Should every case of domestic violence be reported?

I am on my last rotation for medical school. It is a “rural selective”, which is a required elective at a rural or underserved location. I am fulfilling it at a local community health center in the women’s health department. Fun!

I am taking part in a day long orientation today. In one of the presentations, the speaker had a point on one of the slides about mandatory reporting, and included all domestic violence as falling under that category. I rose my hand and suggested that we had been trained that elder abuse and child abuse fell under that category, but other domestic violence did not. I couched that statement by saying it was controversial and I didn’t say I necessarily agreed (although I do).

One of the other attendees got very perturbed by my correction, and said I was wrong. I said I disagreed, politely. The speaker and several other attendees said they thought I was correct, and one pointed out that other vulnerable adults, such as someone with a disability, also fell under the mandatory reporting group. At the end of the speaker’s presentation, the offended woman called me out specifically, and again told me I was incorrect, but again, had nothing to back herself up other than her strong emotional response. Since this was a training on legal requirements of the job and privacy, and this population definitely would include adult victims of domestic violence, I decided to look up the law.

When I located the appropriate information, I read it out loud to the group. This nursing CEU was the first good site I found, and it had very complete information. I read this part:

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the victim is unethical and may cause the abuser to retaliate.

She interrupted me and said “SEE? You have to report gunshot wounds!” and I continued to read the rest of the quote. Then she angrily said “Well of course you need their informed consent!”, and I countered “Well, then that’s not mandatory reporting, is it?” She got more agitated, and started pacing the room, telling me I am saying to send these women home to get killed. I said no, and tried to explain, again, the rationale of establishing trust with the patient, many of whom are not at a place where they are ready to leave or press charges. She said she would definitely report any case she saw of suspected intimate partner violence, and said she didn’t want these women killed. I said that they may not press charges, and then may not trust health care practitioners again, and still get killed.

I know that IPV is a sensitive, triggering topic for many, including me. I was in a relationship with verbal and emotional abuse, and trust me, if people came on too strong about me leaving him when I wasn’t ready to, I avoided them in the future. I would not come to them when there was an incident, because I didn’t want a lecture of how it was my fault for staying. When we went over this in medical school (and I was still in my abusive relationship), one member of my small group said she was a victim of physical violence in a past relationship, and she would absolutely never press charges, she would lie to any health care practitioner or official about it, and defend him under any circumstances, when she was still in the relationship.

These victims already feel an enormous lack of control. It is not our job to control them or act for them. It is our job to be there for them on their terms. Even if it gets us emotional.

“MomTFH” is a medical student who blogs at Mom’s Tinfoil Hat.

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  • sdietrich17

    Not all states have similar laws.  However, I agree, you must have consent of the female vicitim to report in most states.  It can be frustrating at times to see a victim getting the life beat out of her and not being able to report it, but providing support and establishing trust is the most important thing.

    • http://www.momstinfoilhat.wordpress.com MomTFH

      Thanks for your reply. It is frustrating. And, yes, state laws about mandatory reporting vary, so anyone who is in a position in which he or she may be a mandatory reporter should check the laws of the state.

      • ladybear4me

        This makes me thankful in my state we do have mandatory reporting laws. I tell my patients that even if they choose not to make the report, based upon either physical evidence or statements made by the patient themselves or EMS, I am required by law to notify our local law enforcement agency. I have had one patient in 7 years absolutely refuse to talk with them. She ended up back in our care several days later in worse condition.

        I normally try my best to let the victims know that they are not responsible for what someone else does. They are responsible for thier own behavior only, not how someone else reacts and behaves.

        As a survivor of severe domestic violence that ended with the loss of my mother, I tend to be an outspoken advocate for any patient who shows signs of abuse, no matter what gender, age or choices.

