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Two recent tragic cases of domestic violence involved not only the
death of women but their children too. On August 4, 1998 three children
were found dead in a smouldering Ford Capri, killed by their father
because he feared his wife had walked out on him. The father hung himself.
Police identified the 3 children as Lucy aged 7, Thomas, aged 4 and
Hollie, 3 (Guardian August 4, 1998). On March 20, 1999 Peter Hall was
sentenced for stabbing his girl friend, Celeste Bates, aged 31 and killing
her two children. He first murdered her before collecting her 17 month old
son, Milo, from his nursery and taking him to her home, where he killed
him with a pickaxe handle. He then collected 8 year old Daniel from his
childminder and killed him the same way. After the killings he went to a
pub and told drinkers: 'I am going to be famous'. Sentencing Hall at
Manchester Crown Court, Mr Justice Forbes said 'None of your victims had
done you the slightest harm… Together they formed a decent, happy,
loving family unit.. which fell victim to your jealous rage'(Guardian
March 20, 1999).
These two tragic cases illustrate the dangers of overlooking the
problem of domestic violence. The danger that women and children fleeing
from abusive fathers face is not taken seriously and the effect of recent
legislation awarding more rights to fathers has put women fleeing violence
more at risk. Men can apply for contact orders under the Children Act 1989
and use court procedures to track down their victims. Hester & Radford
(1996) reviewed developments regarding contact between children and
parents after separation and divorce. They outline the tactics used by men
in custody cases such as using children as hostages to force women to
return, manipulation of legal procedures relating to child care in attempt
to involve courts and law to continue the harassment. They point out that
the concept of 'parental responsibility' by which men are encouraged to
have more contact with their children does not take into consideration the
harassment women and children suffer. Their research indicates that
violence from men to female partners and the impact of such violence on
children is not being taken into account in judicial settlements of child
contact post separation.
Contrary to public opinion, women and children are much more likely to
be assaulted in the home than outside it. Data from the USA, the UK,
Australia and New Zealand all confirm that interpersonal violence, whether
homicide, sexual assault or physical assault, is largely committed by
those known to the victim. Half of the women murdered world wide are
killed by husbands, partners or lovers. Children are also at risk at this
time. Roughly two thirds of children under 16 murdered by parents are
killed by their fathers or stepfathers. The most dangerous time is after a
couple have broken up.
Domestic violence can have both direct and indirect effects on women's
and children's physical and mental health. Even the direct effects have
not always been recognised and it is only recently that the indirect
effects of, for example, the witnessing of violence by children, are
beginning to be appreciated. Nurses work in a variety of health and
community settings and may often be the first outside the family to know
that abuse is occurring. School nurses may be crucial in preventive work.
Health visitors, nurses in Emergency and Accident departments and
community nurses are uniquely positioned. Mezey (1998) found that women
attending GP surgeries were more likely to disclose domestic violence to
their health visitor. This paper outlines some of the known effects of
domestic violence and discusses how nurses can contribute to meeting this
challenge.
Background
In the 1970s Britain was one of the first countries to set up crisis
centres and refuges where women could escape from violence by their
partners, husbands or fathers. In 1997-1998 there were 54,000 women and
children staying in 240 refuges in England and a further 145,000 sought
advice and help from Women's Aid services (Women's Aid Annual Report
1998). The demand for such services reflected the widespread prevalence of
domestic violence. There has been no national prevalence study in England,
but a number of smaller scale studies confirm that domestic violence is
widespread. A random sample survey of 571 women and 429 men in the London
borough of Islington, London carried out by Mooney (1993) found that one
in three women had been victims of violence over a lifetime and one in ten
had reported an incident in the previous year. Dominy & Radford (1996)
set up safety, health and information stands in indoor markers and
shopping malls across Surrey, a predominantly rural area in the South of
England in 1994 - 1995 and handed out self complete, anonymous
questionnaires to women who passed by. 30 per cent reported having
experienced violence over their lifetime. A number of reports including
one from the British Medical Association (1998) estimated that as many as
1 in 4 women may be affected by domestic violence. A review of studies of
violence against women in 35 countries across the world found that between
1 in 4 to 1 in 2 women surveyed reported having suffered domestic violence
during their lives (Heise et al 1994). The costs and consequences of
domestic violence have been documented by the World Bank and the United
Nations. Major challenges still face us in recognising the effects of
violence on the lives of women and children. Homicide statistics world
wide inform us that women are most likely to be killed by current or
former husbands or partners or lovers (Daly & Wilson 1988, Wilson
& Daly1999) and the health costs on the lives of women and children
are immense. Hackney Safer Cities and the Children's Society commissioned
a study to identify the prevalence and the costs to a local authority of
responding to domestic violence (Stanko et al 1997). It was estimated that
the prevalence of domestic violence to be one in nine women in Hackney in
1996. Examination of service provision (social services, health and the
police force) and an estimation of the prevalence of domestic violence.
The overall cost to agencies in the borough was estimated as over £5
million in 1996. The cost to health services for injuries and
psychological harm, excluding medication and hospitalisation, was
£590,000 in Hackney and £189 million in Greater London. The costs for
social services work was estimated at £2,360,000. The economic costs for
individuals have never been calculated.
In the 1990s the harmful effects of witnessing domestic violence on
children has increasingly been recognised and the links between child
abuse and abuse of women documented ( Mullender & Morley 1995,
Anderson 1997, Hester & Pearson 1998). The setting up and expansion of
ChildLine, a helpline which children can ring anonymously, has revealed
the widespread incidence of such abuse. An analysis of calls made to
ChildLine (Epstein & Keep 1995) indicated how children describe
feeling responsible both for causing the violence and for preventing it
and this in turn engenders an overwhelming sense of helplessness. Over a
third of the sample had been physically abused themselves.
