Case 36

Interaction of domestic violence with the social determinants of health


  1. To consider the interaction of domestic violence with the social determinants of health.


Narrative Case

Mary is a 28 year old woman who suffered childhood abuse and neglect and then domestic violence (DV) in her adult life.  Her partner, Tom, is a 37 year old man who comes from a similar background.  He has never been employed and is chronically dependent on alcohol.

To review Mary’s history, Mary’s mother was addicted to drugs and had a variety of men in her life, many of whom abused Mary.  Being the oldest child, Mary took on the responsibility of getting her siblings fed and to school [1].

Mary did poorly at school and by the time she was in high school was associating with a group of her peers who were also not doing well in school.  She was using drugs herself. At age 14, she moved in with Tom who was 23, and showed her special attention [2]. Tom himself had been thrown out of his home at 14 by an abusive father and spent most of his teenage years in detention centres as a result of petty crimes [3].

The relationship between Mary and Tom developed a certain pattern.  They would drink for days at a time, then they would argue, this would escalate to the point of physical and verbal abuse [4]. Mary was often badly beaten by Tom and became frightened of him. He would tell her to ‘get out’ but the idea of being on her own frightened her even more. Tom would then apologize, they would make love and Mary would forgive him, believing that things would get better [5].

After a number of abortions, Mary had Katy, their first child [6].  Tom was violent towards her during the pregnancy and she became more frightened and moved out to stay with her mother [7]. Mary was very depressed after the birth [8].  She felt alone and abandoned.  She went back to Tom.  She hoped ‘that things would improve’ now that they had a child, but the drinking and violence and verbal abuse continued [9]. She found herself pregnant again, soon after returning to Tom.

Mary was now so depressed that she thought about suicide. She was afraid to leave and was always afraid that Tom would eventually kill her or the children or himself – or all of them [10]. She went to many doctors about her depression and was prescribed numerous anti-depressants, with little help [11]. She never told anyone about the abuse to which she was subjected [12]. She felt that she deserved the beatings, as Tom had told her so often that she was worthless and nobody else would have her, that she now believed this herself [13].

Tom had been drinking for days and there was no money in the house, Mary did not know how she was to feed the children or pay the rent.  There was yet another fight and Mary tried to lock Tom out of the house but he banged on the door and woke the neighbourhood.  The older child woke up crying and afraid that her father would come into the house. Katy then told her mother that Tom had sexually abused her on a number of occasions. Shocked by Katy’s disclosure, Mary then made a very serious attempt to kill herself and her two children.

Mary was charged with the attempted manslaughter of her children and they were removed from her care and placed with the Tom and his mother.


Learning Points

[1]  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.

[2]  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.

[3]  Most youngsters with this profile are running away from impoverished and/or neglectful and/or abusive families.  Their time spent in detention centres further stigmatizes them so that they are less able to secure employment and this often reinforces a criminal life style. Similarly, men like Tom are repeating behaviour that has been their own experience of family life.  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.

[4]  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.  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]  Her childhood background of neglect and abuse meant that Mary was unable to develop a sufficient sense of worthiness or entitlement to be treated any better.  In some cultures this is compounded by social mores, which marginalize women like Mary. Typically she remained in the relationship in spite of repeated violence, partly because her self-protective mechanisms were impaired by trauma and partly because whatever love and affection Tom provided her in between the episodes of violence simply reinforced her attachment to him and the hope that things would get better.

[6]  With little sex education she was vulnerable to pregnancy and STDs. Intravenous drug use compounds the vulnerability to blood borne viruses.  Her mother had no time to tell her about safe sex.

[7]  DV increases during a pregnancy and is the commonest cause of injury in pregnant women. Men like Tom 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.

[8]  Mary had two children in quick succession and was severely depressed following both births. Postpartum depression is common in women in situations of abuse and/or deprivation. There was insufficient follow up in spite of the fact that she was patently at high risk.

[9]  This is a typical pattern of hoping that a child will change him and not recognising that it may in fact worsen the situation.  With a history of teenage pregnancy with additional history of abuse and DV, Mary needed more vigorous follow up from the clinic (eg home visits).

