BMJ  2003;327:686 (20 September), doi:10.1136/bmj.327.7416.686

reviews

Books

Family Violence in Primary Care; Violence Against Women: A Physician's Guide to Identification and Management

In 1985 US surgeon general C Everett Koop declared domestic violence the biggest public health crisis of the decade. In 1994 the United Nations recognised violence against women as a human rights abuse. In the late 1990s national surveys in Canada and the United States reported that a third of women had been physically assaulted by an intimate partner, putting them at risk of injury, a range of physical and emotional health problems, and death. In 2002 a World Health Organization report on violence and health said that up to 70% of female murder victims were killed by their partners or former partners.

Despite this, the healthcare system's role in alleviating violence against women has a short history. Decades of advocacy and scholarship, particularly in north America but also in the United Kingdom, have revealed the largely hurtful rather than helpful practices of health care: dismissive or disbelieving treatment of women, victim blaming, and prescribing psychiatric drugs rather than offering support and counselling.

Dozens of professional associations now issue guidelines about how best to identify and respond to domestic violence. These guidelines are based on the understanding that violence towards women is mostly perpetrated by men that they know; that such violence affects women from all social and ethnic groups; that it results in potentially serious health consequences; and that most women have contact with health services, which creates an opportunity for intervention and assistance.

However, domestic violence poses enormous challenges for healthcare providers. Doctors complain about women's vague presentations, time constraints, and lack of training, and express concern that women appear reluctant to take action—for example, they fail to leave the abusive relationship or resist charging the perpetrator. There are also difficulties when the same practitioner cares for both the victim and perpetrator. Doctors worry that asking about violence will open an unmanageable "Pandora's box."

Perhaps the biggest challenge is to convince practitioners that their role is important. Interventions for violence are not amenable to randomised controlled trials and the health effects of violence do not respond to drug treatments. The lack of "evidence" of treatment efficacy has translated into an assumption that interventions do not work. Medical journals have contested the appropriateness of universal screening ( BMJ 2002;325: 314[Abstract/Free Full Text], this issue, and the Journal of the American Medical Association 2003;289: 589-600[Abstract/Free Full Text]). The debate continues about whether the proper outcomes are being studied, whether women are harmed by healthcare interventions, and what kind of training and support providers need to implement screening. Most studies have failed to ask women themselves what they want or what works. And there has been little acknowledgment that doctors and nurses might be victims or perpetrators.

Family Violence in Primary Care, a collection of essays by UK based practitioners and scholars, emphasises the opportunities that exist in general practice, where long term relationships between the provider and patient allow sensitive topics to be discussed. Its inclusion of the myriad of acts that comprise family violence—child abuse, domestic violence, and elder abuse—is ambitious and inevitably means that certain topics are diluted. A rather obvious omission is sexual assault (or marital rape), estimated to occur in up to a half of abusive relationships.

The book is wide ranging, though, dipping into sociological and psychological theories of the causes of family violence, and mapping the epidemiology of its various forms. Placing in historical and social context the range of issues facing general practitioners, the book deftly argues that family violence results from imbalances of power.

Violence Against Women: A Physician's Guide to Identification and Management takes a more clinical approach, geared toward the American experience and health system. It offers specific protocols for screening and making referrals to mental health and social services. It covers sexual assault examinations and the special needs of women with disabilities, women of colour, and lesbians. Several clinical vignettes bring these issues alive. The book emphasises the doctor's role in promoting individual patient empowerment rather than broader social change.

The value in both these books is their educational material, which serves to dispel stereotypes. Domestic violence is not an isolated event, but often increases in severity and intensity over the course of a relationship. Women may not respond to healthcare interventions in a straightforward way because they fear retaliation for disclosure, being judged, or having their privacy compromised. They may not leave the abusive relationship according to the doctor's plan because they worry about their children's safety, are economically dependent on their partners, experience cultural or family pressure to remain, or simply have nowhere else to go. These books remind us that women are both victims and survivors.

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BMJ jclark{at}bmj.com

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