Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Science should be wary of politics
- Andrew J Ashworth (2 February 2002)
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Domestic Violence: partners, questions and measures
- Adrian A Boyle (5 February 2002)
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Domestic Violence and Gender.
- Mark S Horner (7 February 2002)
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Domestic violence screening acceptable to women
- Joan Webster, Debra K. Creedy (10 February 2002)
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Primary care practices regarding domestic violence: a European sentinel network
- Pierre Chauvin, Cécile Morvant, and Jacques Lebas (21 February 2002)
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Neglected Association Between Domestic Violence and Abortion
- David C. Reardon (22 February 2002)
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Domestic violence weakly documented in Finland
- Juha T. Karvonen, Marjo-Riitta Järvelin, professor, Department of Public Health Science and General Practice, University of Oulu (28 March 2002)
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Response to responses
- Gene S Feder, Jo Richardson, Jeremy Coid (5 April 2002)
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Andrew J Ashworth, General Practitioner Motherwell Health Centre
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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! |
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Adrian A Boyle, Specialist Registrar Emergency Medicine Addenbrooke's Hospital, Cambridge
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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. |
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Mark S Horner, General Practitioner Felton, Northumberland.
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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 |
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Joan Webster, Director of Nursing Research Royal Women's Hospital, Brisbane, Debra K. Creedy
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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 |
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Pierre Chauvin, public health researcher INSERM U444, 27 rue Chaligny, 75012 Paris, France, Cécile Morvant, and Jacques Lebas
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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. |
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David C. Reardon, Director of Research Elliot Institute, Springfield IL
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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. |
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Juha T. Karvonen, Research Fellow Department of Psychiatry, Oulu University Hospital, P.O. Box 26, FIN-90029 OYS, Marjo-Riitta Järvelin, professor, Department of Public Health Science and General Practice, University of Oulu
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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. |
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Gene S Feder, Professor of primary care research and development Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London E1 4NS, Jo Richardson, Jeremy Coid
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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
Jo Richardson
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
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. |
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