Prevalence Study of Domestic Violence Victims in an Emergency Department

Prevalence Study of Domestic Violence Victims in an Emergency Department

INJURY PREVENTION/ORIGINAL CONTRIBUTION Prevalence Study of Domestic Violence Victims in an Emergency Department I From the Department of Psychiatry...

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INJURY PREVENTION/ORIGINAL CONTRIBUTION

Prevalence Study of Domestic Violence Victims in an Emergency Department I

From the Department of Psychiatry, University of Queensland*, and the Royal BrisbaneHospitaV, Herston, Queensland, Australia. Receivedfor publication January 3, I996, Acceptedfor publication March 7, I996.

Gwenneth L Roberts, PhD* Brian I O~l'oole,PhD* Beverley Raphael, MD* Joan M Lawrence, MB BS* Richard Ashby, MB BS*

Supported by grantsfrom the Queensland Department of Family 5ervices and Aboriginal and Islander Affairs, the CriminologyResearch Council, and QueenslandHealth. The views expressed are the responsibility of the authors and are not necessarily those of the Departments or the Council. Copyright © by the American College of Emergency Physicians.

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Study objective: In 1992, a study of the prevalence and predictors of domestic violence victims among individuals who presented to a major public hospital emergency department was conducted to replicate a study conducted by the authors in the same setting 12 months previously. The second study aimed to investigate more accurately the presentation of current victims of domestic violence to the ED. Methods: In a retrospective, cross-sectional study, a screening questionnaire was administered to participants to establish the prevalence of a history and current presentation of domestic violence problems among patients who presentedto the ED of a major public hospital. The study group comprised a representative sample of 670 male and 553 female adults (older than 16 years) who presented to all sections of a public hospital ED during 53 randomly selected 8-hour nursing shifts over an 8-week period in 1992. Results: The results of the second prevalence study confirmed those of the first study. Of the 1,223 respondents in the study, 15.5% disclosed a history of adult domestic violence (8.5% of men, 23.9% of women). Women were at greater risk than men for abuse as adults (raw relative risk [RR], 3.27; 95% confidence interval [Cl], 2.23 to 4.79; RRadjusted for age, history of child abuse, and country of birth, 4.13; CI, 2.86 to 5.95}. Women were at greater risk than men for being doubly abused (as a child and as an adult)(raw RR, 2.17; CI, 1.33 to 3.53). The second prevalence study confirmed what had been indicated in the first study: that 2.0% of women who presentedto the ED (11.6% of all women with a history of adult domestic violence) were current victims of domestic violence and that these women presented mainly between the hours of 5 pm and 8 am, when no social work services were available for referral of victims. Conclusion: These Australian studies support the findings of prevalence studies of domestic violence victims in ED in the United States. The prevalence and risk factors indicate the need

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for training of physicians and nurses in the ED about domestic violence and for provision of appropriate backup referral services such as after-hours social work services. [Roberts GL, O'Toole BI, Raphael B, Lawrence JM, Ashby R: Prevalence study of domestic violence victims in an emergency department. Ann EmergMedJune 1996;27:747-75&]

INTRODUCTION Research regarding domestic violence victims in the emergency department setting has suffered from a number of methodologic problems, including lack of definitional consistency and clarity about domestic violence, inconsistent and inadequately described study designs, and nonrandom sample selection. In 1988, Geffner et aP examined a representative sample of domestic violence investigations and found that only 16.0% described the criteria used to define the sample of abuse victims. Definitions that have been used range from physical criteria or abuse in current relationships x to inclusion of emotional abuse and sexual abuse in past relationships. 3 Some studies have investigated only patients with physical trauma, and others have not distinguished between current and lifetime abuse. 2-5 Studies reporting prevalence estimates between 22.0% and 35.0% for domestic violence among patients presenting to the ED cannot be compared because of lack of definitional agreement. 2,4,5 A randomized study in the United States conducted with EDs in five urban study sites defined domestic violence as physical or nonphysical abuse caused by a boyfriend or husband. 6 The investigators delineated the recency of abuse as incidence, 1-year prevalence, and cumulative lifetime prevalence. The findings showed a lower rate (11.7%) of incidence of domestic violence than has previously been reported, although this study showed a cumulative lifetime prevalence rate of 54.2%. In Australia, it was considered anecdotally that many domestic violence victims used the services of the ED, but the representativeness and percentages of users of the system were unknown. In a prevalence study that we conducted in the ED of an urban public hospital in 1991, using a random time sampling procedure, 23.0% of female (n=557) and 7.0% of male patients (n=656) who were screened for history of domestic violence reported lifetime abuse as adults. 7 Our criterion for domestic violence was abuse of an adult 16 years or older, during or after a family or close relationship, in which one partner was afraid of being physically hurt or actually was physically hurt by the other. The underlying assumption was

