Domestic violence (DV) is a term used to describe many violent relationships such as child abuse, elder abuse and sex abuse. However, it is most commonly used for an intimate relationship between two adults where one partner uses a pattern of assault to exert power and control over the other partner. At present, DV is one of the major public health issues. It not only includes physical violence but also refers to psychological, economic and sexual abuse along with attempts to isolate the partner. For complete understanding of domestic violence in our system, it is helpful to review some historical points like:

• According to British common law in the past, a man was allowed to chastise his wife with any reasonable instrument

• During the 1800s in the US, states laws continued to support a man’s right to control his wife

• The violence against woman act was adopted in 1994

Regarding domestic violence, laws vary country by country. A fixed law has been established in US, but it is not the case in many developing countries. Social acceptance of domestic violence also varies among countries. One of the UNICEF survey shows that the percentage of women (aged 15-49 years) who consider that a husband can hit or beat his wife under certain situations is:

• 90% in Afghanistan

• 90% in Jordan

• 87% in Mali

• 86% in Guinea

• 86% in Timor-Leste

• 81% in Laos

• 80% in Central African Republic etc.

The old rule stating “men have a legal right to use violence to discipline their wives” was removed in the US and many European countries in late 19th/early 20th century [1].

The definition of domestic violence slightly differs according to the context in which it is used. The contexts may be medical, legal, political or social. According to a common person, domestic violence is associated with a physical violence. But, these days, a broader definition (including sexual, psychological and economic abuse) is used for domestic violence.

According to the Convention on Preventing and Combating Violence Against Women and Domestic Violence:

"Domestic violence shall mean all acts of physical, sexual, psychological or economic violence that occur within the family or domestic unit or between former or current spouses or partners, whether or not the perpetrator shares or has shared the same residence with the victim."

The Declaration on the Elimination of Violence against Women divides the violence against women into 3 types:

1. Domestic violence occurring in family

2. Domestic violence occurring in the general community

3. Domestic violence conducted by state

Family violence is described as:

"Physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation.”

Intimate partner violence (IPV) is a term used synonymously with domestic abuse or domestic violence. The Act XX on Domestic Violence 2006, in Malta, defines DV as follows:

"Domestic violence means any act of violence, even if only verbal, perpetrated by a household member upon another household member and includes any omission which causes physical or moral harm to the other."

According to The US Office on Violence against Women, DV can be defined as:

"Pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner [2,3]”.

Followings are some facts regarding statistics of DV:

• The women of US are more likely to have suffered from domestic violence by a male partner than by all other of types of attackers.

• Annually in US, 2-4 million women are assaulted by a male partner

• The incidence of DV in lesbian, gay and bisexual relationships is almost comparable to that of heterosexual partners

• Almost 800,000 cases of DV perpetrated by women against men are reported each year

• Sexual assault of women by their husbands is twice more common than that by the strangers

• In US, every year, almost 2000 females are killed by their current or former male partner

• One in seven females visiting doctor’s clinic gives history of partner abuse

• One in four females has been assaulted at some point in her life

• One in four females getting care in emergency settings for any reason is a domestic violence survivor

• One in six females is assaulted during pregnancy

• One in four females who are attempting suicide is being assaulted

• Acts of physical domestic violence between domestic partners take place in one in six [2,4-6]

Figure-3: Homicide rate in the U.K. evolved during the last decades (Source: www.filipspagnoli.wordpress.com)

Following individuals are at risk of DV:

• Stalked by a partner

• Age less than 30 years

• Planning to leave an abusive relationship

_{Figure 4: Domestic Violence in the form of acid throwing}

• Who has recently left an abusive relationship

• Previously involved in an abusive relationship

• Poverty or poor socioeconomic status

• Unemployed

• Physically or mentally handicapped

• Recently divorced

• Isolated socially from others

• Abused as a child

• Witnessed domestic violence as a child

• Unplanned Pregnancy

Abusers risk factors include:

