W♀men at Risk: Domestic Violence and Women's Health

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Evan Stark & Anne Flitcraft

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  • Part I: Theoretical Perspectives

    Part II: Health Consequences

    Part III: Clinical Interventions

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    Acknowledgments

    The articles and chapters adapted for this book reflect the support of two decades of coworkers and friends.

    The idea of analyzing the medical dimensions of woman battering was conceived while we were participants in two lively group efforts, the East Coast Health Discussion Group (ECHDG), a radical collaboration to revise theories of health and medical care, and the New Haven Project for Battered Women (NHPBW), one of the early shelters for battered women in the United States. ECHDG participants Sally Guttmacher and her husband, the late Eric Holtzman, Joann Lakumnick, Meredith Turshen, Alonzo Plough Jr., and Janette Valentine became our intellectual mentors as well as lifelong friends. Vicente Navarro added a key element to friendship and intellectual guidance by opening the pages of the International Journal of Health Services to our work at a time when feminist, radical, and more conventional academic publications showed little interest in the problem. From the original NHPBW the friendships of Sophie Turner, Patricia Dillon, and Patricia Weel have been particularly important.

    The research reported in Chapter 1 was supervised by Dr. William Frazier, then a young specialist in plastic surgery and director of the emergency department at Yale. In addition to providing research staff and computer support, Frazier introduced us to Steve Record, a methodologist who grasped the challenge of identifying domestic violence in a system that routinely looked past its evidence. The larger trauma study at Yale—the basis for Chapters 3 and 4—was supported by research grants from NIMH (MH 30868) and overseen by Tom Lalley, Director of the Crime and Antisocial Behavior Division. As a consistent advocate for research on women, he helped focus our concerns, demanded the highest level of rigor, and assisted with advice at key stages in the work. Early and ongoing support for our work also came from Mark Rosenberg at the Centers for Disease Control and the Office of Domestic Violence under President Carter. Charles Lindblom and Ted Marmour provided a home for the work at the Institution for Social and Policy Studies, and Gary Tischler supported Anne with an NIMH postdoctoral fellowship. Sociologist Terence Hopkins honed the theoretical framework of our work as supervisor of Evan's Ph.D. dissertation at SUNY-Binghamton. Chapter 2 was written while Evan was on a Fulbright at the University of Essex where the intellectual companionship of Nikki Hart, Mick Mann, Karl Figlio, Paul Thompson, and Peter Townsend helped us through a difficult period.

    Reconstructing the experience of battered women from the evidence in medical records was akin to an archaeological dig. Records were handwritten, filed in vast shelves beneath the hospital, and accessed only through manual requests. We owe an enormous debt to our core research staff of Anne Grey and Judy Robison (later joined by Karen Barr and Dr. Marty Roper). For 4 years, they retrieved, deciphered, and coded thousands of women's medical histories, maintaining their capacity for humor and objectivity in the face of work that was as exhausting emotionally as it was physically. All the while Corky Simoes remained unflappable, extending her numerous duties as administrative secretary to counseling (albeit without license) friends, staff, and wayfarers. The success of our team also depended on a vast army at Yale-New Haven Hospital and Yale Medical School's Department of Surgery, including staff of the medical records department, data entry clerks, social work staff, and nurses in the emergency room.

    The chapters in Parts II and III reflect our efforts over the past decade to bring violence prevention and intervention into contemporary clinical practice. A Henry Rutgers Fellowship, a sabbatical, and support from Ray Caprio, Marcia Wicker, and other Public Administration colleagues have allowed Evan to maintain an agenda that includes training, clinical work, and advocacy alongside traditional scholarship. One result is the growing interest in child protection, mental health, psychiatry, and social work reflected in Chapters 3, 4, and 6. Whatever insight these chapters offer into mothers of abused children, women who attempt suicide, or battered women in the mental health setting is due, in no small part, to the mentoring (and friendship) of Laurie Harkness, Joyce and Rudy Duncan, Jack Sternbach, Jean Hay, Enid Peterson, and Susan Schechter, social workers all.

    The support and enthusiasm—and flexibility—of colleagues at the University of Connecticut's Outpatient Services at the Burgdorf Health Center have enabled Anne to expand her efforts in clinical violence prevention while maintaining her inner-city practice and teaching in general internal medicine. We are profoundly grateful for the help of Marie Begley, R.N., and Drs. Aida Vega, Harry Katz-Pollack, Ellen Nestler, Bruce Gould, Ken Abriola, and Claudia McClintock.

