Primary Care Reports September 8, 1997

Domestic Violence and Primary CareMedicine: Building Understanding—Improving Assessment and Treatment

Authors: Scott S. Meit, PsyD, West Virginia University School of Medicine, Department of Family Medicine; Heather T. Meit, MA, West Virginia University, Department of Counseling, Rehabilitation Counseling, and Counseling Psychology.

Peer Reviewer: Gerald Kay, MD,

Introduction

Domestic violence is part of a broader societal ill that includes the abuse of children and the elderly (i.e., family violence). Indeed, surveys show that in about half of the households where a man batters his partner, he also beats the children.1 For the purposes of this review, however, domestic violence will be discussed in the context of adult partner abuse. Additionally, domestic violence will be examined in terms of physical and/or sexual assault - primarily in medical presentation. It must be understood, however, that domestic violence may present in a manner other than physical/sexual abuse. Abusive partners often exert control through verbal abuse, emotional abuse, exclusive control over finances, threats of harm, destruction of a victim’s support network (i.e., isolation), and destruction of property.2

Role of the Physician

While the role of the physician is multi-faceted, first and foremost, a physician must be amenable to viewing domestic violence as a significant health care issue, understand the prevalence of such abuse, and be willing to routinely screen for its occurrence. The literature has demonstrated significant physician barriers toward effectively identifying domestic violence.3-7 Specifically, physicians’ personal attitudes regarding violence within the home, fears of "opening Pandora’s Box", fears of offending patients with such inquiries, a sense of powerlessness to effect change, and time constraints have been noted.3-7 Related research, however, has clearly demonstrated that most patients want, if not expect, their physicians to inquire about possible abuse.8 Despite this, emergency and primary care medicine studies have consistently demonstrated poor screening practices and underdiagnosis of domestic violence in patient populations.6,9-12,16

Scope of the Problem

Etiology. An appropriate discussion of the etiology and underpinnings of domestic violence quickly takes on an historical and feminist/sociocultural perspective (the reader is advised, however, that there are more than a dozen current theories that attempt to explain partner violence13). It has been reported that 95% of those harmed by an intimate are women; similarly, 95% of perpetrators are men.14,15 These statistics are not indicative of a new sociocultural phenomenon, however. Culturally sanctioned beliefs about the rights and privileges of husbands have historically legitimized a man’s domination over his wife and warranted his use of violence to control her.16 A wife’s (and children’s) status, as being little more than chattel, is clearly evidenced in the very word "family." The word is derived from the Latin, "familia", meaning "servants of the household."17 Similarly, the ancient Roman husband-owner held the power of life and death over his wife and/or child-slave.17 Lest one consider such a citation too remote or archaic, the Florida Supreme Court clarified a woman’s position in the eyes of the law as recently as 1944:

A woman’s responsibilities and faculties remain intact from the age of maturity until she finds her mate, whereupon incompetency seizes her and she needs protection in an extreme degree. Upon the advent of widowhood, she is reinstated with all the capabilities which have been dormant during the marriage, only to lose them again upon remarriage.18

It is also well known that our society is filled with truisms such as "a man’s home is his castle" and "what goes on behind closed doors . . ." Indeed, the saying "a rule of thumb" (meant to convey the idea of a guiding principle) has a less than innocent origin. The saying comes from a nineteenth century English Common-law statute that imposed a limitation upon the physical punishment a man could administer his wife (i.e. he could beat his wife with an implement no wider than his thumb).19,20 This common-law "wisdom" was later upheld in a 1928 Mississippi courtroom and has, of course, become a well incorporated colloquial expression.21

Epidemiology. In the United States, women are six times more likely to experience violence committed by an intimate partner than are men.22 Indeed, two to four million women are beaten by their partners each year.2,23-25 Of those battered, 2000-4000 will die each year from their injuries.24 Further, over half a million rapes and/or sexual assaults are reported by women each year with fewer than 20% of these assaults being committed by strangers.22 In terms of frequency of violence, women victims of domestic violence experience an average of six violent episodes per year.12 Lastly, at least 30% of women in the United States will be a victim of domestic violence at some point in their lifetime.12

