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Case 16

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Domestic Violence in First Nations People on the Vancouver Downtown Eastside and its Connection to the Highway of Tears

Objective:  To illustrate an all too common scenario of domestic and sexual violence involving the First Nations people in Canada.

Narrative Case

Yvonne was a 15 year old First Nations teenager from the Niiska nation in the
province of British Columbia in Canada. She was born on a First Nations reserve
where she was raised in a family where violence was the norm [1]. Her mother and father married at 16 years of age and had six living children and several miscarriages [2].  Her mother was an alcoholic and found it difficult to cope with the duties of motherhood and being a housewife.  She also had tremendous guilt as two of her children had been diagnosed with fetal alcohol syndrome and were extremely difficult to handle. Her father was a labourer and was often away from home working in the oil and gas industry in other parts of the province. When he did come home, he introduced his wife to cocaine, the habit of which he had acquired whilst away [3].  As soon as they were together, there were episodes of verbal abuse often followed by her father beating her mother [4].
 As the oldest of the six living children, Yvonne often took on the responsibility for her younger siblings [5]. She frequently had to miss school as she had to look after the house and her brothers and sisters.


 At age 14 years, her best friend, Brenda, urged her to move  with her to Vancouver. Brenda’s older sister had moved there a year ago and was making a good living as a waitress. The older sister said she could get them a similar job if they came
down and they could share her accommodation until they had money of their own.
 It was hard for Yvonne to tell her mother that she was going to leave, but felt
so hopeless that she thought this would be a chance to get away from her present life which was so miserable [6].


 Soon after arriving in Vancouver, Yvonne and Brenda found that things were not
as rosy as Brenda’s sister had promised. The sister’s accommodation consisted of a room with a single bed and a hot plate in a converted old hotel in the Downtown Eastside that the government had provided for those in dire need. The sister’s waitressing job had ended when she repeatedly missed work due to being hung over from using alcohol and drugs the night before. The sister had been befriended by this nice guy who turned out to be a pimp [7]. He kept the sister on drugs.
 Yvonne and Brenda could not find work and without work they could not afford to leave the sister’s accommodation. The pimp soon had them working for him as well.
 One day, Yvonne decided that she must leave and return home despite all the dangers in doing so.  She did not have the bus fare so was planning to hitchhike back home.  She was never seen again.  Her picture appears on the list of Missing Women– Prostitutes Kidnapped and Presumed Dead while hitchhiking along the Highway of Tears [8].

 

Learning Points

[1] Research indicates that males exposed to domestic violence as children are more likely to engage in domestic violence as adults; similarly, females are more likely to be victims.

[2]  Girls who marry before 18 years are more likely to experience domestic violence than their peers who marry later. Child brides often show signs symptomatic of sexual abuse and post-traumatic stress such as feelings of hopelessness, helplessness and severe depression.

[3] Women who have been abused are fifteen times more likely to abuse alcohol and nine times more likely to abuse drugs than women who have not been abused.

[4]  This is a typical pattern in Domestic Violence: alcohol and/or drug abuse leads to fighting and then reconciliation.  In many cultures a woman had little option but to endure the situation since leaving the man may make her more stigmatized or vulnerable or she may have no economic support without him.

[5]  Female children especially become ‘parentified’, taking on the role of ‘little mother’ in the household.  This pattern of caring for others – no matter how dysfunctional or even abusive they are – becomes entrenched and is repeated in adult life. Generally it is reinforced by cultural prescriptions of appropriate female roles and behaviours.

[6] Most people with this profile are running away from impoverished and/or neglectful and/or abusive families.  They are impulsive and aggressive – they have a fragile sense of self worth and cultural mores of masculinity may dictate that they not acknowledge this fragility but rather that they express aggressive and challenging behaviours.

[7] Adolescent girls who have been abused and neglected are easily attracted to a man who seems able to take care of them and offer protection.  There was also the social imperative that she be attached to a man – in most cultures this is necessary to provide a woman with status and with ‘protection’. In some cultures a woman has no social and/or economic option but to remain with her male partner.

[8] First Nations women disappear while hitchhiking along the Highway of Tears and are never found again.  The communities along the highway share a situation of colonization resulting in experiences of poverty, violence, cultural genocide, residential school impacts, addictions and displacement from land.  In 206 there was a Symposium to raise public awareness and create a call for action.  To see the full Highway of Tears Symposium Recommendations Report, please click here.

Background Information on Domestic Violence

Child marriage directly threatens the health and well-being of girls: complications from pregnancy and childbirth are the main cause of death among adolescent girls aged 15-19 years in developing countries. Girls aged 15 to 20 are twice as likely to die in childbirth as those in their 20s, and girls under the age of 15 are five times as likely to die.

Women who have been abused are fifteen times more likely to abuse alcohol and nine times more likely to abuse drugs than women who have not been abused.  The American Department of Justice, in 2002, found that 36% of victims in domestic violenceprograms also had substance abuse problems.

In a report from Statistics Canada on violent victimisation of Aboriginal women in 2009, 15% of Aboriginal women reported being a victim of spousal violence in the preceding five years compared with 6% of non-Aboriginal women, and 59% were more likely to report injury than the 41% of non-Aboriginal women.

From 1989 to 2006 nine young women went missing or were found murdered along the 724 kilometre length of highway 16 – now commonly referred to as the Highway of Tears. All but one of these victims were Aboriginal women.

First Nations women are overrepresented in prostitution, with an especially high number of Canadian youth in prostitution from First Nations.

