- Email: [email protected]
Policy Statement Violence Against Women
CLINICAL
PRACTICE
G U
DELINES
POLICY STATEMENT* VIOLENCE AGAINST WOMEN This document has been prepared by the Social and Sexual Issues Committee of the Society of Obstetricians and Gynaecologists of Canada and approved by its Council in December 1995.
living with an abusive partner experienced more than one episode, while ten percent experienced more than ten episodes. 2It is recognized by most authorities that acts of violence against women are significantly under-reported. The categorization of violent acts is very broad and includes verbal abuse, threats of violence, throwing objects, throwing objects at a person, pushing, slapping, kicking, hitting, beating, threatening with a weapon or use of a weapon, and sexual aggression. 4 The definition of domestic violence should include psychological abuse, sexual assault, progressive social isolation, deprivation of sustenance, and intimidation. s Clearly there is a very broad range of behaviours, but it should be remembered that the level of abuse usually escalates over time. Despite a high incidence of violent acts against women, only three percent are identified by primary care physicians. 6 Presumably, even fewer cases are identified by consulting obstetricians and gynaecologists. Given the potential for morbidity and mortality, it is essential that physicians become more adept at identifying victims of physical abuse.
SOCIAL AND SEXUAL ISSUES COMMITTEE:
Chair Barbara Parish, MD, FRCSC (Halifax, NS) Past Chair Richard S. Boroditsky, MD, FRCSC (Winnipeg, MB) Members (Winnipeg, MB) Loma J. Grant, MD, FRCSC Yves Lefebvre, MD, FRCSC (Outremont, QC) Myma E. Rourke, RN (Winnipeg, MB) (Verdun, QC) Marc Steben, MD Sydney Thomson, MD, FRCSC (Vancouver, BC) We would like to acknowledge the contribution of Drs. Peter Woodrow (Regina, SK) and John Lamont (Hamilton, ON) in preparing this document. WHAT IS THE PROBLEM?
Violence against women in Canada is a major public health concern. 1 From the age of sixteen, one in two Canadian women will suffer some form of physical or sexual violence;2 the prevalence of domestic violence in Canada is shown to be approximately 29 percent. 2The annual incidence of violence against women is estimated to be ten to 14 percent. 3 An episode of violence is often not the first. Thirty-nine percent of women currently
THE CYCLE OF VIOLENCE
There appears to be a clear pattern in domestic violence, a cycle of three distinct phases: escalation, explosion, and calm with reconciliation (Figure 1 a,b,c).6.)
* Policy Statements: this policy reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.
JOURNAL SOGC
803
AUGUST 1996
, , , FIGURE le
FIGURE la THE CYCLE OF VIOLENCE
MARITAL VIOLENCE OVER TIME
The three phases in the cycle of violence, whether the abuse is verbal, physical, psychological or sexual, vary in time and intensity during a couple's life and from one couple to another.
Abused people get to "know" when the next violent episode is coming. Some abused partners have said sometimes they even provoke the violence to "get it over with."
TENSION ESCALATES Occurrence of several incidents considered minor by the vict im. The victim believes that the situation is tem porary and that s hewill be able to control it.
Over time, the cycle of violence shifts. Honeymoon periods become shorter, or non-existent. They may be replaced by an "indifference" stage. Affection has died; indifference is the only relief from tension and fear.
VIOLENCE EXPLODES Tot al loss of control. Short episode, always serious, lasting up to 24 hours.
Tension and violence increase. And where once the abuser may have kept the abused person with promises ("I'll go for counselling"), now he keeps her with control ("You have no money") and threats ("I'll kidnap the children," "I'll track you down and kill you.")
PERIOD OF CALM AND RECONCILIATION The man seeks forgiveness while the victim is hopeful an d wishes to forget. The period varies in length and may not occur at all in some couples.
Each violent incident increases the likelihood that another will occur. The severity of violence increases-and so does the danger.