[10]  This situation involves psychological entrapment and is sometimes referred to as a‘hostage’ situation (Herman, 1992).  It is common in situations of domestic violence where abused women usually feel helpless and powerless and unable to leave the situation and often they fear for their lives or for the welfare of their children if they attempt to leave.  This perception is actually quite accurate – homicide statistics show that women are most likely to be killed by their partners when they attempt to leave the relationship.  Walker’s concept of Battered Woman Syndrome is similar – the problem of the battered woman’s entrapment is described, as one of ‘learned helplessness’, meaning that the victim learns that to resist is pointless because it only leads to further abuse.  This leads to feelings of helplessness and surrender to the power of the abuser. These descriptions (both Walker and Herman) are psychological ones that assume a woman has a choice, socially and economically.  In Mary’s case this applies because she lives in a culture where she has social and economic support to leave the relationship. However, in many other cultural contexts a woman has no social or economic alternative and then psychological analyses are less important and the most compelling causes of the woman’s entrapment are social and/or economic.

[11] Prescribed medication is unlikely to help while the situation is unaltered. Women are prescribed more psychotropic medication than men – often without attention to the underlying problem – this is especially true in DV.

[12] There is a pattern of consulting doctors but not disclosing.  Primary care physicians need to be alert to DV as a common precipitant of depression.  It is one of the commonest reasons for apparently accidental injury in females and presentation to Emergency Rooms.

[13]  Verbal abuse and attack on her self-image leading, typically, to false beliefs, ie ‘I am what he says I am’. For many women it may be true that no one else will have them – in many cultural groups a woman like Mary, with a child and seen as having ‘deserted’ her husband, will be outcast.

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.


  • 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 49% had experienced DV, 40% in the last 12 months (Australian study)
  • 25% had a history of childhood abuse plus adult DV (Roberts et al, 1998).

Psychiatric sequelae:

Women with acute psychiatric presentation to a community mental health service:

  • 40% have a history of abuse, 16% experienced it in the last 6/12
  • 24% have a history of DV, 8.6% in the last 6/12 (Tham et al 1995).

Domestic violence and substance abuse

  • 75% of women with drug and substance abuse problems have a history of sexual/physical violence.
  • 72% have experienced assaults in their adult life, mostly from partners. (Swift et al, 1996)

Effects of DV on children:

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).


  1. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Washington: American Psychiatric Association, 1994.
  2. Herman JL. Trauma and Recovery. New York: Basic Books, 1992.
  3. Kilpatrick DG, Acierno R, Resnick HS, Saunders BE, Best, CL (1997). A two year longitudinal analysis of the relationship between violent assault and alcohol and drug use in women. Journal of Consulting and Clinical Psychology, 65(5):834–847.
  4. Perry, B.D., Pollard, R.A., Blakely, T.L., Baker, W.L. and Vigilante, D. (1995) Childhood Trauma, The Neurobiology of Adaptation and ‘Use-dependent” Development of the Brain:  How “States” Become “Traits”. Infant Mental Health Journal 16:271-291.
  5. Roberts GL, O’Toole BI, Lawrence JM, Raphael B. (1993) Domestic Violence Victims in a Hospital Emergency Department. The Medical Journal of Australia,  159, 6 September
  6. Roberts, G.L., Lawrence, JM., Williams, GM & Raphael, B (1998) The Impact of Domestic Violence on Women’s Mental Health. Australian and New Zealand Journal of Public Health  22, No 7
  7. Schore, A.N. (1994) Affect Regulation and the Origin of the Self, pp. 261-268. Hillsdale, New Jersey: Erlbaum.
  8. Schore, A.N. (1996) The Experience-Dependent Maturation of a Regulatory System in the Orbital Prefrontal Cortex and the Origin of Developmental Psychopathology. Development and Psychopathology 8:59-87.
  9. Swift W, Copeland J, Hall W (1996.). Characteristics of women with alcohol and other drug problems: findings of an Australian national survey. Addiction 91(8):1141–1150.
  10. Tham, S., Ford, T. and Wilkinson, D. (1995).A survey of domestic violence and other forms of abuse. Journal of Mental Health 4: 317-321
  11. Van der Kolk B. Psychological Trauma. Washington: American Associated Press, 1986. van der Kolk, B., et al. Traumatic Stress. New York: The Guilford Press, 1996.
  12. Walker LE. The Battered Woman Syndrome. 3rd edition. New York: Springer Publishing Co Ltd, 2009.