Demographics. Age has been found to be a significant factor for domestic violence. The third decade of life apparently marks the period of greatest risk for a woman with incidence decreasing steadily with age.12,13,22 Also, while domestic violence has been found to cross all socioeconomic strata, lower socioeconomic status in terms of education, occupation, and income has been found to increase risk.12,13 This especially appears to be the case where total family income dips below $10,000 annually.22

Marital status has also been found to be a significant marker. Women who are separated from their spouse are three times more likely to be victimized than divorced women and 25 times more likely than married women.22 Thus, a woman’s danger increases substantially at the point that she leaves her abusive partner.26

It should also be noted that domestic violence is by no means exclusive to heterosexual relationships. Twenty-two to 46% of gay men and lesbians report having been in a physically violent relationship.24 Further, the abusive homosexual partner may utilize the additional psychological abuse of threatening to reveal their partner’s lifestyle (if previously unknown).19,24 The victim of such domestic violence commonly fears that simultaneous disclosure of longstanding battery, as well as alternative sexual lifestyle, may lead to a loss of employment, family support, community support, and/or adversely affect custody decisions already in force (if children are involved).27

In terms of race/ethnicity, there have been mixed findings. Some studies, for example, have shown a higher prevalence of domestic violence among minority women.28,29 A recent National Crime Victimization Survey, however, demonstrated that women of all races/ethnic backgrounds were for the most part equally vulnerable to the occurrence of violence by an intimate.22

Modifiers

Alcohol/Substance Abuse. It is generally well accepted that there is a strong relationship between alcohol/substance abuse and domestic violence. Early theorists, however, postulated much more of a causal relationship (i.e., disinhibition of man’s aggressive potentials).30 Many domestic violence advocates, however, have decried such assertions given that, "it was the alcohol" has been a typical perpetrator excuse (as well as a rationalization all too often supported by their victims).

Indeed, there is little present day empirical support for either a direct causal relationship between alcohol/substance abuse and family violence or to suggest that merely treating the chemical dependency will lessen the incidence of physical assault.13,31 While one recent study does venture support for the hypothesis that recovery from alcoholism can reduce the risk of violence, the authors are quick to point out that behavioral marital therapy (which focused upon building communications skills as alternatives to hostile/negative interactions) was central to their alcohol treatment.32

It may be best to recognize alcohol/substance abuse for what it is: a significant risk factor associated with domestic violence—both for the perpetrator and the victim.33 In a recent study, for example, 40% of women presenting for substance abuse detoxification and treatment were found in interview to report a history of being abused physically and 33%, a history of being sexually abused.34 Also, there is evidence that, with males, chronic alcohol abuse is a better predictor of domestic violence than is acute intoxication.35 Finally, alcohol/substance abuse has been found to be a significant marker for parents’ physical abuse and/or neglect of their children.36

Communication Patterns. Communication patterns of perpetrators (again, predominantly males) are marked by a lack of assertiveness and a poor ability to directly express needs and/or desires within the context of an intimate relationship. Assertiveness skills deficits have been found to be significantly related to the amount of anger and aggression men express in spouse-specific contexts.13

Personality Traits/Mental Illness. Whether resultant or causal, certain personality traits as well as mental illnesses have been associated with domestic violence. For example, it has been reported that men who perpetrate domestic violence are prone to having borderline antisocial personality traits and that they often have histories of having been child victims of domestic violence, themselves.37 On the other hand, Saunders cautions the possibility that men who batter may not be too different from other men—perhaps only on the far end of a continuum of male socialization.1

Lystad et al.’s review of the literature establishes that, with female victims of domestic violence, multiple signs and symptoms of clinical depression exist.19 Further, it has been observed that as frequency and severity of violence escalates, so follows an increase in depressive symptomatology, self-blame, and deterioration of self-esteem for the female victim.19

Pregnancy. Numerous authors have asserted that a woman is at great risk for being physically assaulted while pregnant.2,29,38 While one study from the Centers for Disease Control found that only certain subgroups are at increased risk for physical violence during pregnancy, health-care providers are advised by that study’s authors to be aware of domestic violence risk among all pregnant women.29

Why Do Victims Stay?