There is also evidence that the courts fail to protect children both
within abusive relationships and after divorce or separation (see
Mullender & Morley 1995, Hester & Radford 1996, Radford et al
1997). Child abuse has also become an issue of public concern and a key
media issue (see Skidmore 1995). UNICEF calculates that trafficking in
children is the third most lucrative illegal trade in the world, after
drugs and weapons and is a multi-billion dollar business. It is estimated
that 5,000 children work in the sex trade in Britain and are the victims
of family abuse, career paedophiles, prostitution, sex tourism and
pornography. Prostitution of young women under 16 is a question of growing
concern ( see Kelly et al 1995, Barrett 1997, Barnardos 1998).
The effects of sexual assault on health
Research studies on rape in the USA, in Canada and in England have
found between 1 in 5 and 1 in 7 women report having been victims of rape,
with girls under 15 years of age being those most at risk. As well as
physical injury, sexual assault can have serious psychological effects
such as anxiety, suicide, depression and post traumatic stress disorder.
In research I conducted for the TV Dispatches programme 'Getting Away with
Rape', out of 100 victims, 1 in 5 lost their virginity as a result of the
rape, 7 became pregnant (one with twins) and 7 caught a sexually
transmitted disease (see Lees 1997, Gregory & Lees 1999). Some women
expressed fear of contracting the HIV virus. 40% of the survivors of the
US 1992 National Women's Study 'Rape in America: A Report to the Nation'
said they feared contracting HIV .
One young woman described the effects as follows:
shock, numbness, humiliation, degradation, disbelief, guilty, self
blame and anger which led to me mutilating myself, embarrassment, loss
of control, severe depression (I take anti depressants) irritability,
mood swings, fear of being alone, crying a lot, inability to sleep,
nightmares, relationship problems with family and friends, no enthusiasm
for life, anorexia, loss of concentration, feelings of being dirty,
defiled, contaminated, (constantly washing), loss of self trust, safety
and independence
Several women described suicidal feelings:
I felt suicidal afterwards and felt it was not worth living. There
were too many changes. I just couldn't cope and I wished he'd killed me.
I wanted to die. I could not stop crying. I thought everybody was
looking at me and could see what I was feeling inside. I felt dirty,
bathing all the time as I needed to be clean. I couldn't sleep, couldn't
eat, I had nightmares. I was frightened to go out. I was scared of being
left alone. I could smell him all the time. I kept scratching myself to
get him out of my body. I smashed all the mirrors in my bedroom and cut
up the clothes I had been wearing.
Apart from depression, several women described how they had 'blocked
out' the experience. Most of the women who did this had not gone to
counselling, and had a delayed reaction later. Their experiences affected
other relationships. Flashbacks, nightmares and sleeplessness were the
most common responses. Janet describes how she felt:
I blocked it out for about 2 years. But even in that time, it made me
feel nervous around men. More recently, I sometimes have flashbacks
(usually during sex). Partly as a result I rarely have sex. I didn't go
for counselling or need medication.
I'm still dealing with the emotional and psychological effects. In
fact it only recently that I've begun to get my head straight about it
all and it's hard. I still want to block it out but I have to deal with
it because I've only just realised that it effects relationships I have
with other men. The degradation and humiliation is something I feel I
have stamped on my forehead sometimes - that makes me feel vulnerable.
Some respondents described how the experience had put them completely
off sex:
I suffered (still do to a lesser extent) from nightmares, insomnia, a
fear of going out, I lost a lot of hair and I found it very difficult to
go near any one now. I was put on sleeping tablets and anti biotics (in
case I had picked up any disease) and I had to see a psychologist. I
became withdrawn, cautious and less trusting. I didn't want sex. The
first time about six months afterwards was horrendous. I have panic
attacks and frighten easily and unnecessarily.
I had been violently raped by someone else three years before this
particular event but by a different man. I do not trust men particularly
and quite often find sex something that is painful. I find it very
difficult and uncomfortable to let anyone touch me.
Others were driven to promiscuity in order to try and help them to feel
something. Such evidence is often used against the complainant if she goes
to court : Anna explained how she felt.
Almost the same week I suddenly wanted love. I craved love and
attention so I had as many boyfriends as I could. I found love through
sex which I now know made things worse and things went downhill from
that time I craved attention even if it was negative and I made my
boyfriends hit me. I didn't fell anything for other people and I ended
up treating most people like dirt. I feel I was put on ice for 5 years.
I couldn't move forward. The only peace I would have is to make sure he
didn't hurt another girl, but I failed to stop that as well.
Survival strategies varied. Some women resorted to drink and/or drugs,
others went on as though nothing had happened. As Annie, raped when she
was only fourteen, explained:
I pretended it hadn't happened and if it had then it was normal like
shopping or school. I didn't know what it was in my head so I couldn't
understand the reality. I said good-bye and went indoors. I didn't cry.
I had a wash and went to bed then went to school the next day.
Some women got VD:
He gave me VD so I had to have injections. I needed medication to
clear the infection. I shake a lot. I couldn't talk about it. I was
ashamed because it had happened before. I was afraid to go out. A friend
would escort me everywhere.
One woman tried to kill herself and several women mutilated or cut
themselves. Janet said she inflicted injury on herself most days. She was
very depressed and scared of relationships with men on any level
whatsoever.
Five women reported being stalked. As Jacky described:
The worst part was after when he continually harassed and shadowed
me. Silent phone calls each night. He followed me in his van or appeared
near my home. I lived in continual fear and intimidation on a regular
basis for 4 years.
