DOMESTIC VIOLENCE AND HEALTH Emma Williamson “This book will help you gain a clearer nature of domestic violence as a health issue. You could be saving a life – or two or three.” Health Matters “ a unique and thorough resource for any UK healthcare professional or researcher involved in the field a ‘must-read’.” Journal of Obstetrics and Gynaecology “ a valuable resource for teaching on healthcare and medical courses and will also be of interest to those concerned with research and policy on this important topic.” Sociology of Health and Illness Domestic violence and health is one of the first indepth studies within Britain to explore the issue of healthcare professionals’ attitudes towards women who are victims of domestic violence. There is a growing interest by healthcare professionals and researchers about the role of healthcare professionals in relation to domestic violence. This book looks at the health experiences of women who are victims of domestic violence and the responses to such injuries by healthcare professionals. The author presents the results of an indepth qualitative study, conducted within Britain, examining domestic violence and health. Women who are treated medically without any acknowledgement of the social, personal and psychological aspects of their condition, are likely to re-present with domestic violence-related injuries. The book includes chapters that look at: • current interest both nationally and internationally • why women access health services • an examination of the physical and non-physical effects of domestic violence • the range of treatment options currently favoured by healthcare professionals and the response of patients to them • differentiations in practice between different health professionals • the impact of domestic violence as a social issue on trends in medical training. These issues are considered in light of debates about medicalisation, the function of the sick role, and both biomedical/wound-led, and holistic/person-led approaches to health provision. Key findings are highlighted, and the author provides recommendations for good practice. Domestic violence and health is essential reading for public health administrators and policy makers, healthcare professionals and feminist researchers, activists and advocates. DOMESTIC VIOLENCE AND HEALTH Emma Williamson The response of the medical profession Domestic Violence.qx 20/5/04 10:40 am Page 1 DOMESTIC VIOLENCE AND HEALTH The response of the medical profession Emma Williamson P P PRESS The • POLICY First published in Great Britain in December 2000 by The Policy Press University of Bristol Fourth Floor, Beacon House Queen’s Road Bristol BS8 1QU UK Tel no +44 (0)117 331 4092 Fax no +44 (0)117 331 4093 E-mail tpp-info@bristol.ac.uk www.policypress.org.uk © The Policy Press, 2000 Transferred to Digital Print 2004 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN 978 186134 215 7 Emma Williamson is a Wellcome Research Fellow in the Centre for Medical Ethics, University of Bristol. The right of Emma Williamson to be identified as author of this work has been asserted by her in accordance with Sections 77 and 78 of the 1988 Copyright, Designs and Patents Act. All rights reserved: no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the Publishers. The statements and opinions contained within this publication are solely those of the author and not of The University of Bristol or The Policy Press. The University of Bristol and The Policy Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. The Policy Press works to counter discrimination on grounds of gender, race, disability, age and sexuality. Cover design by Qube Design Associates, Bristol. Front cover: Photograph kindly supplied by Steve West. Printed and bound in Great Britain by Marston Book Services Limited, Oxford. iii Contents Acknowledgements iv one Introduction 1 two Domestic violence and the medical profession 11 Part One: Domestic violence patients speak out three Physical and non-physical injuries 33 four Treatment experiences 47 five Wider experiences of help seeking 67 Summary to Part One 73 Part Two: Clinicians’ knowledge and clinical experience of domestic violence six Definitions of domestic violence, roles and responsibilities 79 seven Explanations of causes 93 eight Physical versus non-physical injuries 107 nine Treatment options 117 ten Documentation and naming 133 Summary to Part Two 147 Part Three: Clinicians’ training and inter-agency collaboration eleven Intra-professional collaboration and communication 151 twelve Wider multi-agency collaborations 165 thirteen Training 177 Summary to Part Three 191 fourteen Conclusion 193 Bibliography 197 Appendix 1: Details of research participants 215 Appendix 2: Useful information and contacts 219 iv Domestic violence and health Acknowledgements I would like to thank a number of people for their help and support during the course of writing this book. I would like to thank my colleagues in the School for Policy Studies, at the University of Bristol. As always I would like to thank the participants of the research on which this text is based and members of the BSA Violence Against Women Study Group. I would also like to thank Professor Betsy Stanko for her extremely useful comments and suggestions. Particular thanks to Bimmy Rai, previously of DDVAG, for your professional insights and friendship. A big thank you to Stefan Bojanowski, as the saying goes “You never forget a good teacher!”. I would like to thank my friends – you know who you are – and my family, Roy, Gail, Sarah and Thomas Williamson [whose birthday I forgot while writing this book – sorry!]