What underlies abuse
What would primary prevention of violence against women look like if it were conducted at office visits by family physicians? To answer this we need to examine the dynamic underlying the violence. We know that battering is not just the violence, yet we get fixated on that aspect of it. We seek explanations that have to do with violence (the media, gun control, need for skills in conflict resolution, and anger management). We neglect to consider what we also know: That battering is “a set of learned controlling behaviors and attitudes of entitlement that are culturally supported and produce a relationship of entrapment.”30 Such dynamics are difficult for us to face and can be even more difficult to comprehend. Even in the absence of physical abuse the controlling behaviors are directly harmful to women; the health status of women who have been emotionally abused is measurably worse than that of nonabused women.31,32 We must look beyond the violence to the issue of control of women by men.
We need to look at the origins behind men feeling that they have a right to control women, and we need to make a commitment to changing how we raise both girls and boys to eradicate this sense of entitlement. So far, family medicine has made no such commitment. To do so, we need to develop a set of skills to work with parents and children regarding issues of control, hitting, fighting, fighting back, and using violent tactics to get what you want. Fortunately, the clinical tools to do this work have been developed by Stringham,33 who has incorporated questions about violence and control into every visit. He and his colleagues have found that certain screening questions for adolescents have a high predictability for subsequent violence-related injuries and can be used to stratify risk of future injury.34 Using his consistent philosophy over a 20-year period he has shown thousands of families in a working class community how to raise children with self-respect and without violence.
Asking the hard questions
Questioning how a man handles himself and his sexuality with women challenges his manhood, which can be very difficult territory. We would rather talk about exercise and diet than go to the hard questions: Do you ever feel you have to hit or swear at your girlfriend? Do you ever force your wife to have sexual relations when she might not want to? Do you ever feel that you should be able to control her? Also, to whom would we pose these questions: all men, just men who we think are likely to be abusive, men who seem to fit a macho stereotype, men who drink more than we think they should, or men with a shotgun in the pickup truck? Would we ask the local physician, lawyer, or police chief when he comes in for an annual checkup? To ask these questions we need to be clear about our own values and willing to reveal them when the patient says, “Why are you asking me that, Doc?” Confronting patriarchal values does not come naturally to medicine, a field that has traditionally had women as handmaidens at home and in the office and hospital. When we work through the logical steps we can recognize and explain that male domination is not healthy for men or women. To provide violence prevention for women we will need to change health promotion with men, because women’s health depends in part on men’s healthy behaviors.35
Gender-specific curriculum
To help patients change their behavior we need to connect with them as sharing similar values. How can a male family physician approach a potentially battering male patient as a reasonable equal? In what ways can we share the frustration of living with problems (economic, job, parents, kids), and yet distinguish between ourselves as not sharing the same assumptions about male privilege? Female family physicians may have more experience in working with the girlfriends and wives of batterers and have been explicit about both the joys and challenges of that particular work,11 but how can a female family physician work with men who batter? Training programs need to help both male and female physicians clarify their values so that they can see how their gender and experiences will affect how they do this work. In other words, family medicine needs a gender-specific curriculum to teach the skills of working with violent men. At the same time, we need to recognize that when battering is identified one family physician cannot safely be the clinician for both the batterer and the partner.36 We have much to learn about how to transition safely from being the family physician for both members of a battering relationship to being the family physician for 1 or the other.