Emergency Department Responses to Battered Women: Resistance to Medicalization
Author(s): Demie Kurz
Source: Social Problems, Vol. 34, No. 1 (Feb., 1987), pp. 69-81
Published by: Oxford University Press on behalf of the Society for the Study of Social
Problems
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Emergency Department Responses to
Battered Women: Resistance to Medicalization*
DEMIE KURZ, PhiladelphiaHealth ManagementCorporation to "-the injuryof womenby husbandsand medicalresponses "battering are Reformers attemptingto restructure boyfriends-by encouraginghealth care personnelto identifyand intervenein cases involvingbatteredwomen.
In this participantobservation study, I reporton responses staff membersin threehospitalemergency departof ments where thereis resistanceto dealing with batteredwomen. I then describea fourth emergency department where attemptsto medicalizestaff members'views of batteredwomen create morefavorable responsestoward such women. I discussimplications policy regardingtreatmentby batteredwomen and for researchon the for processof medicalization.

Sociologists concerned with the definition and construction of "social problems" and "deviant behaviors" argue that in recent decades a range of problems previously defined in moral or criminal terms, have been redefined as medical problems. Some now use the term "medicalization" to describe how the medical profession can label and gain jurisdiction over many areas of life which involve the workings of the body or mind such as drug addiction, alcohol, aging; birth control, pregnancy, and child birth; and child abuse. (Conrad and Schneider,
1980a; Freidson, 1973; Zola, 1972, 1975). Those studying medicalization are particularly concerned with how the medicalization process can depoliticize "social" problems by redefining them as problems of individual pathology (Conrad, 1975; Kittrie, 1971).
This study examines a new area which reformers in the health care system are attempting to medicalize: the area of "battering," or the injury of women by husbands and boyfriends. Attempts to medicalize battering have their origins in a social movement on behalf of
"battered women" which began in the early 1970s (Schecter, 1982; Tierney, 1982). The battered women's movement brought to public attention the fact that an estimated 1.5 million wives are injured each year by husbands (Strauss et al., 1980), and 1.5 million single, separated, and divorced women are injured by male intimates (Rosenberg et al., 1985). Supporters from within mental health, social service, and governmental organizations have joined advocates for battered women in bringing about the creation of a nationwide network of shelters and shelter services; legislation in most states increasing police powers and criminal penalties against abusers; government funding for programs and agencies for battered women; and increased data collection on the issues by public and private research organizations (Attorney
General's Task Force, 1984; Dobash and Dobash, 1979; Schecter, 1982; Tierney, 1982). The battered women's movement and supporters in the health care system are now calling for the health care system to aid in the identification of battered women and their referral to appropriate sources of help.
From within the health care system, the Surgeon General of the United States (Koop,
1982, 1984), the American College of Physicians (1986), selected State and local health officials
(New Jersey Department of Community Affairs, 1985), and a national network of nurses are among those calling for the health care system to play a role in addressing this problem. They
* The research for this paper was supported by NIMH Grant MH37180-02. The author thanks Howard S. Becker,
Bruce Birchard, Michelle Fine, Carole Joffe, Judith Lorber, and Evan Stark for comments on previous drafts.
Correspondence to: Philadelphia Health Management Corporation, 260 S. Broad Street, Philadelphia, PA 19102.

