Case 26

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

Objectives:

  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.

 

Background:

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.

 

References:

  1. http://www.icrw.org/sites/default/files/publications/Masculinity%20Book_Inside_final_6th%20Nov.pdf
  2. http://www.trust.org/item/20141110100628-ax25b/?source=dpMostPopular

Case 25

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Domestic violence against the elderly in Germany

Objectives

  1. To illustrate that domestic violence can be overlooked due to a lack of knowledge
  2. To show as best case example a succesful intervention of a GP
  3. To demonstrate that it is not always clear – domestic violence case or not?

Narrative cases:

  1. Domestic violence not recognized due to lack of knowledge

During a home visit as a general health practitioner, I saw a family at an isolated rural location (edge of Wuppertal in Germany). A lady of around 80-years of age presented in a weak state [1] with various pains in different places caused by several falls. The patient herself was silent and her home, clothing and family seemed rather neglected. [2]

After writing an admission note for the hospital, I had the vague feeling that something was being withheld from me.  I had asked the family to call an ambulance but should have waited for the ambulance to arrive. I realized this much later when I learnt more about violence against elderly people within the family. [3]

2. Successful intervention of the GP

An 85-year-old woman was said by her family to be unable to pass urine and suffering from severe abdominal pains. This history was given in an excited and wordy account. The patient was very restless, anxious and her bladder clearly full. While writing down the results of my examination, I hear the patient ask her family: “Can I now go to the toilet?” and hear a hissing whispering: “No”!

I wrote a hospital admission note and called the ambulance myself. [4] I had the suspicion that the family had forced the patient not to go to the toilet. I think they did not know how to care for the grandmother and feigned illness in a very clumsy way to bring help from outside. [5] Soon after the visit, I informed my colleague on duty at the hospital about my suspicion. [6] After admission, the patient had been able to pass urine without any problems. Social/familiar background problems could be solved at the hospital by a special care service for needy and lonely patients. [7]

3. Unclear situation- case of domestic violence or not?

A patient on my list  for over 10 years [8], aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house [9]. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and disturbed. The patient insisted that she was kindly nursed by him [10] and a niece with a nurse living nearby looked after her [11].

Until now I have not known what to think about the situation [12]

Learning points

[1] The WHO state there are several risk factors concerning elderly abuse such as illnesses and shared living situations. In addition,  strong dependence on caregivers can make such abuse more likely.

[2] Elderly  abuse can have many different forms and involves more than physical components. The neglect of an elderly person, whether intentional or not, is also considered as abuse. At times, it is difficult to determine whether it is already abuse or still unkemptness.

[3] Here the main problem is described; the general lack of knowledge regarding this topic. The physician did not even think about it! Not only are there few studies on this topic but there are also no reports on this issue worldwide. The topic itself is also regarded as taboo (should stay within the family) and no-one wants to talk about it, which makes recognition even more difficult.

[4] In comparison to the first story, the physician recognized the abuse and decided to intervene. She stayed and made sure that the patient went to hospital.

[5] In this example, the family is clearly overburden with the care of the old lady. They wanted to get help from outside but didn´t know how to do this. The physician was sensitive to the issue but as the awareness is not very high many cases can go undetected. The WHO started preventative programmes for people who are caring for their older relatives. These provided assistance and teaching on how to deal with the situation.

[6] Here we see the positive impact of an intact chain of information between physicians. The physician at the hospital is informed about the suspicion and can further intervene.

[7] This is a best practice example. In most hospitals such a special service is not available. It will assist families that want to get help.

[8] The physician knows the patient for a very long time and the family situation as well. If a relationship like this exists, a physician can recognize changes faster and usually some kind of trust exists between doctor and patient.

[9] Another risk factor is social isolation. It goes together with dependency as the abused person might have only the abuser as their sole contact person.

[10] The physician suspects abuse but does not get a sufficiently detailed answer. Here a standardized sample of questions might help which can be answered with yes or no. Questions like this do already exist such as the H-S/East (Hwalek-Sengstock Elder Abuse) screening test. Recently the WHO has tried to develop a more simple approach using 12 easy to understand questions, EASI – The Elder Abuse Suspicion Index. These questions can be found on the internet (see below). It might also help to question the patient in private. There are many reasons why potential victims do not want to talk about abuse including feeling afraid to be alone or feeling  ashamed.

[11] Once again the importance of a network is seen. The physician could contact this nurse and talk with her about the situation in the patient´s home. In addition, the physician could visit the patient to check the situation for herself.

