Criminal Justice Research Paper
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Intimate Partner Violence Experienced by Physicians: A Review
Barbara Couden Hernandez, PhD, 1
Ellen T. Reibling, PhD, 1
Charles Maddux, BA, 1
and Michael Kahn, MA 2
Abstract
Background: Physicians play a significant role in screening for domestic violence. However, little information is available about the prevalence of physicians who experience intimate partner violence (IPV) or the impli- cations for their clinical practice. National surveys indicate a potential prevalence of 16% for sexual abuse and 32% for abuse by an intimate partner. This extrapolates to more than 395,000 potential physician victims, the majority of which are women. Methods: We conducted a systematic review of IPV and physician victims from 1990 to 2014 that included peer-reviewed journals, trade books, and dissertations that referenced physician victims. Results: We identified 17 publications; nine quantitative studies, four first-person accounts, one qualitative study, and a qualitative dissertation that included two physician subjects. Two case studies of victimized physicians were identified in trade books. Quantitative results noted that women reported higher prevalence for all expe- riences of violence [childhood exposure (6%–32%), adult IPV exposure (7%–24%)] than men (6%–10%). Conclusions: This review highlights the need for improved understanding of physician experience with IPV, and development of physician-sensitive resources and treatment approaches. Contributions and limitations are provided for each publication. IPV exposure impacts clinical practice, including reticence to consistently screen patients. Lower reported prevalence may be related to extreme stigma among physicians that may prevent their reporting and help seeking, but more research is needed. We provide recommendations for clinical practice, education, and future research.
Introduction
Little is known about intimate partner violence (IPV)prevalence within physicians as a population, although physicians are trained to screen patients for victimization. IPV is defined by the Centers for Disease Control as a ‘‘se- rious, preventable public health problem involving physical, sexual, or psychological harm by a current or former partner or spouse.’’
1 Partner abuse and IPV are used interchangeably
in this paper. Abusive behaviors can involve coercion, in- timidation, threats, restriction of freedom or movement, isolation, controlling behaviors, and verbal or psychological abuse. Lifetime prevalence of sexual abuse is 16% and abuse by an intimate partner is 32%, and over 45% of both men and women reported psychological aggression by an intimate partner.
2 If the incidence of partner abuse for physicians is
similar to that of the general public, it can be extrapolated that of the 878,194 practicing physicians in the United States as of 2012 up to 395,000 have experienced some form of IPV.
3
However, IPV experiences in the lives of physicians are in- frequently encountered in the literature.
The paucity of literature shapes several research questions for this review. Where is the physician IPV experience de- scribed in the literature? What is the prevalence of IPV among physicians? How does IPV experience impact phy- sician attitudes and screening practices for IPV victims? How does IPV experience impact physician well-being?
We offer a systematic literature review pertaining to physician IPV victims, with recommendations for health policy, education, practice, and research. A systematic re- view, by definition, searches out, appraises, and synthesizes research evidence and literature regarding what is known about a topic.
4
Methods
A comprehensive and exhaustive literature search span- ning the years 1990 to 2014 was conducted using 14 key phrases, such as professionals and interpersonal violence, women physicians and domestic violence, physicians in abusive relationships, intimate partner violence, physicians and spouse abuse, and medical student abuse in the following
1 Loma Linda University School of Medicine, Loma Linda, California.
2 George Washington University School of Medicine, Washington, DC.
JOURNAL OF WOMEN’S HEALTH Volume 25, Number 3, 2016 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.5216
311
online databases: PsycINFO; Academic Search Premier; Health Source: Nursing/Academic Edition; PsycARTICLES; PsycBOOKS; Health and Psychosocial Instruments; So- cINDEX; Social Work Abstracts; Alt HealthWatch; Health Source-Consumer Edition Library; Information Science & Technology Abstracts; Elton B. Stephens Co. (EBSCO); Excerpta Medica Database (EMBASE); Web of Science,;Pub Med; National Institutes of Health (NIH) and Google Scho- lar. Trade books were reviewed for anecdotal references or case reports that identified features of physician experience. We selected sources with these criteria: papers that described or quantified the physical, sexual, or emotional abuse of physicians by an intimate partner that could have occurred as a teenager or as a medical student. We included medical student IPV experience since personal exposure to IPV could influence physician screening practices whether abuse occurs early or later in the life of a physician. We excluded papers that focused on abuse inflicted by patients or non-related colleagues. Because researchers utilize varying language to describe acts associated with IPV, we constructed Table 1 comparing terms to illustrate the challenge of creating a common language relevant to IPV.
Results
Our search yielded a total of 17 publications that met our criteria. Nine quantitative studies and four first-person ac- counts written by physicians were identified. One qualitative study and a qualitative dissertation that included responses from two affluent IPV survivors were included. Two case studies of physicians who left violent relationships and an anecdotal reference were identified in trade books. These are summarized below by sample and literature type.
Surveys of physicians and medical students
Five cross-sectional studies of physicians were published: two in 1999
5,6 and one in 2007,
7 2012,
8 and 2015.
9 Two
studies only sampled women, 5,7
two studies only sampled in one U.S. state,
6,8 and two were out of the United States
(Sweden 7
and Palestine 9 ). Women represented 27%–51% of
respondents across studies. Data was collected by postal and electronic surveys that ranged from 18–100 items. Medical student studies were published in 1997
10 (only first year stu-
dents), 2003, 11
and 2006, 12
with an additional study com- bining both students and physicians in 1996.
