The Veterinarian's Roles
in Preventing Family Violence: The Experience of the Human Medical
Profession
By PHIL
ARKOW, Chair
Animal Abuse & Family Violence Prevention Project
The Latham Foundation
Child protection professionals
pretty much take it for granted that pediatricians and the rest
of the medical community are integrated into child abuse reporting
systems and prevention programs. It wasn't always this way, of
course. As someone outside the child protection profession, my
perception is that the institutionalization of response mechanisms
that followed the publication of the landmark "Battered Child
Syndrome" article (Kempe et. al, 1962) was this nation's
second-fastest reaction to a public health crisis. Perhaps only
the development of the polio vaccine occurred more rapidly.
Critical to the development of the national reporting system was
the establishment of clinical diagnoses that enabled physicians,
nurses, emergency room personnel, dentists, and others to objectively
recognize trauma in what had previously been called "accident-prone"
children. The mandatory reporter system could not emerge until
medical personnel could identify risk factors and stereotypical
physical, emotional and sexual injuries that are indicative of
non-accidental injury in children. Forty years later, training
manuals are now readily available to identify telltale spiral
fractures, bruising from electric cords or coat hangars, immersion
or cigarette burns, characteristic skin bruises caused by slaps,
and many other markers of child abuse (Kessler & Hyden, 1991).
Identifying the "Battered Child Syndrome" as a definable
medical condition was instrumental in gaining the human medical
profession's acknowledgement that physical abuse of children is
a diagnostic possibility. Today, the profession recognizes that
its responsibility to children includes requiring a full evaluation
of suspected abuse and guaranteeing that no expected repetition
of trauma will be permitted to occur.
Until recently, however, more than 69,000 practitioners of veterinary
medicine, although defined as public health professionals and
who are caregivers who see more human clients than animal patients
(McCulloch, 1976), have been largely excluded from reporting systems
for child abuse, domestic violence and animal abuse.
Today, veterinarians are realizing that their responsibilities
to protect animals can be construed as part of the continuum of
family violence prevention and could be modeled after physicians'
experience vis-à-vis child protection. Colleges of veterinary
medicine and continuing veterinary education curricula are using
newly defined clinical conditions consistent with non-accidental
injury (NAI) to sensitize veterinarians to the possibility that
animal abuse could be a differential diagnosis.
It is an uphill battle.
The need for consistent systems
The child protection
field's 40-year history of institutionalized governmental systems
has been enabled in part by statutory language that includes specific
definitions of physical, sexual, and emotional child abuse and
child neglect.
By contrast, animal anti-cruelty statutes, which in many states
have not changed substantially in over a century, are vague and
archaic, often fail to provide protection for animals, and have
had little, if any, deterrent effect. (Lacroix & Wilson, 1998).
It was not until 2003, for example, that New York State enacted
legislation requiring animals to have adequate shelter.
Although more than 42 states have recently made some forms of
animal abuse felonies, anti-cruelty laws are an inconsistent hodgepodge
varying widely from state to state. Meanwhile, most prosecutors
are less likely to charge or prosecute animal cruelty cases compared
to other violent crimes, except in the most extreme cases. This
reluctance stems from a variety of factors including: real or
perceived limited resources; inexperienced staff; incomplete or
botched investigations; pressure from the community to focus on
other crimes; and bias against taking animal abuse seriously as
a violent crime (Frasch et. al, 1999; Tannenbaum, 1995).
These laws are enforced haphazardly at best by a mix of municipal
and nonprofit agencies with no central coordinating authority.
Municipal animal control agencies and police departments have
varying levels of interest in animal welfare, and nonprofit humane
societies and SPCAs frequently have limited or no enforcement
powers (Lacroix, 1999; Frasch et. al, 1999). Model legislation
and federal funding such as that provided by the 1974 Child Abuse
Prevention and Treatment Act, the concept of a federal organization
similar to NCCAN systematically monitoring statistics, 50 state
agencies supervising over 3,100 county CPS departments these
are all wholly lacking from the animal protection "system."
Attempts to replicate the child protection paradigm in animal
protection have been sporadic. The term "battered pets"
did not enter the literature until 1996 (Munro) and is not yet
classified as a "syndrome." The equine field has developed
standardized assessment tools to help practitioners and animal
cruelty investigators objectively evaluate a horse's body condition,
based upon visual appraisal and palpable fat cover (Henneke, 1995).
