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Domestic Violence
SPECIAL CONTRIBUTION
D omestic Violence Mr Easley is attorney general for the state of North Carolina. Presented at the "Violence Against Women: Issuesfor Health Care Providers" symposium, Chapel Hill, North Carolina, October 1995. Copyright © by the American College of Emergency Physicians.
7 62
Michael Easley,JD
[Easley M: Domestic violence. Ann EmergMedJune 1996; 27:762-763.]
Violence against women is an issue that has come out into the open for us to confront. America is awakening to the reality that women are beaten, often brutally, by their partners. The numbers are staggering. According to estimates by the American Medical Association, more than 4 million women were beaten by their partners last year. One in four women will be beaten by a man in her lifetime. We cannot close our eyes and ears to this. You will hear other numbers: the $44 million in medical costs, the 40,000 physician visits, the 100,000 days in hospital stays. But the most alarming number comes from a poll conducted here in North Carolina. In it, 60% adolescents who had dated said they had experienced a violent episode by the 12th grade. Sadly, the cycle of abuse continues to turn. Violent fathers pass their violent heritage along to their sons, and daughters often find themselves in relationships that mirror the abusive one they saw modeled at home. What can we do about it? North Carolina created the Citizens' Rights Division within the State Department of Justice. We convinced the legislature to remove the spousal defense in rape cases. We have created a Child Victim Assistance Program to help children and their families as they wind through the court system, making sure these youngest of victims are not victimized again. The senior deputy in charge of the Civil Rights Division is an expert on domestic violence. She helps monitor some of our latest laws, including the stalking law, that we and a handful of other states are now using to protect women. Since 1992, police have been able to arrest someone who follows another person on more than one occasion. If this law is used and enforced, it can save lives. State offices can and will do more. But the scope of domestic violence is broad, and to combat it, all
ANNALS OF EMERGENCY MEDICINE 2 7 : 6 JUNE
1996
DOMESTIC VIOLENCE
Easley
of us must be aware of our responsibilities. The role of health professionals is crucial. Violence is a public health issue because it puts more people in the hospital than most major diseases. Thirtyfive percent of women who go to the emergency department do so because of abuse. Many are left without help because physicians fail to identify them as victims of domestic violence. My office can help physicians by letting them know the law. What are your responsibilities to victims of domestic violence? Every professional who comes in contact with a battered woman has an ethical responsibility to provide information that may allow her to end the abuse. Every doctor's office should provide literature on domestic violence and have referral lists of resources for women who indicate they want help. Beyond that, when a woman enters your ED and you suspect physical abuse--even if she says her injuries were caused differently--there are steps you should take. First, you should document thoroughly all injuries. Your records could mean the difference between convicting an abuser and allowing him to go free. Well-kept records are the best assistance the medical profession can give the courts in seeking justice for battered women. They are vital in preventing further abuse and can be used not just for prosecution but for obtaining restraining orders that give women the room they need to break loose from abusive relationships. For medical records to be admissible in court, the doctor may be required to testify that the records were made in the ordinary course of business, at the time of the examination, and with routinely followed procedures. I advise you to ensure that this is the case. The records must also be properly stored, and access to them must be limited to professional staff. A physician's record of the woman's visit should include several components. The first is the chief complaint and description of abusive events, using the patient's words--verbatim--to describe the events. The second component is a detailed description of the injuries--including, if possible, color photographs of the injuries taken before administration of any medical treatment. The photographs should be from different angles and should include an object, such as a ruler, that indicates the size of the injuries. The patient's face should appear in at least one of the pictures, and each photograph should be properly labeled. Physicians who have videotape equipment available should make such a record of the patient. The third part is the diagnosis, including the origin of the injuries, and any results of laboratory tests and other diagnostic procedures.
JUNE 1996
27:6
ANNALS OF EMERGENCY MEDICINE
Beyond documentation, what are your obligations? Perhaps the fundamental question involves reporting the abuse. Do you have a legal responsibility to report suspected domestic violence? In North Carolina, all health professionals are required to report serious injuries resulting from criminal acts of violence or suspected child abuse. However, specific reporting of suspected domestic abuse is not required. Some states have mandatory reporting. The effects of such laws are mixed. A woman may not tell her doctor of abuse if she knows the physician must turn in her partner who then may abuse her again. My opinion is that physicians must make a judgment whether to report. The reason for reporting must have the same goal as other options--to protect the victim from further abuse. Perhaps there are other ways to do this. Doctors must use their unique position to build trust with their patients and provide the help these women need. The doctor should guide the patient toward sources of help, which can and should include legal steps necessary to stop the abuse. The doctor should have on hand the numbers for shelters, attorneys, and the clerk of court, all of whom can help break the cycle of abuse. The key here is giving the woman hope--showing her the way--that she has the power to change her situation. Required reporting takes power away from her and reinforces her victimization. In my career as district attorney and now as attorney general, I have seen many victims of violence. I have prosecuted drug dealers who deal death to our children. I have prosecuted gang members whose cold-blooded murders of innocent people did not even register on their consciences. But the most agonizing prosecutions are those in which the victims could have been saved--ones in which their many cries for help went unnoticed. It was not too long ago that our judicial system turned its back on women abused by their husbands. Police officers believed what happened inside the closed doors of a home was not their concern. Courts often treated husbands as minor transgressors or excused their acts entirely. And the legal system had not put in place any laws to protect women. Now, that has changed. Domestic violence is now a problem for the whole community to combat. The medical profession must do its part. It must understand its role and obligation and live up to its duty. Reprint no. 47/1/72730 Reprints not available from the author.
