The Veterinarian's Roles in Preventing Family Violence: The Experience of the Human Medical Profession
By PHIL ARKOW,

Coordinator, National Link Coalition

Consultant, ASPCA

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). Only recently have similar manuals become available for veterinary medical professionals (Arkow, Boyden & Patterson-Kane, 2011; Munro & Munro, 2008;Merck, 2007; Cooper & Cooper, 2007; Sinclair, Merck & Lockwood, 2006).

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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