    Chapters 7, 8, and 9 have their genealogy in the work of the Domestic Violence Training Project (DVTP), which we codirect. Identified as the main provider of health training in Connecticut, the program has been running since its inception by Kate Paranteau, a lifelong advocate for women whose wisdom, tenacity, and professional skill have earned her—and DVTP—a national reputation. But it is for Kate's friendship—along with the support from fellow DVTP staff Carol Marci and Robyn Tousey-Ayers—that we are most thankful. Grants from Connecticut's Department of Health and the Commonwealth Foundation have allowed us to practice what we preach, that is, system change through professional education, training, and advocacy.

    It would be disingenuous not to acknowledge that our critical stance on policy and practice—including the practice of the battered women's movement with which we strongly identify—has created special problems in legitimacy. If we stand up to be counted in this climate, it is because of the courage we have witnessed in the hundreds of battered women with whom we have worked and because of the support we received from our parents and from Heidi Hartmann, Sharon Vaughan, Elaine (Carmen) Hilberman, Eve Buzawa, Barbara Hart, Lucy Freidman, Ken Fox, Carla DeGerolomo, and so many others whose commitment to women's liberation is matched by a stubborn unwillingness to be politically correct.

    Owing so much to so many, it is finally to one another and to our children, Aaron, Sam, Daniel, and Rachel, that we owe the most important debt.

    EvanStark
    AnneFlitcraft

    Introduction

    In 1975, en route from California to New Haven, we stopped in St. Paul to see an old friend, Sharon Vaughan. Several days of searching produced a work address at a large Victorian house in a not yet gentrified section of the city. We knocked and a woman opened, then quickly closed the door. A second knock—this time with Evan holding our young son—got us admitted.

    Women were everywhere: answering phones in a small office; meeting in huddled groups behind half-closed sliding doors; preparing lunch in the kitchen; and moving, with children in tow, up and down the stairs and in and out the back door. In an alcove at the top of the first landing, two women were sitting, their heads hung on one another's shoulders, their arms loosely draped around each other, audibly sobbing.

    After several minutes, Sharon descended the stairs and buoyantly announced she had just completed her first grant proposal. Then, with all the grace of Kathryn Hepburn, she waved her hand in a gallant sweep and introduced Women's Advocates, the first American shelter for battered women. “What do you think?” she asked, breaking into a broad smile.

    Answering Sharon's question occupied a good portion of the next two decades. The chapters collected in this volume are products of this work.

    A year after the visit to St. Paul, we were living in New Haven, housing women on the run and working with a small group to plan a 24-hour hotline and shelter. We both had been exposed to violence in the community during the 1960s—Anne as a VISTA volunteer in Cleveland and Evan as a community organizer in Minneapolis. But the levels of coercion these women described were beyond anything we had seen or read about. The physical results of dozens, sometimes hundreds, of assaultive episodes were appalling. The women who used our home as a safe house were as likely to be middle class as poor, as likely to be white as black or Hispanic. Regardless of race or background, the women had all gone to tremendous lengths simply to survive. There was one more thing. They recounted long and complicated histories of frustrated help seeking. The medical, criminal justice, and social service professionals, it seemed, had either ignored their plight or done things that actually made it worse.

    During the summer of 1976, a grant to visit shelters in Europe brought us to the Chiswick section of London. We walked past a stone wall with the words “A HOUSE FOR WOMEN” scrawled in large letters and knocked at the door of Chiswick Women's Aid, the best known battered women's refuge in the world. Erin Pizzey answered. Without hesitation, the founder of Women's Aid waved us into an extraordinary scene of noise and chaos. There were 90 women and children staying in the six-bedroom house. “If they can manage this,” Pizzey quipped, “they can handle anything.”

    That night, led by a Jamaican lawyer who had just escaped from her abuser, a group of us took rolls of wallpaper and a portable toilet, crossed town in an old bus that belonged to the shelter, and “seized” an abandoned railroad hotel. Twenty-four hours later, the hotel was ready to host its first battered women.

    The Research Base

    These images of women doing for themselves framed our thinking when, in 1977, Anne asked Dr. William Frazier, director of the emergency room at Yale-New Haven Hospital, if she could do her medical school thesis on battered women who used the surgical emergency service.

    “What's a battered woman?” Dr. Frazier asked.