SOCIAL
Vol. 34, No. 1, February 1987
PROBLEMS,

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KURZ argue that health care personnel should "diagnose" the battering "syndrome," consisting of specific injury and behavior patterns, and intervene on behalf of battered women. Some reformers have published articles in medical journals urging health care personnel to identify battering, and describing symptoms and signs of battering (Campbell and Humphreys, 1984;
Finley, 1981; Goldberg and Carey, 1982; Greany, 1984; Klingbeil, 1986; Loraine, 1981; Petro et al., 1978). Others are holding conferences (Rich and Burgess, 1986) and developing protocols for use by health care personnel to identify battering (Helton, 1986). Reformers have succeeded in putting into place approximately 100 initiatives at the state and local levels to train hospital staff and other health care personnel about battering.'
Reformers argue that intervention in the health care system can result in the timely referral of battered women to sources of help, thus preventing further injury, and in the documentation of injuries on medical records for use by individual women and for the purpose of collecting statistics. They note that the potential benefit of reform is great in that large numbers of battered women come to the health care system. A survey of women in Texas estimated that 360,000 women had at some point in their lives required medical treatment because of abuse (Teske and Parker, 1983). Another study of battered women found that 80 percent of the women went to their physician for a battering injury (Dobash and Dobash,
1980). Stark et al. (1979) found that 19 percent of women trauma patients who came to the hospital emergency departments they studied were either confirmed as or very likely to have been battered.
The efforts of these groups are similar to those of earlier claims-makers who "discovered" specific injury patterns which they claimed were caused by child abuse (Pfohl. 1977). Child abuse reformers succeeded in having the identification of child abuse accepted as a legitimate medical concern and in passing legislation requiring the mandatory reporting of child abuse by physicians. The efforts to promote battering are more recent and less extensive than in the case of child abuse. Unlike child abuse, there are no medical specialties which lay claim to the problem of battering, nor is it expected that there will be legislation mandating that physicians report each individual case of battering. However, a few states have mandated the reporting of statistics on battering, and there is debate on other ways the health care system can help to stop battering (Rich and Burgess, 1986; Koop, 1984).
Since many current efforts are of a voluntary nature and since most future efforts will also require the cooperation of clinicians, it is essential to understand how clinicians will respond to battering. This paper reports on a participant observation study of responses of emergency department (ED) staff to battered women in four hospitals. In three of the hospitals there were one-time efforts to educate staff about battering and to encourage them to identify it. In the fourth hospital, due to the efforts of a reformer who believed in intervention with battered women in EDs, there were ongoing intervention efforts with staff to encourage them to view battering as a problem for medical attention, identify it, and make referrals. I compare the responses of ED staff in these two sets of EDs and analyze the factors which account for a greater response to battering in the fourth ED.
This study has implications both for our understanding of medicalization and for our understanding of the ED response to battering. Those studying medicalization typically focus on how medical professionals readily define emerging concerns as medical problems that belong within their professional domain (Conrad and Schneider, 1980a; Zola, 1972, 1975). Some argue further that, due to sexist attitudes in the medical system, women's problems are particularly likely to be "medicalized" or appropriated by the male medical establishment (Dreifus,
1978; Ehrenreich and English, 1975; Ruzek, 1978). In contrast, the medical staff I studied saw efforts to respond to battering as detracting from the proper performance of their work, not

1. Evan Stark, Nov. 16, 1986: personal communication.

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BatteredWomen enhancing it. I further demonstrate that staff resistance to battering may be influenced by prevailing views of women, but that they are influenced more by other factors.
One previous study also suggests that health care personnel are reluctant to respond to battering. Based on an extensive review of medical records, Stark et al. (1979) found that staff in a New Haven hospital do not identify battering as such, but instead respond to battered women's psychosocial problems-e.g., depression, drug abuse, suicide attempts, or alcoholism-although the women's ED records indicate that these problems arose after the onset of battering. Stark et al. attribute this inclination to overlook battering to staffs adherence to the current medical paradigm, which does not view social factors as significant elements of medical problems. Whereas Start et al. relied only on medical records, I present more direct, observational evidence on the reactions of ED staff to battered women.

Methods
I used the following methods to collect data in four hospital EDs in a large metropolitan area: observations of interactions between battered women and staff; informal interviews with ED staff; and a review of medical records. The staff at each hospital ED during each eight-hour shift generally included one or two physicians, four or five nurses, and one or two orderlies or technicians. One or two interns were occasionally present as well. The staff members in all the hospitals are primarily white, the physicians primarily male, and the
The patients represent a wide range of ethnic and class nurses primarily female. backgrounds. Observers, who were graduate students in sociology and social work, followed the cases of all female trauma patients seen by health care professionals during different shifts. The observations extended over five months in two of the hospitals and two months in the other two.2 A woman was considered battered if (1) the observer heard the woman, or someone accompanying her, say that she had been injured by her husband or boyfriend, or (2) a staff member told the observer that the woman, or someone accompanying her, said she had been injured by a husband or boyfriend. Based on this definition, interactions between 104 battered women and ED staff were observed during this period.
Observers followed as much of the interaction between staff and women as possible and then immediately interviewed staff about what transpired in the interaction-i.e., what was said and done, what physical diagnosis was made, whether the staff thought battering had occurred, and what the staff's impression of the case was. Observers took verbatim field notes on all the interactions. Because of confidentiality agreements it was not possible for observers to speak directly to the female trauma patients.
During the informal interviewing observers questioned as many ED staff as possible about whether they saw battered women, what they were like, how they compared to other patients, or what staff thought could be done for them. Medical records of female trauma patients were reviewed for the same time period as the observation.

