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September 10, 1997, Vol 278, No. 10 >
ARTICLE | September 10, 1997

Guidelines for Managing Domestic Abuse When Male and Female Partners Are Patients of the Same Physician FREE

Lorraine E. Ferris, PhD; Peter G. Norton, PhD, MD; Earl V. Dunn, MD; Elaine H. Gort, MSc; Naushaba Degani, MHSc
[+] Author Affiliations

Complete lists of Delphi Panel members and Consulting Group members appear at the end of this article.

Corresponding author: Lorraine E. Ferris, PhD, Department of Public Health Sciences, Faculty of Medicine, University of Toronto, McMurrich Building, Toronto, Ontario, Canada M5S IA8.


JAMA. 1997;278(10):851-857. doi:10.1001/jama.1997.03550100077043
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Article
References

Objective.  —To provide clinical guidelines for primary care physicians who are dealing with domestic abuse and who have both the abused woman and her partner as patients.

Participants.  —A 15-member expert panel with members having experience in family practice, gynecology, emergency medicine, medical ethics, nursing, psychology, law, and social work; an 11-member consulting group with members representing medicine, consumers, police, psychology, social work, and nursing; and participants from focus groups including 48 previously abused women and 10 previously abusive men. Members of the expert panel and the consulting group were recruited by the research team. Focus group members were recruited through the agencies from which they were receiving services.

Evidence.  —Available research information, and opinions of the expert panel, the consulting group, and the focus group participants.

Consensus Process.  —Scoring of 144 clinical scenarios was performed by the expert panel using a modified Delphi technique involving 4 iterations. Scenarios were rated in terms of best practice for primary care physicians dealing with suspected and confirmed cases of physical abuse. Consulting group members and focus group participants then commented on the panel's results. Final guidelines were approved by the panel and the consulting group, with comments reserved in the guidelines for information from focus group participants.

Conclusions.  —It is not a conflict of interest for the physician to deal with abuse of the female partner when both partners are patients. Both patients have a right to autonomy, confidentiality, honesty, and quality care. Patients should be dealt with independently, thereby facilitating assessment of the magnitude and severity of the victim's injuries. Physicians should not discuss the possibility of domestic abuse with the male partner without the prior consent of the abused female partner. Joint counseling is generally inadvisable and should be attempted only when the violence has ended, provided both partners give independent consent and the physician has adequate training and skills to deal with the situation without escalating the violence. If the physician feels unable to deal effectively with either patient because of the dual relationship, referral to another qualified physician is preferred.