    Dr. Frazier was only the first of several skeptics who listened to us patiently and then gave us unselfish support. At the time, there was no evidence that domestic violence was a common health problem. What we had to offer, besides the partnership between a physician and a sociologist, was experience with shelters and hotlines that demonstrated that male violence against partners was epidemic. It seemed inconceivable that this epidemic could have bypassed the medical gaze.

    So began our 20-year collaboration to identify the medical dimensions and health consequences of domestic violence.

    In taking up this work, we faced two methodological challenges. When we began the research, there were few services or protections for battered women. It was commonly believed that asking patients directly about violence might expose them to further danger, and therefore, interview studies were ethically suspect. The next best source of information were women's medical histories. But using these records posed the problem Kempe, Silverman, Steele, Droegemueller, and Silver (1962) had faced in attempting to document child abuse in the early 1960s. The phenomena we wanted to study were officially invisible. Like Kempe et al., we needed an index of suspicion to uncover cases of domestic violence that had not been designated as such. We addressed this problem by postulating that, like child abuse cases, the injury patterns and context of battering could be used to distinguish domestic violence from accidental injury.

    Starting with a sample of 520 records of women's visits to the surgical emergency service (the basis for Chapter 1), our research eventually encompassed the clinical histories of 4,500 women who used the hospital in the late 1970s and early 1980s, including more than 1,000 battered women, emergency room patients, mothers of abused children, women who attempted suicide, rape victims, psychiatric emergency patients, and women using the hospital's obstetrical service. Our initial goal was simply to document the extent of domestic violence and its significance for women's health. Only gradually, as we analyzed the notes, diagnoses, treatment strategies, and referrals compiled over the years by hundreds of physicians, nurses, social workers, and psychiatrists, did a third goal emerge: to evaluate the appropriateness of the clinical response and suggest ways to improve it.

    Originally published between 1978 and 1995, the papers collected here report the major findings of these studies.

    The chapters in Part I review the empirical findings from the early research, show how domestic violence and the medical response converge in the evolution of a battering syndrome, and link this process to larger social and historical currents. The theoretical framework developed in these chapters draws on feminism and Marxism as well as on more conventional sociological and psychiatric paradigms. We situate woman battering in the struggles that surround sexual inequality, emphasizing the social (rather than the psychological or interpersonal) dimensions of male domination and female subordination. Women are battered in this schema not because individual men use violence or other inappropriate means to stifle their subjectivity but because male resistance to women's personal and political liberation is reinforced by the very systems to which women turn for help, including organized medicine. This part also emphasizes how the key dimensions of battering—from its prevalence and dynamics in a given population to the paradigms used to explain domestic violence in different societies—take shape amidst class, race, and sexual struggles for the most fundamental material, social, and psychic resources.

    Part II views the overall significance of domestic violence for women's health through the prism of child abuse, female suicidality, and homicide, three of its most extreme outcomes. The chapter on mental health that introduces the part on clinical interventions (Part III) reframes prevailing models of treatment in terms of recent knowledge regarding the coercive elements in battering. Part III also traces the implications of the theory and data for improved practice in medicine, social work, and community health.

    For 5 years, our small research staff diligently abstracted millions of bits of information on women and their health problems from records that ranged in size from a few pages to several volumes. In addition to the usual information on complaints, examination results, diagnoses, prescriptions, and referrals, the charts often included extensive commentary as clinicians struggled to explain why a population of previously normal women developed a complex psychosocial and medical history subsequent to a series of “accidents.”

    The initial conclusion of our research was that more women sought medical treatment for injuries resulting from domestic violence than for any other cause. This finding was used to support political initiatives on behalf of battered women, including the controversial Violence Against Women portion of President Bill Clinton's 1994 Crime Bill. Conservative writers and syndicated journalists critiqued our “gender feminist” orientation and dubbed our conclusions “guesstimates” and “noble lies” (Sommers, 1994, p. 202). Meanwhile, in the wake of expanded services and the commitment of medical resources, direct interview and questionnaire studies continued to document substantially the same or higher figures than we uncovered. For example, a recent survey of 648 randomly sampled women who sought treatment at four emergency departments in Denver found that more than half (54.2%) had been threatened or physically injured by a husband or boyfriend at some time in their lives (Abbott, Johnson, Koziol-McLain, & Lowenstein, 1995). This is about 250% higher than our estimate that one female injury victim in five had a history of domestic violence.

