2001 Case 4
How to treat patient with suspected DV(Domestic Violence) ?



42 years old female, hight 156cm,weight 89kg
She was diagnosed as DM about 5 years ago and medical treatment started.
But the control of blood sugar was poor. Since her body weight increeased
10kg per one month, she needed to admitt the hospital for dietary therapy.
In hospital, the weight was decreasing favorably .

But one day, she disappeard. When I met her in a passage in the evening,
she bursted into tears and said that she wanted to go home, because she was
anxious about her husband.
Owing to the doctor, the patient was suffering from domestic violence
by her the husband. However, she said always "My husband is gentle.
I love him." The doctor in charge consulted to the psychiatrist, after this
consultation the patient discarged and she went back her home.

(Question raised by the student)
Although I think that diabetic treatment is required, how far should she
stay in hospital?
Is it really safe for her to go back her home with suspected her husband's
domestic violence?



Comment by Tom Tomlinson



Dear Dr. Shirahama--

It is hard to comment on this case without more knowledge of what social
resources are available in Japan regarding domestic violence, and more
knowledge of what the social attitudes are toward it (e.g., attitudes that
might condone or excuse it.)

I will say that I think keeping the patient in the hospital, while it may be
useful for treating her diabetes, will do little to treat the problem of
violence by her husband. She will eventually be returning home, and unless
something has been done to address the situation there, she would seem to be
as much at risk of violence as she was before her hospitalization.

Thank you very much for posting these cases for our discussion.
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Student's reply to Tomlinson
Thanks for your opinion and I am sorry to be unable to offer information
detailed about this case. I was not able to do at all, having a question in
her going home as a student's position. It investigated what can be done as
a doctor.
First, when there is a crack or there is Domestic Violence, a women's
guidance office and the police can be notified. However, when she does not
wish, there are also a showy crack and an example for which violence
escalates when the husband knew what was notified forcibly, so we have to
carry out carefully.  It is important to have a confidential relation
between doctor-patients, she can say that she has received viorence, and she
has been troubled by it.
We must respond to her feeling, must not blame, and also both common sense
and the conventional view of women must not be forced. It is giving the
recognition "violence's being a crime." Since the woman who has received
violence is blaming self in many cases as "since she had a fault", it is
also important to apply the language which can carry out "you are not bad"
self-affirmation repeatedly. Moreover, when she gets injured, she has to go
to a hospital, and get a diagnosis written.  Information, such as DV
consultation organization, and a shelter, legal aid services, is offered
appropriately. In Saga, two counselors are in a women's guidance office, and
it protects consultation and the sherter where she can evacuation
temporarily (two weeks). Then, there are support institutions, such as a
welfare office, a dormitory for fatherless families, and a woman health
institution. They teach information of the way to offer Family Court etc.
Moreover, the doctor of psychiatry is in a mental health center, and victim
support of a psychiatry domain is offered.
 It is also important to recognize the limit of being able to do as a doctor
, and not to do the role from which she is saved ,to encourage her to take
the responsibility for her life by herself. The education of a victim and an
assailant is also important.
We must not force our feeling of disappointment on "returning decision" of
her.

Please tell me how institutions and organizations there are in your country,
and your opinion.
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Reply from Tomlinson

Thanks very much to the student for providing this information.

It sounds like there are many similarities between Japan and the US
regarding resources and laws concerning domestic violence. For Michigan, the
following web site provides more information:

http://www.mcadsv.org/mrcdsv/index.html

In the US, as in Japan, physicians are usually not in a good position to
provide direct intervention addressing domestic violence, except to
encourage the patient to use other resources. One exception might be the
family practice physician, who sees the patient on a regular basis and can
provide ongoing counseling support, can help document a pattern of violence,
etc.

Tom Tomlinson



Comment by K.Mulhorn



Dear Dr. Shirahama--
I agree with T. Tomlinson and recommend that if there are resources
such as women's organizations or other contacts that she can reach
while she is in the hospital, this could be an important effort of the
staff and clearly a necessary part of successfully navigating this
dangerous home situation.  If these resources are not known, then it
may be recommended that this be a project for staff at the hospital
for future cases.
K.A. Mulhorn



If you kindly send your comments on this case, please send it to the
following mail adress.

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Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic
Clinical Professor, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan
mailto:HQC00330@nifty.ne.jp