Doctor’s View: The public health problem of domestic violence
By Barbara Herbert, M.D.
April 14, 2009
It was another first for the state. Last June, Governor Patrick signed a violence intervention bill making Massachusetts the first state to require health care providers to refer victims of violence to a variety of social services.
The impetus behind the action was clear: the soaring number of deaths from domestic violence. Murders of domestic partners in the Commonwealth were nearly three times higher in 2007 than in 2005, reaching 42 in 2007, with an additional 13 suicides. In 2008, 25 homicides occurred, with 10 suicides.
At the same time the bill was signed, the Department of Public Health (DPH) released a landmark public health advisory on domestic violence, the first time such an advisory has ever been issued for a non-disease-related cause. The bill requires DPH to draft voluntary guidelines suggesting ways that hospitals and community health centers can link domestic violence victims to services.
The bill and advisory were welcomed by victim advocates, as they recognized domestic violence as a public health problem.
Domestic violence has never been just a personal matter; it affects an entire community’s sense of safety. Intervention in domestic violence cases offers models to address other forms of violence, such as dating violence, shaken baby syndrome and elder abuse.
Physicians have been involved, often with the legal community, in public-private prevention and intervention partnerships to decrease domestic violence, just as we have with shaken baby syndrome and elder violence. With the state’s new commitment, we might combine our legal and medical experience to develop more effective interventions, even in an era of diminished public resources.
It is, of course, valuable to remind physicians and attorneys that restraining orders work most of the time to protect victims and their dependents from potentially lethal violence from perpetrators.
Early screening and support from physicians increases the reach and efficacy of these legal interventions in periods of acute crisis. Further, careful physician documentation augments the possibility of meaningful court action to protect survivors whenever they turn to the courts.
State law for some time has required physicians and other providers to report suspected cases of abuse to appropriate protective service agencies.
Physicians must report abuse or neglect of children and disabled persons and abuse, neglect or financial exploitation of elderly persons, defined as those over 60 years old. They must also file written reports within 48 hours of suspecting such treatment with reasonable cause, or face fines up to $1,000.
As an emergency physician who has seen too many victims, I know the responsibility to report and protect patients is well accepted and taken with the utmost seriousness among the medical community.
However, the state’s action also raises physician concerns about the reporting requirements and what action is taken when reports are filed.
Physicians and citizens need to know that the state will take action as a result of reporting. This gives citizens incentive to participate, instills credibility and faith in the system, and tells citizens the system is working as it should. Thus, some mechanism to measure response and reaction by the state should be put forward.
We also need clarification on reporting. How, for example, do we determine the hidden violence of emotional abuse or financial abuse? How aggressively should physicians press patients for information to reach the point that they have “reasonable cause” to believe that violence has occurred?
Some cases are obvious; others, not so. The line between suspicion and reasonable cause can be wide or narrow.
The violence intervention bill is a great step forward. Yet, the voluntary guidelines for providers required by the bill, nearly a year after its enactment, have not been released. That isn’t surprising, given the tremendous burden of new regulations the legislature has imposed on DPH in the past year and given that the complexities of tailoring effective responses to domestic violence are daunting.
It does point out, however, the difficulty of the task of attacking domestic violence. More information and more direction can only help patients, attorneys and physicians.
Barbara Herbert, M.D., an emergency physician, is the Medical Director of St. Elizabeth’s Medical Center’s Comprehensive Addiction Program and Chair of the Massachusetts Medical Society’s Committee on Violence Intervention and Prevention.
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