  • http://www.facebook.com/josh.hyatt Josh Hyatt

    It is important to realize that the reporting requirements are state specific. In California, reporting “suspected” domestic violence is mandatory, with or without the patient’s consent. I found one statement in your posting confusing, “…without the informed consent of the victim is unethical…” There are two fundamental problems with that statement. First, that is the incorrect use of the term informed consent and that legal principle does not apply in this case. Perhaps they meant the “consent” of the patient, but even then that statement, secondly, does not hold to be true from an ethical perspective either. 

    As a bioethicist, the idea that would you not protect someone that is in imminent jeopardy is just simply not true. If the patient tells you not to call abuse, the ethical question is whether or not to respect the autonomy of the patient. You have to do this by weighing their autonomy with the likelihood of maleficence and potential that the patient may have diminished capacity due to a fear of violence and possibly death. That is an extrodinary responsibility to place on a healthcare provider that does not know the circumstances and issues in the entirety. That is why many states, such as California, have enacted laws to make reporting domestic violence mandatory; thereby allowing a professional to sort out the specifics and freeing the physician up to treat patients.    

    My belief is that the rational and ethical thing to do is to report the domestic violence and let the vicitim meet with an investigator and choose whether or not to press charges against the abuser.    

    • http://www.momstinfoilhat.wordpress.com MomTFH

      Thanks for commenting, Josh. I didn’t write that particular statement. It is from the CEU website I link to and quote. I agree that it is not the correct use of the term “informed consent” as it normally applies to medical intervention. I think a more term is just simply “consent”.

      I understand that it is a difficult topic. Unfortunately, I think some victims will not get treatment if they know that the abuse will get reported. Not only might it be due to the reluctance of the victim to have the abuser reported, but, if the abuser knows that treatment may lead to criminal charges, the abuser may exert control and isolation, which is very common in these relationships, and prevent the victim from seeking treatment. 

      I think that practitioners can definitely encourage reporting. But, more importantly, they can encourage connections to safe, trusted people, and can help the victim develop a safety plan.

  • http://profile.yahoo.com/HSIMVPNZYT67UBE42HDLN2EHHA Joyce

    As much as we want to report, as much as we want to get people free of IPV, mandatory reporting would merely cause them to avoid health care. In some cases it would also cause women to miss out on prenatal care and that excellent opportunity to build trust and help women extract themselves from abusive relationships. 

    • http://www.momstinfoilhat.wordpress.com MomTFH

      Yes, this is especially important during pregnancy. A key, often overlooked aspect of this is the unfortunate frequency of contraception tampering or interference in abusive relationships, especially involving younger women. 

  • http://profile.yahoo.com/HSIMVPNZYT67UBE42HDLN2EHHA Joyce

    Josh, I understand what you are saying, I worry that unless the DV counselor is immediately availible this puts the victim in some jeopordy from her abuser. Are arrangements in place to protect a victim in such a case?

    • http://www.facebook.com/josh.hyatt Josh Hyatt

      There should be a system at the hospital to protect the patient and have immediate intervention with the patient. Additionally, I live in an area where investigators are on call 24/7 and respond pretty quickly. If there is a rape, a volunteer patient ombudsman is also called. So I guess it would depend on the location and resources.

  • karen3

    Regardless of reporting, it is really helpful for doctors to validate that patients are suffering from domestic violence.  A doctor who affirmed this to a friend of mine gave her courage to stop blaming herself and leave.  Even more so was the police officer who showed up on her doorstep one day.  She was disabled and  unable to drive and reported the abuse (which was really bad) to at least a dozen health care providers. Once she understood that the doctors had had an obligation to protect her and failed to do so, she was pretty angry.  

    • http://www.momstinfoilhat.wordpress.com MomTFH

      Yes, Karen, thank you. Affirmation that she does not deserve to be treated this way, and that the abuse is wrong is the most important thing. Any practitioner who suspects abuse should address it and offer resources. However, pushing a victim to leave when they are not ready can make a victim feel judged and powerless. 

