Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition

Enrique Gracia

doi:10.1136/jech.2003.019604

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Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition

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Author's second reply to Boyle
Enrique Gracia
Published on: 11 August 2004
Re: Author's reply
Adrian A Boyle
Published on: 27 July 2004
Author's reply
Enrique Gracia
Published on: 15 July 2004
Domestic violence screening, evidence is lacking
Adrian A Boyle
Published on: 25 June 2004

Published on: 11 August 2004
Author's second reply to Boyle
- Enrique Gracia, Professor of Social Psychology
Dear Editor
Boyle [1] raises very interesting points that deserve rigorous research and debate -see, for example, a recent editorial in BMJ by Ferries [2] on these and related issues. I believe that the debate over these issues contributes to increase their visibility for the research and professional communities, a visibility that hopefully will increase public, scientific and professional concern for domestic...
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Dear Editor
Boyle [1] raises very interesting points that deserve rigorous research and debate -see, for example, a recent editorial in BMJ by Ferries [2] on these and related issues. I believe that the debate over these issues contributes to increase their visibility for the research and professional communities, a visibility that hopefully will increase public, scientific and professional concern for domestic violence against women prevention and intervention.
Boyle agrees with the "softer" benefits of routine inquiry for domestic violence. But I would not underestimate what Boyle calls “softer” benefits. After all, social movements and grassroots efforts in the 70’s (which could be include in the “soft” category) are at the origin of public, scientific and professional concern about violence against women. Beginning in the 70s and until now, things have changed substantially. From almost a non-existing social, public health, and human rights issue, nowadays public and scientific concern and awareness of domestic violence has increased most notably. I believe, however, that still is needed another step forward, which is a point that I emphasized in my editorial. Public and professional concern needs to translate into greater personal and collective sense of responsibility at all levels, (both as citizens and as professionals in a variety of fields), as well as in actions indicative of social intolerance towards domestic violence.
This step forward will almost inevitably involve tensions between personal and family privacy and the need to expose family violence, helping the victims, and conducting research [3]. Domestic violence thrives on secrecy, silence, indifference, tolerance and passivity. The health sector, as well as other fields (law enforcement, social services, community organizations…), can help to shape a social environment of intolerance that can contribute to greater exposure and social control of domestic violence against women.
References
(1) Boyle A A. Re: Author's reply [electronic response to Gracia E; Author's reply jech.com 2004http://jech.bmjjournals.com/cgi/eletters/58/7/536
(2) Ferries LE. Intimate partner violence. Doctors should offer referral to existing interventions, while better evidence is awaited. BMJ 2004;328:595–6
(3) American Psychological Association. Report of the American Psychological Association Task Force on Violence and the Family. Washington, DC: Author, 1996.
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Conflict of Interest:
None declared.
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Published on: 27 July 2004
Re: Author's reply
- Adrian A Boyle, Emergency Physician
Dear Editor
Gracia is right about the "softer" benefits of routine inquiry for domestic violence and the role of societal attitudes is crucial in overcoming this problem.[1] Certainly the role of public awareness campaigns, though difficult to evaluate, has probably reduced social tolerance towards violence against women. Evidence and the lack of evidence is a tricky issue for domestic violence screening. This seems t...
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Dear Editor
Gracia is right about the "softer" benefits of routine inquiry for domestic violence and the role of societal attitudes is crucial in overcoming this problem.[1] Certainly the role of public awareness campaigns, though difficult to evaluate, has probably reduced social tolerance towards violence against women. Evidence and the lack of evidence is a tricky issue for domestic violence screening. This seems to be an area where all the normal "rules" about screening seem to be ignored.[2] Screening differs very much from routine inquiry that is more flexible and intuitive, but this distinction is often forgotten.[3] Atkins is wrong to suggest that there is a low risk of harm in asking.[4]
A proportion of women find inquiry unacceptable and this may damage the therapeutic relationship with an individual provider.[5,6] The most dangerous time for a woman in an abusive relationship is when she decides to leave, the risk of violence escalates. Healthcare providers need to be trained properly to deal with the resultant problems that disclosure can cause. The risks are further compounded where there are young children living with the victim. The association between child protection and domestic violence is unclear, though female victims of assault are much more likely to be known to child protection services.[7] Activation of child protection procedures is not without considerable risk and potential for distress. Interestingly "acceptability" is much greater in the peri-natal population than in primary care.[8] Time is a vital resource and it is not clear whether there is enough time for this among busy clinicians. Clinicians may be prepared to make more time if they could be persuaded of the benefits of their efforts.