    Our empirical claims about the importance of domestic violence as a source of female injury are supported by data presented in Chapter 1 as well as in Chapters 3, 4, and 5. Although it has momentous implications for women's health as well as for the allocation of resources, the conclusion should not surprise persons familiar with domestic violence or its effects on systems other than medicine. When we began our work, Parnas (1967) had already reported that police received more calls regarding “domestics” than murder, aggravated assault, battering, and all other serious crimes combined. The key factor here—often missed by our critics—is the historical nature of battering relationships, the extent to which the perpetrator's continued access to his victim creates a cumulative burden of injury on the community that is unique in our society. Some sense of this burden can be garnered from a recent London survey (Mooney, 1993) that reveals that victims of domestic violence had suffered an average of 7.1 assaults during the previous 12 months, resulting in an average of 4.3 injuries and an annual assault incidence rate of 85 per 100. Although further historical and cross-sectional data may negate these findings, it is hard to imagine a source of female injury, accidental or otherwise, that is more common. To appreciate our more limited claim about medically relevant injury, readers need only compare the fact that, whereas nonbattered adults may make one injury visit to an emergency service in their lifetime, battered women average more than one such visit each year.

    A second important finding of our work involved the links of domestic violence to a range of family and women's health problems, including child abuse, homicide, alcohol and drug abuse, rape, poor pregnancy outcomes, and female suicide attempts. Battered women (or their children) suffer a disproportionate risk of these problems only after the onset of domestic violence. The composite picture that emerges is of a battering syndrome that, if not curtailed through early intervention, evolves through predictable stages into a pattern of entrapment that is as devastating as the trauma of physical assault.

    Equally important, as the chapters in Part II document, domestic violence is a major cause of these problems, accounting for half of all child abuse, for instance, a third of female suicide attempts (and half of those by black women), 40% of primary homicides, and equally significant proportions of rape, female alcoholism, drug use, and depressive illness. In the world of social and medical science, evidence that problems are statistically correlated often has little practical importance or else is neglected because it implies that sacred academic or professional boundaries should be bridged. We have known for a decade that deliberate childhood injury and fatality commonly result when a batterer extends his violence to the child. But the child protection establishment has only recently opened a dialogue with the battered women's community. Even fewer inroads have been made into psychiatry or substance abuse treatment.

    A third major conclusion of this work is that the medical response to abuse directly contributes to the isolation and entrapment that are hallmarks of the battering syndrome. Although the chapters in Part I provide an elaborate theoretical explanation for this seeming paradox at the micro- and macrolevels, each part of the volume considers how current ways of understanding and treating domestic violence contribute to its perpetuation. So significant are the effects of medical neglect, minimization, labeling, and victim blaming that, in Chapter 6, we conceptualize battering as a dual trauma constituted from parallel strains of male coercion and clinical mistreatment.

    Recent support for communitywide violence prevention by federal health and justice agencies and professional medical associations are important steps in remedying the dual trauma of interpersonal violence. Coupled with these efforts, the massive use of health services by battered women offers clinicians a window of opportunity for early intervention and prevention. The chapters in Parts II and III provide the information needed to take advantage of this opportunity by routinely identifying, assessing, and referring domestic violence victims at all health care sites, psychiatric and medical, primary as well as emergent.

    Major changes in the status of domestic violence have occurred since we began our work. An enormous body of specialized literature on the problem has appeared and the response to battered women has burgeoned into an international network of services that extends from Boston to Cape Town and includes an extensive state-run regulatory apparatus in addition to thousands of community-based programs. Virtually invisible to medicine two decades ago, today domestic violence is recognized as a major problem by virtually every medical, nursing, and public health organization in the United States.

    The chapters in this volume have been substantially revised and updated to reflect these developments, including our own growing commitment to professional education and to make the theoretical argument and presentation of data more accessible to the large number of students and general readers interested in the problem. It would have taken a completely different book, however, to integrate fully the vast specialized literature or to revise our theoretical conceptions to account for all the current political changes, including the new commitment by medicine. Indeed, by conserving many of the original references in the early essays, we hope to acknowledge important early work and emphasize its relevance to current concerns.

    We are cautiously optimistic about recent developments in the domestic violence field. At the same time, the critical tone of the early essays resonates with our deep concern that the most vital political elements in the movement by and for battered women will be compromised if state protection and the provision of service to victims are overemphasized.

    The clinical issues domestic violence presents are similar to those presented by a range of other social ills. Nevertheless, the scope and political context of domestic violence require a broad reframing of women's health, as well as the changes in medical response outlined in Parts II and III.

