MDs have key role in bringing ugly secret of wife abuse out of closet
Nicole Baer
CMAJ 1997;157:1579-81
[ en bref ]
Nicole Baer is a freelance writer in Nepean, Ont.
© Nicole Baer
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In brief
Domestic abuse is widespread and severely underreported in Canada, but experts hope that physicians, by taking advantage of the physicianpatient relationship, can help move the problem into the open.
En bref
La violence conjugale est très répandue au Canada et elle est gravement sous-déclarée, mais les experts ont bon espoir que les médecins sauront mettre à profit la relation patientmédecin pour contribuer à faire éclater ce problème au grand jour.
Fern Martin recalls vividly how a battered woman denied that she was abused because all her husband did was push her around. "He pushed her through walls," says Martin, who works in a women's shelter in Lanark County, west of Ottawa. "He pushed her with such force that her head and body broke the plaster. But she thought that because she wasn't being punched, and she didn't have black eyes, that she wasn't being abused."
In fact, recognizing the nature, prevalence and severity of family violence is a problem not just for victims but also for professionals like doctors. Indeed, society as a whole is only beginning to come to grips with a health and social problem of staggering magnitude.
The grisly fact is that federal data show 29% of women who have ever been married or in common-law relationships have been victims of physical or sexual violence by partners. The violence, which often begins or gets worse during pregnancy, is typically repetitive and escalates over time. In almost half of all cases, it results in physical injury. And more than 1 in 3 married women has suffered emotional pain and degradation at the hands of extremely possessive, self-centred and controlling spouses.
The violence that is acted out behind Canada's closed doors is so severe that one-third of women assaulted by their spouses feared for their lives at some point in the abusive relationship. An average of 78 Canadian women are killed every year by the men who profess to love them.
For the longest time, wife assault was an ugly secret best ignored or denied. The expression "rule of thumb" comes from an 1824 American law that permitted a husband to "chastise his wife with a whip or rattan no wider than his thumb." The courts further ruled in 1874 that "if no permanent injury has been inflicted, no malice, cruelty, nor dangerous violence, it is better to draw the curtain, shut out the public gaze, and leave the partners to forgive and forget."
In Canada, physical and mental cruelty have been grounds for divorce for less than 30 years. Moreover, systematic efforts to identify, classify and address family violence have only been undertaken in the past 10 years; the federal government's Violence Against Women Survey turned in some of the most ground-breaking research on the subject in 1993.
Plainly, though, the problem is real. In 1970, hardly any shelters for battered women existed in Canada; today, there are about 400 of them. Although Statistics Canada measured an 18% drop in the number of domestic assaults reported to a sample of 61 police forces between 1993 and 1996, people on the front lines of domestic abuse see more and more women emerging with stories of abuse every year.
Within that context, experts agree that doctors -- in particular family physicians and gynecologists -- ought to be adopting several key roles. They should, for instance, be helping women recognize and deal with abusive relationships, and helping society understand that wife battering is a serious health issue affecting many of their patients.
"Our approach is to get physicians to talk about it because they haven't been talking about it," says Dr. André Lalonde, executive director of the Society of Obstetricians and Gynaecologists of Canada (SOGC). "Women are more likely to raise the issue with an 'askable' doctor. By that I mean that they should be able to come to me and think, 'Hey, I'm not just a uterus and a breast. This doctor actually wants to know how I am dealing with life and how I am dealing with relationships.' "
Lalonde says the physical and emotional toll of battering makes physician involvement crucial. Besides broken bones, bruises, burns and lacerations, many abused women present with chronic pain, headaches, unexplained aches, fatigue, depression and anxiety.
Although opinions vary on the best way for doctors to approach the issue, there is consensus that primary care physicians need to demonstrate that they are receptive to discussing violence and are familiar with community-support systems.
Toward that end, several new tools are being developed. The SOGC, for example, has spearheaded the production of a detailed educational package for medical students and clinicians, which includes material that can be left in waiting rooms.
Known as the Violence Against Women Empower Education Program, it is accredited by the Royal College, College of Family Physicians of Canada and La Fédération des médecins omnipraticiens du Québec. The Ontario Medical Association and Canadian Association of Social Workers have also issued documents that provide solid information and practical guidance.
Unfortunately, change has been slow to come. Many doctors feel too pressed for time to delve into a complex and emotional quagmire during a routine checkup. Others aren't aware of the severity of the problem -- one study found physicians estimated the incidence of wife abuse in their practices at less than 2%.
Many doctors, moreover, are simply uncomfortable with the subject. For one thing, revelations of extreme cruelty can be hard on doctors personally. Dr. Nellie Radomsky, a family physician in Red Deer, Alta., says doctors are trained to take charge and fix problems, but dealing with abused women demands a new set of skills. "We're not trained to empower people," says Radomsky, author of Lost Voices, a book on spousal abuse. "We're trained to fix. But when it comes to abuse, there is no quick fix."
Getting women to open up about domestic violence is indeed difficult. Many have spent years minimizing the extent of their suffering or rationalizing it away as a form of self-defence. The Violence Against Women Survey found that 22% of those who experienced wife assault had never told anyone else before disclosing it to the anonymous interviewer.