To extend this type of assessment tool to companion animal species,
Patronek (1998) devised the Tufts Animal Care and Condition scales
that numerically evaluate body condition, weather and environmental
safety, and physical care in dogs to give cruelty investigators
objective means of determining if animals are at risk. The American
Humane Association (Olson, 1998) and the Latham Foundation (Arkow,
2003a; Ascione & Arkow, 1999) have published training manuals
and videos to raise public and professional awareness of animal
abuse and its links with child abuse and domestic violence. Several
studies have surveyed veterinarians to measure the prevalence
of animal abuse among their clientele and their responses when
such abuse is revealed (Sharpe, 1999; Landau, 1999; Munro &
Thrusfield, 2001a; Donley Patronek & Luke, 1999; American
Humane, 2003).
The need for defined risk factors
Munro and Thrusfield
(2001a-d), in an effort to remove the confusion caused by subjective
perceptions of animal maltreatment, promoted a "common language"
that achieves mutual understanding among health professionals.
They described risk factors that should prompt veterinary professionals
to suspect deliberate "non-accidental" injuries (NAI)
among animals presented for examination. These risk factors include:
- discrepant histories: owners
unwilling or unable to explain how injuries occurred; vague or
implausible explanations for injuries; account of accident does
not fit the injury; family members relate different histories;
owner showing a lack of concern for animal
- client utilizes several hospitals in attempt to evade detection
- multiple fractures of different ages in same animal
- injuries to multiple animals in household
- repetitive history of accidents, deaths or turnovers in household
- personal awareness of violence in the household
- age as a risk factor: dogs and cats under 2 years of age are
at greater risk
- breed as a risk factor: pit bulls and related breeds are at
greater risk
- gender as a risk factor: male dogs are at greater risk than
female dogs; no gender-specificity for cats; overwhelmingly, human
perpetrators of violence are males
- low socioeconomic status and substance abuse may be risk factors
- animal exhibits unusual behavioral signs
- Munchausen Syndrome by Proxy
The British veterinary pharmaceutical firm Intervet UK (2003), borrowing from ideas presented by Munro & Thrusfield (2001a-d) and Arkow (2003), has recently published guidelines to sensitize veterinarians to conditions that are highly suggestive of animal abuse. These include:
- Animal welfare concerns (poor
physical condition; absence of food; abandonment; collar too tight;
lack of medical care; dehydration; excessive hair matting; parasitic
infestation)
- Environmental concerns (general lack of sanitation; overcrowding;
presence of dead animals; inadequate ventilation/lighting; excessive
numbers of animals; presence of feces/urine)
- Human welfare concerns (owner unable to afford human or animal
food; owner lives in isolation; evidence of animal fighting, bestiality
or ritualistic sacrifice)
- Physical injuries to animal (bruising; fractures; repetitive
injuries; lesions; burns or scalds; ocular injuries; internal
injuries; administration of recreational drugs; poison; gunshot
wounds; malnutrition; drowning; asphyxiation; untreated diseases)
- Sexual abuse
Veterinarians should be aware of the possibility that a patient presented with traumatic injuries, malnutrition or other maltreatment could be the victim of abuse or neglect. They should regard these suspicions seriously out of concern for the welfare of not only the patient, but also of other animals in the household and the public health of the community.
Reluctance within the profession
Arkow (1992, 1994)
was an early advocate encouraging veterinarians to understand
the implications of family violence on the practice, arguing that
being attentive to possible animal abuse, domestic violence and/or
child abuse would improve the well-being of the patient and of
other animals in the household. Though not specifically trained
in human medicine or mental health, veterinarians regularly encounter
interpersonal and interspecies relationships that are unhealthy
for animals under their care.
However, such encounters are ethically, legally, economically
and personally troubling to practitioners. The ethical dilemma
was first articulated by Rollin (1988): is the veterinarian's
primary obligation to the animal (patient) or to the owner (client)?
The experiences of the human medicine community may be illustrative
of the challenges faced by veterinarians. For example, several
studies have shown that even with knowledge of the underlying
cause of domestic violence trauma, many physicians fail to respond
to battering. Reasons cited most frequently for this reluctance
include:
- close identification with their patients that precludes them
from considering the possibility of domestic violence in their
differential diagnosis;
- fear of offending patients by discussing areas culturally defined
as private or by violating the physician/patient relationship;
- a sense of powerlessness and inadequacy in identifying appropriate
interventions;
- frustration that the ultimate outcome is outside their hands
and that unless the client were motivated to change, medical attempts
at intervention are useless; and
- the overwhelming roles asked of a professional complicated by
the time constraints of a busy practice, particularly if incidents
are of such a low prevalence in a patient population that pursuit
is not seen as a good investment of time. (Sugg & Inui, 1992)
Similarly, reasons cited by physicians for failing to report suspected
child abuse include:
- inadequate training to diagnose the problem;
- risk of alienating or stigmatizing the family;
- lack of confidence in local officials;
- personal, legal and financial risks;
- discomfort with the role of "policeman" or in interviewing
hostile clients;
problems of defining child abuse. (Morris, Johnson & Clasen,
1985)
With its unique twin heritages of agriculture and medicine, veterinary
medicine has long had public health responsibilities, and has
been identified as having an impact on mental health as well (Arkow,
1994). Veterinarians have traditionally been reluctant to include
the prevention of animal abuse, child abuse and domestic violence
among public health responsibilities. This wariness originates
from many sources, including:
1. The perception that veterinarians will not see abuse
- the perception that as animal
authorities they are unlikely to encounter human abuse and are
untrained to recognize and respond to it; and
- the perception that pet owners who care enough about their animals
to provide veterinary care are unlikely to be abusive.
