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Physician Interaction With Battered Women
The Women's Perspective
L. Kevin Hamberger, PhD;
Bruce Ambuel, PhD;
Anne Marbella, MS;
Jennifer Donze, MD
Arch Fam Med. 1998;7:575-582.
ABSTRACT
Background Programs that train health professionals to identify and treat battered women have not previously incorporated systematically obtained advice from battered women to guide physician behavior.
Objectives To survey battered women to (1) rate the desirability of specific physician behaviors, (2) describe their actual experiences with physicians while seeking abuse-related medical services, and (3) examine relationships between participants' demographics, history of victimization, history of seeking medical help, and ratings of physician behavior.
Participants One hundred fifteen women who had been battered by a male partner, recruited from support groups and other battered women's programs in a 5-county area in southeastern Wisconsin.
Methods Self-report survey of demographic information, relationship history, observations of physician behavior, and ratings of desirability for those behaviors. Analysis used cross-tabulations,  2, and multiple t tests with Bonferonni adjustments for multiple comparisons.
Results Women identified specific physician behaviors as desirable and undesirable. Desirability ratings did not differ with history of victimization, history of seeking medical help, or most other demographic variables. African American and white women rated a few physician behaviors differently.
Conclusions We identified discrete sets of desirable and undesirable physician behaviors. Further research is needed to clarify racial differences found in this study. Findings can help guide both clinical practice and the development of physician training curricula.
INTRODUCTION
PRIMARY CARE physicians encounter many battered women in their practice.1-4 In outpatient practices, almost 1 in 4 women have been battered in the past year,1 and 39% to 44% of female patients have been battered in their lifetime.1-2 In emergency departments, 10% to 35% of female patients seen have been battered.3-5 In obstetrical practices, 8% to 17% of patients report being battered during pregnancy, while 13% to 55% of pregnant women report being battered at some time during the year prior to their pregnancy.6-7
Unfortunately, physicians seldom identify battered women. Identification rates range from 0% to 4% in outpatient primary care and obstetrical clinics,1-2,6-7 and from 6% to 10% in emergency departments.5, 8 Many battered women will acknowledge abuse when asked directly,9-10 but many physicians do not ask.1 Reasons for this avoidance include discomfort with the topic, lack of time, lack of knowledge and training in what to do after identifying abuse, and reluctance to view abuse as a medical problem.11-12
When physicians do respond, their responses are sometimes harmful. Some physicians discount reports of abuse.13 Physician beliefs and practices that impede satisfactory identification and intervention of abuse, as described by Goldberg and Carey,14 include (1) rationalization of the violence; (2) belief in the private, inviolate nature of the family; (3) denial of violence and abuse; (4) blaming the victim; (5) overreaction to abuse; (6) excusing the assailant for his actions; and (7) feeling powerless to help the victim. Judgmental overreaction to abuse may alienate the battered woman, causing her to withdraw. While physicians often provide technically competent medical services, battered women often feel dissatisfied with physicians' inappropriate or inadequate responses.15
The proliferation of physician training programs designed to provide knowledge and skill in effective identification and intervention techniques to use with battered women in outpatient and emergency medical practices9, 16-22 do not specify how physicians should ask about domestic battery or how they can identify victims. All reviewed physician training programs provide recommendations based on common sense, and sometimes on the extensive experience of individual proponents. However, there are few studies that support the common practices.
To our knowledge, Mandel and Marcotte23 conducted the only study evaluating physician training in detection and intervention in cases of domestic abuse. This study suggested that educational programs may improve physician responses; however, it did not assess the actual experience of patients.
A recent, qualitative study by Rodriguez et al24 found that battered women value direct questions about abuse, referrals to appropriate agencies that can offer assistance, follow-up, attentive, nonjudgmental support and understanding, and confidentiality. To our knowledge, this was the first report to elicit the perspectives of battered women regarding medical interventions in cases of domestic abuse. The study offers general guidance for physicians, but does not provide information on specific behaviors.
Our current study has 2 aims: First, to describe physician behaviors that battered women find desirable and undesirable during their clinic visits related to abuse; second, to determine whether battered women's opinions were related to personal experiences and characteristics.
