More than meets the eye: recognizing and responding to spousal abuse
Fern Martin, Catherine Younger-Lewis, MD
CMAJ 1997;157:1555-8
[ en bref ]
Fern Martin is a counsellor and public educator at Ontario's Lanark County Interval House and a member of the Lanark County Coalition Against Family Violence. Family physician Catherine Younger-Lewis is book review editor at CMAJ.
© Canadian Medical Association (text and abstract/résumé)
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In brief
Physicians can play key roles in uncovering domestic abuse but they must be proactive because women are often loathe to raise the subject. One tool they can use is a detailed list of different types of abuse, which is published with this article. The authors stress that abuse can take many forms and may not involve physical violence.
En bref
Les médecins peuvent jouer des rôles clés dans la découverte de cas d'abus conjugaux, mais ils doivent se montrer proactifs parce que les femmes hésitent souvent à soulever la question. Ils peuvent utiliser notamment une liste détaillée de types différents d'abus que nous publions avec cet article. Les auteurs soulignent que les abus peuvent se présenter sous de nombreuses formes et ne pas comporter de violence physique.
Any physician who sees female patients may have occasion to help women who are in abusive relationships. If a woman has come to know and trust medical professionals she may confide to them that she is in difficulty, regardless of their specialty. Spousal abuse does not necessarily involve physical violence. Women who are mistreated in less obvious ways may need support in recognizing that their partners' behaviour is unacceptably controlling and constitutes abuse.
The list that accompanies this article (page 1557-8) was first compiled by an Ottawa men's group, New Directions. Many of its members had been convicted of assaulting their partners and were asked to list behaviours they had used to control or harm their wives or girlfriends. With further input from victims of abuse, women's-shelter workers and members of the Lanark County Coalition Against Family Violence, the list doubled in length. Many of the actions listed may be considered innocent when weighed in isolation. In combination and over a period of time, however, they may constitute a pattern of behaviour designed to break another person's spirit.
Presented at this year's annual meeting of the Federation of Medical Women of Canada, the list was received with enthusiasm and emotion. This response signalled to us that it could be a valuable tool for physicians in identifying domestic abuse. Workers at the Lanark County Interval House, a shelter for abused women and their children, consider the list their most effective tool. Women who come to the shelter often worry that the abuse they have experienced isn't serious enough to warrant a plea for help. Shelter workers give them the list and a highlighter, and ask them to identify incidents they have experienced. Many women are surprised by the number of abusive actions they have experienced and come to realize that physical assault is only one aspect of abuse.
The list categorizes abusive behaviours under 8 headings. Each type of abuse involves an imbalance of power in the relationship, whereby the abuser attempts to degrade, intimidate and thereby exert control over his partner.
Emotional abuse
Many women say that they would rather be hit than endure emotional abuse: when they are assaulted physically they know they are being abused. Emotional abuse is more subtle. It often begins or accelerates during pregnancy, when the man sees the fetus as a threat to what he perceives as his central position in the home.
Environmental abuse
In this type of abuse the woman is made to feel afraid in her home or environment. The abuser may attempt to intimidate her by punching walls, throwing objects or damaging items that are important to her: it is usually only the woman's possessions that are broken.
Social abuse
A key component of social abuse is the isolation of the woman from family and friends; the abuser's goal is to prevent her from having a social life that is not centred on him. The abuser may repeatedly cause scenes in public, such that the woman is too embarrassed to be seen with him outside the home and isolates herself.
Financial abuse
Money can be used to exert power. The abuser may attempt to control his partner by ensuring that she has no financial independence or by exploiting her earning ability. He may spend money without her agreement or refuse to spend money on special occasions or on things that are necessary for the family.
Religious abuse
This form of abuse can be particularly effective if the woman's religion or spirituality is important to her. The abuser may ridicule his partner's beliefs, or use religious precepts to justify abusive actions.
Physical abuse
Many women think they have to be hit with a closed fist to experience physical abuse. Any unwanted physical contact may constitute abuse; the contact is often repeated and follows a particular pattern. Physical neglect, such as responding inappropriately to illness or injury, is also abusive.
Sexual abuse
Women in abusive relationships sometime find themselves participating in sexual activities that they find abhorrent in order to pacify their partners. Abusive men may force their partners to have intercourse when they are ill or recovering from childbirth. Talking about sexual abuse is difficult for most women; many choose to call a crisis line anonymously to seek advice.
