Paul J. Hirsch, MD, never gave it a thought. Spousal abuse, wife beating, battering - those were tragic incidents that happened somewhere else, not in the affluent community of Bridgewater, N.J., where he practiced.
Or so he thought until five years ago. To renew his license to practice in New York, Dr. Hirsch was required to take an examination on family violence. Although it was an open-book exam, he had to do a lot of digging for the information. The intensive preparation made him very aware of the issues involved in domestic violence.
Not long afterwards, Dr. Hirsch was examining a young married woman; someone he had known since she was a child. She explained away her bruises with an excuse that she had fallen down stairs.
"The pattern of injuries didn't look like what someone would sustain falling down stairs," said Dr. Hirsch. "It didn't take much more than a direct question about the cause of the injuries for the woman to tell me that her husband had been beating her." Dr. Hirsch urged the woman to talk to her family and to seek help. Later, he learned that the woman had divorced her husband.
Many other cases
Other physicians tell similar stories of suspected family violence: The child with broken bones that the parents say came from falling out of bed; the bruised elderly parent, who fearfully denies the abuser was the adult son or daughter; the woman with the dislocated shoulder who is too embarrassed to tell relatives or friends.
Law enforcement agencies, social welfare departments and medical organizations know that family violence is a major problem in the United States.
Nearly 30 percent of adult women report they have been physically abused by their husband or boyfriend at one time or another. Conservative studies indicate that two million women are assaulted by their partners each year, but experts believe that the true incidence is probably closer to four million cases a year.
The American Medical Association asserts in Diagnostic and Treatment Guidelines on Domestic Violence that "physical and sexual violence against women is a public health problem that has reached epidemic proportions." According to the AMA, various studies indicate that battered women may account for:
Family violence is not just spousal or partner abuse. About 1,300 children died as a result of child abuse and neglect in 1995; an estimated one million cases of child abuse and neglect were confirmed by child protective services the same year.
Estimates range from one to two million cases of elder abuse each year, however, it is believed that as few as one in every 14 incidents is reported to a public agency. The National Center on Elder Abuse reports that the number of incidents increased to 241,000 reports in 1994, from 117,000 in 1986, a 106 percent increase.
The numbers are impressive, but may not reflect the full scope of the problem because the abuse occurs behind the closed doors of a home. Victims are often too fearful of reprisals to report abuse. They may be too embarrassed to seek help from relatives and friends. Some women truly believe that an abuse is an explainable, even deserved incident that will not be repeated if they submissively endure it.
Physicians are trained to treat the bruises and broken bones, but like many other people they often are uncomfortable about prying into a patient's private affairs. Many physicians say they don't want to offend the patient or they feel powerless to act because they don't know what to do. Physicians may want to avoid a "domestic" incident that could lead to being involved with police and the courts. With a reception room full of patients and a heavy schedule of surgery, they treat and move on.
Easy to ignore
It's often easy to ignore the problem, because the victim doesn't volunteer the information. The victim may even not recognize that a physician can help her.
In 1991, then AMA vice-chairman Robert E. McAfee, MD, introduced the Physicians Campaign Against Family Violence. The program was supported by then-U.S. Surgeon General Antonia Novello, MD, and several medical specialty organizations. Today, the AMA's National Coalition of Physicians Against Family Violence has 8,000 members. A National Advisory Council on Family Violence consists of representatives from 30 medical specialty societies, and other organizations such as the American Bar Association. William W. Robertson Jr., MD, represents the Academy on the advisory council.
"Because a physician may be the first nonfamily member to whom an abused woman turns for help, he or she has a unique opportunity and responsibility, to intervene," the AMA said.
Physicians are urged to routinely ask women direct, specific questions about abuse. The questions could be, "Are you in a relationship in which you have been physically hurt or threatened by your partner?" or "Did someone cause these injuries? Who?"
Physicians are urged to reassure the victim that "you are not alone, you are not to blame, there is help available." Physicians should assess the patient's safety. Is it safe for the victim to return home? Can the patient stay with a friend or family? Does the patient need access to a shelter? Is police intervention needed?
A list of shelters, resources and hotline numbers should be in a physician's office for referrals. It's important to document information about "suspected domestic violence" or "partner violence" in the patient's chart.
Physicians need to be aware of state laws. Virtually every state has adopted legislation that requires physicians to report suspected cases of child abuse. A number of states have enacted legislation requiring or permitting, without legal penalty, the reporting of elder abuse. The Academy's Opinion on Ethics on Reporting of Suspected Abuse or Neglect of Children, Disabled Adults or the Elderly points out the physician's ethical responsibility.
Every state has some form of legislation to protect a battered spouse, such as restraining orders against the offender. The Violence Against Women Act, which is part of the 1995 Crime Bill, is providing tougher penalties for abusers.
The National Domestic Violence Hotline: (800) 799-SAFE is staffed 24-hours a day to tell women of the nearest domestic violence program. Many states and cities have hotlines and resources to protect and shelter women.