by David Page
Because kids can't always tell their own stories—some parents won't let them—health care providers must be on the lookout for subtle as well as overt markers of abuse.
Battered Women
Written records about the fate of abused women appeared in the United States sometime in the 1830s. The tragedy has escalated through the last decade of this century and shows no evidence of abating. In the American Journal of Emergency Medicine (January 1995), Dr. E.A. deLahunta describes domestic violence as an epidemic. Women now correctly expect their doctors to inquire about potential abuse. Only education can break the vicious cycle of intergenerational learned violence.
While the topic of domestic violence creates images of poverty in the minds of some, it is a classless disease. In the land of the free, we spread battering around—rich, poor, blue-collar workers, blue bloods, white-collar professionals, tradespeople. A study of forty-two consecutive consenting women seen in a community-based family practice setting revealed the following facts:
• Forty-five percent reported physical, social or emotional violence in their relationships.
• Thirty percent admitted to being physically battered during their lifetimes.
• Sixty-two percent of the women who reported slapping and hitting also admitted to kicking and punching. Some said sexual violence and weapon use were also involved.
• Twelve percent were currently involved in an abusive relationship.
• None of the women were seen for routine checkups but for complaints such as migraine headaches and neck stiffness.
Abuse must first be distinguished from the normal bickering and "gnashing of teeth" that periodically explodes within the most benevolent of relationships.
As in every well-written scene in fiction, episodes of domestic violence in real life have an inciting incident: Somebody does something to annoy or aggravate the other person in the dyad. It may be innocent questioning or nagging. It may fall on the heels of a job loss, excessive drinking or other stresses. It may be familiar, repeated or unexpected. The result is often anger. Usually nothing happens. But not infrequently a physical outburst rushes in on the heels of flash rage. Each inciting event enrages a person who usually possesses poor impulse control at best and often a personal history of parents who exchanged abuse. What happens?
The marginally adjusted individual, with a back story of having been abused, explodes.
We're interested in patterns of injury. As you might anticipate, the batterer's perverted attack is swift, carried out with little imagination. It's a predictable savagery. Here's a partial list of mindless battering methods:
• Slapping to the face, head, ears. It shocks, hurts, but mostly insults and demeans the victim.
• Smashing attack to the head, chest or abdomen with fists. Causes bruises, cuts and larger lacerations; may cause broken bones, e.g., orbit of the eye.
• Strangling of victim with hands, belt, towel, etc. Attacker may time the attack to make victim think she's about to die, stopping just short of asphyxia.
• Kicking attacks to the legs, pelvis, abdomen. May cause pain, bruising, lacerations. May cause internal (blunt) damage; for example, a case of liver laceration has been reported.
• Throwing victim down a flight of stairs. May cause abrasions, cuts or severe internal damage.
• Grabbing victim's clothing or neck and throwing her up against a wall. May involve strangling, head banging, neck snapping; may also include threat of more assaults.
• Using a knife or gun. Weapons may be used to threaten or to actually injure victim. Guns are most often used to threaten unless attacker intends to kill.
There seems to be a pattern to the batterer's attack. Like a Broadway performance, the assault scenario becomes a high-tension three-scene play. Except it's real. Usually, it's repeated. And it's always ugly.
At the heart of domestic violence is a profound lack of communication, beginning usually with males who grew up in paternalistic, disjointed families in which battering was permitted. Like his father, the son quickly learns there's no one to halt his irrational outbursts, which so often end in physical violence. No one talks very much. Wounds heal. Emotional scars remain hidden under a cloak of renewed domestic congeniality, fostered by an ever-hopeful spouse whose physical ailments from repeated assaults are likewise concealed beneath her clothes. Here's the three-act domestic violence play:
Act 1 is a period of either gradual or exponential tension growth until the batterer (once again) elects to lose control and decides to assault the victim.
Act 2 is the actual outburst or explosion of rage—the attack is on. As more assaults occur, they become more violent and more frequent.
Act 3 is referred to as the loving phase of a battering incident. This final encounter involves reconciliation on both sides. The attacker often truly believes he won't do it again when he acts contrite and tells his victim so. Remarkably, the victim believes the batterer only to (barely) live through repeated abusive events.
Why do so many women remain in an abusive relationship? Fear leads the list, both fear of further abuse to herself as well as fear for her children who may already be part of the abusive pattern. Other feelings oil the slippery slope of violence. They include feelings of guilt for somehow being responsible for the batterer's unhappiness and anger. The victim may feel she somehow provoked him or is inadequate as a wife and mother. Many abused women watched their mothers tolerate abuse and may have grown up with an overwhelming sense of shame.
Violence begets more violence. The abused woman feels she cannot escape, and the beatings become more and more severe. Usually, the woman is finanically dependent on the abuser. In the end, she feels desperate, trapped in her violent world, alone, powerless.
