Clinical:Case Study: Gender Trauma Recognition and Intervention

Original materials created in April 1999 by Carole Watshaw, M.D. and Kelly Phillips, M.D.

As clinicians we may be shocked and feel overwhelmed when faced with the prevalence data of violence toward women. Statistics in primary care show that between every second to fifth woman evaluated may be abused. We may ignore this reality by telling ourselves that it is impossible to find time to address these issues. However, it is important to recognize that the time spent on repeated visits for undiagnosed sequelae of intimate violence, e.g., headache, malaise, depression, physical trauma, post traumatic stress disorder, and/or self medication/substance abuse, is far greater than the time and responsibility for appropriate intervention.^[1]

History

CP, a 28 yo woman, saw her family physician twice over a two week period. She complained of tremors, vomiting, headaches, and left-sided chest pain. After an unrevealing medical workup, she was referred to a mental health center with the diagnosis of adjustment disorder with depressed mood. She returned a week later with symptoms of left arm numbness, difficulty concentrating, and a loss of appetite. On this visit, she also mentioned that there were arguments at home. Direct questioning revealed that she was being battered.

Detection is Key

The majority of battered women are not seen for acute injuries, but rather for the myriad of medical and psychological problems associated with chronic abuse and battering.

How to Ask

Many women that Dr. Warshaw sees in her practice are involved with someone who hits them, threatens them, continually puts them down, or tries to control them. Some of these women are too afraid or uncomfortable to initiate discussion about violence themselves, so she routinely asks about these issues.^[2]

Framework

We need to recognize the psychological entrapment from which an abused woman must extricate herself. Entrapment is reinforced by the very real threats this woman may face if she discloses the abuse or leaves.3 We also must realize that in her social context, options for living safely and independently may be limited. This perspective will help clinicians respond more empathetically and effectively.^[3]

Safety is Paramount

Clinicians need to consider a woman’s physical and emotional safety and to help her assess options for safety when she leaves. For a woman living in an environment of ongoing threats, intimidation and violence, being regarded with respect and feeling free to make her own choices lets her know that nonabusive experiences are possible. Making clear that the perpetrator alone is responsible for his or her violent behavior and also is responsible for stopping it counters the abuser’s power to blame your patient.^[4]

Safety and Lethality Assessment

Anyone who is battered needs to be assessed for risk of serious injury or homicide before leaving your health care setting. Risk factors for serious injury or homicide include:

• She states she is afraid for her life.
• Violence involving children.
• The perpetrator has threatened to kill her, her children, and/or to commit suicide.
• Escalation of threats.
• Batterer abuses drugs, especially PCP,amphetamines, or crack cocaine.
• Weapons readily available.
• She has attempted to leave previously.
• Batterer has physically abused her during pregnancy.
• Batterer has sexually assaulted her.
• Batterer is obsessed with her, e.g., stalking,or harassing.^[5]

Advocacy

Involves facilitating rather than directing change by helping battered women to become aware of their options and resources and to make their own choices about how best to end the violence in their lives. This is a new and critical role for clinicians.

Barriers to a Clinician's Effective Response

• Belief that gender trauma does not occur in one’s own patient population.
• Feelings of powerlessness about potential interventions.
• Limited time constraints/reimbursement issues.
• Clinicians feel pressured by new expectations,e.g., screening for domestic violence, sexual assault, etc. without having the skills,supports, or resources to respond adequately.
• The attitudes of a physician’s staff and their misperceptions about gender trauma.^[6]

Support for Clinicians

We need to support ourselves by creating a collaborative team to nurture us in this very difficult work.

Summary

• Studies indicate that battered women represent 22-35% of women seeking care in emergency rooms, 14-25% of women seen in ambulatory medical clinics; and 23% of women seeking routine prenatal care. In outpatient psychiatric settings, the preva lence is 50%.
• We can respond to this population of violated women by changing our own practice to improve our recognition and interventions. These women are ourselves, our spouses, our daughters, our mothers.4
• Addressing gender trauma today presents unique challenges for individual clinicians and

for our current medical systems. Carole Warshaw, M.D. Kelley Phillips, M.D., M.P.H.

References

1. ↑ Warshaw, C. Domestic Violence: Challenges to Medical Practice. Journal of Women’s Health 1993: 2(1) 73-80.
2. ↑ Warshaw, C. Chapter 2 “Identification, Assessment, and Intervention with Victims of Domestic Violence,” in Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. Family Violence Prevention Fund, San Francisco 1996 2nd edition.
3. ↑ Warshaw, C. Intimate Partner Abuse: Developing a Framework for Change in Medical Education.Acad
4. ↑ Warshaw, C. Chapter 2 “Identification, Assessment, and Intervention with Victims of Domestic Violence,” in Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. Family Violence Prevention Fund, San Francisco 1996 2nd edition.
5. ↑ Warshaw, C. Chapter 2 “Identification, Assessment, and Intervention with Victims of Domestic Violence,” in Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. Family Violence Prevention Fund, San Francisco 1996 2nd edition.
6. ↑ Warshaw, C. Domestic Violence: Changing Theory, Changing Practice. JAMWA 1996 51(3) 87-90.