Ritual abuse
This type of abuse needs careful exploration. Physicians should be aware that it occurs, and that children and women are the usual targets.
What can physicians do?
Again and again, women have told workers at the Lanark County Interval House that going through this list of abusive behaviours was the catalyst that made them decide to leave an abusive partner. Several women who returned to a relationship to give their partner "another chance" said that the list helped them to recognize when abusive behaviours were starting to reappear. They were able to be more objective about what was happening to them and this made it easier to decide to leave again.
Physicians with a patient who suggests that she is in an abusive relationship can consider taking the following steps.
- Quickly schedule an appointment in which you can set aside the extra time that will be needed.
- Give the woman the list of abusive behaviours and ask her to highlight any that apply to her. Keep the list in her chart.
- Go over the list. Ask the woman to explain some of the items. For example, "Deliberately leaves a mess for her to clean up" may mean that her partner uncaringly and purposely walks through the house with mud on his boots, or that he deliberately sweeps food off the table onto the floor.
- Listen nonjudgementally.
- Ask the woman what she does to cope.
- If the woman wishes, set up a series of appointments so you can work together until she feels comfortable enough to reach out for other resources. Work out an explanation that she can safely present to her partner -- perhaps that a series of tests is required.
- Help the woman to assemble the resources she will need. These can range from accommodation at a women's shelter to assistance from the police or a lawyer.
- Never take control or make decisions for the woman,
and never arrange a meeting for her unless she first agrees.
- Document, document, document.
- Be clear about your limitations: there is only so much you can do.
- Be aware that the woman may be in a far more dangerous situation than she has stated. Most women minimize the violence they live with.
Physicians who give support to abused women sometimes feel frustrated when their patients are reluctant to do anything to change their situation. When this happens, it may help if the physician calls the local woman's shelter and "unloads." There may be compelling reasons why a woman chooses to stay in an abusive relationship. It is also important to remember that the danger a woman faces in her home may follow her if she flees; indeed, it may get worse. For many, confiding in a physician is a difficult first step and it may take time to build the courage and confidence to go one step further.
This list is based on one made by men who were describing how they controlled or harmed their wives or girlfriends. It has been expanded by the Lanark County, Ont., Coalition Against Family Violence, on the basis of input from women in abusive relationships. A single act may not constitute abuse, but if someone is doing something to harm or control you then you are being abused. You have the right to be treated with respect and to feel safe in your home. A bullet (*) indicates actions that are clearly criminal acts, or may be criminal acts depending upon the circumstances.
Emotional/psychological/verbal abuse
* making her do illegal things
false accusations
name calling, finding fault
verbal threats
yelling
intimidation
making her think she's crazy or stupid
overpowering her emotions
disbelieving her
bringing up old issues
inappropriate expression of jealousy
degrading her
turning a situation against her
brainwashing her
laughing in her face
silence
refusing to do things with or for her
insisting on always getting his own way
pressuring her
neglecting her
expecting her to conform to a role
real or suggested involvement with other women
making her feel guilty
certain mannerisms, such as snapping fingers at her
threatening to get drunk or stoned unless. . . .
manipulating her
starting arguments
withholding affection
punishing her by not sharing in household chores
never really forgiving, holding grudges
lying
treating her as a child
having a double standard for her
saying one thing, meaning another
denying or taking away her responsibilities
failing to keep commitments
threatening her with the loss of immigration status
deliberately creating a mess for her to clean up
threatening to report her to the authorities
making her drop charges
telling jokes that belittle or indicate hatred toward women
refusing to deal with issues
minimizing her work or contribution
pressuring her to stay while drugs or alcohol are being abused
not coming home
coming home drunk or stoned
having pictures that indicate hate or violence against women
egging her on, challenging her to engage in physical violence
friendship or support of men who are abusive
demanding an accounting of her time and routine
taking advantage of her fear of something
putting her on a pedestal
ridiculing her food preferences
threatening suicide unless . . .