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coercive control by one person over the other in an intimate relationship, so domestic violence was considered more than a heated domestic argument, s When the recency of abuse was investigated, it was found that 1.9% of the total sample of women had experienced domestic violence in the 2z~ hours preceding presentation. On the basis of the assumption that those who had experienced domestic violence in the preceding 24 hours were current victims, we suggested in this first study that 1 in 50 women was presenting to the ED with current domestic violence problems. A second prevalence study, reported here, was conducted in the same ED 12 months later with the same research assistants, the same random time-sampling method, the same definition of domestic violence, and the same screening questionnaire. Our aim was to replicate the first study and to more accurately measure the incidence of acute victimization among patients who presented to the ED.

MATERIALS AND METHODS In this study, the same screening questionnaire administered to participants in the first study was used to collect information on the prevalence of domestic violence, types of abuse, recency of the abuse, identity of the abuser, respondent's knowledge of community services for domestic violence, and prevalence of a history of child abuse. An additional question in the second study asked whether the respondent was presenting to the hospital as a direct result of domestic violence problems. We measured the type of abuse by use of a modification of the Conflict Tactics Scale. 9 These items were augmented with other measures to collect information on serious threats to a person's life or children, sexual abuse and emotional abuse (including verbal abuse), social isolation, and economic deprivation. We administered a follow-up questionnaire to patients who reported domestic violence so that we might investigate their use of health services, including their evaluation of health professionals encountered in those services, and barriers that prevented them from disclosing domestic violence to health professionals. In this study we also asked whether the respondent had seen a mental health professional for health problems caused by domestic violence in the preceding year. Details of an exploratory study and the first prevalence study have been reported elsewhere/ During an 8-week period, July-September 1992, 53 of 168 nursing shifts (7 AM to 3 PM, 3 tO 11 PM, 11 PM to

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7 AM) were randomly selected, and questionnaires were administered by research assistants to all eligible attenders in all sections of the ED, enabling representation at all hours. The hospital computer records showed that 2,208 people presented to the ED during the selected shifts. Patients who were too ill (n=91), were unrousable (n=33), or were accompanied by another person who did not leave their side (n=22) were excluded from the study. It was mandatory that the screening questionnaire be administered to patients alone for reasons of confidentiality and validity of data. Of the 2,062 people who were approached, 52 had previously answered the questionnaire and 49 were younger than 16 years. Of the 1,961 who were eligible, 51 were mentally retarded or confused, 45 did not speak English, 38 were senile, 4 were illiterate, 9 were very deaf, and 8 were suicidal, aggressive, or too emotional. Of the potential study population of t,806, the hospital computer records showed that 463 were missed in the study, including persons who were in the resuscitation area or who presented during busy times and were missed by the research assistants. The response rate was 91.1% of patients who were approached (n=1,343), or 67.7% of the eligible population (n=1,806). The demographics of this study were very similar to those of the first study. The sample of 1,223 persons comprised 670 men (54.8%) and 553 women (45.2%) with a mean age of 40.6 years (SD, 19.2) and 45.1 years (SD, 21.8), respectively. Most of the respondents were Australian born (78.3%); as mentioned, non-Englishspeaking people were not screened because of a lack of interpreter facilities. There was a very low representation of Aboriginal (1.1%) and Torres Strait Islander (.2%) ethnic groups in this study. Respondents were approached in all sections of the ED; 70.0% entered the acute section, which handles patients with severe illness and emergencies and operates 24 hours a day; 30% entered the primary care section, which offers ambulatory care services between 9 AM and 5 PM on weekdays. More patients presented between 8 AM and 5 PM (65.2%) than between 5 PM and 8 AM (34.8%). We chose these intervals because no social work referral service was available between 5 eM and 8 Am when the study began. The data were analyzed with the use of SPSS. lo Initial analysis involved frequencies and relative risks (RRs). Multivariate logistic regression was performed with EGRET software. ~~ Results were considered statistically significant if the P value was .05 or less. Approval for conduct of this study was obtained from the Research Ethics Committee, Royal Brisbane Hospital;

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and the Behavioral and Social Sciences Ethical Review Committee, University of Queensland. RESULTS

