6 The Victim
Victims of domestic violence have multiple health problems as a result of the abusiveness of their partners. They seek medical care for injuries resulting from the perpetrators’ acts (e.g., burns, broken bones, internal injuries, vaginal injuries, miscarriages, head injuries, damage to eyes or ears, dental injuries, knife or gunshot wounds, cuts, back injuries) and with illnesses aggravated by the stress of living with their partner’s abusiveness (e.g., asthma, lupus, MS, depression, anxiety, insomnia, eating disorders).
Victims may also be patients in the health care system for issues seemingly unrelated to their victimization, and their treatment for their medical conditions may be compromised by the continuing abuse (e.g., an insulin-dependent patient whose perpetrator controls her by withholding her medications or by refusing to allow her to keep her medical appointments). This victimization by intimate partners puts patients at future risk for medical and psychological sequelae to abuse.
If the domestic violence is not identified and addressed, there are both long and short-term consequences for the victims. Unidentified victims may receive inappropriate treatments for their presenting injury or illness (e.g., over-medications, treatment protocols they are unable to carry out due to the control of the abusers) and/or they may be denied the opportunity to get the information and support they need to protect themselves from future injuries, illnesses or death.
Failure to identify victims of abuse also creates consequences for the health care system. The health care practitioner misses the opportunity for early identification, intervention and ultimate prevention. Initial injuries and illnesses are followed by repeated injuries and illnesses due to the violence. Victims seeking assistance return to the health care system for multiple visits, consuming scarce resources. For some victims the only professional with whom they have contact is the health care provider and they will return again and again in hopes that their suffering will be alleviated.
1. Victims of Domestic Violence Can Be Found in All Age, Racial, Socioeconomic, Educational, Occupational, Religious, Sexual Orientation and Personality Groups
Victims of domestic violence are a very heterogeneous population whose primary commonality is that they are being abused by someone with whom they are, or have been, intimate. They do not fit into any specific age group, racial group, personality profile, socioeconomic, educational, occupational, religious or sexual orientation.
Too often, victimization is seen as a problem for one group but not for another. For example, teen victims of domestic violence are often ignored. While there is a great deal of public discussion about the need for appropriate sex education to help teens protect themselves from unwanted disease or pregnancy, there is little aware- ness of the need for teen education about domestic violence. With further documentation of dating violence (Levy, 1991), there is a call for more attention to this issue by those professionals in contact with adolescents who are just beginning to have intimate relationships. They need assistance in specific ways to avoid violence in their dating relationships. Victims of partner abuse may be 12, 25, 43, 78, 98 or any age in between. All age groups have the potential to be victimized by perpetrators of domestic violence.
Sometimes ignoring the issue takes the form of stereotypes that communicate that wife beating is just a way of life or “culturally acceptable” in “that” group. As noted previously, there is little comprehensive research on the prevalence and “acceptability” of domestic violence in specific groups (e.g., certain cultural groups, gays, lesbians). What research has been done raises as many questions as it answers. What is known is that domestic violence is a problem in all racial, ethnic, sexual orientation, ability, economic class, educational, and occupational groups.
Furthermore, there is no evidence that battered women fit a particular personality profile. Early studies of battered women attempted to focus on characteristics of the victim that would provide a causative explanation for the violence (Snell, Rosenwald, & Robey, 1964). Later studies indicate that no causative link has been found between the characteristics of battered women and their victimization (Hotaling & Sugarman, 1986). Consequently, as with victims of other trauma (e.g., car accidents, floods, muggings), there is no particular personality profile for the person who is battered. Being a victim of domestic violence is due to behaviors of the perpetrator, rather than the personal characteristics of the victim.
2. Victims May or May Not Have Been Abused as Children, or in Previous Relationships
Just as some have looked to the personality or demographic characteristics of the victim to explain her victimization, others have suggested that most domestic violence victims have a history of childhood abuse and/or previous violent relationships, and that this contributes to the current victim- ization. Yet there is no evidence that previ- ous victimization, either as adults or as children, results in women seeking out or causing their current victimization (Dutton, M.A., 1992). Some victims of domestic violence have been victimized in the past and some have not. While it may be helpful to understand an individual victim’s history and her coping strategies in dealing with past and current abuse, the practitioner should exercise caution and avoid making victim blaming interpretations of such history.
3. Some Victims Become Very Isolated as a Result of the Perpetrators’ Control over Their Activities and Contacts with Friends and Family Members
Some of a victim’s behaviors in a health care setting can be understood in light of the control the perpetrator has managed to enforce through her isolation (e.g., her reluctance to commit to a particular treatment protocol that requires multiple appointments, her lack of confidence in her own abilities, or her fear of further harm).
Without outside contact and information, it becomes more difficult for the victim to avoid the psychological control and threats of the perpetrator. Some victims come to believe their abuser when they say the victims would not survive alone if they left, while others resist such distortions.
Even when the victim maintains contact with friends or extended family, those relationships are often mediated through the control of the perpetrator. Consequently, victims do not experience needed support and advocacy. The victim’s experience with others is repeatedly processed through the comments and interpretations of the abuser. Some perpetrators interrogate victims about every detail of their interactions with others and describe to the victims the nature of those relation- ships. The victims’ positive feedback or support from their other relationships is undermined by the perpetrators’ intrusions into those relationships. The more successful perpetrators are in isolating the victims, the more they control what the victims believe (Graham & Rawlings, 1991).