• Who abuses alcohol or drugs

• Who witnessed abuse as a child

• Who was a victim of abuse as a child

• Who abused former partners

• Unemployed or underemployed

• Abuses pets

The causes of DV include:

Biological causes

• Genetic disorders

• Brain dysfunction

Psychological causes

• Personality disorders like poor impulse control, sudden bursts of anger and poor self esteem

• Mental illness

• Disorders like bipolar disorder, schizophrenia, depression etc

• Drug abuse

• Alcohol abuse

• Marital conflict disorder

Jealousy

It is one of the major causes of DV, and occurs in situations like:

• When one partner is either suspected of being unfaithful

• When one partner is planning to leave the relationship

• The fact that women are more successful than men, can be a cause of domestic violence by male partner

Behavioral causes

• Poor socioeconomic status
• Social stress
• Power and control achievement [7-8]

DV can be classified into various types [8-10]. These are:

Physical abuse- it may be in the following forms:

• Punching

• Pinching

• Grabbing

• Tripping

• Pushing

• Using a weapon against you

• Beating

• Pulling hair

• Slapping

• Shoving

• Biting

• Twisting arms

• Kicking

• Throwing you down

• Hitting [8-10]

Psychological abuse- it may be in the following forms:

• Threatening to commit

• Inflict harm to pets

• Threatening to do something to hurt you

• Emotional black mailing

• Threatening to expose the victim’s sexual orientation

• Threatening to take away the children or to harm them

• Threatening to harm some of the family members

• Threatening to report against you [8-10]

Emotional abuse- it may be in the following forms:

• Force you to think that you are lazy

• Make you to think bad about your acts

• Behaving in a way as you are a servant

• Always try to degrade you by putting you down [8-10]

Isolation- It includes:

• Controlling your activities (e.g. financially)

• Limiting your approach to other people

• Taking hold on your activities outside the home [8-10]

Sexual abuse- it includes:

• Attacking or touching your sexual parts of body

• Forcing you do sexual things against your wish

• Considering you as a sex object [8-10]

Using children- it includes:

• Forcing you think guilty about the children

• Use of children to give messages

Economic- it includes:

• Not allowing you to keep a job

• Getting your money

• Making you ask for money

You should identify the following signs and symptoms of DV in a domestic violence survivor:

Psychological signs and symptoms

The following physiological symptoms can be observed during the assessment of DV:

• Observe the behavior of both abuser and the one being abused

• The abuser may appear coercive, attempting to answer all the questions for the victim

• The one being abused may be quiet and passive

• Signs of depression like crying and poor eye contact

• Anxiety

• Chronic fatigue

• Suicidal tendencies

• Battered woman syndrome

• Post-traumatic stress

• Substance abuse [11,1

Physical signs and symptoms

These are:

• Tympanic membrane rupture

• Rectal tear or bruising and pain

• Genital tract injury

• Facial cuts, scraps, bruises or fractures

• Neck cuts, scraps or bruises

• Abdominal cuts or bruises

• Tooth broken

• Arm scrapes or bruises [11,12]

Pattern of physical injuries- these may be:

Centrally placed injuries- such injuries include bathing suit pattern, which initially involve breasts, body, buttocks and genitals. These areas are usually hidden areas, covered by clothing. Other central locations include head and neck.

Bilateral injuries- involving both arms and legs

Defensive posture injuries- like injuries to medial aspect of hand and forearm, bottoms of feet, back, leg, buttocks and back of head

Injuries not correlating with the given explanation- type and severity of the injury differ from the reported cause

Injuries with many stages of healing- such injuries may be present if there is history of ongoing violence [11,12]

The features of violence injuries may include:

• Marks of cigarette burns

• Bite marks

• Rope burns

• Bruises, cuts and scrapes [11,12]

No injury physical signs and symptoms- these sign and symptoms can be observed in the individuals experiencing ongoing abuse. Some of these complaints include:

• Neck pain

• Headache

• Chest pain

• Tachycardia

• Feeling of choking

• Vaginal pain

• Pelvic pain

• Numbness and tingling

• Painful sexual intercourse

• Urinary tract infection [11-12]

Health care providers must routinely screen women for DV. Screening is very important and effective way of detecting DV as it increases the referrals to community resources thus improving the quality of life by preventing the DV related injuries. Screening is performed with a questionnaire filled out by patient or a direct interview carried out by health care provider [13-15].

