Correspondence

Domestic Violence

N Engl J Med 2000; 342:513-514February 17, 2000

Article

To the Editor:

For the safety and confidentiality of the victim of domestic violence, Eisenstat and Bancroft (Sept. 16 issue)1 advise that “domestic violence should not be listed as a discharge or billing diagnosis.” We agree that material given to the patient should not put the patient at risk of further violence from the abuser. However, information in the medical record is critical in providing support for the patient in any legal proceedings and for public health efforts.2,3 Specifically, the physician (not the nurse or social worker) must include in the medical record a diagnosis of “adult battering and other maltreatment” and identify the reported perpetrator by name and relationship to the victim as directly quoted from the victim. Alternatively, the physician may code “E967” and identify the reported perpetrator by name and relationship to the victim. Systemic change may be needed in order to safeguard the confidentiality of records and to protect the patient.

We encourage universal education over universal screening. Domestic violence is the secret epidemic. To combat this epidemic we must break through the secrecy. The message we want to get out to our patients is that domestic violence is harmful, that it has medical and psychiatric consequences, and that it must stop. Clinicians focus, appropriately, on patients. Case-management systems for victims of domestic violence are in place in many large managed-care organizations.4 But for domestic violence to stop, the perpetrator must stop the violence. We can help stop the violence by educating all our patients about domestic violence and by identifying and helping our patients who batter.5 Should the batterers choose to decline help, then our communities have a responsibility to coordinate a response to stop the violence.

Joe E. Thornton, M.D.
Margaret Brackley, R.N., Ph.D.
Evelyn Swenson-Britt, R.N., M.S.
University of Texas Health Science Center, San Antonio, TX 78284-7792

5 References

1. 1

   Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-892
   Full Text | Web of Science | Medline

2. 2

   Bullock KA, Schornstein SL. Improving care for victims of domestic violence. Hospital Physician. September 1998:42-58.
   

3. 3

   Heins J, Brust JD. The physician's role in tracking injuries: the importance of E-codes. Minn Med 1997;80:28-28
   Medline

4. 4

   Cole TB. Case management for domestic violence. JAMA 1999;282:513-514
   CrossRef | Web of Science | Medline

5. 5

   Adams D. Guidelines for doctors on identifying and helping their patients who batter. J Am Med Wom Assoc 1996;51:123-126
   Medline

To the Editor:

For more than 25 years, I have examined abused patients in hospital emergency rooms on behalf of multiple law-enforcement agencies. My procedure includes obtaining detailed informed consent from the patient for examination, photography, and the release of information to her designated physician or physicians and the appropriate law-enforcement agency. As is the practice of many psychiatrists, I put a very brief note in the medical record and write a detailed report to both the physician and the law-enforcement agency. This provides increased privacy for the patient and ensures continuity of care and follow-up, as appropriate. Finally, the entire procedure is paid for by the law-enforcement agency, an arrangement that prevents the abusing partner from being informed by either the hospital or the insurance company.

Walter I. Hofman, M.D.
Merion Pathology Associates, Merion Station, PA 19066-0143

To the Editor:

In their article on domestic violence, Eisenstat and Bancroft ignore a considerable body of evidence, most recently reconfirmed by Schafer et al.,1 that demonstrates that men and women are equally likely to be victims of domestic violence. What differs markedly are the consequences to the victim. Women are far more likely to suffer death or serious injury. Nonetheless, it is inaccurate to state that “more than 90 percent of cases involve women being abused by men.” Furthermore, the assertion of rising prevalence is not substantiated in the literature; what has changed is our awareness of and willingness to act against this enormous social problem.

Although “neither victims nor batterers fit a distinct personality or socioeconomic profile,” there clearly are risk factors for domestic violence that Eisenstat and Bancroft chose not to discuss. These factors include lower socioeconomic status, lower educational level, urban residence, a history of violent behavior, younger age, and a relationship other than marriage between the abuser and the victim (that is, they are separated, divorced, or have never been married).

