Silent no more: Intimate partner violence and our surgical colleagues

Surgical leaders have long noted “emotional durability” as an essential, defining feature of our professional identity.¹ Most surgeons take pride in their ability to maintain composure, exhibit great physical and emotional strength, and exercise control in times of duress. After all, it is the surgeons who often make life-changing decisions at critical moments during a patient’s care.

In contrast, victims of intimate partner violence (IPV) frequently experience a sense of vulnerability, self-doubt, and weakness.^2,3 For the surgeon experiencing IPV, this dichotomy can create significant distress. Individuals who feel their identity mandates strength and composure may find it difficult to acknowledge that they are victims, especially when it is their job to exercise control.

This article focuses on IPV and explores the unique features of surgeons and surgical culture that may perpetuate silence and stigmatize IPV. With awareness and education, we believe surgeons are poised to identify and advocate for individuals, including their colleagues, who are experiencing IPV.

A public health crisis

Although the true prevalence of IPV among U.S. surgeons is unknown, it is important to note that anyone can be a victim, regardless of income, education, race, ethnicity, age, or professional roleThe Centers for Disease Control and Prevention (CDC) defines IPV as “physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner” (that is, spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner).^3,4 It is characterized by behavior that includes unsolicited contact, verbal intimidation and threats, emotional manipulation, restriction of freedom and/or movement, victim isolation, nonconsensual sex, and physical battery.^2-5

IPV can occur in both men and women, heterosexual and same-sex relationships, and is not specific to relationships with sexual intimacy. In the U.S., approximately 20 people per minute are physically abused by an intimate partner, equating to 10 million men and women yearly.³ An estimated 22.3 percent of women and 14 percent of men have experienced at least one act of severe physical violence (such as beating, burning, strangling, and so on) by an intimate partner at some point in their lifetime. These data translate to an incidence of nearly 2.8 million female and more than 2.3 million male victims annually³ and far exceeds other common diseases, such as breast cancer and heart disease (see Figure 1).

Although the true prevalence of IPV among U.S. surgeons is unknown, it is important to note that anyone can be a victim, regardless of income, education, race, ethnicity, age, or professional role. Hernandez and colleagues recently published a systematic review that identified 17 publications, between 1990 and 2014, that discussed physicians as victims of IPV.² These studies found that the incidence of women physician IPV victims ranged from 7 to 24 percent and 6 to 10 percent in physicians who are men. The authors hypothesized that physicians have lower reporting rates than the general population because of associated stigma. Physicians reported feeling “shame from a sense of professional defectiveness owing to the fact that they are trained to screen for IPV yet fell victim to it themselves.” Physicians also were reluctant to identify as victims of IPV because physicians see themselves as providers and not consumers of care. These statements are troubling considering that 70 percent of victims will experience IPV before the age of 25;3 thus, it is likely that medical students and residents coming into surgical training programs either are at risk or may already have experienced instances of IPV.

Perception of IPV within surgery

IPV among surgeons is under-studied; however, some of the literature addresses how surgeons perceive IPV. Sprague and colleagues surveyed 200 medical students and surgical residents and reported that respondents had the following misconceptions about IPV:⁶

• Patients might be offended if asked about IPV (45 percent)
• Some patients’ personalities cause them to be abused (41.1 percent)
• Physicians should not interfere with a couple’s conflicts (21 percent)
• It usually “takes two to tango” (18.3 percent)
• Victims must get something from the abusive relationships (18.2 percent)
• Victims choose to be victims (11.1 percent)

Surgical residents were found to have higher rates of misconception about the victim’s role in IPV when compared with medical students. Male respondents, particularly, were more likely to agree with victim-blaming statements than their female counterparts. For example, male residents were more likely to support statements such as: “Women who choose to step out of traditional roles are a major cause of IPV” (p < 0.0001).⁶ The tendency to blame the victim is particularly concerning given that surgery remains a male-dominated field despite an increasing presence of women trainees. In fact, the American College of Surgeons (ACS) noted an absolute change of 3 percent increase of women in general surgery residency in 2017 compared with 2013.⁷ If their male colleagues are biased or harboring misconceptions about victim blaming/responsibility, they may be less likely to identify or support a trainee who is experiencing IPV.

