Violence against women: a physician's guide to identification and management.

Jane Liebschutz, MD, MPH, Susan Frayne, MD, MPH, Glen Sax, MD, editors.Philadelphia: American College of Physicians, 2003. 342 pages. ISBN: 1-930-513-11-9

Violence against women occurs frequently and is a sentinel event. Ten to fifteen percent, or 6 million women in the United States experience either physical or sexual assault annually, and the lifetime rate is 51% nationally, significantly higher than other developed countries. Women are far more likely to experience violence from intimates than from strangers, and it is often more severe. Sexual abuse of children is common. There are individual, interpersonal, and societal risk factors for perpetration, but most survivors of abuse do not fit a particular profile, because violence against women is a problem originating with its perpetrators.

Violence against women has devastating medical consequences, both psychological and physical. Post-traumatic stress disorder, anxiety, depression, suicidal ideation and attempts, drug and alcohol self-medication, sexual dysfunction, low self-esteem, feelings of helplessness and powerlessness, as well as death, injuries, unintended pregnancy, pregnancy complications, sexually transmitted diseases, gynecologic symptoms, chronic pain, gastrointestinal disorders, heart disease, headaches, other medical conditions, and increased medical utilization are commonly seen in victims clinically. Health care providers are in a unique position to identify a history of experiencing violence, to document, intervene, and refer for services and treatment.

This book is well organized and well written by editors and authors well recognized in the field. The 342 pages are organized into three sections. Section one, titled "Clinical Issues," provides basic practical information all physicians need to care for women who have experienced violence in their lives. It deals sensitively with risk factors, detection and diagnosis, physician interventions, practical examination responsibilities and techniques, treatment and referral issues, and understanding and dealing with the most common patient responses to violence. Section two, "Special Considerations," provides additional information for assisting particular populations of women, such as the elderly, pregnant women, women with disabilities, women with a history of substance abuse, immigrants and refugees, and those in same-sex relationships. Section three provides seven excellent "Clinical Vignettes," illustrative of often difficult clinical situations, and a cogent discussion of the issues and dilemmas frequently encountered by physicians. The cases are not only interesting and instructive for the clinician, but are well designed for teaching.

Throughout the book, the most important points are highlighted in boxes and tables set apart for easy reference in clinical practice. Additional resources and Web sites are listed for internal medicine physicians and patients in the appendix. Notably absent are family physician experts and resources. Three additional chapters would strengthen this book, one on stalking, one on the care of the child victim, and another specifically on detection and intervention with batterers and perpetrators, although some valuable information on perpetrators is located in sections one and three. This book is an excellent resource for physicians, and is highly recommended.

Elizabeth C. McCord, MS, MD

East Tennessee State University, Department of Family Medicine, Johnson City, TN