Clinical and Health Affairs
Beyond “Do you feel safe at home?”
The Physician’s Role in Reducing Intimate Partner Homicide
By Amy Walsh, M.D.
ABSTRACT
Each year, more than a thousand women in the United States die as a result of intimate partner homicide. Firearms are involved in 60 percent of these murders. This article reviews the role firearms play in domestic violence and suggests actions physicians can take to reduce intimate partner homicide involving them. In addition to screening patients for domestic abuse, physicians can strive to improve data collection on intimate partner violence, foster better communication between victims and the police, and support policies that hold police officers and prosecutors accountable for taking guns out of the hands of abusers.
Nationally, about 1,200 women die each year as a result of intimate partner homicide.1,2 In Minnesota last year, at least 21 women died at the hands of their partner.3 One of them was an employee of University of Minnesota Physicians. The woman had been in a relationship that had been violent for some time but escalated after a breakup and dispute over child support. The woman was killed in a murder-suicide, and the perpetrator’s 6-year-old son was seriously wounded by a gunshot. The incident left the couple’s two biological children orphaned and the boy without a father.4
Intimate partner homicides are uniquely tragic because they are preventable.5 Typically, they occur after a series of repeated acts of domestic violence become more severe as time passes.6 In many cases, these incidents bring both victims and perpetrators into contact with the health care and criminal justice systems. One study found that 78% of domestic homicide victims had presented to the emergency department (ED) before the final incident.7 In another, 44% of victims of intimate partner homicide had presented to the ED during the two years prior to their deaths.8 These encounters offer health care providers realistic opportunities for detecting violence in a family or relationship and intervening.
Firearms and Domestic Violence
Husbands and boyfriends are often the most dangerous people in women’s lives. According to Federal Bureau of Investigation data, about 30% of women who are murdered are killed by an intimate partner.9
Studies that include boyfriends, common-law partners, ex-boyfriends, and spouses have found that closer to 50% of female homicide victims were killed by an intimate partner.9 In one study, 39% of California women who were living in domestic abuse shelters stated their partner owned a gun at some point during the relationship.10 About 65% of the women in households with guns stated that their partner had used a gun to scare, threaten, or harm them, with 5% stating that their partner had shot at them.10 Abusers have been known to threaten to shoot their partner; to clean, hold, or load a gun during an argument; to threaten to shoot a pet or person the victim cared about; and to shoot a gun during an argument.11 There is no doubt that in abusive relationships, guns are used to threaten, intimidate, injure, or kill (Table 1).
Restricting possession of firearms to those with a low risk for committing a gun crime is of paramount importance in maintaining public safety. Persons convicted of felonies have long been restricted from owning firearms. However, in 1994, a federal law was amended to prevent those with active protective orders against them from possessing firearms as well. In 1996, another federal law was amended to prohibit individuals who have been convicted of misdemeanor domestic violence from owning or possessing a firearm unless the conviction is overturned.12 It is estimated that the Domestic Violence Offender Gun Ban prevented the sale of 150,000 firearms nationally from 1996 to 2006.13
Both domestic violence advocates and gun rights advocates agree that Minnesota law is adequate for protecting victims from their abusers. Currently, individuals convicted of domestic violence-related crimes are restricted from owning firearms for three years, but only if a firearm was used in committing the offense.14 There is no state restriction for individuals currently under a restraining order; but police are, of course, able to enforce federal laws that prohibit such individuals from gun ownership.
The issue in maintaining public safety is enforcing gun laws. This is especially true in domestic violence cases because they are rarely isolated incidents. In the Safe at Home: 2002 Minnesota Crime Survey, 70% of people who reported domestic abuse stated that violent incidents occurred two or more times per year.15 Yet there is no means for seizing and storing weapons and no judicial consistency in upholding firearm statutes during sentencing of domestic violence offenders. Rothman et al. found that perpetrators who continued to possess firearms after they were prohibited from doing so by federal law were more likely to have attempted homicide or threatened their partners with guns than domestic violence perpetrators who relinquished their firearms.11
An analysis by Vigdor and Mercy found that state laws prohibiting individuals under a restraining order from access to firearms reduced the rate of intimate partner homicide by 8% compared with the rate before they went into effect.16 This was primarily, but not entirely, a reduction in firearm-related homicide, which suggests that removal of firearms may also result in a small decrease in nonfirearm-related violence. However, they did not find an effect on intimate partner homicide for individuals prohibited from possessing a firearm because of a domestic violence misdemeanor. The authors suggested that the relatively low impact of these laws has much more to do with the wide variance in enforcement than with the statutes themselves.16
The Doctor’s Role in Stopping Domestic Homicide
Physicians can play a key role in preventing deaths by breaking the cycle of domestic violence before disaster occurs. The way to do this is by screening for intimate partner violence, assessing the level of danger, and then connecting victims with services, among other things (Table 2).
The Danger Assessment, which helps objectively assess a person’s risk of dying at the hands of their abusers, is a useful tool that includes a calendar to help victims reflect on the frequency of their abuse.17 The assessment has had a significant effect in locations that have systematically implemented it. The state of Maryland now requires all first responders (eg, EMS and police) to use it. Since first responders began using the assessment in 2005, almost 30% of women found to be at high risk of being harmed have sought out domestic violence services.18 By comparison, only 4% of women killed by their partners ever received domestic violence services.19 Understanding how to use the tool well is important. Taking insufficient action with women whose scores are high leaves them at grave risk for homicide; but overreacting to low- to middle-range scores can leave women unnecessarily fearful of being killed.20
Because most victims of domestic violence do not disclose abuse to physicians,7 and only about one in five violent incidents are reported to police,21 the most important work that physicians can do to end domestic homicides may be to join with law enforcement and community groups and speak out about holding those responsible for the arrest, prosecution, sentencing, and probation of batterers accountable for their actions.
