Domestic violence has traditionally been considered a social problem whereby the aim of the violence is to assert control and power. The feministic perspective suggests that patriarchal family structures, men's greater physical strength and sense of entitlement mean that men tend to be the perpetrators, women and children the victims, of abuse. The patriarchal notion that men have the right to control and dominate members of their families tends to render sexual and physical violence within families visible. Whereas in the past beating women was generally supposed to be a cowardly act for men, it is no longer held so.

While it is widely recognised that battering has severe effects on the victim's health, well-being and self-esteem, it is less well known that although domestic violence happens in the home, this has serious and far-reaching public health consequences apart from the potential for injury and death. In fact, researchers are beginning to understand that injuries represent the tip of the iceberg in terms of health effects. It is not surprising that the health-care needs of people who have experienced previous domestic violence may vastly overwhelm the numbers of people who are seeking assistance for current injuries.¹

Indeed, survivors of domestic violence have high rates of health-care use and make massive demands on the health-care system. They make more visits to primary care physicians, specialists, and emergency departments. They report more symptoms, have more procedures and diagnostic tests, and have surgery more often. Yet they are often very unhappy with the care they receive, and they may even be re-traumatised by their health-care providers. Increasing evidence is available that domestic violence has been related to a wide range of chronic diseases and conditions, including chronic pain, ischaemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, skeletal fractures, and hepatitis.¹ Today, it is regarded as a leading cause of morbidity and mortality in women.

It has become more apparent that the majority of battered women have as a matter of fact sought medical attention for injuries resulting from violence at least once. However, medical education has generally avoided the topic of domestic violence. Typically, treatment has tended to focus on injuries and complaints as isolated incidents rather than as symptoms of an ongoing risk. Absence of recognition contributes to the mistaken belief that violence is relatively rare and that it is most often random and anonymous. Deploringly, most victims, estimated to be about 68 to 75%, indicate that they would have acknowledged the violence if their physicians had asked, but for some health-care providers, domestic violence is "not on the radar screen", and they are unlikely to ask patients about it at all.¹ Despite evidence that domestic violence is a legitimate and important health-care issue, many providers still view it as outside their purview.²

In any case, the two most important points of medical contact are generally in the emergency rooms or the family physicians' clinics. According to the National Violence Against Women Survey in the United States, 62% of these women were seen in emergency departments.³ Similar findings from a study in the Accident and Emergency Departments in Hong Kong were reported in a previous Journal issue.⁴

Again, the health and psychological consequences of battering makes it a priority for the family physicians who are placed in an ideal position to recognise violence and intervene appropriately because they provide ongoing, whole-person care and have contact with people of all ages. Through screening,^5,6 patient education, counselling, support and referral, they can contribute to violence prevention and intervention efforts, thus helping to reduce the violence in their patients' lives.

The family physician does not have to be an expert in the psychosocial aspects of domestic violence to effectively prevent future trauma and the development of the associated medical disorders. The clinician's role is to diagnose and identify the problem, then to provide the appropriate referral network.

In providing counsel, the physician best serves the patient by continuing to emphasise the health hazards of domestic violence.⁷ Furthermore, the patient should be educated about the cycle of violence, an analysis of Walker which was to become a milestone in domestic violence theory and the basis of the widely used legal defence, "Battered Women Syndrome".

Hence it is truly timely that Cheung's discussion paper on Partner Abuse in this Journal issue comes to shed more light on the situation in Hong Kong where, according to the statistics provided by the Social Welfare Department of the Government, the number of cases on battered wives has increased tremendously from around 3,000 in 2002 to about 3,300 in 2003, and is no doubt on the rise. This article has the merit of a family physician's point of view in multi-disciplinary perspectives.

At the end of the day, primary prevention of domestic violence will be achieved only by challenging the roles of violence and patriarchy in society of one such as that in Hong Kong. This includes educating parents and teens about nonviolent problem-solving strategies and questioning gender stereotypes on both individual patient interactions and through school or community-based programmes. People in Hong Kong should not subscribe to the erroneous concept that it is better not to mind other's business. Secondary prevention includes the intervention and elimination of intergenerational abuse of all kinds, challenging popular images of gendered violence, and treating co-factors of alcohol and substance abuse. Tertiary prevention can be achieved by identifying victims and their abusers as well as helping each one. It can hardly be overstated that domestic violence is no longer "a skeleton in the closet" that has to be kept in the dark.⁸ When available, battered women's shelters such as the Harmony House for safety are effective, although admittedly not all of the women in need can access them.⁹ A good reference of the general practice management of partner abuse is available in a recent BMJ issue.¹⁰