ethics

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 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 1

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Professional and ethics related violence 

Objectives

  1.    To show how professional women (for example doctors and teachers) in Afghanistan and their families can be targeted because they work with victims of abuse.

 

Narrative

Dr. C. works as a gynaecologist in Afghanistan, providing healthcare to women suffering from abuse, including rape and domestic violence.

Her problems began when she was working in a clinic carrying out abortions on girls who had become pregnant after being raped by a male relative. These girls had to have an abortion or they would have been killed by their relatives or members of their community (an “honour” killing). Dr C. received threatening letters and phone calls from the Taliban, warning that she and her family would be killed because of her work.

Two years later, one evening she heard an explosion and rushed outside. Her children had been playing in the front yard. Her 11-year-old son was lying on the ground, very badly wounded.

He required medical treatment for almost a year, moving from hospital to hospital. Fortunately he was admitted to an army hospital at an American airbase. After surgery, he was left disabled with one leg shorter than the other. The incident affected him badly. He became mentally ill. He is now bullied at school and can no longer fulfil his lifelong dream of becoming a footballer. He is always tired and depressed. But sometimes he says with a smile: ‘Mum, it is good that I became the victim of a Taliban attack, otherwise I would have been without my mum now and you would have been the victim.‟

 

Six months later, her 22-year old brother was killed in a grenade attack in front of her house. The threats to her family were reported to the government, but nobody listened. Dr C. realised that further incidents were inevitable. She decided that her family had to move. She has now stopped doing abortions and keeps a low profile at work. Nobody knows her address. She is doing her best to make victims of violence aware of their human rights.

 

‘When they listen to my story of how I have lost my brother and how my son became disabled as a result of my struggle for womens human rights they get more courage to stand up and defend their rights’.

 

‘The situation here is very bad for women. Women have problems going out to work and girls are prevented from going to school. There are too many cases of violence against women. I have witnessed 30 to 50 cases in a month. When I tell [the women] to report their case to the police they refuse because their family would be ashamed of them and would treat them very badly. They don‟t go to the police and they tolerate the violence and harassment.

We have to help our people, particularly women, they need us and we have to serve the country and the people. I can‟t sit at home and do nothing, this is not in my nature.

Though I understand and have witnessed that there is great danger to my life in every step as a woman human rights advocate, I also understand that we cannot reach our goals and make a difference without accepting this risk to our own lives. Therefore my final goal is that all Afghan women become united to defend their human rights and know that a woman must be treated by men or her husband as a wife, as a mother and as a human’.

Learning points

  1. In some countries such as Afghanistan, violence against women and girls is accepted as part of the culture. Honour killings are not uncommon, and women can be stoned to death because of ‘adultery’ (the women are actually victims of sexual violence and are then blamed).
  2. Education and empowerment of women, and education of men and boys that violence against women is wrong, are important first steps.
  3. There must be a change in the culture towards gender equality – the government must take responsibility, and police must take action to protect women when violence is uncovered.
  4. Professionals who deal with victims of violence must be listened to and protected.