The observation that many victims stay in abusive relationships is often a source of significant provider frustration and may threaten the doctor-patient relationship. Health providers may, in essence, grow to resent and/or blame their patients who do not put an end to such relationships and/or leave one abusive partner only to become involved with another. Women remain in such relations for a number of reasons. Initially described by Lenore Walker in 1979, the "Cycle of Violence" is one factor that apparently maintains such relations.29 (See Figure 1.)

First, it must be understood that abusive relationships are not always abusive. Consistent with the cycle of violence, following an episode of assault, a period of contrition (i.e., "It will never happen again") generally follows. Such respites (also known as the "honeymoon period") are typically quite wonderful times in the life of the relationship. It is not uncommon for a woman to be showered with gifts, thoughtful gestures, and sincere promises to end the violence. Unfortunately, primary communications difficulties along with a host of other markers for violence (already described) bring about the eventual build up of tensions and recurrence of violence.

Another explanation for an abused partner’s reluctance to leave a relationship stems directly from learning theory. Psychologists have demonstrated behavioral paradigms of extinction -- that is, total cessation of a given behavior. It is known that where reinforcement (any introduction of positive stimuli or removal of noxious stimuli which results in maintaining or increasing a target behavior) is intermittent (as with the cycle of violence), extinction is most difficult to achieve.40,41 Taking the classic example of playing a slot machine in a casino (a behavior highly resistant to extinction), one can easily observe this behavioral phenomenon. One is not rewarded with a jackpot with every play of the "one-armed bandit." In fact, one never knows when they might "hit the jackpot;" reinforcement occurs intermittently. There is a seducing effect; one can easily be enticed into continuing to play for extended periods of time in hope that they will hit the jackpot this time—or the next. In the cycle of violence, positive reinforcement (i.e., "honeymoons") and negative reinforcement (i.e., the cessation of offending and violent behaviors) occur intermittently. Moreover, a woman may become acutely aware of what is often termed "the gambler’s dilemma"—she may have already "invested" an extraordinary amount of time, energy and emotion into this relationship. If she "walks away from the table" at such a point it is easy for her to feel that she has truly lost. Staying for "one more hand," however, may instill her with the hope (however desperate or unfounded) that she may yet "win big" and recoup all previous losses (i.e., "if I love him ‘well’ enough, he can change for the better").

The well established experimental paradigm of "learned helplessness" offers still another theory for why women may remain in abusive relationships. The theory contends that after one learns, via repeated exposures, that they are unable to control, alter, or escape an aversive stimulus or situation they will lose motivation and eventually give up trying to free themselves—often becoming depressed.41,42 As aforementioned, much evidence also suggests that a woman is at greatest risk at the point of leaving an abusive male.26 Pathological jealousy and a sense of ownership are common to the perpetrating male and can give rise to desperate and violent actions. A batterer’s threats may include threats of homicide, threatening to abduct the children, or even a threat of suicide. A woman may have also been systematically cut off from friends and family and have no viable support system intact. Years of financial subservitude and/or having no marketable skills may leave many women with few perceived alternatives. Indeed, under such circumstances, many women are trapped; they stay in such relationships, doing what most rational people would do, in order to survive.10

Primary Care Presentations

Patients often will not offer information regarding the abuses that they suffer.10,19 For many victims, there are accompanying feelings of shame and degradation as well as a belief that people will not understand or be able to help.43 Also, it is not at all uncommon for the abusing partner to accompany the victim to the medical setting—mandating the necessity for privacy in clinical interview.2,14 It is important to consider that a physician’s failure to diagnose abuse can have the effect of increasing a woman’s feelings of isolation and further discourage her efforts to dissolve the relationship.44

When the possibility of violence is not effectively screened by the primary care physician (or is denied by the victim, where it has actually occurred), the history of injury is likely to be puzzling and inconsistent in the face of actual physical findings.2,14 This incongruity between history of complaint and physical exam is a classic "red flag" signaling the likelihood of acute domestic violence.