. A very big thank you to the editorial and production team at The Policy Press for working so hard on the original text. And finally special thanks to Eldin Fahmy, for being there, and for restoring my faith. Thank you. This book is dedicated to the memory of my grandmother Hilda Williamson 1925-2000 1 ONE Introduction The purpose of this book is to investigate the medical interactions which occur between a variety of healthcare professionals and women who have experienced domestic violence. This relates specifically to the medical profession as opposed to other professionals who are accessed as part of wider help-seeking activities. Specific questions which will be addressed in this book include: whether domestic violence has undergone a process of medicalisation; whether such a process is likely to occur; what the implications of such a process are or would be; how healthcare professionals reconcile their responsibilities between the provision of healthcare and social action intended to challenge domestic violence; and finally whether women who experience domestic violence perceive the medical profession as a source of adequate help and assistance within a wider help-seeking process. In order to address these questions, the research on which this book is based will first examine the perceptions of women who have experienced domestic violence, before focusing on the perceptions of healthcare professionals themselves. A feminist methodology was utilised in all interviews with stage one participants – women who had experienced domestic violence 1 (10 interviewees), and with second- stage participants – a range of primary healthcare practitioners (23 interviewees) 2 . The second stage participants were recruited through an earlier domestic violence and health study, the results of which are discussed in Abbott and Williamson (1999) 3 . All participants have been allocated pseudonyms. In conjunction with examining the practical aspects of this particular medical interaction, the theoretical aim of this book is to contextualise the effects of the medical interaction in relation to the self-identity of the presenting women. These effects cannot be separated from the domestic violence itself, nor from the help seeking, in relation to other professionals, of women who experience domestic violence. As such, this book explores questions relating to the impact of medicalisation on the lives of women, and the role of professional and gender ideology on the medical interaction. It raises questions about the way in which healthcare professionals communicate, not only with one another, but 2 Domestic violence and health with wider society, through the documentation and recording of patients’ injuries and problems. Finally, this book will identify recommendations and examples of ‘good practice’ in order to assist the medical profession in providing an appropriate service to its female clients who have experienced domestic violence. Put very simply, this book and the research on which it is based asks, ‘Do British healthcare professionals diagnose domestic violence as the primary cause of a domestic violence- related injury and how do they respond?’ Why domestic violence and health? Although there has emerged a wide and varied domestic violence discourse since the emergence of the first women’s refuge in 1972 (Dobash and Dobash, 1992), it is only very recently that research emanating from Britain has focused specifically on the role of healthcare professionals. There are several explanations as to why it has taken so long to begin to address comprehensively the issue of domestic violence and health in a British context. Following the identification of domestic violence as a serious social issue by feminists within the Women’s Liberation Movement of the late 1960s and early 1970s, there emerged a ‘Battered Women’s Movement’ whose aim was to offer crisis provision for women and children fleeing domestic violence (Dobash and Dobash, 1992). Alongside this grass-roots activism there emerged a body of research initiated by feminists to ascertain the extent, causes and responses to domestic violence, as well as other forms of violence against women (Dobash and Dobash, 1979, 1992; Bograd, 1982; Stanko, 1987; Yllo and Bograd, 1988; Herman, 1992a, 1992b; Bart and Moran, 1993; Glass, 1995). Practical or grass-roots research focused initially on the provision of refuges or safe houses for women, both for crisis and for long-term provision (Dobash and Dobash, 1992), and the initial response of the criminal justice system through the police, magistrates and judges (Radford, 1987, 1992; Stanko, 1987). A number of British researchers (Pahl, 1985, 1995; Home Office, 1989; McGibbon et al, 1989; Dobash and Dobash, 1992; Hague and Malos, 1993; McWilliams and McKiernan, 1993; Glass, 1995; Mama, 1996; Stanko et al, 1998) have identified health as an area of concern. However, this has predominantly emerged within wider research examining the help-seeking activities and support networks of women who have themselves experienced domestic violence rather than as a deliberate examination of domestic violence and health. The various reasons why domestic violence and health is now receiving specific attention include: 3 • The previous focus on police procedures and the response of the criminal justice system has now resulted in the adoption in some police forces of specialised domestic violence units to deal with domestic violence cases 4 . Many law enforcement and criminal justice agencies are now routinely represented within local domestic violence multi-agency initiatives, and policies and guidelines exist which are intended to improve the response of the police in particular to domestic violence 5 . • There has been a national increase of multi-agency forums to deal with domestic violence on which the representation of healthcare professionals has been poor (Hague et al, 1996). This research, in conjunction with the experiences of women’s advocates, led to concerns being raised about the impact of such under-representation. • Domestic violence as a healthcare issue has been incorporated within many international discussions of human rights issues as an area of concern to be addressed (UN, 1993a, 1993b; Lorentlen