These assumptions need to be re-examined. Three successive market
research studies from the American Veterinary Medical Association
(2002) describe the demographics of pet caregivers and the status
of pets in contemporary households. In 72.8% of pet-owning households,
the primary caregiver is a female. Parents with children are the
dominant market for companion animals: 64.1% of households with
children under age 6, and 74.8% of households with children over
age 6, have pets. Moreover, nearly half 46.9% of American
pet owners consider pets to be "members of the family";
only 2.2% consider pets to be "property".
Consequently, those most likely to be victimized by child abuse
and domestic violence are the primary market niche for small-animal
practitioners. These potential victims often have strong emotional
ties to their animals.
It is argued that abusive households are unlikely to care enough
to take their animals to the veterinarian, but research has found
this not to be the case. In a study of pet-owning households in
New Jersey with histories of child abuse, DeViney, Dickert &
Lockwood (1983) found that the utilization of veterinary services
was consistent with norms in the non-abusive population. The study
also revealed that the incidence of dog bites in violent homes
was 11 times greater than in the normal population: the dogs responded
to violence in a like manner, creating an additional public health
issue.
Landau (1999) reported that 87% of veterinarians responding to
a survey had treated abused patients, with 50% of veterinarians
treating one to three such patients per year; 60% of respondents
had treated an animal which they suspected had been severely or
intentionally abused or neglected. In addition, 20% of those surveyed
stated they had worked with clients whom they suspected were themselves
being abused.
In a national survey of veterinarians, Sharpe (1999) reported
the mean number of animal abuse cases seen per year at 5.6 per
1,000 patients. Only 2.4% of respondents believed that a veterinarian
should do nothing if animal abuse is suspected and only 14.9%
said they should do nothing if child or spouse abuse is suspected.
In a survey of British veterinarians, Munro & Thrusfield (2001a-d)
reported that 91.3% of veterinarians acknowledge NAI, of whom
48.3% had either suspected or seen NAI. Of 448 reported cases
of NAI, 6% were sexual in nature and nine cases of Munchausen
Syndrome by Proxy were reported.
In replicating the Munro & Thrusfield study, the Colorado
Veterinary Medical Association reported that 61.7% of responding
veterinarians had seen cases of NAI in dogs, cats and rabbits
(American Humane, 2003).
2. The lack of adequate training
Even in the human medicine
field, training is notoriously lax in equipping clinicians to
deal with the complex dynamics of abuse cases and attendant painful
social and personal issues (Skolnick, 1995; Sugg & Inui, 1992;
Chiodo et. al, 1994). "As dentists, we're very well trained
to identify and treat caries or an abscess, but child abuse is
more nebulous," said a New Jersey state dental official (Mark,
1994). The dearth of time spent in medical school studying child
abuse and neglect encourages the notion that child abuse is of
marginal importance (Vulliamy & Sullivan, 2000).
The amount of professional education dedicated to addressing family
violence has increased in recent years; more dentists and dental
hygienists who graduated since 1980, for example, have had some
exposure to elder abuse and child abuse education than those who
graduated prior to 1980. However, dentists and dental hygienists
also widely agreed that their professional education had been
inadequate to help them determine if a patient had been abused.
If physical indicators are equivocal, dental health care workers
express a lack of confidence in their abilities to engage in this
type of sensitive dialogue and to define the suspected situation
(Chiodo et. al, 1994).
Similarly, veterinary practitioners who graduated more than 15
years ago agree that they were not formally trained to recognize
and address the issue of violence. "My four years of veterinary
school and four years of residency had not prepared me for the
story my client was about to tell," wrote Dr. Sharon Fooshee
(1998), describing a cat that had been doused with rubbing alcohol,
thrown into a fireplace, set on fire with a cigarette lighter,
then had its leg broken and rectum slit with a knife. Previously,
the cat had been dunked in a sink and set outdoors in winter to
freeze to the pavement. The cat's sister was also thrown out a
window and fell three stories to a parking lot.
"Part of the problem is that [the subject of abuse] does
need to be added to veterinary education," said Dr. Patty
Olson, then-director of veterinary affairs at American Humane.
