Case 38

Violence Against Women


  1. To review the Istanbul Protocol
  2. To illustrate an application of the Istanbul Protocol

Narrative Case

A young recently married woman (31 years old) asked for divorce after 3 months of marriage. She complained that her husband frequently attacked her and physically hurt her. On examination, 2 months later, she was found pale, slimy and depressed. More than 20 skin lesions were seen, in the form of abrasions, bruises and lacerations, widely distributed on both upper limbs. Most of them were rounded or elliptical and some were brush-shaped indicating dragging of teeth on soft tissues of skin. The pattern of teeth marks were compared to bite marks of the wife to exclude being self-inflected bite-marks. A cast was prepared to the victim’s teeth while the husband refused to be examined for comparison. All lesions were old, dating to more than 3 weeks, showing discolored scars, brownish, coppery or paler than the surrounding normal skin. They appeared neglected, infected or badly treated and showed different stages of healing, and some showed keloid formation (massive fibrous tissue formation) with loss of sensation at certain parts of injured areas. All injuries were photographed with a scale to document these injuries with the proper measurements.


It was concluded that these bite marks dated back to the time of marriage, about 2 months before examination, and they were neglected. Healing was by secondary intension and there was keloid formation. These bite-marks were not self-inflicted. As the husband refused being examined for comparison, the victimized wife got divorced by the court considering his refusal as a confession of guilt and was convicted.  So, effective investigation and documentation according to Istanbul Protocol are important to prevent torture and abuse.

Learning Point

  1. The Istanbul Protocol can be an effective tool in clinical decision making, including appropriate investigations and record keeping in cases of Wife Abuse.


Background Information

The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, sets the international standard for legal and medical investigations of torture and other mistreatment, including intimate partner violence. Its development was the work of more than 75 physicians, lawyers, mental health professionals and human rights monitors from 15 nations representing 40 agencies or organizations. In 1999, the Istanbul Protocol became an official United Nations document.

The standard set by this document, when adhered to, ensures that the physician’s medical record can be used in the prosecution of crime.


  1. The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment:


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 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 23

Intimate partner violence in Nigeria


  1. Intimate partner violence can lead to any form even life threatening injuries


Narrative case

A twenty-two year old single woman had a child out of wedlock and was living with her parents. One day she went to visit the father of her child; he inflicted an injury on her vulva with a sharp object. The girl did not tell anyone though her mother noticed that her gait had changed. She collapsed at home in a pool of blood.

She was immediately taken to hospital and transfused with one unit of whole blood, as blood products were not available at the centre. A detailed history obtained at this point revealed that she was beaten up by the father of her child who also inflicted an injury on her four days prior to presentation. She did not tell her parents about the injury but her mother noticed she has been sad and unable to walk properly. Her mother inquired if there was any problem and she did not receive any reasonable answer.

She is a single mother resulting from an unwanted pregnancy while she was a teenager and she is not married to the man. She decided to have the baby although the father of the child wanted an abortion. She visits the man while she and her child reside with her parents. Her parents are responsible for her upkeep and that of her child. She was discharged home on the four days later and her father paid her hospital bills.


Learning points:

  1. Sometimes much probing has to be done as most women who experience violence from an intimate partner conceal it especially in developing countries for fear of loss of the partner.
  2. Cultural norms and beliefs may play a role in intimate partner violence as some cultures see violence of a woman by her husband as a result of disobedience on the part of the woman. Therefore the women might feel guilty and do not want to tell anyone about the incident because they might fear further punishment.
  3. There should be a high index of suspicion of intimate partner violence in any woman presenting with injuries in the external female genitalia not caused by delivery, and accidents.

Case 20

Effectiveness of a Domestic Violence Perpetrator Programme (DVPP)


Respect is a national Domestic Violence charity working with the perpetrators
DVPP: Domestic Violence Perpetrator Programme
ISS: Independent Support Service associated with the DVPP


  1.  To show the effectiveness of a DVPP in stopping domestic violence at its source, by changing behaviour and managing the risk of perpetrators.
  2. To show the impact on children of domestic violence.



A family safely together

Jason rang the Respect helpline following an incident of violence where he had grabbed his partner Elly by the hair and thrown her to the floor, causing bruising to her face and a sprained wrist. This was not the first time Jason had been violent but it was the first time Elly had been visibly injured.

The Phoneline workers spent some time talking with him about what had happened and then referred him to a local DVPP. Elly was initially reluctant for Jason to involve outside agencies. She felt that she and Jason had a good family and a good way of life. They both had successful jobs and two children together. She felt ashamed at admitting that she was a victim of domestic violence as she always imagined this was something that happened to other people. Nonetheless, when ISS contacted her, she agreed to regular updates about Jason’s progress.

On the programme, Jason quickly learned to be non-violent, but he struggled to be non-controlling.

Jason was asked to conduct a re-enactment exercise in the group. With the guidance of DVPP workers, he re-enacted the worst incident of violence he had committed, step by step, stopping just before he used violence. Until this exercise he had always maintained that the children had never been aware of the abuse. However, during the re-enactment he had to account for the children’s whereabouts and it quickly became obvious to him and the group that the two children were aware and very distressed by him hurting their mother.