Table 1 shows that of the 1,223 respondents in the study, 30.7% of women (n=553), and 15.5% of men (n=670) reported domestic abuse in their lifetime (%2=38.7, dr=l, P<.0001). A total of 15.5% of the sample (n=1,223) disclosed a history of adult domestic violence: 23.9% of the women (n=553) and 8.5% of the men (n=670) were victims (%2=53.6, dr=l, P<.0001). The results of this study were similar to those of the 1991 study. Women had significantly greater risks than men for abuse as adults and for double abuse as children and as adults, but women and men were equally likely to have experienced child abuse only. Logistic regression modeling was used to estimate the RR for each of the variables of sex, age, birthplace, and history of child abuse, taking into account the effects of each of the other variables in the analysis. Table 2 shows the adjusted results for this study. The results of the second prevalence study were very similar to those of the first study and showed that women had four times the risk of domestic violence that men did; it also showed that patients who had experienced child abuse had six times the risk of being a victim of adult domestic violence than those who did not have the experience. Those born overseas had the same risk for domestic violence as those born in Australia. In the 1992 study, the age distribution was not uniform: among patients reporting a history of domestic violence, more women than men were younger than 20 years, more men than women were between 20 and 40 years, and more women than men were older than 40 years. In the second study, the number of men in the Table 1.

Prevalence of disclosure of domestic violence among all patients presenting to the ED of the Royal Brisbane Hospital, 1992, and RR for female compared with male patients.

History of Abuse Net abused Any abuse As an adult As a child As child and adult

% Men % Women [n=670] [n=553] 84.5 15.5 4.9 7.0 3.6

69.2 30.7 16.1 6.9 7.8

% Total [n=1,223] 77.8 22.4 10.0 6.9 5.5

RR (95% CI) 1.98 (1,59 to 2.46) 3.27 (2.23 to 4.79) .98 (.65 to 1.48) 2.17 (1.33 to 3.53)

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16-to-30 age group who reported domestic violence increased significantly, by 12% (%2=54.61, dr=l, P<.0001), compared with same value in the 1991 study. The number of female victims in each age group in the second study was similar to the 1991 results, with rates in the higher age groups remaining higher for women than for men. Table 3 shows the RRs of domestic violence for women and men in each age group when the specific prevalence rates were calculated for each group within the total sample. As in the 1991 study, the RRs for women compared with men were significantly greater than 1.0 for all age groups except the oldest. The group of patients who were older than 70 years of age had a confidence interval (CI) including 1.0; therefore the analysis for this group was not significant. In both studies, most victims (69.0%) reported that their most recent episode of abuse had occurred more than 1 year previously. In the second study, 5.3% reported that they had experienced domestic violence in the preceding 24 hours, compared with 8.3% in the first study. However, in the second study a more accurate assessment was made of current victims presenting to the ED because a question was added to the screening questionnaire asking respondents whether they were at the ED because of domestic violence problems. Fifteen patients (8% of those Table 2.

Results of logistic regression modeling age, sex, country of birth, and history of child abuse as predictors of disclosure of domestic violence. * Variable

Value

Estimate (SE)

RR (95% CI)

(Constant) Sex

--

-1.84 (36)

--

Female Male

2 1

1.42 (.19)

4.13 (2.86 to 5.95) 1

Table 3.

Age group (years) 16-19 20-29 30-39 40-49 50-59 60-69 >70

2 3 4 5 6 7

1.03 (.36) 1.51 (.38) .95 (.40) 1.13 (.40) .73 (.41) -.22 (,45)

2.18 (1.40 to 5.65) 4.51 (2.16 to 9.43) 2,57 (1.16 to 5.69) 3.10 (1.41 to 6.82) 2,08 (.92 to 4.69) .80 (.32 to 1.95)

1 2

1.77 (.20)

5.88 (3.93 to 8.80) 1

-.41 (.22)

.66 (.43 to 1.03) 1

Child abuse Yes No

Country of birth Other countries 2 Australia 1 *RR in comparisonwith the referencevalue.

