UNDERSTANDING DOMESTIC VIOLENCE...15 UNDERSTANDING DOMESTIC VIOLENCE BY ANNE L. GANLEY, PH.D....

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UNDERSTANDING

DOMESTIC

VIOLENCE

BY ANNE L. GANLEY, PH.D.

15

UNDERSTANDINGDOMESTIC VIOLENCE

BY ANNE L. GANLEY, PH.D.

Domestic violence is a problem ofepidemic proportions with far-reach-

ing consequences for individual victims,their children and their communities.Domestic violence results in death, seriousinjury, and chronic medical and mentalhealth issues for victims, their children, theperpetrators, and others. The lethaloutcome of domestic violence is tragicallyevident in media reports that describe asteady stream of homicides against victims,their children, family or friends, those whoare trying to protect them, innocentbystanders, and perpetrators.

Discussing what is known abouthomicides and suicides is only one way tounderstand the lethal nature of domesticviolence. At this time there is little researchmeasuring the impact of assaults and abusein terms of permanent and health-shatter-

ing injuries and illnesses. For everyhomicide victim of domestic violence, thereare many victims struggling with majorhealth problems who did not die whenshot, stabbed, clubbed, burned, choked,beaten or thrown by their abusers.Thousands of these victims struggle withthe health consequences of being trapped inabusive relationships without being identi-fied by health care providers or providedwith proper treatment (Hamberger,Saunders & Honey, 1992).

Domestic violence presents uniquechallenges to the health care system andrequires specialized responses from healthcare providers. Before providers are able toeffectively and efficiently respond topatients experiencing domestic violencethey must first understand the nature andetiology of the problem as well as its impact

INTRODUCTION:THE HEALTH IMPACT OF DOMESTIC VIOLENCE

on victims, children, and the community asa whole. This chapter provides the frame-work for that understanding by reviewing

the definition and causes of domesticviolence as well as specific issues related tovictims, perpetrators, and children.

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I. DEFINITION OF DOMESTIC VIOLENCE

Domestic violence has many names:wife abuse, marital assault, woman battery,spouse abuse, wife beating, conjugalviolence, intimate violence, battering,partner abuse, for example. Sometimesthese terms are used interchangeably torefer to the problem, while at other times aparticular term is used to reflect a specific

meaning (e.g., “woman abuse” to highlightthe fact that most victims are women). Inaddition to these multiple terms, there aredifferent behavioral and legal definitionsfor domestic violence. With so manyvarying terms and definitions, there can bea lack of clarity about what is meant bydomestic violence, leading to inconsisten-

DEFINITION OF DOMESTIC VIOLENCE

Domestic violence is a pattern of assaultive and coercive behav-iors, including physical, sexual, and psychological attacks, aswell as economic coercion, that adults or adolescents useagainst their intimate partners.

Key elements of domestic violence:

1. Conduct perpetrated by adults or adolescents against their intimate partners incurrent or former dating, married or cohabiting relationships of heterosexuals,gay men, and lesbians.

2. A pattern of assaultive and coercive behaviors, including physical, sexual, andpsychological attacks as well as economic coercion.

3. A pattern of behaviors including a variety of tactics — some physically injuriousand some not, some criminal and some not — carried out in multiple, sometimesdaily episodes.

4. A combination of physical attacks, terrorist acts, and controlling tactics used byperpetrators that result in fear as well as physical and psychological harm tovictims and their children.

5. A pattern of purposeful behavior, directed at achieving compliance from orcontrol over the victim.

FIGURE 1-1

cies in identification, assessment, and inter-ventions as well as inconsistencies inresearch.

For the purpose of this manual, abehavioral definition of domestic violenceis used rather than a legal definition, since abehavioral definition is more comprehen-sive and more relevant to the health caresetting.1 (See Figure 1-1) Domestic violenceis herein defined by (1) the relationshipcontext of the violence, (2) the perpetrator’sbehaviors, and (3) the function thosebehaviors serve. Throughout this manual,the terms “domestic violence,” “abuse,”and “battering” will be used interchange-ably.

A. Relationship Context Domestic violence occurs in a relation-

ship where the perpetrator and victim areknown to each other. It occurs in both adultand adolescent intimate relationships. Thevictim and perpetrator may be dating,cohabiting, married, divorced, or separated.They are heterosexual, gay or lesbian.2They may have children in common. Therelationships may be of short or longduration.

The intimate context of the violence isimportant in understanding the nature ofthe problem and in developing effectiveinterventions. To an outside observer,domestic violence may look like stranger-to-stranger violence (e.g., punching,slapping, kicking, choking). Domesticviolence victims experience traumas similarto those of victims of stranger violence(e.g., burns, internal injuries, head injuries,bruises, stab wounds, broken bones,muscle damage, psychological trauma).However, the intimate context of domesticviolence shapes the way in which both the

perpetrator and the victim relate to and areaffected by the violence. And, unfortu-nately, the intimate context all too oftenleads those outside the relationship to takedomestic violence less seriously than othertypes of violence.

In domestic violence, perpetrators haveon-going access to their victims, know theirdaily routines and vulnerabilities, and cancontinue after violent episodes to exerciseconsiderable physical and emotionalcontrol over their daily lives. In addition,these perpetrators have knowledge of theirvictims (e.g., prior medical conditions,allegiance to their children) which they useto target their assaults (e.g., withholdingmedications, grabbing victims from behind,threatening to harm the children), increas-ing the victims’ trauma and fear.

Victims of domestic violence not onlydeal with the particularities of a specifictrauma (e.g., head injury) and the fear offuture assaults by a known assailant, butmust also deal with the complexities of anintimate relationship with that assailant.Many perpetrators believe that they areentitled to use tactics of control with theirpartners and too often find social supportsfor those beliefs. It is the “family” nature ofthese relationships that sometimes gives theperpetrator social, if not legal, permission

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1 Health care providers may want to becomefamiliar with the legal definition of domesticviolence in their jurisdiction and note thesimilarities and differences in the ways domes-tic violence is defined.

2 For the purposes of this manual, masculinepronouns are generally used when referring toperpetrators of domestic violence, whilefeminine pronouns are generally used to refer-ence victims. This is not meant to detract fromthose cases where the victim is male or theperpetrator is female. This pronoun usagereflects the fact that the majority of domesticviolence victims are female. The U.S.Department of Justice estimates that 95% ofreported assaults on spouses or ex-spouses arecommitted by men against women (Douglas,1991). There are no prevalence figures fordomestic violence in gay and lesbian relation-ships, but experts (Lobel, 1986; Renzetti, 1992;Letellier, 1994) indicate that domestic violenceis a significant problem in same-sex relation-ships as well. Consequently, some of theexamples in the manual are specific to gay,lesbian or heterosexual relationships, whileothers apply to all three.

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to use abuse. Unlike victims of strangerviolence, victims of domestic violence facesocial barriers to a separation from theirperpetrators as well as barriers to otherstrategies for self protection (Hart, 1993).

Domestic violence as defined here doesnot include other types of intimate orfamily violence: child abuse/neglect, child-to-parent violence, sibling violence, and theabuse of the elderly (unless the abuse isbeing perpetrated by the elder’s intimatepartner). While other types of familyviolence may result in the same kinds ofphysical injuries and psychological damagefound in domestic violence cases, thedynamics are different, require differentinterventions, and are beyond the scope ofthis manual.

B. Domestic Violence: APattern of Behaviors

Domestic violence is not an isolated,individual event, but rather a pattern ofperpetrator behaviors used against avictim. The pattern consists of a variety ofabusive acts, occurring in multiple episodesover the course of the relationship. Someepisodes consist of a sustained attack withone tactic repeated many times (e.g.,punching), combined with a variety ofother tactics (such as name calling, threats,or attacks against property). Otherepisodes consist of a single act (e.g., a slap,a “certain look”). One tactic (e.g., physicalassault) may be used infrequently, whileother types of abuse (such as name callingor intimidating gestures) may be used daily.Battering episodes last a few minutes toseveral hours or days. While some perpe-trators repeat a particular set of abusiveacts, other perpetrators use a wide varietyof tactics with no particular routine.

Each episode of domestic violence isconnected to the others. One batteringepisode builds on past episodes and sets thestage for future episodes. Perpetrators referto past episodes (e.g., “Remember the lasttime?”) and make threats about future

abuse as a way to maintain control.Batterers use a wide range of coercivebehaviors that result in a wide range ofconsequences, some physically injuriousand some not, but all psychologicallydamaging. Some parts of the pattern arecrimes in most states (e.g., physical assault,sexual assault, menacing, arson, kidnap-ping, harassment) while other batteringacts are not illegal (e.g., name calling, inter-rogating children, denying the victim accessto the family automobile). All parts of thepattern interact with each other and canhave profound physical and emotionaleffects on victims. Victims respond to theentire pattern of perpetrators’ abuse ratherthan simply to one episode or one tactic.While a health care provider may beattempting to make sense of one incidentthat resulted in an injury, the victim isdealing with that single episode in thecontext of all the other obvious and subtleepisodes of abuse.

The abusive and coercive behaviorstake different forms: physical, sexual,psychological, and economic. To under-stand the pattern, different types of domes-tic violence behaviors are described below.The first two categories are types of physi-cally assaultive battering where the perpe-trator has direct contact with the victim’sbody. The other categories involve tacticswhere the perpetrator has no direct physi-cal contact with the victim’s body duringthe attack although the victim is clearly thetarget of the abuse.