How to screen a case of DV?

A health care provider must apply the following steps to carry out the screening of DV-case:

Identify the signs and symptoms of DV- Following table helps recognizing the signs and symptoms in a suspected case of DV:

• Inconsistent explanation of injuries or delay in seeking treatment

• Somatic complaints

• Psychiatric illness

• Frequent visits to the emergency room

• Injuries, especially to head and neck

• Low birth weight

Use screening tools- the following sample screening tools are used to detect the DV [13-15]:

1. Hurt, Insult, Threaten, Scream (HITS) Scale is an important scale to recognize the cases of DV. It is given in the following table [13-15]:

2. Woman Abuse Screening Tool (WAST) is another tool to detect the DV.

3. The Women’s Experience with Battering Scale consists of ten questions and it can be used to detect a case of DV.

_{TABLE: The Women’s Experience with Battering Scale (SOURCE: www.dbhds.virginia.gov)}

Management of the case of DV (How to Help Battered Women)

One can help an abused person (woman) by following the 5 aspects of care. These aspects include [16,17]:

1. Identification of the suspected case of DV

2. Examination of the case

3. Documentation

4. Protection

5. Referral

Figure-19: How to manage DV (Source: www.hotpeachpages.net)

Identification of the suspected case of DV

How to Ask About Domestic Violence?

Interview the patient in privacy on her own, away from anyone who may have accompanied her. Ask the first two question of WAST screen. These questions will indicate if she has been abused or not. After these two questions you can ask the remaining questions of WAST screen to get complete information about violence. Examine the patient to find signs and symptoms of abuse. During asking these questions follow the following rules:

• Sit at or below the patient’s level

• Explain to her that wife abuse exists and thus build a trust

• Ask her in a direct and empathic way, keep proper contact with her and avoid doing other things during conversation with her

• Assure her clearly that you believe violence against women is a criminal act

• Offer support in an empathic, non-judgmental way

• Explain it clearly that her safety will not be compromised if she discloses the truth

• Assure her that your conversation is confidential

• You can call the police to support her only if she wants [16,17]

DOMESTIC VIOLENCE INTERVIEW GUIDE

There are many types or forms of domestic violence and this guide helps you to interview under different circumstances of abuse.

TABLES: DOMESTIC VIOLENCE INTERVIEW GUIDE (source: www.nij.gov)

Examination and assessment of the patient

The signs and symptoms of domestic violence of various types have already been described. Keep them in mind and then examine the patient and assess the type and severity of injury [16,17].

Documentation

It is necessary to document the following essential points regarding DV:

• Site, type and severity of both present and past injuries by using a body map

• Account of incident

• Name of the abuser

• Past history of violence

• Police information

• Emotional and physical symptoms

• Situation about safety of patient’s [16,17]

Protection/Safety

As a health care provider, you must deal with the woman’s safety. When you are finished with the examination regarding the violence, support and help her in planning for her safety once she leaves your office or health care center. You can report to legal agencies if the patient is in danger [16,17].

Referral

A health care provider the battered individuals with a short list of local resources. The list must be printed on a card that can be easily folded into a small size card, thus keeping it out of sight [16,17].

Prevention of DV

There are many steps that can help to prevent domestic violence. Following two tables describe some of these steps in a comprehensive way:

Prevention of DV (Source: www.ncdsv.org)

Spectrum of prevention (Source: www.breakingfree.net)

References