Clinical Psychiatry Open Access

Introduction

Tip 1: What is domestic violence?

Domestic violence (DV) is a violence exerted towards the woman by a family member (or associate). Other terms used synonymously include domestic abuse, wife abuse, family violence, spousal abuse, intimate partner violence (IPV) and battering.

The DV is prevalent all over the world in all cultures, religions, races. The prevalence of DV varies between 40% in American and British studies, and 45% in African and Asian studies [1]. Globally, 15-71% of ever women in unions had been assaulted at some time in their lives [2]. Some studies consider DV as one of the leading causes of morbidity in women in the age group 15-44 [3,4].

Tip 2: Who batters whom in domestic violence?

The answer of this question depends on the cultural background where DV takes place. In nuclear families the abuser usually is the husband in the normal marriage relations. In case of cohabitation unions, the abuser is the intimate partner. In extended families, the abuser can be any nearby man, e.g. husband’s parents and his family (inlaws), her parents and brother brothers. The WHO definition of DV includes even former partnersof abused women. 3Rarely the husband (himself) can be the victim, or both partner (mutual violence) [5].

Tip 3: What are patterns of domestic violence?

The patterns (forms) of DV are classified into three major categories, physical violence, psychological abuses and controlling behaviours.

Physical violence includes anything from pushing, pulling, hitting, to use of firearms with the intention of killing. It results in a spectrum of injuries from a mild swelling to physical disabilities and homicide. Physical abuses include sexual abuses such as e.g. forcing wife to sexual intercourse or coercing (forcing) sexual acts (although some sources consider it as a separate violence entity) [6].

Psychological abuse include a wide variety of abusive actions such as verbal abuses, criticizing wife at public, threatening behaviours, economic restrictions such as denying her the right to work or controlling her income or properties.

The controlling behaviours include shouting or yelling at the wife, restricting her social life, checking her movements (being stalked) and keeping her short of money.

There is an overlap of the different types of DV especially psychological abuse and controlling behaviours (both are considered as an attempt to control the abused partner) [7].

Tip 4: What causes domestic violence?

DV is a product of the interaction of factors at four levels, individual, family, society and community levels [8].

At the individual level causes and risk factors include demographic factors (poor education, young age or wide gap compared to husband, unemployment, urban/rural residence), being abused or frequently witnessing violence at childhood, pregnancy, wife’s acceptance of battering.

At the family level causes of DV include husband’s low education or income compared to wife, alcohol problem drinking, crowded family (living with inlaws, large number of children), overburdening family work load; wife denied decisions of family or personal issues.

At the societal and community level, causes and risk factors of DV include social tolerance of wife battering as a way to resolve conflicts or to punish wives, lack of social support, family and wife isolation, linkage of the concept of masculinity to male honour or dominance, prevalence of some religious concepts that favours male supremacy and confers on men the right to correct their ‘erring’ wives.

The above mentioned factors result in the current subordinate position of women. Thus, men are families’ masters, and women should ‘serve’ them and to show obedience. Violence, then, occurs on breaching these roles [9].

Tip 5: What are the immediate triggers of violent events?

In the presence of the risk factors or susceptibility to DV, very minor or ‘absurd’ things can trigger a violent episode in the family. These triggers include talking back or argument with the husband, not having food ready on time, failure to properly tending home, quarrel with children, refusal of sex, suspicious wife’s behaviours, wife going out without husband’s permission.

Tip 6: What are the possible responses of the abused wife?

Domestic violence should not be considered at all as a private family discomfort between the spouses. The criminality of wife abuse should be stressed, that is punished by the law codes and considered a breach to human rights.

Unfortunately many abused wives preferred the ‘silence’ due to lack of autonomy (resulting from poverty, lack of professional skills or poor education), fear of social stigma, fear of violence escalation, feeling that disclosure of violence is unhelpful, adoption of societal norms of the husband’s right to beat his wife, feeling shame of battered.

Other responses include seeking medical help, approaching a family member, seeking help from NGO or police or considering leaving this ‘bad’ relationship (divorce).

Tip 7: What sequela of domestic violence apart from acute injuries?

Apart from acute injuries, disabilities due to severe assaults, such as weakness, loss of an organ or blindness may occur. Psychiatric conditions such as anxiety, depression and suicidal thoughts and attempts are commonly encountered. Unexplained chronic health problems, e.g. fatigue, abdominal pain, and many psychosomatic disorders may occur and warrant screening for occult DV in appropriate cases [10].

Other problems can occur due to repeated violent acts, e.g. lack of confidence, poor self-esteem, capitalization to abusers’ demands, marital conflicts that may end with divorce and hindrance of women’s professional and social development.