Olsen noted that forensic pathology and toxicology screening are
not as advanced in the veterinary field as they are in human medicine,
making detection of poisons "a huge cause of animal
suffering" a challenge. "We are a long way from
where we need to be," she said (Reisman & Adams, 1996).
The extent of veterinary training was described in a 1997 survey
of all 31 veterinary colleges in North America. Landau (1999)
reported that 97% of the schools strongly agreed or agreed that
veterinarians will encounter severe animal abuse during their
careers; 75% of the schools address the topic of recognizing and
reporting animal abuse in their curricula; 31% have a hospital
policy for reporting suspected severe abuse; and 17% explicitly
make their students aware of that policy. Also, 63% of the schools
strongly agreed or agreed that veterinarians will encounter human
abuse, but only 21% address the topic of recognizing and reporting
severe human abuse. Only two schools at the time had a hospital
policy for reporting suspected severe human abuse, and both schools
made their students aware of this policy.
This training, however, was constrained by the exigencies of the
curriculum. Each student received, on average, only 76 minutes
of training on the topic of animal abuse and 8 minutes on the
topic of client abuse.
It is not clear how widespread this training currently is in veterinary
schools, but a number of veterinary colleges appear to be picking
up the gauntlet. Ethics and Issues classes at several schools,
such as the University of Pennsylvania, Colorado State University
and the University of California at Davis, and continuing education
seminars, such as at Oklahoma State University, have included
the topic in curricula.
There appears to be support for more training in this area. A
survey of veterinarians in Massachusetts (Donley, Patronek &
Luke, 1999) reported that 76.4% of veterinarians expressed concern
about being inadequately trained to distinguish between suboptimal
care and legal neglect; 70% indicated that published criteria
would make them more likely to report suspicions of a "battered
pet." Over 84% of the veterinarians believed that training
about recognizing and reporting animal abuse should be part of
veterinary education.
Veterinarians are not alone in recognizing the absence of formal
training regimens: many of the professions mandated to report
suspected child abuse and neglect have also experienced this constraint.
A literature review revealed that numerous professionals admit
that during their careers they have failed to report suspected
maltreatment to appropriate authorities, often because they lack
training and knowledge about legal obligations and procedures
for reporting (National Clearinghouse on Child Abuse and Neglect
Information, 1999).
The dental field has observed that increasing the content of family
violence education alone will not serve the needs of health care
workers. Rather, curriculum and continuing education must approach
the abuse issue as a whole rather than in a fragmented format,
with education conducted in collaboration with other health care
and community workers. Education should examine the ethical dimensions
of addressing family violence, including assessment and management
responsibilities (Chiodo et. al, 1994). And while books and videos
are excellent resources, the most effective training can come
on the state and district level from professional associations
(Mark, 1994).
3. Fear of litigation
The role of the veterinarian
in society is changing to that of a "health care professional."
This new role will likely lead to a greater public accountability
to meet society's expectations and to increased exposure to liability
when those obligations are not met (Jack, 2000).
In a litigious society, veterinarians are concerned about the
legal implications of reporting family violence. As early as
1966 (American Academy of Pediatrics), physicians were reported
as being apprehensive about reporting child abuse out of fear
of legal action with its accompanying risks of lawsuits, time
spent in court, and patient criticism. Physicians were advised
at the time to avail themselves of other professional consultations
so the decision would come from a group rather than from an individual;
this would be a more accurate diagnosis and help to defuse criticism
and possible legal action. Support from state diagnostic laboratories,
radiologists, and other professionals may defuse retaliatory actions
(King, 1998).
Dental health care workers have been reported as being hesitant
to intervene because they want to ensure that more good than harm
will come from the intervention and because they fear subsequent
litigation (Chiodo et. al, 1994).
Veterinarians have expressed concerns regarding possible civil
and criminal exposure should a veterinarian make a false report,
a good-faith report that proves to be unfounded, or fails to make
a report prescribed by law.
The experience of the child protection field may prove helpful.
As with laws requiring reporting of certain infectious diseases,
interests of public safety can override physician-patient rights
of confidentiality, thereby removing one source of potential litigation.
To encourage reporting, all states provide mandated reporters
with immunity from liability. This immunity may be absolute (in
effect even when reports are made negligently or fraudulently)
or qualified (protects physicians who make reports in good faith
even when no abuse or neglect is revealed). However, the immunity
provisions do not mean that a lawsuit cannot be filed, and physicians
are aware that fighting such suits can be costly (American Medical
Association, 1992). Some states explicitly protect veterinarians
from civil or criminal liability when their reports are made in
good faith.
The American Academy of Pediatrics (1966) noted very early that
state laws which included provisions granting reporting physicians
immunity from liability had removed much apprehension. "The
widespread dissemination of the fact that the physician is legally
mandated to report a case of suspected child abuse should also
remove, or at least reduce, the parents' resentment," the
report concluded.