13 All studies
were cross-sectional with exception of one longitudinal study administered three times over the course of the 4-year medical school curriculum.
12 Table 2 provides study details.
Survey measures varied greatly. Four surveys were derived from validated scales: three studies
9,10,11 were based on
Conflict Tactics Scales 14
and on the NorVold Abuse Ques- tionnaire.
15 Conflict Tactics Scales items assessed personal
exposure to child abuse (emotional, physical, and/or sexual victimization) and intimate partner violence (hurt physically by a partner or forced to have sex). The NorVold Abuse Questionnaire assessed exposure to physical, sexual, or emotional abuse as adult by providing specific criteria at three levels: mild, moderate, or severe. For example, criteria for physical abuse was smacking (mild), beating (moderate), and life threatening (severe), but the perpetrator was phrased as ‘‘anybody’’ and was not limited to a partner. Seven studies asked about exposure to parental violence;
5,6,7,9,10,11,12 one
study called it ‘‘secondhand exposure’’ by viewing verbal, physical, or sexual violence between parents or by knowing a victim.
11
Measures not derived from validated scales varied from asking about lifetime exposure and not discerning between child and/or adult exposure, to longer surveys that allowed respondents to discern between child, teen, and/or adult abuse. Longer surveys also allowed more specific identifi- cation of perpetrators (e.g., ‘‘people in my family,’’ ‘‘family member,’’ ‘‘someone,’’ ‘‘partner,’’ or ‘‘older child or adult caregiver’’). All but one of the studies correlated IPV with other measures, including well-being (i.e., depression), sub- stance abuse, screening practices, help-seeking behaviors, and attitudes toward wife beating.
Physician results
IPV prevalence results varied widely by study design, participants, and length of survey. Physicians who com- pleted the Women Physician Health Study (n = 4,501) re- ported personal or family member sexual abuse (SA) experience or IPV.
5 The lifetime prevalence for IPV was
3.7%, similar to rates of IPV they reported for their mothers (3.8%) and siblings (2.8%). IPV was more frequent in un- married couples and same sex relationships. Physicians with personal exposure to IPV reported lower job satisfaction and impaired mental health compared to those without abuse exposure. This is to date the largest physician sample related to IPV, allowing analysis by medical specialty and sexual orientation.
Subsequent surveys used smaller samples. IPV results varied widely. Rodriguez et al. surveyed California physi- cians (n = 400) in three specialties to correlate screening practices with physical abuse witnessed as a child (15%) or experienced as an adult (12%).
6 Neither gender, age, nor
personal history of IPV affected screening practices. Female nurses and physicians in a Swedish University hospital re- ported personal IPV experience and screening practices (n = 588); 7% (n = 41) were physicians.7 Nearly one-quarter of the subjects reported abuse by a male partner. Emotional abuse was reported by 10.9% of the sample. Over 16% re- ported physical abuse and 6.5% reported sexual abuse. Phy- sicians were significantly more likely than other health care providers to directly question patients about IPV, to identify resources, and recommend interventions.
Massachusetts family practice physicians (n = 297) re- sponded to five questions regarding personal victimization as an adult or child and about their IPV screening practices.
8
Physicians reported seeing parental violence when they were children (11%), sexual coercion or abuse as a teen or adult (5.7%), and history of fearing for their safety due to IPV (7.1%). Physicians who had a history of past abuse were more confident in screening for IPV, and less concerned about time required to do so. Women physicians were almost twice as likely as men (42.4% vs. 24.3%) were to report personal experience with abuse, and adulthood IPV (16% vs. 6.3%). The authors suggested that the prevalence of IPV and its consequences on wellbeing have not been acknowledged in medicine as potential risk factors.
A recent survey of Palestinian physicians (n = 396) corre- lated witnessing parental violence experience (24%) with attitudes concerning wife-beating and intention to care for
312 HERNANDEZ ET AL.
battered women. 9
Individuals with family history of IPV were more likely to accept patriarchal ideologies that justify wife beating and blamed the victim for her abuse. However, almost 59% endorsed helping the victim. Females re- presented 28% of the sample.