 

References

  1.  Library and Archives Canada Cataloguing in Publication British Columbia. Missing Women Commission of Inquiry Forsaken [electronic resource] : the report of the Missing Women  Commission of Inquiry / Wally T. Oppal, Commissioner. Complete contents: Vol. I. The women, their lives and the framework of inquiry,  setting the context for understanding and change – v. II. Nobodies, how and why we  failed the missing and murdered women – v. III. Gone, but not forgotten, building the  women’s legacy of safety together – v. IV. The Commission’s process. – Executive summary. Issued also in printed form Includes bibliographical references. ISBN 978-0-9917299-7-5
  2. Serial murder investigation–British Columbia. 2. Missing persons–Investigation
  3. –British Columbia. 3. Murder victims–British Columbia. 4. Pickton, Robert
  4. William. 5. British Columbia. Missing Women Commission of Inquiry.
  5. Downtown-Eastside (Vancouver, B.C.). 7. Governmental investigations–British
  6. Columbia. I. Oppal, Wallace T II. Title.
  7. HV6762 B75 B75 2012 363.25’9523209711 C2012-980202-6
  8. http://highwayoftears.org/about-us/highway-of-tears
  9. http://highwayoftears.org/uploads/Highway%20of%20Tears%20Symposium%20Recommendations%20Report%20-%20January%202013.pdf
  10.  Child Marriage
  11. http://www.hrw.org/news/2013/06/14/q-child-marriage-and-violations-girls-rights
  12. http://www.icrw.org/child-marriage-facts-and-figures
  13. http://wcd.nic.in/childact/draftmarrige.pdf
  14. http://en.wikipedia.org/wiki/Child_marriage
  15. http://www.unicef.in/documents/childmarriage.pdf
  16. http://greaterkashmir.com/news/2011/Mar/29/the-practice-of-child-marriage-6.asp
  17. http://www.icrw.org/files/images/Child-Marriage-Fact-Sheet-Domestic-Violence.pdf
  18.  Violent victimization of Aboriginal women in the Canadian provinces, 2009
  19. http://www.statcan.gc.ca/pub/85-002-x/2011001/article/11439-eng.htm
  20. Report on Violence Against Women, Mental Health and Substance Abuse by Canadian Women’s Foundation.
  21. http://www.canadianwomen.org/sites/canadianwomen.org/files/PDF%20-%20VP%20Resources%20-%20BCSTH%20CWF%20Report_Final_2011_%20Mental%20Health_Substance%20use.pdf
  22.  Prostitution of Indigenous Women:  Sex Inequality and the colonization of Canada’s First Nations Women
  23. http://www.rapereliefshelter.bc.ca/learn/resources/prostitution-indigenous-women-sex-inequality-and-colonization-canadas-first-nations-

Case 15

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Domestic violence and impact on children

Objective

  1.  Safeguarding children, and considering the impact on them, is a very important component of dealing with domestic violence

Abbreviations

DVPP       Domestic Violence Perpetrator Programme
ISS            independent Support Service

Narrative case

Tom and Sarah separated a year ago because of Tom’s violence and abuse, which culminated in an incident where he was violent in front of their children Jack (9) and Sam (7). Tom had not seen the children since. He was desperate to resume contact and applied for an order to do so through the family court. The court instructed him to attend a Domestic Violence Perpetrator Programme (DVPP) for risk assessment and to complete the group work programme. The programme was required to provide an initial assessment and then report on Tom’s progress half way through and at the end of the programme.

During the programme, Tom started a new relationship with Julie. He gave her contact details to the DVPP workers as required. The ISS then contacted Julie, who said she did not need any support and that Tom had not been violent to her. She said that Tom had admitted his past violence towards Sarah and she was pleased to know he was attending the DVPP. If Tom was ever violent or abusive, she knew she could call the ISS. Just knowing this – and knowing that Tom knew it – made her feel safer.

The DVPP’s half way report was largely positive. Tom had remained non-violent and had not attempted to contact Sarah or the children, despite desperately wanting to. However, he needed to work more on his empathy for Sarah and workers thought that he still underestimated the likely effect upon the children of witnessing violence. In the court proceedings Tom admitted he had been violent and abusive to Sarah and took responsibility for it. Sarah had also been in regular contact with the ISS and was pleased with how Tom appeared to be changing. However, she was still worried about the impacts of contact on the children and wasn’t sure she could trust him. Tom was granted supervised contact at this point.

Tom continued to engage with the programme and appeared profoundly affected by the sessions relating to children and the impact of his behaviour towards Sarah. In the week before his first supervised session he discussed with the group how he would handle the situation – particularly how he might deal with his children’s anger towards him or answer difficult questions about his past violence. The next week he reported how useful this had been as Jack had directly challenged him, asking ‘Why did you hit Mum?’. If he had not been prepared he would not have known what to do. He said he would probably have tried to avoid the question or would have played down how serious it was. Instead, he was able to fully admit what he did, explain it was wrong, say how much he regretted it and give the children a heartfelt apology.

By the time of the final court hearing Tom and Sarah had not seen each other for almost 2 years. Sarah approached Tom through her lawyer and asked to speak with him. He was able to tell her what he had learned on the programme, saying that he was totally responsible for the violence, that she was not to blame and that he deeply regretted the harm he had caused to her and the children. Sarah felt safe enough to tell him how angry, afraid and hurt she had been. She felt more confident that Tom was in the right place to be a decent father – and also knew who to contact with any future concerns. At the final hearing Tom was granted unsupervised contact which has been reliable, safe and positive to date.

Learning points

  1. Perpetrators are often not aware of the impact of domestic violence on their children. Children who have witnessed violence are more likely to become perpetrators themselves in their future relationships.
  2. Providing new partners  and ex- partners of perpetrators with support gives them reassurance and confidence that they and their children will be safe.
  3. The relationship between fathers and their children is often underestimated when couples separate. Wherever possible this relationship must be maintained as long as suitable safeguards are in place.

 

Acknowledgments: This case has been adapted from cases from the UK charity Respect, with their kind permission.

Case 12

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Children are at serious risk in households where there is domestic violence

Objectives

  1. To show how children who live in households where there is domestic violence are seriously at risk and need child protection.
  2. To illustrate how parents can manipulate health care professionals and deliberately set out to deceive them
  3. To demonstrate the need for all agencies involved with children to share information and to ensure it is formally documented.

Narrative Case

This case is about Daniel a 4 year old boy and his 27-year-old-mother Ms. Luscak, who has had four different partners and did not seem able to detect abusive relationships or learn from past experiences [1]. This was made worse by her alcohol misuse [2] and occasional violence towards her partners. Originally from Poland she spoke little English [3].

