Domestic violence Dr Ravi Nanayakkara Objectives • Discuss what is meant by domestic violence, diagnosis of domestic violence and medico legal issues Violence The World Health Organization (WHO) declares violence as intentional use of physical force or power, threatened or action against one self, another or against a group or community that either results in or has a high likelihood of injury, death, psychological harm, maldevelopment. • This definition excluded unintentional incidents such as road traffic injuries. Violence • Self directed • Interpersonal • Collective Violence Self-directed Suicidal behavior Self abuse Interpersonal Family/ partner Child Nature of violence Physical Sexual Psychological Deprivation or neglects Community Elder PARTNER Collective social Acquaintance Stranger Economic Political Model to illustrate the multiple levels of violence 4 3 2 1. Biological and personal factors 2. Relationship with peers, intimate partners etc. 3. Factors related to the community 4. Societal factors that influence violence 1 Domestic violence • Violence occurred at home/domestic environment • Intimate partner violence Wife battery • Child abuse • Abuse of elderly • Domestic violence is a pattern of coercive behavior used to establish power and control over another person--usually an intimate partner. It happens when one person believes they are entitled to control another and can include physical, psychological, emotional, verbal, sexual, and/or economic abuse • Why does domestic violence happen? Abusive relationships can develop gradually. There is a definite cycle that combines the good times with often subtle abusive acts that allow the abuser to gain power and control over the relationship and, eventually, lead the victim to emotional dependence and learned helplessness. By the time a pattern has emerged there are often children involved, financial ties, and emotional bonds that are difficult to break. Intimate partner violence • Intimate partner violence is defined as violence instigated by marital, cohabiting or any other partner within intimate relationships. Battered wife • A woman who has suffered demonstrable and repeated physical injuries at the hands of the man with whom she lives or from the father of one of her children. ICD 995.81 • Intimate Partner Violence (IPV) is a currently emerging problem in Sri Lanka. Although during the past it was thought of as a private matter in the family, now there is some awareness among the community. • Intimate Partner Violence/Domestic violence Violence against women at home 1988 Jaffna 1998 Colombo • Associated with • Poverty • Poor education • Alcohol • Injuries Head and face Blunt injuries prominent Contusions mainly • Sources of Accident Service of National Hospital Sri Lanka stated 5-10% of annual admissions to the unit were following domestic violence. Risk factors for IPV • Socio economic factors • Factors related to health of both partners • Factors related to the partnership of both individuals • Factors related to the male partner • Previous violence • Socio economic factors – Poverty – Low socio economic status of the male partner – Low socio economic status of both partners – Low female contribution to household income – Poor education of the women – Poor education of the man – Young age of the women – Single marital status – Urban residence – Parity • Factors related to health of both partners Fair / poor mental health of the women Partners’ poor mental health Women’s self reported poor health • Factors related to the partnership of both individuals • History of the violence in husband’s family • Parity • Female sterility /not having children • Relationship being longer • Prior domestic violence • Sexual jealousy • Having other partner/s • Conflicts about man’s infidelity • Conflicts about sex • Factors related to the male partner Cigarette smoking Alcohol consumption by male Drug abuse by the partner Man’s boy child preference /not having a male child Involvement in fights at work or in the community Previous violence • Violence in woman’s childhood • Woman abused by the parents • History of violence in husbands family Triggers for IPV • • • • • • • • Not obeying the man Arguing back Not having food ready on time Not caring adequately for the children or home Questioning the man about money or girl friends Going somewhere without the man’s permission Refusing the man sex Man suspecting the woman of infidelity Types of abuse Acts of physical aggression (Slapping, Hitting, beating) Psychological abuse (Threats, intimidation, etc). Forced intercourse and other forms of sexual abuse Various controlling behaviors (Isolation, Restriction of access to assistance) Presentation to JMO • Referred by OPD/ward • Directly from police during their complaint • Various organizations • WIN, Kantha Pihita… Identification IPV • History – Some time victim wants to hide – Ask directly – False story – Risk factors Injury pattern • Anatomical area o Head and face o Upper limbs o Lower limbs o Neck o Chest and abdomen 300 250 200 150 100 50 0 Head and face Neck Chest antr. Chest P o str. A bdo m en antr. A bdo m en P o str. pelvis Upper limb right Upper limb left Lo wer Limb right Lo wer Limb left Study gruo p 266 31 40 37 26 16 3 80 82 32 39 Co mparative gro up 131 13 74 19 23 28 1 121 87 44 16 Study gruop Comparative group Injury pattern • Nature of injuries o Contusions o Abrasions o Lacerations o Cuts o Burns o Fractures o Stabs Injury pattern • • • • Severity / category 80% simple/non grievous 20% Grievous <1% FIOCN/NF The distribution of the category of hurt among the FSIPV Offending weapon • House hold blunt weapon • Broom • Clubs • Cutting weapons • Acid • Hot water FSIPV Mode of assault FSGV No. % (n=300) No. % (n=300) Hand Hands and feet Blunt household weapons Sharp household weapons Weapons used for crimes Chemicals 193 64.3 128 42.7 65 21.7 48 16.0 91 30.3 73 24.3 43 14.3 59 19.6 3 1.0 43 14.3 5 1.6 6 2.0 Hot water Attempted to kill Others 4 1.3 5 1.7 9 3.0 14 4.7 13 4.3 16 5.3 Health consequences of IPV • Physical • Psychological • Sexual • Physical Abdominal/ thoracic injuries Bruises and cuts Chronic pain syndrome Disability Fibromyalgia Fracture Gastrointestinal disorder Irritable bowel syndrome Laceration and abrasion Ocular damage Reduced physical functioning • Sexual and reproductive Gynaecological disorder Infertility Pelvic inflammatory disease Pregnancy complication Sexual dysfunction Sexually transmitted diseases including HIV Unsafe abortion Unwanted pregnancy • Physiological and behavioral Alcohol and drug abuse Depression and anxiety Eating and sleeping disorder Feeling of shame and guilt Phobias and panic disorder Physical inactivity Poor self-esteem Post-traumatic stress disorder Psychosomatic disorder Smoking Suicidal behavior and self-harm Unsafe sexual behavior Postmortem findings • Not common • History – Risk factors, triggers • External injuries • Blunt injuries • Sharp injuries • Acid burns • Internal injuries • Musculo skeletal dissection Medical officers duty • • • • • • • Acute management Management of consequences of IPV Refer to police Refer for counseling, including partner Guide for social support – WIN… Guide for legal support – LAC Follow up including local health care provider Prevention of IPV • • • • • • • • • • Social support for the victims (Occupation, shelter) Legal assistance for the victims Create organizations/groups for support Change social attitude Special police women desks / WPC Educational programmes (School – public) Address the risk factors Create/amend the laws to punish offenders Manage/Follow up the offenders Counseling service (Both) Laws related to Domestic violence Abuse of Elderly • Definition Elder abuse is a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an elder person. Act of commission or omission. Types of abuse • Physical abuse – the infliction of pain or injury. • Psychological or emotional abuse – the infliction of mental anguish. • Financial or material abuse – the illegal or improper exploitation or use of funds or resources of old person. Contd.. • Sexual abuse – non-consensual sexual contact of any kind with older person. • Neglect – refusal or failure to fulfill a care giving obligation. This may or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the older person. Risk factors.. • Individual factors. • Relationship factors. • Community and society factors. Health consequences • • • • Depression Psychological distress Suicide tendency Physical illness due to negligence….. Medical officers duty.. Prevention.. Thank you!