Second Opinion: Domestic violence - NOT a healthcare issue
Q Does your partner beat you up? Rape you? Criticise you?
Women who turn up to see their doctor with a sore throat or a verruca may soon be expected to submit to interrogation along these lines, in written or verbal form. The question 'should all patients be asked about domestic violence?' is discussed at length in a recent British Medical Association (BMA) publication Domestic Violence: a healthcare issue?. The same question appears prominently in a recent survey of GPs, practice nurses and health visitors in east London.
Noting that US guidelines now recommend such questioning as routine, irrespective of the complaint that has brought the patient to the doctor, the BMA authors fear that British reserve still inhibits such an approach here. Still, they are clearly hopeful that a growing awareness of domestic violence will make routine questioning about intimate aspects of women's private lives more widely acceptable.
Domestic violence has suddenly become a major preoccupation of the health establishment. In addition to the BMA book, the Royal College of Obstetrics and Gynaecology and the Royal College of Midwives have both issued statements on the subject. The chief medical officer highlighted domestic violence in his 1996 report and the Royal College of General Practitioners has recently circulated guidelines on 'the GP's role'. All these publications seek to raise awareness of domestic violence among health professionals and to encourage a more interventionist, proactive approach to the problem.
Discussing this matter with my GP colleagues, who are mainly women, I inquired whether they had noticed a recent upsurge in domestic violence. But no; like me, they had certainly encountered the occasional case, but thought it not a very common problem and had not noted any particular increase.
Of course, our low recognition of domestic violence may be a result of our limited conception of the problem. For readers who may have wondered why the question about criticism was included above, the BMA distinguishes three types of domestic violence: physical, sexual and psychological. The latter category includes criticism, verbal abuse and 'being forced to do menial/trivial tasks', as well as humiliation and degradation, extreme jealousy/ possessiveness and 'being made to think they are going mad'. The final estimate of prevalence is that 'one in four women will experience domestic violence at some time in their lives'. Given the breadth of the definition of domestic violence, the only surprise is that it is not closer to 100 per cent.
Though the BMA report concedes that much of the research on which its conclusions are based is 'not of high quality', this does not deter it from regurgitating spurious statistics. Thus, for example, it quotes a major survey of GPs in Canada which revealed that 'almost all' believed that they are missing cases of abuse and just over half of respondents estimated that they are missing 30 per cent or more cases. Such GPs, who can estimate the percentage of an unknown quantity, are wasted in general practice - they should go into epidemiology. As for the BMA, its report manages both to exaggerate and to trivialise the problem of domestic violence.
'What are we supposed to do about it?' was the rather weary chorus from my colleagues when I raised their awareness of the campaign to raise their awareness about domestic violence (whose propaganda they had already consigned to the bin). The answer, presented variously as a 'four-step' programme or a 'seven-step' action list, can be divided into immediate and long-term responses.
The immediate response is a series of measures that encourage the victim to involve other agencies, most importantly the police and the courts. There is a general approval of the fact that the police have adopted a much more interventionist approach, setting up domestic violence units and being ready to enforce court orders against violent spouses or partners.
It is striking, however, that in this era of evidence-based practice, no evidence is adduced that the intervention of the police and the criminal justice system provides effective protection for women. The tragic case of the Asian woman killed by her husband inside a domestic violence unit indicates that the police cannot guarantee women's security.
The long-term consequence of GPs adopting a more proactive approach to domestic violence is more insidious. It means opening up the personal realm of family life and relationships to professional interference on an unprecedented scale. The BMA report comments that the doctor is in a particularly good position to intervene, because he or she does 'not necessarily need to prove the existence of domestic violence...but instead needs to identify and acknowledge that domestic violence is occurring'. The doctor's suspicion of violence is thus deemed sufficient to justify unleashing a comprehensive programme of intervention, possibly involving a wide range of local authority and voluntary organisations, as well as other health professionals.
A popular model, featured prominently in the BMA report, is the Domestic Abuse Intervention Project in Minnesota in America. This seeks, through multiagency working, to transform a range of violent behaviour into non-violent or egalitarian behaviour, showing respect and trust, giving support, being honest and accountable, fairly negotiating, taking shared responsibility, having economic partnership and responsible parenting. Whether or not this approach is effective in terms of deterring domestic violence, it carries the heavy cost of opening up the private sphere to public scrutiny and regulation in a way that is characteristic of authoritarian societies. Such an intrusion into people's intimate life can only be profoundly damaging both for the individual and for society.
It appears that in the Canadian survey cited above, of the 21 reasons given by GPs for not identifying more cases of domestic violence, the two least common were 'it is not a medical matter' and it's 'none of my business'. Though these may be the convictions of a minority, they point the way forward to a form of medical practice that treats illness rather than regulating behaviour, and puts the autonomy of the individual and the privacy of personal life before the imperatives of political correctness.
Dr Michael Fitzpatrick
Reproduced from LM issue 118, March 1999