Daniel had 2 siblings, a 7 year old sister Anna by her first partner, and a 1 year old brother Adam by her fourth partner, Mr. A.  On 27 different occasions, the police were called to domestic violence incidents often complicated by both parents being drunk [4]. On 2 occasions Daniel’s mum took overdoses with the intention of committing suicide [5]. She suffered a number of serious incidents with partners including attempted strangulation, being threatened with a knife, suffering a hand fracture and rape allegations. When asked to press charges she withdrew her statements [6]. On numerous occasions the children were judged not to be at risk and left with the parents with sometimes children’s social care not being informed [7]. The family moved house on a number of occasions due to inability to pay the rent [8].

When pregnant with Adam, Mr. A urged Ms. Luscak to have a termination. She missed 4 antenatal appointments. At one stage she was hospitalised and Mr. A took the drip out of her arm and she self discharged. Ms. L phoned the midwife and told her there was  domestic violence, despite previously denying this fact to healthcare professionals [9].

In January 2011 Daniel had a spiral fracture to the left arm [10] reported as due to jumping off the settee with his sister the previous day. Bruises on his shoulder and lower tummy were said by his mother to be due to falling off his bike regularly. Meetings of health care professionals took place but the long history of domestic violence was not considered.[8] In September 2011, Daniel started school. There were frequent absences as for his sister Anna. On a number of occasions different members of staff noticed injuries including black bruises around the eyes, blood spots on the face, severe marks on the nose, spot bruises on the neck and forehead bruising.  They also became concerned as Daniel was getting markedly thinner and always seemed hungry, taking food from lunchboxes and rubbish bins. [11 ]His sister Anna was told by Ms L to say that Daniel had this pattern of behaviour at home, ate more food than she did and was constantly falling over. Daniel had poor English and although a cooperative boy was shy and reserved and did not talk to the teachers.

Daniel saw a Paediatrician in February 2012 who was unaware of the school’s concerns.  His mother was very convincing that Daniel had an eating disorder and fell over a lot. Tests for medical conditions were initiated.  Three weeks later Daniel died. At post-mortem he was found to have high sodium levels and over 40 injuries including an acute subdural haematoma and an older smaller one.  His mother and stepfather have been convicted of Daniel’s murder and his 2 siblings are in foster care. Daniel had been subject to the most appalling abuse including being starved at home, fed salt to make him sick if school said he had taken food, put in cold baths nearly drowning on one occasion, locked in a box room with the handle taken off the door, had a soiled mattress and urine soaked carpet. He had physical punishments given by his stepfather of situps for 1 hour, standing in the corner, squats and running on the spot which were planned in advance. He had no toys.[12] His sister Anna had tried to protect him as much as possible including physically. She confirmed that Daniel had been hit “many,many times” by the stepfather.

 

Learning Points

[1] Children in households with domestic violence are at serious risk and must be thought about carefully. There is a strong association between witnessing DV and severe PTSD symptoms: withdrawal, clinging, regressive behaviour, hyperactivity, aggression, difficulties in concentration (Kilpatrick et al, 1997).  Child witnesses are much more likely to grow up to be either victims (females) or perpetrators (males).

[2] This is a typical pattern in DV: alcohol and/or drug abuse leads to fighting and then reconciliation.  Often the man feels overcome with remorse after beating the woman and there are pleas for forgiveness, promises to reform, lovemaking and then further cycles. The perpetrator is often very loving and repentant following a violent outburst and this intensifies the partner’s attachment to him.

[3] Abuse of children is more prevalent in socially isolated or disadvantaged families, with alcohol and drug abuse and with domestic violence. This case has all these risk factors including the mother speaking little English.

[4] Every minute in the UK, the police receive a call from the public for assistance for domestic violence. This leads to police receiving an estimated 1,300 calls each day or over 570,000 each year.  However, only 23-35% of incidents of domestic violence are reported to the police.

[5]  Domestic violence commonly results in self-harm and attempted suicide.  Abused women are five times more likely to attempt suicide and one third of all female suicide attempts can be attributed to current or past experience of domestic violence.

[6] The low rate of conviction in cases of domestic violence can be attributed to the victim’s inability or unwillingness to give evidence (Cretney and Davis 1995).

[7] Interagency communication is vital and children’s social care should always be informed. In all the landmark cases in recent years in the UK, there has been lack of communication between agencies (Lord Laming 2003).

[8] Moving house several times is a typical pattern seen and the mother may lose all her possessions

[9] Domestic violence increases during a pregnancy and is the commonest cause of injury in pregnant women. Men often feel threatened by the prospect of having a child – economically they have little to offer and emotionally it means one more person to be cared for. This intensifies the man’s feelings of worthlessness and he defends against this by being more angry and violent. Bacchus (2004) reported 23% of women receiving care on antenatal and postnatal wards had a lifetime experience of domestic violence, and 3% had experienced violence in the current pregnancy.

[10] The possibility of abuse needs to be considered with spiral fractures and a judgment made as to whether the suggested mechanism of injury is plausible. In this case the issue was not considering other red flags i.e. the bruises on the abdomen which are unusual and for which there needs to be a clear explanation and the history of domestic violence.

[11] This eating behaviour is grossly abnormal and needed communicating to health care professional eg school nurse or general practitioner. Again there is lack of communication between different professionals.

[12] Health care professionals need to be able to “think the unthinkable” – this is a catalogue of abuse which if this was not a real case many would think was not possible

Background information

Background information on domestic violence

This is defined as abuse between persons in an intimate relationship, independent of gender, sexuality or marital status.  The term usually excludes abuse of children and the elderly.

Prevalence:

  • One incident of domestic violence is reported to the police every minute in the UK
  • On average, 2 women a week are killed by a current or former male partner.
  • 23% of women experience DV in their relationships at some time.
  • 45% female homicide victims are murdered by their partners. (Australian Bureau of Statistics: Women’s safety survey, 1996.) Women presenting to ER (Australian study)
  • 49% had experienced DV, 40% in the last 12/12.
  • 25% had a history of childhood abuse plus adult DV (Roberts et al, 1998).