Because this is primarily an exploratory, descriptive study, specific hypotheses are not advanced. Nevertheless, we examined the relationship between the women's demographic makeup (age, race, educational level, and employment and marital status) and how they rated the behavior of their physicians. In addition, we explored the relationship of how women rated physician behaviors with their history of child abuse and witnessed parental abuse, current domestic violence, injury from abuse, and whether they were receiving medical treatment for abuse-related issues at the time.
PARTICIPANTS, MATERIALS, AND METHODS
PARTICIPANTS
Survey participants were 115 women who had been abused by a male partner. They were recruited from ongoing support groups and other programs sponsored by local battered women's programs in a 5-county area in southeastern Wisconsin. These agencies are the only providers of battered women's services in their respective communities, with the exception of 1 large city that has several agencies. The participating programs serve geographic areas encompassing urban, suburban, and rural communities.
All participants provided signed, informed consent for survey participation. Not all women who were recruited agreed to participate in the survey.
MATERIALS
Participants completed 3 questionnaires. The first questionnaire, modified from a prior study,1 was used to determine age, race, marital status, employment status, and educational level.
The second questionnaire, the Conflict Tactics Scale,25 was used to assess assault history in intimate relationships throughout the participant's life and in the past 12 months. The Conflict Tactics Scale is the most widely used, valid, and reliable measure of relationship aggression.25-26
The third questionnaire, the Physician Assessment and Treatment of Abuse Inventory, was developed for this study. Ninety-four items describe physician behaviors that an abused woman may encounter while being treated in a clinic. The goal of this questionnaire was to gather battered women's opinions about desirable and undesirable physician behavior. Participants rated the desirability of the 94 behaviors using a 5-point Likert scale. A rating of 1 denotes definitely do not want, and a rating of 5 denotes definitely want. Respondents were also asked to indicate whether they had encountered each behavior when seeking medical care for abuse-related injuries.
Questionnaire Development
The Physician Assessment and Treatment of Abuse Inventory was developed using a 3-step empirical approach. To assure ecological validity, battered women, advocates, and family physicians generated an initial bank of items describing physician behaviors. Next, the research team categorized items into 3 domains, each containing desirable and undesirable behaviors: medical intervention (eg, taking a thorough history, a rough and painful examination), emotional support (eg, empathic listening, criticism for being abused), practical support (eg, providing local referrals, excusing the perpetrator). Finally, a panel of survivors of domestic abuse reviewed the bank of items for social validity, completeness, and readability.
Procedure
A research assistant collaborated with leaders of battered women's programs to recruit participants. Potential participants were given a detailed verbal description of the project, then asked to read and sign a consent form. Participants were then directed to a private area within the women's program facilities to complete the questionnaires. The research assistant was available to answer any questions about survey items. Participants were informed of the purpose of the study after they completed the survey. Because such surveys can cause an emotional reaction in some participants, provisions were made to provide assistance in crisis resolution to those experiencing emotional distress from the survey process. No participants sought services for management of emotional reactions to the survey.
RESULTS
DEMOGRAPHIC INFORMATION
One hundred fifteen women completed the study survey. The mean age of the participants was 31 years. Races included were white (65%), African American (28%), Hispanic (2%), and other or undeclared (5%). Educational level varied: 23% had completed some high school, 32% had completed high school, 35% had completed some college, and 10% had completed college or graduate work. Forty percent were employed, and 30% were either married or living with someone.
Most participants (72%) reported being abused as a child: 60% emotionally, 49% physically, and/or 36% sexually. Fifty-nine percent reported having witnessed the abuse of a parent when they were children, 96% of these stating that their mothers were the victims of abuse.
Fifty-three of the women reported being abused by their current partners. Of these, 84% reported injuries from the abuse, with 41% sustaining severe injuries, such as a laceration or a broken bone; 82% had been pushed, grabbed, or shoved; 61% had been kicked, bitten, or hit with a fist; 57% had been choked; 44% had been threatened with a knife or gun; and 17% had been injured by a knife or gun.
