The Pentagon's policy on homosexuality vividly captures the attitude of many emergency department (ED) professionals toward the underlying situational, psychological, and behavioral problems of victims of domestic violence.<sup>41 Easteal P.W., Easteal S. Attitudes and practices of doctors toward spouse assault victims: An Australian study Violence and Victims 1992 ;  7 : 217-228

Cliquez ici pour aller à la section Références, 64 Gremillion D.H., Kanof E. Overcoming barriers to physician involvement in identifying and referring victims of domestic violence Ann Emerg Med 1996 ;  27 : 769-773

Cliquez ici pour aller à la section Références, 74 King M.C., Ryan J. Abused women: Dispelling myths and encouraging intervention Nurse Practitioner 1989 ;  14 : 47-58

Cliquez ici pour aller à la section Références, 126 Sugg N.K., Inui T. Primary care physicians' response to domestic violence: Opening Pandora's box JAMA 1992 ;  267 : 3157-3160

Cliquez ici pour aller à la section Références</sup> Screening to identify victims of violence has become a part of some, though by no means all<sup>1 Abbot J., Johnson R., Koziol-McLain L. , et al. Domestic violence against women: Incidence and prevalence in an emergency department JAMA 1995 ;  273 : 1763-1767

Cliquez ici pour aller à la section Références, 28 Council on Ethical and Judicial Affairs, American Medical Association Physicians and domestic violence: Ethical Considerations JAMA 1992 ;  267 : 3190-3193

Cliquez ici pour aller à la section Références, 34 Dearwater S.R., Coben J.H., Campbell J.C. , et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments JAMA 1998 ;  280 : 433-438  [cross-ref]

Cliquez ici pour aller à la section Références, 45 Family Violence Prevention Fund   California hospital emergency departments response to domestic violence: Survey report : Family Violence Prevention Fund (August 1993). 

Cliquez ici pour aller à la section Références, 92 Morrison L.J. The battering syndrome: A poor record of detection in the emergency department J Emerg Med 1988 ;  6 : 521-526  [cross-ref]

Cliquez ici pour aller à la section Références, 101 Randall T. Domestic violence intervention calls for more than treating injuries JAMA 1990 ;  264 : 939-940

Cliquez ici pour aller à la section Références</sup> emergency services, partly in response to federal initiatives, state mandates, and the Joint Commission on Accreditation of Health Care Organizations (JCAHCO) standards.<sup>40 Easley M. Domestic violence Ann Emerg Med 1996 ;  27 : 762-763

Cliquez ici pour aller à la section Références, 72 Joint Commission on Accreditation of Health Care Organizations Accreditation Manual for Hospitals, Vol 1: Standards. Oakbrook Terrace, IL; Joint Commission on Accreditation of Health Care Organizations, 1992.

Cliquez ici pour aller à la section Références, 91 Morbidity and Mortality Weekly Reports Emergency department response to domestic violence—California, 1992 MMWR 1993 ;  42 : 817-820

Cliquez ici pour aller à la section Références, 98 Poirer L. The importance of screening for domestic violence in all women Nurse Practitioner 1997 ;  22 : 105-122

Cliquez ici pour aller à la section Références, 100 Randall T. Domestic violence begets other problems of which physicians must be aware to be effective JAMA 1990 ;  264 : 940-944

Cliquez ici pour aller à la section Références</sup> Nevertheless, except for careful documentation of history and injuries, ED clinicians often think they have little to offer someone with an immediate or recent history of assault by an intimate associate. Without readily available, effective interventions, it becomes difficult even to maintain screening protocols and standards of documentation over time.<sup>52 Furbee P.M., Sikora R., Williams J.M. , et al. Comparison of domestic violence screening methods: A pilot study Ann Emerg Med 1998 ;  31 : 495-501  [cross-ref]