4. Why Some Victims Stay/When They Leave
One of the most commonly asked questions about domestic violence is, “Why do victims stay in violent relationships?” The reality is that many victims leave. But to understand this process of leaving, one must once again consider what domestic violence is, what the perpetrator is doing, and what the victim’s options are in her community.
The primary reason given by victims of domestic violence for staying or returning to the perpetrator (or for not following other health care provider recommenda- tions) is fear of violence and the lack of real options for safety with their children. This fear of the violence is realistic. Research on battered women shows that the lethality of the perpetrator’s violence often increases when the perpetrator believes that the victim has left or is about to leave the relationship (Campbell, J., 1992, Wilson & Daly, 1993). The literature suggests several indicators for homicide against the victim: the perpetrators’ obsession with the victim, a pattern of escalating physical violence, increased risk-taking by the batterer, threats to kill the victim and self, substance abuse, and a gun in the household (Campbell, J., 1992; Saunders, 1994; Hart & Gondolf, 1984; Kellerman, et al., 1993).
Some perpetrators repeatedly threaten or attempt to kill or seriously injure their victims, children or others when the victims attempt to leave relationships. The victim may have previously attempted to leave only to have been tracked down by the perpetrator, seriously injured and brought back. Perpetrators do not just let victims leave relationships. They will use violence and all other tactics of control to maintain the relationship. It is a myth that victims stay with perpetrators because they like to be abused. Even in cases where the victim was abused as a child, the victim does not seek out violence and does not want to be battered. Staying in or returning to the relationship may simply be safer than leaving.
The reasons for staying in a violent relationship are multiple and vary for each victim. They include:
a. Fear of the perpetrator’s violence;
b. Immobilization by psychological and physical trauma;
c. Connection to the perpetrator through his access to the children;
d. Illness (e.g., HIV, MS) and dependence on the perpetrator for health care;
e. Belief in cultural/family/religious values that encourage the maintenance of the family unit at all costs;
f. Continual hope and belief in the perpetrator’s promises to change and to stop being violent;
g. Belief that the perpetrator cannot survive (e.g., due to illness with AIDS) or will engage in self-destructive behavior if the victim leaves;
h. Insufficient funding and resources nationwide that result in a lack of shelters and victim advocacy programs to provide transitional support;
i. Lack of real alternatives for employment and financial assistance, especially for victims with children;
j. Lack of affordable legal assistance necessary to obtain a divorce, custody order, restraining order, or protection order;
k. Lack of affordable housing that would provide safety for the victim and children;
l. Being told by others that the abuse is happening because the victim is gay, lesbian, or bisexual and that the abuse would stop if they would “change;” and
m. Being told by the perpetrator, counselors, the courts, police, ministers, family members, or friends that the violence is the victim’s fault, and that the victim could stop the abuse simply by complying with the perpetrator’s demands. In these cases, the victims learn that the systems with the power to intervene will not believe them or act to protect them. Thus, the victims are forced to comply with the perpetrators in hopes of stopping the abuse.
5. Victim Survival Strategies
Victims of domestic violence use many strategies to survive that become inappropriately labeled as “crazy,” codependent, or inappropriate behavior on the part of the victim (e.g., being too fearful to ask partner to use safe sex precautions, being afraid to use legal remedies or seek battered women’s advocacy services, or wanting to return to the perpetrator in spite of severe violence). These victim responses may in fact be normal reactions or strategic decisions for coping with very frightening and dangerous situations (Dutton, M.A., 1992).
When the victim discovers that a system with the power to intervene will not act to safeguard and support her, she may conclude that reconciliation is the safer course. The victim can rarely stop the perpetrator’s abuse. All that she can do is to keep herself and her children as safe as possible, and even this requires the support of someone else. Some victims will begin to terminate the relationship by seeking assistance from the court system or social service agencies, only to see that those systems are not effective in stopping the violence. For example, a protective order may not deter a perpetrator in communities where the police refuse to enforce the order. Where outside protection fails, the victim is forced to rely on strategies that have worked in the past.
Victims use many different strategies to cope with and resist the abuse. Such strategies include agreeing with the perpetrator’s denial and minimization of the violence in public, accepting the perpetrator’s promises that it will never happen again, saying that she “still loves him,” being unwilling to leave the perpetrator or terminate the relationship, and doing what he asks. These strategies may appear to be the result of passiveness or submission on the part of the victim, when in reality she has learned that these are sometimes successful approaches for temporarily avoiding or stopping the violence. Many victims who appear reluctant to carry out actions that the health care provider believes would protect them and their children from further violence actually have the same goal as the health care provider: namely, an end to the violence. They simply have different strategies.
Some victims have told other health care providers about the abuse, even if they did not use the terms “abuse” or “domestic violence.” In the past their descriptions of the abuse may have been ignored, not believed, or met with inappropriate responses. It can be very humiliating to the victim to talk about these issues with someone who is not sensitive. Because of prior attempts to seek assistance from the health care system or other social service agencies, the victim may now be reluctant to assume that her safety and confidentiality will be respected by the current health care provider. In such cases, unless the health care provider initiates the topic, the victim may not even raise the issue with the health care provider. Other victims will readily name the abuse, but minimize it as a way to cope with what is happening until they can determine whether there really are the community supports they need for protection. In such cases, victims sometimes re- engage in the prior survival strategies of complying with the perpetrators while they assess the community.
Successful interventions must be based on an understanding of the victim’s behavior as normal responses to violence perpetrated by an intimate. Rather than viewing the victim’s behaviors as masochistic, passive, crazy, or inappropriate, they should be viewed as survival strategies which contribute to the victim’s safety and the safety of her children.