Case 35

Staying in an abusive relationship may risk a woman´s life

Objective: To show that by staying in an abusive relationship women may risk their life.

Narrative case:

Marie is 45 years old, married for the last 12 years with two children and has a very busy life with an interesting job. She seems very happy but unexpectedly told her family that she had left her husband and moved with the children to a flat and filed for divorce. The family is understandably upset: “ Is there another man? Is the husband unfaithful?”
Finally she admitted that her husband had beaten her for many years. Each time this had happened he told her that he is very sorry, it is the last episode and he offered her a gift or flowers. She thought that she was guilty of something and never spoke about this to her family. However, her husband became increasingly violent, sometimes pushing her out of the flat and closing the door so she was obliged to seek the help of her neighbours. She decided to go to the police to lodge a complaint against her husband but was still not ready to leave him [1]. One evening, she was taking a bath, her husband came into the bathroom and was very angry. He put his hands on her head and tried to drown her. She was really afraid. He stopped just before she fainted [2]. This time it was really too much and she finally managed to leave him, got a divorce and got custody of the children [3].

Learning points

  1. This woman needs help: she must talk to her family or to a close friend. She can get in contact with services and associations specialized in that kind of help and can ask for legal aid. However she needs to have proof such as an account from neighbours , medical certificate etc describing injuries. The law can then decide and make the violent spouse move away.
  2. A woman beaten by her husband is in danger of death: even if he does not want to really kill her   he can go too far
  3. A message to women is to never tolerate the first slap in the face, as it can be the beginning of more violence.

Background information

  • In France every three days a woman dies due to the violence of her husband, her partner or ex partner.
  • A national number can be called in France to get help 3919.


Reference :

Lutte contre les violences faites aux femmes – Grande Cause Nationale 2010 (the Great National Cause 2010 against violence against women)


Case 29

To show the value of Domestic Violence Perpetrator Programmes (DVPPs) in dealing with the cause of the problem


1. To show how Domestic Violence Perpetrator Programmes, in association with a support

service for partners, can successfully manage ongoing risk in a relationship


  • DVPP – Domestic Violence Perpetrator Programme
  • ISS – Independent Support Service, part of DVPP
  • Contacts all partners, relevant ex-partners, and new partners of every DVPP participant
  • MARAC – Multi Agency Risk Assessment Conference

Narrative Case

Zoe and Ben had approached Relate couples’ counselling agency, saying they were having difficulties in their relationship but wanted to stay together. During the screening process, it became clear that Ben was violent and abusive to Zoe. Ben was referred to a DVPP (1). The ISS contacted Zoe (2) Both were assessed using a risk assessment tool. Ben’s account was significantly minimised in comparison to Zoe’s (3). While on the DVPP Ben began talking about various controlling behaviours he was continuing to use, as well as past abuse against Zoe. It became apparent that Ben was extremely jealous and controlling (4). During the session on sexual abuse he talked about coercing Zoe into sex and sexual acts. Ben seemed unaware that this was abusive and continued to show no understanding that this was unacceptable. The DVPP worker, the ISS worker and their manager identified a much higher risk than previously assessed. The ISS met with Zoe and carefully discussed the things which Ben had mentioned in group. Zoe had felt too ashamed of what had happened (5) to mention the sexual abuse previously and was very upset, but confirmed that Ben was regularly abusive and continued to be so. She admitted she was very scared of Ben and he’d recently started saying that he’d never let her go. She agreed that it would be a good idea to involve other agencies through a Multi Agency Risk Assessment Conference (MARAC) (6) and the ISS worker helped her to start planning for her safety. Ben found out that he had been referred to a MARAC without his knowledge and threatened Zoe (7). He then aggressively confronted the DVPP workers. However, by the time he did this, Zoe had phoned the ISS worker saying she wanted to leave. The jealous and controlling behaviours, coupled with Ben’s statement about not letting Zoe leave, led the DVPP and ISS workers to believe there was a high risk of violence or even homicide. The ISS worker arranged a refuge place for Zoe immediately (8). The DVPP worker knew that Ben was likely to be angry and upset when he discovered that Zoe had left and rang to offer extra support. They talked to him about letting go and helped him plan strategies to keep him from harming himself, Zoe or others. Ben remains a high risk to Zoe and any future partners, but by focusing support on him the DVPP was able to contain the risk he posed at this critical time.