AND THE CYCLE BEGINS AGAIN WITH THE PHASES COMING CLOSER TOGETHER AND THE INCIDENTS BECOMING MORE SERIOUS.
2. Traumatic Bonding Two Canadian researchers have proposed a theory to explain the strong attachment abused women feel for their abusive partners. The " reasons" frequently put forward to explain the strong attachment were plausible but did not seem to fit all the facts. For example, one hypothesis is that abused partners have grown up in violent homes and therefore believe that violence is normal. It's true that girls growing up in violent homes are more likely than other girls to have abusive relationships as adults. However, two-thirds of abused w ives d id not grow up in violent homes. Breaking the Cycle of Family Violence
ABUSE DURING PREGNANCY
The incidence of physical abuse during pregnancy has been estimated to be between four to seventeen percent- 5 According to 1993 Canadian data, the incidence of abuse during a current pregnancy appears to be in the region of six to seven percent, with eleven percent of women having experienced abuse prior to the pregnancy. Of those abused during pregnancy, 64 percent reported increased abuse during pregnancy, and 14 percent indicated that the first episode of abuse occurred during the pregnancy. In this study, although 67 percent of abused women received medical treatment for the abuse, only three percent told their prenatal care providers.s Clearly, physical abuse remains a frequently undetected risk factor in a large number of pregnancies.
HONEYMOON
MYTHS AND FACTS9 Source: Correctional Service Canada, "Breaking the Cycle of Family Violence," 1988. Concept: Bonnie Hutchinson; graphics: Jim Brager.
Myth Abuse is not a significant problem. Fact Ten percent of Canadian women live with an abusive partner.
Reproduced with Permission.
JOURNAL SOGe
804
AUGUST 1996
, , , APPROACHABI LITY
Myth An abusive act is usually a one-time event. Fact Most women will have suffered multiple abusive episodes before seeking outside help. Myth Injuries are usually not serious. Fact Twenty percent of all homicides in Canada are domestic. Twenty-five percent of women who attempt suicide are abused. Myth Abuse happens only in disadvantaged families. Fact Abuse occurs in all socio-economic classes, among women from all educational and cultural backgrounds. Data suggest that 65 percent of perpetrators are employed, and that 25 percent have completed high school or higher education. Myth Alcohol is the cause of abuse. Fact Alcohol may be a factor, but treating alcoholism does not end abuse. Myth Women provoke violence. Fact Provocation is an excuse. Violent behaviour is the responsibility of the perpetrator. Myth Pregnant women are less likely to be abused. Fact Typically, violence begins or increases during pregnancy. Myth Physicians are likely to diagnose abuse. Fact Data suggest that the diagnosis is made in only four percent of abused women using medical services. Myth Abuse does not affect other family members. Fact In families where abuse occurs, 25 to 50 percent of the children are also abused or neglected. Sixty-six percent of abused women and 80 percent of abusive men experienced or witnessed violence in their homes as children. to
The physician remains one of the key people to whom a woman may disclose her situation, however, few women will disclose spontaneously. It is the physician's responsibility to provide an environment in which disclosure becomes possible, and to maintain a high index of suspicion regarding actual or potential abuse. Patient education material on physical abuse should be clearly displayed in patient waiting areas, examination rooms, and washrooms. Telephone numbers of local shelters and help lines should be clearly displayed in all patient areas including washrooms. WHEN TO SUSPECT PHYSICAL ABUSE11
Patients who make multiple visits to physicians' offices with ill-defined complaints, including: Headaches Insomnia Choking sensation Hyperventilation Gastro-intestinal symptoms Chronic pain (pelvis, abdomen or back) Other signs and symptoms: Shyness Fear Embarrassment Evasiveness Passivity Frequent crying Often accompanied by a male partner who is reluctant to leave Drug and alcohol abuse or overdose Attempts at self-harm or suicide Insomnia Depression Sexual problems Injuries inconsistent with explanation of mechanism During a physical examination, evidence of recent or remote injuries may be detected. These should all be noted (on a body chart preferably) and the woman asked how they were sustained.