ED Staff Responses to Battering
In this section I describe responses to battered women in the three EDs where staff had some knowledge of battering, but where there were no ongoing efforts to have ED staff re2. In two of the hospitals there were two observation periods. The first was from December 1981 to February 1982; the second, from October to November, 1982. Three observers spent three five-hour shifts per week in the ED or 15 hours each, for a total of 45 hours a week. In the other two hospitals there was a period of observation for two months, April and May, 1983, and only two observers.

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spond to battering on a systematic basis. ED staff were informed about battering at meetings in which staff from the research project explained the purpose of the project: to understand more about battered women who come to EDs and to determine what EDS could do for battered women. Research staff presented battering as a problem which could be medically identified in the ED and for which there were appropriate referral sources. At the meeting, observers told ED staff that they were leaving cards in the ED with the telephone numbers of three hotlines for battered women, although from that point on observers did not mention the cards to staff. The fact that ED directors had allowed these activities to take place was an indication to ED staff that the directors had granted some legitimacy to this issue. On the other hand, at no time did ED or hospital administrators set up procedures for identifying battered women or give any other indication that they viewed the issue as a priority.
Informally, staff knew about battered women from having seen them in the ED. Based on a record review, an average of one woman per day comes to each of these hospitals with injuries inflicted by husbands or boyfriends.3 All staff who were asked about battered women expressed awareness of "these women." ED staff do not usually use the term "battered women," but refer to "the woman who was hit/beaten by her husband/boyfriend."4 A major reason for staffs awareness of the presence of battered women is that in 75 percent of the cases the battered women volunteer that they have been injured by a husband or boyfriend.
In the other 25 percent of the cases, it becomes known because a relative or the police tell the cause of the injury.
In the following section I describe the three major responses to battered women in the three EDs: "positive," "partial,"and "no response." I describe the nature of the interactions in these categories and the reasons staff gave for their responses. Observers questioned as many staff members as possible about particular cases. All staff members were willing to describe the cases if they had time, and approximately half volunteered reasons for their responses.

Positive Responses
In 11 percent of the cases staff take a woman's battering seriously and view it as legitimately deserving of their time and attention. In addition to giving a battered woman medical treatment, staff note battering on the case record, speak to the woman about what happened, her current circumstances, her safety, and attempt to provide some assistance or give the card with hotline numbers. What distinguishes these responses from others is that staff attempt to follow through with a battered woman and ensure that when she leaves, something has been done for her. One nurse talked at length with a woman, and then arranged for her to talk with a policeman who had recently come to the ED. Several others tried to call hotline num-

3. In the record review of female trauma cases collected during the course of the study, 7 percent of the cases were coded as "positive" for battering. These were cases where ED staff had indicated on the medical record that a woman was injured by her husband or boyfriend. Ten percent of the cases were coded as "suggestive" for battering. These were cases where a woman had been assaulted, but no assailant was recorded on the record. Thus, 17 percent of the female trauma cases are either "positive" or "suggestive" for battering. This is equivalent to one woman per day coming to each of these hospitals with injuries inflicted by husbands or boyfriends.
These figures are similar to those of Stark (1984). Using a slightly different coding system, Stark (1984) found that
10.6 percent of the cases were "positive." In 8.7 percent of these cases, where a full trauma history was taken, assault by a male intimate was recorded on the record, and an additional 2 percent were listed elsewhere in the record. Stark categorized 5.9 percent of the cases as "probables" (woman was assaulted, but no assailant was recorded, nor was a mugging recorded on the record), and 2.2 percent as "suggestives" (the recorded etiology of the injury did not seem to account adequately for the injury and there was contradictory information, such as woman fell downstairs and got two black eyes).
4. I use the term "battered women" throughout the paper as a short-hand term for "women injured by husbands and boyfriends." The term originated with the battered women's movement and names a social problem. My use of the term here is not meant to suggest that the view of battering as a social problem is uniformly defined or widespread.