 

Background of risks to children of domestic violence

Unicef figures estimate that globally the number of children exposed to domestic violence is 133-275 million. This varies by country: Developed countries 4.6-11.3million,

SubSaharan Africa 34.9-38.2 million and South Asia 40.7 – 88 million. At least 750,000 children a year witness domestic violence (Department of Health UK). Estimates vary from 30%-66% children are abused either physically or sexually by the same perpetrator. Children are completely dependent on adults and all children witnessing domestic violence are being emotionally abused

Children react in various ways to living with a violent person. Age, race, sex, culture, stage of development, and individual personality affect response. Children can be affected by tension, witnessing arguments, distressing behaviour or assaults. They may get caught in the middle of an incident, sometimes trying to make the violence stop; they may be in another room but be able to hear the abuse or see their mother’s physical injuries following an incident of violence; or they may be forced to take part in verbally abusing the victim. They experience a range of emotions including that they are to blame, anger, guilt, being alone, frightened, powerless, or confused. They may have ambivalent feelings, both towards the abuser, and towards the non-abusing parent.

Effects of domestic violence on children include:

    • Anxiety and depression
    • Difficulty sleeping.
    • Nightmares or flashbacks.
    • Physical symptoms such as headaches and abdominal pain
    • Enuresis
    • Temper tantrums
    • Behave as though they are much younger
    • School problems including truanting, sometimes staying at home to protect their mother
    • Aggression
    • Withdrawal from other people due to internalizing the distress
    • Lowered sense of self-worth
    • Start to use alcohol or drugs.
    • Self-harm eg overdoses or cutting themselves.
    • Develop an eating disorder.
    • Affecting social relationships – they may feel unable to or are prevented in bringing friends to the house

 

References

  1. Bacchus L, Mezey G, Bewley S, Hawort A, (2004) Prevalence of domestic violence when midwives routinely enquire in pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 111; 441-5.
  2. Cretney A, Davis G. (1995) Punishing violence. Routledge, London  
  3. Family Rights Group: www.frg.org.uk
  4. Lord Laming (2003). The Victoria Climbié Inquiry https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf
  5. Mind ‘How to parent when you’re in crisis’. http://www.mind.org.uk
  6. Mullender, A. and Morley, R. ‘Children living with domestic violence’ (London: Whiting and Birch).
  7. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from http://www.rcpsych.ac.uk/info/young.htm).
  8. NSPCC Children living with domestic abuse
  9. http://www.nspcc.org.uk/help-and-advice/worried-about-a-child/online-advice/domestic-violence/domestic-violence_wda86312.html
  10. Parentline Plus.  Support for parents under stress www.parentlineplus.org.uk
  11. Radford L, Aitken R,  Miller P, Ellis J, Roberts J, Firkic A. Meeting the needs of children living with domestic violence in London Research report. 2011 http://www.nspcc.org.uk/Inform/research/findings/domestic_violence_london_pdf_wdf85830.pdf
  12. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from http://www.rcpsych.ac.uk/info/young.htm
  13. Save the Children and  Women’s Aid services.  Safe Learning – an insight into children’s experiences of domestic violence and how these may affect their learning, 2006
  14. Serious case review: Daniel Pelka http://www.coventrylscb.org.uk/dpelka.html
  15. The Hideout website
  16. http://www.thehideout.org.uk/under10/adults/effectonchildren/default.aspa
  17. UNICEF: behind Closed Doors the impact of domestic violence on children
  18. http://www.unicef.org/protection/files/BehindClosedDoors.pdf
  19. Women’s aid organization  – Statistics on Domestic Violence http://www.womensaid.org.uk/domestic_violence_topic.asp?section=0001000100220036sionTitle=statistics
  20. Women’s aid organization – Children and domestic violence http://www.womensaid.org.uk/domestic-violence-survivors-handbook.asp?section=000100010008000100380001.  

Case 11

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Domestic violence in Pakistan

Objectives:

  1. To demonstrate that culture and religious beliefs can result in honour killings
  2. To show the importance of including religious authorities in preventive programmes

 

Narrative case:

A Pakistani woman, Farzana Parveen aged 25 years, was beaten to death by members of her own family in Lahore. [1] Parveen was in love with Mohammad Iqbal, aged 45 years, for many years and had decided to marry him against her family´s wishes. [2] Her father had promised her in marriage to a cousin whom she refused to marry. [3]

Parveen and Iqbal decided to go to a courthouse in Lahore to register their marriage. When they left the courthouse, her father and about 20 members [4] of her extended family awaited her. They tried to pull her away from Iqbal and when she refused to leave him, they hit her with bricks until she was dead. [5] Even though the courthouse was located on a main street in Lahore and the crime occurred in daytime, none of the onlookers tried to intervene. [6]

When Parveen’s father gave himself up after the attack, he called the crime an “honour killing”, saying “I killed my daughter as she had insulted all of our family by marrying a man without our consent, and I have no regrets over it”[7]. The police are still searching for the other perpetrators.

Shocked by the brutal nature of the crime the Pakistani Ulema council began to organize a summit to address honour killings. Pakistani religious leaders published a decree which called honour killings “un-Islamic” [8]. 

Learning points

[1] Although most of the reported cases of honour killings in Pakistan happen in the countryside, cases do happen in big cities as this example shows. People living in the countryside are often more conservative and have a poorer education so educating them is extremely important.

[2] 58% of the victims of honour killings worldwide and 43 % of the victims of honour killings in the Muslim world were killed for being too “western” according to the “Middle East Quarterly” (Chesler, Phyllis, 2010). Women can be accused of this for various reasons such as being “too independent”, disobeying their fathers/family`s wishes and /or cultural and religious expectations. Parveen was obviously killed for being too western – she ignored her families wishes and refused to marry a cousin. Instead she tried to decide by herself which man she wanted to marry. Other victims of honour killings in the Muslim world were mostly killed for “sexual impropriety” which means for example that a victim was raped or had extra-marital affairs. It was reported that Parveen had been three-months pregnant so it is also feasible to assume that the accusation of “sexual impropriety” could have played a role, too.

