1. Domestic violence
2. Elder abuse
3. Child abuse
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Domestic violence is abuse of a person who is known in an intimate sexual or familial way.
Abuse is the misuse of power with the intent of harming or controlling another person. This includes (but is not limited to) physical, verbal, psychological, sexual, or economic abuse (denying access to funds), environmental (destroying property), spiritual, in cars (driving recklessly), etc…
Family violence can occur both to women and to men, but the type of violence differs. Women typically suffer physical and sexual abuse; men tend to experience verbal abuse.
This diagram illustrates types of abuse of a woman by an intimate partner:
- Can be charming
- Able to bond with male professionals (such as the doctor)
- Possessive, jealous
- Disrespectful and minimizing towards partner.
- Fear of further, and more violent, reprisals; threats
- Often the victim simply wants the violence to stop, not to lose his or her spouse to jail
- For the sake of the children
- Potential economic hardship if the abusive partner leaves
- Complications with family relations, e.g. with the in-laws
- The trauma of having to go through legal proceedings
- A desire to maintain some semblance of a family and two parents for the children
- The Swedish novelist Camilla Lackberg described the dilemma facing Anna, the mother of Emma and Adrian. She was abused by her husband Lucas:
“Emma was one of the reasons [Anna] couldn’t stop loving Lucas. Not loving him would feel like denying a part of Emma. He was a part of their daughter, and because of that, a part of Anna as well. He was also a good father to the children. Adrian was still too little to understand, but Emma worshipped Lucas, and Anna simply couldn’t take her away from her father. How could she take the children away from half of their security, rip up everything that was familiar and important to them? Instead she had to try to be strong enough for all of them; then they would be able to get through this. Things weren’t like that at the beginning. Things could be good again. As long as she was strong. After all, he told her that he really didn’t want to hit her, that it was for her own good, because she didn’t do what she was supposed to do. If only she could make more of an effort, be a better wife. She didn’t understand him, he said. If only she could find what made him happy, if only she could do the right things so that he didn’t have to be so disappointed in her all the time.” (C. Lackberg, The Ice Princess. Harper, London, 2004. page 145)
The 72-year-old woke up on a sunny morning, picked up an axe leaning against a garden wall, went back inside and struck her sleeping husband twice in the forehead, killing him instantly. They had been married 50 years.
"Then I took a shower, dressed nicely, took my pills and went to the police to report myself," the tiny woman with short grey hair recalls of that fatal morning in March 2008.
Now an inmate of the only women's prison in Serbia, (...) she says her husband abused, beat and tortured her "for decades. I couldn't stand it any more. It was either him or me."
"I immediately knew it was wrong, but it was already too late," she told AFP tearfully in in a bleak prison visitor's room, adding in a whisper: "I so much regret it."
She tolerated years of abuse because she did not want her two daughters – now 51 and 49 years old – to live without a father. "But as they grew up and became independent, it got worse and finally became unbearable. The more I hoped it would be better, the worse it was."
Although she reported the violence to the police "a number of times," there was "no serious reaction except a few warnings to him to calm down."
(Article by Katarina Subasic, reprinted in the Ottawa Citizen, November 23, 2011)
Finding the optimal way to assist the victims of family violence requires a careful balance between respecting their right to privacy, protecting them from further attacks, ensuring that others, especially children, are protected, and figuring out which is the best agency to help (you? the police? social work?)
What can the doctor do?
1) Some key messages to transmit:
- Abuse and assault are illegal and unacceptable; the victim should not assume it's their fault
- They should be offered a safe place and medical assistance
- There are agencies to assist them
- They should know that you will respect their right to decide how to deal with their domestic situation
- Their confidentiality will be respected, except where suspected child abuse requires you to inform the Children's Aid Society (CAS)
- That the victim knows she/he has this opportunity to talk about her/his situation; make her/him feel believed
- Victims should know of their legal rights (they can lay charges; they can get a restraining order; custody can be arranged for children)
- They can be referred to community resources such as shelter, legal aid, counselling
- Your attitudes and reactions will not further victimize them.
2) Under-reporting of abuse is a reality. You need to be alert to indicators and follow them up. Document the information and the actions you take. Here are some possible interview approaches:
- "How do you and your partner resolve disagreements?"
- "Have you been hit by anyone in the last year?"
- "Are you afraid of your partner?"
- Ask about 'SAFE': S(spousal relationship), A(arguing?), F(having fights?), E(has an emergency plan?)