WHAT THEN IS THE ROLE OF THE PHYSICIAN?
1. 2. 3. 4.
to be aware; to be approachable; to identify problems; and to provide support and medical care.
AWARENESS
First and foremost, physicians must recognize the magnitude of the problem, and realize that violence against women will exist within their practices whether recognized or not.
JOURNAL SOGC
IDENTIFICATION
There are certain barriers to identification of violence by physicians, including;
805
AUGUST 1996
, , , deficiencies in medical training in this area; discomfort with psychosocial issues; view that family violence is private; and personal history of family violence. 1
Within the last year, has anyone forced you to have sexual activities? Are you afraid of your partner? 5 Following disclosure, the physician should state clearly that physical and psychological abuse are not acceptable behaviours, and that no one deserves it. The woman is in no way to blame for the situation. Enquiry should be made into the woman's perception of her own safety, and whether she has any exit plan should she feel in danger.
Ask the questions. Direct, while sensitive, questioning regarding physical abuse should be part of his tory taking. This is not seen as intrusive by most women, and will indicate an openness to discuss the issue of violence, if not at this interview, then in the future should it become necessary.
EXIT PLAN FOR ABUSED WOMEN
SIGNS TO WATCH FOR
We propose the following plan for women who fear for the safety of their children or for themselves. 1. Having a change of clothing packed for herself and her children. This should include necessary medications and extra house and car keys. These can be placed in a suitcase and stored with a friend or neighbour. 2. Cash, cheque book, and a savings account book may also be kept with clothing. 3. Identification papers, birth certificates, social insurance cards, driver's licences, such financial records as mortgage papers, rent receipts, and automobile title should be taken if available. 4. Item of special interestto each child (e.g. Teddy bear). 5. A plan detailing exactly where to go, regardless of time of day, should be made. This may be a friend's or a relative's home or a shelter for battered women and children.s,ll The woman's intentions should be ascertained. Information should be supplied regarding possible avenues of action. She should not be coerced on the basis of "what is best for her." Community and family support systems should be explored, as should her knowledge of community support and resources. Information should be supplied. Specific information should be given regarding available community resources with addresses and telephone numbers. Help in connecting the women with resources may also be required. Education regarding the natural history of abuse is also essential: * Violence is a criminal offence * Violence will often escalate if unchecked * It is unlikely to stop without intervention * Adverse effects on children in family * She is not to blame ll
Acute-Physical injuries: Site: Multiple injuries which cluster: e.g. centrally, head, neck, face, throat, chest, abdomen. Abrasions, contusions, bums and scalds, perType: forated tympanic membrane, fractures of jaw, clavicle, ribs, strangulation marks, internal injuries, and evidence of rape. History does not appear consistent with injuries. Injuries are at different stages of healing. History: Multiple visits to an emergency unit, history of suicide attempts, long term use of psychoactive drugs, history of psychiatric illness, substance abuse, and pregnancy. Chronic: Chronic pain without identifiable cause, psychological, sexual dysfunction, marital and family dysfunction. In situations of sexual aggression, the complaints may be of a more sexual nature including dyspareunia or decreased libido. PROVISION OF SUPPORT AND MEDICAL CARE
It is important to interview the woman alone. Here is a sample of questions to be asked when assessing and screening for abuse. ASSESSMENT AND SCREENING FOR ABUSE
Have you ever been emotionally or physically abused by your partner or someone close to you? Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Since you have become pregnant, have you been hit, slapped, kicked, or otherwise hurt by someone?