Tip 8: Why domestic violence is a health problem?

Due to the social and cultural aspects of DV, some medical professional may not realize that it is a health problem; some of them are unaware of nature and extent of DV even as a social problem. Domestic violence is rarely (if ever) included in medical schools’ curriculae, so the doctors and other health personnel are not taught or trained on identify, support or refer DV victims.

Neither body organs, nor mental health is exempted from the effects of DV in the same spectrum of severity (from mild to severe) as in other health problems.

Some studies indicate that 1 in 10 up to 1 in 5 women attending emergency departments have problems related to DV [11]. Some unexplained medical problems such as chronic headache, fatigue, sleeping disorders, sexual problems, eating disorders are linked to DV.10Some medical conditions such as pregnancy is reported to increase the risk and pattern of assaults to women due to associated hormonal and psychological changes that may depress her mood and activity. Then violent actions can be initiated by even minor events.

Tip 9: What is the better approach of management of domestic violence cases?

As DV is a multi-dimensional problem with social and cultural aspects in addition to the health ‘issue’, so it is better to use the term ‘management’ instead of ‘treatment’ to be differentiated from simple medical problem that can cured by a simple drug prescription.

There are certain points to be considered for an efficient management of DV victims. A private and safe environment should be secured for the encounter. The examiner should ask simple questions in a neutral manner that does not justify the abuse. The patient should be respected, cared of, and listened to in a non-judgmental approach [12].

There are some factors that negatively affect the efficient case taking of DV. For example, tendency of some doctors to blame the victims or even adopting the society’s concepts on women’s battering, questioning the patients in an inappropriate manner, and low index of suspicion toward DV, then is not considered in differential diagnosis of suspected cases.

Tip 10: What are the major lines of management of domestic violence cases?

Pointers to presence of DV in women attending medical clinics include the depressed and withdrawn appearance, poor eye contact and fear of attendants including caregivers. The accompanying husband (or intimate partner) may refuse to leave his woman alone, or even insist to answer questions for her.

The abused woman, usually, has a history of multiple visits to emergency department, with repetitive complaints that are inconsistent with the organic disease. The physical injuries results from DV are usually bilateral, at multiple sites, with fingernail markings. There is a delay in reporting to medical care, with a tendency to self-treatment.

Emergency medical care for DV victims is a top priority, e.g. emergency, surgical and medical treatment of physical injuries, involvement of all medical departments when needed. Suicidal ideas or attempts should be screened for. A psychiatric consultation is needed in some cases for emotional status assessment, and screening for suicidal thoughts and attempts.

After the medical problem(s) are treated, the victim should be helped to access sources of social and legal support. Part of the initial history in the medical encounter should be devoted to disclose modifiable risk factors such as poverty, disempowerment, husband’s alcohol or drug addiction.

Tip 11: What are steps in prevention of domestic violence?

The basic principle of prevention programmes of DV is rising of public and decision-makers awareness to occurrence of the problem ant to provide the support (social, legal, medical….etc.) to victims.

Some reforms in the health system and settings are needed to provide better services for victims. Training of health personnel is necessary to identify, treat, counsel and prevent DV. Issuing of guidelines for DV management (as in other major medical problems) will be helpful as many personnel are not aware with this problem.

Two major objectives of prevention programmes should include women’s empowerment to improve their status in the society combating sociocultural norms that encourage wife battering. Media (including social media sites in the Internet) can initiate debates to criminalize DV and to combat culturally and socially based concepts that encourage women’s subordination, and can encourage women empowerment in their societies.

The prevention programmes need collaboration of multidisciplinary teams (medical professionals, governmental departments, NGOs, legal authorities, academicians and religious men). The preventive programmes should be tailored according to situational cultural and societal concepts on women roles and rights, and to type of DV, as there are significant differences between them, in reference to risk factors and characteristics of abusers and victims.

Tip 12: What is expected of scientific research?

Scientific research on DV plays an important role in its prevention. But there are some factors that should be dealt with for better yield. As DV is a sensitive issue in many cultures, so the response of potential respondents is much lesser than expected. Therefore measures to ensure confidentiality and even safety of potential respondents should be considered. Many studies on DV are hospital-based, and then it is difficult to draw generalized statements for the whole community to prevalence or risk factors of DV. More community-based studies are needed, especially in developing countries. Future studies are expected to assess cultural bases of DV to pave the way to efficient prevention control to change or modify concepts degrading women. There is a paucity of studies on men which are useful to assess causes of DV (from men’s points of view) and the impact of intervention programmes [13].

References

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13. World Health Organization (2001) Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women. Switzerland: World Health Organization.