More than half (54%) of the participants reported seeing a physician for a physical injury resulting from abuse; of these participants, 53% had visited an emergency department and 43% had seen a physician in a private office. Forty-one percent of the women reported seeing a physician for emotional support following an abusive incident at a physician's private office rather than at an emergency department.
SCALE VALIDITY
To examine the ability of the Physician Assessment and Treatment of Abuse Inventory to differentiate desirable physician behaviors from undesirable physician behaviors, we compared mean ratings of hypothesized desirable physician behaviors with undesirable physician behaviors for 3 areas: medical services, emotional support, and practical support. For all 3 categories, behaviors hypothesized to be desirable were rated more highly than behaviors hypothesized to be undesirable (P< .0001), with mean scores higher than 3.87 for desirable behaviors, and mean scores below 1.96 for undesirable behaviors.
PHYSICIAN BEHAVIOR RATINGS
Table 1, Table 2, and Table 3 give desirable and undesirable physician behavior in each of the 3 domains measured by the Physician Assessment and Treatment of Abuse Inventory, as well as the percentage (in parentheses) of help-seeking participants who reported experiencing each behavior.
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Table 1. Ratings* of Specific Physician Behaviors in the Area of Medical Services and Percentage of Battered Women Who Reported Them
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Table 2. Ratings* of Specific Physician Behaviors in the Area of Emotional Support and Percentage of Battered Women Who Reported Experiencing Them
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Table 3. Ratings* of Specific Physician Behaviors in the Area of Practical Support and Percentage of Battered Women Who Reported Experiencing Them
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Medical Service
Desirable and undesirable medical behaviors are listed in Table 1, which also shows the percentage of participants encountering each behavior. Reported highly desirable behaviors included physicians conducting examinations sensitively (74%) and careful examination of injuries (65%). However, only 56% reported receiving a careful explanation of procedures, and only 24% reported that their physician took a careful social history of their relationships.
Regarding highly undesirable behaviors, few participants reported experiencing rough examinations, being ignored by their physician when attempting to disclose abuse, or being accused that they were lying. However, other undesirable behaviors were common: 56% of the patients reported that physicians too easily accepted false explanations for their injuries, and 45% reported that physicians treated injuries without asking their cause.
Emotional Support
Desirable and undesirable emotionally supportive physician behaviors and the percentage of participants reporting encountering those behaviors are listed in Table 2. Desirable behaviors included careful listening (80%), responding with compassion (75%), and providing emotional support (65%). However, fewer women reported that their physician reassured them that they were not to blame for the abuse and that their feelings of anger and embarrassment were normal (53% each). Undesirable (nonsupportive) behaviors included minimizing the severity of injury (33%) and implying that the patient had triggered the abuse (24%). Ten percent felt that their physicians acted angry toward them, and 3% reported that their physicians joked about domestic violence during the examination.
Practical Support
Practical support measures are listed in Table 3, along with percentages of patients who reported receiving them. Slightly more than half the women reported receiving practical support, and 10 of the 24 desirable behaviors were reported by less than one third of the women. Desirable support measures such as providing information and phone numbers for safety and legal resources, informing patients that spousal battery is illegal, displaying posters and literature in the office on domestic violence, requiring the abuser to leave the room, offering use of a telephone to call a shelter, and encouragement to develop a safety plan each were reported by less than 5% of respondents.
Thirty-seven percent of women encountered undesirable practical support in the form of being told that things could be worse or that they should go home and make up with their partner; 15% reported being told that they were responsible for the violence, and 5% reported being told that men cannot help being violent.
PARTICIPANT DEMOGRAPHICS AND RATINGS OF PHYSICIANS
Analyses of the relationship between participants' ratings of physician behaviors and participants' demographic characteristics involved multiple comparisons, inflating the risk of a type I error. We therefore used the Bonferonni method, and a P value of .0005 was the criterion for a difference to be considered significant.
There were no differences in ratings of physician behavior among participants based on educational level, employment status, marital or cohabitation status, or age. There were, however, differences related to racial background. White women rated 10 physician behaviors as less desirable than did African American women (Table 4). Members of other ethnic groups were excluded from these analyses due to the small sample sizes.