[12] As already described in [2] it can be rather difficult without screening tools to determine abuse. This underlines the importance of raising awareness and proper training for physicians

Further Information

According to the WHO elder abuse is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person”. It can have many different forms “such as physical, psychological or emotional, sexual and financial.”

The importance of this topic has long been underestimated but it has gained growing attention. Still elder abuse is believed to be underreported by up to 80% with a prevalence ranging from 1% to 35% according to various questionnaires. There exists a remarkably lack of studies concerning it. The biggest study regarding this topic was in 2002 the “Missing voices: views of older persons on older abuse” study conducted by the WHO. It was conducted in eight different countries: Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden.

This study demonstrated the necessity of addressing this topic. The WHO has started to develop screening tools to make it easier to raise physicians’ awareness and help to detect more cases. Different methods and questionnaires previously used such as the H-S/East but were regarded as taking too much time to ask, were difficult to understand and non specific. Taking these issues into account, EASI the “Elder Abuse Suspicion Index” was drawn up which consists of only six questions of which five are answered by the patient and the last one by the doctor.

 

The WHO identified five fields of risk factors:

  1. Individual: illnesses (mental disorders, alcohol abuse), gender (in countries where woman have a lower society status than men, they are more likely to experience elder abuse)
  2. Relationship: shared living situation, dependence, financial dependence of the caregiver on the elderly person, history of poor relationships within the family, overburden of the caregiver
  3. Community: social isolation of the elderly person
  4. Socio-cultural: financial problems, general depiction of old people as weak and helpless, erosion of bonds between the generations, migration of young couples
  5. Institutional: low standards, poorly trained and overworked staff, economic reasons (the economic situation of a home for the elderly is more important than the well-being of its residents)

 

As with any type of abuse, elder abuse can cause not only physical injuries but may lead to long-lasting psychological problems such as anxiety and depression.

After raising awareness, the WHO proposes various measures to tackle this form of abuse such as a general screening for abuse and better caregiver support and training. They are demanding mandatory reporting on each case, building  safe houses and shelters for victims and the foundation of self-help groups.

All these measures show great similarity to the measures against domestic violence.

HWALEK-SENGSTOCK ELDER ABUSE SCREENING TEST (H-S/EAST)

Purpose: Screening device for service providers interested in identifying people at high risk of needing protective services.

Instructions: Read the questions and write in the answers. A response of “no” to items 1, 6, 12, and 14; a response of “someone else” to item 4; and a response of “yes” to all others is scored in the “abused” direction.

 

  1. Do you have anyone who spends time with you, taking you shopping or to the doctor?
  2. Are you helping to support someone?
  3. Are you sad or lonely often?
  4. Who makes decisions about your life—like how you should live or where you should live?
  5. Do you feel uncomfortable with anyone in your family?
  6. Can you take your own medication and get around by yourself?
  7. Do you feel that nobody wants you around?
  8. Does anyone in your family drink a lot?
  9. Does someone in your family make you stay in bed or tell you you’re sick when you know you’re not?
  10. Has anyone forced you to do things you didn’t want to do?
  11. Has anyone taken things that belong to you without your O.K.?
  12. Do you trust most of the people in your family?
  13. Does anyone tell you that you give them too much trouble?
  14. Do you have enough privacy at home?
  15. Has anyone close to you tried to hurt you or harm you recently?

EASI Questions

Instruction: Q.1-Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

  1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
  2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?
  3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
  4. Has anyone tried to force you to sign papers or to use your money against your will?
  5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
  6. Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?

 

Sources

  1. WHO. A global response to elder abuse and neglect. 2008. ISBN: 978924156381 http://www.who.int/ageing/publications/elder_abuse2008/en/ (25.09.2015)
  2. WHO. Discussing screening for elder abuse at primary health care level. 2008. ISBN: 978 92 4 159453 0. http://www.who.int/ageing/publications/discussing_screening/en/ (25.09.2015
  3. WHO. Missing voices: views of olfrt persons on elder abuse. 2002. http://www.who.int/ageing/publications/missing_voices/en/ (25.09.2015)
  4. Fact sheet on elder abuse. http://www.who.int/mediacentre/factsheets/fs357/en/. Dec. 2014. (26.09.2015)
  5. The elder abuse suspicion index. https://www.mcgill.ca/familymed/research-grad/research/projects/elder. 2015 (28.09.2015)
  6. http://www.medicine.uiowa.edu/uploadedFiles/Departments/FamilyMedicine/Content/Research/Research_Projects/hwalek.pdf (28.09.2015)
  7. https://www.mcgill.ca/files/familymed/EASI_Web.pdf (28.09.2015)

Case 24

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Long-term Physical & Psychological Sequelae of Childhood Sexual Abuse

Objectives:

  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).

