CHAPTER 82 Domestic Violence
Although the term domestic violence may be broadly interpreted to include child and elder abuse, in this chapter it refers to violence that occurs in the context of an intimate relationship. Similar terms for this phenomenon include battering, partner violence, spouse abuse, and wife-beating. Domestic violence is a pattern of intentionally violent, coercive, or controlling behaviors by a current or previously intimate partner of the victim. The violence is a means toward the goal, which is to assert and to maintain power and control over the victim.1 This behavioral pattern may encompass humiliation, emotional torment, economic control, social isolation, and sexual assault, as well as threatened and actual physical injury. Because the majority of domestic violence involves male perpetrators in heterosexual relationships,2,3 this chapter will use the convention of female pronouns for victims and male pronouns for perpetrators. This is not to imply the totality of the problem, which includes male victims and female batterers, as well as violence in same-sex relationships.
There is neither societal stratum nor current or past civilization shown to be exempt from domestic violence. This endemic affliction has grave and extensive public health implications, not the least of which are the physical injury, physical and mental disability, and possible death of the abused. The societal costs of domestic violence include health care expense, lost wages, and decreased or lost productivity, as well as the generational implications of, and the long-term effects on, children who witness such violence.3–5 Studies of routine screening have shown that detection, though necessary, is not sufficient for successful intervention.6–9 Despite improved provider awareness, attitudes, stereotypes, time constraints, a sense of futility, and perceived lack of resources remain barriers to detection.10,11 Victims live with shame, fear, limited (and often highly controlled) resources, and a perpetrator-distorted sense of reality, which serve as deterrents to disclosure. The danger is real. If not handled well, disclosure and detection may seriously increase the victim’s risk: a victim who leaves has a 75% greater risk (than those who stay) of being murdered by her batterer.12
Although controversy exists,13–16 a large national survey3 demonstrated that domestic violence in the United States affects women six times as often as men, with approximately 4.5 million annual episodes of abuse perpetrated against women by an intimate partner or a former partner. Female victims experience a mean of 3.4 assaults per year, which translates to 1.5 million American women assaulted by an intimate partner yearly, or a victimization rate of 44.2 per 1,000 women. Most (85%) episodes of domestic violence involve men who abuse their female partners. In fact, women are more likely to be assaulted, raped, or murdered by a current or previous male partner than by a stranger (72.1% versus 10.6%). While American men experience more pervasive violence, they are more likely to be assaulted by a stranger (56.2%) than by an intimate female partner or previous partner (16.6%). The difference in the rates of partner abuse experienced by women versus men escalates with the severity of violence, with women being 7 to 14 times more likely to be beaten up, choked, or threatened with a firearm or drowning. An estimated 30% to 50% of married couples experience some instance of physical violence. Although not as extensively studied, same-sex couples appear to have rates of violence similar to their heterosexual counterparts.17,18 When women are violent toward their male partners, it is often, though not always, in the setting of self-defense, and less likely to cause physical injury.3 Domestic violence has a recurrent and escalating pattern, with spousal murder accounting for approximately 1 out of 10 homicides (11%). Approximately one-third of female homicide victims are murdered by a current or former intimate partner.19
Much is known about the prevalence of abused women in various medical settings. In the emergency department (ED), 11% of women seen for any cause are in abusive relationships,20 although only 2% of women seen in the ED may seek treatment for abuse-related acute trauma.21 Among women seen emergently for non–motor vehicle trauma, the prevalence of intimate partner abuse may be as high as 40%. The lifetime prevalence of abuse in women seen in the ED may be over 50%.20 For women being seen in a general medical setting, 14% to 28% may be victims of domestic violence,22,23 while 7% to 16% of those obtaining routine prenatal care have been victimized.24–26 In the pediatric setting, more than half of the mothers of abused children are themselves being abused.27
Psychiatrists have an even greater opportunity and challenge to ascertain and to address the needs of abused women, who account for one-fourth of all women treated at emergency psychiatric services, one-third of all women who attempt suicide,28 one-half of all women in outpatient psychiatric care, and almost two-thirds of women on inpatient psychiatric units.29