Of greater impact on mandatory reporters are provisions exposing
them to civil lawsuits for failure to report suspected child abuse.
The potential financial liability for further injury of a child
whose maltreatment should have been detected and prevented by
a timely report can be quite extensive. At least six states statutorily
prescribe civil liability for failure to report (National Clearinghouse
on Child Abuse and Neglect Information, 1999). Prosecutions for
failure to report, however, have been rare. Whether failure-to-report
provisions would be enacted regarding the reporting of the abuse
of animals who are considered property without legal standing
remains undetermined.
In the domestic violence field, a woman reported to be a victim
may deny this and seek legal redress against the person who reported
her. It is also possible that a battered woman or her family may
seek legal redress against a physician who failed to identify
and intervene, especially if she suffered injury or death. In
addition to maintaining good liability coverage and working with
the state medical association's legal department, physicians are
encouraged to routinely screen all women for domestic violence
as an effective means of reducing this medicolegal risk (Salber
& Taliaferro, 1995).
Recommendations to reduce exposure include maintaining liability
insurance and signing "hold harmless" agreements with
government and nonprofit agencies to prevent shifting of liability
to the veterinarian (King, 1998). Maintaining careful and comprehensive
documentation and medical records -- including health assessment,
medical history, social history, statements made, observed behaviors,
detailed description of injuries, an opinion on whether the injuries
were adequately explained, results of laboratory tests and diagnostic
procedures, and photographs and imaging studies -- will reduce
the time the practitioner may be required to spend in judicial
proceedings and may reduce the exposure to liability.
4. Fear of adverse economic impact
The possible erosion of the
client base is a concern that has been voiced by veterinarians
who fear alienating clientele. The practitioner must weigh this
concern against what may happen to the victim(s) should the veterinarian
choose to not get involved.
The experiences of the child protection field may help to resolve
this concern. There is no conclusive evidence that physicians
have suffered significant economic adversity from being part of
the mandated reporter system. In one survey of pediatricians and
family physicians in Ohio, four respondents who had reported cases
of child abuse were surprised to find that many families whom
they reported continued to visit their offices for medical care.
Only 3% of respondents believed that "some" physicians
were concerned about being sued by the family for reporting a
suspicion (Morris, Johnson & Clasen, 1985).
A nationwide survey of psychotherapists confirmed earlier reports
that the breach of confidentiality consequent to a report of child
maltreatment does not inevitably cause a collapse of the therapeutic
relationship. Although some 25% of clients may drop out as a result
of mandated reports, most are retained in treatment and many are
able to overcome the negative feelings elicited by the report.
Further, most of the therapists who had filed reports believed
that their reporting resulted in at least the temporary cessation
of the abuse (Steinberg, Levine & Doueck, 1997).
Physicians who experience conflicts between their duty to report
and their desire to keep their concern between themselves and
the family may also use the mandatory reporting statutes to help
explain their actions to parents. By relying on the necessity
to report as specified by statute, and by remaining neutral in
their attitudes, physicians may resolve the conflict. Physicians
may also refer the child for definitive forensic medical assessment
while continuing to offer supporting medical services to the child
and family. The economic concern cannot legally be addressed by
failing to report the suspected abuse because this can endanger
the child (American Medical Association, 1992).
5. The perception that no
action will be taken
Several studies have
commented on the perception among pediatricians and psychotherapists,
among others, that even reports made by mandated sources are likely
to be deemed unfounded by child protection officials, or will
not be acted upon in an overworked and underfunded system. Reporters
may feel that nothing good happens as a result of making a report.
They may be left with a sense that the report did more harm than
good. Physicians are unlikely to report child abuse if they lack
confidence in the CPS agency, cannot predict a favorable outcome,
or do not receive feedback after they have made their report (Vulliamy
& Sullivan, 2000; Steinberg, Levine & Doueck, 1997).
In the child protection field, a significant number of reports
are not investigated and many of those that are investigated are
dismissed as unsubstantiated or unable to be prosecuted. It is
likely that the percentage of animal abuse cases reported to humane
authorities that result in prosecutions will also be low, which
may serve to reduce the exposure of reporters. The investigating
authority may elect to pursue educational rather than prosecutorial
interventions, which may reduce the liability of reporters.
Several surveys have reported low levels of reporting within the
medicine and dentistry professions, largely due to clinicians'
uncertainty regarding correct identification and appropriate interventions
and a lack of confidence in mandatory reporting laws. Referral
to community resources is often the most appropriate intervention
(Chiodo et. al, 1994). Reporting of suspected abuse may be the
last resort in the armamentarium of options available to the veterinary
professional.