Francis X. Brickfield, M.D.
3910 Tallow Tree Court, Fairfax, VA 22033

1 References

1. 1

   Schafer J, Caetano R, Clark CL. Rates of intimate partner violence in the United States. Am J Public Health 1998;88:1702-1704
   CrossRef | Web of Science | Medline

To the Editor:

The overwhelming body of research points to parity between men and women as perpetrators of intimate violence, yet in their review, Eisenstat and Bancroft cite selectively a small number of articles to bolster the notion that domestic violence is an exercise of male oppression. Most research demonstrates that the rates are roughly equal and that women are more likely to initiate violence than men.1 The article perpetuates the false notion that men constitute the majority of child abusers, even though federal statistics clearly show that women are the perpetrators of almost 61 percent of child abuse. Women are the perpetrators of 55.3 percent of physical abuse, 71.9 percent of neglect, 78.3 percent of medical neglect, and 57 percent of emotional abuse. Men constitute the majority of perpetrators only of sexual abuse (71.5 percent), but sexual abuse accounts for only 15.3 percent of child abuse.2

Wayne Blackmon, M.D., J.D.
George Washington University Law School, Washington, DC 20052

2 References

1. 1

   Fiebert MS. References examining assaults by women on their spouses or male partners: an annotated bibliography. Sex Cult 1997;1:273-286
   

2. 2

   Child maltreatment 1996: reports from the states to the National Center on Child Abuse and Neglect. Washington, D.C.: National Clearinghouse on Child Abuse and Neglect Information, 1996.
   

Author/Editor Response

The authors reply:

To the Editor: We concur with the suggestions for careful documentation in the medical chart of injuries observed and of the patient's description of how they occurred. However, we continue to consider it unsafe to refer explicitly to domestic violence in the diagnosis, because the abuser may see forms relating to discharge or insurance. The abuser's discovery that his partner has disclosed abuse to her doctor could lead to an escalation of violence.

Regarding the physical abuse of men by women, evidence supports our conclusion that the incidence is low. The research that has claimed to show similar levels of violence between men and women does not adequately distinguish between abusive and self-protective behavior or between frightening and annoying violence. This work has also relied heavily on self-reporting, which causes the results to be distorted because of abusers' high level of denial. Even in these studies, most of the serious violence and injury were inflicted on women.

We are not suggesting that men alone have the capacity to batter (nor did we state that men perpetrate most child abuse). The research on battering in same-sex relationships demonstrates that women can abuse their female partners and that men can be victims of their male partners. However, there are important biologic and social realities that make it difficult for a woman to instill in her male partner the kind of pervasive fear that gives abuse its powerful effect. Homicides related to domestic violence, sexual assaults (including rapes) of partners, and the kind of terror that leads victims to flee into hiding most often involve man-on-woman battering. Providers need to be alert to the possibility that a batterer may present himself as the victim to gain information about his partner or to block her from obtaining a protective order. We have handled rare cases over the years in which the man has been in genuine fear of his female partner, so that appropriate attention to his safety was required.

The evidence of differences in the prevalence of domestic violence according to class, educational level, urban or nonurban residence, or marital status is highly contentious in the published research. All studies of this subject show that levels of domestic violence are high in all categories, so the usefulness of making these distinctions is small.

Lundy Bancroft, B.A.
Stephanie A. Eisenstat, M.D.
Massachusetts General Hospital, Boston, MA 02114

Citing Articles (2)

Citing Articles

1. 1

   Robert J. Reid, Amy E. Bonomi, Frederick P. Rivara, Melissa L. Anderson, Paul A. Fishman, David S. Carrell, Robert S. Thompson. (2008) Intimate Partner Violence Among Men. American Journal of Preventive Medicine 34:6, 478-485
   CrossRef

2. 2

   Eleonora Dal Grande, Jacqueline Hickling, Anne Taylor, Tony Woollacott. (2003) Domestic violence in South Australia: a population survey of males and females. Australian and New Zealand Journal of Public Health 27:5, 543-550
   CrossRef