All the women felt they had been changed by the experience but were
determined to try and avoid it affecting their life. Several women wrote
how determined they were to avoid feeling humiliated or degraded. Almost
all the women became far more cautious, and were less confident about
going out on their own. This can be seen as a positive survival strategy.
I became more aware of the potential for such situations, determined
not to allow them to affect my life or my children. I became more
conscious of men's moods
Jane who had fought off her attacker, who was married with three
children, described her loss of confidence:
I do not wear make up, smart clothes, perfume, swim wear, a blouse
unless it is covered with a big jumper. I keep myself and my body from
view. I do not go out to a restaurant as I would feel I would have to
wear feminine clothes. To feel that you have no other function other
than as an object to be used and thrown away completely destroys your
confidence and makes you feel powerless, worthless, ashamed and guilty.
A common reaction was self blame
I think that the problem with most women including myself, is that
somehow we feel that it is our fault that this has happened. Because I
had nobody to talk to about it. I continued to blame myself. It also did
a lot of damage to my self-esteem as I already had a low opinion of
myself. I think that things have to change drastically so that women no
longer feel to blame and men start feeling responsible for what they
have done.
Two important developments have influenced the way rape is handled.
Firstly, during the 1980s research has advanced our knowledge about the
short and long term effects of rape - often referred to as the rape trauma
syndrome, a post traumatic stress response ( see Holmstrom and Burgess
1978, Hall 1985, Mezey & Taylor 1988, Newburn 1993). Typical reactions
include helplessness ( see Williams & Holmes 1981), sleeplessness,
flashbacks, nightmares, anger, suicidal feelings, phobic reactions,
depression, mood swings, fear of being alone, relationship problems (in
particular not enjoying sex), anorexia, loss of concentration and self
esteem and blaming oneself. Personal relationships are often disrupted,
and sexual relationships often break up. A finding of crucial importance
is that such reactions are often delayed. In other words the experiences
are 'blocked out'. Therefore, complainants may often appear calm and
controlled, or they may be angry rather than distraught. These are common
responses to other traumas too. Forensic doctors need to be aware of such
reactions and be careful what implications they draw from the
complainant's demeanour, as these can be very prejudicial in court as we
shall see in the next chapter.
The use of a medical term, rape trauma syndrome, to describe such
symptoms has some disadvantages. Absence of particular symptoms can be
used maliciously by defence doctors for example, as evidence that the
complainant is making false allegations or has not been raped. One of the
ironies is that the very qualities that help women survive are the ones
that are most inappropriate for obtaining a conviction; the rape victim is
expected to display emotion even many months after the event and in
public. The use of medical terms can also reduce the complexity of the
woman's experiences to a set of 'individual symptoms' which once
understood can be cured by the medical profession alone (see Foley 1994:
44). It can also give the impression that the reactions are
psychopathological rather than normal. On the other hand it is vital that
reactions to rape are understood so that they can be taken into account
appropriately. Victims can then be reassured that their reactions are
perfectly normal.
A second important advance has been the publication of the Conservative
government's Victim's Charter in 1990 which set out principles of good
practice so as to put the care and welfare of victims of crime at the
centre of the investigative process. A campaign to get these implemented
successfully was launched in 1995 with the publication of the rights of
victims of crime police paper. These rights were grouped under five main
headings: to be free of the burden of decisions relating to the offender,
to receive information and explanation about the progress of the case and
to have the opportunity to provide their own information about the case
for use in the criminal justice process; to be protected in any way
necessary; to receive compensation and to receive respect, recognition and
support. In 1991 the Home Office published the Victim's Charter in which
criminal justice agencies were asked to re-assess services to victims.
We are only now beginning to understand more about the experiences of
women who report rape or indecent assault to the police. Three recent
studies have however thrown some light on recent improvements in police
practice and their limitations. In Temkin's (1996, 1997) study of the
experiences of 23 women who reported rape to the Sussex police between
1991 and 1993, she focused on three aspects: their reactions to police
processes at every stage from reporting to the trial, their overall
attitudes and finally those aspects of their experience which were
particularly positive or negative. The results were compared with the
questionnaire study undertaken by Adler (1991). Secondly, Victim Support
(1996) carried out a survey of 92 Victim Support schemes and 17 Witness
Services who had supported 938 and 590 victims respectively during 1995.
An evaluation study was also conducted by the Northumbria REACH project
(Maddock & Scott 1996) when eleven women who had reported rape to the
police were interviewed. The Northumbria REACH developed from an alliance
with the Tyneside Rape Crisis Centre and the Northumbria police.
Treatment of Physical and Psychological Trauma
Doctors and nurses can have an marked effect on a victim's recovery,
the treatment that she receives can determine whether she is helped in
the recovery process or undergoes further trauma (Burgess and Holmstrom
1974)
In my study of rape victims, eleven women interviewed had been
medically examined ( Lees 1997). Only two of the eleven were seen by a
woman doctor, although all but one had requested to see a woman. The
medical examination was described by seven of the women as a stressful
experience, some saw it as an endurance test, and three described it as
utterly degrading, in one case as bad as the rape itself. Only one woman
who had been examined by a woman doctor, said the examination had been
carried out very sympathetically: She described the 'lady doctor as really
good' and said that 'she had tried to joke to ease the situation'. Some
women had mixed reactions to it. Una, for example, whose allegation of
rape was reduced to indecent assault and not held up in court was grateful
for the results of the medical although she had found it stressful:
It was OK. In fact it was worth its weight in gold, that medical
report. Because he's such a good liar without the report he would have
got off on the ABH charge too.