Medical students’ results
Studies involving medical students identified similar trends in IPV prevalence. deLahunta assessed 787 medical students and faculty at the University of Rochester Medical
Table 1. Terms and Definitions Defining Intimate Partner Violence
Type of abuse Category Terms reported in literature
Child abuse General Physical or sexual victimization of a child by an older child or adult caregiver 10
Abuse by parent, stepparent, or other caretaker as child or adolescent 7
Experiencing violence by the father and mother 9
Injury When growing up, someone in family hit so hard it left bruises or marks 8
Sexual When growing up, someone tried to touch me in a sexual way or tried to make me touch them8
Physical Exposure to parents or family
Domestic violence history in mother 5
Family (parents/siblings/grandparents) 12
When growing up, one of your parents ever threatened, hit, slap, kick or otherwise hurt each other
6,8
Witnessing father-to-mother or mother-to-father domestic violence 9
Personal or secondhand exposure to violence between parents or knowing a victim
13
General Adult domestic violence 10
Personal Ever feared for your safety or been hit, slapped, kicked, or physically hurt by intimate or previously intimate partner
6,8
Physical injury or threat of injury by a family member of intimate partner 13
Partner ever physically hurt you 13
Specific behavior(s) Partner throwing something at you 13
Arguments ending in pushing, shoving, slapping, hitting, or kicking 13
Partner ever used a weapon (knife, gun, club, belt, or other object) to hurt you 13
Anybody hitting you, smacking your face, or holding you firmly against your will
7
Anybody hitting you with fists or with a hard object, kicking you, pushing you violently, given you a beating, thrashing you, or doing anything similar to you
7
Anybody threatening your life, for instance, trying to strangle you, showing a weapon or knife, or any other similar act
7
Specific injuries Partner ever inflicted an injury on you that required medical care 7
Sexual General Sexual abuse ever experienced 5,12
Sexual assault 11
Specific behaviors by known person
Rape or other sexual acts that made the respondent afraid or uncomfortable, perpetrated by a family member or intimate partner
7
Any partner forced you to have sex or engaged in sexual practices that make you feel uncomfortable
13
Any sexual assault As teenager or adult, forced to have sex or engage in sexual practices against my will
7
Sexual assault or rape as adolescent or adult 11
Anybody against your will touched parts of your body other than genitals in a sexual way or forced you to touch other parts of his or her body in a sexual way
7
In any way been sexually humiliated (e.g., by being forced to watch a pornographic movie or similar against your will, forced to show your body naked, or forced to watch when somebody else showed his/her body naked)
7
Anybody against your will touched your genitals, used your body to satisfy him/ herself, or forced you to touch anybody else’s genitals
7
Anybody against your will put or tried to put his penis into your vagina, mouth, or rectum; put or tried to put an object or other parts of the body into your vagina, mouth, or rectum
7
Psychological General Personal or secondhand exposure to verbal violence between parents or knowing a victim
7
Specific behaviors Anybody systematically and for a long period trying to repress, degrade or humiliate you
13
Anybody systematically and by threat or force trying to restrict your contacts with others or totally control what you may and may not do
13
Somebody systematically and for a long period threatened you or somebody close to you
7
PHYSICIAN IPV REVIEW 313
T a
b l e
2 .
Q u
a n
t i t a
t i v
e S
t u
d i e s
o f
P h
y s i c i a
n E
x p e r i e n
c e
w i t h
D o
m e s t i c
V i o
l e n
c e
A u th
o r,
y e a r,
p u b li
c a ti
o n
S a m
p le
c h a ra
c te
ri st
ic s
M e th
o d
D e si
g n
M e a su
re s/
IP V
d e fi n it
io n
F in
d in
g s
re g a rd
in g
p e rs
o n a l
e x p e ri
e n c e
S ta
te d
li m
it a ti
o n s
C o n tr
ib u ti
o n
a n d
im p li
c a ti
o n s
P h
y si
c ia
n s
D o y le
e t
a l.
, 1 9 9 9
5
J o u rn
a l
o f
W o m
e n ’s
H e a lt
h a n d
G e n d e r-
B a se
d M
e d ic
in e
P h y si
c ia
n s
p a rt
ic ip
a n ts
(n =
4 5 0 1 )
F e m
a le
o n ly
S u b se
t o f
lo n g it
u d in
a l
st u d y
A ss
e ss
e d
in fa
m il
y n o w
o r
in th
e p a st
D o m
e st
ic v io
le n c e ,
se x u a l
a ss
a u lt
7 .4
% re
p o rt
e d
so m
e o r
b o th
U se
d si
n g le
it e m
fo r
sc re
e n in
g ,
p o te
n ti
a l
u n d e rr
e p o rt
in g
d u e
to fe
a r
o r
ri sk
s o f
b e in
g id
e n ti
fi e d ,
n o
d e fi
n it
io n s
o f
a b u se
p ro
v id
e d
A ss
e ss
e d
fa m
il y
a b u se
, c o rr
e la
te d
w it
h su
ic id
e ,
d e p re
ss io
n ,
su b st
a n c e
a b u se
, c h ro
n ic
fa ti
g u e
sy n d ro
m e
N e e d
to in
c re
a se
p h y si
c ia
n –
p a ti
e n t
c o m
fo rt
in d is
c u ss
in g
IP V
R o d ri
g u e z
e t
a l.
