Case 1: A 41-year-old woman with one child presented to a fertility unit with secondary unexplained infertility. After a course of follicle-stimulating hormone (FSH) cycles with intrauterine insemination, the woman and her husband underwent in vitro fertilization (IVF) and conceived twins on their second cycle. Shortly thereafter, the couple began fighting about finances. After an evening of drinking and smoking marijuana, the woman, feeling threatened, jumped off their deck and locked herself in another part of the house. Her husband knocked down the door and bludgeoned the woman to death—in front of their five-year-old son.
Case 2: A woman in her late 20s reported to the nurse in a fertility clinic that her husband was forcing her to undergo IVF treatments and that he was having sexual relations with her adult sister in their home. This was conveyed to the physician, who dismissed the nurse's report, stating that there was miscommunication because English was not the patient's first language; furthermore, the patient had not stated this information directly to the physician.
Case 3: A 42-year-old patient undergoing fertility treatment sought counseling after three failed IVF cycles. As the couple was beginning the adoption process, the woman confided that her husband was physically abusing her, but refused to allow the psychologist to share this information with the medical team or the adoption agency. The psychologist learned that there was no mandate for reporting domestic violence in that state, and since there was not yet a child in the house, there was no recourse to report the potential risk to a child under child abuse reporting guidelines.
Many of us practicing reproductive medicine don't consider ourselves to be in the “front line” of domestic violence. We are uncomfortable screening for it and don't know what to do should it confront us. And yet domestic violence is more prevalent and possibly more deadly than other medical conditions for which we test routinely.
According to David McCollum, MD, of the AMA Advisory Council on Violence and Abuse, “This is a health care problem as significant as cancer, diabetes, or heart disease when measured by the number of people affected or by the dollars spent. As such it demands the unwavering attention of the medical community and a financial commitment on the same order of magnitude as that given to other major chronic health issues” (1).
Each year, approximately 1.5 million women in the US are raped and/or physically assaulted by an intimate partner (2). More than a million women seek medical assistance for their injuries from domestic violence; more than from rape, auto accidents, and muggings combined. OB-GYNs, emergency room physicians, psychiatrists, and internists are most likely to be the medical personnel involved in caring for these women. It is estimated that 75% of women first identified in a medical setting as abused will be subjected to further physical violence (3).
What is domestic violence?
Domestic violence, also called intimate partner violence, spouse abuse, or battering, is a pattern of behaviors manifested primarily against women by an intimate partner or spouse, usually male. (In a small minority of circumstances, the male may be the victim; however, because most victims are female, this article will refer to the victim as “she.”) The behaviors include physical and sexual violence, emotional abuse and neglect, threats, and controlling behavior.
Abusers often blame the victim for the abuse, belittle her and accuse her of wrongdoing. They may place her in danger intentionally or limit her access to important social and physical resources. The abuser may control her employment, her spending, and her social contacts, further isolating her from sources of support and help.
Physical violence may include “simple” assault, attacks with weapons, restraints, leaving her in a dangerous place, or refusing to allow her treatment for medical needs. The most severe manifestation is murder. More than 1000 women are murdered by their partner or former partner each year. According to FBI reports, 30% of female homicides are committed by the intimate partner or former partner.
Fifty percent of men who abuse their female partner also abuse their children (4). Fear of further abuse toward children may keep a woman from seeking aid.
The abuser often begins by acting jealous and domineering. The first physical manifestations may occur when the abuser is intoxicated or under the influence of drugs. He is often very remorseful and solicitous afterward, but the usual pattern is for the abuse to escalate rather than diminish. The average battered woman is attacked three times each year.
Abuse cuts across all demographic and socioeconomic strata, although some women appear to be at higher risk. The woman's perception of the abuse, as well as her ability to remove herself from an abusive environment, may vary in different religious or social contexts. Socioeconomic status also affects the woman's presentation to the medical system, with higher-status women more likely to be seen in private settings; other women may be seen more frequently in clinics or hospital emergency rooms.