[3] In Pakistan arranged marriages are common (about 77%) and occur often inside the family. Most of the women are promised to a man they only hardly know during childhood. In this case the bride was 25 years old so, she was not a minor any more but cases of arranged marriages during childhood are still common in Pakistan even though a few laws regarding this topic have been passed in the last few years. Male-dominant religions such as Islam in combination with a very strict and strong Islamic council can strengthen patriarchal structures. Due to traditional practices such as arranged marriages where women have no rights, female oppression is common. Not surprisingly, men do consider women as less valuable than men. Poverty and a poor education reinforce this view.

[4] In about one third of honour killings in the Muslim world the father is involved. In 83% of the reported cases, however other members of the family are also involved. 42 % of cases were committed by multiple perpetrators such as this case shows (about 20 members of Parveen`s family were involved in the killing). Due to the principle “Karo Kari” and a special law the family of the victim can forgive the perpetrators and no further prosecution takes place. Honour killings are still considered as a private matter and not reported to the police.

[5] About 50% of the victims were tortured by burning, stoning, hitting to death or stabbing more than ten times and died in agony. In this case, Parveen was hit with bricks until she died.

[6] A study from 2011 administered by the Pew research centre reports that about 40% of the Pakistani public believes that honour killings of women can be sometimes justified. As pointed out in [4] it is considered as something private. Preventive measures such as education should aim to change this way of thinking and to encourage spectators to intervene.

[7] The father himself believes that honour killings are justified as explained in [4], he obviously feels no guilt, even though he has killed his own daughter. The fact that he surrendered directly after the incident to the police does also illustrated the point that many perpetrators are convinced they will escape justice.

[8] As honour killings are often based on wrong and fanatical religious beliefs, it is extremely important to include religious authorities as they have been found to have more influence on the population than laws and the government. Especially in tackling the problem described in [4] and [6] the help of the religious authorities are necessary.

Background information

As the Human rights committee of Pakistan reports, about 869 women were killed in the name of honour in the first half of 2013, but the real number is considered as being much higher. In addition, at least 56 women were killed for giving birth to a girl because girls are still seen as being of less value than boys.

The overall situation in Pakistan for women is still very difficult. In the first half of 2013, 1204 cases of physical violence against women were reported and ¾ of the Pakistani women said that they had been subjected to violence before. Explicit laws against domestic violence or violence against women in general only exist in one province of Pakistan, in Sindh. Often crimes are not reported because the woman is also held responsible for being raped and can be sentenced to death for extramarital sex. As the council of Islamic ideology has a very strong position in Pakistan, testimonies of women have only half the value of the man`s in court. In order to be able to accuse a man of being a rapist at least four female witnesses are needed. Religion hinders women also in participation in politics: during the last election a religious edict, a fatwa was published which said that female participation in the election is un-Islamic, even though about 19.5% of the politicians in Pakistan are females.

References

  1. Pakistan woman stoned by family outside court. Aljazeera. 28 may 2014. http://www.aljazeera.com/humanrights/2014/05/pakistan-woman-stoned-family-outside-court-201452873717897513.html (7/24/14)
  2. Pakistan clerics issue stoning death decree. 1 June 2014. http://www.aljazeera.com/news/asia/2014/06/pakistan-clerics-issue-honour-killing-fatwa-201461960536332.html (7/24/14)
  3. Chesler P. Worldwide Trends in honor killings. The Middle East Quarterly. Spring 2010, Vol. 17, number 2, page 3-11. Published by the Phyllis Chesler Organization. http://www.phyllis-chesler.com/764/worldwide-trends-in-honor-killings (7/26/2014)
  4. State of Human Rights in 2013. Published by the Human Rights Committee of Pakistan. March 2014, URL: hrcp-web.org, ISBN- 978-969-8324-70-4

Case 10

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Lifelong Impact of Childhood Sexual Violence – Joanne’s story

Objectives

  1. To show how childhood sexual violence is kept secret within affected families
  2. To show how the consequences of childhood abuse manifest in physical illness
  3. To discuss impact on multiple health domains over a lifetime

Narrative Case

Joanne is a 53-year-old patient I have known for over 10 years in my family practice. She has had multiple health conditions including severe asthma, migraines, and most importantly, chronic pain as well as depression that was diagnosed as chronic myofascial pain over 20 years ago. She has been treated for the pain and depression for over 20 years. She still frequently rates her pain as 10/10 in severity and describes the major impact it has had on her life, work and marriage. She went on to develop OA of the back including some disc pathology and pinched nerves leading to intractable neuropathic pain, and has had multiple surgeries, carpal tunnel syndrome leading to surgery, elbow tendonitis leading to surgery, ulnar entrapment syndrome leading to surgery, dental pathology and bone loss leading to surgery, and more. Repeatedly the surgeries fail to calm the various pains attributed to multiple orthopaedic pathologies.

Joanne has a family history of mental illness. 5 years ago, Joanne’s sister attempted suicide. In reading her note and talking to her afterwards, Joanne learned that the man with whom they were living had assaulted her sister sexually. When Joanne was 8, her parents divorced and she and her sister lived with an aunt and uncle. From age 9 through 16, whenever her aunt left the house, Joanne (as well as her sister) were repeatedly sexually assaulted by her uncle. He would hold her down with one hand over her face and force oral sex on her. She describes feeling suffocated and this being the start of her asthma. She has been angry about this but had never mentioned it to anyone until her sister’s attempted suicide, not even when she and I directly discussed this over the many years I knew her. Hearing her sister’s story, she acknowledged her own. She drew her courage and confronted the uncle and actually taped his response to her question “Why did you do this to me all these years?” and he replied, “You never stopped me”. She, with the help of counselling from multiple sources, and with much trepidation, ultimately decided to press legal charges against her uncle, a process that took five further years, all the way to the Supreme Court of Canada. Her uncle was ultimately found guilty. Her depression was now more clearly related to her trauma as posttraumatic stress disorder (PTSD). The stress of this confrontation process itself has had huge impact on her health over a period of about five years, both before the disclosure and after. She describes feeling guilty for never having told anyone before and possibly having prevented him from doing this to her sister, to her cousins and his grandchildren. Her anger is always under the surface.

