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Physician Interaction With Battered Women

The Womens Perspective


L. Kevin Hamberger, PhD; Bruce Ambuel, PhD; Anne Marbella, MS; Jennifer Donze, MD
Background: Programs that train health professionals
to identify and treat battered women have not previ-
ously incorporated systematically obtained advice from
battered women to guide physician behavior.
Objectives: To survey batteredwomento (1) rate the de-
sirability of specific physician behaviors, (2) describe their
actualexperienceswithphysicianswhileseekingabuse-related
medical services, and(3)examinerelationshipsbetweenpar-
ticipants demographics, historyof victimization, historyof
seeking medical help, and ratings of physician behavior.
Participants: One hundredfifteenwomenwho hadbeen
battered by a male partner, recruited fromsupport groups
and other battered womens programs in a 5-county area
in southeastern Wisconsin.
Methods: Self-report survey of demographic informa-
tion, relationship history, observations of physician
behavior, and ratings of desirability for those behav-
iors. Analysis used cross-tabulations,
2
, and multiple t
tests with Bonferonni adjustments for multiple com-
parisons.
Results: Women identified specific physician behav-
iors as desirable and undesirable. Desirability ratings did
not differ with history of victimization, history of seek-
ing medical help, or most other demographic variables.
African American and white women rated a few physi-
cian 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.
Arch Fam Med. 1998;7:575-582
P
RIMARY CARE physicians en-
counter manybatteredwomen
in their practice.
1-4
In outpa-
tient practices, almost 1 in 4
women have been battered in
the past year,
1
and39%to44%of female pa-
tients have been battered in their life-
time.
1,2
In emergency departments, 10%to
35%of female patients seen have been bat-
tered.
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 from6%to 10%in emergency depart-
ments.
5,8
Many battered women will ac-
knowledge abuse when asked directly,
9,10
but many physicians do not ask.
1
Rea-
sons for this avoidance include discom-
fort with the topic, lack of time, lack of
knowledge and training in what to do af-
ter 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
Physicianbeliefs and practices that impede
satisfactory identification and interven-
tionof abuse, as describedby Goldberg and
Carey,
14
include (1) rationalization of the
violence; (2) belief in the private, invio-
late nature of the family; (3) denial of vio-
lence 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
overreactionto abuse may alienate the bat-
tered woman, causing her to withdraw.
While physicians often provide techni-
cally competent medical services, bat-
tered women often feel dissatisfied with
physicians inappropriate or inadequate re-
sponses.
15
The proliferation of physician train-
ing programs designed to provide knowl-
edge andskill ineffective identificationand
ORIGINAL CONTRIBUTION
From the Department of Family
and Community Medicine,
Medical College of Wisconsin,
Milwaukee.
ARCH FAM MED/ VOL 7, NOV/DEC 1998
575
1998 American Medical Association. All rights reserved.
intervention techniques to use with battered women in
outpatient and emergency medical practices
9,16-22
do not
specify how physicians should ask about domestic bat-
tery or how they can identify victims. All reviewed phy-
sician training programs provide recommendations based
on common sense, and sometimes on the extensive ex-
perience of individual proponents. However, there are
few studies that support the common practices.
Toour knowledge, Mandel andMarcotte
23
conducted
the only study evaluating physician training in detection
andinterventionincases of domesticabuse. This studysug-
gested that educational programs may improve physician
responses; however, it didnot assess the actual experience
of patients.
Arecent, qualitative study by Rodriguez et al
24
found
that battered women value direct questions about abuse,
referrals to appropriate agencies that can offer assis-
tance, follow-up, attentive, nonjudgmental support and
understanding, and confidentiality. To our knowledge,
this was the first report to elicit the perspectives of bat-
tered women regarding medical interventions in cases of
domestic abuse. The study offers general guidance for phy-
sicians, but does not provide information on specific be-
haviors.
