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How Do You Define Abuse?
abuse (n): 1. Physical maltreatment. 2. abuse (vt): To use so as to injure or damage: MALTREAT. 3. To attack in words: REVILE. Merriam-Webster, 1993
often met with skepticism. In a nationwide community survey examining aggressive behaviors among couples in the United States, Straus and Gelles1 found an 11% annual incidence of husband-to-wife physical violence, and a 22% prevalence over a woman’s lifetime. Using similar methods in primary care practices, others have found far higher rates; for example, a 22% prevalence of abuse in the past year.2,3 Some readers believed these estimates are exaggerated. Were the researchers really assessing “abuse”? Indeed, many repeated, severe, and harmful acts were represented in these studies; however, the data also included low-frequency, low-severity behaviors. Thus, using their data, one slap in a lifetime could be labeled as “abuse.” The extremes of the definition of abuse are easy to identify. The stereotyped view of wife abuse depicts frequent, severe, intentional, unidirectional, aggressive behavior in the husband-perpetrator, and serious psychological and physical consequences in the wife-victim. This definition is juxtaposed against the definition of a nonabusive relationship, marked by a complete absence of aggressive behaviors, both verbal and physical. However, this creates an enormous gray area. What type of marital argument could be labeled emotional abuse? Consider the couple who trade insults when they are angry with each other, or the husband who publicly berates his wife. What frequency or severity of aggressive acts could be defined as physical abuse? Consider the husband who slaps his wife once per year, or one who slaps his wife once per month, or one who stabs his wife once, or the couples who hit each other. Is an aggressive behavior considered abusive if it has no ill effects? Consider the small woman who regularly punches her large husband, or the husband who controls his wife’s behavior through shame and guilt.
REVALENCE FIGURES describing wife abuse are
See also page 25
Language limits our ability to label these gray areas. When aggression does not fall into the stereotypical view of abuse, a patient may have no language to describe it and no well-defined way to ask for help.4 For example, an acquaintance once telephoned me to clarify a personal event regarding a man she had been dating for about 8 weeks. After an evening out, they returned to his apartment where he scolded and berated her for dancing with another man. Then he used a wrestling move to sweep her feet out from under her, and she fell. For hours, whenever she tried to rise from the floor, he would cause her to fall again. He never hit her or used his hands
on her or threatened her with harm—he treated it as a joke—but he would not allow her to stand up or leave, and she fell again and again. The next day she had bruises all over her body. After relating the event to me, she asked “Is this abuse?” We had no word to describe what had happened to her, and she was hesitant to end the relationship based on one undefined event. To a person on the inside of a violent relationship, defining abuse is extremely difficult. The relationship itself creates a context that blurs the distinctions between harmful and harmless. The first hit—a singular, unique and surprising act—is rarely considered abuse. Aggressive acts that follow are judged against time together that also includes loving acts. Violence is minimized, justified, or reframed to protect the positive aspects of the relationship. In addition, the perpetrator can reinforce “no harm done” explanations by limiting the victim’s contact with people who might challenge this definition of the aggression. However, over time, as abuse repeats (which it generally does5), or as it begins to affect other aspects of life (such as the children), the victim will redefine these events as abusive. Kelly4 found that frequency was the most important factor influencing how soon a woman defined a man’s behavior as abusive. Mills6 described a model of progression through a violent relationship that reflected the evolution of the victim’s definitions of abuse and of herself over time. Stages included: (1) entering the relationship; (2) managing the violence, including self-protection and justifying the relationship; (3) experiencing a loss of self, referring to selfidentity and perspective; (4) reevaluating the relationship; and (5) restructuring the self, as either a survivor or a victim. Not until stage 4 did victims view their relationship as abusive. To a person on the outside of a violent relationship, defining abuse—especially in those gray areas—is controversial, with varying professionals declaring abuse as under-reported or overreported. The examination by Wagner and Mongan7 of how women view abuse was a response to critics of violence research who wonder, “Do researchers really assess ‘abuse’?” She used researchers’ language— threatening, throwing, pushing, slapping, kicking, hitting, beating up, and using weapons—and asked women if they considered these actions “abusive.” Nearly every subject did. In addition, compared with others, women who identified themselves as abused were more likely to believe that using insults and spiteful words were abusive acts. Their perspective on the entire pattern of violence in relationships may be unknown to women who have not been abused, or to women who are
Downloaded from www.archfammed.com on May 8, 2011 ©1998 American Medical Association. All rights reserved.