REFERENCES

1 +
Hill MN, Weisman CS.  Physicians' perceptions of consensus reports . Int J Technol Assess Health Care . 1991;;7:30-41.
2 +
Straus MA, Gelles RJ.  Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys . J Marriage Fam . 1986;;48:465-479.
3 +
Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR.  Domestic violence against women. Incidence and prevalence in an emergency department population . JAMA . 1995;;273:1763-1767.
4 +
McCauley J, Kern DE, Kolodner K, et al.  The 'battering syndrome': prevalence and clinical characteristics of domestic violence in primary care internal medicine practices . Ann Intern Med . 1995;;123:737-746.
5 +
Burge SK.  Violence against women as a health care issue . Fam Med . 1989;;21:368-373.
6 +
Hoffman B, Toner BB.  The prevalence of spousal abuse in psychiatric in-patients: a preliminary study . Can J Community Ment Health . 1988;;7:53-60.
7 +
Novello AC, Rosenberg M, Saltzman L, Shosky J.  A medical response to domestic violence . JAMA . 1992;;267:3132.
8 +
Ontario Medical Association Co. Ontario Medical Review: Reports on Wife Assault . Ottawa, Ontario: Ontario Medical Association Co; 1986;.
9 +
Wilcoxen M. Assaulted Women: A Handbook for Health Professionals . Toronto, Ontario: Support Services for Assaulted Women; 1981;.
10 +
Urban/Rural Systems Associates (URSA) Institute. Domestic Violence Programs: National Analysis . San Francisco, Calif: URSA Institute; 1980;.
11 +
Bowker LH, Maurer L.  The medical treatment of battered wives . Women Health . 1987;;12:25-45.
12 +
Jaffe P, Wolfe DA, Wilson S, Zak L.  Emotional and physical health problems of battered women . Am J Psychiatry . 1986;;31:625-629.
13 +
Wolfe D, Jaffe PG, Wilson SK, Zak L.  Children of battered women: the relationship of child behaviour to family violence and maternal stress . J Consult Clin Psychol . 1985;;53:657-665.
14 +
Mehta P, Dandrea LA.  The battered woman . Am Fam Physician . 1988;;37:193-199.
15 +
Jaffe PG, Wolfe DA, Wilson SK. Children of Battered Women . Thousand Oaks, Calif: Sage Publishing; 1990;.
16 +
Lent B.  Diagnosing wife assault . Can Fam Physician . 1986;;32:547-549.
17 +
Herbert CP.  Family violence and family physicians: opportunity and obligation . Can Fam Physician . 1991;;37:385-390.
18 +
Alpert EJ.  Violence in intimate relationships and the practicing internist: new 'disease' or new agenda? Ann Intern Med . 1995;;123:774-781.
19 +
Ferris LE, Norton P, Dunn EV. A Study to Examine Dual Relationships: When the Wife Abuse Victim and Offender Are Patients of the Same Primary Care Physician . Ottawa, Ontario: Health Canada; 1995;. Grant 4887-06-93/00.
20 +
Ghent WR, DaSylva NP, Farren ME.  Family violence: guidelines for recognition and management . Can Med Assoc J . 1985;;132:541-553.
21 +
Bishop J, Patterson PGR.  Guidelines for the evaluation and management of family violence . Can J Psychiatry . 1992;;37:458-471.
22 +
Brown JB, Lent B, Sas G.  Identifying and treating wife abuse . J Fam Pract . 1993;;36:185-191.
23 +
Council on Scientific Affairs, American Medical Association.  Violence against women: relevance for medical practitioners . JAMA . 1992;;267:3184-3189.
24 +
Ontario Medical Association Committee on Wife Assault.  Spousal assault: The criminal justice system and the role of the physician . In: Reports on Wife Assault . Toronto, Ontario: Ontario Medical Association; 1991;.
25 +
American Medical AssociationDiagnostic and Treatment Guidelines on Domestic Violence . Chicago, Ill: American Medical Association; 1992;.
26 +
Tarasoff v. Regents of University of California, et al., 131 Cal Rpt 14,551 P 2d 34,334 (Cal 1976).
27 +
Salber P, Taliaferro E. The Physician's Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse...Another Way to Save a Life . Volcano, Calif: Volcano Press; 1995;.
28 +
Sassetti MR.  Domestic violence . Prim Care . 1993;;20:289-305.
29 +
American Medical Association. Diagnostic and Treatment Guidelines on Child Physical Abuse and Neglect . Chicago, Ill: American Medical Association; 1992;.
30 +
Viken RM.  Family violence: aids to recognition . Postgrad Med J . 1982;;71:115-122.
31 +
Ferris LE, McMain-Klein M, Silver L.  Documenting wife abuse: a guide for physicians . Can Med Assoc J . 1997;;156:1015-1022.
32 +
Trute B, Sarsfield P, Mackenzie D.  Medical response to wife abuse: a survey of physicians' attitudes and practices . Can J Community Ment Health . 1988;;7:61-71.