Three doctors appeared to have been callously unsympathetic, even
cruel. Others may not have been deliberately heartless, but do not appear
to have appreciated the acute sensitivity of victims whose bodies have
been abused. Careful thought needs to go into ways of avoiding such
degradation. One problem seems to be that the forensic requirements are
put into effect with little flexibility. Such descriptions as the
following give one little confidence in the service:
So I got examined by the doctor. She wasn't very nice. It was
terrible. She gave me the morning after pill and she didn't explain
anything about it. I was throwing up I didn't know I'd be throwing up
for nothing. She wasn't the slightest bit sympathetic or anything like
that. She didn't care. She was just doing her job.
I looked down at myself with this sheet wrapped around me and he (the
medical officer) turned to the WPC and said 'Cover her up will you?'. I
felt like a piece of something on a slab - cover that up we should not
be looking at that.
Examination by male surgeons came in for stiff criticism. Amanda,
herself a medical professional working in a local hospital, was very
unhappy with the treatment she had received from the male police surgeon:
The one thing I didn't like was the police surgeon. I don't think the
police told him I was the victim and he seemed to treat me as if somehow
I was a criminal. I ended up in tears. He just seemed so rude to me, all
the time, and he wanted me to spit in a pot and I couldn't and every
time I tried to spit I wanted to be sick. It was really horrible the way
he treated me. Because of being in the medical profession I notice
things like that as I'm into training doctors and that one was not one
of mine. I'm sure no-one told him that this is a victim not a criminal.
I'm sure no one said anything to him.
Jenny, whose house had been broken into at 3 am in the morning and who
had been kept prisoner for several hours, was appalled by the medical
examination and the length of time it took:
The police doctor was the worst person. I was with the police for 12
hours. I think all police doctors should be women. He was most
unpleasant. He had a list of things to do that he methodically went
through. Some of it was dreadful like unwrapping yourself on pieces of
brown paper until you are quite naked. This was followed by a long
internal examination. He said he had to remove four pubic hairs, and
just pulled them viciously out. I was in a state of hysteria.
Part of the difficulty appears to be the undue concentration on the
investigatory aspects to the neglect of humane considerations. The
inflexible implementation of procedures may sometimes override common
sense and lead to the victim's unnecessary discomfort. One complainant was
not allowed to drink for five hours after an horrendous assault, although
she had not had oral sex.
Some doctors failed to explain why certain procedures were necessary.
In Nora's case, where the assailant had broken into her bedroom, but had
not in fact raped her she said:
They did the whole bit - spit in the tube and swabs of this and swabs
of that. It was all very degrading. He didn't explain what they were
doing it for. It's just such an awful experience. It's as simple as
that.
Forensic evidence is of course, relevant only in establishing that
intercourse took place, not whether it took place with or without consent.
However, there is a great deal of fuzzy thinking around this simple
statement, and forensic evidence can be used against rather than for the
complainant in a number of ways, some of them insidious as the interviews
reveal. In the absence of vaginal injuries, which are rare, forensic
evidence can be used by the defence to argue that the woman consented.
Arguments about whether the woman 'lubricated' are particularly
pernicious. One police officer interviewed, who had been on the special
course on sexual assault at Hendon Police Training College ( Where the
Metropolitan ( London) Police are trained) insisted quite fallaciously
that forensic tests could ascertain from the fluids whether or not the
complainant had consented. If some police believe this, it is not
surprising that jurors are often confused.
Four of the complainants were examined in rape examination suites but
the surroundings were not viewed as the main priority. In the case of the
72 year old, she was examined at home. In the other cases the women were
examined in doctor's surgeries. Rape suites were not really appreciated
when most women wanted above all else to be examined by a woman doctor,
not a man. As Anna explained:
The police medical centre was absolutely beautiful and they were
after spending something like 1.2 million to do it up, but the female
doctor wouldn't come out and the only one who would was a man doctor.
They did say they would report her (the woman doctor) for not coming
out. The doctor who came was a bit pissed off having to get out of bed
in the middle of the night. They couldn't get a woman.
She explained how because they couldn't find a woman doctor she had
agreed to being examined by a man. She had regretted this afterwards. She
explained why:
I think I was mistaken in doing that because after that I just
freaked at the thought of any internal investigations, let alone by a
man. I thought it wouldn't make any difference to me whether it was a
man or a woman but it did matter a lot. The doctor was business like and
not sympathetic.
Just a few things that stood out to me when I thought about what was
happening there. At one point the doctor examining me said 'Well your
vagina feels moist, seems like a normal vagina' and I thought 'What is
he telling me that for, is he saying I enjoyed it or there is no trauma
there so it did not happen?' I did not really know what his comment was
for. I was lying on the couch with that paper sheet underneath me and he
was pulling out pubic hairs with what looked like automatic tweezers
which pull the hair but cut it as well.
Delays in finding a doctor to undertake the examinations was another
area of complaint. Some women had to wait for hours while in a state of
shock. Women are not allowed to drink or wash, so are often in great
discomfort. A further area of concern was the realization that the
doctor's report might well be used as evidence. Several women were
concerned about the impression they were giving and some perceived the
doctor as threatening as Jenny explained :
You are very sensitive and everything that is said becomes unkind
although it may not have been intended. You are so exposed and you know
that the reactions and comments of the doctor are going to validate what
you've said and his reactions and comments are actually what's happened
to you or comments on the state of your body or whatever. I really feel
that in shock you tend to be bright and businesslike. I felt I was being
too cheery and I wasn't sobbing and I thought ' Is he thinking that it's
just a lark or something? You're just so aware of your own responses but
then they are going ahead without you having much control over them,
because you've got so much going on inside your head and you're on
automatic pilot. So you say 'Yes thank you I'll get on the couch' when
really what you want to say is 'Go away, leave me alone I want to go to
bed and just forget about it'.