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Table 4. Physician Behaviors That Were Rated* Differently by African American and White Battered Women
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RATINGS RELATED TO HISTORY OF HELP-SEEKING
Ratings by women who had sought medical care for abuse-related problems did not differ from those by women who had never sought such assistance. As not all women who sought medical services encountered all 94 physician behaviors, we compared desirability ratings for each item between this group and non–help-seeking women. Help-seeking women reported the following 6 positive and negative behaviors drawn from all 3 physician behavior domains as significantly more desirable (P<.005) than did non–help-seeking women: being told that domestic violence is caused by alcohol or other drug abuse (19), being referred to a psychiatrist (53), being treated with compassion (61), being asked about questions/concerns (62), being told to leave the abusive partner (75), and being referred to couples counseling (86). No thematic pattern emerged from this analysis.
COMMENT
GENERAL IMPLICATIONS
To our knowledge, this is the first systematic, quantitative effort to survey battered women about physician behaviors that they regard as supportive and unsupportive. In some cases, our findings validate current efforts and recommendations for teaching physicians how to handle cases of domestic abuse. In other cases, findings provide new insight that can guide future efforts to meet the needs of battered women who seek help within the health care system.
WOMEN'S VIEW OF SUPPORTIVE AND UNSUPPORTIVE BEHAVIOR
Battered women reported that they value medical support that includes taking a complete history, with detailed assessment of current and past violence, but without creating an atmosphere of interrogation. Physical examination should be thorough, careful, and gentle, and should be followed by an explanation of the procedures and findings and treatment of all injuries.
The participants valued emotional support in the form of confidentiality. The partner should be directed, not asked, to leave the examination room. The emotionally supportive physician listens carefully and reassures the woman that the abuse is not her fault, and that her feelings of shame, fear, anger, depression are understandable.
Valued practical support includes telling the patient that spouse abuse is illegal and wrong and that she has a right to be safe. The physician should provide information and telephone numbers for local resources such as shelters, support groups, and legal services. Physician concern for the woman's safety is desirable, but battered women do not want their physicians to take actions without their knowledge. The physician should also ask about the safety of children in the home (after informing the patient about mandated reporting), help the patient begin safety planning in the event of future abuse, and schedule a follow-up visit.
This group's reported experiences suggest that, in general, physicians listened carefully, were sensitive to body language, responded with compassion, conducted dignified and sensitive medical examinations, and attended carefully to injuries. These physician behaviors are generally desirable for all patients whether or not domestic violence is present.
On the other hand, physicians were less successful in delivering elements of care that specifically target battered women's unique needs. Specifically, women reported that many physicians neglected to ask how an injury occurred, take a history of violence, ask about the safety of their children, refer them to community resources and provide telephone numbers, or schedule a follow-up appointment.
Although battered women in this study indicated that most physicians provided supportive care, some reported that physicians did not. Almost one third of women in this group reported that their physician examined them roughly, minimized an injury or the abuse in general, accused the patient of lying, blamed the patient for the abuse, excused the abusive man, and/or failed to provide resources and a follow-up appointment. A few women (<5%) experienced extremely negative behaviors, including joking about spousal abuse, blaming the patient for the abuse, and telling the patient that men cannot help being violent.
IMPLICATIONS FOR CONTINUING EDUCATION
These results indicate a need for continuing medical education to reach less skilled physicians, as well as quality assurance mechanisms to identify the few physicians who may be causing harm to battered women.
Our findings also provide empirical validation of training programs that teach physicians to ask about abuse, provide emotional support in a confidential setting, develop safety plans, and provide resource information.
The high value women in this study placed on effective medical support was unexpected. Research has suggested that psychosocial aspects of interventions with battered women are most important and medical services are secondary.11 Our findings refute the common belief that physicians who become involved in assisting battered women abandon traditional medicine and become social engineers.13 In fact, it seems as if battered women expect their physicians to conduct excellent medical interventions relating to domestic abuse.
Another unexpected finding was that battered women greatly appreciate questions about the safety of their children. Battered women frequently remain in relationships with batterers until they perceive a threat to their children.27 Therefore, physician training programs on domestic abuse should include components related to the assessment of children's safety. This should include teaching physicians how to ask about and evaluate children's safety in a sensitive manner, so as not to unfairly jeopardize the mother's legal status.