33 +
Hart B.  Beyond the 'duty to warn': a therapist's 'duty to protect' battered women and children . In: Yllo K, Bograd M, eds. Feminist Perspectives on Wife Abuse . Thousand Oaks, Calif: Sage Publishing; 1988;:234-248.
34 +
Sonkin DJ, Margin D, Walker LE. The Male Batterer: A Treatment Approach . New York, NY: Springer Publishing Co Inc; 1985;.
35 +
Strauss MA.  Measuring intrafamily conflict and violence: the Conflict Tactics (CT) scales . J Marriage Fam . 1979;;41:75-88.
36 +
Neidig P. The Modified Conflict Tactics Scale . Beaufort, SC: Behavioural Science Associates; 1986;.
37 +
Ferris LE, Sandercock J, Hoffman B, et al. Risk assessments for acute violence to third parties: a review of the literature. Can J Psychiatry. In press.
38 +
Beck JC, White KA, Gage B.  Emergency psychiatric assessment of violence . Am J Psychiatry . 1991;;148:1562-1565.
39 +
Swanson J.  Mental disorder, substance abuse, and community violence: an epidemiological approach . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments In Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:101-136.
40 +
Hart SD, Hare RD, Forth AE.  Psychopathy as a risk marker for violence: development and validation of a screening version of the revised psychopathy checklist . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments In Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:81-98.
41 +
Convit A, Jaeger J, Lin SP, Meisner M, Volavka J.  Prediction of assaultive behavior in psychiatric inpatients: is it possible?  In: Brizer DA, Crowner M, eds. Current Approaches to the Prediction of Violence . Washington, DC: American Psychiatric Press; 1989;.
42 +
Lidz CW, Mulvey EP, Gardner W. The accuracy of predictions of violence to others . JAMA . 1993;;269:1007-1011.
43 +
Else LT, Wonderlich SA, Beatty WW, Christie DW, Staton RD.  Personality characteristics of men who physically abuse women . Hosp Community Psych . 1993;;44:54-58.
44 +
Widiger TA, Trull TJ.  Personality disorders and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:203-226.
45 +
Teplin LA, Abram KM, McClelland GM.  Does psychiatric disorder predict violent crime among released jail detainees? Am Psychol . 1994;;49:335-342.
46 +
McNiel DE.  Hallucinations and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:183-202.
47 +
Taylor PJ, Garety P, Buchanan A, Reed A, Wessely S, Ray K.  Delusions and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:161-182.
48 +
Rossi AM, Jacobs M, Monteleone M, et al.  Characteristics of psychiatric patients who engage in assaultive or other fear-inducing behaviors . J Nerv Ment Dis . 1986;;174:154-160.
49 +
Binder RL, McNiel DE.  Effects of diagnosis and context on dangerousness . Am J Psychiatry . 1988;;145:728-732.
50 +
McNiel DE, Binder RL.  The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence . Hosp Community Psych . 1994;;45:133-137.
51 +
Gondolf EW, Mulvey EP, Lidz CW.  Characteristics of perpetrators of family and nonfamily assaults . Hosp Comm Psych . 1990;;41:191-193.
52 +
Asnis GM, Kaplan ML, van Praag HM, Sanderson WC.  Homicidal behaviors among psychiatric outpatients . Hosp Comm Psych . 1994;;45:127-132.
53 +
Apter A, Kotler M, Sevy S, Plutchik R, Brown SL, Foster H.  Correlates of risk of suicide in violent and nonviolent psychiatric patients . Am J Psychiatry . 1991;;148:883-887.
54 +
Convit A, Jaeger J, Lin SP, Meisner M, Volavka J.  Predicting assaultiveness in psychiatric patients: a pilot study . Hosp Comm Psych . 1988;;39:429-434.
55 +
Apter A, Plutchik R, van Praag HM.  Anxiety, impulsivity, and depressed mood in relation to suicidal and violent behavior . Acta Psychiatr Scand . 1993;;87:1-5.
56 +
Segal SP, Watson MA, Goldfinger SM, Averbuck DS.  Civil commitment in the psychiatric emergency room, II: mental disorders indicators and three dangerousness criteria . Arch Gen Psychiatry . 1988;;45:753-758.
57 +
McNiel DE, Binder RL.  Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence . Am J Psychiatry . 1995;;152:901-906.
58 +
Saunders DG.  A typology of men who batter: three types derived from cluster analysis . Am J Orthopsychiatry . 1992;;62:264-275.
59 +
Hart SD, Dutton DG, Newlove T.  The prevalence of personality disorder among wife assaulters . JPersonal Disord . 1992;;7:328-340.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Hill MN, Weisman CS.  Physicians' perceptions of consensus reports . Int J Technol Assess Health Care . 1991;;7:30-41.