For the non-acute patient who is an undiagnosed victim of domestic violence, however, several other diagnostic labels may begin to enter the physician’s differential. Unfortunately, "problem patient" often tops the list. Women who are victims of domestic violence often overutilize medical services, present with multiple vague somatic symptoms, and diffuse pain.19,33,45 They may vigorously seek medications, they often present with many signs/symptoms of depression and/or anxiety, and often they have past suicide attempts.19,33

Such symptomatology is not surprising if, indeed, the patient is an undiagnosed victim of chronic domestic violence. Womens’ experiences in such circumstances have been likened to being held hostage and, indeed, recently presented research suggests that psychological abuse may be more important in predicting symptoms of post traumatic stress disorder (PTSD) than actual physical violence.46 One additional irony, however, is that should an accurate psychiatric diagnosis be assigned and the condition treated, the abusive partner (and/or his legal representative) may later utilize this medical record information in his defense and/or in attempt to gain custody of children (i.e., "she’s crazy, its documented"). For this reason, states are increasingly enacting special laws to protect the confidentiality of communications made between battered women and their providers.19 It is imperative, though, that the primary care physician be sensitive to the potential deleterious effects of diagnostic labeling (e.g., somaticiser, drug seeker, chronic pain patient, depressive).

Assessment and Treatment in Primary Care

Location of Domestic Violence Injuries and Specific Types of Injury. Head, neck, and facial injuries are common consequences of domestic violence and have been found to differentiate between victims of domestic violence vs. those with injuries stemming from other circumstances.47 As might be expected, ocular and dental injuries are especially common.48-51 A recent study has additionally noted injuries to the thorax and abdomen52 and injuries suffered during pregnancy have been associated with increased risk for perinatal morbidity.53,54

Muelleman et al identified 12 specific injury types that (within the confines of their study) were observed more frequently in women victims of domestic violence.52 (See Table 1.) This list of injury types may serve as a useful guideline to prompt physicians toward further inquiry. These researchers caution, however, that observed low positive predictive values for these kinds of injuries support the use of universal screening measures.

Screening. Consistent with recommendations for universal screening of the female patient,12,29,52 several domestic violence screening aids have been introduced in research and practice. The SAFE questions, for example, have been found helpful in making a diagnosis of domestic violence among adult women.55 The "SAFE" acronym, not unlike the well known CAGE questions, serve as a mnemonic to encourage the physician to inquire into a patient’s stress/safety (S), whether she feels afraid/abused (A), whether she has or can access the support of friends/family (F), and the extent to which she has an emergency (E) plan in place. Although not yet empirically validated, the SAFE questions do have the advantages of simplicity of administration for the busy physician as well as empowerment of the patient/victim.44 Several empirically validated screeners (that compare favorably to much longer research instruments) exist, as well.38,43,56,57 (See Table 2.)

Assessment. A thorough assessment is essential to the diagnosis of domestic violence, as well as determining the severity of the abuse and the need for an immediate safety plan for the victim and, if applicable, her family members. Table 3 highlights the most salient features of the assessment process.

The need for privacy when examining and interviewing suspected victims of abuse is quite obvious. The victim will not, in all likelihood, admit to any abuse while the perpetrator is present, for fear of retribution. Similarly, she may not want to reveal such information in front of friends or other family members who may have accompanied her to the appointment. Therefore, speak with your patient in a private location, without other persons present—being careful to document both your own clinical questions as well as your patient’s answers.

In regard to physical examination, your patient may have injuries in less noticeable areas of her body (e.g., breasts, genital area, inner thighs), and she may be embarrassed/fearful about disrobing in front of the perpetrator or other accompanying persons (Note: if it is against the clinic/hospital policy to allow patients to be seen alone, seek to change this policy as an advocacy project—for the benefit of future victims of domestic violence who may be seen in the facility).