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Battered Women

bers and shelters, and waited for return calls if necessary. Some arranged to talk to women alone, who then told them they were battered.
The fairly small number of staff members involved in these interactions do not respond to all battered women in this way; their responses are contingent on several factors. First, staff respond to women they see as "true victims." The women have to be polite, have no discrediting attributes, and, in addition, staff members have to feel that some unfortunate event has happened to them. Staff members see women as "true victims" when they perceive them to be in immediate physical danger. As one medical student said,
She wants to talk to someone about what to do and where she can go. It has happenedfive or six times before though she does not seem to have been seriouslyinjured, but I mean this is pretty serious. He pulled a knife ... she is really in a quandaryas to what to do now.
Another resident said:
Well, when I askedher todayif she passedout last night when this happened,she said no. But then she said that two weeks ago, she passedout when he triedto strangleher. I couldn'tbelieve it-this is really sick.
Secondly, staff members feel sympathetic towards women who say they are taking action to leave the violent relationship. Some women mention that they have contacted the police in order to press charges; some express their strong interest in leaving the relationship; some have already contacted an abuse agency or state their intention to do so; and some express strong interest in contacting hospital social services. One physician spoke approvingly of a patient who said: "He has beaten me the first time and this will be the last time." Staff have a genuine feeling for the predicament of these women.
Thirdly, if staff believe the woman has a pleasant personality, this influences how legitimately deserving of their time and attention they feel she is. In one ED many staff commented sympathetically about a particular woman. As the physician said:
I told her completelyoff the record"youcan do better."I mean she looks good,she seems to be nice.
She shouldn'thave to put up with that stuff. Do you know what that fool did? She was in here
Wednesdaynight and that fool was telling her I want to get out of here. I mean he's nothing but a bastard. She doesn'tneed that.

A Partial Responseto Battered Women
In 49 percent of the cases, staff makes a "partial" response to the battering side of a case.
They do similar things as those staff in the first category, such as asking the woman about her situation, giving her a card with the hotline phone numbers, calling the hotline numbers for the woman, or trying to arrange transportation home for the woman. However, staff members' involvement in these cases is brief and has a routine quality, and they do not typically think of different things they might do for a battered woman. They give a woman a small amount of their time, but give higher priority to other cases. Thus, the response may or may not be appropriate for that woman's condition. Staff may lose track of a woman who says she is in danger, or give extra time to a woman who does not appear to be in immediate danger.
In half of these cases, staff members gave reasons for their partial responses while describing their interactions with these battered women. The factor they mention most often is that the women are not responsive. In a few cases they described them as "not interested." An attending physician said directly to a couple: "So you don't want to talk about it," to which they replied, "That's right."
For the most part staff describe "unresponsive" women as "evasive," or purposely vague and inconsistent in describing how they were injured. In 16 percent of all cases in all four
EDs, staff describe the women as evasive, hiding something, or unwilling to talk. In such interactions the women may say their injury was due to an accident. For example, one wo-

