Intimate partner violence
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39168.644757.BE (Published 05 April 2007) Cite this as: BMJ 2007;334:706
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests