Primary Health Care: Open Access

“Domestic violence is a pattern of behavior which involves violence or other abuse by one person against another in a domestic setting, such as in marriage or cohabitation [1]. It includes physical violence, sexual violence, psychological violence, and emotional abuse [1]. It usually starts with threats, name-calling, and it can end to pushing, slapping, and other violent acts [2].

Domestic violence is a global phenomenon and remains a serious problem in Iraq. The Iraqi Family Health Survey [IFHS] 2006/2007 found that one in five Iraqi women are subject to physical domestic violence and 6 percent of married women reported physical violence according to a Ministry of Planning study at 2012 [3].

In England there were an estimated 1.8 million adults aged 16 to 59 who said they were a victim of domestic abuse in the last year according to The Crime Survey for England and Wales 2016 [4].

In the United States, 1 in 3 women has been victims of physical violence by an intimate partner within their lifetime according to a survey done in 2011 [5]. According to the Centers for Disease Control and Prevention [CDC] in the USA, domestic violence was the second most common cause of death during pregnancy and in the postpartum period [6].

Domestic violence is more common in developing countries than in the developed world, and rural areas are worse affected than urban ones as In Pakistan, according to a report in 2012-2013 around 389 cases of domestic violence were reported that year [5,6].

Abused women may experience psychological problems, such as post-traumatic stress disorder and this affect their children that could often show psychological problems from an early age, such as hostility, aggression and violence which may later donate to continuing the tendency of abuse when they reach adulthood [7].

It is found that alcoholism, substance abuse, external stressors, poverty, losses, the family disruption could mainly increase the risk of violence [8]. Also, past history of abusive relationships, rigid family rule, mental or physical disability in the family, social isolation and when partner deciding to leave or leaving the relationship could be associated with increased risk of violence [8,9].

37 years old female presented with chest pain, giving a history of trauma to chest caused by fall from stairs. By examination; the patient looks anxious, withdrawn with mask face. There are multiple bruises on the chest. The patient refuses to examine the whole body excusing that she is in pain. X-ray of the chest shows anterior 1st rib fracture. The history included asking the patient if she had suffered from physical abuse, the patient denied excusing that it was just an accident. The physician tried to ensure her that she will get help if she was exposing to violence but the patient looked hopeless answering that she would get better.

Physical abuse should be suspected when a patient is presented with frequent injuries with an excuse of an accident. Showing low self-esteem, being depressed, anxious and even suicidal thought [10]. The physician should be alert to signs of abuse and search for injuries, always believe the victim and take all reports of violence and abuse seriously with confidentiality [8].

Declaring the patient that she is being abused is the 1st step in therapy, as many women refuse to talk due to fear from a husband or due to cultural effect. A study in middle east showed that 89% of Arabian women reject to say that their husbands abusing them [7].

This demanding enlighten the patient if she had any indication of partner abuse as; showing jealousy of her family and friends and time spent away, Embarrassing or shaming her with put-downs, discouraging her from seeing friends or family members, taking her money or refusing to give her money for expenses, preventing her from making her own decisions, destroying her property, preventing her from working or attending school, telling her that she is a bad parent or threaten to take away or hurt her children, slapping, choking, or hitting her, and may threaten to kill her or kill himself [2,8].

The physician should inquire the patient if the partner is culturally rooted belief that violence toward women is acceptable or tolerated [8]. Unfortunately, this is so common in Middle East countries, especially in rural areas as national data from Egypt and Jordan showed that almost 9 in 10 ever-married women accept at least one reason for wife beating [11]. In spite of advanced steps were taken in Iraq still many women feel fearful to open up and talk, in addition to wars and refugee conflict that increase domestic violence significantly [3].

As the patient in this case, she refused to clarify if she had suffered physical abuse causing multiple bruises in chest excusing that she had fallen from stairs. Although clinical exam of the chest does not correlate with her history that she had multiple bruises with the anterior 1st rib fracture on the x-ray that goes along with many case reports of physical abuse due to direct blunt trauma to the chest could be by hand fist or an object [12].

The patient refused to examine the whole body for other injuries that she could be afraid to expose other injuries related to abuse or she had just chest injuries that did not go along with the history she had given as falling from stairs usually associated with multiple bruises in different parts of the body. In addition, she looked depressed, anxious, withdrawn with mask face which goes with abuse [10].

This report aimed to make the physician more alert of domestic abuse with an active role in dealing with abused women by ensuring the patient, giving support and encouraging her to speak up as gender abuse has sensitive consideration in a closed society that requires the physician to make efforts to detect it initially and managing it later. The recent case could add more information to very little published articles in this issue and pay attention to such cases.