6. Confidentiality concerns
Like physicians, veterinarians
have concerns about client confidentiality. Courts in some states
have explicitly refused to recognize a veterinarian-client privilege;
other states allow it, either in veterinary practice acts, administrative
rules or statutes affecting a variety of health professionals.
There are circumstances where confidentiality requirements are
explicitly waived to protect the health and welfare of the individual,
the animals, and/or others who may be endangered (Patronek, 1998).
Some textbooks on veterinary ethics emphasize that veterinary
clients are not just consumers but animal owners who entrust a
particular kind of property property in which they may invest
significant emotional importance to the veterinarian. Ethical
concerns regarding confidentiality are described more in terms
of the veterinarian's responsibility to inform the client of maltreatment
that occurred to animals under care, rather than the practitioner's
obligation to discuss clients' maltreatment of animals (Tannenbaum,
1995).
Confidentiality is a particular challenge for numerous professions.
For example, child protection caseworkers who observe animal abuse
are restricted by state laws from revealing the names of their
clients, and animal protection agencies are reluctant to pursue
a report made anonymously. As will be shown shortly, the veterinary
profession may be ahead of the curve in this area, as professional
associations in the U.S., Canada and the U.K. have sanctioned
the waiving of doctor-client confidentiality when public health
and safety are jeopardized.
"Confidentiality holds for personal privacy of clients unless
the veterinarian is required to reveal the confidences of a medical
record because of the health or welfare of either the person or
animal," said Dr. Mary Beth Leininger, past president of
the AVMA. "As an organization and as a group of professionals,
we feel an obligation to safeguard the health and well-being of
not only the animals we care for, but of the need to care for
society, as well." (King, 1998)
7. Gender bias may also be a factor
It is difficult and dangerous
to stereotype, but there may be more interest in this subject
among younger veterinarians, an increasing percentage of whom
are females. Currently, 55% of the American Veterinary Medical
Association's members are male and 45% are female; among the student
AVMA membership, the ratio is 30% male to 70% female (Shepherd,
2003).
An informal survey of veterinarians at several state and national
conferences by Lacroix (2000) found that both male and female
responding veterinarians were willing to display information about
domestic violence in their clinics and wanted more information
about the "Link," but the ratio of females to males
responding to the survey was 2:1. Whether this suggests that females
were more likely than males to respond to the questionnaire, or
were overrepresented as participants in Lacroix's workshops, cannot
be determined.
The field of human medicine has published several reports regarding
gender- and age-based willingness to report suspected family violence.
Younger physicians have been reported to be more willing to report
suspected child abuse than older ones, perhaps because knowledge
and attitudes regarding the topic have been affected by recent
inclusion of child abuse training into medical schools and residency
programs (Morris, Johnson & Clasen, 1985).
It has been reported that even though female physicians express
concern about offending the patient when broaching the subject
of domestic violence, none of the female physicians in one study
suggested that such inquiries would jeopardize the physician-patient
relationship (Sugg & Inui, 1992).
A possible gender bias was discussed by Chiodo et. al (1994) in
a survey of Oregon dental health care workers, in which 92% of
responding dentists were male and 99.2% of responding dental hygienists
were female. Dental hygienists have been identified as having
a significant role in being aware of possible family violence,
recognizing trauma, documenting injuries, follow up care, and
mandatory reporting (ten Bensel, King & Bastein, 1977). This
may have implications in the veterinary field, in which veterinary
assistants and technicians are predominantly female.
Other sources of veterinary reluctance
include:
- fear of further compromising
the safety of victims
- lack of knowledge of available community resources
- fear of violent retaliation by perpetrators that compromises
the safety of hospital staff
- inexperience in dealing with misleading case histories
- absence of widely accepted standards for identifying and treating
NAI
- inconsistent legal mandates
- fragmented and sporadic professional responses and institutional
norms
- personal opposition to governmental intrusion into people's
lives
Reasons for involvement
As early as 1985, the
U.S. Surgeon General began emphasizing that traditional approaches
to solving the problem of violence in America through sociologic,
law enforcement and criminal justice systems interventions
had led to "unmitigated failure." (Koop & Lundberg,
1992) Authorities began calling for an interdisciplinary approach,
subject to medical and epidemiological research that focused on
violence as a public health issue. Such an approach showed more
promise in rooting out the causes of violence and identifying
best treatments.
Calling violence "a public health emergency," the U.S.
Surgeon General observed that "physicians and other health
professionals are firsthand witnesses to the consequences of violence.