1. PHYSICAL ASSAULTS

Physical abuse may include spitting,scratching, biting, grabbing, shaking,shoving, pushing, restraining, throwing,twisting, slapping (with open or closedhand), punching, choking, burning, and/oruse of weapons (e.g., household objects,knives, guns) against the victim. The physi-cal assaults may or may not cause injuries.Sometimes a seemingly less serious type ofphysical abuse, such as a shove or push, canresult in the most serious injury. The perpe-trator may push the victim against a couch,

a wall, down a flight of stairs, or out of amoving car, all of which could result invarying degrees of trauma (e.g., bruising,broken bones, spinal cord injuries).Sometimes the physical abuse does notcause a specific injury but does cause otherhealth problems. For example, one perpe-trator frequently abused his partner duringmeals and late at night. He would push,restrain, and spit at his partner as well asabuse her verbally. While there were novisible injuries, the victim suffered fromsevere sleep deprivation and poor nutri-tion, since both her sleep and eatingpatterns were repeatedly interrupted by herabuser’s conduct.

2. SEXUAL ASSAULTS

Some perpetrators sexually batter theirvictims. Sexual battering consists of a widerange of conduct that may includepressured sex when the victim does notwant sex, coerced sex by manipulation orthreat, physically forced sex, or sexualassault accompanied by violence. Victimsmay be coerced or forced to perform a kindof sex they do not want (e.g., sex with thirdparties, physically painful sex, sexual activ-ity they find offensive, verbal degradationduring sex, viewing sexually violent mater-ial) or at a time they do not want it (e.g.,when exhausted, when ill, in front ofchildren, after a physical assault, whenasleep). Some perpetrators attack theirvictims’ genitals with blows or weapons.Some perpetrators deny victims contracep-tion or protection against sexually trans-mitted diseases. The perpetrators’ messageto the victims is that they have no say overtheir own bodies. Sometimes victims willresist and are then punished, andsometimes they comply in hopes that thesexual abuse will end quickly. For somebattered victims this sexual violation isprofound and may be difficult to discuss.Some victims are unsure whether thissexual behavior is really abuse, whileothers see it as the ultimate betrayal.

3. PSYCHOLOGICAL ASSAULTS

There are different types of psychologi-cal assaults.

a. Threats of violence and harm

The perpetrator’s threats of violence orharm may be directed against the victim orothers important to the victim or they maybe suicide threats. Sometimes the threatincludes killing the victim and others andthen committing suicide. The threats maybe made directly with words (e.g., “I’mgoing to kill you,” “No one is going to haveyou,” “Your mother is going to pay,” “Icannot live without you”) or with actions(e.g., stalking, displaying weapons, hostagetaking, suicide attempts). Perpetrators maybe violent towards others (e.g., neighbors,family members) as a means of terrorizingvictims. Perpetrators may coerce victimsinto doing something illegal (e.g., prostitu-tion, larceny) and then threaten to exposethem, or may make false accusationsagainst them (e.g., reports to ChildProtective Services, to the welfare depart-ment, or to immigration).

b. Attacks against property or petsand other acts of intimidation.

Attacks against property and pets arenot random acts. It is the wall the victim isstanding near that gets hit, or the door sheis hiding behind that gets torn off of itshinges, the victim’s favorite china that issmashed or her pet cat that is strangled infront of her, the table that she is sitting nearthat gets pounded or one of the perpetra-tor’s favorite objects that gets smashedwhile he says, “Look what you made medo.” The message to the victim is always,“You can be next.”

The intimidation can also be carriedout without damage to property, by theperpetrator yelling and screaming in thevictim’s face, standing over the victimduring a fight, driving recklessly when thevictim or children are present, stalking, orputting the victim under surveillance. The


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intimidation may not always include athreat of physical harm, but may instead becarried out by damaging the victim’srelationships with others or her reputationin her community by discrediting her withemployers, ministers, friends, neighbors.

c. Emotional abuse

Emotional abuse is a tactic of controlthat consists of a wide variety of verbalattacks and humiliations, includingrepeated verbal attacks against the victim’sworth as an individual or role as a parent,family member, friend, co-worker, orcommunity member. The verbal attacksoften emphasize the victim’s vulnerabilities(such as her past history as an incest victim,language abilities, skills as a parent,religious beliefs, sexual orientation, or HIVstatus).

Sometimes the batterer will play “mindgames” to undercut the victim’s sense ofreality (e.g., specifically directing her to dosomething, then claiming that he neverasked her to do it when she complies).Sometimes emotional abuse consists offorcing the victim to do degrading things(e.g., going to the perpetrator’s mistress’home to retrieve her children, getting onher knees and using a toothbrush to cleanup food the perpetrator smeared on thekitchen floor, or going against her ownmoral standards). Emotional abuse mayalso include humiliating the victim in frontof family, friends or strangers. Perpetratorsmay repeatedly claim that victims are crazy,incompetent, and unable “to do anythingright.” These tactics of abuse are similar tothose used against prisoners of war orhostages and they are used for the samepurpose: to maintain the perpetrator’spower and control.

Emotional abuse in domestic violencecases is not merely a matter of someonegetting angry and calling his partner a fewnames or cursing. Not all verbal insultsbetween partners are acts of violence. Inorder for verbal abuse to be considereddomestic violence, it must be part of apattern of coercive behaviors in which the

perpetrator uses or threatens to use physi-cal force. In domestic violence, verbalattacks and other tactics of control areintertwined with the threat of harm inorder to maintain the perpetrator’sdominance through fear. While repeatedverbal abuse is damaging to partners andrelationships over time, it alone does notestablish the same climate of fear as verbalabuse combined with the use or threat ofphysical harm.

The presence of emotionally abusiveacts may indicate undisclosed use of physi-cal force or it may indicate possible futuredomestic violence. There is no way at thistime in domestic violence research topredict which emotionally abusive relation-ships will become violent and which willnever progress beyond verbal abuse. If thevictim feels abused or controlled or afraidof her partner without showing or offeringclear descriptions of physical harm, thenthe cautious approach would be to acceptthe patient’s views as stated and to respondwith concerns about the victim’s safety andpsychological well-being.

d. Isolation

Perpetrators often try to controlvictims’ time, activities and contact withothers. They gain control over themthrough a combination of isolating anddisinformation tactics. Isolating tacticsmay become more overtly abusive overtime. At first perpetrators cut victims offfrom supportive relationships by claims ofloving them “so much” and wanting to bewith them all the time. In response to thesestatements, victims may initially spendincreasing amounts of time with theirperpetrators. These subtle means of isolat-ing the victim are then replaced with moreovert verbal abuse (e.g., complaints about“interfering” family or “dykey” lookingfriends, complaints about her spending toomuch time with others); sometimes theperpetrator uses physical assaults or threatsof assault to separate the victim from herfamily or friends. He may lock her out ofher house or control her movements by

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taking her car keys or forcing her to quither job. Through incremental isolation,some perpetrators increase their psycholog-ical control to the point where they deter-mine reality for the victims.

Perpetrators’ use of disinformationtactics such as distorting what is realthrough lying, providing contradictoryinformation, or withholding information iscompounded by the forced isolation of thevictims. For example, perpetrators may lieto victims about their legal rights or theoutcomes of medical interventions. Whilemany victims are able to maintain theirindependent thoughts and actions, othersbelieve what the perpetrators say becausethe victims are isolated from contraryinformation. Through his victim’s isola-tion, the perpetrator prevents discovery ofthe abuse and avoids being held responsiblefor it.

The perpetrator isolates the victim byacting jealous and interrupting social/support networks. Some perpetrators actvery possessive about their victims’ timeand attention. They often accuse them ofsexual infidelity and of other supposedinfidelities, such as spending too much timewith children, the extended family, atwork, or with friends. They claim thatfamily or friends are trying to ruin theirrelationship. This jealousy about allegedlovers, friends, or family is a tactic ofcontrol.

e. Use of children

Some abusive acts are directed againstor involve the children in order to controlor punish the adult victim (e.g., physicalattacks against a child, sexual use of thechildren, forcing children to watch theabuse of the victim, engaging children inthe abuse of the victim). A perpetrator mayuse children to maintain control over hispartner by not paying child support,requiring the children to spy, requiring thatat least one child always be in the companyof the victim, threatening to take childrenaway from her, involving her in long legalfights over custody, or kidnapping or

taking the children hostage as a way toforce the victim’s compliance.

Children are also drawn into theassaults and are sometimes injured simplybecause they are present (e.g., the victim isholding an infant when pushed against thewall) or because the child attempts to inter-vene in the fight. The perpetrator’s visita-tions with the children are used asopportunities to monitor or control thevictim. These visitations become night-mares for the children as they are interro-gated about the victim’s daily life. (Forfurther discussion see Section III. C. of thischapter.)

4. USE OF ECONOMICS

Perpetrators control victims bycontrolling their access to all of the familyresources: time, transportation, food,clothing, shelter, insurance, and money. Itdoes not matter who the primary provideris or if both partners contribute. The perpe-trator is the one who controls how thefinances are spent. He may actively resistthe victim becoming financially self-suffi-cient as a way to maintain power andcontrol. Conversely, he may refuse to workand insist that she support the family. Hemay expect her to be the family “book-keeper,” requiring that she keep all recordsand write all checks, or he may keep finan-cial information away from her. In allinstances he alone makes the decisions.Victims are put in the position of having toget “permission” to spend money on basicfamily needs.

When the victim leaves the batteringrelationship, the perpetrator may useeconomics as a way to maintain control orforce her to return: refusing to pay bills,instituting legal procedures costly to thevictim, destroying assets in which she has ashare, or refusing to work “on the books”where there would be legal access to hisincome. All of these tactics may be usedregardless of the economic class of thefamily.


