Public Health
Wife assault in Canada

CMAJ 2000;163(3):328

Only a minority of spousal assaults come to the attention of Canada's judicial and medical systems. In a 1993 national telephone survey of 12 300 women, 29% of respondents who had ever married reported that they had been subjected to violence — they had been pushed, grabbed, shoved, slapped, sexually assaulted, hit with an object or had a gun or knife used against them — by their partner at some point in the relationship.¹ This proportion is comparable to results of national surveys in the US (25%), Australia (23%) and England and Wales (23%).²

Only 25% of the Canadian respondents who had experienced assault had reported an incident of violence to the police.¹ They were more likely to make a report if their children witnessed the incident, if a weapon was used or if they feared for their lives. However, 57% of women who were injured, 51% of women who were assaulted more than 10 times and almost 50% of the women who feared for their lives did not call the police.¹

According to the records of 179 police forces in 6 provinces, common assault (an assault that doesn't involve a weapon or cause serious injury) represented 74% of domestic violence incidents reported in 1997.² More serious forms of assault (assault with a weapon, assault causing bodily harm or aggravated assault) accounted for 14% of the incidents, while criminal harassment (stalking) comprised 7%. The vast majority of victims (96%) suffered either no injuries or minor injuries that required either no professional attention or at most first aid. This suggests that physicians who rely on characteristic patterns such as centrally distributed injuries, defensive injuries of the forearm and bruises in various stages of healing to identify victims of abuse are likely missing most cases.

Clinical management

Domestic violence can be a diagnostic challenge because victims present with ambiguous signs and symptoms such as dental trauma, chronic pelvic pain, eating disorders, lack of prenatal care and delays in seeking help. Although physicians may be uncomfortable introducing the subject of abuse, most victims report that they hope the clinician will ask whether they have been abused and, if asked in a caring manner, would be prepared to discuss it.³

Routine gynecologic, obstetric and pediatric visits provide opportunities for screening. In a recent pilot study to introduce domestic-violence screening during well-baby visits in a pediatrician's clinic, 47 (31%) of 154 women screened revealed a history of domestic violence at some point in their lives.⁴ Before routine screening was introduced, only 1 report of domestic violence had been made in the previous
4 years.

Screening should be done in private and introduced with a general question: "We are concerned about the health effects of domestic violence, so we now ask a few questions of all our patients." Two simple screening questions — "Do you ever feel unsafe at home?" and "Has anyone at home hit you or tried to injure you in any way?" — have a sensitivity of 71% and a specificity of 85%.³ Doctors might also ask "Has anyone ever threatened you or tried to control you?" or "Have you ever felt afraid of your partner?" Women should also be made aware that abuse takes many forms.⁵

When patients admit to being abused, the physician needs to identify and clearly document the relevant history and physical findings, refer the patient to appropriate community and advocacy services, and assess whether the patient is at immediate risk upon leaving the premises. A handbook to help physicians deal with the issue and the judicial system's responses to it has recently been published.⁶

Prevention

Many risk factors are associated with wife assault. Predictors include the couple's young age (18–24 years), living in a common-law relationship, chronic unemployment of the male partner, the witnessing of violence as a child and the presence of emotional abuse. Women who have recently separated from their partners or who are pregnant are at increased risk.¹

Spousal assault is a complex issue that requires a collaboration between government, community, legal, health and police services. In Canada, gains were made in 1983 with the implementation of Bill C-127, which allowed officers to make an arrest when they had reasonable and probable grounds to believe an assault had been committed. Before, officers had to witness the assault or the resulting bodily harm to make an arrest.² Thus, rather than leaving the scene without laying charges, the law now allows officers to intervene at an earlier stage and possibly prevent later escalations of the violence.

For further information, contact the National Clearinghouse on Family Violence, Health Canada, tel 800 267-1291; www.hc-sc.gc.ca/nc-cn. — Erica Weir, CMAJ

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1. Family Violence in Canada: A statistical profile 1998. Ottawa: Statistics Canada. Cat no 85-24-XIE.
2. Family Violence in Canada: A statistical profile 1999. Ottawa: Statistics Canada. Cat no 85-24-XIE.
3. Eisenstat SA, Bancroft L. Primary care: domestic violence. N Engl J Med 1999;341:886-92. [MEDLINE]
4. Siegel RM, Hill TD, Henderson VA, Ernst HM, Boat BW. Screening for domestic violence in the community pediatric setting. Pediatrics 1999;104:874-7. [MEDLINE]
5. Martin F, Younger-Lewis C. More than meets the eye: recognizing and responding to spousal abuse. CMAJ 1997;157(11):1555-8. [MEDLINE]
6. Ferris L, Nurani A, Silver L. A handbook dealing with women abuse and the Canadian criminal justice system: guidelines for physicians. Ottawa: Minister of Public Works and Government Services, 1999.

© 2000 Canadian Medical Association or its licensors