Doctors cannot stop domestic violence

‘Intimate partner violence, which may be physical, sexual or emotional, is a major public health problem because of the long-term health consequences for women who have experienced it and for their children who witness the overt violence and coercion.’ (1)

This statement, in a recent editorial in the British Journal of General Practice, signals a renewed campaign sponsored by the medical establishment, to make the detection of domestic violence – now relabelled ‘intimate partner violence’ – the responsibility of family doctors.

Controversy rages over whether GPs should ‘screen’ their patients, by routinely inquiring whether patients are victims of abuse, or limit such inquiries to women who present with mental health problems. But medical authorities agree that GPs need more training in the recognition of abuse and in the approved techniques for dealing with it – even though, as the author of the editorial quoted above admits, there has been no confirmation of the ‘effectiveness of interventions following screening’.

In addition to receiving exhortations to do more about domestic violence, as a GP I am now obliged to undergo special ‘child protection’ training and am also the target of propaganda to raise my awareness of ‘elder abuse’ and other areas of victimhood in which needs remain ‘unmet’.

The discussion of domestic violence that has assumed such prominence in medical journals suffers from a lack of historical and sociological perspective. The concepts of ‘abuse’ and its presumed consequences of ‘low self-esteem’ and ‘post-traumatic stress syndrome’ are taken at face value instead of being understood as recently constructed categories that provide a framework for the reinterpretation of personal experience at a particular historical moment.

Over the past decade an obsession with abuse as a pervasive feature of all intimate relationships has risen to acquire an extraordinary prominence in Western society. It is now widely accepted that diverse forms of intimidation and exploitation are commonplace – if not universal – in relationships between sexual partners (including same-sex relationships and male as well as female victims), between adults and children (child abuse, especially sexual abuse, not forgetting ‘elder abuse’), even among children (bullying, pathological peer pressure). Abusive relationships of all sorts provide the themes for a vast outpouring of novels, plays, films, documentaries – not to mention court cases and news reports.

Take, for example, the current non-fiction paperback bestsellers in Britain. Six of the Top 10 books feature themes of abuse. At number 2, Kathy O’Beirne tells her story, ‘a true tale of a childhood destroyed by neglect and fear’. At number 3, Roberta Taylor’s memoir of an East End childhood offers an account of ‘an embattled family at war with itself and the outside world’, a story of ‘emotional blackmail, illegitimacy, adoption and even murder’. The list includes two books by Torey Hayden, whose experience as a psychotherapist with abused and traumatised children has provided the raw material for a series of tearjerkers. Sharon Osbourne’s autobiography tells of ‘life with a wife-beating, drug-addicted, sex-crazed alcoholic’. After this catalogue of degradation, it is almost a relief to find – albeit at number 10 – Gloria Hunniford’s uplifting tribute to her daughter who died from cancer.

Two recent childhood memoirs offer a valuable contrast. Bryan Magee tells the story of his upbringing in East London in the 1930s; John McGahern grew up in rural Ireland in the 1940s and 1950s (2, 3). Both are finely observed and elegantly told stories of childhood and family life. Both are also deeply moving accounts of childhood trauma and neglect. Both writers detail the pervasive violence of their respective societies and relate their experiences of violence in the home, at school and in the wider community. Both are also accounts, not of ‘survival’ – the highest aspiration of the contemporary culture of abuse – but of transcendence.

If the violence that characterised family life in the recent past is shocking, so too is the level of emotional ill-treatment. The memoirs of TV chef Nigel Slater and Beatles biographer Philip Norman emphasise the callous neglect of children in middle-class English families in the 1950s, when it seems that many parents behaved without regard for the mental states of their children (4, 5).

While the worlds described in these memoirs are recognisable, they also seem strikingly remote. What is remarkable is the dramatic decline in the scale and social acceptability of violence in the home over the course of the postwar decades. This trend was accompanied by a growing recognition of the emotional needs of children – reflected in controversies about maternal deprivation and institutionalisation and the steady retreat from corporal punishment in schools and in the home. No doubt the causes of these major cultural shifts are complex. In his history of the twentieth century, Eric Hobsbawm writes of the social and cultural ‘revolutions’ that took place between 1945 and 1990, characterised by rising living standards, greater sexual equality and the decline of patriarchal authority in the family (5).

In short, it appears that the development of more civilised relations between the sexes and the generations was the consequence of the wider social progress that occurred in the second half of the twentieth century. By contrast, over the past decade, not only has social progress apparently ceased, but in the prevailing climate of postmodernist cyncisim, the very concept has been repudiated. At a time when society has lost faith in the possibility of collective solutions to personal and social problems, the individual is reduced to the status of victim whose survival depends upon professional recognition and support.

The project of medicalising ‘intimate partner violence’ can best be understood as a morbid symptom of the culture of abuse. Far from helping vulnerable individuals, it is likely to compound their diminished autonomy and reinforce their dependency. The lesson of history is that improving the quality of human relationships is a social not a medical project.

Dr Michael Fitzpatrick is author of The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). An edited version of this article appeared in the June issue of the British Journal of General Practice.

(1) Feder G. Responding to intimate partner violence: what role for general practice? (editorial). British Journal of General Practice 2006; 56: 243-4 (April)

(2) Magee B. Clouds of Glory: A Hoxton Childhood. London: Jonathan Cape, 2004

(3) McGahern J. Memoir. London: Faber, 2005

(4) Slater N. Toast: The Story of a Boy’s Hunger. London: Harper, 2004

(5) Norman P. Babycham Night: A Boyhood at the End of the Pier. London: Pan, 2004

(6) Hobsbawm E. Age of Extremes: The Short Twentieth Century. London: Michael Joseph, 1994