The batterer often lives in a disjointed world of rage, with an unshakable personal belief system that includes resentment for others, feelings of insecurity and, not infrequently, a measure of paranoia. Many males who batter cherish an atavistic view of the interpersonal relationship between men and women. The home is his domain, his castle, his space to rule as he sees fit. And that rhymes with hit. Which is what happens over and over again.
In a pamphlet entitled "Assaults on Women: Rape and Wife-Beating," Natalie Jaffee states:
Most injuries were to the head and neck and, in addition to bruises, strangle marks, black eyes and split lips, resulted in eye damage, fractured jaws, broken noses and permanent hearing loss. Assaults to the trunk of the body were almost as common and produced a broken collarbone, bruised and broken ribs, a fractured tailbone, internal hemorrhaging and a lacerated liver.
So why do women stay in the abusive relationship? Besides having no money, no place to go, no place to hide—not to mention fear of the batterer's rage if he discovered she was leaving before she actually escaped—she often hopes he will change. She loves him. Of course, the batterer seldom changes. Or she may believe divorce is wrong. Or she may fear not having adequate skills to rejoin the job market.
What can an abused woman do to escape?
• Secrete away as much money as possible.
• Keep the phone number of the local police nearby.
• Collect and conceal documents needed later.
• Decide where to go, e.g., with a friend or to a shelter.
• Go to ER and have photographs taken of areas of injury. Write down the names of all doctors, nurses and police officers involved for future reference.
• Seek counseling and support if lack of self-esteem is hindering an escape.
Your battered character may find help through special hot lines, in
shelters, in a community mental health care facility, through some women's associations or through friends. The horror of domestic violence serves as an embarrassing backdrop to modern American life. It belongs in fiction as Stephen King demonstrated in his surreal novel Rose Madder.
More information may be obtained from:
Center of Woman Policy Studies 2000 P St. N
W, No. 508 Washington, DC 20036
National Coalition Against Domestic Violence 1500 Massachusetts Ave. NW, Suite 35 Washington, DC 20005
Abused Elders
Old folks are easy prey.
In fact, the elderly are a natural setup for abuse for several reasons, not the least of which is their dependency. It seems that whether the caregiver is related to the victim or not, the mere fact of being old, wasted and invalid reminds young caregivers that aging will eventually trap them as well. Frustration, fatigue and a sense of futility about their own future years may weigh heavily on the minds of both victim and abuser. What are the symptoms and signs of abuse of elderly people? The answer may include any number of complaints, and close observation may suggest an elder abuse problem. Many of these considerations seem normal for an elderly person whose life is nearly over. Without many remaining friends and with well-meaning but preoccupied families, old folks often regress into a clouded acceptance of their inevitable and possibly imminent death. They may express a desire to die, may cry easily, lose their appetite and withdraw socially. These symptoms can progress to a refusal to take medication or to bathe, after which physical deterioration may swiftly ensue. Still, any of these findings should raise suspicion of elder abuse.
Other clues to elder abuse:
• Elder asks to be separated from caretaker who is abusing him.
• Elder seems overly alert when the caregiver is around and watches the caregiver's every move.
• Elderly seems fearful in the presence of the caregiver.
• Elder seems to live in the past, never talks about current activities, particularly those involving the caregiver. As many elderly reminisce, this is a particularly sensitive issue.
The old person in your story may be wearing evidence that points to abuse, physical ailments that carry suspicion, odd body marks. A few types of common injuries that may present with a strange twist include:
• Bruises that remind you of something familiar, such as fingers, rope, other household objects
• Abrasions on the wrists or legs suggestive of restraints
• Burns with blistering from hot water in unusual places or excessive for the explanation provided
• Bruises on both forearms suggesting self-defense along with bruises elsewhere
• Bruises on both sides of the body, for example, inside the thighs, top of shoulders (pinching "annoyance" bruises)
• Bleeding from nose, mouth, vagina or anus
• Unexplained chest, abdominal or pelvic pain
Neglect may be more obvious than abuse. It is insidious, cruel and reportable. Some of the symptoms may simply seem a little off the mark. For example, the victim may be dehydrated, soiled, apathetic and improperly clothed for the season. Other evidence of neglect includes over- or under-medication, and lack of eyeglasses, walker or hearing aid. Unpleasant odors or stool or urine stains, unwashed hair, lice, and dirty hands and fingernails all point to a neglected person unable to care for herself. What about the caretaker? Any clues there? The caregiver may light up a torch of his own and send out additional signals of misgivings. Once again, we must approach the caregiver's record cautiously. Look at the situation from his point of view. The elderly patient can be slow-moving, combative, resentful and frequently downright stubborn. Caregivers may be out of the mainstream of health care and nursing, for example, returning to the work force because of domestic financial problems. Or substance abuse may figure in the equation. Trapped for what may seem like endless hours with elderly clients, even the most well-tempered caregiver becomes irritated. When does annoyance cross the line to abuse? Remember, a lot of abuse may be invisible. Threats of withholding
medication, ambulation assistance and creature comforts, or just threatening to carry out physical abuse, can be devastating. And threats can't be seen. The elder may be too frightened to report the abuser. Refusal to touch or to comfort the old person or isolating the person from others also represents an invidious sort of neglectful abuse.
