Doctoring domestic violence

There is nothing GPs can do about violence in the home - and they shouldn't even try.

Dr Michael Fitzpatrick

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‘Routine questioning about domestic violence [by GPs] should be thought of as a way of uncovering and reframing a hidden stigma.’ (‘Reported frequency of domestic violence: cross-sectional survey of women attending general practice’, Fiona Bradley et al, British Medical Journal, 2 February 2002 (1))

If a ‘hidden stigma’ is a contradiction in terms, the term ‘violence’ is also used here with little respect for definition. The goal of this survey, conducted in 22 general practices in Ireland, was to ‘uncover’ a wide range of interpersonal bad behaviour and to ‘reframe’ it in terms of violence. A common feature of the flourishing literature on domestic violence in medical practice is the inflation of the concept of violence beyond its familiar usage, which refers to the deployment of physical force.

The authors of this survey use a definition of domestic violence that ‘incorporates three dimensions of abuse: controlling behaviours, violent incidents and consequent injuries’. ‘Controlling behaviours’ include ‘shouted, screamed at you’, ‘criticised you’, ‘put you down in front of others’, ‘restricted your social life’, ‘checked your movements’, ‘threatened you’, ‘shouted at, threatened the kids’ and ‘kept you short of money’. Violent behaviours include ‘punched walls, furniture’, ‘shouted at, threatened the kids’, ‘pushed, grabbed, shoved you’, as well as a range of more directly aggressive acts.

Questionnaires completed by 1700 women revealed that 69 percent had experienced controlling behaviours (as specified) and 39 percent had experienced violent incidents. The only surprise is that, with these definitions on offer, the rates were not even higher.

What is achieved by this sort of survey, which encourages women to re-interpret their experiences of personal strife in terms of different categories of violence and abuse?

It confirms the authors’ prejudice that domestic violence (as they have defined it) is a problem affecting, not a small minority, but a substantial majority of society. This justifies approaching domestic violence as though it were a universal activity: every man should be assumed to be abusing his spouse until proved otherwise. The immediate losers in this propagandist distortion of the meaning of violence are those women who suffer serious assaults by their partners, whose experience is trivialised by lumping it together with victims of ‘being shouted at’.

The ‘reframing’ of diverse forms of interpersonal conflict as manifestations of violence reveals a simplistic and misanthropic view of human relationships. From this jaundiced perspective, all men are bastards, all women are victims; all human beings are vicious or pathetic, degraded creatures, and the only hope for humanity lies through expert professional intervention.

At a time when the decline of political and social engagement has diminished the public sphere, there has been a tendency for people to retreat into the realm of personal and family relationships. But in the view of many contemporary observers, this private world is no haven, but a sphere of brutality and abuse, in which adults exploit children, men terrorise women and even siblings and grandparents are at risk of violence.

For the authors of this report, the very act of inquiry into domestic violence is beneficial in itself, because it opens up the private realm to public scrutiny. However, as an accompanying editorial in the same issue of the British Medical Journal (BMJ) points out, the promoters of the cause of domestic violence in general practice are in favour of more direct interventions. They are keen on inviting action by the police and the courts, but more importantly, they want GPs to play a more active role in policing the home front, encouraging training and counselling programmes of both a preventive and therapeutic character.

Director of the Gender and Health Group Rachel Jewkes, author of the BMJ editorial, is concerned that the ‘lack of evidence of effectiveness of interventions may pose a barrier to action’, insisting that ‘it is premature to suggest that lack of evidence equates to ineffectiveness’ (2). But surely it is ‘premature’ to propose widespread intervention before there is evidence of its efficacy? (Unless, of course, you consider that the need for such intervention is self-evident, in which case there is no need to evaluate pilot projects in the first place.)

The advocates of a more intrusive role for GPs in domestic conflicts appear not to recognise any potential dangers in this dramatic expansion in medical practice. But the resulting erosion of the boundary between the private and public spheres and the extension of medical intervention into intimate personal behaviour and the relationships of patients has far-reaching consequences. The diminution of the scope and autonomy of the private sphere constrains the potential for development of the individual through intimate relationships. Such development, from childhood through to adult life, requires privacy and can only be damaged by external interference, however well-meaning.

Doctors have very limited knowledge or expertise in the sphere of intra-personal and interpersonal development. Their crass intrusion into these areas as the face of public authority claiming to protect women from the vicissitudes of interpersonal strife is destined to end in disaster. It will do nothing to protect women, but it will undermine doctors’ capacity to fulfil a professional medical role, which sometimes requires them to maintain a degree of distance from their patients’ personal difficulties.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

Statistical abuse, by Josie Appleton

spiked-issue: Domestic violence

(1) ‘Reported frequency of domestic violence: cross-sectional survey of women attending general practice’, Fiona Bradley et al, British Medical Journal, 2 February 2002; 324: 271-4

(2) ‘Preventing domestic violence’, Rachel Jewkes, British Medical Journal, 2 February 2002; 324:253-4

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