Our current study has 2 aims: First, to describe phy-
sician behaviors that battered women find desirable and
undesirable during their clinic visits related to abuse; sec-
ond, todetermine whether batteredwomens opinions were
related to personal experiences and characteristics.
Because this is primarily an exploratory, descrip-
tive study, specific hypotheses are not advanced. Nev-
ertheless, we examinedthe relationshipbetweenthe wom-
ens demographic makeup (age, race, educational level,
and employment and marital status) and howthey rated
the behavior of their physicians. In addition, we ex-
plored the relationship of how women rated physician
behaviors with their history of child abuse and wit-
nessed parental abuse, current domestic violence, in-
jury fromabuse, and whether they were receiving medi-
cal treatment for abuse-related issues at the time.
RESULTS
DEMOGRAPHIC INFORMATION
One hundred fifteen women completed the study sur-
vey. The mean age of the participants was 31 years. Races
includedwere white (65%), AfricanAmerican(28%), His-
PARTICIPANTS, MATERIALS,
AND METHODS
PARTICIPANTS
Survey participants were 115 women who had been abused
by a male partner. They were recruited from ongoing sup-
port groups and other programs sponsored by local bat-
tered womens programs in a 5-county area in southeastern
Wisconsin. These agencies are the only providers of bat-
teredwomens services intheir respective communities, with
the exception of 1 large city that has several agencies. The
participating programs serve geographic areas encompass-
ing 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 question-
naire, modifiedfromaprior study,
1
wasusedtodetermineage,
race, marital status, employment status, andeducational level.
The second questionnaire, the Conflict Tactics Scale,
25
was used to assess assault history in intimate relationships
throughout the participants 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
abusedwomanmay encounter while being treatedina clinic.
The goal of this questionnaire was to gather battered wom-
ens opinions about desirable and undesirable physician be-
havior. Participants rated the desirability of the 94 behav-
iors 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 Inven-
tory was developed using a 3-step empirical approach. To
assure ecological validity, battered women, advocates, and
family physicians generated an initial bank of items de-
scribing physician behaviors. Next, the research team cat-
egorized items into 3 domains, each containing desirable
and undesirable behaviors: medical intervention (eg, tak-
ing a thorough history, a rough and painful examination),
emotional support (eg, empathic listening, criticismfor be-
ing abused), practical support (eg, providing local refer-
rals, excusing the perpetrator). Finally, a panel of survi-
vors of domestic abuse reviewed the bank of items for social
validity, completeness, and readability.
Procedure
A research assistant collaborated with leaders of battered
womens programs to recruit participants. Potential par-
ticipants were given a detailed verbal description of the
project, then asked to read and sign a consent form. Par-
ticipants were thendirectedtoa private area withinthe wom-
ens programfacilities to complete the questionnaires. The
research assistant was available to answer any questions
about survey items. Participants were informed of the pur-
pose of the study after they completed the survey. Because
such surveys can cause an emotional reaction in some par-
ticipants, provisions were made to provide assistance in cri-
sis resolution to those experiencing emotional distress from
the survey process. No participants sought services for man-
agement of emotional reactions to the survey.
ARCH FAM MED/ VOL 7, NOV/DEC 1998
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panic (2%), and other or undeclared (5%). Educational
level varied: 23%had completed some high school, 32%
had completed highschool, 35%had completed some col-
lege, and 10% had completed college or graduate work.
Forty percent were employed, and 30%were either mar-
ried 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%reportedinjuries from
the abuse, with 41% sustaining severe injuries, such as a
lacerationor a brokenbone; 82%hadbeenpushed, grabbed,
or shoved; 61% had been kicked, bitten, or hit with a fist;
57%hadbeenchoked; 44%hadbeenthreatenedwithaknife
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 emer-
gency department and 43%had seen a physician in a pri-
vate office. Forty-one percent of the women reported see-
ing a physicianfor emotional support following anabusive
incident at a physicians private office rather than at an
emergency department.