I know they've got to do it immediately as soon as possible
afterwards, but I would have expected the doctor to say a few kind or
more personal things. He was very impersonal and very distant. If he
would have said - 'You must be feeling bad' or something, but I don't
remember him saying anything like that. He did explain what was going to
be done in the medical. I just felt that he didn't have any sympathy or
compassion and he had no notion of what state I was in. He was just
doing his job so that he could go back to bed. I didn't get a good
feeling from him, whereas I did from some of the police officers.
Being seen by a woman doctor did not however prevent one woman from
being very dissatisfied with the questions she was asked. The overall
effect of cross examining women during the medical can lead them to feel
they are to blame for the attack. Anything more likely to undermine their
confidence, already shaken by the horror of the attack, is difficult to
visualise as Fiona, who had been raped by a stranger, explained:
It was her attitude. It was like it was a big effort that she had
been called out at 7 am in the morning. She could have been a lot more
sympathetic in explaining what she was doing. She said she would explain
everything when I had had a bath, but when I got back from having my
bath she was gone. It was afterwards that I found out why the medical
doctor asks questions like 'when was the last time you had sex?' and
these questions are brought up in court. As it turned out she said 'how
long have you known your boyfriend' and I said 'Well actually he was my
childhood sweetheart' and she said 'Alright'. She made me feel like
everything was a trap or something and that almost everything would be
held against me. Even like the alcohol test they did on me. Although the
alcohol test showed up clear there was very low level of alcohol on my
breath, I thought they'd use it against me. It seems they're out to get
you all the time. I don't know how they'd have gone on about my asking
for it ( the rape) when I'd never met him before.
VD/HIV Testing
Forty per cent of the survivors of the US 1992 National Women's Study
'Rape in America: A Report to the Nation' 1 said they feared contracting
HIV. The question of HIV and sexual assault is only just beginning to be
addressed in Britain. It raises all sorts of crucial questions such as
whether suspects should under some circumstances be tested. The long
delays before trials mean that the victim needs to have access to these
results quickly. Clearly in the event of being infected, even if this is
unlikely, immediate testing is essential. It is not at present possible to
pinpoint the moment or source of infection, but it may soon be possible to
match infections with source (see Moran 1994). Some British National
Health Service sexual assault counselling agencies are already
encountering women who have been found to be HIV-positive after sexual
assaults. According to some researchers in the US some women are carrying
condoms as a preventive measure, so that in the event of an assault they
can try and persuade the assailant to use protection ( See Moran 1994)
Complainants experienced particular difficulty in getting VD tests
carried out. Several suggested that it would have helped if they had had a
piece of paper documenting that they had been raped so that they did not
have to announce this often at the admission desk in the clinic in front
of other people. This caused great embarrassment as one woman explained:
The next traumatic thing was the clinic. I had been told that there
was a time when people who had been raped were specifically able to go
and there'd be a nice environment. I walked in and there were men
sitting with their girlfriends and when I got to the hatch I had to
announce it because the woman behind were looking at me as if to say
'What's the matter with you? I was astounded myself at my own physical
reaction to being examined. The doctor had to stop several times during
the examination. I wanted to have a thorough examination, even the HIV
test because I wanted to know everything. It was a really unpleasant
experience, despite the fact that I had a very sympathetic woman. If it
had been a man I don't know what I would have done. We had a long chat
and talked about everything.
Several women were so traumatized by the medical examination that they
could not face going to have a VD test let alone be tested for HIV as
Anna, who failed to go to University College Hospital, explained:
I was told to go to hospital to have VD tests, but after the medical
examination, I just couldn't do it. I mean that examination was worse
than what had happened to me. Basically she used her fingers on me -
this nurse who was trying to examine me. I started screaming and shaking
and just kept screaming at her to get away from me. I just couldn't cope
with it. The porter came out and said 'Oh my God, I'll get another
nurse, she's got a smaller hand and she's really gentle'. I've never
gone to a doctor since, only ever a female doctor. Even when I gave
birth I refused a male surgeon to come in and insisted on a woman.
Mary could not face having an HIV test until two years later:
I actually went for an AIDS test about two years after the attack. I
went through a lot of discomfort waiting for the results. I ended up
talking to the nurse for about an hour and I was absolutely traumatised
by it. I think I just felt that, after the rape, I was worried that I
might be pregnant, and then, I wasn't. But I thought this would be
another hurdle to go through.
The Need for More Women Police Surgeons
A number of other studies had indicated that complainants were rarely
given the choice of a woman doctor. The Women's National Commission (1985)
reported that in some areas complainants were given a real choice of a
male or female surgeon whereas in others they were not. There was clearly
still a widespread shortage of women police surgeons. In the Metropolitan
Police Division in 1985 only eleven out of 87 police surgeons were women.
The report recommended that every woman who had been sexually assaulted
should be able to insist on having a woman doctor to examine her. In 1986
when the Home Office issued another circular, the need to recruit more
female police surgeons, or to employ more women doctors specifically for
the examination, was emphasized. It was recognised that in theory this is
offered, but in practice a woman doctor was often not available.
Professor Jennifer Temkin, (1996) who carried out a study of the
medical treatment of rape victims, interviewed a sample of 14 women who
reported rape to the Sussex police from 1991 to 1993. All of them had had
a medical examination. None had been examined in a police station, but
only two had been examined in a rape examination suite, two in hospital
and the other ten in doctors' surgeries. Additionally, she found that
although general practitioners were generally used and a rota system
operated, there was still a shortage of female doctors prepared to do
forensic work. Police officers reported long delays before victims could
be seen by a doctor and sometimes facilities outside the area had to be
called on.
