose someone to accept abuse. They also should become familiar with the clinical presentations of domestic violence and be aware of any personal prejudices or misunderstandings that may prevent them from considering this possibility.

Battery is a crime, and yet few states specifically require reporting of domestic violence. A small number of states require mandatory arrest of batterers, and a few jurisdictions aggressively pursue cases of domestic violence and prosecute batterers even when victims refuse to press charges.

Even when emergency physicians detect abuse, mandatory reporting to authorities-especially against a victim's will-may not be the best thing to do because it can put the victim at greater risk of injury and even death. Studies show that women who leave batterers are at a 75-percent greater risk of being killed by them. Virtually all jurisdictions impose civil or criminal penalties for failing to report suspected incidents of child abuse or neglect.

It is extremely important for emergency physicians to know their state laws and how their local criminal justice systems deal with the issue so they can properly and adequately inform their patients.

Since family violence often makes victims feel helpless and alone, emergency physicians can play an extremely important role in breaking the cycle of domestic violence.

Even if a victim is not ready to leave the relationship or identify the batterer, physicians can recognize and confirm to him or her that this is a serious problem that must be solved. Emergency physicians can let victims know they are not alone, they don't deserve to be beaten, and help is available.

Every emergency department should have written material with the names and telephone numbers of local shelters, advocacy groups and legal assistance to give to patients if they feel it is safe to take it.