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man with a facial injury said only that she had been in a car accident. According to the nurse, "She wouldn't say a thing. She was completely non-communicative. I couldn't even get a history." The nurse initially believed the woman, "although it didn't really fit for a car accident. Her lip was split and that was all." The nurse, upon hearing that the woman's husband was waiting for her, went to speak to him. He immediately volunteered that the injury had occurred during an argument.
A staff person will become particularly irritated if he or she suspects battering, takes the time to ask the woman, and the woman will not give an answer. In one case, a nurse asked a woman with a broken jaw what she had been struck with. The woman replied, "a hand."
The nurse then asked the woman if she had been struck by a "significant other," and the woman did not reply. The nurse offered the woman a card with phone numbers of battered women's agencies and asked her if she needed shelter. The woman said no, but that she would keep the card. The woman was admitted to the hospital with a broken jaw.
The second factor that staff mention in describing their interactions in cases of partial response is that the battered women have a condition which makes interacting with them difficult. Staff say these women are "AOB"(Alcohol on Breath), have taken drugs, act in ways staff believe are "crazy" or "inappropriate," or are "fighters." Staff describe 24 percent of all cases in all four EDs in terms of these stigmatized qualities.
Women who have been drinking, are generally assumed to be upset, vague, and difficult to understand. One badly beaten woman, with a high blood alcohol level, told four different stories about how she had been beaten. The following exchange reveals the typical staff attitude towards battered women with "AOB."
What is your impressionof this case?
OBSERVER:
NURSE:
Somebodybeat the shit out of her.
Is
OBSERVER: is hard to nurse for these cases?
She had "AOB." I feel sorryfor her? No, I feel like if somebodydrinks,at least they
Do
NURSE: have controlover that part of it.
OBSERVER: Does it make your job harder?

NURSE:

Well, yes. Forexample,she can'trememberwhat happened. Is that from the alcohol or the concussion? And she is dizzy-that could be from drinkingtoo. Also, when people drink they let it all out. She is upset and maybe because of the alcohol it is more extreme.

Women labeled "AOB"are assumed to be all alike-unable and unwilling to cooperate with staff-although a review of "AOB" cases showed that over a third of these women became more cooperative and willing to talk in the ED as the effects of the alcohol wore off. Staff members perceived drug cases in a similar manner to "AOB" cases. When women act in a bizarre way, staff label them "crazy," express intense dislike for them, and view them as a waste of time. One "crazy" woman wouldn't stop talking, said inappropriate things, and would not sign her forms. Another talked about killing herself and her husband, and then stole valium from the ED.
A third aspect of these cases that staff members mention is the belief that they cannot help or produce "results" with these women. Staff develop an attitude summarized by the statement, "There's nothing much we can do." While staff can give a woman a card with the phone numbers of the battered women's hotlines, they do not know if their efforts will result in the woman's using the hotlines or getting help in some other way. Some staff would also like to be able to help a battered woman get into a shelter, but this is difficult to accomplish.
As one nurse said, "There are so few shelters and so few vacancies that when we make a referral it's very difficult to find a place." On one occasion a woman wanted shelter and a staff person called the hotlines. No one answered.

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BatteredWomen

Staff Do Not Respond
In 40 percent of the cases staff do not respond to the battering side of a case. The reason staff members most often give for not responding is the same reason given for "partial responses"-the women are "evasive." The second reason staff members give for "non-response" also parallels reasons for a "partial response": that the women have a stigmatizing trait-they are "AOB," have used drugs, or act "crazy." Third, staff members say they are sometimes too busy to respond. As one nurse said, "She had two bruised eyes. I had no time to spend with her. I was too busy." A doctor told the observer, "We couldn't get any more information about her. We were too rushed this morning."
The fourth reason staff members give for not responding is that they do not view battering as a legitimate medical concern. They question women patients about the cause of their injuries strictly to diagnose and treat their physical problems; once they ascertain, for example, that a woman was struck, staff do not ask who struck her. As one physician said, "I did not ask anything about her social situation. I only asked about how he hit her with the prong of the fork." Even if a woman volunteers the information about what happened to her, it is ignored.
NURSE:

She has epigastralpain-tingling in her hands-that could be from hyperventilation.
She has been upset abouther husband... she was cryingthe whole time. She did not sleep last night.
OBSERVER: you ask if her pains were connected with this situation?
Did
NURSE:
It is not necessary. Since it couldbe coronaryyou have to be careful-she is in the age in group. But I think it is emotional. She could even have been hyperventilating her sleep. Do
OBSERVER: you see any direct links between her pain and her upset?
NURSE:
Not really. She does not reportany stabbingpain.
DOCTOR: She strikesme as being very upset. She says she had a fight with her husband. But we can not let that cloud our analysis.
Also, some staff view battering as a personal problem and define an inquiry about battering as an invasion into the patient's affairs. As one surgeon said, "It is none of my business who hit her. I am just here to treat her." One person mentioned a possible additional reason that staff do not respond. This staff person did not want to be legally responsible for bringing up the subject of battering, although she had no information about her legal liability. One staff person also mentioned fear of retaliation by a man if she got involved in a battering case.