In response, the Lanark County Coalition Against Family Violence has developed a screening tool, The Eight Types of Abuse (see pages 1557-8), to enable abused women to recognize abusive situations. Women who arrive at the local shelter are given a highly detailed listing of harmful, controlling, intimidating and humiliating tactics employed by abusers, and told to mark off all that apply. If many are highlighted, a pattern of cruelty and denigration emerges.
"Over and over," says Fern Martin, "we have seen a transformation in the women in the shelter because they weren't sure that they qualified for our services. And for them to see that there's more to abuse than physical abuse and more to physical abuse than being punched -- it's as if a light bulb has come on."
The Lanark County list has been well received by some physicians, who are using it to promote dialogue. Cathy Younger-Lewis, an Ottawa family physician and CMAJ editor, heard Martin speak about the list during the annual meeting of the Federation of Medical Women of Canada last August. She said it has changed the way she practises.
"I have been in practice 20 years and this is the first time I ever really understood violence and what I should be doing about it," she says. "I wasn't asking the right questions. I was looking for black eyes."
But how best to phrase those questions? The SOGC's Lalonde, who practises part time, prefers an oblique start to the conversation because many women are too emotionally vulnerable for direct questioning.
The society's education program suggests a circuitous approach. "In general, how would you describe your relationship? How do you and your partner work out arguments? Do arguments ever result in you feeling down or bad about yourself?" The doctor would then follow up with inquiries about the woman's fear of her partner and whether there has been physical or emotional abuse.
However, Dr. John Lamont, a Hamilton, Ont., sexual therapist and professor emeritus of obstetrics and gynecology at McMaster University, says doctors must be blunt. "To identify problems, you have to ask very specific questions. You can't say, 'How are things at home?' and expect them to start talking about abuse. You have to say, 'Have you ever been hit or hurt by someone close to you? Have you been forced to have sex against your will?' "
Lamont thinks it is important for physicians to screen patients routinely. Radomsky agrees -- she's been doing it for several years. Because all patients know that everyone will be asked the same point-blank questions, they don't feel singled out. Whether they open up or not, says Radomsky, the very fact of routine questioning lets all victims know that their doctor is willing to discuss the subject.
Once patients are ready to talk, they may also be ready to seek help. For some, counselling will be beneficial. Others may turn to family and social supports. About one in four will turn to police and the judicial system.
However, the startling and frustrating discovery for many people untutored in victim psychology is that so many women stay with abusive partners, even when the violence is severe and getting worse. Indeed, approximately 40% of women injured in a spousal assault or threatened with a gun or knife by a partner had never left home.
Experts agree that women stay in or return to abusive situations because of economic dependency, low self-esteem, a paralysing helplessness or a desire to hold the family together. Many women also fear being hunted down by an enraged partner. The fear is well founded: a battered woman who has left her husband is 6 times more likely to be murdered by him than if the pair still lived together.
Dr. Mary Donlevy of Vancouver says the Lanark County list and the surrounding discussion opened her eyes to this difficult reality. It has also caused her to modulate her assumptions about the degree of autonomy battered women actually have. "I think now I wouldn't be quite so adamant or strident in my position," she admits. Instead of urging women to walk away, Donlevy plans to help them assess the level of risk in their relationships, discuss their strategies for keeping themselves and their children safe, and offer advice appropriate to their situations. "I'll just suggest to them what the alternatives are, but recognize at the same time that they are probably developing coping mechanisms better than we tend to acknowledge."
Donlevy also underlines the importance of noting all signs of physical and emotional abuse on charts. Several years ago, her records were used to stay manslaughter charges against a patient who had killed her husband following years of unbearable violence.
Fern Martin admits the shocking misery she has learned about has caused her to burn out twice since she founded the Lanark County shelter in 1979. "I think I've come to realize that not every woman is going to make it and that we're not going to solve this problem in 10 years as I thought we would when we initially opened," she admits. "It's going to take generations."
Still, she does not despair. There are positive changes, principally in education. Elementary and high schools across Canada have developed curricula that touch on family violence. As well, medical schools are teaching students to be sensitive to the possibilities and consequences of domestic abuse.
However, Joan Gullen, a family counsellor who has delivered such seminars to second-year medical students at the University of Ottawa for 5 years, recently a rough reception by a handful of highly critical students.
"It was like they didn't want to let the issue touch them," recalls Gullen, head of an Ottawa-area group that fights violence against women. "They're entitled to their opinions, but it was not an honest exchange of ideas. It was quite alarming."
Although the students were by no means representative of the class, Gullen feels there is generally a backlash in society that is once again threatening to shove spousal abuse back into the closet.
Dr. Paula Stewart, an associate professor of epidemiology and community medicine at the U of O, feels young doctors can learn to spot family violence in their own practices and deal with the attendant issues effectively and compassionately. At the same time, she says, they can and must prepare to play a more prominent role as advocates for women's health and safety. "It's important, as recognized professionals with power and authority in society, that they use the weight of the 'doctor' title to influence people around them."
Free resource material on spousal assault is available through Health Canada's National Clearinghouse on Family Violence, 613 957-2938 or 800 267-1291.
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