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5. THE CONNECTION BETWEENVIOLENCE AND OTHERTACTICS OF CONTROL

It is the perpetrators’ use of physicaland sexual force or threats to harm personor property that gives power to theirpsychologically abusive acts. Psychologicalbattering becomes an effective weapon incontrolling victims because they knowfrom experience that perpetrators will attimes back up their threats or taunts withphysical assaults. Sometimes the perpetra-tor uses physical force infrequently, withno discernible pattern. However, evenwhen the assault only happens once orends without injury, that incident estab-lishes the threat of violence. If the perpe-trator has been violent against someoneelse (e.g., a previous intimate partner, inwar, on the street), reference to thathistory can also establish the threat ofviolence against the victim. The fact thatthe perpetrator has used violence in thepast to get what he wants gives him powerover her by instilling fear and conveying apromise of violence absent her compli-ance.

Perpetrators will use that fear tocoercively control their victims throughother, non-physical tactics. Sometimesperpetrators are able to gain compliancefrom the victim by simply saying,“Remember what happened the last timeyou tried to get a job?”, referring to a timewhen the perpetrator assaulted the victimfor getting “the wrong kind of job.”Because of the past use of physical force,there is an implied threat in the statementand the victim becomes reluctant topursue a job against the perpetrator’swishes. Sometimes the perpetrator willrefer to his violence against others (e.g.,“You know, I was a trained killer in themilitary,” “You’re acting like Susie andyou know what happened to her”) orsometimes use more overt threats to killor maim the victim or others.

Psychological control through inter-mittent use of physical assault along withpsychological abuse is typical of domestic

violence and is the same control tacticused against hostages or prisoners of war(Graham & Rawlings, 1991; Ganley,1981). Sometimes physical abuse, threatsof harm, and isolation tactics are interwo-ven with seemingly loving gestures (e.g.,expensive gifts, intense displays ofdevotion, sending flowers after an assault,making romantic promises, tearfullypromising it will never happen again).Amnesty International (1973) describessuch “occasional indulgences” as amethod of coercion used in torture. Withsuch tactics, the perpetrator providespositive motivation for victim compli-ance. The perpetrator is able to controlthe victim through this combination ofphysical and psychological tactics sincethe perpetrator connects the threat ofphysical harm so closely with the psycho-logical tactics. The message is alwaysthere that if the victim does not respond tothis “loving” gesture or verbal abuse, thenthe perpetrator will escalate and usewhichever tactic, including force, is neces-sary to get what he wants.

6. THE RESEARCH ON MUTUALBATTERING

Some mistakenly believe that both theperpetrator and the victim are abusive,one physically and one verbally. Oneresearch study indicates that domesticviolence perpetrators are more (ratherthan less) verbally abusive than theirvictims, other persons in distressed/non-violent relationships or persons in non-distressed intimate relationships (Margolin,Gleberman, John, & Ransford, 1987).Another study found that while bothbattering men and battered women useverbal aggression, only the battering mencombined their verbal aggression withacts of violence to control their partners(Jacobson et al. 1994). Even if both useverbal aggression, the reality is that averbal insult is not the same as a fist to theface. Verbal and physical aggression donot have the same power to cause physical

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harm and terror.Some argue that there is “mutual

battering” where both individuals usephysical force against each other. In suchcases careful assessment often reveals thatone partner is the primary physical aggres-sor while the other attempts to defendherself or protect her children (e.g., shestabbed him as he was choking her) or thatthe perpetrator’s violence is more severe(e.g., his punching/choking versus herscratching) (Saunders, 1986; Hamberger &Potente, 1994). Research of heterosexualcouples indicates that women’s motivationfor using physical force is self-defense whilemen use force for power and control(Saunders & Browne, 1991; Wilson &Daly, 1992; Jacobson et al., 1994).“Mutual combat” among gay and lesbianpartners is also rare. Even though gay andlesbian partners may be approximately thesame size and weight, there is usually aprimary aggressor who is creating theatmosphere of fear and intimidation thatcharacterizes abusive relationships (Letellier,1994; Lobel, 1986; Renzetti, 1992). Self-defense against an abusive partner does notconstitute “mutual battering.” Moreover,what perpetrators report as abusive behav-ior against themselves are often acts ofresistance to the abuse. Victims engage insurvival strategies during which theysometimes resist the demands and coercivecontrol of the perpetrators. (See Section III.A.) Perpetrators respond to such resistancewith escalating tactics of control andviolence.

7. CHANGES IN THEPERPETRATOR’S ABUSIVEPATTERN

A perpetrator’s pattern of abusivebehaviors may change. Sometimes theperpetrator uses more psychological tacticsand at other times more physical tactics.There is no evidence that domestic violenceprogresses in a linear fashion from verbalinsults to minor assaults to homicide.Some perpetrators’ physical violence

escalates, while for others the use of physi-cal force stabilizes or even decreases astheir use of other tactics increases.Perpetrators change tactics and use thetactics that are most useful in gainingcontrol. There is no evidence that a perpe-trator’s abusive behavior simply stops onits own. Even in the research where the useof physical force seems to have stopped fora period of time (Hamberger & Hastings,1990; Sheppard, 1988; Jacobson, et al.,1995), it is unclear whether the perpetra-tors have merely switched to non-physicaltactics of control and whether the cessationof physical force will be permanent.Changes in the pattern do not necessarilymean the end of the abusive conduct.

C. DOMESTIC VIOLENCE:PURPOSEFUL,COERCIVE BEHAVIOR

Domestic violence is purposeful andinstrumental behavior. The abuse isdirected at achieving compliance from orcontrol over the victim. The pattern is notrandom or “out of control” behavior.Perpetrators who minimize or excuse theirbehavior by claiming they “lost it” or“were out of control” have actually madespecific choices. Perpetrators follow theirown internal set of rules and regulationsfor their use of abusive behaviors. Somewill batter only in particular ways (e.g., hitcertain parts of the body). Others useviolence only toward their victims eventhough they may be in conflict with theirboss, other family members, or the healthcare provider. Some will hit only in private,while others hit in public. Some will breakonly the victim’s possessions and not theirown while others will not engage in anyproperty destruction. Such decision-making indicates that they are actually incontrol of their abusive behaviors. (Ganley,1981, 1991; Adams, 1989).

Domestic violence involves a pattern ofbehavior and certain tactics require a great


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deal of planning to execute (e.g., stalking,interrogating family members). Somebatterers impose rules on the victims(Fischer, Vidmar, & Ellis, 1993), carefullymonitoring their compliance and punishingthem for any “infractions” of the imposedrules. Such attention to detail contradictsthe notion that perpetrators “lost” controlor that their abusive conduct is the result ofpoor impulse control.

Interviews with perpetrators reveal thatwhen using both overt and subtle forms ofabuse, perpetrators know what they wantfrom victims (Ganley, 1995). Perpetrators

use varying combinations of physical forceand/or threats of harm and intimidatingacts to instill fear in victims. At times theywill use other kinds of manipulationsthrough gifts, promises, and indulgences.Regardless of the tactic chosen, the perpe-trators’ intent is to get something from thevictims, to establish domination over them,or to punish them. Perpetrators selectivelychoose tactics that work to control theirvictims. (Ganley, 1981; Serum, 1982; Pence& Paymar, 1993). See Appendix B forPower and Control Wheel.

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II. CAUSES OF DOMESTIC VIOLENCE

A. Domestic Violence:Learned Behavior

Domestic violence is behavior learnedthrough observation and reinforcement.Like other forms of aggression, domesticviolence is not caused by genetics or illness.People are not born perpetrators and forthe most part there is no disease or illnessthat turns a non-abusive person into anabuser. Domestic violence is a behavioracquired over time through multiple obser-vations and interactions with individualsand institutions (Bandura, 1979; Dutton,D., 1988). The behaviors, as well as theperpetrator’s internal “rules and regula-tions” about when, where, against whom,how, and by whom domestic violence is tobe used, are learned. Domestic violence andthe beliefs that support it are learnedthrough direct observation (e.g., the malechild witnessing the abuse of his mother byhis father or from the proliferation ofimages of violence against women in themedia). It is also learned through thereinforcement of the perpetrators’ experi-ences (e.g., perpetrators receiving peersupport or not being held responsible,

arrested, prosecuted, or sentenced appro-priately for their violence).

Domestic violence is observed andreinforced not only in the family but also insociety. It is overtly and covertly reinforcedby society’s major institutions: familial,social, legal, religious, educational, mentalhealth, medical, entertainment, and themedia (Bandura, 1977; Dutton, D. 1988;Ganley, 1989; Dobash & Dobash, 1979).These social institutions advocate the use ofviolence as legitimate means of controllingfamily members (e.g., religious beliefs/positions that state that a woman shouldsubmit to the will of her husband, laws thatdo not consider violence against intimates acrime, medical and mental health systemsthat blame victims for “provoking” theviolence). These practices reinforce the useof violence to control intimates by failing tohold perpetrators responsible for theiractions and by failing to protect victims.(See Jones (1994) for a more completediscussion of social supports for battering. )

Domestic violence is repeated becauseit works and thus the pattern of behavior isreinforced. The use of the abusive conductallows the perpetrator to gain control of thevictim through fear and violence. Gaining

the victim’s compliance, even temporarily,provides partial reinforcement for theperpetrator’s use of abusive tactics. Oftenthe battering behavior is also reinforced bythe responses of peers, family authorities,and bystanders. More importantly, theperpetrator is able to reinforce his ownabusive behavior. He is able to justify hisactions to himself because of the sociallysanctioned belief that men have the right tocontrol women in relationships and havethe right to use force to ensure that control.

