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Domestic violence is a significant public health problem in the United States. It is estimated that three to four million women per year are victims of battering in the U.S. Battering is the most common cause of injury to women, accounting for more injuries each year than car accidents and muggings combined. Approximately half of female homicide victims are killed by current or former partners. Though the vast majority (90 percent) of domestic violence cases involve women victims and male batterers, physical abuse of men by female partners does occur, and battering also occurs in gay and lesbian relationships. Battering occurs in all socioeconomic groups, and no racial or ethnic differences have been consistently found among victims of domestic violence.

The terms "domestic violence," "abuse" and "battering" are often used interchangeably. However, the term "battering" connotes more than incidents of physical aggression. Batterers may use physical and sexual assault, threats, intimidation, and economic deprivation to exercise coercive control over their partners. A "battering syndrome" has been described in female victims of domestic abuse, in which a history of physical abuse is accompanied by an increased risk of rape, miscarriages and abortion, alcohol and drug abuse, attempted suicide, and psychiatric symptoms.² Violence between partners may be an isolated incident in some couples, but survey data suggest that two-thirds or more of battered women suffer repeated assaults, ² and a single violent incident may be enough to establish an atmosphere of threat and danger in a relationship. It is important to understand this context of abuse when interviewing and counseling domestic violence victims.

Battered women frequently seek medical care, more often for psychiatric symptoms and vague physical complaints than for acute injuries. It is estimated that battered women may account for as many as 22 to 35 percent of women seeking medical care for any reason in emergency rooms, and 14 percent of women seen in ambulatory-care internal medicine clinics, and account for a significant proportion of women seen in psychiatric and ob-gyn settings. Physicians should maintain a high degree of suspicion for domestic violence in patients with unexplained physical symptoms, particularly gastrointestinal complaints, sleep or appetite disturbance, headaches, sexual dysfunction, pelvic pain or dyspareunia, or urinary tract symptoms. The American Medical Association recommends routine inquiry about domestic violence for all female patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings.

Despite the prevalence of domestic violence in health care settings, a number of studies have documented physicians’ failure to diagnose such abuse.³ The ethical principles of beneficence and nonmaleficence require physicians to diagnose and intervene in cases of domestic violence.³ There are many barriers to talking about abuse, on the part of both patients and physicians. Battered women may feel ashamed about the abuse, they may believe that doctors cannot or do not want to help, they may feel protective of their partner, or they may fear that telling about the abuse will put them at risk for more violence. Factors that may prevent physicians from asking about domestic violence include lack of awareness of the prevalence of domestic violence, a belief that identifying and intervening in domestic violence cases is not part of the physician’s role, discomfort with the feelings evoked by hearing about abuse, concern about the time involved in asking about and dealing with abuse if uncovered, and feeling helpless or not knowing how to intervene. Potential consequences of not diagnosing domestic violence include the labeling of battered women as "hysterics" or somatizers, or performance of unnecessary diagnostic work-ups, as well as the loss of opportunities to intervene in potentially life-saving ways.

The following guidelines may facilitate the interviewing of battered women. The patient should be interviewed alone, never with her partner or other family or friends present; the presence of others might cause the patient to feel ashamed or to fear reprisal from her partner. The patient should be told that any discussion of abuse is confidential, and that no information about it will be revealed to any third party without her explicit consent (note: some states have laws mandating reporting of domestic violence, but New York is not one of them.) The physician should be nonjudgmental, and should universalize and validate the woman’s experience, for example by telling her that she is not alone, that abuse is common, that she does not deserve such treatment, and that help is available for her.⁴

Although it is vital to communicate to the woman that you, the physician, do not condone violence and are concerned about her safety, it is also important to avoid taking a stance as to whether or not she should leave her partner. Women in abusive relationships may feel it is difficult or impossible to leave for a variety of reasons. They may be financially dependent on their partners, who may not have allowed them to work or may have complete control of family finances. If the couple has children, women may not want to break up the family, or may feel they have nowhere to take the children if they leave home. Battered women may feel at increased risk if they try to leave, especially if their partners have threatened to harm or kill them, or kill themselves, if escape is attempted. Emotional ambivalence about abusive partners often plays a large role as well, with loving, affectionate or protective feelings existing side by side with anger, fear or hatred. Studies of abusive relationships have described a cycle of abuse in which battering incidents are often followed by remorse and pleas for forgiveness by batterers. During such "honeymoon" periods, women may have second thoughts about leaving or pressing charges against their partners. Insisting that a woman leave her partner, or communicating that she is crazy if she doesn’t do so, is likely to be experienced by the patient as unempathic, critical and unhelpful.

While it is important to maintain an empathic attitude towards the complexities of battered women’s situations, it is also crucial to assess the degree of danger before the woman leaves your office. The following questions should be covered:

• How severe has the abuse been? Has the woman ever sought medical attention, been hospitalized, sustained any broken bones or loss of consciousness?
• Are there guns or other weapons in the home? Has her partner ever used them or threatened to use them?
• Has the abuse escalated in frequency or intensity lately?
• Does her partner drink or use drugs? If so, has such use escalated lately?
• Does her partner control her coming and going, her access to money, the phone, friends or family?
• Has her partner threatened to kill her, himself, or others?
• How afraid is she right now?
• If the couple has children, does he also abuse the children? Child abuse has been reported to occur in 33 percent to 54 percent of families in which there is adult domestic violence.⁴

A safety plan should be discussed with the woman. She may recognize signs of escalating anger and potential for violence in her partner, and may be able to formulate a strategy for escape at such times, if she is not ready to permanently leave. Ask if she has a place to go at such times, or if she knows how to access a battered women’s shelter. She may want to keep money, keys and ID hidden in a safe place for use in case of a quick get-away. If there are children in the home, she should teach them how to call or go for help, or dial 911 in case of violence.

Documentation in the medical record is important, both for patient care and for potential use in legal cases. The patient’s account of the abuse should be recorded verbatim, with quotation marks, rather than writing a summary comment such as "patient has been abused." A written description of injuries should be made, using a drawing or body chart. If the woman has physical evidence of injury such as bruises, abrasions, etc., these should be photographed (with the woman’s permission) and included in her chart.

Community resources for battered women should be discussed with the patient, and she should be given written information. Referrals can be made (see Table 1) for counseling and support groups, battered women’s shelters, legal assistance (eg: help in filing for a court order of protection or pressing criminal charges), or financial assistance (eg: applying for public assistance). Although battered women may frequently have symptoms of anxiety or depression, psychiatric referral should be made in conjunction with referrals to agencies or services for battered women, and it should be explained to the patient that the psychiatric symptoms are likely a result of living in an abusive relationship, not vice versa. In making referrals, it is important to remember that it may take some time for the woman to feel ready to make any change or to seek help, and to try not to feel discouraged or impatient if she does not immediately follow through.

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