Once a private location has been secured for the examination/interview, charting the findings is the next critical step. Accurate, factual documentation is crucial. Be careful not to include personal opinion or conjecture, but do note any incongruity between presenting complaint and physical findings. Clinically, of course, it will be beneficial to note where current injuries are (as there may be several) and to monitor the healing process as well as any evidence of former injury. Such documentation can also serve as a powerful tool over time in demonstrating to the patient evidence of a pattern of violence that she may have been reluctant to acknowledge. The use of a body map and medical photography (a Polaroid camera will often suffice) can also offer compelling documentation in support of the medical record. In addition to clinical purposes, there are other important reasons to document findings. Legally, the findings may be needed if a woman seeks a restraining order, in a divorce, or for purposes of custody determination. Unfortunately, such documentation may also be needed for court testimony should your female patient commit suicide, fall victim to spousal homicide, or commit a spousal homicide.

Assessing Dangerousness

Suicide. While a comprehensive review of the literature on suicide is beyond the scope of this paper, the reality of suicide in the context of ongoing domestic violence must be underscored. Physicians may inadvertently overlook the fact that suicide can be perceived as a viable, even attractive, option to a victim of chronic partner abuse. Suicide attempt rates are three times higher for women than for men.58 Which women are more likely to be at increased risk for attempting suicide, however, remains a difficult determination. Even with the available demographics and correlates that the literature has produced (see Table 4),58 accurate prediction of a low frequency behavior on an individual case basis remains a daunting task. Fremouw et a, for example, caution that using aggregate measures (e.g., statistics) to predict individual behavior is fraught with dangers.59 Perhaps the most salient variables/markers to consider, however, are those associated with persons who actually complete suicides. It has been found, for example, that 57-86% of completers had previously received diagnoses of major depression and/or alcoholism.58 As an additional point of caution, though, it must be underscored that a provider’s perception of an acute event impacting the patient (e.g., one bad fight) may introduce an enormous potential for distraction and error in clinical decision making.58 A physician, with such a patient presentation, may fail to recognize a more enduring depressive illness, the severity/veracity of presenting symptoms, and/or the degree of suicide risk. Lastly, important buffers that may guard against suicide (and should be considered in therapeutic intervention) include a strong social support network, stable employment, religious involvement, as well as the absence of (or successful treatment of) depression and alcohol/substance abuse.59

Homicide. Homicide (spousal homicide in particular) is also a rare event and therefore most difficult to predict.1,26 Spousal homicides, for example, are responsible for only 8.8% of the homicides in the United States.19 As homicide, like suicide, is an event that results in mortality, it demands serious consideration on the part of physicians and other health care professionals. Table 5 presents a series of demographics and behavioral correlates that have been associated with severe domestic violence and/or domestic violence homicide.1,19,22,26

The average age of husbands who murder their wives is 41, and for wives who murder their husbands, 37.60 Though many studies have found a similar ratio between wife-to- husband assault and husband-to-wife assault, it is important to point out that womens’ violence is more often retaliatory and less often results in serious injury of the male partner.13 Thus, many more wife defendants (44%) than husband defendants (10%) report having been assaulted by their spouse (i.e., threatened with a weapon or being physically harmed) at or around the time that they have committed murder.60 Similarly, provocation is more often present in wife defendant cases, and wife defendants are less likely than husband defendants to be convicted - presumably for this very reason.60 In cases of combination murder-suicide, it is also known that the perpetrator is most commonly a husband who kills his wife and children before taking his own life, or a wife who kills her children before taking her own life.58 Thus, assessing suicidality/homicidality may directly impact the safety of involved children, as well.

In light of the above statistics, the primary care physician must determine what role they are to play toward preventing potential homicide? Campbell reports that one of the major ways to decrease spousal homicide is to identify and intervene with battered women at risk for homicide.26 Standardized screening instruments can be useful in this regard. For example, the Danger Assessment (DA) Instrument is a 16-item brief questionnaire (many of these items are reflected in Table 5) that can be used as a basis for discussion with battered women by health care professionals in primary care settings.26 For those physicians who may not be comfortable in assessing homicidality, however, a referral to a mental health professional may be more appropriate.