The Northumbria REACH (Maddock & Scott 1996) study included giving
questionnaires to police officers about their views of the medical
services. An alliance between the Tyneside Rape Crisis Centre and the
Northumbria police in the early 1980s had led to the recruitment of 35
women doctors who became known as the Women Police Doctors Groups. Male
police surgeons did not approve, probably due to the overtime rates paid
for night work which they regarded as one of their 'perks'. This has been
a problem in other areas. By the mid 1990s the police reported that the
doctors list often needed updating. They also complained that the doctor
chose where the complainant would be examined and this often involved her
having to travel long distances. They considered that easier availability
of women doctors would improve the service offered which could be achieved
if more doctors participated in the scheme. A number of officers
additionally commented on the need for doctors to be up to date with
taking samples and forensic packaging.
In Temkin's (1996) study of complainants' reactions to the medical were
generally negative. Twelve ( 86 per cent) were wholly, mainly or partly
negative, so that only two women were entirely positive. Four gave a mixed
response and a further four were mainly negative, but made one or two
positive comments about the support received during the medical from a
female police officer present. Temkin analysed the responses to cover the
following themes: examination by a male doctor, the doctor's manner and
attitude, the way in which the examination was conducted and the
examination itself.
Nine out of fourteen women were medically examined by a female doctor,
considerably more than in our study. Four of the remaining five commented
negatively about being examined by a man. Temkin (1996:17) strongly
recommends that 'a sufficient number of fully trained, empathetic, female
doctors to examine complainants more or less as soon as they report the
offence should be a minimum requirement for an efficient consumer-led
service for victims'. She adds that this is not the only reform which is
needed, but that some of the procedures should be dropped as they are not
forensically necessary. The plucking of pubic hairs was a case in point .
The practice was discontinued by the Metropolitan Police Forensic Science
Laboratory in 1990 after requests by doctors who pointed out that later
blood tests could provide such information where it was needed.
Another issue Temkin raises is how much questioning of the victim by
the doctor is actually necessary. Victims are usually made to repeat their
statement although the information could easily be obtained from the
police officer. There are two further problems that can arise from the
doctor taking too many details. Firstly, defence lawyers make much of any
discrepancies between different accounts, and, even more unfairly, on some
occasions glean details of the past sexual history of the victim which
they confront her with in court. In a rape case which was monitored by
Lees (1997) at the Central Criminal Court the fact that the complainant
had had an abortion (totally disconnected with the alleged rape), was used
with great effect to discredit her in court. It is, therefore, vital that
the doctor does not include such details in the medical report in order to
avoid its use by the defence. A second consideration is that there is
evidence that the complainant's statements and medical reports are
circulated in prison as pornography (see Radford 1989).Temkin concludes
that upset occasioned to rape victims by medical examinations has yet to
be minimised. She persuasively (1996:18) argues that women in the 1990s
describe the medical in such terms as: 'more degrading and demoralising
than the rape itself', 'a nightmare', 'another violation', 'being raped
all over again' which comprises a very serious and disappointing
indictment of the progress which has been achieved in the provision of
criminal justice for victims of rape'.
Similar findings emerged from interviews with eight women undertaken by
Victim Support in January 1996. 2 Two women who were seen in a rape
examination suite and given relevant information by a woman doctor were
very satisfied with their treatment. They described the doctors as
'brilliant' ( p 20) and 'wonderful' (p 37). One of these women movingly
described what happened: 'I walked into the room and this lady came
straight up to me and said 'Oh my God, what has he done to you?' It was
wonderful. I wish everyone could have had her. How could they ever use
male doctors?' (Even in this case the victim was not given all the medical
information about her condition - she was not told, for example that she
had internal cuts until the court case).
The other women reported that they were too often given no real choice,
as they were only able to see a doctor if they were prepared to wait for
long periods of time. One woman, for example, was told she could see a
male doctor straight away, but if she wanted to see a female doctor she
would have to wait all evening.
Three women were not even given the choice nor were they seen in a rape
examination suite. One of these specifically asked for a woman doctor but
was told that none was available. Another was not given the choice. She
commented: 'I was seen by a man doctor who was quite old and I felt
uncomfortable with him. I would have preferred a woman but no-one asked
me'. She was provided with no advice on medical matters. Instead she had
to find the information out for herself (Victim Support Report 1996:27).
One woman described the examination as 'horrendous' and said she
definitely would not have gone through with reporting it if she had known
what the medical would be like. The report commented that a sympathetic
female doctor in a specially designed rape examination suite would make
all the difference to what was essentially a traumatic experience and
recommended the urgent recruitment of more female doctors who should be
given specialist training. It specified that the examination should take
place without delay and that every woman should have ready access to
specially prepared facilities for the medical.
The Effects of Domestic Violence on Health
In order to assess the impact of domestic violence on health, the
mental as well as the physical effects need to be taken into account.
There is growing evidence that violence has serious and long term effects
on the health of women and children, which is often undiagnosed and
untreated. Physical injury can result both from sexual and other physical
assaults and the psychological effects of such abuse including the
witnessing of abuse and emotional abuse can be life threatening.
A strong association has been found between domestic violence and
psychiatric illness, Para suicide, alcohol and drug abuse. Roberts et al
(1997) found that in a study conducted in 1991 of victims of domestic
violence attendees in the emergency department, there was a progression
from multiple attendances for physical trauma over five years to alcohol
and drug problems, to current violence and suicide attempts.
There is a great need for training and raised awareness of the needs of
disabled women, many of whom have been rendered so by the violence they
have faced from their partners (see McCarthy 1997). The community care
ethos is based on maintaining women in their own homes where women
experiencing abuse are least safe. Disabled women's groups have recently
emerged such as the British Council of Organisations of Disabled People
Women's Group and the Greater London Association of Disabled People
organised a conference around women's safety issues in 1995.