763
D omestic Violence Mr Easley is attorney general for the state of North Carolina. Presented at the "Violence Against Women: Issuesfor Health Care Providers" symposium, Chapel Hill, North Carolina, October 1995. Copyright © by the American College of Emergency Physicians.
7 62
Michael Easley,JD
[Easley M: Domestic violence. Ann EmergMedJune 1996; 27:762-763.]
Violence against women is an issue that has come out into the open for us to confront. America is awakening to the reality that women are beaten, often brutally, by their partners. The numbers are staggering. According to estimates by the American Medical Association, more than 4 million women were beaten by their partners last year. One in four women will be beaten by a man in her lifetime. We cannot close our eyes and ears to this. You will hear other numbers: the $44 million in medical costs, the 40,000 physician visits, the 100,000 days in hospital stays. But the most alarming number comes from a poll conducted here in North Carolina. In it, 60% adolescents who had dated said they had experienced a violent episode by the 12th grade. Sadly, the cycle of abuse continues to turn. Violent fathers pass their violent heritage along to their sons, and daughters often find themselves in relationships that mirror the abusive one they saw modeled at home. What can we do about it? North Carolina created the Citizens' Rights Division within the State Department of Justice. We convinced the legislature to remove the spousal defense in rape cases. We have created a Child Victim Assistance Program to help children and their families as they wind through the court system, making sure these youngest of victims are not victimized again. The senior deputy in charge of the Civil Rights Division is an expert on domestic violence. She helps monitor some of our latest laws, including the stalking law, that we and a handful of other states are now using to protect women. Since 1992, police have been able to arrest someone who follows another person on more than one occasion. If this law is used and enforced, it can save lives. State offices can and will do more. But the scope of domestic violence is broad, and to combat it, all
ANNALS OF EMERGENCY MEDICINE 2 7 : 6 JUNE
1996
DOMESTIC VIOLENCE
Easley
of us must be aware of our responsibilities. The role of health professionals is crucial. Violence is a public health issue because it puts more people in the hospital than most major diseases. Thirtyfive percent of women who go to the emergency department do so because of abuse. Many are left without help because physicians fail to identify them as victims of domestic violence. My office can help physicians by letting them know the law. What are your responsibilities to victims of domestic violence? Every professional who comes in contact with a battered woman has an ethical responsibility to provide information that may allow her to end the abuse. Every doctor's office should provide literature on domestic violence and have referral lists of resources for women who indicate they want help. Beyond that, when a woman enters your ED and you suspect physical abuse--even if she says her injuries were caused differently--there are steps you should take. First, you should document thoroughly all injuries. Your records could mean the difference between convicting an abuser and allowing him to go free. Well-kept records are the best assistance the medical profession can give the courts in seeking justice for battered women. They are vital in preventing further abuse and can be used not just for prosecution but for obtaining restraining orders that give women the room they need to break loose from abusive relationships. For medical records to be admissible in court, the doctor may be required to testify that the records were made in the ordinary course of business, at the time of the examination, and with routinely followed procedures. I advise you to ensure that this is the case. The records must also be properly stored, and access to them must be limited to professional staff. A physician's record of the woman's visit should include several components. The first is the chief complaint and description of abusive events, using the patient's words--verbatim--to describe the events. The second component is a detailed description of the injuries--including, if possible, color photographs of the injuries taken before administration of any medical treatment. The photographs should be from different angles and should include an object, such as a ruler, that indicates the size of the injuries. The patient's face should appear in at least one of the pictures, and each photograph should be properly labeled. Physicians who have videotape equipment available should make such a record of the patient. The third part is the diagnosis, including the origin of the injuries, and any results of laboratory tests and other diagnostic procedures.
JUNE 1996
27:6
ANNALS OF EMERGENCY MEDICINE
Beyond documentation, what are your obligations? Perhaps the fundamental question involves reporting the abuse. Do you have a legal responsibility to report suspected domestic violence? In North Carolina, all health professionals are required to report serious injuries resulting from criminal acts of violence or suspected child abuse. However, specific reporting of suspected domestic abuse is not required. Some states have mandatory reporting. The effects of such laws are mixed. A woman may not tell her doctor of abuse if she knows the physician must turn in her partner who then may abuse her again. My opinion is that physicians must make a judgment whether to report. The reason for reporting must have the same goal as other options--to protect the victim from further abuse. Perhaps there are other ways to do this. Doctors must use their unique position to build trust with their patients and provide the help these women need. The doctor should guide the patient toward sources of help, which can and should include legal steps necessary to stop the abuse. The doctor should have on hand the numbers for shelters, attorneys, and the clerk of court, all of whom can help break the cycle of abuse. The key here is giving the woman hope--showing her the way--that she has the power to change her situation. Required reporting takes power away from her and reinforces her victimization. In my career as district attorney and now as attorney general, I have seen many victims of violence. I have prosecuted drug dealers who deal death to our children. I have prosecuted gang members whose cold-blooded murders of innocent people did not even register on their consciences. But the most agonizing prosecutions are those in which the victims could have been saved--ones in which their many cries for help went unnoticed. It was not too long ago that our judicial system turned its back on women abused by their husbands. Police officers believed what happened inside the closed doors of a home was not their concern. Courts often treated husbands as minor transgressors or excused their acts entirely. And the legal system had not put in place any laws to protect women. Now, that has changed. Domestic violence is now a problem for the whole community to combat. The medical profession must do its part. It must understand its role and obligation and live up to its duty. Reprint no. 47/1/72730 Reprints not available from the author.
763