, 1 9 9 9
6
J A
M A
P h y si
c ia
n s,
C a li
fo rn
ia (n
= 4 0 0 )
F e m
a le
4 2 %
2 4
it e m
su rv
e y
C ro
ss -s
e c ti
o n a l
T w
o it
e m
s: W
it n e ss
e d
p h y si
c a l
a b u se
b e tw
e e n
p a re
n ts
o r
e x p e ri
e n c e d
a s
a d u lt
1 2 %
IP V
C A
la w
m a y
re su
lt in
h ig
h e r
c o m
p li
a n c e ,
g e n d e r
n e u tr
a l
d e fi
n it
io n s,
n e e d
to in
c lu
d e
o th
e r
‘‘ fr
o n tl
in e ’’
h e a lt
h c a re
p ro
v id
e rs
C o rr
e la
te d
w it
h sc
re e n in
g p ra
c ti
c e s
in c lu
d in
g b a rr
ie rs
, a n a ly
si s
b y
sp e c ia
lt y
N e e d
fo r
sy st
e m
a ti
c c h a n g e
re g a rd
in g
p h y si
c ia
n IP
V e d u c a ti
o n
S te
n so
n a n d
H e im
e r,
2 0 0 7
7
W o m
e n ’s
H e a lt
h Is
su e s
P h y si
c ia
n s
a n d
n u rs
e s,
S w
e d e n
(n =
5 8 8 ,
7 %
p h y si
c ia
n s)
F e m
a le
o n ly
1 5 -i
te m
su rv
e y
C ro
ss -s
e c ti
o n a l
N o rV
o ld
A b u se
Q u e st
io n n a ir
e P
h y si
c a l:
sm a c k in
g (m
il d ),
b e a ti
n g
(m o d e ra
te ),
li fe
th re
a te
n in
g (s
e v e re
) b y
a n y b o d y
S e x u a l:
u n w
a n te
d to
u c h
(m il
d ),
h u m
il ia
te d
o r
g e n it
a ls
to u c h e d
(m o d e ra
te ),
p e n e tr
a ti
o n
(s e v e re
) b y
a n y b o d y
E m
o ti
o n a l:
sy st
e m
a ti
c h u m
il ia
ti o n
(m il
d ),
c o n tr
o ll
in g
(m o d e ra
te ),
li v in
g in
fe a r
(s e v e re
)
N 2 3 .5
% IP
V E
x c lu
d e d
p o te
n ti
a l
v ic
ti m
s w
h o
w e re
o n
lo n g
te rm
si c k
le a v e ,
a sp
e c ts
o f
c a re
se lf
-r e p o rt
e d
In c lu
d e d
e m
o ti
o n a l
a b u se
it e m
s, a ss
e ss
e d
se v e ri
ty o f
a b u se
, v a li
d a te
d S
w e d is
h in
st ru
m e n t,
c o rr
e la
te d
w it
h a sp
e c ts
o f
c a re
a n d
k n o w
le d g e
IP V
tr a in
in g
n e e d e d
in c u rr
ic u lu
m a n d
in -s
e rv
ic e
C a n d ib
e t
a l.
, 2 0 1 2
8
F a m
il y
M e d ic
in e
P h y si
c ia
n s,
M a ss
a c h u se
tt s
(n =
2 9 7 )
F e m
a le
5 1 %
5 4
it e m
su rv
e y
C ro
ss -s
e c ti
o n a l
C h il
d a b u se
: p h y si
c a l
b y
p e o p le
in m
y fa
m il
y o r
se x u a l
b y
so m
e o n e
P h y si
c a l
a b u se
: fe
a re
d fo
r sa
fe ty
o r
h it
b y
p a rt
n e r
S e x u a l
a b u se
: a s
te e n a g e r
o r
a d u lt
fo rc
e d
to h a v e
se x
1 1 %
IP V
S e lf
-r e p o rt
, su
b je
c ts
c o u ld
o p t
o u t,
p o te
n ti
a l
o v e r
re p o rt
in g
o f
sc re
e n in
g p ra
c ti
c e s
C o rr
e la
te d
w it
h sc
re e n in
g p ra
c ti
c e s
D e v e lo
p c o m
p e te
n c ie
s to
p ro
v id
e sa
fe e n v ir
o n m
e n t
fo r
tr a in
e e s
to u n d e rs
ta n d
im p a c t
o f
p e rs
o n a l
e x p e ri
e n c e
o n
sc re
e n in
g p ra
c ti
c e s
H a j
e t
a l.
, 2 0 1 5
9
J o u rn
a l
o f
F a m
il y
V io
le n c e
P h y si
c ia
n s,
P a le
st in
ia n
(n =
3 9 6 )
F e m
a le
2 7 .4
% 3 7 -i
te m
su rv
e y
C ro
ss -s
e c ti
o n a l
C o n fl
ic t
T a c ti
c s
S c a le
s E
x p o su
re to
p a re
n ta
l p h y si
c a l
v io
le n c e
o r
p sy
c h o lo
g ic
a l
a g g re
ss io
n
2 4 %
w it
n e ss
e d
fa th
e r
to m
o th
e r
v io
le n c e
R e tr
o sp
e c ti
v e
se lf
-r e p o rt
o f
fa m
il y
v io
le n c e ,
d if
fi c u lt
to sa
m p le
g iv
e n
p o li
ti c a l
is su
e s
in re
g io
n
C o rr
e la
te d
w it
h a tt
it u d e s
to w
a rd
w if
e b e a ti
n g ,
in te
n ti
o n
to h e lp
b a tt
e re
d w
o m
e n ,
v a li
d a te
d in
A ra
b ic
L o n g
d is
c u ss
io n
re g a rd
in g
re se
a rc
h n e e d e d ,
n e e d
fo r
tr a in
in g
th a t
c o n si
d e rs
c u lt
u ra
l a n d
p e rs
o n a l
b e li
e fs
(c o n ti
n u e d
)
314
T a
b l e
2 .