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reporting domestic violence; 1.2% of the total sample) answered yes to this question. One in 100 ED visits (male and female) was a direct and acknowledged result of domestic violence, as reported by the victim. Because 80% of patients who reported that they were presenting with domestic violence problems were women, we estimate that approximately 1 woman in 50 presenting to the ED is a current victim of domestic violence, confirming the suggestion arising from the first prevalence study. More than half of these victims came to the ED between the hours of 5 PM and 8 AM, when no social work referral services were available. Respondents were asked the identity of their abusers. In the 1992 prevalence study, men were significantly more likely to report abuse from girlfriends (Fisher's exact test, P=.04) than they were in the first prevalence study. In the second study, women were more likely to report abuse by a spouse than were men (RR, 1.38; 95% CI, 1.14 to 1.66). Men were more likely to be abused in a de facto relationship than women (RR, 1.63; 95% CI, .1.03 to 2.57), and men were more likely than women to be abused by relatives other than spouses (RR, 1.95; 95% CI, 1.29 to 2.97). The RRs for men and women being abused by girlfriends and boyfriends were similar in the second study. Those who disclosed domestic violence were asked to identify the types of violence they had experienced. Table 4 shows the proportions of men and women in the 1992 sample of victims who reported experiencing each type of abusive act. Women were at greater risk than men for being choked, beaten, and sexually abused. Men had a greater risk than women for having objects thrown at them and for weapons being used against them. Those who reported domestic violence were asked further questions regarding their use of health services in

Age-specific prevalence of disclosure of domestic violence and RR for women compared with men. Age Group (Years)

Men (%) [n=670]*

Women (%) [n=553]*

RR (95% CI)

<20 1.5 18.2 14.89 (1.91 to 88.18) 20-29 103 28.5 3.46 (1.83 to 6.59) 30-39 17.9 32.8 2.25 (1.04 to 4.86) 40-49 7.9 27.0 4.31 (1.46 to 13.33) 50-59 8.0 33.3 5.75 {1.97 to 17,60) 60-69 3.7 22.4 7.40 (1.88 to 25.42) >70 1.5 9.7 6.88 (.87 to 58,61 } *Percentagesare calculatedwithTn each age group; hence,the columns do not add to 100%.

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relation t o domestic violence. Sixty-four patients (34.0% of domestic violence victims) reported injuries or health problems caused by domestic violence within the past year, and 37 (57.8%) of this group reported that they had received medical treatment for these injuries or problems. One fifth of those who reported domestic violence had seen a mental health professional within the previous year. Most victims (54.1%) had attended a general practitioner, 40.5% had attended the ED at Royal Brisbane Hospital, 21.6% had attended other hospitals, and 29.7% had seen other health professionals. Those patients who reported injuries or health problems during the past year were asked whether they had told the health professional that the problem was caused by domestic violence. Victims reported 95 occasions on which they saw a health professional, and 42.0% told the health professional about the domestic violence. Victims were asked for their assessment of the health professionals they had consulted (including doctors, nurses, and social workers). In the 1991 study, victims perceived doctors as the least helpful of the health professionals, but this situation appeared to have improved by the 1992 study, in which victims perceived the responses of doctors as comparable to those of other health professionals. Patients who responded that they had not told the health professional that their problem was caused by domestic violence were asked the reason why. The most common reasons were that the victims felt it was their problem; felt shame, guilt, or embarrassment; felt too frightened of a partner to ask for help; felt that no one would believe them; or were accompanied by an abusing partner when seeing a health professional.

DISCUSSION

These prevalence studies have provided hitherto unknown data about domestic violence victims in an ED in Australia. The findings were consistent, with the results of the second study reinforcing those of the first, in the second prevalence study, 31.0% of women and 15.0% of men reported a lifetime history of violence (including child abuse). A history of adult domestic violence was reported by 24.0% of women and 8.0% of men. These high prevalence rates were comparable to research findings in EDs in the United States. 2,4 The findings differed from those of Abbott et al, 6 who found the incidence of acute domestic violence to be 11.7% among women with partners and the prevalence of lifetime domestic violence to be 54.2%. However, their study was not comparable with the present study because almost half of the sample were nonwhite and the calculations for acute domestic violence were based only on the responses of women with partners. In the present study, most respondents were Australian born and white, and calculations for incidence were based on the responses of all women who answered the screening questionnaire. Logistic regression analysis conducted in the 1991 and 1992 prevalence studies showed that the greatest risk factors for being a victim of domestic violence were being female (~-.5 times greater than men) and having a history of child abuse (5 to 6 times greaser than those not abused as children). The latter finding confirms the results of other studies, which have reported significant associations between adult victimization and experience of child abuse.12,13 The second study made a more accurate assessment of the current presentation of victims with domestic violence problems than did the first study. It found that 1 in 50

Table 4. Proportion of men and women experiencing each type of abusive act, and RR for women compared with men.

