Author's note: Since the majority of domestic violence victims are female, the pronoun "she" is used continuously throughout this article; this is not, however, intended to diminish incidences of abuse suffered by male victims. This article is for informational purposes and not a substitute for professional training or continuing education.

October is a magical time of year: Shorter days yield to cooler nights while the leaves turn color and fall gracefully from the trees, forming yellow, orange and red sidewalk mosaics. We buy bags of candy for the invasion of trick-or-treaters (hoping we don't eat it all ourselves before the big day arrives) and generally prepare for what is sure to be another busy holiday season.

What many people don't know, however, is that October also marks a less celebrated -- but no less relevant -- occasion: Domestic Violence Awareness Month, an event first organized in October 1987 by the National Coalition Against Domestic Violence for the purpose of focusing awareness on the crisis of domestic violence.¹

Definition and Background

In Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers, Warshaw and Ganley define domestic violence -- also known as intimate partner violence -- as "...a pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks, as well as economic coercion, that adults or adolescents use against their intimate partners."²

As hard as it is to contemplate the implications of violence in the home, it is even harder for those whose reality includes living in constant fear of abuse by spouses or partners. Consider these startling statistics from the Family Violence Prevention Fund (FVPF):

• "Nearly one-third of American women (31 percent) report being physically or sexually abused by a husband or boyfriend at some point in their lives;
• In the year 2001, more than half a million American women were victims of nonfatal violence committed by an intimate partner;
• On average, more than three women are murdered by their husbands or boyfriends in this country every day. In 2000, 1,247 women were killed by an intimate partner. The same year, 440 men were killed by an intimate partner;
• About half of all female victims of intimate violence report an injury of some type, and about 20 percent of them seek medical assistance."

As these statistics show, domestic violence is prevalent in the U.S.; moreover, its victims are both male and female, and it can be found in every race, ethnicity, culture, social structure and income bracket, as well as within heterosexual, homosexual and transgender relationships. There is no "typical" victim of domestic violence, and "... no causative link has been found between the characteristics of battered women and their victimization ... Being a victim of domestic violence is due to behaviors of the perpetrator, rather than the personal characteristics of the victim."²

In their book, , Ben Benjamin, PhD, and Cherie Sohnen-Moe write, "On the average, one of every five clients a [massage] practitioner sees has a history of some kind of trauma or abuse."

Although not every victim of abuse has necessarily been a victim of intimate partner violence, it is likely a massage therapist will, at some point, come into contact with a client who either is or has been subjected to domestic violence. And according to the FVPF, "A recent study found that 44 percent of victims of domestic violence talked to someone about the abuse; 37 percent of those women talked to their health care provider."⁵

Although massage therapists are not considered health care providers , the demand for massage therapy as an adjunctive health care treatment has been increasing. Thus, massage therapists might very well see the signs of abuse before these signs are visible to others.

Sheryl Heron, MD, MPH, is an associate professor and associate residency director at Emory University School of Medicine's Department of Emergency Medicine in Atlanta, Ga. She was appointed to the Georgia Commission on Family Violence in 2002, and has dedicated much of her career to domestic violence education and awareness.

When it comes to domestic violence, Dr. Heron believes in a coordinated community response -- that every facet of the community, including religious institutions, health care providers and service-oriented businesses (like massage) must address the issue in order for victims to have easy access to help. Dr. Heron believes that massage therapists are in a unique position to help victims, since many may seek massage as a way to heal.⁶

The Role of the Massage Therapist

There are a number of signs a massage therapist can look for to determine if a client is a victim of intimate partner violence, most notably, the presence of bruises, cuts and lacerations on the face, head and body, or in areas usually covered by clothing, including the back, chest, breasts, abdomen and extremities. Soft-tissue injuries, sprains, fractures, eye or ear trauma, complaints of injuries lacking visible evidence, chronic illness, injuries that do not appear to heal over time (suggesting repeated abuse), or injuries that do not coincide with a client's explanation of how the injury occurred, are also key indicators of violence.^2,6

Unlike medical doctors and other health care professionals, massage therapists are not typically bound by mandatory reporting laws when abuse is discovered (check the laws in your state); however, Dr. Heron says there is nothing wrong with a massage therapist asking pointedly, but gently, if a client is a victim of intimate partner abuse.

"[Therapists] can tell their clients that they are not asking to probe or pry but that they are in line in the fight against domestic violence in their community," she suggests.⁶

The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings suggests the following framing questions to help clients feel safe and comfortable about disclosing whether they are victims of intimate partner violence:

"'Because violence is so common in many people's lives, I've begun to ask all my patients about it.'

