“You need to come in to the E.D. ASAP.” A new patient was admitted at 2 a.m. and requested for a crisis counselor. Back in 2009 when I was volunteering in New York City, unlike with cases of sexual assault, survivors of domestic violence had to specifically request for the presence of an advocate. This woman, I’ll call her Sadie, had already taken the first courageous step to seek help.
I briskly walked past distressed family members looking anxiously around for a glimpse of a messenger bearing good news. After knocking on the door and asking for permission to enter, I walked in to find Sadie struggling to rest her left leg, which was covered with blood. Completely abandoning the usual protocol for first explaining my role and how I could best support her, I blurted out, “What happened?”
Sadie and her friend, who was in the room as well, recounted how they were at a club when they were confronted by a violent woman, who was later revealed to be the new girlfriend of Sadie’s ex-boyfriend. She began to punch Sadie, but Sadie had been able to fight her attacker off. However, soon after, Sadie was attacked by her ex-boyfriend, who broke a beer bottle over her leg.
I winced as I looked back at her leg.
I told Sadie that I was glad she was now safe and getting care. I would be there to help make sure her medical and other needs were met and could help if she decided to go ahead and press charges. Only once during my three years as a crisis counselor did a survivor of domestic violence or sexual assault decide to go ahead and press charges. The process itself can be traumatizing in many ways.
After several hours, the attending physician came in to check on Sadie. She was very efficient when it came to cleaning the wound and taking out the small pieces of glass. As per protocol, I then presented her with the domestic violence medical forms. She expressed that she was pressed for time, so I offered to fill in as much as I could. However, I expressed that she needed to provide the medical documentation for the incident. The physician then looked directly at me and exclaimed, “This is not a domestic violence case! Domestic violence happens in the home. She was in a club.”
I tried to quickly mask the look of pure horror on my face. I began to rebuke, but Sadie began saying in the background, “It’s alright. It’s not that big of a deal. I’ll be fine.” The physician quickly ducked out.
If one were to get technical, domestic violence would only happen in a domestic setting — perhaps this is why the term intimate partner violence may work better in some cases. But, it was nevertheless dumbfounding to me that a physician, who first goes through years of rigorous education and training and is an esteemed professional — one that I was aspiring to become — would succumb to such a narrow and literal interpretation of domestic violence.
Physicians need to be doing a better job at creating a space in which survivors feel comfortable with reaching out for help because evidence suggests that domestic violence survivors are not only more likely to interface with the health care system, but the abuse they are exposed to is also associated with poorer health outcomes.
After all, for better or worse, the white coat gives the physician a significant amount of authority. Physicians can help validate patients’ concerns, and through a non-judgmental, respectful approach, can encourage survivors to speak up about their abuse.
Identifying abuse in the clinical setting is key. In January 2013, the U.S. Preventive Services Task Force announced that it now “recommends clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services.” This is a great step towards addressing the epidemic of domestic violence.
But, the steps taken thus far fail to completely address the frustration that many physicians experience when confronted with the vast complexities of domestic violence. In many ways, they too may be grappling with the following question:
Why don’t people in abusive relationships just leave?
This is a question that is all too often asked. There are numerous barriers that prevent survivors of domestic violence from leaving abusive situations, including but not limited to, racism in the criminal justice system, immigration status and fear for one’s safety.
Financial barriers also play a significant role. Recent estimates show that approximately 94 percent of domestic violence survivors have experienced economic abuse. Economic abuse can entail preventing the survivor from keeping employment, engaging in credit-related transactions such as to accrue debt in the survivor’s name without his or her consent, or prohibiting the survivor from accessing their current funds. Even if a survivor is able to escape, crippled financial literacy can pressure the survivor to return to the abusive situation.
Furthermore, a lack of affordable housing can prevent survivors of domestic violence from escaping abuse. One report by the ACLU found that half of all cities in the United States point to domestic violence as a primary cause of homelessness. In response, states like New York have announced plans to expand emergency housing for domestic violence survivors.
Yet, increasing access to safe and affordable housing is just one component of
economic empowerment for survivors of domestic violence. In order to truly support economic empowerment, organizations providing services to survivors of domestic violence must assist them in areas such as securing further education or training, subsidizing childcare and even something as speciously basic as attaining a driver’s license. Education, child-care and access to transportation are each vital to a person’s capacity for both securing and maintaining employment. Indeed, such factors have previously been shown to comprise the most common barriers to low-income women’s employment.
Indeed, domestic violence is both a complicated and an urgent issue that needs to be addressed by the health care profession. Some suggest mandating each and every physician undergo training on how to conduct effective screening for domestic violence. While such training may help ensure that fewer physicians are ignorant or incompetent regarding domestic violence, such as the attending I unfortunately encountered in the emergency department, it won’t adequately address the complexities of domestic violence on its own.
Physicians should certainly be entrusted with taking appropriate measures to identify survivors of domestic violence and documenting medical evidence accordingly. However, the burden of addressing all of the psychosocial factors contributing to abuse cannot realistically fall solely on their shoulders. Greater investment in resources and professionals who can support a more team-based approach to addressing the epidemic of domestic violence in this country is sorely needed.
Contributing Writer
Yale School of Medicine
Tehreem Rehman is an MD/MPH candidate at Yale/Johns Hopkins. She is invested in addressing the impact of adversity and trauma on psychopathology, clinical and community interventions for violence, and the relationship between healthcare provider biases and health inequity. Tehreem blogs at www.tehreemrehman.wordpress.com and can be reached on Twitter @tehreem_rehman.