The most efficient way to reduce intimate partner homicide is to empower women economically and politically, as there is evidence that homicide rates correlate with poverty rates. For example, welfare benefits paid to individuals with dependent children have a direct negative relationship with homicide rates, suggesting that women who are economically self-sufficient are more likely to avoid situations that place them in danger.22 Education and job training help women achieve economic independence, giving them options that might enable them to leave an abusive relationship. Palma-Solis et al. found that relative increases in female employment, gender equality, and political participation by women correlated with a decrease in the rate of intimate partner homicide worldwide.22
Partnering with Law Enforcement
Physicians have already played a role in reducing the number of intimate partner homicides. Over the last 40 years, there has been a significant reduction in the lethality of assault, in no small part because of advances in emergency response, better technology, and improved trauma management.23 In Hennepin County, several physicians have joined with police, public defenders, city and county attorneys, advocacy organizations, academics, social workers, and judges to review domestic fatalities as part of the Hennepin County Domestic Fatality Review Board. This group makes annual recommendations with the aim of identifying gaps in the system, often focusing on fostering better communication between professionals and improving law enforcement. In 2003, the board identified strangulation as an important predictor of lethality. This led to a new state law making strangulation a felony offense.24 Their recommendations also have led to changes in the training of and procedures followed by police and county attorneys. For example, police are trained to identify strangulation and attempted strangulation cases, and attorneys are taught to recognize strangulation cases and prosecute them aggressively.
Law enforcement is the key to reducing intimate partner homicide. Although physicians can’t enforce laws, they can work with local law enforcement agencies in a number of ways. First, they can routinely share what they know about violence trends with local law enforcement. They should not assume that police know these trends. A hospital ED is an important source of nonconfidential information about violence. Within the ED, efforts should be made to connect victims interested in pressing charges with the appropriate local law enforcement agency.25 In addition to asking all assault patients at the time of ED registration whether they would like assistance reporting the abuse, emergency physicians and other ED staff can collect data on the circumstances of violence (with particular attention to violence in the home, on licensed premises, and in schools) and regularly disclose to the police nonconfidential information about assault times, weapons, assailants, and locations.25
Physician-police interaction can have a positive impact on public health. For example, emergency physicians in England discovered that broken glasses frequently were being used in bar fights. This prompted bars and restaurants to use glasses made of tougher material, which has led to a decrease in injuries.25 Groups throughout the country have been able to examine the interactions between victims and law enforcement, the medical community, and social services to recognize that strangulation is a significant indicator that the severity of domestic violence is increasing.
It is crucial that guns be kept out of the hands of abusers. To accomplish this, we need to make sure law enforcement officials look for guns at crime scenes, that probation officers frequently ask about the presence of firearms in the home and inspect the home for firearms, and that perpetrators of domestic violence are prosecuted and convicted. The City of Minneapolis is currently expanding a pilot project that resulted in a dramatic increase in conviction rates in domestic violence cases in the Fifth Precinct (from 54% in 2007 to 76% in 2008) by improving documentation of the events and injuries. However, it should be noted that Minneapolis police only asked the victim and perpetrator about the presence of a gun 20% of the time; they did not document searches of the scene.26
Fear of public outcry regarding firearm seizure may contribute to the reticence of police to seize weapons and of attorneys to prosecute gun offenders despite the fact that the public wants guns out of the hands of abusers. In a 2006 study by Sorenson, California residents were asked what they thought was the appropriate punishment for a perpetrator of domestic violence. Seventy percent of men and 84% of women surveyed wanted firearms taken away from these perpetrators.27 If such data were more widely disseminated, police, prosecutors, and judges might be more willing to take action on weapons, knowing they have public support.
Conclusion
The medical community has a role to play in increasing awareness of the increased risk that victims of domestic abuse face if they live in a home with weapons. Health care professionals must work to raise awareness of the need for increased prosecution and penalties for firearms possession by both felons and misdemeanor domestic violence offenders. Physicians can bring a nonpolitical, public health-oriented perspective to the discussion. No one wants to watch women continue to suffer at the hands of their batterers, and there are a number of actions that can be taken on their behalf: identifying victims and connecting them with services, advocating for women’s health and economic independence, raising awareness about the danger of firearms in the wrong hands, and encouraging those in power to take action to prevent dangerous people from keeping firearms are a few. Education, referral, and ongoing support and follow up for abused women could eventually reduce the prevalence of injury caused by abuse by as much as 75%.21 It is not easy to count the number of women who are not killed or beaten, but increasing those numbers should be the goal of all in health care. MM
Amy Walsh graduated from the University of Minnesota Medical School in May of 2009 and is an intern in emergency medicine at the University of Iowa. The author would like to thank Steven Miles, M.D., for his guidance in defining the research topic and reviewing this manuscript.
For More Information
If you are interested in establishing a domestic violence program in your clinic or improving your ability to screen and work with victims of domestic abuse, you’ll find helpful resources in the Family Violence Prevention Fund’s National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings (www.endabuse.org/section/programs/health_care/_consensus_guidelines).
The guidelines offer physicians recommendations for best practices in screening, safety planning, and implementing programs within a clinic or hospital. You will also find the Abuse Assessment Screen and the Danger Assessment, two validated screening tools, one for domestic abuse and the other for risk of intimate partner homicide, on the website. |
References
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