Learning Points

  1. Careful selection of participants into a Domestic Violence Perpetrators’ Programme (DVPP)  is essential.
  2. Support for partners, relevant ex-partners, and new partners (ISS), with advocacy, information about the programme and their partners’ attendance, is an integral part of any DVPP
  3. Many men on DVPPs do not initially realise the extent and severity of the abuse which they are inflicting on their partners.
  4. Coercive control is a form of abuse, which is not physical or sexual, but rather emotional and psychological.
  5. Victims are often reluctant to admit they are being sexually abused because they are ashamed.
  6. Many different sectors are involved in preventing, detecting and treating domestic violence (police, social services, health, education, probation and housing). Often communication between the sectors is poor, and the contribution that health professionals could make has not been developed and fostered. A MARAC is a way of ensuring good communication.
  7. Victims of domestic violence are vulnerable while treatment of the perpetrator is ongoing, and support for them is very important
  8. Refugees are an important part of domestic abuse services, especially if there is a risk of homicide or serious injury. Adequate funding for refuges must be ring-fenced.


Background information

There has been a failure in the past decade to adequately address the subject of violence against women, with the focus largely on women as victims. There has been growing interest in the involvement of men as perpetrators or potential perpetrators, but conclusive evidence of the effectiveness of perpetrator programmes is still lacking. An evaluation tool has been developed, and programmes must be properly accredited. It is very important that focusing on men does not overshadow work with women and girls. In the UK, funding for Refuges is under threat unless they are shown to accept male victims, who form only a very small proportion of those affected, and are at low risk of violence.


  1. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2014. Published online Nov 21.
  2. National Institute for Health and Care Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. NICE, 2014

Case 26

Domestic Violence Case from India:
Dowry Harassment as a Factor in Domestic Violence


  1. To demonstrate how cultural practices, in this case the expectation by a groom’s family of a dowry, can become implicated in domestic violence.

Narrative Case:

I would like to share a story with you today of a brave girl Sujata and her amazing father who would do anything for his beloved daughter. Sujata was a bright girl studying to be a doctor. Her parents, both doctors, proud of her achievements, were looking for a prospective groom with similar educational pursuits. Marriages in India are still arranged by parents even for educated children. They eventually found such a boy. The wedding was done lavishly by Sujata’s father. Her parents were sad to see their beloved daughter depart for her in-laws home, but were also very happy that the groom’s family did not want any dowry.

Sujata was also happy with her marriage. Her husband Suresh was also doing his post graduate studies after his MBBS. Rituals, poojas and a wedding reception in Suresh’s hometown were done. After a month or so Sujata joined her PG course in Suresh’s hometown. Everything seemed to fit in so well.

A few weeks later Sujata asked her in-laws about visiting her parents. They readily accepted. Her father-in law asked her to come and meet him on the eve of her departure. He asked her to get a substantial sum of money from her father, so that Sujata and Suresh could open a new hospital. Sujata was shocked to hear this. She was also infuriated. She did not say anything and walked away. She spoke to Suresh later in the day, expecting that at least he would reject the idea. But she was devastated when he agreed with his father. Suresh said “Your dad is a very busy doctor with a flourishing practice, so what’s wrong if he gives some money to his daughter for her professional ventures.” Sujata flatly refused to ask her parents for money.

From this point her torture began. Sujata’s in-laws and Suresh took away her cell phone and locked her in a room at the corner of the house. She was occasionally given food for sustenance. Whenever Sujata’s parents called, they were told that Sujata has gone to the hospital. When her friends and colleagues came and called, Sujata’s in-laws started accusing Sujata about her bad character and complained about their lack of knowledge of her whereabouts.

Her worried parents were frantically calling Sujata’s marital house. When they couldn’t get any news of Sujata, they started calling her friends and colleagues. No one knew where Sujata was.

So her enraged father spoke to one of his very close friends who was a Senior Police Inspector. Sujata’s Father along with the Inspector in civil dress visited her marital home. As guests, they were given a warm welcome. Sujata’s in-laws behaved as if everything was normal. When asked about Sujata, they started accusing her father saying his daughter never told them where she went and whom she went with. Dr. Patil, Sujata’s father, lost his temper and frantically started searching every room in the house, fearing for the life of his daughter.   He finally heard his daughter’s voice coming from a small room in the corner. He broke the lock and took his daughter home with him without another backward glance.