We see, diagnose, treat, mend, patch, console, and care for the
victims of violence and their families thousands of times each
day." In encouraging all health care professionals to open
and maintain channels with other disciplines in efforts to end
violence, the Surgeon General concluded, "As health professionals,
the prevention of violence by using public health methods in our
communities is as much our responsibility as is the treatment
of its victims." (Novello, Shosky & Froehlke, 1992)
Further, failure by the entire medical profession to intervene
can contribute to a victim's sense of hopelessness and despair
with no practical alternative to escape, leading victims into
what has been called "iatrogenic retraumatization"
abuse caused by the medical profession itself (Skolnick, 1995).
At a national conference of Physicians for a Violence-Free Society,
Dr. Carol Warshaw observed that common reasons for physicians
to not ask their patients about domestic violence is that they
don't have time, it's not part of their role, it's too intrusive,
or they believe it won't do any good.
"Time is a real factor, but when we compare the time it would
take to ask about abuse and make appropriate referrals with the
time spent on repeated visits, multiple workups, and treating
the long-term sequelae of unrecognized abuse, not having time
loses its validity as a reason not to intervene," Warshaw
said. Regarding physicians' reluctance to probe into what are
considered private matters, Warshaw said, "In an area where
competence and mastery are highly valued, it's difficult to risk
venturing into subjects that make us feel less confident. We often
find it easier to focus on problems we know we can solve. Feelings
of discomfort can be overcome the same way we overcome feelings
of discomfort when asking a patient about his or her sexual history
by understanding that these questions are legitimate and
important." (Skolnick, 1995)
The nexus at which the roles of the medical professional and the
social worker, animal cruelty officer, or law enforcement officer
overlap is a critical point where sharing information can prevent
future harm. The community has delegated the responsibility of
protection to officials who are unable to meet that duty if they
do not know that abuse is occurring. (Vulliamy & Sullivan,
2000).
Consequently, all medical professionals, who have taken oaths
to protect well-being, must include the prevention of family violence
among more traditional public health responsibilities. Veterinary
involvement is indicated for the following reasons:
- failure to provide early intervention perpetuates public health
problems
- failure to get involved puts others at risk
- veterinary medicine is a care giving profession whose practitioners
have taken an oath to prevent suffering
- veterinarians have well established roles in public and mental
health
- veterinarians are well trained to identify and correct substandard
care
- veterinarians should be at the forefront of setting the highest
standards for animal welfare
- participation in family violence prevention programs is an opportunity
to build multidisciplinary bridges between veterinary medicine
and the animal welfare, care giving and human medicine professions
- inclusion in family violence prevention programs will elevate
the status of the profession and the status and well-being of
animals
Because veterinarians are frequently the best qualified to determine if an animal is suffering unnecessary and excessive pain or if an injury or death was unjustifiable, because veterinary confidences may be revealed if the veterinarian is required to do so by law or if the health or welfare of others is endangered, and because veterinarians are largely given full immunity from civil or criminal liability for reporting suspected abuse to appropriate authorities in good faith, veterinary involvement is indicated (Phillips, 1994).
Responses to veterinary
needs
Veterinary associations
in the U.S., Canada and the U.K. have responded to this issue
with new professional codes of conduct. Several state and provincial
governments have also enacted statutory mandates that help delineate
veterinary responsibilities.
The most comprehensive, and the newest such protocol, was published
in the U.K. by the Royal College of Veterinary Surgeons (The Veterinary
Record, 2003). This Guide to Professional Conduct declares "the
public interest in protecting an animal overrides the professional
obligation to maintain client confidentiality."
In addition, British veterinarians are now advised to discuss
their concerns with clients, to consider whether child abuse or
domestic violence might be present (with or without the presence
of animal abuse), and to consider reporting their concerns to
appropriate animal protection, child protection or law enforcement
authorities.
The British policy significantly expands earlier provisions by
the American and Canadian Veterinary Medical Associations (Arkow,
2003b) that said, respectively:
- that veterinarians have the
responsibility to report cruelty to animals, animal abuse or neglect
as defined by state law or local ordinances to appropriate authorities
to protect the health and welfare of animals and people;
- that in situations that cannot be resolved through education,
it is the veterinarian's responsibility to report suspected animal
abuse to appropriate authorities to protect the patient from further
abuse. Veterinary schools are encouraged to discuss this issue.
The professional response has been accompanied by legislative activity. California and Colorado require veterinarians to report suspected child abuse. Veterinarians in Alabama, Arizona, Illinois, Minnesota, West Virginia, Alberta and Quebec are required to report suspected aggravated cruelty, animal torture, animal fighting or dog fighting. Arizona, California, Florida, Georgia, Idaho, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, Oregon, Pennsylvania and Rhode Island provide veterinarians with immunity from civil or criminal liability if they make reports in good faith of suspected animal cruelty. At this writing, Canada is considering redefining animal abuse as a crime of violence rather than a crime against property. In the U.S., federal funds have been made available through the Department of Justice's Office of Community Oriented Policing Services (COPS) for interdisciplinary domestic violence prevention teams that include animal protection agencies.