B. Domestic Violence andGender

Domestic violence is a gender-specificbehavior which is socially and historicallyconstructed. Men are socialized to takecontrol and to use physical force whennecessary to maintain dominance. Whilemost victims of male violence are othermen, the majority of victims of domesticviolence are female, although female-to-male, male-to-male (gay), and female-to-female (lesbian) violence also occurs inintimate relationships. Male violenceagainst women in intimate relationships is asocial problem condoned and supported bythe customs and traditions of a particularsociety. There is a great deal of discussionabout whether gender is the sole factordetermining the pattern of abusive controlin intimate relationships or one of a clusterof significant variables (Miller, 1994;Renzetti, 1994). However, gender is clearlya salient issue when considering the follow-ing factors: the prevalence of male-to-female domestic violence, injuries to femalevictims, the use of physical force as part ofa pattern of dominance, and specificresponses of victims and perpetrators todomestic violence.

As previously noted, in the majority ofreported domestic violence cases, theperpetrators are men and the victims arewomen (Douglas, 1991). In heterosexualrelationships, some women sometimes usephysical force, but their use of physical

force is not always at the same rate orseverity as men’s (Dobash & Dobash,1979, 1992; Gelles, 1994). Studies indicatethat while both men and women sometimesuse similar physical behaviors, the physicaleffects of male violence are far more seriousthan female aggression as measured by thefrequency and severity of injuries (Berk,Berk, Loseke, & Rauma, 1983). Furthermore,the impact of the physical aggression variesaccording to the gender of the victim —female victims of male intimate violenceexperience more negative consequencesthan male victims of female intimateviolence (Vivian & Langhinrichsen-Rohling,1994).

Furthermore, the purpose of women’suse of physical force appears to be differentthan men’s. In studies of heterosexualrelationships, women use physical forceagainst partners for self-defense, whereasmen use force for power and control(Saunders, 1986; Hamberger & Potente,1994; Jacobson, et al., 1994). In homicidestudies, women are shown to be morelikely than men to have committedhomicide in self-defense. In contrast, maleperpetrators of homicide are more likely tostalk victims, kill victims and/or otherfamily members, and/or commit suicidethan female perpetrators of homicide(Wilson & Daly, 1992). The research onbattered women who kill also suggests thatwomen’s use of physical force is related toprotecting themselves from the severeviolence of male perpetrators (Gillespie,1989). Browne (1987) found no distin-guishing characteristics between batteredwomen who kill and those who do not. Theonly differences found in comparing thesetwo groups of battered women were foundin their batterers (i.e., the men who werekilled had been more violent against thevictims as well as the children than thosewho were not killed).

Obviously, in same-sex domesticviolence the gender pattern is different.However, the reality of same-sex domesticviolence does not discount the genderissues of domestic violence. Male violenceagainst women in heterosexual intimaterelationships is a paradigm for intimate


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violence in gay and lesbian relationships:one partner is intimidating and controllingthe other through the use of or threat ofphysical violence.

Even though the gender pattern is notthe same for same-sex relationships as forheterosexual, there are gender issuesrelated to how gay and lesbian victims andperpetrators relate to the abuse and to howothers view same-sex domestic violence.For example, because of their gendersocialization, gay victims may have diffi-culty identifying as victims because it isseen as “unmanly” (Letellier, 1994); thegay community may discount the violencebecause “that is the way men are” while thelesbian community may deny lesbiandomestic violence because “women are notlike that;” and the homophobic mainstreamdismisses the domestic violence as just partof being gay or lesbian. While same-sexdomestic violence is slowly receiving atten-tion in the literature (e.g., Lobel, 1986;Renzetti, 1992; Letellier, 1994), there havebeen no studies comparing heterosexual,lesbian and gay domestic violence.Consequently, additional questions regard-ing gender and domestic violence still needto be answered.

C. Domestic Violence andCultural Issues

Domestic violence occurs in allcultural/ethnic groups both outside andwithin the United States. Cross-culturalstudies involving non-literate societies(Levinson, 1989; Campbell, J., 1993;Erchak & Rosenfeld, 1994) indicates thatwife beating is more typical than husbandbeating in those societies and that theprevalence and severity of wife beating isinfluenced by a variety social factors withina particular society (e.g., tolerance ofviolence, competitiveness between men andwomen, presence of support networks forwomen). While a review of that literature isbeyond the scope of this chapter, it is refer-enced here as a reminder that domestic

violence is socially constructed andlearned.

While researchers seek to understandthe significance of cultural differences asrelated to domestic violence,3 it is helpfulfor the health care provider to focus onwhat is known. Domestic violence occursin all cultural/ethnic groups and has seriousphysical and emotional consequences forvictims, their children and their communi-ties. The health impact of domesticviolence to victims has been documented invarious ethnic groups: Latino, AfricanAmerican, Asian, Native American, andCaucasian.

Cultural factors should not be used todismiss the reality of domestic violence in apatient’s life. Perpetrators and others willsometimes offer various cultural rational-izations for the conduct (e.g., “That’s theway she knows I love her,” “It’s part of ourculture,” “It is their way of life”) and theremay be certain cultural specificity in theexpression of those rationalizations (e.g.,“______ women are very violent, too”).This “cultural defense” for domesticviolence has even been inappropriatelyoffered in courts in attempts to explainaway domestic violence homicides.

Culture sometimes shapes the specifictactic of control used by the perpetrator.Some perpetrators use cultural factors ofthe victims as a way to further the abusivecontrol (e.g., immigrant status, languageskills). Perpetrators may accuse victims ofacting “uppity,” “American,” “white” orof being a “bitch” when they assert theirhuman rights. These tactics of control areshaded with cultural issues to give theperpetrator dominance over the victim.

While culture does not alter the reality

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3 There is conflicting data in the U.S. as towhether domestic violence is more prevalentwithin one ethnic group when compared withother ethnic groups (Straus & Gelles, 1990).When differences have been found, variousexplanations for those differences have beensuggested. More research is needed to fullyunderstand the connection (see Hawkins, 1986.Lockhart, 1987; Brice-Baker, 1994; Marsh,1993; Plass, 1993; Torres, 1993).

of the health consequences of domesticviolence, cultural factors can influenceidentification, assessment, and interventionfor the problem. The cultural identities ofboth the patient and the health careprovider may affect the identification andassessment of domestic violence. A healthcare provider unfamiliar with a particularethnic group may misinterpret a patient’sactions as indicative of abuse (e.g., avoid-ance of eye contact) or as indicating thatshe is not a battered woman (e.g., a victim’srage and threats against her abuser).Victims from different cultural groups havedifferent values and beliefs about interper-sonal communication, the role of healthcare providers, the role of police, and therole of family members which shape howthey reveal or don’t reveal their experienceof domestic violence.

Cultural issues should be considered indesigning effective responses and interven-tions for both the victims (Torres, 1993;Campbell, D., 1993; Ho, 1990; Hamptom,1987; Jang, 1991; Plass, 1993) and theperpetrators (Williams, 1994). Just ashealth facilities have worked to offer allhealth care services in ways that are acces-sible to diverse populations with a varietyof languages and ethnicities, responses topatients experiencing domestic violencemust also be culturally appropriate.

D. Domestic Violence vs.Illness-based Violence

While domestic violence is learned,there is other violence that results fromillness. A small percentage of violenceagainst adult intimates is illness-based butis misidentified as domestic violence. Thisviolence is caused by organic or psychoticimpairments and is not part of a learnedpattern of coercive control of an intimatepartner. Individuals with diseases such asAlzheimer’s disease, Huntington’s Chorea,or psychosis may strike out at an intimatepartner. Sometimes that violence getsidentified as domestic violence.

An assessment will distinguish illness-based violence from learning-basedviolence. With illness-based violence, thereis usually no selection of a particular victim(whoever is present when the short circuitoccurs will get attacked: health careprovider, family member, friend, stranger,etc.). However, with learning-basedviolence, the perpetrator directs his abusiveconduct toward a particular person orpersons. In addition, with illness-basedviolence there is usually a constellation ofother clear symptoms of a disease process.For example, with an organic brain disease,there are changes in speech, gait, or physi-cal coordination. With an illness such aspsychosis there are multiple symptoms ofthe psychotic process (e.g., “He attackedher because she is a CIA agent sent by thePope to spy on him using the TVmonitor”). Poor recall of the event alone isnot an indicator of illness-based violence(see Section III. B. 2. of this chapter onperpetrator minimization and denial). Withillness-based violence the acts are stronglyassociated with the progression of a disease(e.g., the patient showed no prior acts ofviolence or abuse in the 20-year marriageuntil other symptoms of the organicprocess had appeared).

There has been no systematic researchto determine the percentage of cases identi-fied by police or courts as domesticviolence that are attributable to illness. In aclinical sample of those individuals identi-fied by community police and courts andreferred to a medical center as domesticviolence perpetrators, less than 5% wereviolent as a result of an organic process(Ganley, 1995). More research is needed onthis issue.

Illness-based violence can be mosteffectively managed by appropriatemedical or mental health interventions andcase management (e.g., instituting daytreatment programs, appropriate medica-tions, respite care, institutionalizationwhen necessary). While attention must begiven to the safety of the victims in suchcases, it is more appropriately dealt with bythose knowledgeable about the particularillness. While the victim may benefit from


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emergency shelter services and safetyplanning, the perpetrator of illness-basedviolence would not benefit from specializeddomestic violence interventions.

E. Domestic Violence IsNot Caused by Alcoholor Other Drugs

Many people use or abuse drugswithout ever battering their partners.Alcohol and other drugs such as marijuana,depressants, anti-depressants, or anti-anxiety drugs do not cause individuals tobecome violent. Although alcohol anddrugs may be used as the excuse for thebattering, research indicates that thecomplex pattern of coercive behaviorswhich comprise domestic violence is notcaused by consuming particular chemicals(Critchlow, 1986; Taylor & Leonard,1983; Pihl & Smith, 1988, Gondolf &Foster, 1991).