Pregnancy
Domestic abuse often starts or escalates in pregnancy. Relatively few
women die during pregnancy or childbirth, but when pregnant women are more
likely to suffer domestic violence at the hands of their partner and are
more likely to commit suicide. A 1998 Confidential Enquiry into Maternity
Deaths, which reports every three years, looked at public health matters
that endanger women's lives. The inquiry looked at 375 deaths of which 268
were considered to be related to medical problems in the pregnancy or
within six weeks of giving birth. The inquiry found that six women in the
past three years died as a result of domestic violence and thousands were
injured. They drew on studies which showed that in about a third of cases
the violence started in pregnancy, perhaps because the man perceives the
woman to be withdrawing from him or because her condition leads to
arguments.
The report noted the failures of some junior medical, obstetric, A and
E staff, GPs and midwives to diagnose dangerous conditions or refer the
women to specialists who would spot them. To remedy this, it recommended
that
-
ante-natal clinics have procedures for identifying women who may
become depressed to be aware of the signs that a woman is being
battered or is falling into a potentially suicidal depression (
Boseley 1998)
-
details of psychiatric disorder, substance abuse or previous
self-harm should be taken when a woman books into hospital.
-
All pregnant women should have at least one consultation with the
lead professional involved in pregnancy care which is not attended by
her partner or any family member and that a set of confidential notes
should be kept separate from those held by the patient.
In November 1997 the Royal College of Midwives produced guidelines
entitled 'Domestic Abuse in Pregnancy' to help midwives recognise and deal
with it. The guidelines points out that the links between domestic abuse
and adverse pregnancy outcomes suggest that midwives should assume a
greater role in its detection and management. The guidelines outline how
to identify domestic violence, the important of documenting the abuse, and
the need to inform women of their options. The guidelines emphasise that
discussing domestic abuse can be difficult and embarrassing and argue that
it is best to ask direct questions rather than hedging around the issue.
Health Services and Domestic Violence
Until recently government bodies have failed to give any guidance about
treating domestic violence. In 1997 the Department of Health issued a
circular on the new Family Law Act which included limited guidance on both
general issues and on interagency initiatives. Currently, however, there
is little co-ordination of strategic responses of health services to
domestic violence either at national or local level. Women have difficulty
in gaining physical access to services and there is a need to raise public
awareness, and for the monitoring of services.
Recent studies (see Henderson 1997, BMA 1998) found that health
services were among the least likely of all services to disseminate any
information on domestic violence. It is not only doctors, community health
workers, and hospital accident and emergency services, but also staff from
specialities as wide ranging as palliative and paediatrics, geriatric
medicine and genito-urinary services that need training (see Mullender
& Morley 1996: 130).
Since Accident and Emergency departments are available in some
hospitals on a 24 hour basis and do not require appointments, they are
often the place where women go if they are injured. Research indicates
that domestic violence is frequently not audited or even recorded and
staff are not generally trained to recognise or to respond effectively to
it (see McWilliams & McKiernan 1993, BMA report 1998). Women who had
been treated were interviewed by McWilliams and McKiernan. The majority of
women interviewed believed that the hospital staff should question them
more and thought that if approached with sensitivity, women would be
prepared to talk. They also expressed the need for advice and information.
By treating the injuries and ignoring the context in which the injuries
occurred, health service professionals could easily exacerbate the
difficulties women faced. Insufficient time and lack of awareness of the
problem means that staff are not identifying the cause of the problem at
an early stage. Confidentiality between doctor and patient is regarded as
the prime concern and doctors have no legal responsibility to contact the
police unless the patient agrees unlike in France where this is
obligatory.
Some local authorities are trying to provide a more co-ordinated
service and to provide training. For example, the Accident and Emergency
Department of Leeds General Infirmary is part of co-ordinated community
care planning and inter-agency work to meet the needs of women
experiencing violence. Another project in Glasgow (1996) involved a full
scale audit to ascertain the current proportions of abused women using
services and what responses they received. There is some evidence that
doctors (general practitioners or GPs) are considerably more helpful than
other health workers but training for them is still lacking (see BMA 1998
report). No formal studies have been undertaken nationally in the UK on
the extent of education received by medical students and doctors at
undergraduate or post-graduate level unlike in the US where it is well
established. The Journal of the American Medical Colleges, recently
produced a 115 page supplement entirely devoted to the subject of
educating the nation's doctors about family violence and abuse. this
included the importance of acquiring knowledge and skills as well as
developing new knowledge and learning to work in partnership with
community groups.
The British Medical Association (1998) report on
Domestic Violence:
A Health Care Issue is a comprehensive, but accessible discussion
document to raise awareness of the nature and prevalence of domestic
violence, and to discuss the role of health care workers in identifying
the problems and devising strategies to help to manage and reduce the
problem. The report points out that health professionals do not need to
prove the existence of violence ( like legal professionals), but need to
identify and acknowledge it when it does occur. Confidentiality must be
discussed with patient, but doctor should underline secrecy cannot always
be guaranteed. It points out that it is important that health workers
recognise symptoms of escalating domestic violence, especially. those with
possible homicidal outcome. Such factors include rising severity and
frequency of domestic violence, sexual assault, alcohol or drugs use by
perpetrator and past suicidal attempts by woman should be monitored. It is
important to provide women with a supportive environment, with posters and
material in surgeries displaying where to find help for domestic violence.