Negative Stereotypesof Battered Women
In describing particular cases, staff members state that the demeanor of the womentheir "evasiveness" and disruptive behavior-is a primary factor preventing their addressing the battering side of a case. In 40 percent of their interactions, staff members encounter women they believe possess "troublesome" traits. However, it is clear that ED staff believe the number of such women is higher. When questioned about their views of battered women generally, staff members indicated that battered women are a source of frustration, and some staff members held these women personally responsible for the batterings they received:
It is difficultto feel sorryfor these women as they have a choice to leave the situation(nurse).
Why do anything for people who do not take responsibilityfor themselves? What good does it do when they won't come in and do somethingfor themselves. Lastnight we had a batteredwoman.
It took five hours for her to be convinced to come in by neighbors(cardiology resident). When staff see a woman leave the ED with an abuser, this reinforces their view that the women are irresponsible. They remember these incidents:

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It is ridiculous because the women go back. We see it all the time. They are in the examining room.
The man has gouged out her eye or stabbed her or something like that and she is in the ER and gets mad because we won't let the guy in (physician).
Others come to view battering as an inevitable

problem of these women's

social class.

She is a blue collar worker. These people come from neighborhoods where husbands beat up their wives all the time. There is nothing much to say-it is a clear case (intern).
I know battering takes place in middle class families but I do not associate it with middle class people such as myself .... I have only seen cases in [a poor section of the city]. There it is a way of life, one comes to expect that type of behavior and learns to live with it (physician).
Well, it is normal for a woman to fight with a man in this area. What are you going to do about those women? ... That is the culture in this area (nurse).

Occasionally staff members describe the problem as due to women's traits. They use popular negative social characterizations of women and battered women to describe the source of the problem. As one nurse said:
A lot of women do thingsto provokea man. Probably most of them do. I know there are some real crazy women around here.
Thus, many staff members treat battered women as "deliberate deviants" (Lorber, 1967), who have actively or willfully caused their own condition. Lorber demonstrates that medical personnel do not think that "deliberate deviants" are worthy of their time and attention. Staff members form this stereotype of battered women despite the fact that a great variety of battered women come to the ED-e.g., women who are about to take action to change their situation, those who are actively thinking about what to do, or those who are afraid or unwilling to change their situation.

Medicalization

Efforts in One ED

This section describes the efforts of a physician assistant in the fourth ED to have other staff members identify and refer battered women. The physician assistant had begun to identify battering cases on her own, and then had made herself knowledgeable about it. She believes the battering aspect of a case is a legitimate medical concern and compatible with her own role. She refers to battering as a "syndrome" with distinct medical symptoms, and urges others to "diagnose" the condition. This physician assistant believes it is necessary to understand that battering is the cause of the injury in order to treat the injury physically, to see the related physical and social effects, and to take some preventive measures to ensure that it will not happen again. She argues that the fact that battering is "chronic" makes it a legitimate concern for the ED because women will repeatedly come back for treatment unless it is stopped. In addition, the physician assistant is able to have productive encounters with women who are "evasive," "AOB," and "troublemakers." She views these behaviors not as illegitimate, but rather as behaviors expected of those under the stress of battering. For example, the physician assistant talked to one angry battered woman-who other staff members defined as a "troublemaker" that they wanted out of the ED as soon as possible-with a sympathetic tone. The woman began to respond calmly to the physician assistant and to reflect on her situation. From time to time the physician assistant did find a battered woman to be trouble, such as a woman who claimed to be uninterested in anything about battering. However, this physician assistant believes that most battered women are not trouble.
The advocate made several changes in her ED. First, she developed and received ap-