Care for animal victims of domestic
violence
A contributing factor
preventing potentially hundreds of thousands of battered women
from escaping abusive relationships is fear of harm to their animals
through direct acts of violence or indirect neglect (Ascione,
Weber & Wood, 1997; Ascione, 1998). This has been identified
as a significant barrier for battered women and an animal welfare
issue in rural as well as urban areas (Lembke, 1999; Hornosty
& Doherty; 2002; Doherty, 2002).
Veterinarians should also be alert to the possibility that a client
may be a victim of an abusive relationship and that providing
foster care or medical treatment for her animals may remove a
barrier to her escape from that abuse. While not trained as family
counselors, veterinarians should recognize that interpersonal
violence puts companion animals and livestock at risk, and that
efforts to reduce interpersonal violence will benefit all members
of the family.
The impact of domestic violence on children has been studied extensively,
with the David and Lucille Packard Foundation (1999) reporting
that between 3.3 million and 10 million children are exposed to
domestic violence each year and that this exposure can have significant
negative effects on their behavioral, emotional, social and cognitive
development. The implications and extent of animal abuse
perpetrated by batterers, by children, or by domestic violence
victims unable to care for all members of their household
within this constellation of violence, are only now beginning
to be explored.
At least 40 women's shelters have established "safe haven"
programs that provide foster care for animal victims of domestic
violence (Ascione, 2000). Veterinarians are included in these
programs as well as in other community networks of support services
for domestic violence agencies. By providing resources, foster
care, medical treatment and other services they can help women
to leave abusive homes. Veterinarians are considered part of the
community's health care systems response to domestic violence
prevention (Community Crisis Center, n.d.). This has positive
benefits to the children and animals in these homes as well.
Other avenues of response
There are numerous
other ways in which veterinarians can utilize their unique heritage,
training and compassion to assist family violence prevention programs.
These include:
- participating in multidisciplinary
community response teams;
- providing medical care for abused pets;
- assisting in educational or therapeutic support programs for
at-risk youth and convicted animal abuse offenders;
- serving as expert witnesses in cruelty prosecutions;
- assisting animal shelters with investigation, documentation,
imaging studies, pathology and necropsies in abuse cases;
- providing cross-training to help humane and human services agencies
better recognize animal maltreatment;
- alerting staff to be watchful for all forms of family violence
and to provide appropriate resource materials about community
domestic violence, child protection and animal protection agencies;
- discussing welfare concerns with clients; and
- when such discussions fail to resolve matters, or when such
discussions increase rather than allay concerns, referring cases
of suspected abuse to appropriate authorities.
Conclusion
The field of human
medicine crossed many of the thresholds discussed in this article
in the early years of the modern child protection movement. A
prescient statement by the American Academy of Pediatrics (1966)
noted that increased medical interest coupled with public alarm
had triggered then-recent legislative and advocacy efforts in
the child protection field and that "aroused public and professional
interest will, no doubt, cause more [cases] to be reported in
future years." In the new "battered child syndrome"
paradigm, the role of the physician had changed: The physician
who, previously, when he suspected physical abuse, limited his
participation to the best possible professional care for the child
and to personal investigation of the family and/or a referral
to the social service department of the hospital for an investigation,
now had a legislative duty to report these cases to a community
authority (DeFrancis, 1964). The time has come for veterinary
medicine to join the human medicine field in assuming public health
responsibilities in the prevention of violence
When animals are abused, people are at risk; when people are abused,
animals are at risk (Arkow, 1996). Family violence in its various
forms continues to be widespread, despite the efforts of many
different protective agencies. Although the problem is not clearly
understood and there are no obvious solutions, family violence
may be abated through a multidisciplinary approach which includes
considering the welfare of animals. Veterinary involvement in
family violence prevention has been comparatively slow to build
but is attracting increasing attention.
Research and professional experience provide compelling evidence
that the veterinarian is not only a public health authority, but
a type of "family practitioner" with a potential for
preventing several forms of family violence. Training materials
are being developed to help medical professionals to recognize
various forms of abuse and to make reports or referrals to appropriate
human and humane service agencies. The veterinary profession has
the responsibilities to identify and to promulgate standardized
diagnostic criteria and clinical and environmental indicators
of non-accidental injury (NAI) to animals, and to be engaged in
community programs that prevent family violence.
Veterinary consideration for the protection of all family members
will elevate the status of animals and of the profession, protect
all family members who are at risk, make intervention strategies
more effective and more interdisciplinary, and set the highest
standards of animal well-being and family violence prevention.
As professionals with long-standing and committed humane interests,
veterinarians are well positioned to find creative approaches
that abate violence and that help heal animals of many species
including the human one (Lockwood, 2000).
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