Cliquez ici pour aller à la section Références, 64 Gremillion D.H., Kanof E. Overcoming barriers to physician involvement in identifying and referring victims of domestic violence Ann Emerg Med 1996 ;  27 : 769-773

Cliquez ici pour aller à la section Références, 87 McLeer S.V. Education is not enough: A systems failure in protecting battered women Ann Emerg Med 1989 ;  18 : 651-653  [cross-ref]

Cliquez ici pour aller à la section Références, 103 Roberts G.L., Lawrence J.M., O'Toole B.I. , et al. Domestic violence in the emergency department: I. Two case–control studies of victims Gen Hosp Psychiatry 1997 ;  19 : 5-11  [cross-ref]

Cliquez ici pour aller à la section Références, 136 Warshaw C. Establishing an appropriate response to domestic violence in your practice, institution, and community Improving the Health Care Response to Domestic Violence: A Manual for Health Care Providers San Francisco: Family Violence Prevention Fund (1998). 

Cliquez ici pour aller à la section Références</sup> Some advocates and social scientists consider the medical response to battered women so inadequate that it appears among the factors that perpetuate rather than mitigate abuse.<sup>49 Fontanarosa P.B. The unrelenting epidemic of violence in America: Truths and consequences JAMA 1995 ;  273 : 1792-1793

Cliquez ici pour aller à la section Références, 120 Stark E., Flitcraft A., Frazier W. Medicine and patriarchal violence Int J Health Serv 1979 ;  9 : 461-493  [cross-ref]

Cliquez ici pour aller à la section Références, 137 Warshaw C. Limitations of the medical model in the care of battered women Gender and Society 1989 ;  3 : 506-517  [cross-ref]

Cliquez ici pour aller à la section Références</sup>

Certainly, room exists for improvement,<sup>135 Warshaw C. Domestic violence: Changing theory, changing practice JAMWA 1996 ;  51 : 87-91

Cliquez ici pour aller à la section Références</sup> especially in the emergency treatment of battered women. The ED is paradoxically the best and the worst setting for intervention with victims of domestic violence. Its deficiencies are obvious. Treatment is highly focused and moves at a fast pace. The technical resources of the ED do not match the social and psychological needs of victims seeking help. The authoritarian treatment relationship often required in an emergency discourages patient–victims from disclosing their status,<sup>51 Fullin K.J., Cosgrove A. Empowering physicians to respond to domestic violence Wisconsin Med J 1992 ;  91 : 280-283

Cliquez ici pour aller à la section Références, 120 Stark E., Flitcraft A., Frazier W. Medicine and patriarchal violence Int J Health Serv 1979 ;  9 : 461-493  [cross-ref]

Cliquez ici pour aller à la section Références, 138 Wilson K.J.   When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse CA: Hunter House (1997). 

Cliquez ici pour aller à la section Références</sup> about which they may be ashamed and confused.

Nevertheless, the ER is arguably the best place for intervention, at least medically informed intervention, in the lives of victims of violence. Battered women often list medical services as their main or preferred source of help.<sup>65 Hadley S. Working with battered women in the Emergency Department: A model program J Emerg Nurs 1992 ;  18 : 22

Cliquez ici pour aller à la section Références, 93 Olson L., Anctil C., Fullerton L. , et al. Increasing emergency physician recognition of domestic violence Ann Emerg Med 1996 ;  27 : 741-746

Cliquez ici pour aller à la section Références, 107 Sassetti M.R. Domestic violence Primary Care 1993 ;  20 : 289-305

Cliquez ici pour aller à la section Références</sup> Although much domestic abuse occurs within a matrix of personal and social factors that resist change,<sup>33 Davies J., Lyon E., Monti-Catania D.   Safety Planning with Battered Women: Complex Lives/Difficult Choices Thousand Oaks CA: Sage Publications (1998). 