SCALE VALIDITY
To examine the ability of the Physician Assessment and
Treatment of Abuse Inventorytodifferentiate desirable phy-
sicianbehaviors fromundesirable physicianbehaviors, we
compared mean ratings of hypothesized desirable physi-
cian behaviors with undesirable physician behaviors for
3 areas: medical services, emotional support, and practi-
cal support. For all 3 categories, behaviors hypothesized
to be desirable were rated more highly than behaviors hy-
pothesizedtobe undesirable (P.0001), withmeanscores
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 3give desirable and unde-
sirablephysicianbehaviorineachof the3domainsmeasured
bythePhysicianAssessment andTreatment of AbuseInven-
tory, aswell asthepercentage(inparentheses)ofhelp-seeking
participants who reported experiencing each behavior.
Medical Service
DesirableandundesirablemedicalbehaviorsarelistedinTable
1, whichalsoshows thepercentageof participants encoun-
tering each behavior. Reported highly desirable behaviors
included physicians conducting examinations sensitively
(74%) and careful examination of injuries (65%). How-
ever, only 56%reported receiving a careful explanation of
procedures, andonly24%reportedthat their physiciantook
a careful social history of their relationships.
Regarding highly undesirable behaviors, few partici-
pants reportedexperiencing roughexaminations, being ig-
noredbytheir physicianwhenattemptingtodisclose abuse,
Table 1. Ratings* of Specific Physician Behaviors in the Area of Medical Services and Percentage of Battered Women
Who Reported Them
Rating
Women
Reporting, %
Desirable Behaviors
The medical examination was done in a dignified and sensitive manner. 4.6 73.7
The doctor asked you if you had any questions or concerns. 4.6 70.0
The doctor seemed to do a careful physical examination of your injuries. 4.5 65.0
The doctor explained each examination procedure, either before or while it was being done, in order to reassure you. 4.5 56.1
The doctor asked careful questions about how the injury occurred. 4.4 58.5
The doctor took careful notes about your injuries. 4.4 56.8
The doctor attended to actual physical injuries that you had. 4.3 76.3
The doctor asked about alcohol and/or other drug abuse by your partner. 4.3 50.0
The doctor asked about previous assaults against you by your partner. 4.3 48.8
The doctor asked if your children (if any) were in danger from the violence. 4.2 41.0
The doctor asked if your children (if any) had seen you being abused. 4.0 43.2
The doctor took a careful history of your relationships to understand the cause of the injury. 3.8 24.4
The doctor asked whether you were suicidal. 3.5 46.3
Undesirable Behaviors
The doctor treated physical injuries, but did not ask how they occurred. 3.0 35.0
Even though you did not want to tell the doctor what really happened, the doctor tried to force you to do so. 2.9 21.4
The doctor referred you to a psychiatrist. 2.8 27.0
The doctor went along with your explanation of injury too easily, even though it wasnt true. 2.1 56.4
You tried to tell the doctor about the abuse, but he/she didnt respond. 2.0 20.0
You told the doctor you were abused, but he/she didnt seem to listen. 1.9 18.7
The doctor accused you of lying about how you were injured. 1.9 17.1
The doctor said that it was not his/her place to talk to you about how your physical injury occurred. 1.9 7.1
The doctors examination of your injuries was painful and rough. 1.8 25.0
The doctor told you that you were not badly hurt. 1.8 19.5
*Rating was determined using a 5-point Likert scale, where a rating of 1 denoted definitely do not want; and 5, definitely want.
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or being accused that they were lying. However, other un-
desirable behaviors were common: 56%of the patients re-
ported that physicians too easily accepted false explana-
tions for their injuries, and 45% reported that physicians
treated injuries without asking their cause.
Emotional Support
Desirable and undesirable emotionally supportive phy-
sician behaviors and the percentage of participants re-
porting encountering those behaviors are listed in Table
2. Desirable behaviors included careful listening (80%),
responding with compassion (75%), and providing emo-
tional 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). Undesir-
able (nonsupportive) behaviors included minimizing the
severity of injury (33%) and implying that the patient had
triggered the abuse (24%). Ten percent felt that their phy-
sicians acted angry toward them, and 3% reported that
their physicians joked about domestic violence during
the examination.