Some people who consume alcohol ordrugs are violent with or without thechemical in their bodies. An addict’sviolence may be part of a lifestyle whereeverything, including family life, is orches-trated around the acquisition andconsumption of the drug. Other addicts areso focused on their addiction that theywithdraw from relationships and do notengage in any controlling behavior directedat family members.

On the other hand, there is conflictingevidence whether certain drugs (e.g.,steroids, PCP, speed, cocaine or cocaine’sderivative, “crack”) chemically reactwithin the brain to cause violent behavioror whether they induce paranoia orpsychosis, which is then sometimes accom-panied by violent behaviors. Furtherresearch is needed to explore the cause-and-effect relationship between thoseparticular drugs and violence.

While research studies cited above havefound high correlations between aggressionand the consumption of various substances,there is no data clearly proving a cause-

and-effect relationship. There are a widevariety of explanations for these highcorrelations. Some say that alcohol anddrugs provide a disinhibiting effect whichgives the individual permission to do thingsthat they otherwise would not do. Otherspoint to the increased irritability or hostil-ity which some individuals experiencewhen using drugs and which may lead toviolence. Others state that the high correla-tions merely result from the overlap of twowidespread social problems: domesticviolence and substance abuse.

Clinical experience cautions againstviewing domestic violence as being causedby alcoholism, drug addiction or substanceabuse. Such a view can misdirect interven-tions solely to the chemical use rather thanto the domestic violence. For those who areaddicted to alcohol and other drugs,stopping domestic violence behavior isdifficult without also stopping the addic-tions. However, it is not sufficient to treatthe chemically addicted perpetrator ofdomestic violence solely for either addic-tion or domestic violence. Interventions forboth require one of the following: (a)concurrent interventions for domesticviolence and substance dependence/abuse,(b) inpatient substance abuse treatmentwith a mandatory follow-up program fordomestic violence, or (c) an involuntarysubstance abuse commitment (which isdone in some, but not all, states) withrehabilitation directed at both the addic-tion and the domestic violence.

The presence of alcohol or drugs ishighly relevant to the assessment of lethal-ity. The use of, or addiction to, substancesmay increase the potential lethality ofdomestic violence and must be carefullyconsidered when addressing the safety ofthe victim, the children, and the commu-nity (Browne, 1987).

F. Domestic Violence IsNot Caused by Anger

The role of anger in domestic violence

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is complex and cannot be simplisticallyreduced to one of cause-and-effect. Somebattering episodes occur when the perpe-trator is not angry or emotionally charged,and others occur when the perpetrator isemotionally charged or angry. Someabusive conduct is carried out calmly togain the victim’s compliance. Some displaysof anger or rage by the perpetrator aremerely tactics used to intimidate the victim,and can be quickly altered when the abuserthinks it is necessary (e.g., upon arrival ofpolice).

Current research indicates that there isa wide variety of arousal or anger patternsamong identified perpetrators as well asamong those who are identified as notabusive (Gottman et al., 1995; Jacobsen etal., 1994). These studies suggest that theremay be different types of batterers. Abusersin one cluster actually reduced their heartrates during observed marital conflicts,suggesting a calm preparation for fightingrather than an out-of-control or angryresponse. Such research challenges thenotion that domestic violence is merely ananger problem and raises questions aboutthe efficacy of anger-management programsfor batterers.

Remembering that domestic violence isa pattern of behaviors rather than isolated,individual events helps to explain thenumber of abusive episodes that occurwhen the perpetrator is not angry. Evenwhen experiencing anger, the perpetratorstill chooses to respond to that anger byacting abusively. Ultimately, the individualis responsible for how he expresses anger orany other emotion.

G. Domestic Violence IsNot Caused by Stress

Life is filled with many differentsources of stress (e.g., stress from the job,stress from not having a job, relationshipconflicts, losses, illness, discrimination, orpoverty). People respond to stress in a widevariety of ways (e.g., problem solving,

substance abuse, eating, laughing, with-drawal, and violence) (Bandura, 1973).People choose ways to reduce stress accord-ing to what they have learned about strate-gies that have worked for them in the past.

It is important to hold individualsresponsible for the choices they makeregarding how they reduce stress, especiallywhen those choices involve violence orother illegal behaviors. A robbery or amugging by a stranger is not excusedsimply because the perpetrator claims he isstressed. Similarly, the perpetrator ofdomestic violence cannot be excusedsimply because he is stressed. Moreover, asalready noted, many episodes of domesticviolence occur when the perpetrator is notemotionally charged or stressed. Sincedomestic violence is a variety of tacticsrepeated over time for the purpose ofcontrolling the victim, specific stresses areless meaningful in explaining a longitudinalpattern of abusive control (Pence &Paymar, 1993).

H. Domestic Violence IsNot Caused by theVictim’s Behavior or bythe Relationship

People can be in conflicted relation-ships and experience negative feelingsabout the behavior of their partner withoutchoosing to respond with violence.Focusing on the relationship or the victim’sbehavior as an explanation for domesticviolence removes the perpetrator’s respon-sibility for the violence and coercion andsupports the perpetrators’ minimization,denial, blaming, and rationalization for theviolent behavior. Blaming the victim formaking the perpetrator angry, or blamingthe violence on problems in the relationship(e.g., poor communication) provides theperpetrator with excuses and justificationsfor the conduct. This reinforces the perpe-trator’s use of abuse to control familymembers and thus contributes to the

escalation of the pattern of domesticviolence.

Many batterers bring this pattern ofcontrol into their adult relationships andrepeat it in all their adult intimate relation-ships, regardless of significant differencesin the personalities or conduct of theirintimate partners or in the characteristicsof those particular relationships. Thesevariables in partners and relationshipssupports the position that while domesticviolence takes place within a relationship,it is not caused by the relationship.Research indicates that there are nopersonality profiles for battered women(Hotaling & Sugarman, 1986). Batteredwomen are no different from non-batteredwomen in terms of psychological charac-teristics. Once again, this challenges themyth that there is something about thewoman that causes the perpetrator’sviolence. Furthermore, a study by Jacobsonet al. (1994) indicates that no victim behav-ior could alter the perpetrator’s behavior.This also suggests that the victim’s behavior

is not the determining factor in whether ornot the perpetrator is abusive.

Domestic violence in adolescentrelationships further challenges the notionthat the abuse is the result of the victim’sbehavior. Often times the adolescent abuseronly superficially knows his victim, havingdated her only a few days or weeks beforebeginning the abuse. Such an abuser isoften acting out an image of how toconduct an intimate relationship based onthe recommendations of his peers, musicvideos, models set by family members, etc.The adolescent’s abusive conduct is influ-enced more by that image or script than bythe victim’s behavior.

Both adult and adolescent batterersbring into their intimate relationshipscertain expectations of who is to be incharge and what mechanisms are accept-able for enforcing that dominance. Thoseattitudes and beliefs, rather than thevictim’s behavior, determine whether or notthey are violent.

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III. DOMESTIC VIOLENCE: THE VICTIM, THEPERPETRATOR, THE CHILDREN AND THECOMMUNITY

A. The VictimVictims of domestic violence have

multiple health problems as a result of theabusiveness of their partners. They seekmedical care for injuries resulting from theperpetrators’ acts (e.g., burns, brokenbones, internal injuries, vaginal injuries,miscarriages, head injuries, damage to eyesor ears, dental injuries, knife or gunshotwounds, cuts, back injuries) and withillnesses aggravated by the stress of livingwith their partner’s abusiveness (e.g.,asthma, lupus, MS, depression, anxiety,insomnia, eating disorders).

Victims may also be patients in the

health care system for issues seeminglyunrelated to their victimization, and theirtreatment for their medical conditions maybe compromised by the continuing abuse(e.g., an insulin-dependent patient whoseperpetrator controls her by withholding hermedications or by refusing to allow her tokeep her medical appointments). Thisvictimization by intimate partners putspatients at future risk for medical andpsychological sequelae to abuse.

If the domestic violence is not identifiedand addressed, there are both long andshort-term consequences for the victims.Unidentified victims may receive inappro-priate treatments for their presenting injury

or illness (e.g., over-medications, treatmentprotocols they are unable to carry out dueto the control of the abusers) and/or theymay be denied the opportunity to get theinformation and support they need toprotect themselves from future injuries,illnesses or death.

Failure to identify victims of abuse alsocreates consequences for the health caresystem. The health care practitioner missesthe opportunity for early identification,intervention and ultimate prevention.Initial injuries and illnesses are followed byrepeated injuries and illnesses due to theviolence. Victims seeking assistance returnto the health care system for multiple visits,consuming scarce resources. For somevictims the only professional with whomthey have contact is the health careprovider and they will return again andagain in hopes that their suffering will bealleviated.

1. VICTIMS OF DOMESTICVIOLENCE CAN BE FOUND INALL AGE, RACIAL,SOCIOECONOMIC,EDUCATIONAL,OCCUPATIONAL, RELIGIOUS,SEXUAL ORIENTATION ANDPERSONALITY GROUPS

Victims of domestic violence are a veryheterogeneous population whose primarycommonality is that they are being abusedby someone with whom they are, or havebeen, intimate. They do not fit into anyspecific age group, racial group, personalityprofile, socioeconomic, educational, occupa-tional, religious or sexual orientation.

Too often, victimization is seen as aproblem for one group but not for another.For example, teen victims of domesticviolence are often ignored. While there is agreat deal of public discussion about theneed for appropriate sex education to helpteens protect themselves from unwanteddisease or pregnancy, there is little aware-ness of the need for teen education aboutdomestic violence. With further documen-

tation of dating violence (Levy, 1991),there is a call for more attention to thisissue by those professionals in contact withadolescents who are just beginning to haveintimate relationships. They need assis-tance in specific ways to avoid violence intheir dating relationships. Victims ofpartner abuse may be 12, 25, 43, 78, 98 orany age in between. All age groups have thepotential to be victimized by perpetratorsof domestic violence.