(C o
n t i n
u e d
)
A u th
o r,
y e a r,
p u b li
c a ti
o n
S a m
p le
c h a ra
c te
ri st
ic s
M e th
o d
D e si
g n
M e a su
re s/
IP V
d e fi n it
io n
F in
d in
g s
re g a rd
in g
p e rs
o n a l
e x p e ri
e n c e
S ta
te d
li m
it a ti
o n s
C o n tr
ib u ti
o n
a n d
im p li
c a ti
o n s
P h
y si
c ia
n s
a n
d m
e d
ic a l
st u
d e n
ts d e L
a h u n ta
a n d
T u ls
k y ,
1 9 9 6
1 3
J A
M A
M e d ic
a l
st u d e n ts
a n d
fu ll
-t im
e fa
c u lt
y ,
N e w
Y o rk
(n =
7 8 7 )
F e m
a le
4 6 %
3 0 -i
te m
su rv
e y
C ro
ss -s
e c ti
o n a l
C h il
d a b u se
: e x p e ri
e n c e d
p h y si
c a l
o r
se x u a l
IP V
: p a rt
n e r
h u rt
p h y si
c a ll
y ,
u se
d a
w e a p o n ,
o r
fo rc
e d
se x
8 %
IP V
In st
ru m
e n ts
n o t
v a li
d a te
d w
it h
p h y si
c ia
n s,
se lf
- re
p o rt
a n d
p o te
n ti
a l
fo r
se le
c ti
o n
b ia
s
E st
a b li
sh e d
p re
v a le
n c e
o f
li fe
ti m
e a b u se
e x p e ri
e n c e
a m
o n g
p h y si
c ia
n s
N e e d
to in
it ia
te in
te rv
e n ti
o n s
o n
b e h a lf
o f
su rv
iv o rs
o f
fa m
il y
v io
le n c e
M e d
ic a l
st u
d e n
ts C
u ll
ia n e
e t
a l.
, 1 9 9 7
1 0
A c a d e m
ic M
e d ic
in e
M e d ic
a l
st u d e n ts
, fi
rs t
y e a r
(n =
3 7 0 )
F e m
a le
4 8 %
7 0 -i
te m
su rv
e y
C ro
ss -s
e c ti
o n a l
C o n fl
ic t
T a c ti
c s
sc a le
s C
h il
d a b u se
: p h y si
c a l
o r
se x u a l
v ic
ti m
iz a ti
o n
b y
o ld
e r
c h il
d o r
a d u lt
c a re
g iv
e r.
F a m
il y
v io
le n c e :
a d u lt
d o m
e st
ic v io
le n c e
a s
p h y si
c a l
in ju
ry o r
th re
a t
o f
in ju
ry b y
fa m
il y
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o r
in ti
m a te
p a rt
n e r
S e x u a l
a ss
a u lt
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p e
o r
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th e
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a fr
a id
o r
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p e rp
e tr
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fa m
il y
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b e r
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3 8 %
re p o rt
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a n y
p e rs
o n a l
a b u se
h is
to ry
N o n e
C o rr
e la
te d
p e rs
o n a l
h is
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w it
h k n o w
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su ic
id a l
id e a ti
o n
a n d
a tt
it u d e s
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fa m
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v io
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g ra
te fa
m il
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in fo
rm a ti
o n
in to
m e d ic
a l
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m w
it h
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ti v it
y fo
r st
u d e n ts
w it
h p e rs
o n a l
h is
to ry
A m
b u e l
e t
a l.
, 2 0 0 3
1 1
J o u rn
a l
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p a ra
ti v e
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d ie
s
M e d ic
a l
st u d e n ts
, a ll
y e a rs
(n =
4 7 2 )
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a le
4 4 %
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te m
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ss -s
e c ti
o n a l
C o n fl
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T a c ti
c s
S c a le
s, V
io le
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ty S
c o re
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d a b u se
: p h y si
c a l
o r
se x u a l
v ic
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iz a ti
o n
b y
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st e p p a re
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o th
e r
c a re
ta k e r
a s
c h il
d o r
a d o le
sc e n t.
F a m
il y
v io
le n c e :
p e rs
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a n d
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re to
v e rb
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o r
se x u a l
v io
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k n o w
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. S
e x u a l
a ss
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: se
x u a l
a ss
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e x p o su
re to
se v e re
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p le
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s in
th a t
sm a ll
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p le
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to q u e st
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re g a rd
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fu tu
re w
o rk
im p a c t
C o rr
e la
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p e rs
o n a l
w e ll
-b e in
g w
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e x p o su
re to
v io
le n c e
a n d
im p a c t
o n
se lf
, e d u c a ti
o n
a n d
w o rk
, in
c lu
d in
g h o w
e m
o ti
o n a ll
y c h a ll
e n g in
g w
il l
it b e
to w
o rk
w it
h p a ti
e n ts
w it
h si
m il
a r
e x p e ri
e n c e s
a n d
h e lp
- se
e k in
g b e h a v io
rs O
ff e r
a c c e ss
ib le
a n d
c o n fi
d e n ti
a l
st u d e n t
su p p o rt
se rv
ic e s,
c a u ti
o n
re g a rd
in g
c re
a ti
n g
sa fe
a n d
ju st
le a rn
in g
e n v ir
o n m
e n t,
e sp
e c ia
ll y
fo r
w o m
e n
w it
h a b u se
h is
to ry
F ra
n k
e t
a l.