ARCH FAM MED/ VOL 7, JAN/FEB 1998 31
these behaviors can control the other partner. How women define their experiences of violence. JAN/FEB 1998 32 . NY: Springer Publishing Co Inc. 1986. Ill: American Medical Association.8:103-123. identify helpful resources in the community. several strategies maintain power and control: verbal insults or humiliation. and recent life stressors such as job loss. even when no hitting occurs. J Marriage Fam. Bograd M. Feld SL. PhD Department of Family Medicine University of Texas Health Science Center San Antonio REFERENCES 1. American Medical Association. Arch Fam Med. A can undermine those relationships and socially isolate B. economic control. A. male privilege (in male-against-female abuse). Physical. and a change of clothing. 5.in earlier stages of abusive relationships but who have not yet self-identified as victims. and the enormous gray areas in the definition. Connect them with community resources that specialize in helping victims of violence. Feminist Perspectives on Wife Abuse. Prevalence of domestic violence in community practice and rate of physician inquiry. Dangerousness is indicated by ready access to weapons. however. Criminology. or sexual infidelity. Mongan PF.” because this behavior replicates the perpetrator’s power and control strategies. or disagreement. 7.24:283-287. minimization.com on May 8. 1989. family neglect.” or “violence” unless the patient uses them first. pregnancy. If a victim of physical violence is not ready to change the living situation today (and most will not be). 3. 1985. Sandra K. To maintain control. and using children. important papers. The safe plan should include an escape route.27:141-161. help develop a “safe plan”—an emergency plan for escape if the partner becomes violent. Kelly L. conflict.” or “threaten. 1988:114-132. 1996. Pence E. or public humiliation. Wagner PJ.archfammed. Dennerstein L. 1993.” Do not use abstract words like “abuse. Med J Aust. avoid “taking charge. Burge. including emotional abuse. Finally. Fam Med. 2011 ©1998 American Medical Association. sexual and emotional violence against women: a general practice-based prevalence study. and ask them how they handle stress. Given the limitations of language. Urgent persuasion for change is warranted for the more physically dangerous relationships.” “hurt. themorepowerfulpartnermustsuppresstheother’sattempts to act or think independently or to detach from the partner. Qual Sociol. how should physicians identify and intervene with abuse? To begin. and a package with money. Hamberger LK. such as counseling centers. Chicago. Ryan V. and work in a collaborative fashion to promote the patient’s safety and recovery from victimization. follow up with the patient on a regular basis to assess levels of safety and psychological recovery.8 These strategies are almost always found in physically abusive relationships. Treat the medical problems and educate patients about the psychological effects of emotional or physical aggression. Help patients clarify the personal impact of their experiences and offer a sympathetic perspective. All rights reserved. 1995. Gelles RJ. the variation in insider and outsider perspectives. 1992. eds. Mazza D. 2. 6. The assault on the self: stages in coping with battering husbands. emotional abuse is an especially gray area. can suppress B’s contrary opinions with insults. Education Groups for Men Who Batter: The Duluth Model. a mode of transportation. a pattern of repeated. Straus MA. Of all forms of abuse. To prevent B from making independent financial decisions. Paymar M. however. B’s attempts at self-improvement through further education or advanced employment can be met with ridicule or accusations of bad parenting. For example. Straus MA.7:25-29. New York. and legal services. 8.334:1005-1010. physicians’ interventions should address both medical and psychological recovery9 with a focus on maintaining safety.48: 465-479. Diagnostic and Treatment Guidelines on Domestic Violence. 1998. threats. (N Engl J Med. If B’s friends disapprove of A. ARCH FAM MED/ VOL 7. the more powerful partner. routinely talk to patients about their relationships. 164:14-17. Validating the concept of abuse: women’s perceptions of defining behaviors and the effects of emotional abuse on health indicators. Calif: Sage Publications.) Downloaded from www. The article by Wagner and Mongan7 is the first to demonstrate that emotional abuse is associated with poorer health status and functioning and thus deserves intervention by health care personnel. alcohol or drug abuse or suicidality in the violent partner. 4. Escalation and desistance of wife assault in marriage. isolation. In abusive relationships. perhaps because the damage is less obvious or the aggression is more subtle. 1992. Saunders DG. Hovey M. A can counter B’s criticisms with threats or intimidation.” “assault. 9. shelters. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. A can control family finances and discourage employment by B. Emotional abuse gets less attention from health professionals. Newbury Park. or marital separation. criticism. In: Yllo K. a destination. How does one identify it? Pence and Paymar8 describe the key element in abusive relationships as a pattern of one partner’s power over the other. Mills T. For all levels of partner violence. Clinical Pearl Induction of Labor for Rupture of Membranes Induction of labor for term pregnancy with prelabor rupture of membranes was associated with more patient satisfaction and lower maternal infection but no difference in the rate of neonatal infection or cesarean section. intimidation. The key to intervention is to find a common language to describe the abusive experiences. escalating violence. Follow this with specific questions about violent and controlling behaviors using behavioral terms such as “hit.
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