JOURNAL SOGC
806
AUGUST 1996
, , , It is not the physician's role to contact legal authorities, unless a minor is involved or unless that is the wish of the woman. Physical abuse is not solely a medical condition. It is the physician's role to supply medical and supportive care through the period of transition and healing process. An interdisciplinary approach is the key in providing support to the woman, regardless of what her decisions are. Inappropriate interventions can cause the situation to escalate in the home, leading to more severe violence, further endangering the woman. Clear documentation of injuries is essential and future legal action should be discussed. Be prepared and available for court appearances if necessary. Support the woman's decision, even if you disagree. If you feel unable to supply that support, refer the woman for future care to a practitioner who can.
J SOGe
1996;18:803-07
REFERENCES 1.
Nuttall SE, Greaves U, Lent B. Wife battering: an emerging problem in public health. Can J Public Health 1985;76:287-99. 2. Canadian Centre for Justice Statistics. Wife assault: the findings of a national survey. Juristat Service Bulletin, Statistics Canada 1994; 14(9); 1-22. 3. MacLeod L. Wife battering in Canada: the vicious cycle. The Canadian Advisory Council on the Status of Women, Ottawa, 1980. 4. Richwald GA, McClusky Te. Family violence during pregnancy. Adv Int Maternal Clinical Health 1985;5:87-96. 5. American College of Obstetricians and Gynecologists. Domestic Violence. ACOG Tech Bull 1995;209:1-9. 6. Walker LE. The battered woman syndrome. New York. Springer Publishing Co., 1984. 7. Correctional Service Canada. Breaking the cycle offamily violence.1988. 8. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J 1993;149(9):1257-63. 9. Community Health Committee, Medical Society of Nova Scotia. Women abuse: a handbook for physicians. 1991:1-11. 10. Jaffe P, Burris CA. Wife abuse as a crime: the impact of . police laying charges. Canadian Journal of Criminology 1983;25:209-18. 11. Brown JB, Lent B, Sas G. Identifying and treating wife abuse. J Fam Pract 1993;26(2): 185-91. 12. Norton LB., Peipert JF, Zierler S et at. Battering in pregnancy: an assessment of two screening methods. Obstet GynecoI1995;85(3): 321-5.
JOURNAL SOGC
807
AUGUST 1996
PRACTICE
G U
DELINES
POLICY STATEMENT* VIOLENCE AGAINST WOMEN This document has been prepared by the Social and Sexual Issues Committee of the Society of Obstetricians and Gynaecologists of Canada and approved by its Council in December 1995.
living with an abusive partner experienced more than one episode, while ten percent experienced more than ten episodes. 2It is recognized by most authorities that acts of violence against women are significantly under-reported. The categorization of violent acts is very broad and includes verbal abuse, threats of violence, throwing objects, throwing objects at a person, pushing, slapping, kicking, hitting, beating, threatening with a weapon or use of a weapon, and sexual aggression. 4 The definition of domestic violence should include psychological abuse, sexual assault, progressive social isolation, deprivation of sustenance, and intimidation. s Clearly there is a very broad range of behaviours, but it should be remembered that the level of abuse usually escalates over time. Despite a high incidence of violent acts against women, only three percent are identified by primary care physicians. 6 Presumably, even fewer cases are identified by consulting obstetricians and gynaecologists. Given the potential for morbidity and mortality, it is essential that physicians become more adept at identifying victims of physical abuse.
SOCIAL AND SEXUAL ISSUES COMMITTEE:
Chair Barbara Parish, MD, FRCSC (Halifax, NS) Past Chair Richard S. Boroditsky, MD, FRCSC (Winnipeg, MB) Members (Winnipeg, MB) Loma J. Grant, MD, FRCSC Yves Lefebvre, MD, FRCSC (Outremont, QC) Myma E. Rourke, RN (Winnipeg, MB) (Verdun, QC) Marc Steben, MD Sydney Thomson, MD, FRCSC (Vancouver, BC) We would like to acknowledge the contribution of Drs. Peter Woodrow (Regina, SK) and John Lamont (Hamilton, ON) in preparing this document. WHAT IS THE PROBLEM?
