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EDITORIALS: Lorraine E Ferris Intimate partner violence BMJ 2007; 334: 706-707 [Full text]

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A curate's egg

Alfred P J Lake   (9 April 2007)

Misleading Editorial Headlines Mislead Opinion

Anonymous Doctor   (10 April 2007)

Violence against women: No longer intimate

Vibha Pandey, Ranchi, India-834006   (12 April 2007)

Trust, confidence , and confidentiality

Chris N Jones   (18 April 2007)

A curate's egg 9 April 2007
Alfred P J Lake, Consultant in Anaesthesia and Pain Management Glan Clwyd Hospital, Rhyl LL18 5UJ Send response to journal: Re: A curate's egg	Good in parts but one would have hoped for greater change and acceptance of the evidence about appropriately termed intimate partner violence over the 3 years since the last editorial (1). Gender bias still features when gender neutrality will yield benefits; to reinforce a stereotype of the victims being female and the perpetrators male only supports the entrenched positions of those who, despite the evidence, will not move forward particularly because demonising males is seen as helpful to the anti-family feminist agenda. In this editorial ‘women’ features eleven times whereas ‘men’ only once and that in a very negative context (Box 1). ‘Editor’s choice’ reprises the theme. The idea that intimate partner violence only affects women remains gospel to some which means that male victims suffer a lack of understanding and recognition. Staff involved in this work need to be taught to recognise the injury patterns of intimate partner violence in men as well as women, provide information and support in their workplace and not fail a significant proportion of the very group of people they should be helping. A lack of gender neutrality with respect to this is widely used by women as a tool to effect marriage breakdown which itself leads to much more damage overall to society through its adverse consequences for both fathers and children. 1. Ferris LE. Intimate partner violence. British Medical Journal 2004; 328: 595-6. Competing interests: None declared
Misleading Editorial Headlines Mislead Opinion 10 April 2007
Anonymous Doctor, N/A N/A Send response to journal: Re: Misleading Editorial Headlines Mislead Opinion	Though headlined as gender and sexual preference neutral an editorial commissioned from a (heterosexual?) apparently female author by a (heterosexual female?) editor is limited to male on female abuse. No competing interest is declared. In an anonymous personal view by a heterosexual woman(1) in the same edition we are reminded that “It happens to men and to women, and is perpetrated by men and by women, in different sex and same sex relationships,” Horner (2) has pointed out that the very thin epidemiologic evidence we have indicates a similar prevalence of 4.2% between genders in heterosexual relationships, though Richardson et al (3) argue that the nature of the violence and its reporting in subsequent questionnaire studies demonstrate that violence by men on women is worse than that of women on men (homosexual violence is not addressed). Absence of evidence of female perpetrated abuse is not evidence of absence of it occurring, nor does it justify ignoring it in public health interventions. I am a partner in General Practice in my second marriage. My first wife abused me using various weapons including knives to my throat, an attack with a hot Iron (the scar is the only physical evidence that I am not, as she has argued, fantasising), and having my head held under the surface of a bath I was in. Had I reported her violence, she made it clear to me that she would argue that it was self-defence since it is widely understood in society that domestic violence is a male on female behaviour. Though the scar on my arm is small and causes no problem, and notwithstanding the psychotherapy that has helped a little with over 10 years passing since my divorce, I have still been terrified in my former wife’s presence during, for example, my son’s (she has questioned his paternity to him as part of the pattern of abuse) recent significant illness. In a Scottish General Practice, I find that, after separation, both genders report irrespective of sexual preference that the psychological abuse resulting in reduced self-esteem was far more damaging than the physical trauma they suffered. More women than men report having been physically abused but more men than women report being socially and psychologically abused during the separation, for example by their wives failing to comply with agreements and orders on access to their children. It appears that the pattern of psychosocial abuse by female perpetrators on male victims may be more pervasive that the generally accepted “normal” pathology where there is a tacit acceptance that male on female abuse is more generally more severe even though the evidence for this is about extemes rather than the median. When I was being abused the publication of this piece would have made it more difficult for me to report my distress by its implication that only heterosexual male intimate partners are violent. If the author and editor have abused their academic power by driving female perpetrated domestic abuse even further underground then they have themselves become complicit in the very outrage they seek to reduce. This is an excellent editorial about what amounts to an appraisal system, perhaps the author and the commissioning editor would be prepared to respond to this letter by appraising their actions according to the CanMEDS system and reflecting on the potential outcomes of their use of this vehicle to take a position (however inadvertent) in gender politics. Because I have declared myself as a former victim and because I fear that my former wife would interpret this attempted contribution to the debate as a cowardly attack on her and communicate that opinion to my children, I request that my personal details are withheld from publication. 1 Anonymous. Keeping it Secret BMJ 2007,334:747 2 Horner MS. It's not only men who commit domestic violence. BMJ 2002;325:44. Jo R Richardson, Gene Feder, Jeremy Coid The effects of domestic violence are far greater for women than men BMJ (17 July 2002) Competing interests: I am a man who was abused by my former wife