Treatment. Treatment is the next consideration. Some physicians may question the need for ongoing involvement with a victim of domestic violence beyond initial physical work-up. It is important to remember, however, that most individuals who have been traumatized are more likely to be seen in primary care or emergency medicine settings than in the mental health sector.61 Therefore, the physician may be the only source of information for a patient. One of the most important pieces of information that can be disseminated to a victim is that of the "Safety Plan" (see Figure 2 for a pictorial representation, which may be especially useful with victims who have reading difficulties). The "safety plan" communicates to the victim the need for preparation when and if she considers leaving the violent situation. It reminds your patient what information she will need to copy and amass if she has time to prepare for her departure. Be sure to remind patients, however, that their safety and that of their children supersedes the need for these items when imminent danger threatens. In other words, the point of crisis is not the time to consider gathering personal effects; law enforcement personnel should be called and a woman should seek safety (with her children immediately). In most situations, police will permit a woman to gather essential belongings or accompany her to the home at a later time in order to enable this.

Follow-up. Regular follow-up visits with these patients are of vital importance. The patient should feel that she has an open dialogue with her physician. Her feelings toward her abuser may vary from visit to visit, depending on the stage of the "cycle of violence" that she may be experiencing at the time of her visit. As such, her comfort level with discussing the topic of the abuse, the amount of information that she may be interested in receiving, or her desire to take action toward changing her situation, may also vary. Thus, follow-up visits take on an importance for reasons other than physical check-ups.

Referral. Once a safety plan is in place and the patient’s medical needs have been addressed, her need for additional supportive services should be explored. Do not simply shift responsibility for the patient’s care to the mental health system. The woman may already have heard from the abuser that she is "crazy", and a referral to a therapist may reinforce this belief. In addition, a visit to a physician’s office may be easier to explain to the abuser (and safer) than a visit to a mental health facility. In the event that your patient does wish to pursue psychotherapy and/or is open to the possibility of a coordinated referral, the physician may wish to look for in-house services first. Staff psychologists, social workers or other mental health clinicians may be available within the facility. It is important to determine in advance however, that such persons have experience in working with victims of domestic violence. Some providers of mental health and pastoral services unwittingly attempt to reunite victims with their perpetrators too early in the treatment process or make other uninformed clinical decisions that may put the victim at further risk of abuse. The local domestic violence shelter (see Identifying community resources, below) may also have names of therapists in the community who specialize in treating victims alone, batterers alone, or victims and batterers conjointly. Pro bono and/or low cost counseling and/or support groups for victims may be available, as well.

Continuity of care becomes important in the event that a woman chooses to accept a referral to a provider for ongoing counseling regarding domestic violence. It will most likely prove beneficial for you to maintain contact with the treating mental health provider (if the client is willing and has signed an appropriate release with you and the mental health provider). Such coordination of care will provide you with important feedback regarding the course of mental health treatment and will also allow the mental health provider to voice appropriate concerns and solicit your expertise (e.g., with somatic complaints and/or vegetative depressive signs/ symptoms). Moreover, in a crisis situation, an established relationship with the mental health provider can provide the physician with a valuable resource.

Identifying community resources. One positive sign of change witnessed through the 1980s and continuing on into the 1990s is the availability of social service organizations whose primary missions center upon providing advocacy and treatment for the victim of domestic violence. Locating these resources, however, can be time consuming if one does not know where or how to begin the search. Many communities publish a directory of local social service agencies—most United Way offices can assist you in obtaining a copy, if one is available. If such a directory does not exist in one’s practice area, the local telephone directory is the next best option. The white or yellow pages will list telephone numbers for domestic violence 24-hour hotlines and shelters (addresses of shelters will never be published, for obvious safety reasons). If there is not a listing under domestic violence, try spouse abuse or rape/domestic violence. There are also several national family violence hotlines (see Table 6) that can assist patients in identifying area resources. These national numbers may be especially helpful for practitioners who practice in multi-state locations who may be less acquainted with border state resources. It is, of course, helpful to identify one’s self as a physician when speaking to hotlines or shelters (particularly if a male provider). Abusive husbands and boyfriends often call such hotlines in an effort to locate missing wives or girlfriends. Batterers have also been known to be quite creative in their attempts to locate their significant others. A batterer may, for example, identify himself as the woman’s treating physician and say he is calling to check on her, or request information, or even say that he would like to stop by and see his "patient" (thus, requesting the address of the shelter). In response to such tactics, a shelter is very likely to seek some verification and may ask for a phone number to contact the caller directly. It is helpful to understand why such screening methods are used, and to avoid becoming offended if one does place a call to such a facility and receives a potentially less-than-warm reception. Remember, the domestic violence worker is acting as an advocate for victims just as the physician is.