References

  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

 

Case 23

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Intimate partner violence in Nigeria

Objectives

  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 22

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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 21

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Case study from Kenya on FGM and cultural practices which violate girls’ rights

Objective:

To show how cultural practices violate the rights of girls.

Narrative Case:

The UN convention on the rights of children define this group as those aged under 18 years. One ethnic grouping in Kenya honours the rites of passage for adolescent boys by unfortunately violating the rights of girls.

Mwandi is fifteen years old. She has known since she started her menses at the age of 12 years that she was destined for something special. Her mother kept a close eye on her and did not allow her to spend nights away from home at her friend’s houses like other girls. Early one morning her mother woke her up and after she had bathed, dressed her up nicely and took her to a strange hut in the nearby village where she was told to lie on a bed and keep her legs open[1].  Before she could scream, she felt a sharp excruciating pain down below after which she felt the sting of some herbal preparations [2]. She was told to keep her legs together. That was the beginning of the end of her childhood. Two weeks later when it had all healed up her mother gave her some special fragrant herbs to bathe with and told her she had to be good as she was going to bring honour to their family.

Later she learnt that ‘warrior’ boys are confined in a camp for various rites. Tradition and culture means girl children are circumcised and given to ‘warriors’ as sexual companions.There was no protection offered against sexually transmitted infections when she developed sores and was later told at the clinic that she was HIV positive [3]. Treatment consisted of herbs that her mother procured from a medicine man [4].

If girls get pregnant, because these relationships are outside marriage, the mother of the girl has to find a way of aborting the foetus. This is done by crushing the head of the foetus against the girl’s pelvis.  Mwandi was brought to the clinic by an aunt who visited the village and noticed the severe pain and extreme bleeding (menorrhagia) she was having [5,6].

 

Learning Points:

[1] Perpetrators are primary caregivers, parents, teachers and close relatives in Kenya and many other countries where culture and tradition are the predominant reason for a large number of practices that are harmful and violent, especially to girls.

[2] Female genital mutilation is believed to help control sexual urge in young girls and keep them chaste. The same tradition and culture is however throwing these virgin girls at young men to whom they are not married.

[3] There is no sex education of either young men or the young women to protect them against sexually transmitted infections (STIs) or pregnancies.

[4] There is a lack of healthcare available for those who get STIs.

[5] Women doctors must be aware of these practices and use every available opportunity to educate their patients on the dangers of these practices and the continued violations of the rights of children especially girls.

[6] Women doctors need to work with community opinion leaders to offer education on the effects and outcomes of these harmful practices.

 

Bibliography

  1. Mohamed  FJ. Does Kenya have the courage to lead on women’s rights in Africa? The Guardian April 21 2014. Available at : http://www.theguardian.com/global-development/poverty-matters/2014/apr/21/kenya-courage-lead-africa-womens-rights [Accessed 28th August 2015]
  2. Munyao WL.  Gender Issues Affecting the Girl Child in Kenya International Journal of Humanities and Social Science 2013; 3(4): 125-9. Available at: http://www.ijhssnet.com/journals/Vol_3_No_4_Special_Issue_February_2013/13.pdf [Accessed 28th August 2015]
  1. Queens University Belfast. Children’ rights resources. Available at http://www.qub.ac.uk/research-centres/CentreforChildrensRights/ChildrensRights-BasedResearch/ChildrensRightsResources [Accessed 28th August 2015]
  1.  Armstrong S. In Kenya, a Victory for Girls and Rights. The New York Times June 4 2013. Available at: http://www.nytimes.com/2013/06/05/opinion/global/in-kenya-a-victory-for-girls-and-rights.html?_r=0  [Accessed 28th August 2015]

 

 

Case 20

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Effectiveness of a Domestic Violence Perpetrator Programme (DVPP)

Note:  

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

Objectives

  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.

 

Narrative

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 19

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A typical case of the elderly domestic violence in Finland

Objectives

  1. To illustrate the family dynamics in a case of elder abuse.
  2. To show how financial problems and alcohol abuse by the caregiver can trigger abuse, one of the more common forms of elder abuse
  3. To illustrate the value of a multidisciplinary team in the assessment and care of an abused person.

