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 24

Long-term Physical & Psychological Sequelae of Childhood Sexual Abuse


  1. To highlight the longterm physical and psychological effects of childhood sexual abuse (CSA)
  2. To emphasise the doctor’s important role in identifying patients with a history of CSA so that victim-survivors are treated holistically, using a multifactorial perspective with a biopsychosocial lens, which sees a complex interplay between past and present; physiological, psychological and social factors [1]
  3. To underline that holistic, rather than symptomatic treatment will help prevent retraumatisation of victim-survivors (victims of CSA are much more likely to be raped as adults) [2] as therapy helps them develop a stronger, more positive sense of themselves. Inadvertent iatrogenic retraumatisation by doctors eg with painful Pap smears will also be avoided by doctors who understand the aftermath of CSA


Narrative Case:

When Elyse, a 28 year old nurse developed debilitating irritable bowel syndrome (IBS), she went to a new doctor. In response to the doctor’s detailed questions as part of initial assessment, Elyse told her that work was okay but she was having a few problems with her boyfriend. Sex was sometimes painful, but she tried not to show it. She had occasional migraines, her periods were heavy and painful and she was treated with antidepressants for 3 years in her early twenties. She was a binge drinker as a teenager. She’d only ever had one Pap smear 8 years ago and it was excruciating.

The doctor said to Elyse that when women had a range of painful and debilitating symptoms like she did, sometimes something emotionally painful had happened to them in the past – physically or sexually. Elyse, to her surprise, felt safe enough to tell this doctor what she hadn’t told anyone in over 20 years. Then again, no-one had ever asked. Her uncle had sexually abused her: but she couldn’t see how what her uncle had done could be connected to any of her symptoms – it happened over 20 years ago.

After talking about the abuse for the first time, Elyse became anxious. The doctor was very supportive. She told Elyse that she was suffering from a form of posttraumatic stress, likening her experiences to a soldier. She said Elyse must never blame herself; the shame belonged to the perpetrator. Having kept it all in for so long, Elyse had developed a range of physical and psychological symptoms as well as having the emotional pain of abuse to deal with. The doctor said that first they needed a plan to deal with the painful aftermath of disclosure, and then she wanted to see Elyse regularly to make sure that her physical and psychological health were attended to and treated holistically.

Background information

Prevalence: One in three women are affected by a history of SV (in Australia). The overwhelming majority do not tell anyone, including their treating health professionals, for decades, if at all [3].

Learning points and Background

  1. The long-term health consequences of sexual trauma in women include a range of psychosomatic symptoms including IBS, headaches, gynaecological and obstetric problems, various mental health problems and health risk behaviours as well as avoidance of preventative health examinations such as Pap smears. Such avoidance is of concern as these women have an increased risk for sexually transmitted infections, cervical dysplasia, and an increased prevalence of invasive cervical cancer  [2]
  2. Depression, anxiety, stress and posttraumatic stress disorder (PTSD) associated with historical SV may increase affected women’s risk for other problems including alcohol abuse, binge drinking and substance abuse. CSA victim-survivors also have a greater risk for suicide and accidental fatal drug overdose [2]
  3. A biopsychosocial model of diagnosis and treatment conceptualises symptoms such as IBS, vaginismus (pain with sex and/or Pap smears), recurrent headaches and gynaecological symptoms as psychosomatic symptoms: the symptom, expressed in the body (soma), has its origins in mind (psyche) and body and alerts us to painful feelings. Based on this understanding, an integrated approach which addresses painful feelings as well as treating bodily symptoms is required [4]
  4. Patients should be asked about a history of SV if they present with multiple psychosomatic symptoms or health problems, have a history of engaging in health-risk behaviours eg drugs, alcohol or unprotected sex, or avoid or have difficulty with medical examinations or procedures [5] eg pain with Pap smears or avoidance of Pap smears [6]. Given that the biggest risk factor for cervical cancer is not being screened regularly, it is important to ask women if they have had their routine health checks, and if not, find out why not.
  5. Most victim/survivors do not tell their treating practitioners about a history of SV unless they are asked [3]
  6. Patients should only be asked after a good rapport and trust have been established between patient and doctor.
  7. The doctor should only ask if she feels comfortable discussing these sensitive matters and dealing with the aftermath of disclosure. Undergraduate and postgraduate teaching should have modules to help doctors feel competent in this important area of practice [3]. The doctor needs to know of appropriate professionals she can refer to if she is not going to do the counselling herself [5] as well as providing ongoing medical care to treat and prevent health problems.
  8. Many patients think that they should have sex even if it hurts. Some doctors and patients believe that “getting a Pap smear over quickly” will shorten the duration of pain and therefore be helpful. However, doing this can inadvertently re-traumatize a patient who has a history of sexual abuse (iatrogenic traumatic examination). To avoid this, doctors should never proceed with a Pap smear if the patient says it is painful or if she is afraid. Similarly, patients should be encouraged not to participate in painful penetrative sex, whilst still maintaining a sexual relationship. In both cases the pain or fear need to be treated first.

In Australia, a referral can be made to a psychotherapist who can help the patient make connections between the physical (how it feels) and emotional (what has happened/ is happening in her life and how it has affected her). She can also be referred to a specially-trained physiotherapist with skills in patient education (anatomy, physiology of sexual response) and gentle examination. Penetrative sex can be resumes and a Pap smear can be done when the patient feels comfortable emotionally and physically (confident there will be no pain).


  1. Boyer SC, Goldfinger C, Thibault-Gagnon S, Pukall CF. Management of female sexual pain disorders. Adv Psychosom Med 2011; 31: 83-104
  2. Taylor,SC, Pugh J, Goodwach R, Coles J. Sexual trauma in women. The importance of identifying a history of sexual violence. Australian Family Physician 2012;41:538-541
  3. Australian Women’s Coalition, Australian Federation of Medical Women, Victorian Medical Women’s Society. Happy Healthy Women Not Just Survivors Consultation Report: Advocating for a long-term model of care for survivors of sexual assault. 2010.
  4. Goodwach,R. Sex Therapy: Historical Evolution, Current Practice. Part 2. ANZJFT 2005; 26,4,178-183
  5. Leserman J. Sexual abuse history: Prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906-15.
  6. Farley M, Golding JM, Minkoff JR. Is a history of trauma associated with a reduced likelihood of cervical cancer screening. J Fam Pract 2002, 51: 827-31