Health Care Practitioners Focus on Family Violence

No peace in the world without peace in the nations
No peace in the nations without peace in the town
No peace in the town without peace in the home
No peace in the home without peace in the heart
- Tao Te Ching

With more than 25,000 domestic violence incidents reported in Wisconsin each year it’s no surprise that efforts to minimize the health consequences have multiplied. From new general protocols to simple words of individual support, health care professionals are now putting a spotlight on a problem that not too long ago was often treated as a “family matter.”

Bruce Ambuel, PhD, Medical College of Wisconsin Associate Professor of Family and Community Medicine and Director of Behavioral Health at the Waukesha Family Practice Center, discussed some of the current approaches to domestic violence in a recent interview with HealthLink.

“It’s always helpful to start with ‘Domestic Violence 101’ as it is difficult for people to understand even with all the publicity,” Dr. Ambuel said. “The Centers for Disease Control and Prevention (CDC) defines violence as ‘the threatened or actual use of physical force or power against another person.’ When we’re talking about domestic violence, we’re talking about violence that occurs within an intimate partner relationship or occurs between two people that used to have an intimate partner relationship. It could be married partners, it could be ex-spouses following a divorce, it could be boyfriend and girlfriend or ex-boyfriend and ex-girlfriend.”

What Dr. Ambuel further described as “a pattern of coercive control and terror” manifests itself in incidents of physical violence with disturbing frequency. The CDC’s National Center for Injury Prevention and Control (NCIPC) reports that more than 1.5 million women nationwide are the victims of an intimate partner’s physical assault each year. NCIPC estimates that the yearly direct medical cost of caring for battered women is about $1.8 billion.

The most recent Domestic Abuse Incident Report from the Wisconsin Department of Justice showed 25,021 incidents in the year 2000. Milwaukee County alone was the location for 7,123 of those incidents. Because domestic violence is chronically under-reported to both law enforcement and health care providers, the number of incidents is probably significantly higher. Dr. Daniel J. DeBehnke, MD, Director of Clinical Services for the Medical College Department of Emergency Medicine, told HealthLink that “It’s probably safe to say that we see – in the Froedtert Hospital emergency room alone – at least two domestic violence victims a week, perhaps as many as 500 a year.”

Profound Impact on Women’s Health
The sheer number of individuals presenting and the advocacy of social service agencies including women’s groups and shelters have inspired a far more proactive systematic approach to the treatment of victims of domestic violence. In Milwaukee County an estimated 85% of these victims are women, according to the state incident report.

“Typically, when we think about partner violence we think about physical assaults,” Dr. Ambuel said. “But physical violence is just one aspect. It can also involve forced or unwanted sexual contact, controlling someone’s activities, controlling who their friends are and where they go. It can involve controlling money and it can involve forced use of drugs or alcohol. So there are many manifestations. In an abusive relationship the physical violence may be very intermittent, but the psychological abuse and control is a daily event.”

“Looking at physical health care in particular, Dr. Ambuel said, “surveys that have been done in family doctors’ offices, internal medicine offices and other primary care settings show that about one in four women will say that they have been pushed, shoved, hit, kicked or more severely assaulted by an intimate partner within the past year.

“Living with the reality of domestic violence has a profound impact on women’s health. First of all there’s the risk of injury and death, which is a real and significant risk. And if you look at long-term use of the health care system, women who are victims of domestic violence receive more surgeries and hospitalizations for every kind of condition, not just for injuries that they might sustain. They see the doctor more often. They actually see the doctor less for preventive care but more for acute problems like chronic headaches, gastrointestinal problems, aches and pains, and stress-related conditions. They also experience more psychiatric and psychological problems. They experience more depression, more psychiatric hospitalizations, more suicide attempts.“

Intervention: Asking the Right Questions in the Right Way
Many of the newer techniques used by health care providers to address domestic violence involve a process of discovery using “universal screening” in a proactive way. Among the fairly recent developments:

• Extensive training that introduces professionals to the concept and dynamics of domestic violence, with a focus on asking victims the right questions in the right way. One such training program developed with the help of Medical College of Wisconsin staff included more than 800 health care providers in Racine and is a good overall example of how and why the universal screening approach has become preferred practice.
• New Joint Commission on Hospital Accreditation standards that have added criteria for protocols governing the identification of and intervention with domestic violence victims. The new standards have had “a really positive effect nationwide on the health system response to domestic violence,” Dr. Ambuel said.
• Better information about the problem and about community resources in the hands of front line health care workers, resulting in more immediate referrals to women’s shelters, other social service agencies, and/or other health care providers to get family violence victims the support they need once they are identified.

“Many hospitals, in their emergency departments and for their inpatient care, now have started to routinely ask women whether or not they are victims of domestic violence and then offer resources for those women who are identified,” Dr. Ambuel said. He added that training in domestic violence screening is necessary so that required questions are asked in a way that is sensitive and helpful.

“In the last ten years there has been a tremendous increase in awareness among physicians and nurses and in the health care system. Around 1990 a concerted effort began among advocates and a variety of professional associations including the American Medical Association began to take an interest in the issue of domestic violence. Research came out about how common domestic violence really is among patients in health care settings that has been persuasive in encouraging people to ask about it.”

Steps You Can Take
Dr. Ambuel suggested some steps that friends and family members can take to assist domestic violence victims. “It can be very distressing if you have a brother or a sister or a close friend who you know is in an abusive relationship. What you can do is offer the person support. Let them know that you don’t judge them and that you care about them. Tell them that it’s not their fault, and that they have a right to be respected. And then, encourage them to contact some resources in the community.

“I’d say that the best first (non-emergency) resource contact for women should be with a women’s shelter or domestic violence program in their area,” Dr. Ambuel said. If a local listing is unavailable, victims, potential victims, and others can find service providers near them by contacting the National Domestic Violence Hotline online or at 1-800-799-SAFE (7233); TDD 1-800-787-3224; website www.ndvh.org.

“Doctors and nurses can help,” Dr. Ambuel said. “Every day, they care for victims. They can make a profound difference by saying ‘I am sorry this happened. It’s not your fault. You have a right to respect. Here’s a number you can call.’ Parents can help by talking to teens about their relationships at home and about how they resolve disputes. And the general public can advocate by continuing to encourage doctors to ask about domestic violence and thanking them when they do.”

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.