- Alternatively, the Antenatal Psychological Health Assessment (Alpha) Tool: 15 questions on risk factors for adverse family outcomes (post-partum depression, abuse, couple dysfunction). (LM Wilson et al, CMAJ 1996 (March 15); 154:785-99)
- Warning sign: one partner answers too many questions and excludes the other partner.
3) If you do suspect a case of abuse:
- Assess: Is there immediate danger? Where are other family members?
- Do not confront the partner (that is not your role)
- If there is immediate danger, ask her/his permission to call the police
- If there appears to be no immediate danger, validate this: try and find out more about the situation: degree and type of violence or threat; is there danger to others? Is the perpetrator using drugs or alcohol? Psychiatric history? What other service providers is she/he in contact with?
- What assistance will the victim need? How emotionally strong is she/he? Does she/he have financial resources? How much support is there from family and friends? Is she/he using drugs or alcohol? History of suicide attempts?
- In particular, assess risk to children. Is there a history of violence toward the children? Where are the children? How can they be protected?
- Document: take a thorough history and document in detail medical signs of abuse; get photographic evidence if possible. Your chart may be required for subsequent legal proceedings. Record facts & findings, not opinions.
4) Various centres in Ottawa provide services to support victims of violence: the Community Resource Centres are one option; the Immigrant Women Services is another; Disabled women are at elevated risk. The Ottawa Coalition to End Violence Against Women (OCTEVAW) produces various documents. There is also a National Clearinghouse on Stop Family Violence. There will be similar services in the community in which you eventually practice.
5) If you suspect a male patient of abusing his partner,
- Choose a time when he is calm to tackle the subject.
- Be clear about what you have seen.
- His behaviour is his responsibility: do not validate any attempt he makes to blame others.
- He may minimize the seriousness of the situation; keep the conversation focused on your concern for the safety of his family.
- Reiterate that abuse is never an answer and look for opportunities to offer to refer him for support.
6) Beyond these immediate responses as a physician, there are also ways you may help in the longer term. This table links your responses back to the CanMeds roles:
|Clinician||Develop skills in identifying victims; intervene to treat the medical condition and refer appropriately|
|Professional||Deliver ethical & compassionate care; be aware of complex causative factors; be aware of your limits|
|Communicator||Empathetic listening; establish trust; share decision making; leave the door open to further discussion when the patient is ready to disclose|
|Manager||Contribute to making the system alert to violence and to responding appropriately|
|Advocate||Work to improve public awareness; help your patient navigate the system to access resources|
|Collaborator||Act as a link to non-health sector (justice system) ; know your local resources|
|Scholar||Identify knowledge gaps and educate patients and others about violence|
|Person||Know your own feelings towards violence|
|(See L.E. Ferris; BMJ 2007;334:706)|
Elder abuse generally means "the physical, psychosocial or financial mistreatment of a senior." Neglect is a common form of abuse.
A national Canadian study on the occurrence of elder abuse was conducted in 1989. Ninety-one per cent of Canadian seniors reside in private dwellings. The survey contacted 2000 seniors at home; the findings indicate the following:
- Approximately 4% of elders in Canadian private dwellings (approximately 98 000 people) have been abused.
- Financial abuse is the most prevalent category, affecting 60,000 Canadian elders. It is more likely to be perpetrated by a distant relative or a non-relative than by a close family member. Only 7% of financial abusers are financially dependent on their elderly victims.
- Chronic verbal aggression, a component of psychosocial abuse, affects approximately 34 000 elderly Canadians.
- More than 18 000 elderly persons in Canada are subjected to more than one type of abuse.
- Approximately 12 000 seniors in Canada have experienced physical abuse. Victims of physical abuse are more likely than non-victims to be married and in most cases the aggressor is the spouse.
- Risk factors for abuse include family stress and frustration as the elderly person becomes more dependent; migration of young couples to urban centres; social isolation due to mental or physical frailties; erosion of cultural bonds between the generations.
Physician's Reporting Responsibility:
In 2008, Health Canada published the "Canadian Incidence Study of Reported Child Abuse and Neglect." Here is a brief summary:
- In 2008, about 235,800 investigations of child maltreatment were carried out among children aged 0 to 15. This was up from 135,000 ten years earlier.
- Of these, 85,440 were substantiated (14 per thousand children in the country). 18,000 remained suspected, but were not proven.
- Of the proven cases, two categories, neglect and exposure to intimate partner violence were the most common (each represented 34% of all reports: 29,000 cases). Physical abuse formed 20% of all cases (17,000 children), while emotional maltreatment formed 9% of cases (7,400 children) and sexual abuse comprised 3% of all reports (2,600 children).