Violence against women in Canada is a major public health concern. 1 From the age of sixteen, one in two Canadian women will suffer some form of physical or sexual violence;2 the prevalence of domestic violence in Canada is shown to be approximately 29 percent. 2The annual incidence of violence against women is estimated to be ten to 14 percent. 3 An episode of violence is often not the first. Thirty-nine percent of women currently
THE CYCLE OF VIOLENCE
There appears to be a clear pattern in domestic violence, a cycle of three distinct phases: escalation, explosion, and calm with reconciliation (Figure 1 a,b,c).6.)
* Policy Statements: this policy reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.
JOURNAL SOGC
803
AUGUST 1996
, , , FIGURE le
FIGURE la THE CYCLE OF VIOLENCE
MARITAL VIOLENCE OVER TIME
The three phases in the cycle of violence, whether the abuse is verbal, physical, psychological or sexual, vary in time and intensity during a couple's life and from one couple to another.
Abused people get to "know" when the next violent episode is coming. Some abused partners have said sometimes they even provoke the violence to "get it over with."
TENSION ESCALATES Occurrence of several incidents considered minor by the vict im. The victim believes that the situation is tem porary and that s hewill be able to control it.
Over time, the cycle of violence shifts. Honeymoon periods become shorter, or non-existent. They may be replaced by an "indifference" stage. Affection has died; indifference is the only relief from tension and fear.
VIOLENCE EXPLODES Tot al loss of control. Short episode, always serious, lasting up to 24 hours.
Tension and violence increase. And where once the abuser may have kept the abused person with promises ("I'll go for counselling"), now he keeps her with control ("You have no money") and threats ("I'll kidnap the children," "I'll track you down and kill you.")
PERIOD OF CALM AND RECONCILIATION The man seeks forgiveness while the victim is hopeful an d wishes to forget. The period varies in length and may not occur at all in some couples.
Each violent incident increases the likelihood that another will occur. The severity of violence increases-and so does the danger.
AND THE CYCLE BEGINS AGAIN WITH THE PHASES COMING CLOSER TOGETHER AND THE INCIDENTS BECOMING MORE SERIOUS.
2. Traumatic Bonding Two Canadian researchers have proposed a theory to explain the strong attachment abused women feel for their abusive partners. The " reasons" frequently put forward to explain the strong attachment were plausible but did not seem to fit all the facts. For example, one hypothesis is that abused partners have grown up in violent homes and therefore believe that violence is normal. It's true that girls growing up in violent homes are more likely than other girls to have abusive relationships as adults. However, two-thirds of abused w ives d id not grow up in violent homes. Breaking the Cycle of Family Violence
ABUSE DURING PREGNANCY
The incidence of physical abuse during pregnancy has been estimated to be between four to seventeen percent- 5 According to 1993 Canadian data, the incidence of abuse during a current pregnancy appears to be in the region of six to seven percent, with eleven percent of women having experienced abuse prior to the pregnancy. Of those abused during pregnancy, 64 percent reported increased abuse during pregnancy, and 14 percent indicated that the first episode of abuse occurred during the pregnancy. In this study, although 67 percent of abused women received medical treatment for the abuse, only three percent told their prenatal care providers.s Clearly, physical abuse remains a frequently undetected risk factor in a large number of pregnancies.
HONEYMOON
MYTHS AND FACTS9 Source: Correctional Service Canada, "Breaking the Cycle of Family Violence," 1988. Concept: Bonnie Hutchinson; graphics: Jim Brager.
Myth Abuse is not a significant problem. Fact Ten percent of Canadian women live with an abusive partner.
Reproduced with Permission.