Reported Experience

Men (%) [n=57]

Pushing 70.1 (40) Kicking 68.4 {39) Throwing objects 61.4 {35) Choking 15.7 (9) Beating 31.5 (18) Weapon used 36.8 (21) Serious threat 36.8 (21) Sexual abuse 12.3 (7) Emotional abuse 63.1 (36) *Columns do not add to 100% becauseof multiple responses.

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Women (%) [n=132]

Total (%) [n=189]

Relative Risk (95% CI)

81.1 {107) 73.4 (97) 44.6 (59) 33.3 (44) 54.5172) 21.2 (28) 37.1 (49) 28.8 (38) 81.8 (108)

77.8 {147) 72.0 (136) 49.7 {94) 28.0 (53) 47.6 {90) 25.9 (49) 37,0 (70) 23.8 (45) 76.2 (144)

1.08 (.90 to 1.29) 1,00 (.82 to 1.21) .70 (.53 to .92) 1.86 (1.00 to 3.43) 1.64 {1.10 to 2.44) .58 (.36 to .92) .94 (.63 to 1.40) 2.34 (1.11 to 4.93) 1.20 (.98 to 1.47)

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women was coming to the ED as a result of domestic violence, usually between the hours of 5 PM and 8 AM, when no social work referral service was available. It was observed by the research team that some staff were not aware of community resources for victims who came after hours (eg, referral to emergency accommodation), nor did they have time to attend to the psychosocial aspects of domestic violence problems in a busy ED. Even though this was a social emergency, other life-threatening emergencies took priority over the crisis of domestic violence victims, whose physical injuries were sometimes minor. This finding indicates the need for provision of an afterhours service that can address the problems of these victims at a crisis point in their lives. It was found that domestic violence victims who were sent from the ED with an appointment to see a social worker invariably did not keep the appointment. Either they were constrained from coming to the appointment by an abusive partner, or they returned home with the hope that the violent situation would improve. One of the outcomes of this study was the implementation of an on-call after-hours social work service at the ED, Royal Brisbane Hospital. This service has received a consistent number of referrals, over a period of 3 years, of 1 to 3 victims per week. The consistent number of referrals by doctors and nurses to this service indicates that doctors and nurses in the ED are identifying and referring victims of domestic violence for appropriate management. The awareness of domestic violence by doctors and nurses appears to have been raised by dissemination of the results of these prevalence studies and by an education program that was conducted for doctors and nurses in the ED between the two prevalence studies. The social work service is now being evaluated by the authors in a further study being conducted among female patients in the ED. In the first study, women aged 20 to 40 years were most likely to report a history of adult domestic violence, and this remained true for the second study. Even so, women in higher age groups also reported domestic violence, with 10.0% of those older than 70 years of age reporting violence. Current abuse is therefore still a reality for older women. The higher rates of abuse for younger women may have been a result of the shorter time span since the abuse occurred and the problem of recall for older women. The desire of the latter to forget or deny abuse that happened a long time ago, or even acknowledgment that the abusive spouse was deceased, may have accounted for the lower rates among older women.

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In both studies, men and women reported similar rates of different types of abuse, including emotional abuse and physical abuse, ranging from pushing, slapping, and throwing of objects to use of weapons and serious threats. Women reported significantly more sexual abuse than men and, in the second study, more beatings. The only area in which men reported more abuse than women was when weapons were used. All of these findings have a limited interpretation because the measures that were used, the Conflict Tactics Scales,9 are deficient in recording the severity of the abuse. They do not include the context, meaning, pattern, and consequences of the abuse, nor who initiated the abuse, which may vary between men and women. Measurement techniques need to be developed to incorporate all these variables. One third of the victims reported health problems or injuries caused by domestic violence within the previous year, and most of them had received medical treatment for these problems. Only a small number of these victims had not told a health professional about the domestic violence. This indicates that health professionals must be able to respond appropriately when domestic violence is disclosed to them. Although most victims had attended a general practitioner, these figures may not reflect the use of health services by victims of domestic violence in the wider community. A greater proportion of domestic violence victims in the community may use general practitioners and rarely or never use the hospital system, especially for minor injuries. This emphasizes the importance of general practitioners addressing the issue of domestic violence. In the first study, doctors were perceived by victims as the least helpful of health professionals when domestic violence was disclosed to them. This situation had improved by the time of the second study, in which victims perceived the response of doctors to be comparable to that of other health professionals. The improved assessment of the hospital doctors may have resulted from the educational intervention program conducted for doctors and nurses in the ED between the two prevalence studies. Nurses were perceived as the most helpful in listening to victims of domestic violence. This may reflect the larger amount of time that nurses spend with patients and may also be a function of the nursing profession being predominantly female. Social workers ranked higher than other health professionals in giving advice to victims, and this may reflect the counseling role taken by social workers in addressing domestic violence problems. One of the hypotheses tested in this study related to the barriers to disclosure of domestic violence. In fact, the