, 2 0 0 6
1 2
J o u rn
a l
o f
W o m
e n ’s
H e a lt
h
M e d ic
a l
st u d e n ts
, a ll
y e a rs
(n =
2 ,3
1 6 )
1 8 -i
te m
su rv
e y
L o n g it
u d in
a l,
3 ·
P h y si
c a l:
a n y
li fe
ti m
e p e rs
o n a l
o r
fa m
il y
S e x u a l:
a n y
li fe
ti m
e p e rs
o n a l
3 %
w o m
e n ,
1 %
m e n
S e lf
-r e p o rt
e d
a n d
IP V
d e fi
n it
io n s
w e re
se lf
- d e fi
n e d ,
sa m
p le
w a s
n o t
ra n d o m
ly se
le c te
d
C o rr
e la
te d
IP V
w it
h in
te n ti
o n
to sc
re e n , o n ly
lo n g it
u d in
a l
st u d y
Im p ro
v e
c a m
p a ig
n s
to in
v o lv
e p h y si
c ia
n s
in sc
re e n in
g
IP V
, in
ti m
a te
p a rt
n e r
v io
le n c e .
315
Center regarding personal exposure to abuse. 13
Rates of physical or sexual abuse (SA) by an intimate partner were 12.6% and childhood sexual abuse was reported at 15%. Lifetime prevalence of SA, physical abuse, or both was 23.9%. Medical students reported a significantly higher lifetime prevalence of abuse than faculty (34.1% vs. 19.9%). The authors assumed that non-respondents (n = 536) did not experience IPV, which was reflected in low prevalence rates.
Freshman medical students (n = 370) from three New England schools answered a 70-item questionnaire regarding their knowledge of, and exposure to family violence, personal exposure to child sexual abuse, adult sexual abuse, and adult physical abuse perpetrated by an intimate partner or family member.
10 Thirty-two per cent of the sample reported a
history of domestic violence and 10% reported a history of sexual assault by a family member or intimate partner. IPV training and physician advocacy in cases of IPV were en- dorsed significantly more often by those with personal history of childhood and adult abuse. The authors reported that 48% of the sample were women, but the prevalence of abuse was not reported by gender.
Students (n = 472) at a Midwest school of medicine were surveyed regarding child abuse, acquaintance or partner abuse, and lifestyle factors such as general wellbeing, alcohol-related behaviors, mood, and number of friends.
11
Moderate violence (slapping, hitting, pinching, shoving) by a partner or acquaintance was reported by 39% of the sample, and 22% reported severe violence consisting of being bitten, hit, or otherwise seriously assaulted. Thirty-one percent of both men and women indicated that they expected to find it emotionally challenging to work with patients whose violent experiences were similar to theirs, while 26% of men and 40% of women indicated that their abuse experience had some negative impact on their ability to feel good about
themselves. Twice as many women as men sought profes- sional intervention for their exposure to violence. Screening practices were not surveyed.
The only longitudinal study surveyed students (n = 2316) in 16 U.S. medical schools regarding their attitudes and clinical practices related to IPV.
12 In addition to reporting
their screening practices, they responded to three items concerning family or personal history of domestic violence or lifetime history of sexual abuse. Personal IPV experience was 3% for women and 1% for men, and a lifetime prevalence for family or personal history or both was at 12% for women and 7% for men. African American and Latino students reported higher lifetime prevalence (women, 18%; men, 7%). Female gender, history of domestic violence, and being an under- represented minority were highly associated with increased screening and reporting of patient IPV.
Qualitative literature
Qualitative studies consisted of one qualitative interview study
16 (n = 38), four first person physician accounts, 17,18,19,20
and three anecdotal references to physicians in trade pub- lications concerning IPV.
21,22,23 Table 3 provides study
details.
Interviews and case studies
Sugg and Innui (1992) interviewed 38 primary care phy- sicians with predominantly white, middle-class patients.
16
Male (14%) and female (31%) physicians reported a personal history of child abuse or IPV. Physicians expressed dis- comfort screening for IPV regardless of exposure to personal abuse.
First-person accounts featured individual physicians de- scribing their IPV experience. All descriptions were of
Table 3. Qualitative Studies of Physician Experience with Domestic Violence
Authorship Publication Sample characteristics Focus
Interviews and case studies Sugg and Innui,
1992 16
JAMA Primary care physicians (n = 38)
Combined reports of child or adult abuse
Bundow, 1992 17
JAMA, Resident Forum First person physician account of IPV
Urges physicians to become educated and get involved
Wetterman and Weipert, in Johnson and Grant, 2005
18
Domestic Violence Case study Examines potential bias among service agencies toward affluent and educated victim
Anonymous, 2007 17
British Medical Journal First person physician account of IPV
Urging physician victims to seek help
Broderick, 2007 20
Annals of Internal Medicine First person physician account of IPV
Awareness that IPV can happen to a physician
Anecdotal references to physicians Weitzman, 2000
21 Not to People Like Us: Hidden
Abuse in Upscale Marriages Anecdotal references to
physicians Examines roots of secrecy and
underutilization of services by affluent women victims
Weiss, 2004 22
Surviving Domestic Violence: Voices of Women Who Broke Free
Anecdotal references to physicians
Examines roots of physician victim self-blame
Haselschwerdt, 2013
23 Managing secrecy and disclosure of
domestic violence in affluent communities: a grounded theory ethnography
References to experience of two physicians
Examines isolation experienced by high status victims
316 HERNANDEZ ET AL.
women in former relationships and IPV was evidenced by physical and emotional abuse. Abuse also included harm to pets and threats to harm her family if she left. One of the most poignant narratives was concerning an immigrant physician married to an abusive American citizen.