Sometimes ignoring the issue takes theform of stereotypes that communicate thatwife beating is just a way of life or “cultur-ally acceptable” in “that” group. As notedpreviously, there is little comprehensiveresearch on the prevalence and “acceptabil-ity” of domestic violence in specific groups(e.g., certain cultural groups, gays,lesbians). What research has been doneraises as many questions as it answers.What is known is that domestic violence isa problem in all racial, ethnic, sexual orien-tation, ability, economic class, educational,and occupational groups.

Furthermore, there is no evidence thatbattered women fit a particular personalityprofile. Early studies of battered womenattempted to focus on characteristics of thevictim that would provide a causativeexplanation for the violence (Snell,Rosenwald, & Robey, 1964). Later studiesindicate that no causative link has beenfound between the characteristics ofbattered women and their victimization(Hotaling & Sugarman, 1986). Consequently,as with victims of other trauma (e.g., caraccidents, floods, muggings), there is noparticular personality profile for the personwho is battered. Being a victim of domesticviolence is due to behaviors of the perpetra-tor, rather than the personal characteristicsof the victim.

2. VICTIMS MAY OR MAY NOTHAVE BEEN ABUSED ASCHILDREN, OR IN PREVIOUSRELATIONSHIPS

Just as some have looked to the person-


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ality or demographic characteristics of thevictim to explain her victimization, othershave suggested that most domestic violencevictims have a history of childhood abuseand/or previous violent relationships, andthat this contributes to the current victim-ization. Yet there is no evidence that previ-ous victimization, either as adults or aschildren, results in women seeking out orcausing their current victimization (Dutton,M.A., 1992). Some victims of domesticviolence have been victimized in the pastand some have not. While it may be helpfulto understand an individual victim’s historyand her coping strategies in dealing withpast and current abuse, the practitionershould exercise caution and avoid makingvictim blaming interpretations of suchhistory.

3. SOME VICTIMS BECOME VERYISOLATED AS A RESULT OF THEPERPETRATORS’ CONTROLOVER THEIR ACTIVITIES ANDCONTACTS WITH FRIENDS ANDFAMILY MEMBERS

Some of a victim’s behaviors in a healthcare setting can be understood in light ofthe control the perpetrator has managed toenforce through her isolation (e.g., herreluctance to commit to a particular treat-ment protocol that requires multipleappointments, her lack of confidence in herown abilities, or her fear of further harm).

Without outside contact and informa-tion, it becomes more difficult for thevictim to avoid the psychological controland threats of the perpetrator. Some victimscome to believe their abuser when they saythe victims would not survive alone if theyleft, while others resist such distortions.

Even when the victim maintainscontact with friends or extended family,those relationships are often mediatedthrough the control of the perpetrator.Consequently, victims do not experienceneeded support and advocacy. The victim’sexperience with others is repeatedly

processed through the comments and inter-pretations of the abuser. Some perpetratorsinterrogate victims about every detail oftheir interactions with others and describeto the victims the nature of those relation-ships. The victims’ positive feedback orsupport from their other relationships isundermined by the perpetrators’ intrusionsinto those relationships. The more success-ful perpetrators are in isolating the victims,the more they control what the victimsbelieve (Graham & Rawlings, 1991).

4. WHY SOME VICTIMSSTAY/WHEN THEY LEAVE

One of the most commonly askedquestions about domestic violence is, “Whydo victims stay in violent relationships?”The reality is that many victims leave. Butto understand this process of leaving, onemust once again consider what domesticviolence is, what the perpetrator is doing,and what the victim’s options are in hercommunity.

The primary reason given by victims ofdomestic violence for staying or returningto the perpetrator (or for not followingother health care provider recommenda-tions) is fear of violence and the lack of realoptions for safety with their children. Thisfear of the violence is realistic. Research onbattered women shows that the lethality ofthe perpetrator’s violence often increaseswhen the perpetrator believes that thevictim has left or is about to leave therelationship (Campbell, J., 1992, Wilson &Daly, 1993). The literature suggests severalindicators for homicide against the victim:the perpetrators’ obsession with the victim,a pattern of escalating physical violence,increased risk-taking by the batterer,threats to kill the victim and self, substanceabuse, and a gun in the household(Campbell, J., 1992; Saunders, 1994; Hart& Gondolf, 1984; Kellerman, et al., 1993).

Some perpetrators repeatedly threatenor attempt to kill or seriously injure theirvictims, children or others when the victimsattempt to leave relationships. The victim

may have previously attempted to leaveonly to have been tracked down by theperpetrator, seriously injured and broughtback. Perpetrators do not just let victimsleave relationships. They will use violenceand all other tactics of control to maintainthe relationship. It is a myth that victimsstay with perpetrators because they like tobe abused. Even in cases where the victimwas abused as a child, the victim does notseek out violence and does not want to bebattered. Staying in or returning to therelationship may simply be safer thanleaving.

The reasons for staying in a violentrelationship are multiple and vary for eachvictim. They include:

a. Fear of the perpetrator’s violence;

b. Immobilization by psychological andphysical trauma;

c. Connection to the perpetrator throughhis access to the children;

d. Illness (e.g., HIV, MS) and dependanceon the perpetrator for health care;

e. Belief in cultural/family/religious valuesthat encourage the maintenance of thefamily unit at all costs;

f. Continual hope and belief in the perpe-trator’s promises to change and to stopbeing violent;

g. Belief that the perpetrator cannotsurvive (e.g., due to illness with AIDS)or will engage in self-destructive behav-ior if the victim leaves;

h. Insufficient funding and resourcesnationwide that result in a lack ofshelters and victim advocacy programsto provide transitional support;

i. Lack of real alternatives for employ-ment and financial assistance,especially for victims with children;

j. Lack of affordable legal assistance

necessary to obtain a divorce, custodyorder, restraining order, or protectionorder;

k. Lack of affordable housing that wouldprovide safety for the victim andchildren;

l. Being told by others that the abuse ishappening because the victim is gay,lesbian, or bisexual and that the abusewould stop if they would “change;”and

m. Being told by the perpetrator, counselors,the courts, police, ministers, familymembers, or friends that the violence isthe victim’s fault, and that the victimcould stop the abuse simply by comply-ing with the perpetrator’s demands. Inthese cases, the victims learn that thesystems with the power to intervenewill not believe them or act to protectthem. Thus, the victims are forced tocomply with the perpetrators in hopesof stopping the abuse.

5. VICTIM SURVIVAL STRATEGIES

Victims of domestic violence use manystrategies to survive that become inappropri-ately labeled as “crazy,” codependent, orinappropriate behavior on the part of thevictim (e.g., being too fearful to ask partnerto use safe sex precautions, being afraid touse legal remedies or seek battered women’sadvocacy services, or wanting to return tothe perpetrator in spite of severe violence).These victim responses may in fact benormal reactions or strategic decisions forcoping with very frightening and dangeroussituations (Dutton, M.A., 1992).

When the victim discovers that a systemwith the power to intervene will not act tosafeguard and support her, she mayconclude that reconciliation is the safercourse. The victim can rarely stop theperpetrator’s abuse. All that she can do is tokeep herself and her children as safe aspossible, and even this requires the supportof someone else. Some victims will begin to


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terminate the relationship by seeking assis-tance from the court system or social serviceagencies, only to see that those systems arenot effective in stopping the violence. Forexample, a protective order may not deter aperpetrator in communities where thepolice refuse to enforce the order. Whereoutside protection fails, the victim is forcedto rely on strategies that have worked in thepast.

Victims use many different strategies tocope with and resist the abuse. Such strate-gies include agreeing with the perpetrator’sdenial and minimization of the violence inpublic, accepting the perpetrator’s promisesthat it will never happen again, saying thatshe “still loves him,” being unwilling toleave the perpetrator or terminate therelationship, and doing what he asks. Thesestrategies may appear to be the result ofpassiveness or submission on the part of thevictim, when in reality she has learned thatthese are sometimes successful approachesfor temporarily avoiding or stopping theviolence. Many victims who appear reluc-tant to carry out actions that the health careprovider believes would protect them andtheir children from further violence actuallyhave the same goal as the health careprovider: namely, an end to the violence.They simply have different strategies.

Some victims have told other healthcare providers about the abuse, even if theydid not use the terms “abuse” or “domesticviolence.” In the past their descriptions ofthe abuse may have been ignored, notbelieved, or met with inappropriateresponses. It can be very humiliating to thevictim to talk about these issues withsomeone who is not sensitive. Because ofprior attempts to seek assistance from thehealth care system or other social serviceagencies, the victim may now be reluctantto assume that her safety and confidentialitywill be respected by the current health careprovider. In such cases, unless the healthcare provider initiates the topic, the victimmay not even raise the issue with the healthcare provider. Other victims will readilyname the abuse, but minimize it as a way tocope with what is happening until they candetermine whether there really are the

community supports they need for protec-tion. In such cases, victims sometimes re-engage in the prior survival strategies ofcomplying with the perpetrators while theyassess the community.

Successful interventions must be basedon an understanding of the victim’s behav-ior as normal responses to violence perpe-trated by an intimate. Rather than viewingthe victim’s behaviors as masochistic,passive, crazy, or inappropriate, theyshould be viewed as survival strategieswhich contribute to the victim’s safety andthe safety of her children.

B. The Perpetrators Perpetrators come into the health care

system both for problems related to theirabusive behaviors and for those that arenot. They are patients in emergency depart-ments, primary care practices, or specialtyclinics. They may be inpatients or outpa-tients. There are few published studies ofprevalence for domestic violence perpetra-tors in the various clinics serving men(except Gondolf & Foster, 1991).However, certain medical centers (e.g.,Veterans Administration Medical Centers,military medical facilities, some HMO’s)with on-site perpetrator interventionprograms do report receiving referrals ofabusers from medical personnel who seethese patients in a wide variety of medicalclinics.