This was an important contributory factor in getting Jason to end his verbal and emotional abuse. He had already developed an increased awareness of his own stresses. Further awareness of the effects of his behaviour upon the children as witnesses to violence helped positively motivate Jason to remain non-abusive. This was confirmed by the ISS contact with Elly and by the end of the programme Jason had achieved a sustained period of non-violent and non-abusive behaviour. Elly felt that she and the children were safe to continue living with him, knowing that the ISS was there, should things change.

Learning points

  1. Women are often reluctant to disclose abuse, because they are ashamed. Having children and not wishing to ‘rock the boat’ is another reason to remain silent.
  2. Domestic violence and abuse is more commonly associated with poverty or hardship , but    can occur in any social class.
  3. Knowing that children are aware of their father’s abuse of their mother is a very important factor in changing the perpetrator’s behaviour. Many men are not aware of the distress they are causing their children.
  4. Children from families where domestic violence has occurred are more likely to become perpetrators themselves
  5. Without the DVPP/ISS it is  more likely that domestic violence will continue, perhaps leading to more serious violence, greater impact on the children, police call-outs, and involvement of the criminal justice system and health services.  Recurrence of domestic violence with a new partner is a real risk.


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


Case 18

Domestic violence is independent of education, economic situation, social class or culture


  1.  To show that domestic violence is independent of education, economic situation, social class or culture.
  2.  To show that emotional abuse is often a precursor to serious acts of physical abuse.

Narrative Case

Dr. Bob Smith is a general surgeon and his wife, Dr. Carol Jones, is a general practitioner, both practising in an urban setting.  They have been in practice for ten years. They met in medical school and married in their first year of residency.  They have two children, ages 5 and 7.  [1]

Carol took three weeks off on maternity leave with each child, as her practice was still relatively new at that time and she did not feel she could take the year maternity leave that many of her friends in salaried positions could take. [2]

Things are not going well. Bob is on call every second night since the third general surgeon left for the States last year and the hospital has not been able to attract another surgeon.  He is so tired that he wonders at the completion of some surgeries whether he has done his best.  He is currently in the middle of a legal suit, which is taking so much of his time.  He finds that if he comes home at night and drinks vodka, he feels much more relaxed and yet does not have to worry about the smell of alcohol on his breath if he should get called back. [3] He does not want to seek help in case word of his difficulties negatively influences his medical practice.

Carol is becoming increasingly stressed as well.  Her office is always overbooked, as she has had to cut down to 3 days of office work, to be able to take care of the needs of the children.  She still has the office overhead to contend with, but not the volume of patients to justify the costs.  She is feeling more like a single parent, running the two children to lessons and sports by herself as Bob is always either at the office or the hospital.

On one particularly tiring day, Carol comes home after the children’s swimming lesson to find Bob drunk and asleep on the couch.  After putting the children to bed, Carol awakens Bob and confronts him with his increasing use of alcohol and withdrawal from family duties.  Bob is so angry that he hits Carol and blackens her eye.

At the office the next day, Carol makes up an excuse about a household injury to explain her black eye.  She realizes that Bob is a good husband and that the stress of work, the current litigation, both coupled with alcohol, brought out this atypical behaviour. [4]

After repeated episodes of physical abuse, their relationship deteriorates and Carol tells Bob that she is going to leave him and take the children.  Bob pleads for Carol to go to joint counselling, as he has not been himself and really does love them all.

Carol does not have much hope for success from the counselling, but feels guilty about leaving, so she gives counselling a try.  The female counsellor feels threatened dealing with two physicians.  After six sessions, nothing is resolved and Carol makes plans to leave with the children. [5]

Bob finishes his court case and is found guilty of malpractice.  He wonders what is the point in living—his reputation as a surgeon is tarnished, his wife and children are leaving him and he is exhausted and overworked.  He goes home and drinks.  When he hears Carol and the children driving into the garage, he picks up his hunting rifle, killing them and then turning it on himself. [6]

Learning points

[1] Medical marriages are often difficult.  The woman often has to take second place to her husband in career choice and academic advancement.

[2] Women physicians often have an excessive sense of commitment to make their work successful, just to show that they are capable of “having it all”-career, family, husband, etc.

[3] Bob realizes that he is not coping but as a physician and leader in the community does not want to let anyone know that he needs any help.  He turns to substance abuse.

[4]   Despite having counselled patients against staying in a relationship where there has been physical abuse, Carol makes excuses for Bob’s behaviour.

[5]  Being in a position of authority when seeking personal help is not always an advantage.  The male often presents a more threatening figure than the female and this may affect the performance of the caregiver and consequently the outcome.

[6]  Accustomed to being in control and being an authority figure, Bob cannot cope with all these loses and having humbled himself to go to counselling and that failing, he decides that there is only one alternative.  He struggles with feeling powerless in a society that tells him he should be powerful, with the seeming lack of options and with the socialization that has taught him not to seek help.  All this translates into violence against his female 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 8

Domestic violence in Greece


  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.


  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

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