Currently Joanne is using appropriate medication, working hard to take care of herself, yet still feels “totally debilitated” and says she would like to “amputate her painful right arm” She uses willpower to control the pain along with her long acting opioids and feels she will never be able to return to work. Aside from chronic pain and depression, she is having financial problems, social isolation, nightmares and significant dental problems, which she attributes to her sexual abuse directly. Her asthma may also link to the abuse as vocal chord dysfunction. She attributes vaginal warts and anal pain since childhood as well. Most recently she has been attending the “Darkness to Light” program from the Voicefound organization to help her and she still has court issues as the “victim impact” is still being quantified. She is not yet out of the woods for having come forward. She is a survivor and she is able to see it as a positive step towards reclaiming her wellness however.

Learning Points

[1] Girls in Canada are sometimes subjected to repeated rape by family members and will not be able to discuss the past traumatic issues even when asked directly about this. These are well-guarded family secrets and there are many reasons why. There are resources that can help healthcare providers facilitate this necessary but difficult step in the healing process.

[2] Even as physicians who are well aware that childhood sexual assault puts women at higher risk for many different illnesses, chronic pain, marital problems and depression, we will be dealing with patients who are simply unable to tell their story. The index of suspicion of childhood trauma must go up when dealing with comorbidities such as chronic pain, depression, unexplained pelvic or anal pain and many other chronic debilitating conditions. These are described in further depth in the background information that follows

(3) Guilt and anger are very powerful pathogens. Community resources can help a woman understand past events and put them into context. Police services can help. Family services, psychologists, social workers, and other counsellors as well, as this problem needs a village to solve it. A family physician that knows a woman over time can build trust slowly. Even an astute asthma specialist can help identify the problem. Eyes and ears must be open for the underlying story. The practitioner’s index of suspicion can be honed. The office can have reading material that demonstrates this is a topic that would be welcome to discuss. The environment has to be right, the timing as well. Not all stories are told all at once

(4) Telling a story is not the end of the problem but more like a beginning of healing. Community resources like Voicefound can help.

(5) The physician’s patient records that contain detailed clear accounts of childhood abuse are extremely valuable for the adult seeking legal help, and should remain available to those who seek them. Joanne’s case might have taken far less than 5 years if that information had been available to her.

Background information (related to child sexual abuse)

  1. A Review of Child Sexual Abuse Prevalence Studies suggests the child sexual abuse prevalence rate for girls is 10.7% to 17.4%* and the rate for boys is 3.8% to 4.6% .95% will know their perpetrator.
  2. The National Clearinghouse on Family Violence has data on prevalence as well as resources for prevention:
  3. National Clearinghouse on Family Violence
  4. Family Violence Prevention Unit
  5. Public Health Agency of Canada www.phac-aspc.gc.ca/nc-cn
  6. Canadian data on child maltreatment including sexual and physical abuse and neglect can be found at http://www.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfnts-2006-maltr-eng.pdf

References

  1. Excellent Resources for survivors and for healthcare providers can be found at Voicefound.   http://www.voicefound.ca/
  2. A handbook for health care providers summarizes prevalence, traumogenic illness, and how to approach survivors in practice: http://www.voicefound.ca/wp-content/uploads/2011/03/Handbook-on-Sensitive-Practice.pdf
  3. Darkness to Light sexual abuse prevention training is available at workshops through Voicefound:http://www.voicefound.ca/events-category/stewards-of-children-training/
  4. http://www.d2l.org/site/c.4dICIJOkGcISE/b.6035035/k.8258/Prevent_Child_Sexual_Abuse.htm#.VEW4ibxdWO8

Case 9

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Domestic violence in Italy

Objectives

  1. To show that women often confuse love with possession and do not realize that they may be in danger from this relationship.
  2. To show how it is possible to start from a history of violence and then move to the woman finding her true self, becoming stronger, more courageous, proud of herself and her newfound beauty

Narrative Case

Lucia is a lawyer aged 37 years. One evening in 2013, she returned home after going swimming and was confronted by a hooded man who poured acid on her face. The attacker was a previous partner with whom Lucia had a stormy relationship which she broke off one year previously. He was arrested the same night and subsequently sentenced to 20 years in prison.

He was a professional liar about his 10 year relationship with another woman by whom he had a son. Lucia was complicit in this vicious circle by forgiving his lies and giving him new possibilities. When she choosed to put an end to so much exasperation, his behaviour became obsessive: stalking, ambiguous writings, intruding in the house and tampering with the gas system with the risk of blowing up the whole building. Lucia’s abandonment of their relationship had triggered in him the spark of resentment.

Lucia survived, but began a dark and painful period marked by the risk of being blind. She underwent a series of plastic surgery operations to repair the damage and restore her facial features. Lucia also embarked on a course of treatment to fight the fragility that made her under the thumb of a violent relationship. She said: “Some stories are born from weakness and lacks what you have inside of you”. She becomes a symbol of great strength and courage to all women like her who have been (or are) love sick prisoners.

Learning Points

[1] Women do not want to see the danger of the relationship because love makes us blind. We need to work on ourselves and accept that if a relationship does not work it must be put aside.

[2] Understanding and love of oneself makes a person less vulnerable. A first step is to understand what is happening and how to re-appropriate our lives, our bodies and our time.

[3] Lucia’s situation is classic in which possession is mistaken for love; anger becomes ferocity, until into the essence of cruelty: the acid is thrown in her face: “If I can not have you, I will gate you”.

Background information

Prevalence: in Italy in 2013, there were 120 women killed by their partners, but it is not known the number of attempted murders.