JOURNAL SOGe
804
AUGUST 1996
, , , APPROACHABI LITY
Myth An abusive act is usually a one-time event. Fact Most women will have suffered multiple abusive episodes before seeking outside help. Myth Injuries are usually not serious. Fact Twenty percent of all homicides in Canada are domestic. Twenty-five percent of women who attempt suicide are abused. Myth Abuse happens only in disadvantaged families. Fact Abuse occurs in all socio-economic classes, among women from all educational and cultural backgrounds. Data suggest that 65 percent of perpetrators are employed, and that 25 percent have completed high school or higher education. Myth Alcohol is the cause of abuse. Fact Alcohol may be a factor, but treating alcoholism does not end abuse. Myth Women provoke violence. Fact Provocation is an excuse. Violent behaviour is the responsibility of the perpetrator. Myth Pregnant women are less likely to be abused. Fact Typically, violence begins or increases during pregnancy. Myth Physicians are likely to diagnose abuse. Fact Data suggest that the diagnosis is made in only four percent of abused women using medical services. Myth Abuse does not affect other family members. Fact In families where abuse occurs, 25 to 50 percent of the children are also abused or neglected. Sixty-six percent of abused women and 80 percent of abusive men experienced or witnessed violence in their homes as children. to
The physician remains one of the key people to whom a woman may disclose her situation, however, few women will disclose spontaneously. It is the physician's responsibility to provide an environment in which disclosure becomes possible, and to maintain a high index of suspicion regarding actual or potential abuse. Patient education material on physical abuse should be clearly displayed in patient waiting areas, examination rooms, and washrooms. Telephone numbers of local shelters and help lines should be clearly displayed in all patient areas including washrooms. WHEN TO SUSPECT PHYSICAL ABUSE11
Patients who make multiple visits to physicians' offices with ill-defined complaints, including: Headaches Insomnia Choking sensation Hyperventilation Gastro-intestinal symptoms Chronic pain (pelvis, abdomen or back) Other signs and symptoms: Shyness Fear Embarrassment Evasiveness Passivity Frequent crying Often accompanied by a male partner who is reluctant to leave Drug and alcohol abuse or overdose Attempts at self-harm or suicide Insomnia Depression Sexual problems Injuries inconsistent with explanation of mechanism During a physical examination, evidence of recent or remote injuries may be detected. These should all be noted (on a body chart preferably) and the woman asked how they were sustained.
WHAT THEN IS THE ROLE OF THE PHYSICIAN?
1. 2. 3. 4.
to be aware; to be approachable; to identify problems; and to provide support and medical care.
AWARENESS
First and foremost, physicians must recognize the magnitude of the problem, and realize that violence against women will exist within their practices whether recognized or not.
JOURNAL SOGC
IDENTIFICATION
There are certain barriers to identification of violence by physicians, including;
805
AUGUST 1996
, , , deficiencies in medical training in this area; discomfort with psychosocial issues; view that family violence is private; and personal history of family violence. 1
Within the last year, has anyone forced you to have sexual activities? Are you afraid of your partner? 5 Following disclosure, the physician should state clearly that physical and psychological abuse are not acceptable behaviours, and that no one deserves it. The woman is in no way to blame for the situation. Enquiry should be made into the woman's perception of her own safety, and whether she has any exit plan should she feel in danger.
Ask the questions. Direct, while sensitive, questioning regarding physical abuse should be part of his tory taking. This is not seen as intrusive by most women, and will indicate an openness to discuss the issue of violence, if not at this interview, then in the future should it become necessary.