Next day Sujata’s In-laws and husband started calling up saying they didn’t mean any harm and they were sorry. How could they let the hen who would lay golden eggs go? But Dr. Patil refused to forgive the people who had hurt his daughter so badly. The day after that Suresh departed for Sujata’s home town to pick her up. He had called Sujata to convince her to come back. Sujata’s father along with his Inspector friend went to collect him at the bus stand. They handcuffed him and arrested him on charges of domestic violence.

Today Sujata lives with her second husband who is very supportive of her and her lovely daughter. What would have happened had Sujata not stood up against Suresh and his parents? What if her father had not stood by her decision and had asked her to compromise? Lets appreciate Sujata’s and her father’s courage, her life took a better turn.


Learning Points:

  1. Even though the groom’s family is well-educated, the cultural roles of women are difficult to change.
  2. In India, as in many countries, women are still treated as unequal to men and are expected to be obedient to their husbands.



Marriage is a wonderful term. Everyone has lots of dreams, thoughts, expectations from it. Marriage is a term synonymous with sharing, caring, nurturing, love and growth. Do all married couples share such companionship? Of course not, because no two people are alike. But what instigates one partner to hurt the other one?  Deaths due to Dowry harassment are not uncommon in India. The laws are very strict and giving or demanding dowry is punishable by law. However, it has not been possible to eradicate this system totally. As can be noted in this story, it is prevalent even in educated, upper middle class families. Basically it is caused by poor empowerment of women & lack of education which makes girls from poor families vulnerable. Cases such as these shows that this social evil has to be fought with strength & needs a good support from girl’s family.




Case 22

Domestic violence in a health care professional

Objective: To illustrate the typical excuses of women who keep staying in an abusive relationship

Narrative case:

Nicole is 35, married for 8 years and has two young children. She works as a nurse in a hospital. She comes for an anaesthetic consultation before surgery in the day care unit. She is pretty and healthy with no past medical history of note. As part of clinical examination, she is asked to take off her blouse which has long sleeves and the scarf around her neck but she refused [1]. The female doctor tells her that without examination there is no anesthesia: she is a nurse and she surely understands this fact. She removed her clothes and it is immediately obvious why she was so hesitant: she had many bruises on her arms and around her neck as if somebody had tried to strangle her [2]. She admitted that her husband beats her “but only when he thinks that she has done something wrong”. The doctor says she can give Nicole a medical certificate describing her bruises and advises her to take it to the police station where she lives [3].  She says “I can’t do this because of my two children”. She is counselled that one day her husband will kill her and that she must think about her children’s future. She agreed and left with the certificate. One week later she came back for her anaesthetic and is asked if she has complained at the police office. She said: “No, it was too dangerous for my children but I have always got the certificate”[4]. She has not been seen again.

Learning points:

  1. It is necessary to be concerned about any woman who does not want to take off her clothes for a medical examination by a female doctor. It is important to think about the fact that she does not want the doctor to discover what she wants to hide.
  2. Even healthcare professionals, in this case a female nurse, can try to hide the physical findings which show she has been subject to domestic violence from a female doctor.
  3. It is important to try and convince a woman battered by her husband that she has the right and even the duty (if she has children) to lodge a complaint against him. However, this is often very difficult because she feels guilty about her husband’s behaviour.  
  4. Women subject to domestic violence often do not complain because they have young children and feel they dare not do this for fear of the consequences from their partner.





Case 16

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.



  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  womens legacy of safety together – v. IV. The Commissions 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 363.259523209711 C2012-980202-6
  10.  Child Marriage
  18.  Violent victimization of Aboriginal women in the Canadian provinces, 2009
  20. Report on Violence Against Women, Mental Health and Substance Abuse by Canadian Womens Foundation.
  22.  Prostitution of Indigenous Women:  Sex Inequality and the colonization of Canadas First Nations Women

Case 7

Honour as a Factor in Domestic Violence in India


  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:


  1. This article discusses son preference in India:
  2. This is a reference for drug and alcohol abuse and addiction in India:

Case 6

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.



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

Domestic Violence in Pregnancy at


Case 5

Domestic violence leading to death by so-­called accident


  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.