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BatteredWomen proval for a file card system which all staff were to use to note the battering cases they identified. These cases would then be referred to the physician assistant or the ED social worker who was concerned about battering. The ED director put treatment of battering into the official ED manual, and also allowed the physician assistant to conduct training sessions on battering for new residents and interns.
As a result of the physician assistant's efforts, there was a much greater likelihood of
"positive" responses to battered women in this ED. Forty-seven percent of the cases were in the "positive" category as opposed to 11 percent from the other three EDs. This high number of "positive" cases was mainly due to the actions of a group of eight ED staff members including a physician, several nurses, and a social worker. These staff members, influenced by the physician assistant, responded to battered women in a manner similar to her. They not only identified battering and referred the women, but briefly talked to the women and told them they didn't deserve such treatment. In a quarter of these cases the women were perceived to be "AOB," drug users, or "evasive," and yet staff members still responded in a "positive" manner. The one difference between the advocate and other staff members is that the latter expressed frustration in several cases where they felt there was nothing they could do for the women. In a few cases the women had received help from the battering agencies but had returned home for lack of alternative places to live. Staff members also expressed frustration in a few cases where the women appeared to be "repeaters." As one nurse who helped many battered women said: "I mean now that she is here I want to give her good care. But it's just going to happen again."
In 21 percent of the cases in this ED, in contrast to 49 percent in the other three EDs, staff made a "partial"response. Their response was categorized as "partial"because they took only one action-they filled out cards for the physician assistant's card file system. However, even this response was somewhat different from those in the other three EDs because these staff members did not view filling out a card as "trouble"; they accepted the identification of battered women as part of their role. Interestingly, the attitudes of staff members towards battered women in cases of "partial"response were similar to those of staff in the other three EDs.
In half the cases the women were "AOB,"used drugs, or were "evasive." Staff members were not anxious to spend time with these cases; they wanted to fill out a card for them and send them along as soon as possible. As one nurse said, "I think she's a little drunk and a little crazy. She says he threw her through three rooms. She's not like the women with no place to go. Thirty-two percent of the cases in this ED fell in the third category, "no response," as compared to 40 percent in the other EDs. Staff members here gave reasons for their nonresponsiveness that were similar to those mentioned by their counterparts in the other EDs.
In half these cases, the women were "AOB"or had used drugs. As one nurse said, "She said she was on drugs as soon as she took her coat off. After that I wasn't even interested." In the other half of these cases, staff do not respond to battering because they did not think the women were interested; because they themselves were too busy or forgot to inquire about battering; or because they didn't see the social aspects of battering as part of their medical responsibilities. Discussion
I have described two sets of responses to battered women in EDs. In the three EDs with a minimal educational effort about battering, three factors affect staff response to battered women. First, staff respond to and form their images of battered women based on their evaluation of the women's demeanor. They respond positively to women who appear as "true