2 +
Straus MA, Gelles RJ.  Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys . J Marriage Fam . 1986;;48:465-479.
3 +
Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR.  Domestic violence against women. Incidence and prevalence in an emergency department population . JAMA . 1995;;273:1763-1767.
4 +
McCauley J, Kern DE, Kolodner K, et al.  The 'battering syndrome': prevalence and clinical characteristics of domestic violence in primary care internal medicine practices . Ann Intern Med . 1995;;123:737-746.
5 +
Burge SK.  Violence against women as a health care issue . Fam Med . 1989;;21:368-373.
6 +
Hoffman B, Toner BB.  The prevalence of spousal abuse in psychiatric in-patients: a preliminary study . Can J Community Ment Health . 1988;;7:53-60.
7 +
Novello AC, Rosenberg M, Saltzman L, Shosky J.  A medical response to domestic violence . JAMA . 1992;;267:3132.
8 +
Ontario Medical Association Co. Ontario Medical Review: Reports on Wife Assault . Ottawa, Ontario: Ontario Medical Association Co; 1986;.
9 +
Wilcoxen M. Assaulted Women: A Handbook for Health Professionals . Toronto, Ontario: Support Services for Assaulted Women; 1981;.
10 +
Urban/Rural Systems Associates (URSA) Institute. Domestic Violence Programs: National Analysis . San Francisco, Calif: URSA Institute; 1980;.
11 +
Bowker LH, Maurer L.  The medical treatment of battered wives . Women Health . 1987;;12:25-45.
12 +
Jaffe P, Wolfe DA, Wilson S, Zak L.  Emotional and physical health problems of battered women . Am J Psychiatry . 1986;;31:625-629.
13 +
Wolfe D, Jaffe PG, Wilson SK, Zak L.  Children of battered women: the relationship of child behaviour to family violence and maternal stress . J Consult Clin Psychol . 1985;;53:657-665.
14 +
Mehta P, Dandrea LA.  The battered woman . Am Fam Physician . 1988;;37:193-199.
15 +
Jaffe PG, Wolfe DA, Wilson SK. Children of Battered Women . Thousand Oaks, Calif: Sage Publishing; 1990;.
16 +
Lent B.  Diagnosing wife assault . Can Fam Physician . 1986;;32:547-549.
17 +
Herbert CP.  Family violence and family physicians: opportunity and obligation . Can Fam Physician . 1991;;37:385-390.
18 +
Alpert EJ.  Violence in intimate relationships and the practicing internist: new 'disease' or new agenda? Ann Intern Med . 1995;;123:774-781.
19 +
Ferris LE, Norton P, Dunn EV. A Study to Examine Dual Relationships: When the Wife Abuse Victim and Offender Are Patients of the Same Primary Care Physician . Ottawa, Ontario: Health Canada; 1995;. Grant 4887-06-93/00.
20 +
Ghent WR, DaSylva NP, Farren ME.  Family violence: guidelines for recognition and management . Can Med Assoc J . 1985;;132:541-553.
21 +
Bishop J, Patterson PGR.  Guidelines for the evaluation and management of family violence . Can J Psychiatry . 1992;;37:458-471.
22 +
Brown JB, Lent B, Sas G.  Identifying and treating wife abuse . J Fam Pract . 1993;;36:185-191.
23 +
Council on Scientific Affairs, American Medical Association.  Violence against women: relevance for medical practitioners . JAMA . 1992;;267:3184-3189.
24 +
Ontario Medical Association Committee on Wife Assault.  Spousal assault: The criminal justice system and the role of the physician . In: Reports on Wife Assault . Toronto, Ontario: Ontario Medical Association; 1991;.
25 +
American Medical AssociationDiagnostic and Treatment Guidelines on Domestic Violence . Chicago, Ill: American Medical Association; 1992;.
26 +
Tarasoff v. Regents of University of California, et al., 131 Cal Rpt 14,551 P 2d 34,334 (Cal 1976).
27 +
Salber P, Taliaferro E. The Physician's Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse...Another Way to Save a Life . Volcano, Calif: Volcano Press; 1995;.
28 +
Sassetti MR.  Domestic violence . Prim Care . 1993;;20:289-305.
29 +
American Medical Association. Diagnostic and Treatment Guidelines on Child Physical Abuse and Neglect . Chicago, Ill: American Medical Association; 1992;.
30 +
Viken RM.  Family violence: aids to recognition . Postgrad Med J . 1982;;71:115-122.
31 +
Ferris LE, McMain-Klein M, Silver L.  Documenting wife abuse: a guide for physicians . Can Med Assoc J . 1997;;156:1015-1022.
32 +
Trute B, Sarsfield P, Mackenzie D.  Medical response to wife abuse: a survey of physicians' attitudes and practices . Can J Community Ment Health . 1988;;7:61-71.
33 +
