Domestic Violence and Primary Care

Katherine Mathews, M.D.
Departments of Pediatrics and Neurology, University of Iowa Hospitals and Clinics

First Published: 2000
Last Revised: January 2003
Peer Review Status: Internally Peer Reviewed

I recently had the opportunity to listen to the tape of a 911 dispatcher talking to a young girl calling for help because her father was beating her mother. The terror and pain in her voice left no question in my mind that violence in the home is an issue of vital importance to anyone who is concerned about the physical and psychological welfare of children.

The term "domestic violence" is used here to mean violent or threatening behavior between intimate adults. It can include physical, emotional, or sexual assault. Ninety-five percent of victims of domestic violence are women. Such violence is common. Surveys in a variety of settings show that acute or recent domestic violence affects from a tenth to a third of all American households. These numbers are at least doubled if one examines an American woman’s lifetime risk of being the victim of domestic violence. Every year about 2 million women in this country are assaulted and seriously hurt by their domestic partner.

Domestic violence crosses socioeconomic lines. A pilot study of domestic violence screening in a community pediatric setting found no significant differences in incidence between women with private insurance and women with families using Medicaid. High socioeconomic status does not protect against violent behavior in the home. Similarly, studies done in Iowa as well as in other areas of the country show that domestic violence affects families in both urban and rural areas. Research also shows that neither an abused nor an abusive adult can be identified by appearance, or by how they interact socially outside the home.

Impact of domestic violence on children

The millions of children growing up in households affected by domestic violence are at risk for both physical and psychological injury. A growing body of evidence demonstrates that the damage to the wellbeing of these children may begin in childhood, but it persists throughout their lives.

• A high correlation exists between domestic violence and violence directed toward the children. About 30-60% of the families that experience domestic violence will also experience child abuse. Screening for domestic violence often uncovers previously unreported child abuse. Screening mothers of abused children reveals a high rate of domestic violence.
• Domestic violence can also affect the unborn fetus; pregnancy is a high-risk time for women whose partners are abusive.
• Children who witness domestic violence learn to respond to conflict with violent behavior. Children growing up in abusive homes are more likely than peers to be abusive and violent themselves.
• Domestic violence is kept secret. Most children have no one to talk to about the problem. Domestic violence may interfere with a child’s ability to form close relationships with others. It is isolating.
• An abused adult may feel trapped and impotent. Often, abused adults lack the emotional resources or social supports necessary to provide the parenting their children need. If they use drugs or alcohol, or have other maladaptive behaviors, this can further erode their ability to give support and guidance to children in the home.

Role of the health care provider

Physicians in a wide range of specialties are recognizing that domestic violence is a serious public health problem. Many professional medical organizations, including the AAP, AAFP, and the AMA, have developed policy statements that deal with the medical identification of and response to domestic violence. Domestic violence is recognized as an issue with significant medical consequences, including death.

As a health care provider, you can take several steps to address the problem of domestic violence in your own practice.

1. Examine your own biases and beliefs:

• Do you believe that people who are abused by their partners probably deserve it?
• Do you believe that people who are abused "drive their partners to it" or in some way provoke assault?
• Do you feel that physical or psychological violence is appropriate in any other setting in our society?
• Do you know anyone who has been the victim of domestic violence? What was your response?

2. Learn how to talk with families about violence in the home. Talk with patients in a private setting. Introduce the topic by noting that violence is recognized as a risk factor for a variety of health problems. Screening questions may include the following:

• Do you feel safe in your home?
• Does your partner ever hurt you or threaten to hurt you?
• Are you afraid of your partner?

Remember that the medical record is a relatively public document, and that both parents have the legal right to read their child’s chart. Because of the risk to the victim who reports violence in the home, charting should be done cautiously. In some settings a separate screening form may be developed that does not need to be released with the rest of the record.

3. Integrate assessment for domestic violence into routine history taking and into health maintenance for children. The AAP Task Force on Violence recommends routinely assessing for domestic violence, from infancy through late adolescence. This indicates to the patient that you recognize domestic violence as a health care concern, and that you are willing to talk about it.

In addition, situations that should prompt specific questions about domestic violence in the home include:

• Suspected or confirmed child abuse.
• A child who is visiting your office too often as the result of minor medical concerns or stress-related illnesses, such as chronic headaches or stomachaches.
• Frequent visits to the emergency room, particularly at night or during hours that both parents are home. The ER may provide a safe setting where an abused parent can escape a dangerous situation. It may also be viewed as a relatively anonymous way for a family to get medical care when they are struggling with the stress and stigma of domestic violence.

4. If you suspect or know that domestic violence is occurring, schedule follow-up care. Your office may be one of the few safe places for an adult who is being abused. Your nonjudgmental concern may provide the support needed for intervention to begin.

5. Know the resources in your county or community. One reason physicians don’t ask about domestic violence is their lack of knowledge about how to respond if abuse is revealed. Learn about the resources in your community:

• Assistance for the victim, such as local phone numbers for battered women’s shelters
• Restraint and education of the abusive partner
• Counseling for family members, including children

In Iowa, you can call the statewide hotline for victims of domestic violence at 1-800-942-0333. This hotline is answered 24 hours a day, 7 days a week by trained staff with expertise in domestic violence. They offer phone counseling and referral to domestic violence services around the state.

6. If resources in your community are inadequate, advocate for change.

7. Encourage and support the education of other health care providers in your community. The entire health care community needs to be sensitive to the issue of domestic violence and its effect on children in the home. The health care community needs to encourage training for providers in screening, assessment, and intervention related to domestic abuse.

Domestic violence has a physical and psychological impact on all members of a family. Children in homes where domestic violence occurs are at risk for injury. They may experience psychological problems, and may display violent behavior themselves. Health care providers who are committed to preventive health care are in a unique position to help break the cycle of violence. Asking questions, being supportive, acknowledging that domestic violence is a common problem, and referring the victim to help can significantly affect outcomes.

See related Provider Textbooks about Family Medicine or Pediatrics.

See related Provider Topics Child Abuse, Child and Teen Health, Domestic Violence, Family Medicine, Food, Nutrition and Metabolism, Injuries and Wounds, Pediatrics, Social/Family Issues or Women's Health.

See related Patient Textbooks about Family Medicine or Pediatrics.

See related Patient Topics Child Abuse, Child and Teen Health, Family Medicine, Food, Nutrition and Metabolism, Injuries and Wounds, Pediatrics, Social/Family Issues or Women's Health.

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