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victims" and with dislike to those seen to be "evasive" or possessing a stigmatized status such as "AOB." Second, staff feel there is not much they can do about battered women. Third, they don't believe that battering is a legitimate medical problem. Staff members' responses have significant consequences for women. Those staff who respond to women in a "partial" manner spend less time with women and may or may not find out the facts of their cases, determine whether they are in danger, or document battering on the medical record. Staff in the "non-response" category may ignore battering. In the case of women with "stigmatizing" traits, staff may not "see" battering at all. This is consistent with the conclusion of Stark et al.
(1979) that staff diagnose and treat battered women not as battered, but as suffering from depression, drug abuse, suicide attempts, or alcoholism.
Staff members focus on demeanor-women's perceived lack of responsiveness and their stigmatizing qualities-because they feel these qualities determine whether and how they will be able to interact with battered women. There are few ways for ED staff to measure the success of their work, and they feel particularly unsure about "results" with battered women.
Staff find those who seem like a "true victim" easiest to identify and help, and they find those who are "unresponsive" or "evasive" or have other stigmatized qualities, to be trouble.
The second and third factors affecting staff's lack of response-that they feel that there is little they can do, and that they don't see this as a legitimate medical problem-mean that staff feel that responding to battered women detracts from their "real" work. This, combined with their view of many battered women as trouble, results in staff viewing their treatment of battered women as a kind of "dirty work" (Hughes, 1971). As Roth (1972) and Sudnow (1967) have shown, ED staff consider those cases which are life-threatening and qualify as "real" emergencies as most legitimate and worthy of their time and attention; other cases are seen as belonging in medical clinics. Staff do respond to battered women whom they perceive to be in "serious" danger. These cases qualify as "real" emergencies and fit the most valued, "heroic," aspect of the medical role. However, while many injuries due to battering are serious, they are seldom life-threatening. Furthermore, staff define battered women as "social" cases in which the women are responsible for their condition. Thus, in the majority of cases staff believe dealing with battered women is "dirty work," work which detracts from their ability to carry out their role, work which is symbolically degrading.
In contrast, the advocate in the fourth ED views her efforts to help battered women as
"honorable work" which is central to her conception of her treatment role. A small number of other staff members also adopt and practice her orientation toward battered women. The majority of staff members accept the advocate system as legitimate, apart from whether or not they believe the women themselves are legitimate candidates for assistance. This is because the referral system enables the majority of staff members to be less concerned with demeanor.
It makes them feel they have a clear, simple task-to get the information for the card-and that they are therefore less dependent on the woman's demeanor. Also, staff members are assured of some result or measure of success-a referral-and thus are not left with the sense, as in the other EDs, that there is "nothing they can do."
However, even with an advocate and a referral system, many staff members continue to view the evasive and stigmatized cases as trouble. Staff members' negative perceptions of women's demeanor still contribute to "partial" responses or "non-responses" in many cases.
Staff members who respond "positively" have less difficulty with demeanor, but sometimes they question whether they are actually accomplishing anything with battered women.
Some feminist writers argue that sexist attitudes strongly affect the response of the health care system to women and that medical professionals are eager to "medicalize" women's issues, or appropriate these issues for their own uses (Dreifus, 1978; Ehrenreich and English,
1975; Ruzek, 1978). While I found that attitudes towards women were a factor in staff responses, the main reason staff members were not interested in appropriating battering was that they felt it difficult to make a successful intervention in such cases. One could argue that

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BatteredWomen gender is still a major factor in ED treatment-that if women were more valued by the health care system, medical personnel would define the problem of battering as important. But then we need to reconceptualize more precisely how sexism affects the response to battered women. To do this we need further study of which of women's conditions become medicalized and which do not.
This study demonstrates the importance of looking at the role of clinicians in interpreting and carrying out concepts of medicalization originating from other advocates. First, it suggests a need to look at how conceptions of demeanor and trouble shape clinicians' responses to certain conditions. In theory, medicalization is supposed to mean that moral judgments, or attitudes of "badness" (Conrad and Schneider, 1980a) are replaced by concepts of illness; but this may not always be the case. Second, as Conrad and Schneider (1980b) note, medicalization takes place on three levels-conceptual, institutional, and interactional. This study shows the possibility of an appearance of medicalization on one level while moral judgments prevail on another, thus suggesting a need for more study of the relationship between different levels of the medicalization process.

Conclusion
What does this study suggest about the medicalization of battering in the future? The stereotypes of "troublesome" women and the individualistic orientation toward battering held by ED staff members are consistent with the position that these women should be referred to mental health services for treatment of their personal "problems." Accordingly, "medicalization" could come to mean referral to mental health professionals. An American College of
Physicians (1986) position paper recommends that physicians refer battered women to social workers and mental health services. Whereas health care professionals may not intervene directly in cases of battering, they may be willing to serve as referral agents in a medicalized system that redefines battering as a problem of mental health.
However, at least in theory, advocacy or referral systems could develop strong connections with the battered women's movement and its programs. The physician assistant in this study was strongly oriented toward referring women to battered women's services rather than to the mental health system. The National Coalition on Domestic Violence (1985) provides materials on battering for health care personnel and urges them to train health care personnel about battering. Some health care reformers advocate working closely with shelters and hotlines sponsored by the battered women's movement (Rosenberg et al., 1985). Yet, it goes without saying that, in practice, the medical system has avoided close connections with popular movements (Freidson, 1973).
Thus, this study suggests that the orientation of advocacy and referral systems will be important in determining the course of the medicalization of battering. Those reform groups which mount the most extensive efforts to institute advocacy and referral programs will be able to shape the medical response to battering. However, in the absence of institutionalized advocacy and referral efforts, the response of the health care system to battering will not be long-lasting and medicalization will not take hold.

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