Psychiatrists, as well as other health care providers, should maintain a high level of suspicion regardless of the patient’s socioeconomic, educational, professional, ethnic, racial, or religious affiliation. Domestic violence is the great equalizer; it respects no such boundaries.30
However, certain women (and couples) are at greater risk,2,31 and they deserve heightened sensitivity and scrutiny. Table 82-1 lists some of these features. Young women (in their teens and twenties), especially if single (divorced or separated) or pregnant, are more likely to be abused by a current or former partner. Filing a restraining order, especially a temporary restraining order, further increases the risk.32 This act of independence may fuel the abuser’s need to assert his domination and control. A woman may be “poor” because her abuser controls (and limits) the financial and other resources available to her. Abused women often turn to drugs or to alcohol (for an escape, and to tolerate or numb their experience of abuse). Drug or alcohol use by a woman’s partner may also increase her risk, as his irritability, irrationality, and disinhibition increase. The presence of an excessively jealous (controlling, easily angered) or possessive partner,12 especially one who seems overly involved in the woman’s medical visit, or refuses to leave the examination or interview room, should significantly raise the clinician’s level of suspicion.31
Table 82-2 lists some of the other traits found to correlate with men at increased risk of injuring their partners.33 It is not surprising that men with an antisocial personality disorder are overly represented among violent perpetrators. However, it may be less intuitive that young men, especially with limited financial means and education, are also at increased risk. Depression is also associated with increased violence in men.34
The only unifying feature of victims of domestic violence is the existence of a partner who is violent. All segments of the population are represented. No previctimization personality type has been defined or identified to predispose a person to be abused. However, the repeated abuse experience often leads to a pattern of behavior that appears character disordered. Persistent emotional badgering, physical abuse, or sexual assault may result in intense shame and an overwhelming sense of worthlessness and incompetence. When such women seek medical attention, especially when accompanied by their batterer, they often seem dependent and overly passive. They frequently do not look abused, or have injuries or obvious evidence of battering. They may have vague physical or behavioral complaints. They may be seen as “somatic” and emotionally unstable.35 (Such a woman may fare even less well in the legal arena.)
In fact, an abused woman may be entirely dependent on her abuser. Social isolation serves to cut off any outside contact or support, including, and especially, from the victim’s own family of origin or long-time friends. Humiliating economic control and deprivation further restrict her independence and increase her vulnerability. Living with chronic fear and threats may be even more detrimental than the actual physical abuse.1 While a victim may find ways to endure, dissociate, or numb the physical pain and fear, threats to her children, family, or pets5 may be continually unbearable. Even total submission may seem a reasonable price to pay to keep those she cares about safe. Such passive, dependent, and submissive behavior is the result of repeated abuse, not a predisposing condition. In fact, it is the goal, not the cause, of the abuse.1
Certain psychiatric disorders are more commonly associated with domestic violence.34,36 Drug and alcohol use and addiction disorders are more common among victims of abuse. Eating disorders are also associated with domestic violence.31 Not surprisingly, depression and anxiety are frequent co-morbidities.34 Of women seen in emergency settings, those with current or past partner abuse are more than three times as likely to have made a suicide attempt.20 Posttraumatic stress disorder (PTSD), with the associated hyperarousal, flashbacks, and nightmares, is especially common in, though not limited to, victims who also have a childhood history of abuse.37 This syndrome may go unrecognized when the patient does not volunteer the traumatic precipitant, which underscores the need for astute pattern recognition skills. Various chronic pain syndromes (including headaches, pelvic pain, intractable abdominal pain, and musculoskeletal problems) are also associated with domestic violence.35,38,39
There may be shared cultural and developmental experiences that predispose to certain personality traits, but perpetrators of domestic violence are not limited to any particular segment of society. However, just as the impact of violence shapes the pattern of victim behavior and appearance, there is an identifiable pattern of behavior, experience, and style in those who have become violent in their intimate relationships (Table 82-3).