18 The woman was
subjected to violent beatings, rapes, public humiliation, and allegations by her husband that she was mentally unstable. Police failed to intervene when called for a domestic dispute since her husband described her as ‘‘foreign’’ and ‘‘crazy.’’ She was unable to pursue licensure due to her husband’s actions that kept her focused on survival for herself and her children. She was involuntarily committed to a psychiatric facility, lost custody of her children, was relegated to su- pervised visits, and had to watch their health deteriorate as her husband neglected them. Shelter staff, who felt they should control her childrens’ care engaged in a power struggle with her. This story illustrated the need for adequate, culturally sensitive, and appropriate interventions.
Another narrative underscored a common physician atti- tude that healthcare utilization is for patients not doctors, and that physicians should be able to manage or prevent such personal situations, which delays helpseeking.
19 A physician
commented on the article by citing her own past abuse but recommended that abuse stories are private and inappropri- ate for the medical journal readership. A second physician commented by describing violent abuse by her mother after she was a practicing physician; only one colleague inquired about potential abuse even though she was visibly bruised. She urged readers to seek help to address the emotional ef- fects of IPV and to encourage perpetrators to obtain help.
All of the narratives recommended that physicians educate themselves about the prevalence of IPV among colleagues and to increase their understanding of screening and helping interventions.
Anecdotal references
Two books and one published dissertation included de- scriptions of physicians experiencing IPV.
21,22,23 One pedi-
atrician explained that her husband became abusive after they married. While family and hospital staff were supportive, she felt shame that she, a physician, could experience IPV. This was reinforced by a colleague who exclaimed, ‘‘You’re so articulate. . You’re so smart, so sure of yourself. How could you?’’ The author reflected on the impact of this experience by summarizing, ‘‘Nobody does a better job of blaming the victims than the victims themselves’’
22 (p. 144). Another
physician explained that despite obvious signs, she was not screened for IPV. She observed that some physicians fear offending women of status who are victims and hence, fail to screen or offer interventions.
The dissertation followed 10 mothers, two of whom were physicians, who experienced IPV in upper class house- holds.
23 One physician reported that her husband made false
allegations to the licensing board in an effort to get her li- cense revoked. Another husband allegedly hacked into his wife’s computer altering medical records to confuse and discredit her to her colleagues. The author pointed out that affluent individuals are often assigned qualities such as ‘‘unethical, entitled, arrogant, and narcissistic’’ (p. 7), lead- ing to societal apathy and diminished interest about their personal challenges. Women married to men of average or
low means received abundant support from the community and the court system after reporting their IPV. Those married to affluent men tended to maintain secrecy and the appear- ance of a cohesive family, even though their husbands tended to abuse power through bribery of officials, threats, stalking, and violation of restraining orders.
Discussion
Our review supported answers to the research questions: What is the prevalence of IPV among physicians and where is that in the literature, how does IPV impact their work screening for IPV victims, and what is the impact on physi- cian well-being? Women reported higher prevalence for all experiences of violence. Prevalence of childhood exposure to abuse ranged from 6% to 32%, and adult IPV exposure ran- ged from 7% to 24% (6% to 10% for men). Lower prevalence than the general population may be related to extreme stigma. Findings related to the impact of IPV on screening practices indicated that heightened awareness of IPV and reticence to consistently screen patients are common consequences. Suicidal ideation, alcohol abuse, low job satisfaction, and negative health implications were reported as distal corre- lates of IPV.
The studies provide information to support research de- velopment. All of the studies introduced survey items that could be used in development of a physician survey, ranging from 5 to 30 items including both scaled and open-ended questions. Survey items reflected a comprehensive list of violent behaviors, ranging from physical aggression to hav- ing something ‘‘thrown at you.’’ Reliability and validity of survey items were not reported for any surveys, and some did not clarify if the physician was a victim or perpetrator of IPV. Childhood exposure to adult IPV, sexual abuse, and adult experience of IPV were not differentiated in some cases. Qualitative descriptions of physician IPV highlighted expe- riences of female victims, emphasizing the need for physi- cians to become educated about the reality of IPV among their peers. Qualitative analyses also introduced several recommendations quoted directly from the physician victims, which had the potential of increasing face validity. Case studies included comments made about physician victims by family members, colleagues, and caseworkers and vic- tim recommendations, increasing face validity. Qualitative studies did not supply interview questions. Five readings emphasized physician victim stigma, largely due to their affluence (i.e., ‘‘abuse does not happen to people like me’’), education level, and the expectation that physicians are be- lieved to be resistant both to social ills and human responses to those issues. Only one qualitative study highlighted the impact of IPV on job performance, and none of the interviews reviewed the impact of violence experienced in childhood. Most of the studies emphasized the problem but did not highlight any evidence-based solutions.
Physicians’ responses to IPV were typical responses of victims: fear for their lives, emotional isolation, deceiving family and colleagues about their victimization, dressing to cover bruises, shock about their abuse, and difficulty holding their abuser accountable.
