Domestic violence: Sometimes, it can hurt not to ask

HONOLULU—Imagine this scenario: You had the flu and go to see your doctor to find out whether a secondary sinus infection has set in. In the course of the visit, your doctor calmly asks, “So how are things at home?” You say things are fine and then your doctor probes further, “Do you feel safe there?  Can you share your perspectives?” she asks. You again answer and your doctor comes back a third time, “What happens when you and your partner fight? Is there yelling? Does anyone throw things?” You look quizzically at your doc and wonder what’s going on—or perhaps you’re glad someone has finally asked.

Whatever your perspective, and regardless of how you might answer, Nanci Kreidman wants all healthcare providers to ask you the right questions. Kreidman is the executive director of the Domestic Violence Action Center (DVAC). Domestic violence, she says, still cuts across all socio-economic levels.

It continues to be a difficult thing to identify those who may be in trouble, Kreidman says. A root cause, she explains, “is still gender disparity that interferes with and serves as a barrier for women to take good care of their health.” In other words, women themselves.

If you’re a woman, you may recognize in yourself the predisposition to put children, partner, and work ahead of your own needs. Kreidman says women tend to put themselves last, and when coupled with issues of low self esteem and lack of empowerment, the chances for discovery of a violent situation at home decreases. Any additional opportunities a woman may have to disclose situations affecting home life might just be the difference between feeling comfortable to divulge a potentially life-threatening circumstance. It’s why DVAC is advocating that whenever a woman is seen by any healthcare professional –- for anything from an annual pap smear to an emergency room visit—that doctor, nurse practitioner, or nurse opens the door to a fuller discussion of the women’s health.

A focus for DVAC lies in training people how to ask specific, home-life targeted questions. DVAC partners with a number of community organizations, including the Waianae Coast Comprehensive Health Center, to work with Filipino and Native Hawaiian women on the Leeward side. DVAC is one of sixteen organizations across the nation recently awarded a grant from the Office on Women’s Health, which administrates the Coalition for a Healthy Community Initiative. Launched in 2009 to address gender-based health issues in women and girls, the initiative selected DVAC as the only organization to regard gender-based healthcare through the lens of domestic violence.

While Kreidman would like to see training begin in medical school, to the point where would-be docs become comfortable in asking pointed questions every time they see woman patient, she is first implementing that kind of focus in the organization’s current work—building awareness and getting to those already out in the field. Women are not routinely invited to talk about what’s happening at home, she says. And if they are, the inquiry is usually the result of trauma.

“It’s episodic,” Kreidman says. “If it’s an egregious assault or injury, maybe the doctor or nurse will ask, but I think doctors and nurses have wanted to stay out of it. Like the rest of the community, they don’t want to get involved.”

Getting the healthcare provider community to see that it can and should be involved has been better done on the mainland. Stephanie Alexander, a public health advisor to the Office on Women’s Health in Washington, says she has been asked about her home life during doctor visits with her baby. When she mentioned this to her then husband, he took umbrage that someone would think ill of him and how he treated his family. That’s exactly why she agrees with Kreidman that if questions were routinely asked, they would be asked of men, too, and would be regarded as a normal part of a any type of interaction between provider and patient. Still, her current concern is for women and girls.

“One million women die annually from preventable diseases, which are attributed to social or cultural factors,” Alexander says, “chronic diseases, suicide based on mental health issues, heart diseases, which are completely preventable if women were to take the time to and feel empowered to say ‘I’m just as important as my husband and children.’” 

Alexander says when it comes to the cost for women experiencing domestic violence, to the rest of us, it’s also expensive: about $1,200 over an average woman’s healthcare costs.

“It’s matter of access and empowerment,” according to Alexander, and that’s not different from what she sees across the country. “There are social empowerment issues, empowerment issues overall in terms of low self esteem, isolation, the need to please. Those are the common threads I keep hearing throughout the nation.”

In Hawaii, Alexander says the conversations are much the same. And although there is a cultural piece that may vary, how gender roles play out is the main issue.

“Across the board, there are always subcultural issues in communities as they relate to gender,” Alexander says, “how women are seen in their communities as well as in their homes. Still, today, there are gender based disparities in healthcare systems.”

Waiting for better medical school training or retrofitting current healthcare providers as a group will take time. And time may be in short supply for a woman (or a man) in a domestically violent home. It’s small comfort that more people now understand domestic violence and are willing to speak more openly about it than they were a generation ago. Despite decades of pop culture babbling about the necessity of treating people in a holistic manner, it seems the holistic view among healthcare providers of all stripes may not yet be at the point where screening questions about home lives and the status of relationships are regarded as normal.

Maybe it’s that we live in a “Culture of Nice” and we don’t want to trespass into someone’s personal life. And perhaps, as Kreidman suggests, medical professionals also don’t really want to know who might be in trouble because it might mean they’d have even more to cope with on their often overly full plates. But someone has got to ask. And ask all of us.

We’re frequently told “situations change” and “stress kills.” For someone (you, me, a friend, family member, neighbor, or coworker) dealing with the secret shame of domestic violence or the confluence of stress and the vagaries of life, having a healthcare provider ask candidly and persistently about our perceived safety in our relationships might be the lynch-pin in saving lives.

The entire interview with Nanci Kreidman and Stephanie Alexander is on the Town Square archive at www.hawaiipublicradio.org.