Domestic violence: why the Florida legislature must do more to protect the "silent" victims.

• Author: Makar, Marjorie Conner

Consider the following not uncommon scenario: A triage nurse[1] in a busy emergency room of a hospital in a large metropolitan area assesses a female patient and documents in her nurse's note the following findings: "Hit by a fist to Rt eye. Seeing white flashes in both eyes X 2 mos." The emergency room physician later evaluates the same patient and documents the following note: "Pt 24 y/o BF c/o hx[2] head trauma but presents with complaint of flashing lights in peripheral vision. Pt. first noticed it after blunt trauma to R eye. It has since spread to the L eye. Pt. symptoms assoc with tingling over the head. Not assoc with position. No risk factor for vascular disease except HTN.[3]" On exam, the physician documents "mild swelling right eye, eye--EOMI,[4] PERRLA.[5] Fundus--neg,[6] visual field intact, vision 11/100 bilaterally. No bruits.[7] No murmur, lungs clear." The physician diagnoses the patient with "blunt trauma of the face, HTN," and reschedules her to return to the ophthalmology clinic in one week for a blood pressure check.[8]

In this example, the physician fails to elaborate upon the history obtained by the triage nurse. In fact, the physician has removed the victim from the picture, and only her right eye remains. The physician has also removed the perpetrator from the note. The fist is no longer connected to the person who inflicted the abuse. The physician's note does not acknowledge the physical act but instead refers to "blunt trauma." The physician's evaluation leaves little room for the victim to discuss what may have been her most pressing reason for seeking care--that she has been the victim of domestic abuse.

To combat this ever-increasing problem, the Florida Legislature has taken bold steps to require that every health care professional licensed in the state receive ongoing education concerning how to identify and screen for domestic violence victims, and what measures should be taken to ensure that the victim and her family receive referral to the proper resources.[9] This article will review how domestic violence is defined in Florida, and how pervasive domestic violence is. It will address in what settings physicians are likely to encounter these victims and will further elaborate on what cues physicians must be attuned to in order to identify these "silent" victims. The article will discuss how physicians struggle with the ethical and legal obligations they must adhere to in order to satisfy not only their statutory obligations but also to maintain the standards of the profession. It will review how other states have dealt with mandatory reporting requirements for physicians who encounter victims in their practice, and will recommend that Florida enact similar legislation. Finally, the article will discuss briefly the resources that are currently available for victims and their families.

Defining Domestic Violence

Domestic violence, which sometimes is referred to as spouse abuse or battering, refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship.[10] Unfortunately, researchers in the field of domestic violence have not agreed on a uniform definition of what constitutes violence or an abusive relationship. The prevailing suspicion about domestic violence is that assaults are "physical, frequent, and life-threatening."[11] Advocates for battered women contend that financial abuse and property abuse are also forms of domestic violence perpetrated against women.[12] Whatever the definition, it is important for physicians and the attorneys who counsel them to understand that domestic violence, in the form of emotional and psychological abuse and physical violence, is prevalent in our society, and the abuse can be stemmed only through a multi-disciplinary approach.

Unfortunately, domestic violence and abuse has become a fact of life for many American women and children.[13] Statistics demonstrate that between four and six million women are abused annually in the United States,[14] and that a woman is more likely to suffer assault, rape, or murder by a husband or partner than by a stranger.[15] As a result of these troubling statistics, Governor Lawton Chiles appointed a Task Force on Domestic Violence on September 28, 1993, to investigate the problems associated with domestic violence in Florida and to compile recommendations as to how the problems should be approached and, ultimately, resolved. On January 31, 1994, the task force issued its first report on domestic violence. This report recommended standards to measure accurately the extent of domestic violence and strategies for increasing public awareness and education; it identified programs and resources that are presently available to victims in Florida; it made legislative and budgetary suggestions for needed changes and provided a methodology for implementing these changes; and it identified areas of domestic violence that require further study.[16]

As a result of this report, the Florida Legislature enacted legislation during the 1995 legislative session implementing various suggestions of the task force. An important effort achieved by the legislature was to define the term. Although domestic violence has many names--wife abuse, marital assault, woman battery, spouse abuse, wife beating, conjugal violence, intimate violence, battering, partner abuse, and family violence--in Florida, domestic violence is defined as any "assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member[17] by another who is or was residing in the same single dwelling unit."[18] Because this definition is more a behavioral definition, rather than a legal one, it has been criticized for not being specific enough.[19] This is a valid criticism and as physicians, attorneys, and law enforcement officers struggle to understand the definition as it applies to their professional obligations, the Florida Legislature will certainly have to revise the definition accordingly.

Most importantly, as a result of the Governor's Task Force on Domestic Violence, the Florida Legislature amended F.S. [sections] 455.222 to require that all physicians, osteopaths, nurses, dentists, midwifes, psychologists, and psychotherapists obtain, as part of their biennial continuing education requirements, a one-hour continuing education course on domestic violence.[20] To date, this mandate has exposed vast numbers of health care professionals practicing in Florida to the issue of domestic violence.[21]

Demographics, Dynamics, and Victim Identification

As part of the statutorily mandated continuing education course, physicians and other health care professionals must understand that any patient who walks into their offices may be a potential victim. For example, researchers have demonstrated that abuse of women cannot be predicted by any demographic feature related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class.[22] In fact, in at least one study, the majority of battered women surveyed were intelligent and well-educated--or at least more educated than their batterers.[23] Many of these women held jobs in which they were delegated some measure of responsibility.[24] Many battered women come from middle-class families and are successful career women.[25] The battered woman may have low self-esteem, hold traditional views about the woman's role in the home, believe she is responsible for the batterer's conduct, and she may deny the anger she feels toward the batterer.[26] She may put forward a capable, confident face in her public life, while at home she slips into a passive role over which her batterer has complete control.[27] These, of course, are generalities with no one woman fitting all of the characteristics described. This general description serves, however, to effectively dispel the false stereotype of the battered woman and to help demonstrate that battered women are people with whom everyone might identify in some way.[28]

Because women who are abused often suffer severe physical injuries, they will likely seek care from...