Many women are able to marshal their resources to leave abusive relationships but not all can do so, despite their determination. If the woman has limited financial resources and her partner monitors her behavior, her access to transportation, and her social contacts, it can be very difficult for her to seek help. Once she does reach out, there are other barriers. One study showed that the average woman who had entered a shelter had contacted five different sources of help before leaving her abusive partner.
Our social service system is often unable to provide women with the resources they need to leave an abusive environment. Victims are turned away daily from shelters because of lack of resources. One study estimated that there are three times as many animal shelters as battered women's shelters in the US!
To outside observers, the abused woman's mindset can be perplexing. Most women want the violence to stop but do not want to end the relationship. Major reasons women stay when they are able to leave include:
•The perception that the violence is her own fault;
•Shame and denial;
•Religious or cultural beliefs that such behavior must be endured to preserve the marriage or family.
The welfare of any children is paramount and women often lack the financial means to support their children alone, or fear reprisal if they leave their partner. In fact, women are at much greater risk of serious violence if they indicate to the abuser that they intend to leave, so such fears are warranted.
Role of the medical professional
Failure of medical and social service professionals to respond to violence may ultimately prove very serious or even fatal. It is important for caregivers to understand their crucial role in this epidemic.
There is little question that medical professionals feel undertrained and underequipped to handle domestic violence, although the level of awareness appears to be growing (5). Fear of alienating or offending the woman, or of escalating the harm, are common concerns. Lack of knowledge, resources, and time are other issues.
Several national medical organizations have made domestic violence a priority and have provided screening and management tools. Because of its prevalence and the difficulty identifying risk factors for domestic violence, the AMA has recommended routine screening of women in primary care, prenatal, emergency, surgical, pediatric and psychiatric settings (3). ACOG recommendations include screening at all of the following (4):
•Yearly visits
•Family planning visits
•Preconceptionally
•During each trimester of pregnancy and postpartum.
Because women may not recognize themselves as “abused,” a series of specific questions are most likely to identify those at risk. ACOG has developed three simple questions (see appendix).
It is imperative that the questions be asked when the woman is alone. Physicians or other health professionals may choose to make a simple statement such as, “Because abuse and violence are so common in women's lives and there is help available, I've begun to ask about it routinely.” Even if the woman chooses not to disclose her situation upon initial contact, knowing that the medical team is receptive may make future disclosure possible.
It is a good idea to have pamphlets in the office or clinic, such as those available from ACOG (“Domestic Violence” 1-800-762-2264 ext. 830, or online at www.sales.acog.com). This signals to the patient that the practice will be responsive to her needs. Often seen in public bathrooms on the back of the door stalls are emergency phone numbers for women's safe houses and hotlines. Placing these in the office bathrooms may provide a discreet way for a patient to protect herself in the future if necessary.
Medical professionals are often unsure of how to respond to violence or threats of violence. Ideally the phone numbers of local shelters would be readily available; if not, an easy number to remember is 800-799-SAFE (7233); 800-787-3224 (TDD). This is the national hotline providing information from trained counselors about shelters, advocacy, health resources, and counseling.
If a medical professional becomes aware of use of a deadly weapon, it is mandatory in most states to report this (6). Mandatory reporting of other injuries varies from state to state.
Domestic violence in the reproductive health setting
It appears that pregnancy may be a time of high risk for women, but it is not known how often fertility treatment leads to increased stress in the partnership, possibly resulting in conflict and violence. The Women's Council and the Mental Health Professionals Group of the ASRM have identified domestic violence screening and awareness in the fertility practice setting as a goal after being approached by the AMA to participate in a national task force. The last several annual national ASRM meetings have included luncheon round tables on this topic to help educate caregivers in this area.
It is our goal to increase awareness and break down barriers to proper screening and care of these women. Naturally, physicians and other medical professionals should take the lead in preventing the injury and death of their patients.
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