Narrative case:

A 79 year old woman, living with her son in a 2-room apartment, came to the day clinic [1]. The patient said that she fell over her rollator and bruised herself the previous evening. She had difficulties breathing, pain all over her body and was sad, shaking, meanwhile making no eye contact during talking [2]. She started to cry on a number of occasions during the conversation and examination. The doctor, a specialist in geriatric medicine, examined the patient and was surprised by the number of bruises and hematomas on her body and left cheek and orbit, where later a fracture of the cheek bone was diagnosed. There were also some bruises on both forearms. On x-ray examination, multiple old rib fractures were found. From previous documentation it was found she was examined earlier due to a falling problem, with no orthostatic reaction and she did not appear to be using prescribed  blood pressure lowering drugs. The patient denied alcohol consumption. Domestic violence is suspected by the examining doctor.

During treatment, the patient was found to be suffering from malnutrition and weighed only 45 kg with a plasma albumin well below normal. She refused to eat and expressed wishes of wanting to die [3]. Her cognitive status was defined by tests as mild cognitive impairment [4]. When carefully asked about what happened on the night prior to hospital admission, she confirmed that her son abused her and he had come home drunk late at night. She says that the relationship with her 49 year old son had deteriorated lately due to his alcoholism. Her son is often out of the house. He has been unemployed [5] for quite some time and threateningly demanded that she shared her small pension with him. Lately, the patient had on a number of occasions refused to give her money away because she was afraid [6] her son would simply drink more. Whilst telling this fact,the patient started to cry bitterly. Later in conversation, it came out that for about two years her son physically abused his mother regularly.

This case was discussed by a team, consisting of the medical doctor, nurses, social worker, physiotherapist and functional therapist [7]. A guardian for the patient’s economic interests was organized. The patient received supportive psychotherapy to deal with the problem and the social worker organized separate living facilities for the mother and son (mother was able to stay in her own home). Additionally weekly contact with other elderly people was organized by the city council and the local church. Our patient also has regular (three times weekly) visits by the nurse from the local health centre in order to support her to be able to stay and function at home (regular medicine usage, buying together products from the local store, etc). As the patient experienced strong fear reactions towards her son, a temporary restraining order was put in place  [8].

 

Learning points:

[1] The WHO has identified various risk factors connected with elderly abuse such as  shared living which was the case here. The apartment in this case was quite small and there is likely to have been  a lack of privacy for both the patient and her son.

[2] EASI, the Elder Abuse Suspicion Index (see appendix) lists various signs that may indicate abuse such as poor eye contact, a withdrawn nature and malnourishment. Most patients refuse to report the abuse; they are ashamed or are afraid of the perpetrator. Another problem is that in hospitals the patient usually does not know the physicians and the lack of trust also prevents them from telling the truth.

[3] Elder abuse does not only cause physical injuries, but can also lead to depression. Patients see no possibility of escape. The patient is depressed and rejects food and wishes to die.

[4] A weak elderly patient or patients with illnesses as well as mental problems are more likely to experience abuse.

[5] Here we see the typical case of elderly women abuse: threats and physical violence based on economical abuse, which gets worse with time. The son has financial problems and is unemployed which might lower his self-esteem. Caring for his mother might be too much for him.

[6] The son is alcohol dependent, which might be triggered by his current unemployment and the worsening financial situation. As the abuse worsens the situation, he is caught in a vicious circle now depending on his mother`s pension which she refuses to share. Dependence on someone is also considered as a risk factor leading to elderly abuse.

[7] This is an excellent example of a positive outcome – a team of various specialists discuss the problem and find a solution, thereby ending the circle of violence. Not only physicians but a multi professional team including a social worker and a legal guardian for the patient’s economic interests to find the best possible solution.

[8] The problems are solved but it is important to consider whether the patient was able to live on her own which might not always be the case. The WHO says that a good network of physicians, nurses and social workers is necessary to tackle the problem of elderly abuse as well as self-help groups for victims, safe houses and shelters.

 

To summarize: this case demonstrates these issues:

 

  1. The loss of an older person’s independence can result in a vulnerability that makes them more at risk of abuse.
  2. Social factors such as unemployment or financial stress are other factors in abuse scenarios.
  3. In some situations, the abuse can be so severe that family breakdown occurs.
  4. Alcohol abuse can be a factor in elder abuse, as in other forms of Domestic Violence.

 

Background information:

Finnish population studies tells us that 40% of women 15 age and older become victims of physical or sexual violence. Forty percent of women who live in a long relationship are abused by the spouse (Heiskanen & Piispa 1998).

 

Family abuse is existing in all social groups and the research on the reasons for it, is undeveloped. Risks for family abuse usually are: mutual dependence on each other, living together, social isolation. Economic difficulties and borderline poverty increase the burden on the family in general, weaken female position in the family and damage men ego.