24,25,26 Physicians reported shame
from a sense of professional defectiveness owing to the fact that they are trained to screen for IPV yet fell victim to it them- selves. Physicians reported loss of financial independence,
PHYSICIAN IPV REVIEW 317
retaliation, and potential suffering of children and parents as reasons to stay with their abuser. Affluent women were likely to underutilize resources and use a brief vacation as respite from their abuse. However, these short breaks from violence served to isolate the victims and did not supply the psychosocial support or therapy that could have empowered them to escape their abuse.
18
Issues of racism, social privilege, and cultural insensitivity were described in reference to a physician of color. One ac- count was written without the use of pronouns, which could indicate either a heterosexual or same sex relationship; however, the unique IPV issues of physicians in same sex relationships were not described. Although prevalence of male victimization was provided in three quantitative studies, the qualitative literature did not describe their experience as victims. Physicians recommended openness with colleagues about IPV, obtaining mental health and legal support, and becoming educated about physician IPV.
Findings regarding impact on work performance were mixed. Frank found that students reporting childhood expo- sure were significantly more likely to talk to patients about IPV, but the percentage was still low (6%).
12 Candib reported
that screening practices were higher among victims, 8
but other studies assert that might vary by participant ideology, as in the case of Palestinian physician victims of childhood abuse who were more likely to blame the victim and less likely to support services for battered women.
8,9
Some investigators reported findings that are difficult to interpret as solely pertaining to IPV. For example, some survey questions do not specify sexual abuse as an adult or within the context of an intimate relationship, and others reported history of child abuse with IPV prevalence. This is quite possibly due to the perception that child abuse and IPV are comorbid conditions.
27
The stigma and difficulty of physicians in accepting the presence or history of IPV is not dissimilar to the experience of mental health providers who work with abused women. Their coping mechanism was to ‘‘split off’’ this objectionable part of their lives while they were at work, as though this alternative life and identity did not exist.
28
Women of influence are typically disbelieved, receive less empathy, and face prolonged legal or custody battles that diminish financial stability making their experience particu- larly challenging.
29 Unique challenges of physicians include
societal resentment of their social privilege, 16
fear of hu- miliating publicity accompanying police intervention,
30 the
belief that physicians are providers and not consumers of care,
31 physicians’ tendency toward self-doubt, guilt, and an
exaggerated sense of responsibility, 32
and that many IPV interventions target socially vulnerable individuals.
33 Phy-
sicians are reluctant to identify themselves as victims of IPV. This may be due to the belief that a physician’s knowledge of IPV should prevent the experience from occurring. Centers such as Women of Means shelter near Naples, Florida
34 and
the Weitzman Center of Chicago, Illinois, offer shelter and education about violence in affluent families. Lastly, medical students can be educated to screen for IPV in wealthy men and women, as well as those patients that reflect victim profiles in police reports and shelter studies.
30,35,36 The in-
adequacy of IPV training in medical education as a whole is reflected in student misconceptions about IPV such as the notion that some patients choose abusive relationships for
secondary gain and patients are offended by IPV screening. 37
Because IPV education is typically embedded in other be- havioral health topics taught during basic science,
38 medical
students would benefit by applying mnemonics or algorithms during medical simulation in order to anchor screening practices
39 as well as curricula taught by first line domestic
violence shelter personnel. 40
Medical students must be made aware of common barriers to IPV-related help seeking such as religious beliefs,
41 ethnicity,
42 and immigration status.
43
The role of stigma, shame, and isolation for marginalized populations such as sexual and ethnic minorities should also be considered as causes for underreporting of IPV.
44 Al-
though universal screening is recommended, 45
IPV screening should at least be conducted with all female patients 12 years and older,
46 particularly since victims of IPV may be iden-
tified when their children are seen in pediatric clinics, 47
or may present in primary care with mental health concerns,
48
sleep issues, 49
or in the emergency department for other in- juries.
50 Although there are at least 13 IPV screening tools,
51
medical students should have exposure to three common screening instruments with proven sensitivity to present or current IPV: the HITS Scale (Hurt, Insult, Threaten, Scream),
52 Woman Abuse Screening Tool (WAST)
53 and
HARK (Humiliation, Afraid, Rape, Kick) tool. 54
Conclusions
A national survey of male and female physicians is needed, as some previous studies suffer from methodological issues that threaten validity. Qualitative descriptions of physician experiences and effective interventions would be useful. These must address issues of ‘‘functional poverty’’ of physicians whose partners withhold financial resources from them.
21
Given the limited literature, several recommendations may be offered. Prevalence studies are needed across the medical student, resident, practicing, and academic physician popu- lations to determine if societal discourse and generational membership influences reporting and help-seeking efforts. Exploratory qualitative investigation and case studies would be useful to obtain a clearer understanding of the issue, what it means to be a physician and experience IPV, and how physicians enter into and exit abusive relationships. Such studies can inform future quantitative study variables
55 by
identifying recommendations to develop intervention pro- grams and appropriate resources for physicians. A survey of therapists and shelter workers may offer insight regarding treatment needs and effective case management.
Although attempts have been made to describe and address physician IPV, stigma and silence continue to frame this experience in which the majority of victims are women. We anticipate that this literature overview will encourage further investigation and development of resources that address the unique needs and challenges of physicians.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to: Barbara Couden Hernandez, PhD Department of Medical Education
Loma Linda University School of Medicine 11332 Mountain View Avenue, Suite C
Loma Linda, California 92354
E-mail: [email protected]
320 HERNANDEZ ET AL.
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