    In our view, male violence against partners in contemporary society is a defensive response to women's progressive liberation from maternity and domestic servitude, a liberation that is as inevitable in an expanding capitalist economy as it is inconceivable apart from women's self-activity across a broad terrain. That women will be “free” yet must always free themselves is no less true in individual relationships than in society as a whole, and this paradox is the immediate source of the suffering that concerns us here.

    We have chosen health as the focus of inquiry because that is where we work, because it is in the medical system that the most physical and behavioral consequences of assault are seen most vividly, and because we believe that viewing domestic violence through the prism of women's health throws new light on medical practice, not only on domestic violence. If we criticize medical practice (and say little about the negative effects of legal, criminal justice, or social work intervention), this is because, more than the other services, medicine's identification with science and healing symbolizes its central role as an interpreter of the human condition.

    The most dramatic evidence in these chapters concerns the physical injury and death women and children suffer as the direct result of male violence. This reflects our initial belief that horrendous criminal acts of violence lay at the heart of woman battering. It was this belief that led us to emphasize shelter for women, that brought us to the emergency room as the site of research, and that is reflected in our early emphasis on injury. What we have learned since—in no small part from the hundreds of battered women with whom we have worked—is that our initial belief was wrong. In fact, the clinical dimensions of battering—from repeated injury to addiction, suicidality, child abuse, severe mental illness, and homicide—are best understood less as the product of male violence than as the cumulative result of women's entrapment by an extreme (though common) form of male domination. Violence is a necessary condition in trapping women in battering relationships. But it is rarely sufficient to explain the level of harm, degradation, or pathology that follows domestic violence. The medical, psychiatric, and behavioral problems presented by battered women arise because male strategies of coercion, isolation, and control converge with discriminatory structures and institutional practices to make it extremely difficult, sometimes impossible, for women to escape from abusive relationships when they most want or need to.

    The distinction between violence and coercion may seem too subtle to have practical implications. On the contrary, however, shifting the emphasis from violent acts to the ways in which male control converges with larger processes of discrimination has enormous importance in identifying who is being victimized, which strategies we define as criminal, where and how we intervene, and how we balance advocacy for women's liberation with the important emphasis on personal safety through police protection and shelter. It is impossible to study the health of battered women without discerning their desire to share in power, not simply to be protected from its excesses. Nor is this a concern only for health providers. Keeping our “mind on freedom,” as the old civil rights song put it, remains the greatest challenge as the battered women's movement seeks to protect women from individual injury by forging working alliances with the very political, legal, economic, and service systems once believed to be the primary source of women's social injury.

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    Name Index

    About the Authors

    Evan Stark and Anne Flitcraft are nationally recognized authorities on interpersonal violence, including woman battering, child abuse, and homicide. Since 1976 when they helped found one of the first shelters for battered women in the United States, they have worked as researchers, in direct service, and as advocates for the rights and needs of battered women and their children in policy debates and in the courts.

    With a Ph.D. from the State University of New York and an M.S.W from Fordham University, Evan Stark is Associate Professor of Public Administration and Social Work at Rutgers University. A graduate of the Yale School of Medicine, Anne Flitcraft is an Associate Professor of Medicine at the University of Connecticut Health Center, where she teaches Primary Care Internal Medicine and maintains a clinical practice at the Burgorf Health Center in the North End Community of Hartford. Dr. Stark and Dr. Flitcraft codirect the Domestic Violence Training Project, an award-winning program dedicated to enhancing the health care system's response to domestic violence.

    Twenty years ago, Dr. Stark and Dr. Flitcraft directed the first major federal research program on domestic violence in health care settings and identified domestic violence as a leading cause of female injury and the context for multiple medical and mental health problems. Former cochairs of the U.S. Surgeon General's Working Group on Domestic Violence and Public Health, the couple has served as consultants on domestic violence to the U.S. Civil Rights Commission, the Centers for Disease Control, the U.S. House and Senate, the National Institutes of Justice and the National Research Council.

    For their efforts in bringing this issue to the attention of contemporary medicine and their leadership in the developing health care programs on domestic violence, Dr. Stark and Dr. Flitcraft received the National Health Council's Trendsetter Award and Connecticut's Governor's Victim Services Award. In addition, Dr. Flitcraft received the Elizabeth Blackwell Award, the highest honor bestowed by the American Medical Women's Association, and Dr. Stark received the Sanctity of Life Award from Brandeis University.

    Dr. Flitcraft works with numerous state and national medical organizations to enhance access to care for battered women. Dr. Stark frequently testifies on behalf of battered women in criminal and civil cases.


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