Perpetrators sometimes seek healthcare assistance for physical injuries theycaused to themselves in the process of strik-ing their partners or when terrorizing themwith attacks against property (e.g., brokenhands, feet, limbs, back injuries, headinjuries, internal injuries, muscle strains,burns, cuts). Sometimes they are seekingmedical attention for illnesses aggravatedby their abusive behavior (e.g., diabetes,asthma, high blood pressure, heartproblems, depression). Sometimes theyhave injuries from suicide attempts made tocoerce their partners to remain in therelationship. One abuser shattered the

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bone of his lower leg when the sledgeham-mer he was using to destroy his partner’sapartment kicked back.) Another terror-ized his partner by telephoning her andthreatening for 30 minutes to kill himselfwith dynamite. As she listened helplessly,he blew off one of his arms. Both men wereidentified as domestic violence perpetratorsby medical personnel during treatment fortheir physical injuries and were referred todomestic violence intervention programs.

Sometimes perpetrators are seekingmedical care for injuries caused by thevictims’ desperate attempts to protectthemselves or their children or by victimswho strike back after years of abuse (e.g.,injuries from objects being thrown, burns,knife or gunshot wounds). Sometimes thebatterers are in the system for problemstotally unrelated to their abusive behavior(e.g., bone marrow transplant, spinal cordinjury, post traumatic stress disorder, schiz-ophrenia, gall bladder surgery).

There is no simple, predictive profilethat can be used to determine whether ornot someone is a perpetrator of domesticviolence. However, there are some commoncharacteristics of abusers that are helpful tokeep in mind when interacting either with avictim or with a perpetrator.

1. PERPETRATORS OF DOMESTICVIOLENCE CAN BE FOUND INALL AGE, RACIAL,SOCIOECONOMIC,EDUCATIONAL, SEXUALORIENTATION,OCCUPATIONAL, ANDRELIGIOUS GROUPS

Perpetrators are a very heterogeneouspopulation whose primary commonalty istheir use of violence. They may be young,old, or in-between. They may be artists,athletes, teachers, health care providers,professionals, working class, unemployed,middle class, rich, or poor. They may beProtestant, Catholic, Muslim, Jewish,Buddhist, agnostic, or atheist.

Perpetrators do not fit into any specificpersonality or diagnostic category. Whilethere is a great deal of discussion in theliterature about the psychological profile ofbatterers, especially as it relates to predict-ing outcome in their rehabilitation(Saunders, 1993), it is premature to offerpersonality profile(s) for abusers. Thereappear to be clusters of personality charac-teristics for different abusers (Tolman &Bennett, 1990; Hamberger & Hastings,1990; Saunders, 1992), just as there areclusters of personality characteristics fornon-abusers. The literature suggests thatthere are different types of batterers whouse different controlling tactics to differentdegrees (Gondolf, 1988; Issac, Cockran,Brown & Adams, 1994). Part of thisvariance may be explained by differenttypes of batterers or by the fact that thosestudied are at different stages in their ownhistories as batterers.

The diversity of perpetrators is limitedonly by the diversity represented in acommunity. Sometimes a health careprovider or community agency will dealwith one group more than another (e.g., aparticular socioeconomic class, ethnicgroup, or age group). This may lead tosome inaccurate generalizations aboutperpetrators (or victims) as providers startto think of abusers solely in terms of thecases they see. In order not to make errorsin identification of domestic violence, thehealth care provider should remain open tothe possibility of domestic violence beingan issue for diverse individuals. Clinicalexperience is a reminder that perpetratorscome in many forms and ultimately canonly be identified by knowing how theyrelate to their intimate partners.


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2. DOMESTIC VIOLENCEPERPETRATORS AVOID TAKINGRESPONSIBILITY FOR THEIRCONDUCT BY MINIMIZING,DENYING, LYING ABOUT ORJUSTIFYING THEIR ABUSIVETACTICS

Perpetrators minimize their abusiveconduct and its impact on the victim andothers by making the abuse appear lessfrequent and less severe than it really is(e.g., “I only hit once,” “I just pushed herto the floor,” “The children never saw theabuse,” “She bruises easily,” “I’m not oneof those wife-beaters. I have never punchedher”). In talking with others about theproblem, perpetrators will sometimes useeuphemisms for their violence, such as“We’re not getting along so well” or “Wehad a little fight last night,” when referringto incidents in which the victim requiredmajor medical attention for seriousinjuries.

Sometimes perpetrators acknowledgewhat they do, but justify it by externalizingresponsibility for their behavior to others orto factors supposedly outside their control.The health care provider will hear manydifferent ways abusers justify or blameothers for their abusiveness. Perpetratorsprimarily blame the victims for the violence:“She wouldn’t listen to me,” “She’s analcoholic,” “She’s crazy,” “I can’t handleher,” “My lover is the abuser,” “Thispregnancy has made her wild,” “She’ssuffering from post-partum depression,”“She’s clumsy,” or “She’s running aroundon me.” They also blame other factors: “Ihave PTSD (post-traumatic stress disor-der)/hypoglycemia/ attention-deficit disor-der/mood swings,” “I was drinking,” “Thekids are just too much,” or “The EMT gothis facts wrong. I didn’t do nothing that youwouldn’t do.” Sometimes they do not lieabout their behavior because they believethey have the right to do what they do.When blaming, perpetrators fail to mentiontheir violent behaviors and avoid takingresponsibility for them.

Sometimes perpetrators lie about theirabuse to avoid the external consequencesof their behavior and to maintain controlover their partner. They will lie to thevictim, family, friends, police, judges,health care providers, and anyone else whohas contact with them. They lie becausethey do not want to deal with possibleconsequences (e.g., arrests, prosecution,jail, loss of visitation, etc.).

Sometimes perpetrators use denial andminimization not only to avoid the externalconsequences but also to protectthemselves from the personal discomfort ofrecognizing that they are abusing someonethey love. This denial is a means of deceiv-ing themselves. Just as there are alcoholicswho are in denial about their drinking,there are perpetrators in denial about theirbattering. There are some perpetrators whoare conflicted about what they are doingand they distort it through minimization,denial, or rationalization to make it moreacceptable to themselves.

Regardless of why a perpetrator isdistorting the truth, this distortion can bemisleading to both victims and to healthcare providers and can present barriers toidentifying domestic violence. Health careproviders should be aware of perpetrators’tendency to lie, deny, or minimize theviolence and avoid colluding with abusers.

3. DOMESTIC VIOLENCEPERPETRATORS CONTROL THEVICTIM THROUGH THEHEALTH CARE SYSTEM

Perpetrators use multiple tactics ofcontrol against the victim. Sometimes theyenlist others in that control either throughdisinformation or intimidation. The tacticsof control may be used to coerce the victimto stop talking about the abuse with thehealth care worker, to reunite with theperpetrator, to drop her objections to jointcustody, etc. The following are examples ofcontrolling behaviors that the health carepractitioner may witness or hear about.

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■ Physical assaults or threats of violenceagainst the victim, children, or sometimesthe health care provider; threats ofsuicide; threats to take the children orharassment;

■ Stalking the victim to and from healthcare appointments;

■ Accompanying the victim to allappointments; sending the victim“looks” during appointments; refusingto let the victim be interviewed orexamined alone;

■ Bringing family or friends to themedical facility to intimidate or cajolethe victim or the health care provider;

■ Blaming the victim through longspeeches about all the victim’s behav-iors that supposedly “provoke” theabuse;

■ Crying and other displays of emotionor statements of profound devotion orremorse to the victim, alternated withthreats or other psychological abuse;

■ Canceling the victim’s appointmentswith the health care provider; sabotag-ing her efforts to attend appointmentsby not providing child care, transporta-tion, etc.;

■ “Physician-hopping” or “therapist-hopping;”

■ Denying the victim access to the perpe-trator’s medical records that maysupport her issues or attempting tocontrol or gain access to her medicalrecords;

■ Withholding medication; under- orover-medicating the victim;

■ Using the legal system against thevictim by requesting mutual orders ofprotection, making false charges ofharassment/abuse against the victim,filing multiple divorce proceedings;

■ Continually testing the limits of visita-tion/support agreements by arrivinglate or not showing at appointed timesor arriving drunk;

■ Threatening and/or implementingcustody fights; and

■ Using any evidence of damage resultingfrom the abuse as evidence that thevictim is an unfit parent (victim’scounseling records, victim’s treatmentfor depression or other medical condi-tions, etc.).

Sometimes in his attempts to controlthe victim, a perpetrator will attempt tocontrol the health care provider with thesame tactics of power and control usedagainst the victim.

■ Portraying self as the good patient whoconstantly praises the health careprovider;

■ Intimidating the health care providerwith a variety of threats or acts;

■ Harassment of health care provider byrepeated phone calls, civil suits orthreats of legal action, or false reportsto superiors concerning supposedbreaches of confidentiality, inappropri-ate treatment, or rude behavior;

■ Splitting health care teams by creatingdivisiveness among professionals(e.g.,”The doc is one of those women’slibbers,” “The nurse doesn’t like me,”“He takes my wife’s side”).

4. DOMESTIC VIOLENCEPERPETRATORS MAY HAVEGOOD QUALITIES IN SPITE OFTHEIR ABUSIVENESS

Some domestic violence perpetratorsmay be good providers, hard workers, goodconversationalists, witty, charming, attrac-


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tive, and intelligent, yet they still batter theirvictims. Sometimes health care providers aswell as victims are misled by these positivequalities and assume that the violence didnot really happen or is an aberration of theperpetrator’s real personality since onlyindividuals who are “monsters” couldcommit such acts. They may believe that theviolence can be ignored because such a“good” person will most certainly stop theabuse. The reality is that even seeminglynormal and nice people may batter and maybe very dangerous. Battering stops onlywhen perpetrators are held responsible forboth their abuse and for making the changesnecessary to stop the violence.

