Domestic Violence Awareness Month: Clinicians May Be First Responders

October is National Domestic Violence Awareness Month, focusing national attention on a problem for which physicians and other health care workers—including psychiatrists—may be first responders.

According to the website of the National Coalition Against Domestic Violence, the annual observation in October evolved from the first “Day of Unity” sponsored by the Coalition in October 1981. The intent was to connect battered women’s advocates across the nation working to end violence against women and their children. The Day of Unity soon became a special week when a range of activities was conducted at the local, state, and national levels.

In October 1987, the first Domestic Violence Awareness Month was observed. That same year the first national toll-free hotline was begun. And in 1989 the first Domestic Violence Awareness Month Commemorative Legislation was passed by the U.S. Congress, according to the coalition website.

Psychiatrist Gail Robinson, M.D., noted that domestic violence can include physical, sexual, emotional, and verbal assault (including denigrating language and blaming the partner) and violence against objects such as punching the wall beside the partner.

Robinson, who is APA’s minority and underrepresented trustee, is at the University of Toronto as director of the Women’s Mental Health Program, senior psychiatrist of the University Health Network, and a professor of psychiatry.

Robinson said risk factors for being a victim of domestic violence include observing violence between parents in the home when young; having attitudes that accept violence and gender inequality; and experiencing marital conflict or disruption. “Substance abuse and low self-esteem have been noted as increasing vulnerability to domestic violence; however, they may be a consequence of the violence rather than a cause of the violence,” she said.

Robinson added that violence causes more health consequences then car accidents or muggings.

“Physically there may be outward signs of violence, such as bruises or fractures. If a woman is pregnant—violence continues to occur during pregnancy, often directed to the women’s abdomen—there may be at increased risk of miscarriage, premature deliveries, or small-for-date babies.”

“Any health care worker may play an important role in dealing with domestic violence. Women often come to the emergency department or their doctor’s office more than six times before anyone starts to suspect domestic violence is occurring,” she said.

Robinson’s advice to clinicians: “Always ask about the presence of conflict in the family when taking a history, as women find it difficult to report unless they get the sense that they will be heard and not ignored or blamed. Having pamphlets or posters about domestic violence in the waiting room can provide an atmosphere that encourages women to report. It is important for the psychiatrist to have some practical information about safety measures such as domestic violence hotlines and where to go if the woman has to leave.

“Advise the woman to try to find a place, possibly at a friend’s, to set aside a suitcase with some clothes for her and the children, and some identification and money, should she feel she has to flee the house on short notice.”

She added, “Although it may seem obvious to the psychiatrist that the woman should leave right away, it is important to realize that this is a very difficult decision. The psychiatrist should not get frustrated because after three or four visits the woman has not decided to leave. Educating women about domestic violence, including how prevalent it is, how they are not to blame for it no matter what they do, and how it makes them feel helpless and hopeless, can be a very important step.”

Men can also be victims of violence within opposite-sex couples, but numbers are particularly difficult to know as men are likely to be even more reluctant to report, Robinson said.

Domestic violence is not exclusively a problem between heterosexual couples. A new study appearing last month in the Journal of Sex and Marital Therapy by Northwestern Medicine scientists examined recent studies on domestic violence among gay and lesbian couples and found that same-sex domestic violence affects one-quarter to nearly three-quarters of lesbian, gay, and bisexual individuals—figures that equal or exceed those for straight couples.

Colleen Stiles-Shields, Ph.D., and Richard Carrolla, Ph.D., of the Northwestern University Feinberg School of Medicine, acknowledged in their paper that variability in sampling methods and a host of other methodological problems make it difficult to know the true prevalence. They also said that data are sparse and that more and better research is needed.

“Domestic violence is not limited to opposite-sex couples but is as common, if not more so, in same-sex couples,” psychiatrist Robert Cabaj, M.D., told Psychiatric News. “There are several factors to consider—substance abuse is more common within the LGBT community in most studies, and substance abuse contributes to domestic violence. Economic struggles are also tied to domestic violence, and most female-female couples are in the lower economic or earning brackets based on the fact that women in general earn less than men.”

Also, Cabaj said, gender role expectations may contribute to some domestic violence. “Men are often raised to be ‘dominant’ or ‘deciding,’ and blending two men with similar role expectations may cause additional strains in the relationship.”

“Domestic violence can occur in LGBT families with the same frequency as it does in straight ones,” agreed psychiatrist Jack Drescher, M.D., past president of the Group for the Advancement of Psychiatry. “Clinicians need to be alert to domestic violence presentations in their clinical practices and to understand what kind of interventions may be helpful to their patients and their families.”

Drescher said advice to gay individuals experiencing domestic violence is similar to what Robinson advises for victims in opposite-sex relationships. But he said a complicating factor is when either one or both members are closeted and unwilling to reveal that they are in a relationship.

“[For the victim] there is the extra burden of having to come out at the same time as having to report domestic violence,” Drescher said. “In those situations, the best advice may be [for the victim of abuse] to seek out someone they trust and tell them what is going on.”

Figures from the report “National Intimate Partner and Sexual Violence Survey: 2010 Findings on Victimization by Sexual Orientation” republished by the Centers for Disease Control and Prevention in January 2013, are striking, though the CDC notes similar limitations in the available data to getting a true picture of prevalence. The report found that the lifetime prevalence of rape, physical violence, and/or stalking by an intimate partner was 43.8 percent for lesbian women, 61.1 percent for bisexual women, and 35 percent for heterosexual women.

For gay men the lifetime prevalence of rape, physical violence, and/or stalking by an intimate partner was 26.0 percent, for bisexual men it was 37.3 percent, and for heterosexual men it was 29 percent.

Commenting on the statistics, an article in the October/November The Advocate stated: “These studies refute the myths that only straight women get battered, that men are never victims, and that women never batter—in other words [the myth that] domestic violence is not an LGBT issue. In fact, it is one of our most serious health risks, affecting significant numbers within our communities.” ■