Psychiatric sequelae: Lucia abandoned her profession as a lawyer, but found the strength to start again and is now more aware, more determined and bolder. She lives with her disfigured face and is an authentic reminder of the phenomenon of violence against women. On March 8, 2014 she was appointed by the Head of State, Knight of the Republic for the courage, determination and dignity with which reacted to the severe physical consequences of the infamous attack suffered.

Reference:

Annibali L,  Fasano G. My story ‘not’ love (La mia storia di non amore) Rizzoli Editori, 2014

 

Case 8

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Domestic violence in Greece

Objectives

  1. To show the impact of extraordinary economic situations e.g. a financial crisis on the rate of domestic violence
  2. To show how victims of violence often find excuses for their injuries and believe that they must have done something wrong.

Narrative case

Melina, a 35 year old Greek woman, lives with her husband and family in Athens.  One day a friend noticed a bruise on Melina’s face. When asked about it, Melina first tried to find excuses [1] but her friend persisted [2]. She then admitted that her husband had become violent in the last couple of weeks after he lost his job because of the financial crisis [3]. Melina, an interior designer, had also lost her job [4]. She did not go to the police or seek any form of help until she confided in her good friend [5]. She pointed out how guilty and ashamed she felt about the whole situation and believed that she was in some way responsible and that she herself might have been to blame [6].

With the help of her friend she was able to acknowledge that she lived in a violent and abusive relationship [7] and decided to seek professional help. Today she lives a confident life away from her abusive ex-husband.

Learning outcomes

[1] Many victims deny their problem because they feel too ashamed or think that the incident was not serious enough. According to an EU study, 34% of victims of physical or sexual violence who did not go to the police thought that the incident was too minor. 7% did not want the perpetrator to be brought to justice or they feared the end of the relationship.

[2] As many victims are reluctant to reveal domestic violence, it is extremely important to have someone from outside their family to talk to them. Asking about bruises offers an opportunity for the victim to talk. The biggest problem with domestic violence is ignorance and silence by both the victim and others around them.

Doctors need to be trained to recognize signs of domestic violence and must be given guidelines on how to talk to women about it.

[3] Losing a job can be devastating for a man. He feels useless because he cannot fulfil the role of “breadwinner” for the family. Sometimes this frustration can turn into aggression against members of his own family.

[4] The fact that the victim is an interior designer shows that having a higher level of education does not protect a woman from domestic violence. An EU-study shows that there is no significant difference in the incidence of domestic violence between women with very little education and those with tertiary education. The fact that she lost her job as well as her husband means that monetary problems are likely. 30% of women who are unsatisfied with their household income have suffered physical or sexual violence while only 18% of women who are satisfied with their financial situation have experienced domestic violence.

[5] In Greece only 14% of victims reported the incident to the police. In Europe as a whole only one third (33%) of victims seek any form of help (hospital / lawyers / women´s shelters or faith-based organizations etc). The reasons for this vary but it is alarming that according to the EU-study only 63% of victims who seek help at a police station were satisfied with the police. Further work must be done to improve the service so that victims are encouraged to report more cases of violence to the police.

[6] Feeling ashamed and guilty, as well as embarrassed is a typical reaction of victims. Remarkably, the most common feeling after an incident of sexual or physical violence seems to be anger: according to the EU study 63% of the victims felt that way. However, as many victims did not seek help or go to the police and it is not known if anger is directed towards the perpetrator or themselves. The second strongest feeling was fear (52%). Together with the feeling of shock (34%) this might explain why so many victims did not report the incident.

[7] When victims of physical or sexual violence were asked what had helped them to survive and overcome this incident, the most common answers were the support of their family and/or friends (35%) and their own personal strength (32%). Here, again, one can see the importance of the support of people the victim knows and confides in.  10% reported that another important step to overcome the incident had been to acknowledge that they lived in a violent relationship. Sadly only 6% of the victims reported that professional support played a role, which underlines the fact that many victims do not seek professional help. Often women do not know that support services exist. This shows that a) information flow has to be improved and b) more low-threshold services (organization that do not ask for any information such as the name or the perpetrator but do help everybody who wants help) are needed. However in countries such as Greece with a major financial crisis there are often no funds available.

Further information

Violence against women is still a major problem in the EU. About 33% of women in the EU study reported experiencing physical or sexual violence at least once since the age of fifteen years. In Greece, 5% reported such an experience had happened in the last 12 months with their current partner and overall 7% had experienced such an assault.

References

  1. Svarna, Foteini. Greece-Financial crisis & Domestic Violence. WUNRN. 29 May 2014.
  2. Violence against Women- an EU-wide study. European Union Agency for Fundamental Rights. Luxembourg. Publications Office of the European Union. 2014

 

Case 7

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Honour as a Factor in Domestic Violence in India

Objectives:

  1. To demonstrate the impact that a woman’s sense of honour can have in domestic violence.
  2. To demonstrate the role of drug or alcohol abuse or addiction in domestic violence.

Narrative Case:

This is a true story of a lady aged 39 years who was my patient for many years. She was educated up to 7th Standard but did not complete high school as she was married off by her parents at the age of 17 years to a Police Constable. She had 2 children aged 19 years & 21 years, both being daughters. This did not satisfy the husband as he was keen on getting a son.

She used to come with some bruises off & on. Once she even had a fracture of the forearm. She said she had fallen. But some direct & indirect questioning led her to confess that she was facing Domestic Violence.

Her husband had become alcoholic & started an illicit relationship to fulfill his dream of getting a son. His job was with Crime Branch in the Police force & he was used to seeing violence in society. He would come home from work, get drunk & beat her up often. The girls used to get frightened but were not in a position to help. Money was in short supply as he had to support the other woman in his life.

We did a lot of counseling & called her daughters to discuss possible solutions. Her husband had never once accompanied her to a Doctor’s Clinic. The daughters denied any sexual assault by the father. They were interested in studies & getting a job & getting out of this household.  