Practical Support
Practical support measures are listedinTable 3, along with
percentages of patients whoreportedreceivingthem. Slightly
more thanhalf the womenreportedreceiving practical sup-
port, and 10 of the 24 desirable behaviors were reported
byless thanone thirdof the women. Desirable support mea-
sures such as providing information and phone numbers
for safety andlegal resources, informing patients that spou-
sal battery is illegal, displaying posters and literature inthe
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 re-
ported by less than 5% of respondents.
Thirty-seven percent of women encountered unde-
sirable 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 rat-
ings of physician behaviors and participants demo-
graphic 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 cri-
terion for a difference to be considered significant.
There were no differences in ratings of physician be-
havior among participants based oneducational level, em-
ployment status, marital or cohabitation status, or age.
There were, however, differences related to racial back-
ground. White women rated 10 physician behaviors as
less desirable than did African American women
(Table 4). Members of other ethnic groups were ex-
cluded fromthese analyses due to the small sample sizes.
Table 2. Ratings* of Specific Physician Behaviors in the Area of Emotional Support and Percentage of Battered Women
Who Reported Experiencing Them
Rating
Women
Reporting, %
Desirable Behaviors
The doctor listened to you. 4.6 80.0
The doctor gave you emotional support. 4.6 64.9
The doctor reassured you that being beaten was not your fault. 4.6 63.4
The doctor treated you with compassion. 4.5 75.0
The doctor told you that your feelings (especially of anger or embarrassment) were okay and normal under the circumstances. 4.5 52.4
The doctor noticed by your body language that you were nervous and upset. 4.3 83.3
The doctor told you that your feelings were understandable. 4.3 55.0
The doctor communicated understanding and support for you when you were reluctant to tell how you were injured. 4.3 51.3
The doctor said you were not to blame for the violence. 4.2 52.5
The doctor helped you admit you were battered. 4.0 37.5
The doctor encouraged you to talk about your anger. 4.0 37.5
The doctor frankly told you that he/she thought you had been abused. 4.0 28.6
The doctor encouraged you to tell him/her what really happened, even if it hurt. 3.9 29.3
Undesirable Behaviors
The doctor told you that your attacker was a bastard (or any other bad name) for what he had done. 2.5 14.6
The doctor asked what you did to trigger the violence against you. 2.1 23.8
The doctor acted as though your situation was not serious because the physical injuries were not serious. 2.0 32.5
The doctor told you that you were responsible for the problem. 1.9 2.4
The doctor acted as though he/she did not care that assault had occurred. 1.8 31.7
Your doctor spent as much time sympathizing with your abuser as with you. 1.8 17.5
The doctor acted as if you were to blame for being assaulted. 1.8 9.8
The doctor joked about domestic abuse while examining you. 1.8 2.4
The doctor acted angry with you for having been assaulted. 1.8 9.8
The doctor told you that you were overreacting to the situation. 1.5 20.5
*Rating was determined using a 5-point Likert scale, where a rating of 1 denotes definitely do not want; and 5, definitely want.
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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 rat-
ings for each item between this group and nonhelp-
seeking women. Help-seeking women reported the fol-
lowing 6 positive and negative behaviors drawn from all
3 physician behavior domains as significantly more
desirable (P.005) than did nonhelp-seeking women:
being told that domestic violence is caused by alcohol
or other drug abuse (19), being referred to a psychia-
trist (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.