Hart B.  Beyond the 'duty to warn': a therapist's 'duty to protect' battered women and children . In: Yllo K, Bograd M, eds. Feminist Perspectives on Wife Abuse . Thousand Oaks, Calif: Sage Publishing; 1988;:234-248.
34 +
Sonkin DJ, Margin D, Walker LE. The Male Batterer: A Treatment Approach . New York, NY: Springer Publishing Co Inc; 1985;.
35 +
Strauss MA.  Measuring intrafamily conflict and violence: the Conflict Tactics (CT) scales . J Marriage Fam . 1979;;41:75-88.
36 +
Neidig P. The Modified Conflict Tactics Scale . Beaufort, SC: Behavioural Science Associates; 1986;.
37 +
Ferris LE, Sandercock J, Hoffman B, et al. Risk assessments for acute violence to third parties: a review of the literature. Can J Psychiatry. In press.
38 +
Beck JC, White KA, Gage B.  Emergency psychiatric assessment of violence . Am J Psychiatry . 1991;;148:1562-1565.
39 +
Swanson J.  Mental disorder, substance abuse, and community violence: an epidemiological approach . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments In Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:101-136.
40 +
Hart SD, Hare RD, Forth AE.  Psychopathy as a risk marker for violence: development and validation of a screening version of the revised psychopathy checklist . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments In Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:81-98.
41 +
Convit A, Jaeger J, Lin SP, Meisner M, Volavka J.  Prediction of assaultive behavior in psychiatric inpatients: is it possible?  In: Brizer DA, Crowner M, eds. Current Approaches to the Prediction of Violence . Washington, DC: American Psychiatric Press; 1989;.
42 +
Lidz CW, Mulvey EP, Gardner W. The accuracy of predictions of violence to others . JAMA . 1993;;269:1007-1011.
43 +
Else LT, Wonderlich SA, Beatty WW, Christie DW, Staton RD.  Personality characteristics of men who physically abuse women . Hosp Community Psych . 1993;;44:54-58.
44 +
Widiger TA, Trull TJ.  Personality disorders and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:203-226.
45 +
Teplin LA, Abram KM, McClelland GM.  Does psychiatric disorder predict violent crime among released jail detainees? Am Psychol . 1994;;49:335-342.
46 +
McNiel DE.  Hallucinations and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:183-202.
47 +
Taylor PJ, Garety P, Buchanan A, Reed A, Wessely S, Ray K.  Delusions and violence . In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment . Chicago, Ill: The University of Chicago Press; 1994;:161-182.
48 +
Rossi AM, Jacobs M, Monteleone M, et al.  Characteristics of psychiatric patients who engage in assaultive or other fear-inducing behaviors . J Nerv Ment Dis . 1986;;174:154-160.
49 +
Binder RL, McNiel DE.  Effects of diagnosis and context on dangerousness . Am J Psychiatry . 1988;;145:728-732.
50 +
McNiel DE, Binder RL.  The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence . Hosp Community Psych . 1994;;45:133-137.
51 +
Gondolf EW, Mulvey EP, Lidz CW.  Characteristics of perpetrators of family and nonfamily assaults . Hosp Comm Psych . 1990;;41:191-193.
52 +
Asnis GM, Kaplan ML, van Praag HM, Sanderson WC.  Homicidal behaviors among psychiatric outpatients . Hosp Comm Psych . 1994;;45:127-132.
53 +
Apter A, Kotler M, Sevy S, Plutchik R, Brown SL, Foster H.  Correlates of risk of suicide in violent and nonviolent psychiatric patients . Am J Psychiatry . 1991;;148:883-887.
54 +
Convit A, Jaeger J, Lin SP, Meisner M, Volavka J.  Predicting assaultiveness in psychiatric patients: a pilot study . Hosp Comm Psych . 1988;;39:429-434.
55 +
Apter A, Plutchik R, van Praag HM.  Anxiety, impulsivity, and depressed mood in relation to suicidal and violent behavior . Acta Psychiatr Scand . 1993;;87:1-5.
56 +
Segal SP, Watson MA, Goldfinger SM, Averbuck DS.  Civil commitment in the psychiatric emergency room, II: mental disorders indicators and three dangerousness criteria . Arch Gen Psychiatry . 1988;;45:753-758.
57 +
McNiel DE, Binder RL.  Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence . Am J Psychiatry . 1995;;152:901-906.
58 +
Saunders DG.  A typology of men who batter: three types derived from cluster analysis . Am J Orthopsychiatry . 1992;;62:264-275.
59 +
Hart SD, Dutton DG, Newlove T.  The prevalence of personality disorder among wife assaulters . JPersonal Disord . 1992;;7:328-340.

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