Emotional abuse surrounding reproduction, pregnancy and childbirth
refusing to allow or forcing her to use contraception
forcing her to have an abortion
refusing sex on the grounds that her pregnant body is ugly
denial that the child is his
refusing to support her during the pregnancy
refusing to support her during the birth
denying her access to her newborn child
not supporting her or helping out after she comes home with the baby
demanding sex soon after childbirth
blaming her because the infant is the "wrong" sex
refusing to allow her to breast-feed
sulking or making her feel bad for time spent with the baby
Environmental abuse in home or vehicle
Abuse in the home
* harming pets
* ripping clothing
* locking her in or out
* throwing or destroying her possessions
slamming doors
throwing objects or food
denying her use of the phone
punching walls
mowing over her garden
Abuse in the vehicle
* driving too fast
* driving recklessly, pounding the steering wheel
* driving while intoxicated
* forcing her into a vehicle
* pushing her out of a vehicle when it's in motion
* threatening to kill her by driving into an oncoming car, etc.
* chasing or hitting her with a vehicle
* killing or injuring her in a deliberate accident
* hitting her while she's driving
prohibiting her from using a vehicle by tampering with the engine, taking the keys, etc.
putting his foot over hers on the gas pedal
grabbing the steering wheel while she's driving
Social abuse
controlling what she does, whom she sees and talks to, what she reads and where she goes
failing to pass on messages
putting down or ignoring her in public
not allowing her access to family or friends
interfering with her family or friends
change of personality with others
being rude to her friends or relatives
dictating her mode of dress
dictating her behaviour
habitually choosing friends, activities or work rather than being with her
making a "scene" in public
making her account for herself
censoring her mail
treating her like a servant
not giving her space or privacy
insisting on accompanying her into the doctor's office
Social abuse involving children
* assaulting her in front of the children
initiating false child-abuse charges against her
making her stay at home with the children
teaching children to abuse their mother through name calling, hitting, etc.
embarrassing her in front of the children
not sharing responsibility for the children
threatening to abduct the children or telling her she'll never get custody
putting down her parenting ability
Social abuse during separation or divorce
buying the children's affection with expensive gifts
not showing up on time to pick up children or not having them back on time
pumping children for information about their mother's boyfriends, etc.
telling children their mother is responsible for breaking up the family
using children to transport messages
denying her access to the children
failing to supply a valid phone number
Financial abuse
* taking her money
* forging her name
giving her false receipts
cancelling her insurance
sabotaging her efforts to attain economic freedom
withholding money
spending money foolishly or beyond means
pressuring her to take full responsibility for finances
not paying fair share of bills
not spending money on special occasions
spending on addictions, gambling, sexual services
pressuring or controlling her working conditions
keeping family finances a secret
preventing her from taking a job
Ritual abuse
* mutilation
* animal mutilation
* forced cannibalism
* human sacrifices
suggesting or promoting suicide
forcing her to participate in rituals
forcing her to witness rituals
Physical abuse
* any unwanted physical contact
* kicking, punching or pinching her
* pulling or pushing her
* slapping, hitting or shaking her
* cutting or burning her
* pulling her hair
* head butting
* squeezing her hand or twisting her arm
* choking or smothering her
* force-feeding her
* spitting on her
* throwing her or throwing things at her
* hitting her with objects or whipping her
* restraining her in any way
* urinating on her
* breaking her bones
* knifing or shooting her
* threatening to kill or injure her
ignoring her illness or injury
denying or restricting her food or drink
pressuring or tricking her into alcohol or drug use
standing too close/intimidating her
hiding or withholding necessary medication
Sexual abuse
* any unwanted sexual contact
* forcing her to have sex; hounding her to have sex
* forcing her to have sex with others
* forcing her to have sex with animals
* uttering threats to obtain sex
* pinching, slapping, grabbing or poking her breasts or genitals
* forcing sex when she's sick or after childbirth or surgery
sleeping around
knowingly transmitting sexual diseases
treating her as a sex object
being rough
pressuring her to pose for pornographic photos
displaying pornography that makes her feel uncomfortable
using sex as the basis or solution for an argument
criticizing her sexual ability
unwanted fondling in public
purposely not washing and expecting sex
name calling (whore, slut, frigid, bitch)
accusations of affairs
degrading her body parts
telling sexual jokes or making sexual comments in public
demanding sex for drugs or alcohol
demanding sex as payment or trade
administering drugs or alcohol for sexual advantage
insisting on checking her body for sexual contact
Religious abuse
using religion to justify abuse or dominance
using church position to pressure for sex or favours
using her, then demanding forgiveness
excessive spending for religion
interpreting religion your way
preventing her from attending church
requiring sex acts or drug use as religious acts
mocking her beliefs
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| CMAJ December 1, 1997 (vol 157, no 11)
/ JAMC le 1er décembre 1997 (vol 157, no 11) |
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