 

In Finland about 50 women die yearly because of the violence directed to them and 2/3 of those die as victims of the domestic violence. Sufferers of the domestic violence, who commit suicide, are left out of these statistics. Restraining order procedure was adopted in Finland in 1999.

 

Elderly women can be subjects to psychological, physical, sexual and economical abuse. In 70 % of the cases abuser is child or spouse. The most common type of abuse of the elderly woman is economical. Special form of abuse is refusal of the family member to help or to treat elderly when elderly is totally incapable to take care of herself. To leave without help when help is needed is an abuse. Victims of the domestic violence use more health system services than other population, but elderly usually are cautious to break the taboo. They experience physical and communicational difficulties in approaching health system, but often shame, guilt and even protection of the family member are on the way.

 

Here we see typical case of the elderly women abuse, threat and physical violence based on economical abuse, which got worse with time. Situation was prolonged and got out of hands because elderly women had physical and psychological weakness, did not want to disclose problems with her son, was ashamed of his alcoholism, and somehow, felt responsible for his behavior.

 

References:

 

  1. Heiskanen, M. and Piipsa, M. Faith, Hope and Battering: A Survey of Men’s violence to Women in Finland, Helsinki, Statistics Finland

 

Case 18

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

Objectives

  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 17

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Domestic Violence in Immigrant Family in Canada

Objective:  To illustrate how adjusting to a new culture conflicts with traditional values and results in violence

Narrative Case

Inderpal was the youngest of three siblings.  She had an older sister and an older brother, both of whom had been born in the Punjab in India.  Her family moved to Surrey, BC, from India, looking for better opportunities for their children.  Inderpal was born when her older siblings were 10 and 12 and she was the only one of the three children born in Canada.  

The family was very traditional and the temple was a big part of their lives.  Despite living in Canada, her older sister and brother thought and acted like their immigrant parents and never caused their parents any grief.  Inderpal was very Canadian and had a multi-ethic group of friends. [1]

In high school, Inderpal liked to go to parties where she would smoke and drink and do drugs.  When she started to date a white boy from College, her family felt that she had overstepped the limits.  Despite their demands to stop dating this boy, Inderpal said she was Canadian and could do what she wanted.  When the family would go to temple, they could see others looking at them and knew they were talking about Inderpal’s behaviour.

Inderpal’s brother felt that she was destroying the honour of the family.  He had given it lots of thought and decided that he must make things right.  One night he waited for her to leave a party, intercepted her and dragged her into the bush, where he promptly stabbed and killed her.  He put her body in the trunk of the car and drove out to a rural area where he could leave her body where it would not be found. [2]

Learning Points

[1]  Despite moving to Canada, assimilation is not easy, as Canada encourages multi-culturism where immigrants are encouraged to live according to their traditions and values.  When immigrants come from very traditional countries, there is often difficulty embracing the more liberal Western way of life.  This often leads to family conflict.

[2]  Honour killings are the term given to murders performed because the victim has brought shame to the family by their behaviour.

Background Information

Honour killings are distinct from domestic violence for three reasons:

  • Honour killings are planned in advance
  • Honour killings can involve multiple family members in the killings
  • Perpetrators of honour killings often do not face negative stigma in their families or communities

In 2000, the United Nations Population Fund (UNFPA) estimated that there were at least 5,000 honour killings world-wide annually, which may be an underestimate because many cases go unreported or are falsely reported as suicides.  Although this practice is currently primarily associated in media reports with certain Arab cultures, variations of harmful cultural practices toward women involving violence based on notions of honour have been known in many cultures world-wide  and in many historical times.

Background:

This reference provides general information and background about Honour Killings, including a basic classification system and consideration of the “reasons” given for this type of violence against women:

http://www.meforum.org/2646/worldwide-trends-in-honor-killings

References

  1. The Canadian Bar Association Service Barriers for Immigrant Women Facing Domestic Violence http://www.cba.org/CBA/conf_women/Women_Newsletters2013/barriers.aspx
  2. Honour Killings on the Rise in Canada http://www.canada.com/life/Honour+killings+rise+Canada+Expert/3165638/story.html
  3. LawNow  A Spotlight on Family Violence and Immigrant Women in Canada
  4. http://www.lawnow.org/family-violence-and-immigrant-women/
  5. Preliminary Examination of So Called Honour Killings in Canada; Prepared for the Canadian Department of Justice
  6. http://www.justice.gc.ca/eng/rp-pr/cj-jp/fv-vf/hk-ch/hk_eng.pdf