EXIT PLAN FOR ABUSED WOMEN
SIGNS TO WATCH FOR
We propose the following plan for women who fear for the safety of their children or for themselves. 1. Having a change of clothing packed for herself and her children. This should include necessary medications and extra house and car keys. These can be placed in a suitcase and stored with a friend or neighbour. 2. Cash, cheque book, and a savings account book may also be kept with clothing. 3. Identification papers, birth certificates, social insurance cards, driver's licences, such financial records as mortgage papers, rent receipts, and automobile title should be taken if available. 4. Item of special interestto each child (e.g. Teddy bear). 5. A plan detailing exactly where to go, regardless of time of day, should be made. This may be a friend's or a relative's home or a shelter for battered women and children.s,ll The woman's intentions should be ascertained. Information should be supplied regarding possible avenues of action. She should not be coerced on the basis of "what is best for her." Community and family support systems should be explored, as should her knowledge of community support and resources. Information should be supplied. Specific information should be given regarding available community resources with addresses and telephone numbers. Help in connecting the women with resources may also be required. Education regarding the natural history of abuse is also essential: * Violence is a criminal offence * Violence will often escalate if unchecked * It is unlikely to stop without intervention * Adverse effects on children in family * She is not to blame ll
Acute-Physical injuries: Site: Multiple injuries which cluster: e.g. centrally, head, neck, face, throat, chest, abdomen. Abrasions, contusions, bums and scalds, perType: forated tympanic membrane, fractures of jaw, clavicle, ribs, strangulation marks, internal injuries, and evidence of rape. History does not appear consistent with injuries. Injuries are at different stages of healing. History: Multiple visits to an emergency unit, history of suicide attempts, long term use of psychoactive drugs, history of psychiatric illness, substance abuse, and pregnancy. Chronic: Chronic pain without identifiable cause, psychological, sexual dysfunction, marital and family dysfunction. In situations of sexual aggression, the complaints may be of a more sexual nature including dyspareunia or decreased libido. PROVISION OF SUPPORT AND MEDICAL CARE
It is important to interview the woman alone. Here is a sample of questions to be asked when assessing and screening for abuse. ASSESSMENT AND SCREENING FOR ABUSE
Have you ever been emotionally or physically abused by your partner or someone close to you? Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Since you have become pregnant, have you been hit, slapped, kicked, or otherwise hurt by someone?
JOURNAL SOGC
806
AUGUST 1996
, , , It is not the physician's role to contact legal authorities, unless a minor is involved or unless that is the wish of the woman. Physical abuse is not solely a medical condition. It is the physician's role to supply medical and supportive care through the period of transition and healing process. An interdisciplinary approach is the key in providing support to the woman, regardless of what her decisions are. Inappropriate interventions can cause the situation to escalate in the home, leading to more severe violence, further endangering the woman. Clear documentation of injuries is essential and future legal action should be discussed. Be prepared and available for court appearances if necessary. Support the woman's decision, even if you disagree. If you feel unable to supply that support, refer the woman for future care to a practitioner who can.
J SOGe
1996;18:803-07
REFERENCES 1.
Nuttall SE, Greaves U, Lent B. Wife battering: an emerging problem in public health. Can J Public Health 1985;76:287-99. 2. Canadian Centre for Justice Statistics. Wife assault: the findings of a national survey. Juristat Service Bulletin, Statistics Canada 1994; 14(9); 1-22. 3. MacLeod L. Wife battering in Canada: the vicious cycle. The Canadian Advisory Council on the Status of Women, Ottawa, 1980. 4. Richwald GA, McClusky Te. Family violence during pregnancy. Adv Int Maternal Clinical Health 1985;5:87-96. 5. American College of Obstetricians and Gynecologists. Domestic Violence. ACOG Tech Bull 1995;209:1-9. 6. Walker LE. The battered woman syndrome. New York. Springer Publishing Co., 1984. 7. Correctional Service Canada. Breaking the cycle offamily violence.1988. 8. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J 1993;149(9):1257-63. 9. Community Health Committee, Medical Society of Nova Scotia. Women abuse: a handbook for physicians. 1991:1-11. 10. Jaffe P, Burris CA. Wife abuse as a crime: the impact of . police laying charges. Canadian Journal of Criminology 1983;25:209-18. 11. Brown JB, Lent B, Sas G. Identifying and treating wife abuse. J Fam Pract 1993;26(2): 185-91. 12. Norton LB., Peipert JF, Zierler S et at. Battering in pregnancy: an assessment of two screening methods. Obstet GynecoI1995;85(3): 321-5.
JOURNAL SOGC
807
AUGUST 1996