The woman refused any sort of help. First of all, she could not make a Police case, as the husband was part of that force & had many friends. She did not want any neighbours to know & did not allow any counselor to visit their home. Her constant refrain was that she had to cope with it otherwise the daughter’s lives will be ruined. Any story of domestic violence would ruin the chances of marriage for her girls as arranged marriages are the norms in that society. Only her parents were sympathetic but they were old & sick & needed help themselves.

When last seen, she had become very thin & pale & developed hypertension. The violence was continuing. There was no social life with him & he was not interested in sex with her. He was spending more time with the other family. She was very sure for her decision to carry on. Some marriage proposals were coming for her daughters & her sole intention was to live for them. All she looked forwards to was to settle them well and see them happily married. As far as her own life she said she had no hopes for any happiness & wanted to live only for her children & to look after her old parents. She was never going to consider divorce or separation & come out openly with her life story. Rather than that “dishonour” she would rather die in one of the violent episodes.

Learning points:

This story brings out 3 issues.

  1. Some women refuse any help. For them it is a question of honour. They feel too ashamed to let others know about violence. They cannot accept being socially ostracized. Family support is not there if parents are old and poor.
  2. Secondly, we put so much faith in the Police Force. They are sensitized to issues of domestic violence. But they come from the same social background. Because they deal with crime and acts of violence, they are susceptible to alcoholism. This in turn makes them take out their frustrations at home. Counseling in such cases becomes extremely difficult. If this case had been registered against this constable he would certainly have lost his job & the family would have lost everything.
  3. Finally, addiction to alcohol is prevalent worldwide. It is the under lying cause in many cases of domestic violence. In India, there is Prohibition & alcohol sale is regulated. However, it has not reduced alcoholism since the laws were enacted 67 years ago.

Background Information:

This article highlights the high prevalence of violence against women in India, including a review of some cultural aspects of this violence:

http://www.trust.org/item/20141110100628-ax25b/?source=dpMostPopular

References:

  1. This article discusses son preference in India: http://www.trust.org/item/20141110100628-ax25b/?source=dpMostPopular
  2. This is a reference for drug and alcohol abuse and addiction in India: http://www.trust.org/item/20141110100628-ax25b/?source=dpMostPopular

Case 6

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Case of First Domestic Violence in Pregnancy

Objective: To show that violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened

Narrative Case

Mandy was a 23-year old patient currently 28 weeks pregnant.  I had delivered her and was her only doctor since birth.  I knew her quite well as she had asthma and spent more than the usual time in my office.  I also looked after her mother and sister and grandmother.

She did not do well in school and hung with the rough crowd.  Although we had talked about contraception on previous visits, she was unreliable taking her birth control pills.  Therefore, it was not a surprise to find her presenting to my office for pregnancy care.  Her relationship was unstable but at present she was living with the baby’s father, an El Salvadorian immigrant involved in the drug trade. [1]

The pregnancy was progressing uneventfully until one day Mandy presented with facial bruising and abdominal pain.  Through sobs, Mandy told me that her boyfriend had beaten her up because she refused to have sex with him.  He punched her in the face and kicked her in the belly.  She had called the police and they arrested him overnight but he was being released later that morning. She had been to emergency and found to be physically okay.  She did not know what to do. [2]

Pregnancy-wise, she was fine, but was emotionally distraught and not sure of her options.

I was able to put her in contact with the Ending Violence Association, which is an umbrella organization for services available for victims of domestic and sexual violence.  They were able to get her into a safe house, where counselling and social services were available.  She managed to make a clean break from the relationship and went on to deliver a healthy son, with ongoing support from social services and her family. [3]

Learning Points  

[1]  Many women have a longitudinal relationship with a physician, particularly during pregnancy and well baby visits.  This allows for more opportunities for screening and prevention.  Only about 17% of all pregnancy women are screened for domestic violence at their first visit and 10% at subsequent visits.

[2]  Violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened.  It is estimated that one in five women will be abused during pregnancy. As homicide during pregnancy now surpasses the previous leading causes of death (automobile accidents and falls), it is more important than ever that we know the signs and properly screen women for domestic violence.  However, the doctors and emergency room providers need to know the signs of abuse and what to do about them.  

[3]  It is important for primary care providers to have easy access to services for victims of domestic and sexual violence.  It is important to make sure that they are safe from further harm and have access to services that allow them to make choices that are best for them and their baby.

 

References

Centre for Disease Control
Intimate Partner Violence During Pregnancy, A Guide for Clinicians

http://www.cdc.gov/reproductivehealth/violence/intimatepartnerviolence/sld001.htm

Domestic Violence in Pregnancy at about.com

http://pregnancy.about.com/cs/domesticviolence/a/domesticviol.htm

 

Case 5

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Domestic violence leading to death by so-­called accident

Objectives

  1.   To show how detected but denied physical violence can lead to fatality.
  2.   To  show  how  law-­‐enforcement  and  hospital  staff  can  be  better  trained  to  pick  up on these cases and have better (legal) tools to intervene on time.

Narrative Case

A divorced woman of approximately 39 years (Sonia) with a daughter from her marriage goes to live with her new boyfriend. She was a clerk in a hospital and regularly came to work with cuts and bruises. Clearly they were from physical abuse but she insisted that they were the product of accidents and slip-­‐ups by her. In addition, she began to be drawn into the alcohol abuse perpetuated by her boyfriend. Possibly she did the latter to make the physical abuse less dreadful for her to undergo. In any case she never had the courage to get away from him. One day, upon not arriving at work, the police were dispatched to her home where she was found dead at the bottom of the stairs. The boyfriend said she fell while drunk and he didn’t find her until he himself was woken by police, as he was sleeping off his drunken stupor. The case was concurrently dismissed by prosecutors because of lack of evidence, although many believe it was at least manslaughter by the boyfriend.

Learning Points

[1]  Sometimes  the  obvious  should  lead  to  investigation,  even  if  the  party  involved denies wrongdoing, or covers up wrongdoing by their partner

[2] More  specific  training  could  be  given  to  law enforcement  and  or  hospital staff  to detect abuse sooner and be able to intervene more quickly.