Table 3. Ratings* of Specific Physician Behaviors in the Area of Practical Support and Percentage of Battered Women
Who Reported Experiencing Them
Rating
Women
Reporting, %
Desirable Behaviors
The doctor said that your partner had no right, legal or otherwise, to assault you. 4.6 47.6
The doctor provided information about temporary safety (such as a womens shelter). 4.5 46.3
Before you left, the doctor met with you again to see if you needed anything else. 4.5 45.0
The doctor provided you with telephone numbers of people you could call for help (such as the district attorney, a shelter, etc.) 4.5 35.7
The doctor helped you create a plan to protect the safety of your children (if any). 4.5 32.4
The doctor gave you the contact person to get help from the legal system. 4.4 35.7
The doctor encouraged you to make an emergency plan in case violence erupted again. 4.4 31.0
The doctor told you that spousal abuse is wrong under any circumstance. 4.3 51.2
The doctor asked to see you in 24 to 48 hours to see how you were doing. 4.3 41.5
The doctor scheduled you to return for a follow-up visit to see how things were going. 4.3 40.0
The doctor asked you if you wanted to use the telephone to contact a womens shelter. 4.3 38.1
You were given information about support groups. 4.3 36.6
The doctor really tried to get you in touch with social services, such as housing, welfare, or legal aid. 4.3 32.5
If the batterer was in the room with you, the doctor ordered him to leave to ensure that your discussion would be private. 4.3 32.4
The doctor informed you of your legal rights (to press charges, to get a restraining order, etc.). 4.3 31.7
The doctor scheduled you for a follow-up visit to discuss a safety plan in case of future incidents of battery occurred. 4.3 21.4
The doctor asked you if you would like to call the police or if you would like him/her to call them for you. 4.2 52.4
The doctor asked one of his/her nurses to come in and spend additional time talking with you about the abuse. 4.2 36.6
If the abuser was present in the room, the doctor made him leave. 4.2 30.6
The doctor reviewed a safety plan for you to follow in future cases of abuse once more before you left. 4.2 26.8
In your physicians office, you saw brochures and posters about domestic violence. 4.2 26.2
The doctor informed you that spouse abuse is illegal. 4.1 32.5
The doctor shook your hand before you left. 4.0 44.7
The physician told you that abuse tends to continue and get worse over time if nothing is done about it. 3.9 43.9
The doctor asked you to identify family, friends, or other people you could rely on for some help. 3.9 42.9
The doctor said that many other women share this problem. 3.6 40.5
Undesirable Behavior
The doctor did not reschedule any follow-up visits. 3.5 23.8
The doctor insisted that you get away from your abusive partner. 3.3 26.0
The doctor called the police without your permission. 3.0 9.5
The doctor recommended that you and your abuser get couples counseling. 2.9 33.8
The doctor suggested that you go home and tell your abuser to see a counselor. 2.9 28.6
The doctor offered to talk to your partner/abuser about his reactions. 2.9 17.9
The doctor suggested a family meeting so he/she could talk with you and your abuser. 2.6 9.5
The doctor seemed more interested in getting help for your abuser than for you. 2.5 17.5
The doctor told you to get a lawyer, not a doctor. 2.5 7.1
The doctor told you that your injuries were not severe enough to justify calling the police. 2.4 15.0
The doctor called a womens shelter without asking you first. 2.4 7.1
The doctor told you that domestic violence is caused by alcohol and drug abuse. 2.1 20.5
The doctor told you that many relationships go through this phase. 2.1 7.3
The doctor told you that violence can be caused by a womans alcohol or other drug abuse. 2.0 9.5
The doctor suggested that you confront your abuser and threaten divorce if he doesnt change. 2.0 5.0
The doctor told you things could be worse. 1.9 30.0
The doctor told you that the most important goal was to save your relationship. 1.9 7.3
The doctor suggested that you could stop the abuse by changing your behavior. 1.8 14.6
The doctor told you that men cannot help being violent. 1.8 4.8
The doctor suggested that women are responsible, in part, for domestic violence. 1.8 14.6
The doctor told you to go home and make up with your partner. 1.6 7.1
*Rating was determined using a 5-point Likert scale, where a rating of 1 denotes definitely do not want; and 5 definitely want.
