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What You Need To Know:
Spousal Abuse (1)
A Ang
 
INTRODUCTION
Spousal abuse is not uncommon. It can affect both sexes and occurs in all socioeconomic classes. In the United States, domestic violence is the leading cause of injury to young women and up to a third of men who are counselled for abusing their partners are educated professionals. Women are more often abused than men. However, cases with dramatic injuries to men (eg castration) have recently been highlighted by the media. Although the exact incidence of spousal abuse locally is not known for sure, it has been estimated that about 6 women per day reported to the police of being assaulted by their husbands and approximately 130 cases (mostly women) were treated at the Accident & Emergency Department of a government hospital in 1996.
The police and doctors at the A & E department are often the first ones outside the family to be involved in cases with serious physical injuries requiring treatment. Others, such as friends, relatives and general practitioners are likely to have contact with the abused in the earlier stages of spousal abuse or when the physical abuse is less severe. As such, they play an important role in dealing with this problem in the community .  
There are many theories proposed to explain the cause of spousal abuse. Research suggests that the following factors contribute to increased likelihood of men abusing their spouses: violence in the family of origin, alcohol abuse, personality disorders, low self-esteem, easily threatened masculinity, traditionist view of gender roles, poor verbal or expressive skills, employment difficulties and social isolation(1). 
 

What is spousal abuse?
Spousal abuse may be regarded as any intentional act that causes physical pain or injury to the spouse or any behaviour that coerces the partner into involuntary submission. Examples of severe levels of physical abuse include choking, beating or inducing pain with objects, burning, throwing the person bodily against the wall, throwing things at the person, kicking, slapping, punching, and rape. Less severe forms include pinching, pushing, restraining, grabbing and sexual acts that humiliate the spouse. The less severe levels of physical abuse can sometimes be attributed to momentary loss of temper on the part of the abuser and dismissed as acceptable behaviour within marriage in the same way that quarrels and arguments are regarded. However, repeated physical abuse over a period of time can have longer term psychological effects in the abused. Abusive acts contribute to a feeling of helplessness, guilt and impotence in the abused over time. The abuser threatens, humiliates, coerces and manipulates the spouse through verbal intimidations, actual violent behaviour (whether destruction of possessions, use of weapons, physical or sexual violence), the use of children or financial restrictions.
 

How to detect spousal abuse? 

Have a high index of suspicion
Generally, women who are abused physically are often quite isolated. Their partners may have placed many restrictions in an attempt to control their lives. For example, the woman is forbidden from seeing friends unaccompanied, is not allowed to use the telephone, is limited in her freedom, and has hardly any say in the household financial and domestic affairs. Consequently, these women come across at a consultation as having poor self-esteem, poor eye contact during conversation, and speaking very poorly of themselves. As such, she is unlikely to talk spontaneously about the abuse out of fear or a sense of helplessness. She may report feelings of anxiety, depression or inability to cope. Many women complained of non-specific constant and recurring aches and pains. In some cases, the abused wives may report suicidal ideation and may even have attempted suicide. In cases where physical injuries have been sustained, she may wear sun-glasses, scarves or long sleeved clothing to conceal the bruises. If she is working, she is likely to have been on sick leave for many days. Having a high index of suspicion in patients with the above profile is the initial step in making the diagnosis of spousal abuse.
 

Understand the progression of violence in spousal abuse
In the pre-battering stage, very often there is verbal abuse; threatening gestures; and hitting, throwing or breaking of objects. It is said that when abusers exhibit these behaviour, the majority eventually resort to battering. After an episode of violence, the abuser may make gestures to indicate his affection for the abused spouse, his concern for the family, and his desire to stop his violent behaviour through religion, abstinence from alcohol and even counselling. These promises are often given with the condition that she accepts him back. However, the cycle of violence gets repeated all over again some time later and typically the “honeymoon” period becomes more and more illusive(2). 
Doctors who are not aware of this cyclical pattern in domestic violence may stop short of making a diagnosis. The doctor may even assure the abused that the abuse is likely to stop as the abuser has indicated remorse.
 

 
Direct and sensitive questioning about actual abuse 
Some doctors are hesitant about asking for specific examples of actual abuse because they worry that the patient might be offended, fear that asking would lead to family break-up and may not be aware of the resources in the community for dealing with the problem. The final step involves sensitive but direct questioning if physical abuse has taken place and whether the injuries required medical attention in these instances. These instances should be clearly documented with the dates when injuries were sustained and the course of action taken (eg whether police report was made, seen at A & E department, investigation and treatment given).
The Conflict Tactics Scales by Straus(3) provides a tested, acceptable and helpful approach to elicit the presence of spousal abuse in community surveys of couples. It could be adapted for use in the clinical setting. The doctor could begin by saying, “No matter how well a couple get along, there are times when they disagree, get annoyed with the other person, or just have spats or fights because they are in a bad mood or tired. They also use many different ways of trying to settle their differences. I wonder how many times in the last year has your partner: 
(a)  did or said something to spite you?
(b)  threatened to hit or throw something at you?
(c)  threw, smashed, hit or kicked something?
(d)  threw something at you?
(e)  pushed, grabbed, or shoved you?
(f)  slapped you?
(g)  kicked, bit or hit you with a fist or with something?
(h)  beaten you?
(i)  choked you?
(j)  threatened you with a knife or gun?”

If the answer is positive for any of the questions (f) to (j), the level of physical violence is deemed to be severe. The women may need immediate help to formulate a safety plan to prepare in advance for the possibility of further escalating violence. Such a plan involves giving consideration to what needs to be done during a violent incident and the preparations needed to leave safely.
 

CONCLUSION
Spousal abuse is often not detected in its earlier stages because the abusive behaviour may not amount to actual criminal acts inviting police intervention. However, early identification of spousal abuse plays an important role in improving the physical and mental health of the abused and family, and it offers an opportunity to intervene in this intimate form of violence before irretrievable damage or marital breakdown occurs.