Jenna, a 17-year-old Caucasian female, sought medical consultation due to chronic headaches. She appeared nervous and tense during the physical exam. Her speech was pressured, as she described her behaviors that have been “random and not under my control,” such as, breaking up with her boyfriend over her cell phone, and then immediately texting him that she was sorry and she did not want to break up with him. She was being home-schooled by her adoptive mother because she felt bullied by her classmates.
When asked about her living arrangements, she admitted that her parents have allowed her boyfriend to sleep with her in her bedroom. When asked about sexual behaviors, she said, “I don’t like it much.” When asked if her boyfriend hurt her, she replied, “He doesn’t mean to.”
Her adoptive father was waiting in the clinic’s reception area. I asked her if it were okay to invite him into the discussion about what to do about the boyfriend. She thought that was a good idea.
The father explained that Jenna has always been oppositional and hard to handle. Both he and his wife agreed to let her make her own decisions. Jenna agreed, with her father’s support, to breakup with the boyfriend for good. When asked whether she was afraid he might hurt her, she looked at her father, who said, “I won’t let him near you. I wish I would have known before this.”
Domestic abuse is often subtle. Sometimes on a very busy day, it is easy to miss the subtle nuances that a patient is communicating. And when asked directly, the patient may deny or minimize its influence on his or her health. But when a patient cringes at physical touch during an exam or seems preoccupied or distracted during the psychosocial and medical history taking, there is covert communication that there are family secrets to keep hidden.
On Mother’s Day a number of years ago, I was fishing with my 10-year-old son and caught a 20-pound carp. He was thrilled by the conquest. It was dark by the time we got home but I was determined to fillet the trophy and cook it in celebration of a fun day together. Under insufficient light, I firmly grabbed the fish’s head, and cut down to begin filleting only to fillet my thumb in the process. I could not stop the bleeding. My family took me to the ER. As the physician was stitching the gash, he asked nonchalantly, “Do you feel safe at home?” I immediately responded, “Are you suggesting this wound was purposeful rather than accidental.” He said calmly, “I just want to know if you feel safe.” “Yes, I do.”
Today, we are more cognizant of the signs of abuse. The bigger issue is, how to help those who engage in abuse, either as a victim or as a perpetrator. Too frequently, the codependency between the victim and perpetrator is so firmly entrenched that one believes he or she cannot live without the other regardless of the long-term effects on their own health as well as the family at large. Also of concern is that domestic violence extends beyond the physical.
The ultimate goal of domestic violence is gaining power and control through a variety of means. There are eight (8) non-physical types of behaviors that produce violence in a home.
- Intimidation is a threat that uses aggressive and endangering behaviors to strike fear in others.
- Emotional abuse is essentially playing mind games to convince another that he or she is crazy, stupid, unworthy of anything good. The perpetrator responds to the victim’s behaviors with jealousy and suspicion because the victim is “up to no good.”
- Isolation is a process that restricts the victim’s life to the whims of the perpetrator. He or she is not allowed to have friends, can read only certain books, has limited time away from home, and/or ultimately shuts off communication with family due to being humiliated or embarrassed in front of them by the perpetrator.
- Minimizing, denying, and blaming: When the victim builds up the courage to confront the perpetrator, the victim is told that the abuse did not occur. That in fact, the victim caused the perpetrator to respond the way he or she did. This produces confusion with the victim doubting whether the abuse was imaginary or actually happened.
- Using children or pets: The perpetrator uses children or pets to induce guilt and fear. The perpetrator threatens to take away or hurt the children or pets to punish the partner.
- The victim becomes a servant to the perpetrator.
- Financial abuse: The perpetrator prevents the victim from getting or keeping a job. The victim is forced to ask for an allowance to purchase necessities for the household.
- Using coercion and threats: The perpetrator threatens the victim with suicide, harm, reporting him or her to social services for being an unfit parent, or destroying their home or other property.
By the time a victim of domestic abuse is seeking a medical consult, he or she is usually ready to stop the vicious cycle through whatever means possible. A referral to a mental health professional can be the first step to a new beginning. The safety of the victim and the children is the ultimate concern. The victim needs a plan and a safe haven. A number of community resources, churches, and the victim’s family may offer temporary shelter until the violence resolves.