Cliquez ici pour aller à la section Références, 132 Walker L.E. Battered women and learned helplessness Victimology: An International Journal 1977 ;  2 : 525-534

Cliquez ici pour aller à la section Références</sup> patients in the ED are by definition in a state of crisis. Illness or injury has disrupted their usual patterns of coping and relating, and they can be open to steps they have rejected in the past. The largest factor compelling ED intervention is more mundane: given the way batterers isolate their victims, the ED may be the only setting in which an abused spouse, partner, or child stands a chance of receiving help.<sup>20 Campbell J.C., Pliska M.J., Taylor W. , et al. Battered women's experiences in the emergency department J Emerg Nurs 1994 ;  20 : 280-288

Cliquez ici pour aller à la section Références</sup> As the apochryphal gambler explained when asked why he gambled at a casino where he knew the roulette wheel was rigged: “The wheel may be crooked, but it's the only wheel in town.”

Appropriate ED responses to domestic violence require clinicians to have a sophisticated understanding of abusive relationships and the psychological state of victims. This article provides a brief orientation to violent relationships and their medical/psychological consequences. The acronym RADAR (Routinely screen female patients, Ask direct questions, Document your findings, Assess patient safety, Review options and referrals) reminds clinicians of the overall shape of appropriate intervention.<sup>66 Harwell T.S., Casten R.J., Armstrong K.A. , et al. Results of a domestic violence training program offered to the staff of urban community health centers: Evaluation Committee of the Philadelphia Family Violence Working Group Am J Prev Med 1998 ;  15 : 235-242  [cross-ref]

Cliquez ici pour aller à la section Références</sup> This article expands mainly on the last two steps of this protocol.

Prochaska's<sup>99 Prochaska J.O., DiClemente C.C., Norcross J.C. In search of how people change: Applications to addictive behavior Am Psychologist 1992 ;  47 : 1102-1114  [cross-ref]

Cliquez ici pour aller à la section Références</sup> model of intentional, clinician-facilitated change in health-related behaviors provides a theoretic framework for responding to victims of domestic violence in the ED. This model emphasizes the need to tailor advice to the patient's degree of readiness to use it. Applied to victims of violence, intervention to promote change must take into account where the woman stands in the process of living with, confronting, escaping, or recovering from a violent relationship. The goal is not to persuade a woman to leave a violent partner, which may not be her best option, but to empower her to improve her safety and well-being.<sup>21 Campbell J.C., Sheridan D.J. Emergency nursing interventions with battered women J Emerg Nurs 1989 ;  15 : 12-17

Cliquez ici pour aller à la section Références, 24 Chescheir N. Violence against women: Response from clinicians Ann Emerg Med 1996 ;  27 : 766-769

Cliquez ici pour aller à la section Références, 51 Fullin K.J., Cosgrove A. Empowering physicians to respond to domestic violence Wisconsin Med J 1992 ;  91 : 280-283

Cliquez ici pour aller à la section Références, 107 Sassetti M.R. Domestic violence Primary Care 1993 ;  20 : 289-305

Cliquez ici pour aller à la section Références</sup>

Concretely, medical personnel should assess the victim's understanding of the role of violence in her life and especially in her medical condition, with particular emphasis on her current risk for further injury.<sup>21This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références, 46This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références</sup> Clinicians should express concern and highlight the medical consequences of problem, if the patient is not already aware of them. Rather than prescribe a course of action, the clinician should then explore the woman's asessment of her choices and resources, offer information to help her revise her assessment if necessary, and determine her current need for or interest in specific medical, social, legal, or advocacy services.<sup>51This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références, 98This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références</sup> Consistent with the principles of patient-centered interviewing in primary care<sup>90This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références, 116This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références</sup> and of “woman-based advocacy” provided by specialized domestic violence services,<sup>33This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

Cliquez ici pour aller à la section Références</sup> ED staff must replace neglect or “one-size-fits-all” intervention with a flexible, respectful, and helpful stance toward any victim at any stage of handling the problem.^{*This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.}