- Those figures represent the primary classification. Emotional harm can evidently accompany other forms of maltreatment, and was documented in 29% of all substantiated cases of maltreatment, more than half of which required treatment.
- 22% of substantiated cases were of Aboriginal heritage: 18%First Nations and 3% Métis.
- Risk factors among the primary caregivers of abused children: 46% had themselves been victims of maltreatment; 39% lacked social supports; 27% had mental health issues and 21% abused alcohol. 17% had a history of drug abuse.
Sexual Abuse. An extensive study of child sexual abuse in Canada was conducted by the Committee on Sexual Offences Against Children and Youth. It reported that:
- 53% of adult females and 31% of males have been victims of one or more unwanted sexual acts.
- Approximately four in five of those incidents happened during childhood or adolescence.
- An article by Dr. Ken Finkel in the CMAJ estimated that 25% of women and 10% of men are sexually abused before the age of 16.
- In Metro Toronto alone it has been estimated that over 2,000 children may be sexually abused each year.
People with disabilities are at increased risk of maltreatment. The risk rises with the level of disability and is especially common among people who are intellectually disabled. A 1990 study undertaken by the Disabled Women's Network of Canada (DAWN) found that 40% of women with disabilities reported having been raped, abused or assaulted. 80% of victims were said to be "intellectually challenged."
The victim knows the person who commits violence against a disabled woman in about 90% of cases: about one third are "friends"; one third are relatives (often a step-father or uncle); a little under a third are people in positions of authority (care workers, teachers).
Perhaps 10,000 people are homeless in Canada on any given night. This is a rough estimate, however, and seems on the low side. Aside from the obvious difficulty in finding homeless people in order to count them, it's quite difficult to define homelessness (those living in shelters or just those outside shelters? What about those "temporarily staying with a friend"? Minimum duration?)
Roughly 1,000 people will sleep in a shelter in Ottawa tonight (statistic from Dr J. Turnbull).
The homeless hub web site gave statistics for Toronto for 2013.
- The total estimated homeless population in Toronto on April 17, 2013 was 5,219 – similar to the estimate from 2009.
- 76% were in shelters; 9% were outdoors and 7% were in violence shelters for women. The rest were in health facilities, police detention, etc.
- The average length of homelessness in Toronto is around 3 years.
- One estimate by the city health department cites 2,800 homeless people in Ottawa: a higher percentage than in Toronto.
- Over 1/3 of the outdoor homeless were Aboriginal. Aboriginal people form 2% of Vancouver's population but 30% of its homeless population.
- 20% of homeless youth identify as part of the LGBTQ community.
Common precipitating causes of homelessness include escaping from abuse, suffering from mental illness, or substance use problems. Family conflict can often lead to youth homelessness. The underlying promoting factor is generally economic hardship, perhaps resulting from job loss, which means that a person in one of the above categories will not have affordable housing to go to.
Homeless people are at increased risk for poor health: respiratory tract infections; TB and HIV; addictions; abuse; suicide; poor management of chronic conditions such as diabetes, ulcers, skin conditions, etc.
The Shepherds of Good Hope (Les Bergers de l'Espoir) is at 233 Murray St. It offers an emergency shelter (120 beds), an alcoholics' recovery and detoxification centre for 20 clients, and a 40-bed outreach centre for people, mostly with mental illness, who cannot stay at other centres.
The Mission is located at 35 Waller St (just north of the university campus). It provides shelter (over 200 beds) and a wide range of services to assist clients re-integrate into society and regain a healthy lifestyle. It also runs a hospice for the terminally ill, in which homeless people can receive visits from their friends who would have difficulty in visiting them in a hospital setting.
Bruce House provides sheltered accommodation for 38 people in a range of apartments. It offers support services for disabled people, including counselling, advocacy and even palliative care.
The Salvation Army runs several shelters in Ottawa. The main one is the Booth centre, at 171 George St. It has about 170 beds and provides meals, clothing, counselling and care management. It also has a section devoted to young men (16 to 19 years old).
The Women's Emergency Shelter (Le Pilier) is at 172 O'Connor St and accommodates 43 women, providing support required to meet crises.
There is also a Young Women's Emergency Shelter at 1338 Wellington St, offering short-term stay for women aged 12 to 20.
Harmony House arranges for medium-term housing for women and their children escaping from abusive relationships.
The Ottawa Inner City Health Project provides medical services to homeless people. It has space for up to 20 men who are recovering from physical illness, and a palliative care unit.
Updated December 11, 2018