More obvious and inappropriate is the caregiver who:
• Seems agitated or outright hostile
• Won't discuss issues of the elderly person's welfare and is insensitive to the patient's concerns
• Is rough when handling the old person
• Is impulsive or cuts into discussion when elder is talking
• Overreacts to the elder's more minor concerns
• Doesn't seem to be able to communicate effectively with the elder Any evidence of fondling the elderly or of outright verbal or physical abuse should lead to dismissal of the caregiver, followed by a report to the proper health care association.
Victims of domestic abuse often view themselves as completely dependent on their abusers, and many of them are dependent for economic support. But there is a way out for battered women, abused kids and mistreated elders. Increasing physician awareness is beginning to help turn the tide as more doctors move past ignoring the problem, or merely offering sympathy, to becoming proactive.
Most states have laws that mandate the reporting of domestic abuses. But the victim and the family must work with the health care team to make appropriate changes in the abused person's environment. It's not easy, but it can be done. No one has to be a victim.
A woman is raped in the United States every six minutes, and it is commonly assumed that a significant number of other sexual assaults are never reported. Not all victims are young. Some sixty thousand women over fifty years of age report sexual assault annually. If we include cases of reluctant sexual contact between adults, the number soars.
It has been estimated that 30 percent of all women have been sexually assaulted in childhood or during their adolescent years. One out of every eight males has been sexually assaulted by age eighteen. Sexual assault is the fastest growing crime in America. Unfortunately, not many sex criminals get caught. Too often the victim possesses a poor self-image coupled with the perception by many women that theirs is a poor legal position. Thus, many raped women don't seek medical or legal help, and many rapes go unreported. Presently, health care providers are becoming increasingly aware of this horrible dilemma that confronts sexually assaulted women.
What Is Rape?
Rape is defined as the carnal knowledge of a victim without his or her consent that occurs through fear, coercion, fraud or force. Carnal knowledge is considered any degree of penetration of a body orifice whether or not ejaculation occurs. Lack of consent is integral to a definition of rape, and the threat of harm or death, with or without the use of a weapon, determines the legal degree of criminal sexual assault. Rape may occur in the setting of a drugged, intoxicated, sleeping or mentally incompetent victim. Any act from fondling to penetration of a body opening with the penis or another object constitutes sexual assault.
Rape is a legal term. The examining doctor's responsibility is to discover and treat traumatic injuries, collect forensic evidence, comfort the victim and direct her to ongoing therapy.
A useful method of classifying victims of sexual assault is by age. Each age group brings up different issues. The categories are:
• Adults (over eighteen years old)
• Children
• Adolescents
• Elderly
In interest of space, we'll focus on adult and child sexual assault.
Careful assessment of the rape victim regardless of age is critical, as is gentleness during the vulnerable first examination. It is not the doctor's job to establish whether or not the patient was raped. Rather the physician must obtain all information germane to the assault, diagnose injuries, collect forensic data and treat and counsel the victim. The courts determine who is guilty of the crime.
Why Do Men Rape Women?
The answer is complicated, and the following issues have been assessed and a unified theory of criminal sexual behavior has been synthesized by experts in the field. The answer to why men rape women includes data from abnormal behavior, the contribution of geneti
cs, the nature of the male nervous system and the male's hormonal background. Much of the behavior is learned, of course.
Some contemporary theorists' suggestions on why rape occurs:
• Natural selection probably favored males who learned and indulged in forced copulation while women learned to resist. Men took
advantage of their superior strength to sexually subdue women.
• The tendency to use forced copulation as a strategy depends on the size of the sex drive and the person's perception of how successful the aggressive sexual encounter may be. Males learned they can get away with rape. Even today little legal deterrent exists.
• Two drives predominate to motivate the rapist: the sex drive itself and the urge to dominate and control the victim. The expression of power—hinged on anger—is undoubtedly a major part of the urge to attack and subdue.
• Genes that evolved on the Y (male) chromosome affect the secretion of hormones and the function of the brain, which alters the strength of the sex drive. The rapist's sensitivity to adverse or uncomfortable stimuli is different, which permits him to commit the crime.
Not all rapists are the same. Their backgrounds vary as do their personalities. As suggested by the list above, the factors that go into stimulating an individual to commit this crime are numerous. Still, in our society there exist many preconceived ideas about the person who commits what is often considered a crime of base instinct.
Myths About Rape
Myths about forced sex arose because of society's historic view of woman's place in western culture. In the seventeenth century, it was felt that the husband could not rape his wife as she had, through "matrimonial consent," given herself to him in all aspects. During the women's movement in the 1960s, this so-called "spousal exemption" came under attack and the concept of consent was redefined.