Other barriers to adequate IPV screening identified by both surgical residents and medical students included a concern for their own personal safety when inquiring about a history of IPV (32.6 percent) and fear that patients might take offense when asked about IPV (22.8 percent). Despite these barriers being more evident among the medical student responders, surgical residents did admit to rarely inquiring about IPV in patients with physical injury, pelvic pain, high blood pressure, irritable bowel syndrome, headaches, depression, and anxiety. It also was noted that only 48 percent of surgical residents were able to identify a victim, whereas even fewer (27 percent) were able to identify the perpetrator.⁶

These results mirror a study by Bhandari and colleagues in which 186 Canadian attending orthopaedic surgeons were surveyed regarding perceptions, attitudes, and knowledge related to IPV.⁸ Although 28 percent of the orthopaedic injuries treated annually were associated with IPV, approximately 95 percent of participants believed that the prevalence of IPV was actually less than 10 percent in their patient population. Moreover, when surveyed, this cohort was less likely to disagree with victim-blaming statements, including the following:⁸

• Victims have personalities (passive and/or dependent) that predispose them to abuse (20 percent)
• Victims “get something” from an abusive relationship (14 percent)
• Victims choose to be victims (5 percent)
• Both abusers and victims are responsible for the abuse (5 percent)

Other barriers to IPV screening included uncertainty regarding correct IPV reporting pathways (64 percent), concern for personal safety when inquiring about patterns of abuse (30 percent), and a belief that inquiring about IPV is an invasion of privacy (9 percent).⁸

Acknowledging the misconceptions and implicit biases regarding IPV that exist in our field is an opportunity to reinforce and adjust our own views. Multiple studies have reported a need to improve IPV education, citing that IPV identification is important in the practice of surgery, with 77.2 percent of surgical trainees being open to additional IPV training.⁶ Furthermore, more than 90 percent of trainees and attendings alike recognize IPV as an important comorbidity that should be addressed as a part of their practice.^6,8 Thus, with increased education, surgeons will be able not only to advocate for our patients, but also for our colleagues.

Risk factors

Individual, relationship, and societal factors influence the overall risk of IPV. The CDC provides an exhaustive list of risk factors; however, it is important to keep in mind that they may not relate to all circumstances of IPV. Risk factors for perpetrators include low self-esteem, self-doubt, feelings of anger and/or inadequacy, a controlling personality, and substance abuse.⁵ Victims also may experience loss of control, low self-esteem, self-doubt, and dependence. Past experience with domestic violence, either as a child or in a relationship, however, is the strongest predictor of IPV for both perpetrators and victims. Interestingly, personal experience with IPV also is one of the strongest factors associated with increased screening by physicians.² At the societal level, community acceptance of gender-specific roles, tolerance of aggression and IPV behavior, socioeconomic stress, and a lack of external support increase the risk and endurance of violence.

There are reasons to believe many of the same risk factors associated with IPV potentially can be enhanced by surgical culture. Physicians’ tendency to experience self-doubt, guilt, and an exaggerated sense of responsibility2 in both their professional and personal lives, particularly during their training, can perpetuate victimization and violence. This behavior is especially dangerous because it can lead to split identities in which the work persona exists in a world outside of the one where they experience abuse,² translating into a culture of silence in which victim identification among colleagues can be extremely challenging. Surgical culture further enhances this behavior as a remnant of an outdated and often romanticized idea of the surgeon being “superhuman without fundamental personal needs for self-care and a life outside of medicine.”^9-11 This notion inevitably is accompanied by the consequence of being perceived as “unworthy of trust” by colleagues if seen as “vulnerable,”^9-11 leading to burnout and complete loss of control. Surgical residents are particularly susceptible to falling into the “super-human” mentality as a result of the demanding nature of training. This can cause high levels of stress, leading to feelings of loss of control, depression, anxiety, low job satisfaction, substance abuse, depersonalization, poor communication or lashing out, and emotional exhaustion.^9-13 Together, these symptoms increase the risk that our trainees and colleagues may become victims or perpetrators of IPV.