C. The Children Children, like the victim, appear in the

health care system with a variety of physi-cal injuries, illnesses or medical conditionsdirectly related to the perpetrator’s abuseand with other health issues. Understandingthe domestic violence etiology of thoseconditions is important both in treating thecurrent conditions and in preventing futureproblems. Even if the child’s problem is notrelated to the domestic violence, treatmentfor any condition can be compromised bythe abusive, controlling behavior of thebatterer.

1. PERPETRATORS TRAUMATIZECHILDREN IN THE PROCESS OFBATTERING THEIR ADULTPARTNERS

Perpetrators of domestic violence trau-matize and terrorize children in four ways:

a. By intentionally injuring the children asa way of threatening and controllingthe victim (e.g., a child is used as aphysical weapon against the victim bybeing thrown at the victim or a child isphysically or sexually abused as a wayto coerce the victim to do certainthings);

b. By unintentionally injuring the childrenduring the attack on the abused parentwhen the child gets caught in the fightor attempts to intervene (e.g., an infantis injured when the mother is pushedagainst the wall while holding the child;a small child is kicked when trying tostop the perpetrator’s attack against thevictim);

c. By creating an environment wherechildren witness the abuse or its effects.Research reveals that children whowitness domestic violence are affectedin the same way as children who arephysically and sexually abused(Goodman & Rosenberg, 1987). Inspite of what perpetrators may say,children have often either directlywitnessed the physical and psychologi-cal assaults or have indirectly witnessedit by overhearing the episodes or byseeing the aftermath of the injuries andproperty damage; and

d. By using the children to coercivelycontrol the abused partner while thevictim is living with the perpetrator andwhen the partners are separated. Theintent is to continue the abuse of theadult victim, sometimes with littleregard for the damage this controllingbehavior has on the children (Walker &Edwall, 1987).

Examples of the perpetrator’s behaviorthat traumatizes and terrorizes childreninclude but are not limited to:

■ Asserting that the children’s “bad”behavior is the reason for the assault onthe victim;

■ Isolating the children along with theabused parent (e.g., not allowing thechildren to enter peer activities orfriendships);

■ Engaging the children in the abuse ofthe other parent (e.g., making the childparticipate in the physical or emotionalassaults against the adult);

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■ Forcing the children to watch theviolence against the abused parent;

■ Threatening violence against thechildren, pets, or other loved objects.Attacks against pets or loved objectsare particularly traumatic for youngchildren who often do not make adistinction between themselves and thepet or object. Consequently, the perpe-trator’s attack against the pet is experi-enced by the children as an attackagainst them;

■ Interrogating the children about theabused parent’s activities;

■ Forcing the abused parent to always beaccompanied by the children;

■ Taking the children away after eachviolent episode to ensure that the adultvictim will not flee the perpetrator;

■ Holding children hostage or abductingthe children in efforts to punish thevictim or to gain the victim’s compli-ance;

■ Using lengthy custody battles as a wayto continue abusing the other parent;

■ Engaging in long tirades aimed at thechildren about the abused parent’sbehaviors that caused the separation;and

■ Demanding unlimited visitation oraccess by telephone (e.g., insisting thatadolescent siblings stay alternate nightswith the perpetrator after the separa-tion, ignoring their need for time witheach other or with their friends)

2. CONSEQUENCES OF DOMESTICVIOLENCE ON CHILDREN

Children living with domestic violencein the home are often the forgotten victims.Current research indicates that domestic

violence affects children in a variety ofways, and that the effects are both short-and long-term (Jaffe, Wolfe & Wilson,1990; Peled, Jaffe & Edleson, 1994;Schecter & Edleson, 1994). Children maybe physically, emotionally, and cognitivelydamaged as a result of domestic violence.The nature and extent of the damagecaused by the perpetrator’s violence willvary depending primarily on three factors:

a. The type and history of abusive controlused by the perpetrator;

b. The age, gender, and developmentalstage of the child;

c. Situational factors, such as other socialsupports.

Consequences of the perpetrator’sabuse vary according to the age and devel-opmental stage of the child (Jaffe, et al.,1990). During infancy, the crucial develop-mental task for the very young child is thedevelopment of emotional attachments toothers. Being able to make attachments toothers provides a foundation for healthydevelopment. Domestic violence not onlyinterrupts the infant’s attachment to theperpetrator but can also interrupt thechild’s attachment to the victim. The perpe-trator may directly interfere with thevictim’s care of the young child. The perpe-trator’s violence may not permit bondingbetween either parent and the child. Thisresults in difficulty for the child in formingfuture relationships and blocks the devel-opment of other age appropriate-skills andabilities.

The primary tasks of children betweenages five and ten are role development andcognitive development. The perpetrator’sviolence and pattern of control can impedeor derail both of these tasks. For example, achild may have difficulty learning basicconcepts in school because of his or heranxieties about what is happening at home.

The central developmental task ofteenagers is becoming autonomous. Thisoccurs as teens separate from relationshipswith parents and establish peer relation-


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ships. Often what is learned in familyrelationships is duplicated in peerrelationships. Consequently, for teensliving in violent homes there is no positivemodel for learning the skills necessary forestablishing mutuality in healthy adultrelationships (e.g., listening, support,non-violent problem-solving, compro-mise). The teenager will sometimes sidewith the abusive parent, viewing thatparent as the one who is most powerful.

Like the adult victims, childrenexperience a great deal of fear and havemultiple ways of expressing that fear. Thenegative effects of the perpetrator’s abusein interrupting childhood developmentcan be seen in cognitive, psychological,and physical symptoms (Jaffe, et al.,1990) such as:

a. eating, sleeping disorders;

b. mood related disorders such asdepression and emotional neediness;

c. overcompliance, clinginess, withdra-wal;

d. aggressive acting out/destructiverages;

e. detachment, avoidance, a fantasyfamily life;

f. somatic complaints;

g. finger biting, restlessness, shaking,stuttering;

h. school problems; and

i. suicidal ideation.

The child’s experience of domesticviolence also results in changes in percep-tions and problem solving skills. Youngchildren often incorrectly see themselvesas the cause of the perpetrator’s violenceagainst the intimate partner. Children will

use either passive behaviors (e.g.,withdrawal, compliance) or aggressivebehaviors (e.g., verbal and/or physicalstriking out) rather than assertive problemsolving skills to cope with the problem.

3. CHILDREN, PARENTING, ANDDOMESTIC VIOLENCE

In the face of overwhelming odds,battered women do many things toprotect their children from perpetrators:intervening in the perpetrator’s violencedirected at the children, sending thechildren to others when they are indanger, teaching the children safety plans,reminding the children that they are notresponsible for domestic violence, andbeing very loving and engaged with thechildren. Sometimes the victim cannoteffectively protect the children from theperpetrator’s violence because the victimis relatively powerless to protect herselffrom the perpetrator.

One of the goals of intervention forvictims with children is for victims to getthe support and advocacy necessary toeffectively protect their children. Themost effective way to protect the childrenis to protect and support the non-abusingparent. Removing the child from the careof a loving battered woman is not theanswer. Nor is putting the child into atreatment program without also ensuringthat he/she has a safe home. Holding theperpetrator, not the victim, responsible forthe abuse is critical in protecting both thevictim and the child.

Many children are not harmedirreparably by experiencing domesticviolence in their families. A caring,supportive network can lessen thenegative effects to children, helping themrebuild their sense of self as caring,competent beings. Once they are safe,they can return to normal developmentaltasks.

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D. THE COMMUNITY

Domestic violence ripples out into thecommunity when the perpetrator’s violenceresults in the death or injury of thoseattempting to assist the victim or innocentbystanders. Such tragic consequences ofdomestic violence in the community can beseen on a daily basis in newspapers acrossthe country as they recount the latesthomicide of an ex-spouse, current partner,children, innocent bystanders, or thosewho attempt to intervene in the violence.Although rarely identified by the media as“domestic violence” homicides, these fatal-ities almost always involve a history ofabusive and controlling behavior by theperpetrator against the adult intimate.

■ In California, a domestic violenceperpetrator kills the victim, his daugh-ters, several of the victim’s co-workers,and a police officer.

■ In New York, the boyfriend of anemployee burns down a nightclub,

resulting in numerous deaths ofpatrons inside.

■ In Colorado, a lawyer is shot in courtby a domestic violence defendant.

■ In Washington, six residents of anapartment building die in a fire set by aperpetrator attempting to kill his ex-wife.

■ In Washington, a battered woman, herunborn child, and two women friendsare shot and killed in Superior Courtby the husband before closingarguments in an annulment hearing.

There are also many financial costs ofdomestic violence that the community mustbear in terms of medical care, absenteeism,and the response of the justice system. Thecost to the community in lost lives andresources is a constant reminder thatdomestic violence is not a family affair, noris it merely a private affair. It is a commu-nity affair demanding a communityresponse.


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CONCLUSION

Health care providers can play animportant role in a coordinated communityresponse to domestic violence by acting inways that increase the safety of the victimand the children, supporting victims inmaking their own decisions about theirlives, and holding perpetrators, not victims,

responsible for their domestic violence.Understanding domestic violence as anissue of abusive control of intimaterelationships with health-shattering conse-quences is the first step to effective inter-ventions.

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UNDERSTANDING DOMESTIC VIOLENCE...15 UNDERSTANDING DOMESTIC VIOLENCE BY ANNE L. GANLEY, PH.D....

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