Randomised controlled evidence about the benefits of interventions is conflicting.[9,10] This is partly because interventions may be culturally specific, the interventions are complex and follow-up in these women can be difficult. However, routine inquiry should only proceed when there is enough evidence to demonstrate that the risks are outweighed by the benefits and this should require RCT level evidence. Proceeding beforehand may cause more problems than it would solve.
References
(1) Gracia E. Re: author's reply [electronic response to Boyle AA. Domestic violence screening, evidence is lacking] jech.com 2004 URL direct link to eLetter
(2) The National Screening Committee. 2004. http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind.htm
(3) Taket A, Nurse J, Smith K, Watson J, Shakespeare J, Lavis V et al. Routinely asking women about domestic violence in health settings. BMJ 2003; 327:673-676.
(4) US Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Baltimore: Wilkins & Wilkins. 1996.
(5) Gielen AC, O'Campo PJ, Campbell JC, Schollenberger J, Woods AB, Jones AS et al. Women's opinions about domestic violence screening and mandatory reporting. American Journal of Public Health 2003; 19(4):279- 285.
(6) Partovi SN, Nelson BK, Bryan ED, Walsh MJ. Faculty triage shortens emergency department length of stay. Academic Emergency Medicine 2001; 8(10):990-995.
(7) Ward L, Shepherd J, Edmond AM. Relationship between adult victims of assault and children at risk of abuse. BMJ 1993; 306:1101-1102.
(8) Bindman AB, Grumbach K, Keane D, Rauch L, Luce JM. Consequences of queuing for care at a public hospital emergency department. JAMA 1991; 266(8):1091-1096.
(9) Sullivan CM, Bybee D, I. Reducing violence using community-based advocacy for women with abusive partners. J Consult Clin Psychol 1999; 67(1):43-53.
(10) Dunford FW, Huizinga D, Elliott DS. The role of arrest in domestic assault: the omaha police experiment. Criminology 1990; 28(2):183 -206.
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Conflict of Interest:
None declared.
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Published on: 15 July 2004
Author's reply
- Enrique Gracia, Professor of Social Psychology
Dear Editor
The letter by Boyle points out that there is not sufficient evidence to recommend screening for domestic violence, which is not to say that there is sufficient evidence to recommend against screening.[1] Recommendations for screening or routine inquiry for domestic violence have been made on other grounds.
For example, the US Preventive Services Task Force concluded that “there is insuffici...
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Dear Editor
The letter by Boyle points out that there is not sufficient evidence to recommend screening for domestic violence, which is not to say that there is sufficient evidence to recommend against screening.[1] Recommendations for screening or routine inquiry for domestic violence have been made on other grounds.
For example, the US Preventive Services Task Force concluded that “there is insufficient evidence to recommend for or against the use of specific screening instruments to detect family violence, but recommendations about physical abuse patients may be made on other grounds” [2]. David Atkins, coordinator of the US Preventive Services Task Force, said that “asking patients about abuse as part of routine history-taking may be indicated on the basis of the substantial prevalence of undetected abuse among women, the potential value of this information in the care of the patient, and the low risk of harm in asking” [3].
Also the Canadian Task Force on Preventative Health Care adopted the position that there is insufficient evidence to recommend for or against routine screening for violence although, despite the lack of evidence, concluded that the prevalence of and significant impairment associated with violence against women make it important to maintain a high index of suspicion when assessing patients [4-6]. Other medical organizations and accreditation bodies do recommend screening women or routine enquiry for domestic violence in health settings [7-10]. In Australia different initiatives are seeking to incorporate routine screening programs for domestic violence in health services and their evaluations support screening [11-14].
The editorial by Gracia pointed to the hidden nature of domestic violence, and one of the advantages of routine enquiring is that it uncovers hidden cases of domestic violence helping to break the social silence, inhibition and climate of tolerance surrounding the victims [15, 16]. For Bradley et al screening should be thought of as a way of uncovering and reframing a hidden stigma.[17] The importance of inquiring about domestic violence for increasing identification rates is also recognized in a influential review which concluded that there was insufficient evidence to recommend screening programmes. Ramsay et al acknowledge that “we know that introducing a programme is likely to increase the number of women experiencing domestic violence who are identified by health professionals, but not that subsequent interventions are effective” [18]. It is true that lack of evidence about effectiveness may discourage health services to implement them, but again, as Jewkes argues, not only the question of what is effectiveness in this context has not been resolved, but also equating lack of evidence to ineffectiveness is premature [19]. For example in a workshop hosted by the Centers for Disease Control and Prevention in USA, participants agreed that screening for domestic violence should be evaluated scientifically but there was also consensus that physicians should not wait for the results of randomized clinical trials to begin screening in their own practices [3].