Signs and symptoms of IPV

Recognizing the signs and symptoms of IPV is the first step in helping a colleague escape a violent relationship. In addition to physical injuries, victims of IPV may exhibit certain characteristics that can suggest abuse. If an individual is isolated from their loved ones, does not have control over finances, has unexplained injuries, has low self-esteem, exhibits self-harming tendencies, or has depression and anxiety, the individual may be a victim of IPV.¹³ In the workplace, victims may show unexplained poor work performance, such as tardiness, inattention to detail, or poor concentration. In residents, it also may manifest as disorganization, failure to progress technically, or poor performance on exams.

Often the victim’s partner can provide valuable clues to patterns of abuse. Hovering, frequently calling or texting even when they know the victim is scrubbed or unavailable, demeaning or belittling their partner publicly, accusing the victim of cheating, or not “allowing” their partner to be alone with co-workers all may be signs of abuse. The following list represents some specific signs of an abusive or violent partner:^4,5,14,15

• Controls their actions
• Controls their birth control
• Prevents them from seeing friends or family
• Discourages them from working or going to school
• Destroys their property
• Physically threatens or hurts them
• Blames them for the abuse
• Threatens to hurt themselves, their victim, or others if the victim tries to leave
• Humiliates them on purpose
• Checks their phone, e-mail, social networks, or tracks them in any other way

Advocating for colleagues

In 2014, the ACS Committee on Trauma recognized the importance of IPV, declaring that “it is the responsibility of the treating surgeon not only to care for the immediate injury and to reassure the patient, but also to identify resources in his or her hospital and to help identify resources in the community.”¹⁶ Three years later, during her term as ACS President, Barbara Lee Bass, MD, FACS, FRCSEng(Hon), FRCSI(Hon), FCOSECSA(Hon), recognized that IPV also was a major concern for surgeons personally. Dr. Bass’s and the College’s awareness of this issue was raised as a result of the tragic death of Sherilyn A. Gordon, MD, FACS. Dr. Gordon, a colleague of Dr. Bass at Houston Methodist Hospital, TX, was murdered by her husband, who then took his own life. Dr. Gordon was a celebrated transplant surgeon at Houston Methodist J.C. Walter Jr. Transplant Center and associate professor of surgery at Houston Methodist Hospital. She also served as the general surgery residency program director, the assistant dean for graduate medical education (GME) at Texas A&M Health Science Center, and the first physician to serve as the designated institutional official for GME at Houston Methodist Hospital.¹⁷

In addition to making IPV a platform issue for her presidency, Dr. Bass established the ACS IPV Taskforce in January 2018, and updated the ACS Statement on IPV to include the following recommendations: “Surgeons should identify and intervene when colleagues and trainees are victims of IPV or can be identified as an at-risk situation. Surgeons and surgical departments should develop programs within their practices and departments to help identify and support colleagues who are victims of IPV using national and international guidelines.”¹⁸

Surgeons are uniquely positioned to advocate for both patients and colleagues experiencing IPV and have access to a number of valuable resources. The Joint Commission requires hospitals and clinics to screen all patients for IPV and provide access to social service support.¹⁹ Social workers and case managers often have a wealth of information regarding counseling, shelters, legal advice, and protective services. In addition, human resources departments often offer services specifically for employees experiencing violence within and outside of the workplace, including referring victims to a counselor, ensuring workplace safety by escorting victims to and from parking lots and work areas, screening calls, and conducting threat assessments.²⁰

For surgeons experiencing IPV, however, it is plausible that knowledge of resources and access to services is not a limiting factor in receiving assistance. Rather, acknowledging IPV means acknowledging their vulnerability in a culture in which strength, determination, and conviction are the cornerstones of surgical identity. Thankfully, the work of surgery—completed over long hours and in the close quarters of the operating room—often bonds us together, forging close relationships built on trust. The private nature of our work and the secluded settings within which we practice may facilitate open discussions in these safe spaces.

If you suspect that a colleague or trainee is experiencing IPV, ask. Perhaps they are unready to disclose their situation, but you have taken the first steps to identify yourself as a trusted friend and someone to turn to when they feel the time is right. Although you may be mistaken in your concern, they will know that you cared enough to ask.

Acknowledgment

The authors would like to thank Emily Funsten, MD, and Heather Logghe, MD, FACS, for their contributions to this article during their research fellowships in the laboratory of Dr. Sims at the University of Pennsylvania, Philadelphia. The authors believe dedication to addressing IPV in trainees and colleagues will continue to shape our culture of surgery.

References

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