Violence against women: No longer intimate 12 April 2007
Vibha Pandey, Psychiatric Social Worker Central Institute of Psychiatry, Ranchi, India-834006 Send response to journal: Re: Violence against women: No longer intimate	Domestic violence, one of the burning issues today, is not restricted to any particular race, religion, culture or even country; rather it exists all over the world. Looking into this problem, the CanMEDS [1] program by the Royal College of Physicians and Surgeons of Canada is a step in the right direction. Although presently practiced in Canada, I hope similar programs are adopted by countries around the world. However, I believe that one drawback of this program would be the personal initiative of the victim to step forward without which help cannot be provided. A country like India where the majority of women are still expected to play traditional roles could hinder reporting. In fact, legislation such as the Protection of Women from Domestic Violence Act 2005 [2] which empowers any informant to report such cases would strengthen such programs. The Can MEDS program is also very demanding of a doctor by expecting him to play several roles, that of a medical expert, a communicator, a collaborator, health advocate manager, scholar, as well as a professional. Competency of such a “specialist” will have to be also taken into account. Finally, one wonders how much empathy one can expect from doctors, who are themselves part of the same community that wreaks it and turn a blind eye to it? The situation is no different for women since the initiators of domestic violence against women happen to be women themselves 1.Frank JR, ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada. 2005. http://rcpsc.medical.org/canmeds 2.Protection of Women from domestic violence Act, 2005 Chapter III, accessed at http://ncw.nic.in/DomesticViolenceBill2005.pdf Competing interests: None declared
Trust, confidence , and confidentiality 18 April 2007
Chris N Jones, Consultant Forensic Psychiatrist Norvic Clinic; St Andrew's Business Park; NR7 0HT Send response to journal: Re: Trust, confidence , and confidentiality	Sir The simultaneous publication of several articles addressing issues of domestic violence highlights some of the contradictions and controversies inherent in current clinical practice. You report (1) a GP leader as criticising Patricia Hewitt for suggesting that information about domestic violence is not always kept confidential: “No GP would break confidentiality”, he asserts. Really? In the same issue Piyal Sen (2), reviewing a film dealing with many of the same issues, suggests that doctors in a particular case should have done just that “to avert the subsequent tragedy”, and is surely not alone in supporting such disclosure. When there is any suggestion of risk to children – not unusual in domestic violence cases - guidelines require almost routine breach of confidentiality. Balancing the needs of the patient and the needs of society, as Professor Ferris recognizes (3), is not straightforward. The WHO recommendations quoted emphasize the need for “respectful, secure, and confidential” services, but these principles may be incompatible with other, legally mandated, duties. Historically doctors have concentrated on their duties to an individual patient but developments in areas such as child protection, public safety, and Multi-Agency Public Protection Arrangements increasingly require doctors to prioritise the needs of others over those of the patient. Finally the anonymous Personal View (4) reminds us, should it be necessary, of the harrowing personal experience behind any academic discussion of medical ethics. The writer clearly valued the support of a compassionate, non-judgemental and sympathetic GP: it seems clear that trust and confidence, as well as confidentiality, was fundamental to that support. Even so, the advice to doctors seeing such patients is to “get help” for the patient, perhaps (though not explicitly stated) breaching confidentiality if necessary. Should doctors report domestic violence even without the patient’s consent? There are certainly occasions on which a disempowered victim might be considered less than fully competent to make such a decision, and reporting might be seen to be in their best interests. Research suggests that while the general public broadly support this approach, actual victims of domestic violence are less likely to do so, and say that they would be less willing to present for medical treatment if control over such decisions was taken from them(5,6). What are doctors to do? More importantly, what can patients reliably expect from their doctors? Ultimately trust is about perception as much as, if not more than, actual practice. If patients cannot be sure that doctors will keep such things confidential then victims of domestic violence will not be willing to access the sort of support described in the Personal View. If as a profession we cannot present a clearly articulated and consistent position, and do not resist the pressure for medical confidences to be diverted for public protection purposes, then we should not be surprised if our most vulnerable patients lose trust in us. Ultimately it is the victims, such as your anonymous correspondent, who will pay the price. Dr Chris Jones Consultant Forensic Psychiatrist Norvic Clinic NR7 0HT christopher.jones@nwmhp.nhs.uk 1. Day M. Hewitt says some Muslim GPs breach confidentiality. Br Med J 2007;334:711. 2. Sen P. Home truths about domestic violence. Br Med J 2007;334:748. 3. Ferris LE. Intimate partner violence. Br Med J 2007;334:706-7. 4. Keeping it secret. Br Med J 2007;334:747. 5. Rodriguez MA, McLoughlin E, Nah G, Campbell JC. Mandatory reporting of domestic violence injuries to the Police; what do Emergency Department patients think? J Am Med Assoc 2001;286(5):580-583. 6. Rodriguez MA, Sheldon WR, Bauer HM, Perez-Stable E. The factors associated with disclosure of intimate partner abuse to clinicians. J Family Practice 2001;50(4):338-344. Competing interests: None declared