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majority of subjects disclosed domestic violence to a health professional, and this indicates the need for the training of doctors to respond appropriately when victims disclose to them. These studies confirmed the hypothesis that the most common barriers to victims' disclosing domestic violence were feeling that it is no one's problem but the victim's own; feeling ashamed, guilty, and embarrassed about the violence; and feeling too scared of an abusive partner to ask for help from a health professional. These reasons were indications of the roles that health professionals may play in advocacy and empowerment of victims, enabling them to seek help for the violence. The topic of domestic violence warrants much more attention by health professionals than has been given previously. The high rates of presentation of domestic violence victims in this study indicate that the ED is an appropriate place for addressing the issue of domestic violence and for intervention with victims, who are usually in a state of crisis at presentation. If appropriate services are put in place and victims are referred to the relevant community services, the use of expensive hospital services might be reduced. Another problem highlighted in this study is the incomplete management of the psychosocial aspects of domestic violence victims. This points to the necessity for education of health professionals in the identification of victims of domestic violence and for referral services to deal with the psychosocial aspects of the social emergency of domestic violence. Failure to address these problems may result in a "second injury" to victims by the institution and subsequent exacerbation of their psychological symptoms. > If victims of domestic violence are identified and managed appropriately in the ED, not only will the benefits flow directly to the victims, but it will indicate to the community that health professionals believe that this is an important and serious issue that needs to be addressed. This will be an important step forward in the prevention of domestic violence.

6. Abbott J, Johnson R, KozioI-McLainJ, et ah Domestic vio]ence against women: Incidenceand prevalence in an emergencydepartment population. JAMA 1995;273:1763-1767. 7. Roberts GL, O'Toote BI, LawrenceJM, et ah Domestic violence victims in a hospital emergency department. Mad J Aust 1993;159:307-310. 8. Okun L: WomanAbuse: Facts Replacing Myths. New York: State University of New York Press, 1986:113. 9. Straus MA: Measuring intra-family conflict and violence: The Conflict Tactics Scales. J Marriage Faro1979;41:75-88. 10. SPSSfor Windows Base System User's Guide:Release 5.0. Chicago: SPSS, 1992. 11. EGRET(computerprogram). Seattle: Statistics and Epidemiology ResearchCorporation, 1990.

12. Green A: ChildMaltreatment. A Handbook for Mental Health and Child Care Professionals. New York: Jason Aronsen, 1980. 13. Russell D. The Secret Trauma:Incest in the Lives of Girls and Women. New York: Basic Books, 1988. 14. Symonds M. The "second injury" to victims (special issue). Evaluation andChange 1980:3638. Gratitude is expressed te the medical and nursing staff in the emergency department of Royal Brisbane Hospital for their excellent cooperation in this project. Acknowledgement is made of the many people who responded to the questionnaire presented to them in the emergency department. Without their willing responses, this study would not have been possible, and they have contributed to the quality of the project.

Reprint no. 47/1/73229 Address for reprints: Gwenneth Roberts, PhD Trauma Studies Group Department of Psychiatry Edith Cavell Building Royal Brisbane Hospital Herston 4029 Queensland, Australia 61-7-3365 5570 Fax 61-7-3365 5466 E-mail [email protected]

REFERENCES 1. Geffner R, RosenbaumA, Hughes H: Researchissues concerning family violence, in Hasselt VB, Morrison KL, Bellack AS, et al, eds: Handbook of Fatuity Violence. New York: Plenum Press, 1988:457. 2. GoldbergWG, Tomlanovich MC: Domestic violence victims in the emergencydepartment: New findings. JAMA 1984;251:3259-3264. 3. Dalton DA, Kantner JE: Aggression in battered and non-battered women as reflected in the hand test. PsycholRap 1983;53:703-709. 4. Stark E, Flitcraft A, Zuckerman D, et el: Wife Abuse in the Medical Setting."An Introduction for Health Personnel Rockville, Maryland: National Clearinghouseon Domestic Violence, 1981. 5. McLeer SV, Anwar R: A study of battered women presenting in an emergencydeparEment.Am J Public Health 1989;79:65-66.

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