RACIAL DIFFERENCES
The pattern of differences between non-Hispanic white women and African American women was unexpected. Behaviors that were rated differently between the 2 groups were the following: physicians sympathizing with abusers, rationalizing the violence, not allowing the woman to tell the story of her abuse, and providing rough, painful physical examinations of injuries. African American women rated these behaviors as neutral, whereas white women rated them more negatively.
The reasons for these differences are unclear. They may relate to the locations where women were treated: African American women were more likely than white women to receive treatment in an emergency department (21 = 4.88, P<.03). In emergency departments, there is less continuity of care and care may be less personalized. Women may have lower expectations of physician behaviors when seeking abuse-related services in this setting. African American women also encounter ongoing societal oppression and institutional racism. This may lead to decreased trust in or expectations of public institutions including those designed to assist them.28
STUDY LIMITATIONS
The reader is cautioned that these findings are based on a small number of respondents. Although the pattern of findings suggests that there may be racial differences in battered women's experiences and preferences, further research is needed to explore the validity and causes of these observed differences.
Although this study adds to the literature on physician interventions in cases of domestic abuse, several factors suggest that caution should be used when applying these conclusions to other settings such as a family practice clinic. First, the study is based on a convenience sample of women recruited from programs for battered women, and we were unable to track nonparticipants. Confidentiality requirements prevented us from comparing participants with those who declined to participate, and therefore we do not know if our sample is representative of the larger group. Second, survey participants who sought medical treatment for abuse-related problems were not segregated on the basis of whether they received care in a private office, emergency department, or both. One reason for not dividing participants into various groups was concern about the accompanying reduction in sample size and power.
Another limitation of this study is the use of retrospective self-report. Such reports may be influenced by factors other than direct experience. This limitation is mitigated by 2 factors. First, there were no differences in desirability ratings by women who sought help and women who did not seek medical help for abuse-related problems. Second, even among women who sought help, not all women had experienced each type of physician behavior. Few differences in desirability ratings were related to direct experience with a particular physician behavior.
A final limitation of this study is that physician characteristics were not studied. Although the primary focus of the study was the perspective of battered women on their interactions with physicians, the sex and race of the physicians and the setting of care may have had an effect on their experiences. We are conducting additional research to examine this issue.
STUDY STRENGTHS
The survey was developed using a systematic, empirical approach that assured ecological and social validity by involving physicians and battered women in generating items and reviewing the resulting instrument. This instrument was found to discriminate desirable from undesirable physician behaviors in each of 3 domains measured.
Another strength of this study is that the desirability rating of specific physician behaviors was, at most, minimally affected by the women's history of seeking help for domestic abuse. Women who had never sought medical treatment for abuse-related injuries and those who had sought treatment did not rate any of the 94 items differently. This indicates that the study measured global attitudes and opinions of battered women that were not determined by situation.
This study describes, from the battered woman's perspective, desirable and undesirable physician behaviors relating to the treatment of domestic abuse. It offers family physicians previously unreported information to improve the way they treat patients who are victims of domestic abuse. Participants in this study valued competent medical care, emotional support, and practical advice, suggesting that effective physician interventions will include all 3 dimensions. As our results suggest that physicians provide more emotional support and medical service and less practical support, physicians may need to make extra efforts to improve in the latter area. Future research is needed to explore the relationships among patients' actual experience with physicians, desired physician behavior, and factors such as race and treatment setting (emergency vs outpatient department).
AUTHOR INFORMATION
Accepted for publication July 28, 1997.
We acknowledge the collaboration of the following organizations and individuals in Wisconsin in support of this project: Women's Horizons Inc, the Domestic Violence Project, Kenosha; The Women's Resource Center, Racine; Sojourner Truth House, Milwaukee; The Waukesha Women's Center, Waukesha; the Association for the Prevention of Family Violence, Elkhorn; and Jean Lahti and Karen Roberts for assistance with data management.
Corresponding author: L. Kevin Hamberger, PhD, Family Practice Center, All Saints Healthcare Systems Inc, PO Box 548, Racine, WI 53401-0548.
From the Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee.
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