Advocacy. The physician has an important role not only in intervention (as outlined above) but in prevention as well. First of all, every contact with a victim of domestic violence, whether professional or personal, affords the opportunity to be an advocate. Whether as empathic listener, provider of information, or catalyst for intervention, primary care physicians are positioned to empower and promote positive change.14 Secondly, in professional circumstances, caring for patients’ physical injuries and accurately documenting them (via body maps, photographs, statements from the victim, etc.) is good advocacy, along with safety assessments, resource/referral information and follow-up. Also, posters about domestic violence can be hung in examining rooms and restrooms and business card-sized (easily concealable) resource information can be made available. Lastly, make domestic violence an area of expertise, whether in professional practice or community service; become knowledgeable enough to act as a mentor to physicians (and other health professionals) in training, give public talks & provide community education.14,62 As mentioned previously, some women have never discussed this issue with anyone, and may become empowered to change their situation by something that is said at a lecture. If public speaking is not for you, consider donating time or money to your local domestic violence program.

Conclusions

Clearly, the importance of domestic violence as an issue in the primary care population has been established by many authors. This paper has outlined the historical significance, the scope of the problem, modifying variables, and the reasons that victims may stay in such a situation. The role of the physician, presentation of domestic violence in primary care, and issues surrounding assessment and treatment have also been addressed. A new pictorial representation of the "safety plan" has also been introduced, as well as a discussion about suicide and homicide among victims and perpetrators of domestic violence.

It is now incumbent upon primary care physicians in all practices, in all geographic regions of the country, to push their comfort level and ask the tough questions of their patients. For many, it will involve dealing with a topic that was never addressed in medical school curricula. The positive result, however, is that more patients will become better informed about domestic violence and hopefully, safer, due to the individual efforts of many.

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CME Questions

1. The number of women in the U. S. estimated to have been beaten by their partners each year is:

a. 2000 to 4000

b. 25,000 to 50,000

c. 250,000 to 500,000

d. 500,000 to 1 million

e. 2 million to 4 million

2. Marital status is a significant demographic marker of domestic violence. Which status type has research shown to be at greatest risk of partner abuse?

a. single/never married

b. cohabitating

c. married

d. separated

e. divorced

3. Which of the following is a true statement regarding alcohol abuse and domestic violence?

a. Alcohol abuse causes domestic violence.

b. Treating alcohol abuse will eliminate domestic violence.

c. Alcohol abuse is a significant risk factor associated with domestic violence.

d. Alcohol abuse is only associated with perpetrators of domestic violence.

e. Acute intoxication is a better predictor of domestic violence than is chronic alcohol abuse.

4. What is the classic "red flag" signalling the likelihood of acute domestic violence?

a. The patient has broken bones and/or a black eye.

b. There is a history of multiple ER visits.

c. There is incongruity between history of complaint and physical exam.

d. The patient denies that she has been physically abused.

e. The patient’s partner denies that the patient has been abused.

5. The most important consideration in making a referral to a mental health provider for ongoing treatment of domestic violence is:

a. The provider must be licensed.

b. The provider must be willing to utilize couple’s therapy.

c. The provider must utilize individual treatment for the victim.

d. The provider must be female.

e. The provider must have experience in working with victims of domestic violence.