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COMMENT
GENERAL IMPLICATIONS
To our knowledge, this is the first systematic, quantita-
tive effort to survey battered women about physician be-
haviors that they regard as supportive and unsupport-
ive. 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 newinsight that can guide future efforts to meet
the needs of battered women who seek help within the
health care system.
WOMENS VIEW OF SUPPORTIVE
AND UNSUPPORTIVE BEHAVIOR
Battered women reported that they value medical sup-
port that includes taking a complete history, with de-
tailed assessment of current and past violence, but with-
out 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 valuedemotional support inthe form
of confidentiality. The partner should be directed, not
asked, toleave the examinationroom. The emotionallysup-
portive physicianlistens carefully andreassures the woman
that the abuse is not her fault, andthat her feelings of shame,
fear, anger, depression are understandable.
Valued practical support includes telling the pa-
tient that spouse abuse is illegal and wrong and that she
has a right to be safe. The physician should provide in-
formationandtelephone numbers for local resources such
as shelters, support groups, and legal services. Physi-
cian concern for the womans safety is desirable, but bat-
tered women do not want their physicians to take ac-
tions without their knowledge. The physician should also
ask about the safety of children in the home (after in-
forming the patient about mandated reporting), help the
patient begin safety planning in the event of future abuse,
and schedule a follow-up visit.
This groups reported experiences suggest that, in
general, physicians listened carefully, were sensitive to
body language, responded with compassion, conducted
dignified and sensitive medical examinations, and at-
tended carefully to injuries. These physician behaviors
are generally desirable for all patients whether or not do-
mestic violence is present.
On the other hand, physicians were less successful
in delivering elements of care that specifically target bat-
tered womens unique needs. Specifically, women re-
ported that many physicians neglected to ask howan in-
jury occurred, take a history of violence, ask about the
safety of their children, refer them to community re-
sources and provide telephone numbers, or schedule a
follow-up appointment.
Althoughbatteredwomeninthis study indicatedthat
most physicians provided supportive care, some reported
that physicians did not. Almost one third of womeninthis
groupreportedthat their physicianexaminedthemroughly,
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%) experi-
encedextremelynegative behaviors, includingjokingabout
spousal abuse, blaming the patient for the abuse, and tell-
ing the patient that men cannot help being violent.
IMPLICATIONS FOR
CONTINUING EDUCATION
These results indicate a need for continuing medical edu-
cation to reach less skilled physicians, as well as quality
assurance mechanisms to identify the fewphysicians who
may be causing harm to battered women.
Our findings also provide empirical validation of
training programs that teachphysicians toaskabout abuse,
provide emotional support in a confidential setting, de-
velop safety plans, and provide resource information.
The high value women in this study placed on ef-
fective medical support was unexpected. Research has
suggested that psychosocial aspects of interventions with
battered women are most important and medical ser-
vices are secondary.
11
Our findings refute the common
belief that physicians who become involved in assisting
battered women abandon traditional medicine and be-
come social engineers.
13
In fact, it seems as if battered
Table 4. Physician Behaviors That Were Rated* Differently by African American and White Battered Women
Behavior
Mean Rating
African American White
Your doctor spent as much time sympathizing with your abuser as with you. 3.3 1.5
The doctors examination of your injuries was painful and rough. 2.9 1.5
The doctor told you that many relationships go through this phase. 3.2 1.7
The doctor told you that things could be worse. 3.2 1.5
The doctor suggested that you could stop the abuse by changing your behavior. 3.1 1.4
The doctor told you that men cannot help being violent. 3.0 1.5
The doctor suggested that women are responsible, in part, for domestic violence. 2.6 1.4
The doctor said that it was not their place to talk to you about how your physical injury occurred. 3.2 1.6
You told the doctor you were abused, but he/she didnt seem to listen. 3.1 1.7
You tried to tell the doctor about the abuse, but he/she didnt respond. 3.4 1.8
*Rating was determined using a 5-point Likert scale, where a rating of 1 denotes definitely do not want; and 5, definitely want.
P.002.