'I am concerned that your symptoms may have been caused by someone hurting you.'

'I don't know if this is (or ever has been) a problem for you, but many patients I see are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I've started asking about it routinely.'"⁷

More direct questions include:

"'Did someone cause these injuries? Was it your partner/husband?'

'Has your partner or ex-partner ever hit you or physically hurt you?'

'Do you ever feel afraid of your partner? Do you feel you are in danger?'"⁷

Should a client disclose that she is indeed a victim, massage therapists must listen and validate their client's experience without judging, laying blame, or pressuring the client to do something she is not ready for. Emphasize that the information the client shares is strictly confidential; however, try to negotiate with the client to document the disclosure of abuse in her patient chart.

Documentation of the victim's abuse could help her in court if her perpetrator is prosecuted; however, for safety reasons, it is important to chart only what the client wants documented about her injuries and/or experience. If a victim indicates she does not want the experience documented, Dr. Heron emphasizes the practitioner must respect her wishes."Say: 'I understand and respect that [choice].'"⁶

"Domestic violence is about power and control," Dr. Heron adds. She cautions therapists not to "exhibit another power/control situation. Victims must feel empowered." Dr. Heron affirms that listening without judgment "gives women a chance to make decisions about [their] lives without re-victimization."

Although Dr. Heron concedes that it can be frustrating for practitioners when victims decline help, she notes that if clients know their massage therapist has access to resources, they will know it is safe to return for help in the future. "You meet your clients where they are and give them autonomy with your knowledge of domestic violence," she says.⁶

So, what steps can massage therapists take to help victims of abuse?

For one, therapists can hang posters and display informational brochures in their rooms or offices (Educational resources are available for a nominal fee through the FVPF.) This conveys the message that the therapist is socially responsible and sensitive to the issue of domestic violence, which also opens the door for victims to confide in their therapist and/or seek help. Therapists should also have referral numbers to local or national violence hotlines, such as the National Domestic Violence Hotline (800-799-SAFE).

Focus on Education and Awareness

Although Dr. Heron believes that massage therapists and health care practitioners in general could benefit from more education in the area of domestic violence, she affirms there is more to education than practitioner awareness -- there is public awareness.

Tanya Brown, youngest sister of the late Nicole Brown Simpson, and a certified domestic violence counselor and co-founder of the Nicole Brown Charitable Foundation, agrees; moreover, Brown believes that education and awareness begin in the home.⁸

"Violence starts at home with shouting, yelling, screaming," she asserts. "We need to bring respect, trust and honesty back to our kitchen tables. How about getting to really know your kids? Have them sit with you...ask them, 'How was your day?' Have conversations. By doing this you are promoting a healthy environment for children."

Though Brown advocates awareness, she notes that outsiders should exercise caution when trying to help victims.

"Domestic violence is the most dangerous call for [police] officers to go on. I strongly suggest that you don't get involved directly with wanting to 'save' the victim. You, too, could be in danger. Have those hotline numbers ready. Ultimately, it is up to the [victim] to get themselves help. You just lead them to the resources."

Irrespective of whether victims have access to resources through their massage therapists, Dr. Heron makes one point clear: "Abuse is a crime. We all need to be informed, educated and committed."

For more information, readers are encouraged to contact FVPF at 888-792-2873 or http://endabuse.org, or the Nicole Brown Charitable Foundation at www.nbcf.org.

References

1. National Coalition Against Domestic Violence Web site. Domestic Violence Awareness Month. www.ncadv.org/community/dvamonth.htm.
2. Warshaw C, and Ganley AL. Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers, 1998. Online. http://endabuse.org/programs/display.php3?DocID=238.
3. "Domestic Violence is a Serious, Widespread Social Problem in America: The Facts. Family Violence Prevention Fund." http://endabuse.org/resources/facts.
4. Benjamin B, Sohnen-Moe, C. The Ethics of Touch. SMA, 2003. www.sohnen-moe.com.
5. "The Facts on Health Care and Domestic Violence." Family Violence Prevention Fund. http://endabuse.org/resources/facts/HealthCare.pdf.
6. Phone Interview with Dr. Sheryl Heron, Aug. 30, 2004.
7. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Family Violence Prevention Fund. http://endabuse.org/programs/healthcare/files/consensus.pdf/.
8. E-mail interview with Tanya Brown. Sept. 1, 2004. www.tanyabrown.net.