and Løkke, 1997; WHO, 1997). • There has emerged since the 1960s an increasingly individualistic approach to the effects and causes of domestic violence which has seen an increase in therapeutic interventions, which in many cases are incorporated within existing healthcare services (Dobash and Dobash, 1992; Herman, 1992a, 1992b; Glass, 1995; Schornstein, 1997; Gondolf, 1998). • Healthcare professions themselves are beginning to acknowledge the existence of domestic violence within their own workload, and are beginning to discuss, although predominantly within a North American context, the implications of domestic violence on their professional practice and communities generally (efor example, AMA, 1992; McAfee, 1994; Friend et al, 1998). At present there are various individuals within Britain conducting research to ascertain the effectiveness of healthcare professionals’ response to patients presenting with domestic violence-related injuries. This research includes that being conducted by healthcare professionals, professional bodies, government initiatives, domestic violence inter- agency collaborations, and feminist researchers and women’s advocates. The World Health Organisation (WHO, 1997), the United Nations (UN, 1993a, 1993b), and the European Council (Lorentlen and Løkke, 1997), have all identified the importance of domestic violence for health provision on a global scale. Within Britain, following from recommendations developed at the Fourth World Conference on Women Introduction [...]... Another important aspect of this problem is the perceptions of women who have experienced domestic violence Much of the literature around domestic violence fails to adequately incorporate the experiences and perceptions of women who experience domestic violence, but this is not a criticism applicable to the work of Glass (1995) She bases her 26 Domestic violence and the medical profession book, and the. .. 183-4) 27 Domestic violence and health Because the wider experiences of self are important to our understanding of domestic violence, and therefore of its impact on health, the research on which this book is based considers the subjective experiences of the research participants2 Asking the question: “Why doesn’t she leave?” The overriding focus of Glass’ (1995) analysis of domestic violence and the power... preferred and utilised by the participating healthcare professionals; and issues of the documentation and naming of domestic violence Throughout Part Two the perceptions of the participating healthcare professionals are compared with the experiences of women illustrated in Part One Part Three brings together key issues raised by both groups of participants to examine relationships between the different health. .. British healthcare professionals diagnose domestic violence as the primary cause of injury?’ Therapy and disease categorisations It is possible that the problems identified in the previous sections exist because the issue of domestic violence as a health concern cannot be easily fitted within a biomedical concept of health due to the social and gendered origins of domestic violence Concepts such as the. .. (1994) and Letellier (1994) respectively 10 For a list of the healthcare professionals represented in stage two, see Appendix 1, Table A2 10 TWO Domestic violence and the medical profession Much of the British domestic violence and health research emanates from localised studies focusing on women’s wider experiences of domestic violence (Pahl, 1985, 1995; Home Office, 1989; McGibbon et al, 1989; Dobash and. .. incident of abusive behaviour or the escalation of violence already present within the relationship, health professionals still appear reluctant to address the issue Focusing on the interaction by health professionals within this statistically relevant medical setting, professionals have offered numerous reasons why they have not recognised and intervened in cases of abuse and violence These include: 14 Domestic. .. to this national problem based upon their citizenry and professional accountability (Denham, 1995, p 19) 15 Domestic violence and health The reasons why some practitioners are addressing the issue of domestic violence are admirable Where there has been recognition of the personal, social and professional implications of domestic violence as a serious health issue, the discussions which have emerged... wounds and haemorrhages (Easteal and Easteal, 1992; Bates et al, 1995; Stanko et al, 1998) Box 1 identifies the types of injuries women who experience domestic violence have inflicted upon them by male partners and which they present to healthcare professionals One of the aims of the research on which this text is based is to examine how health professionals deal with the issue of domestic violence. .. this lack of knowledge have been outlined already and include the previous focus on responses from other statutory and voluntary agencies Focusing on the response of the medical profession to domestic violence is important, as many women will require healthcare services, whether they utilise them or not, for a diverse range of injuries (both physical and nonphysical) which are caused by domestic violence. .. 1987, p 73) 28 Domestic violence and the medical profession The quotation above reiterates the problems associated with asking specific questions by locating the negative responses of healthcare professionals within the expectation that women should leave violent and abusive partners Perceptions of domestic violence patients are important, therefore, as are expectations about the behaviour of such patients . Williamson The response of the medical profession Domestic Violence. qx 20/5/04 10:40 am Page 1 DOMESTIC VIOLENCE AND HEALTH The response of the medical profession Emma. participating healthcare professionals; and issues of the documentation and naming of domestic violence. Throughout Part Two the perceptions of the participating healthcare