Too often we hear that some husband has massacred his wife and children and then killed himself, with the details vividly broadcast in national headlines and news clips. One outcome of such media coverage is the marginalization of the perpetrators: These men are portrayed as unusual, psychotic, and deranged. They are depicted as different from us. We like to believe that the unusual origins of their psychoses explain how they could perform such violent acts. These events appear to be random floating blocks of ice, rather than the tip of the iceberg. Also, the fact of what happened—the ultimate violence against a woman and her children—gets lost in the spectacle of the homicide/suicide. The daily violence against women—the slappings and beatings, controlling behaviors, streams of verbal abuse, and denigration—seem disconnected from these juicy media stories. And we do not make the connection.
The heightened social awareness of violence in general does not seem to enhance our ability to go about the methodical work of screening and prevention, 2 stubborn problem areas in the current medical approach to violence against women. Despite the development of effective and validated screening instruments to detect violence against women (eg, the Woman Abuse Screening Tool [WAST], the HITS questions, and the 3-question screen),1-3 medical professionals do not consistently conduct such screening in the family practice, pediatric, obstetrical and gynecological, and emergency sites where it has been recommended. Screening activities fall off once any dedicated research or intervention program comes to an end,4 and even the presence of on-site counselors to provide services to abused women does not increase the rate of screening.5 Formal mechanical strategies may work: Restructuring emergency department forms to require inquiry about domestic violence increases case finding.6 Advocates suggest that screening be incorporated into continuous quality improvement activities to maintain them on an ongoing basis.5 This recommendation indicates that clinicians will not do this activity unless they are being watched or there are some consequences.
Why abuse is not identified
The barriers to screening have been elucidated by a variety of investigators7,8 and include time, skill, comfort, resources, and fear on the part of clinicians, although clinicians are more likely to attribute the lack of screening to patient characteristics than to themselves.9 The willingness of battered women to disclose abuse and the factors conducive to disclosure (privacy, respect, believing the woman, nonjudgmental approach, referral to resources) have also been investigated.10 However, none of this information changes what we are actually doing in clinical settings on a consistent basis.
Battering is truly a problem we do not wish to identify. Despite the screening instruments, improved knowledge base, and training, most clinicians do not seem to want to know if there’s a problem. Still, a small group of dedicated clinicians are consistently doing this work and reaping rewards.11 What is different about these clinicians? Do most clinicians have difficulty with the subject because battering challenges closely held assumptions about family and men and women?12 We need to know more about these factors if we are going to influence screening; the problem does not lie in our instruments but in ourselves.
The importance of primary prevention
The second problem—one that is ultimately more serious and has remained invisible—has to do with our failure to recognize the need for primary prevention. Zola13 wrote about the parable of the health care worker pulling drowning victims out of the raging river. This person was so busy resuscitating the victims that she was unable to look upstream to see why all the bodies were falling in. Family medicine has also neglected to look upstream. We are busy perfecting our tools for pulling the bodies out, even examining how we feel about doing that gruesome work, but we have been slow to march up the banks and see how we can stop the bodies from being pushed in. We seem to have gotten stuck at secondary prevention (eg, identifying teenage girls and women already in abusive relationships), and we have forgotten our professional commitment to primary prevention.
Yet the extent of violence against women sampled in the primary care and emergency room settings (which we have reason to believe involves nearly 36% to 44% of women in relationships with men during their lifetimes14,15) reveals the serious need for primary prevention efforts. Who is talking to the parents of small children and adolescents about how wrong it is to hit girls or women or force them have sexual relations? Home visiting programs with mothers from delivery until the child reaches the age of 3 years appear to prevent use of violence by the parents and those children16-18 but have not received wide application as a public health tool. Interventions in elementary schools to deter violent behaviors seem indicated, since gender roles of male domination and female submission are well established by first grade.19 Such programs have the potential to deter violence at the early elementary school level and decrease adolescent behavioral problems.20 School-based interventions linked with community resources addressing dating violence at the middle school level are effective,21 and some recommend adolescence as the ideal time to address prevention of partner abuse.22,23 Thus, despite the relative lack of long-term outcome data, it appears that community-based primary prevention programs for violence show promise,24-29 but none of these involve physicians.