The report also argues that following disclosure, woman's description
of what has happened should be respected. The current safety of woman and
children should be gauged and the doctor should encourage her to make her
own decisions rather than tell her what to do. The importance of keeping
detailed records is stressed as subsequent evidence of violence may be
requested - Body maps to illustrate injuries, photographs, GP records
confirming effects of violence and mental health problems. Patients should
also keep a record of the violence. A seven step overall approach is
recommended which includes privacy and confidentiality; questioning;
respect and validation; assessment and treatment; record keeping and
concise documentation; information giving; and support and follow up.
The need for training
The training for health professionals on domestic violence is improving
but little information is available on what exactly is covered. A survey
in 1986 of accredited USA and Canadian medical schools found that just
under half of those who replied were providing some instruction on
domestic violence although not in any depth. By 1994 87 per cent of US
medical schools allocated some curricular time to adult domestic violence.
In the UK, according to the recent report Domestic Violence: A Health Care
Issue ( British Medical Association 1998:41) a survey of 254 doctors in
the Midlands found that a mere ten per cent had received some training
either at undergraduate or post graduate level. Training courses for
nurses, midwives and health visitors in Britain all deal with gender
issues and with violence in the family but there is great individual
variation between courses and few concentrated on domestic violence (Pahl
1995). In Greater Glasgow implementing a women's health policy included
the production of an open learning pack by one of the local hospital
accident and emergency departments in conjunction with implementing a
protocol on domestic violence
According to the report Commissioned by the Department of Health and
Social Services in Belfast, Northern Ireland (McWilliams and
McKiernan1993) the responses of statutory agencies were often to ignore or
minimise the violence, appearing to give legitimation to its use. Social
workers sometimes made judgements against wives because they were 'in a
refuge' while their husbands were 'living in a nice home'. This meant that
several women lost custody of all or some of the children. Community
psychiatric nurses estimated that 8 to 10 per cent of their current cases
related to domestic violence
The 1990s have seen considerable public policy and professional concern
about domestic violence as the consequences for mothers and children have
gradually begun to be recognised. In 1998 the Department of Health
commissioned the development of the Reader 'Making an Impact' and a
Training Resource pack to increase awareness about the impact on children
of domestic violence and to develop professional understanding of how best
to offer help and support. The materials were devised by Barnardo's, the
NSPCC, and the Domestic Violence Research Group of the University of
Bristol with the assistance of a multi-disciplinary team. there is some
evidence that social work responses still often adhere to pathologising or
family systems models. The main reason is that women in violent
relationships are seen as 'clients in need of therapy, rather than people
in need of alternatives and choices' ( Dobash & Dobash 1992: 234). In
1997 Women's Aid carried out a survey of refuges to investigate the impact
of child contact arrangements. 54 refuges took part, and 67 per cent
reported that women had been abused when they were handing over children
for contact visits and 31 per cent reported that children had been
physically or sexually abused during contact. 8 refuges stated that
contact orders gave the address of the refuge, endangering the safety of
all women and children staying there and 23 refuges stated that a child
had been forced to reveal the address of the refuge during contact visits.
The following guidelines have been developed and would be useful for
training purposes: In 1997 the West London Health Promotion Agency
published a pack containing the first guidelines on domestic abuse in
pregnancy by Royal College of Midwives (1997) since research has indicated
that pregnancy may trigger or exacerbate male violence in home. Good
Practice Guidelines on domestic violence were produced by the Leeds
Inter-Agency Project ( Women and Violence) where a training pack for
'Training For Trainers' has also been developed. This is to support and
enable participants to successfully offer the 'Violence against women by
known men' training programme and should be used in conjunction with the
pack. Each pack comprises material for a two day training programme.
Trained trainers will undertake four days of training in total. The basis
of this programme has been used extensively throughout the UK. Peer
assessment and feedback is an essential aspect of he programme.
Facilitators are advised to be aware of the potential for insensitive
feedback and negativity form participants. The laying of ground rules
clearly at the beginning is very important. ( The pack was written by
Andrea Tara-Chand and is available from LIAP, CHEL, 26 Rounday Rd, Leeds
LS7 IAB. It was funded by the Home Office Programme Development Unit).
Good practice guidelines have also been developed by some local
authorities to develop work with ethnic minorities. Domestic violence
response units have been set up in Haringey and Lambeth both in heart of
black communities. UJIMA a black housing association set up the first
refuge for black women in 1988. By 1997 about 40 of the 240 refuge
services in England run specialist refuges. Rai & Thiara (1997)
documented the living experiences of black women's use of refuge support
services.
Sen's (1997) study of the needs of ethnic minorities undertaken for the
Camden Equalities Unit highlights the frequent exclusion of ethnic
minority women (in this case Bangladeshi, Chinese and Horn of Africa
women) from discussions on domestic violence and stresses the need to
provide appropriate services to women from these communities. She found
that cultural constraints do not prevent women from minority groups from
using the services and that where appropriate services are provided, women
will use them. She recommends development of further specific services
taking account of ethnic minority women's needs. This requires more ethnic
minority staff, ethnic monitoring of users and keeping centralised records
and further training on the impact of domestic violence on children.
Finally Jackson (1996) documents how deeply racism is affecting the
provision of support and care for the abused black child.. She argues that
child abuse is taken less seriously if the child is from an ethnic
minority and points to the lack of ethnic monitoring of children in care.
Conclusion
Domestic violence can have both direct and indirect effects. The direct
effects can at the extreme involve death, but also women suffer many
injuries, some of which lead to long term disability. Pregnancy is known
to render women particularly vulnerable to abuse and injuries to the
foetus can result. Injuries to the breast may predispose women to breast
cancer. Indirect effects include suicide and self harm, post traumatic
stress, depression and eating disorders. Children suffer from witnessing
violence and may present such symptoms as sleep disorders, bed wetting and
other disturbances. Health professionals, in particular nurses working in
the community are in a key position to assist women and children to escape
from violence.
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