      • karen3

        I can understand your point, but in my friend’s case her husband monitored her every move, she could not drive and he limited access to the phone.  Her doctors were, literally, the only people she ever saw without being monitored.  She asked for help and got none.  In that case, calling the police was really critical — and in her case, her life was at risk because her husband was refusing her life sustaining meds — she could not get her meds and it was causing neurologic issues that precluded her from functioning. She was in no position to “decide” — she was barely able to dress herself. If someone appears to be abused, its worth it to ask some questions as to the person’s capacity to assist themselves.

        • http://www.momstinfoilhat.wordpress.com MomTFH

          Yes, and not having mandatory reporting laws does not prevent this. Doctors should ask a victim if they are ready to report and/or leave, and help them create a safety plan even if they are not ready. 

          I believe a victim with a very controlling abuser may be prevented from accessing help if there are mandatory reporting laws. 
          It sounds like your friend’s doctors neglected her terribly, and I am sorry.

        • http://pulse.yahoo.com/_N3E4IOMPME5QLOLIJ5ZUWH7SJE knottymama

          Sounds like an abused patient with a disability. Most abused women would stop seeing that (and probably any) doctor – if their abuser gave them a choice at all.

  • http://twitter.com/Hootsbudy John Ballard

    Three points.

    1)  The earlier comment about the issue being state-specific is important. Reporting protocols apparently are not the same everywhere.

    2) If ever there was a case for seeking a second (or third) opinion this is it. There is great strength in numbers.

    3) No matter what happens, MOMTFH (odd screen name there) don’t leave the practice of medicine. You have a healing sensitivity that is rare and valuable.

  • http://www.momstinfoilhat.wordpress.com MomTFH

    John, thanks so much!

    Great points. The video they showed us at the training showed a wonderful collaboration between many types of caregivers. I think you are absolutely right that talking to peers and coworkers is valuable, not only to the patient, but also to raise the level of suspicion, awareness and sensitivity among caregivers.

  • sFord48

    I have in the past not been completely honest with my doctor because of reporting laws.

    • http://www.momstinfoilhat.wordpress.com MomTFH

      Thanks for sharing that. I’m sorry that you’ve been in that position. I hope that neither you nor someone you care about is in danger.

    • http://www.facebook.com/josh.hyatt Josh Hyatt

      Have you considered seeing a therapist? Legally, therapists can only report imminent danger. If there is not imminent danger, a therapist may be able to assist you in finding resources or help. Additionally, you can contact DV clinics and shelters anonymously for assistance.

  • CircleRock77

    This is a great discussion of the complicated issues in reporting abuse of all types.  State laws vary and health care professionals must understand the local requirements for mandatory reporting as well as ethical questions relevant to each specific case.  I have worked with both victims and offenders in a rural mental health setting for over 15 years.  The guiding principles of “do no harm” and allowing the person to be involved in the decision (as much as possible) are important guidelines.  The person who has no safe place to go….must have a place to go as part of reporting the abuse and legal system decisions will be part of the process.  Will an order of protection be a part of the solution?  Does the person have emotional and practical support to be able to stay away from the abuser? Is shelter available and how long will they allow a person to stay and what resources do they offer?   The medical care provider will need support from other mental health or social services providers to provide the type of comprehensive help needed for these individuals. 

  • davemills555

    Should every case of domestic violence be reported? Apparently not in the states represented by the 31 Senators that voted against reauthorizing funding for the Violence Against Women’s Act of 1994. Among them include both Senators from the states of North Carolina, Kentucky, Alabama, Oklahoma and Utah. Other Senators voting against this important women’s rights bill include Grassley (Mr. Death Panels) of Iowa, Cornyn of Texas, Blunt of Missouri, Johnson of Wisconsin, Kyl of Arizona, Lugar of Indiana, Rubio of Florida, Thune of South Dakota and last but not least Senator Pat Toomey of the north-east swing state of Pennsylvania. Apparently these Neanderthal Senators think that women are treated equally and fairly in their respective states. My Senator is among these Neanderthals. Women in my state will work very hard to prevent them from getting re-elected. In my opinion, these backward Senators are conducting a full scale assault against women in America. Women in America need to wake up and see what is happening in the Republican Party with regard to dismantling women’s rights.