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womenexpect their physicians to conduct excellent medi-
cal 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 re-
lationships 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 childrens safety. This should in-
clude teaching physicians how to ask about and evalu-
ate childrens safety in a sensitive manner, so as not to
unfairly jeopardize the mothers legal status.
RACIAL DIFFERENCES
The pattern of differences between non-Hispanic white
women and African American women was unexpected.
Behaviors that were rated differently betweenthe 2 groups
were the following: physicians sympathizing with abus-
ers, rationalizing the violence, not allowing the woman
to tell the story of her abuse, and providing rough, pain-
ful 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 depart-
ment (
2
1
= 4.88, P.03). In emergency departments,
there is less continuity of care and care may be less per-
sonalized. Women may have lower expectations of phy-
sician behaviors when seeking abuse-related services in
this setting. African American women also encounter on-
going 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 womens 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 phy-
sician interventions in cases of domestic abuse, several
factors suggest that caution should be used when apply-
ing these conclusions to other settings such as a family
practice clinic. First, the study is based on a conve-
nience sample of women recruited fromprograms for bat-
tered women, and we were unable to track nonpartici-
pants. Confidentiality requirements prevented us from
comparing participants with those who declined to par-
ticipate, and therefore we do not know if our sample is
representative of the larger group. Second, survey par-
ticipants who sought medical treatment for abuse-
related problems were not segregated on the basis of
whether they received care in a private office, emer-
gency 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 retro-
spective self-report. Suchreports may be influencedby fac-
tors other than direct experience. This limitation is miti-
gated by 2 factors. First, there were no differences in
desirability ratings by womenwhosought helpandwomen
who did not seek medical help for abuse-related prob-
lems. Second, even among women who sought help, not
all women had experienced each type of physician behav-
ior. Few differences in desirability ratings were related to
direct experience with a particular physician behavior.
Afinal limitation of this study is that physician char-
acteristics were not studied. Although the primary fo-
cus 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 addi-
tional research to examine this issue.
STUDY STRENGTHS
The survey was developed using a systematic, empirical
approach that assured ecological and social validity by in-
volving physicians andbatteredwomeningenerating items
and reviewing the resulting instrument. This instrument
was foundto discriminate desirable fromundesirable phy-
sician behaviors in each of 3 domains measured.
Another strength of this study is that the desirabil-
ity rating of specific physician behaviors was, at most,
minimally affected by the womens history of seeking help
for domestic abuse. Women who had never sought medi-
cal 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 glo-
bal attitudes and opinions of battered women that were
not determined by situation.
This study describes, fromthe battered womans per-
spective, desirable and undesirable physician behaviors
relating to the treatment of domestic abuse. It offers fam-
ily physicians previously unreported information to im-
prove the way they treat patients who are victims of do-
mestic abuse. Participants in this study valued competent
medical care, emotional support, andpractical advice, sug-
gesting that effective physician interventions will in-
clude all 3 dimensions. As our results suggest that phy-
sicians provide more emotional support and medical
service and less practical support, physicians may need
to make extra efforts to improve in the latter area. Fu-
ture researchis neededto explore the relationships among
patients actual experience with physicians, desired phy-
sician behavior, and factors such as race and treatment
setting (emergency vs outpatient department).
Accepted for publication July 28, 1997.
We acknowledge the collaboration of the following or-
ganizations and individuals in Wisconsin in support of this
project: Womens Horizons Inc, the Domestic Violence Project,
Kenosha; The Womens Resource Center, Racine; Sojour-
ner Truth House, Milwaukee; The Waukesha Womens
Center, Waukesha; the Association for the Prevention of
Family Violence, Elkhorn; and Jean Lahti and Karen Rob-
erts for assistance with data management.
ARCH FAM MED/ VOL 7, NOV/DEC 1998
581
1998 American Medical Association. All rights reserved.
Corresponding author: L. Kevin Hamberger, PhD, Fam-
ily Practice Center, All Saints Healthcare Systems Inc, PO
Box 548, Racine, WI 53401-0548.
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