Among the benefits of routine screening, not always easy to evaluate in clinical trials (but also worth evaluating), are the increase of awareness about domestic violence both among health professionals and the wider community, greater pressure for increasing high quality training resources for health professionals, improvement of knowledge, skills and sensitive attitudes among professionals, greater pressure to increase resources for victims after disclosure, benefits as a result of early intervention for victims both physical and psychological, increase of the social visibility of this problem, changes on social tolerance of violence in relationships, and also greater awareness and perceived relevance among the research community and funding agencies. And all these potential benefits may contribute to a coordinated response aiming to uncover hidden cases of domestic violence, reduce the social silence, tolerance and inhibition surrounding the victims, and progressively melt the iceberg of domestic violence against women.
References
(1) Boyle A A. Domestic violence screening, evidence is lacking [electronic response to Gracia E. Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition.] jech.com 2004 http://jech.bmjjournals.com/cgi/eletters/58/7/536
(2) US Preventive Services Task Force. Guide to Clinical Preventive Services (2nd ed.) Baltimore, MD: Wilkins and Wilkins, 1996.
(3) Cole, T. Is domestic violence screening helpful? JAMA 2000;284:551-3
(4) MacMillan HL, Wathen CN with the Canadian Task Force on Preventive Health Care. Prevention and treatment of violence against women: Systematic review & recommendations. CTFPHC Technical Report #01-4. London, ON: Canadian Task Force. September, 2001
(5) Wathen CN, MacMillan HL, with the Canadian Task Force on Preventive Health Care. Prevention of violence against women. Recommendation statement form the Canadian Task Force on Preventive Health Care. CMAJ 2003;169:582-4.
(6) MacMillan HL, Wathen CN. Violence against women: integrating the evidence into clinical practice. CMAJ 2003;169:570-1.
(7) American Medical Association, Council on Scientific Affairs. Violence against women: Relevance for medical practitioners. JAMA 1992;267:3184-9.
(8) Waalen J, Goodwin MM, Spitz AM, et al. Screening for intimate partner violence by health care providers: barriers and interventions. Am J Prev Med 2000;19:230-7.
(9) Department of Health. Domestic violence: a resource manual for health care professionals. London: Stationery Office, 2000.
(10) Rhodes KV, Levinson W. Interventions for intimate partner violence against women: clinical applications. JAMA 2003;289:601-5.
(11) New South West Health. Policy and procedures for identifying and responding to domestic violence. NSW Health Department, Sydney, 2003.
(12) Quensland Health. Queensland domestic violence initiative. Stage 2 Evaluation Report. Quensland Government, 2003. http://www.health.qld.gov.au/violence/domestic/dvpubs/Stage2tmcol.PDF
(13) Women’s Health Strategy Unit. Northern Territory Department of Health and Community Services. Domestic violence screening pilot evaluation report. Department of Health and Community Services. Northern Territory Government, 2003.
(14) Laing L, with Australian Domestic & Family Violence Clearinghouse. Routine screening for domestic violence in health services. Australian Domestic & Family Violence Clearinghouse, 2001.
(15) Gracia E. Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition. J Epidemiol Community Health 2004;58:536-537
(16) Taket A, Nurse J, Smith K, et al. Routinely asking women about domestic violence in health settings. BMJ 2003;327:673-6.
(17) Bradley F., Smith M., Long J, et al. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002;324:1-6
(18) Ramsay, J, Richardson J, Carter YH, et al. Should health professionals screen for domestic violence? Systematic review. BMJ 2002;325:314.
(19) Jewkes R. Preventing domestic violence. BMJ 2002;324:253-4.
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Conflict of Interest:
None declared.
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Published on: 25 June 2004
Domestic violence screening, evidence is lacking
- Adrian A Boyle, Honorary Specialist Registrar in Emergency Medicine
Dear Editor
The editorial by Gracia highlights the hidden nature of domestic violence and he is right to outline the role of society in uncovering this problem.[1] Definitional issues for epidemiologists are extremely complex in this field, and are further complicated by differing definitions used in criminal justice and voluntary organisations. There is little clear consensus as to the definition of 'domestic' or '...
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Dear Editor
The editorial by Gracia highlights the hidden nature of domestic violence and he is right to outline the role of society in uncovering this problem.[1] Definitional issues for epidemiologists are extremely complex in this field, and are further complicated by differing definitions used in criminal justice and voluntary organisations. There is little clear consensus as to the definition of 'domestic' or 'violence' and this has hampered research, policy and practice. Evidence of the benefit of screening in emergency departments is considerably more limited than he suggests; there are no controlled trials with meaningful outcomes.[2] Many studies have shown impressive 'before and after' increases in detection rates, though whether these reduce violence or morbidity is unproven.[3] The evidence needs to be considerably stronger and consistent with National Guidelines before screening is recommended.[4]
References
(1) Gracia E. Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition. J Epidemiol Community Health 2004; 58(7):536-537.
(2) Jewkes R. Preventing domestic violence. BMJ 2002; 324(7332):253- 254.
(3) Morrison LJ, Allan R, Grunfeld A. Improving the Emergency Department detection rate of domestic violence using direct questioning. Journal of Emergency Medicine 2000; 19(2):117-124.
(4) Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002; 325(7359):314.
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Conflict of Interest:
None declared.
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