5.1. Testimonial smothering and (barriers to) DVA disclosure

In theory, quieting and smothering are closely related: a speaker's testimony is smothered when they withhold their testimony because they reasonably believe that their testimony will be misunderstood in a way that leads the hearer to form harmful beliefs. We will see that in practice this is also the case. In the following sections, I will present evidence from patients and evidence from practitioners. It is important at this point about what exactly would count as confirmatory evidence for this hypothesis. Remember, Dotson does not provide necessary or sufficient conditions for testimonial smothering; rather, she describes three circumstances which systematically accompany instances of testimonial smothering. These circumstances are closely connected with thwarted DVA disclosure in clinical contexts, or so I will argue in the following paragraphs. This is, therefore, an inference to the best explanation. The best explanation of the phenomenon that the majority of women do not disclose personal histories of DVA to healthcare practitioners in clinical contexts is that their testimony is smothered. In support of this claim, I will draw on empirical evidence about why women with personal histories of DVA withhold or truncate their testimony in clinical contexts. (It is important to note that this evidence is primarily drawn from the USA and the UK. Consequently, I would caution against generalising these results uncritically.) First, I argue that DVA disclosure is a kind of ‘unsafe or risky’ testimony. Second, I present some evidence for the claim that women with personal histories of DVA lack evidence that their audience is testimonial competent (in a context where such competence cannot be taken for granted) and often accompanied by situated ignorance about DVA.Footnote ¹⁵

5.2. DVA disclosure as unsafe and risky testimony

Women with personal histories of DVA often withhold or truncate their testimony in clinical contexts. It has been estimated that approximately two-thirds of women with personal histories of DVA do not disclose them in clinical contexts (Friedman et al. Reference Friedman, Samet, Roberts, Hudlin and Hans1992; McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998). More recent findings suggest that only 5% of patients with histories of DVA are identified by healthcare practitioners (McGarry and Nairn Reference McGarry and Nairn2015), at least in part because those patients do not disclose them. Why, then, do some women with personal histories of DVA not disclose them to healthcare practitioners? There is considerable evidence that DVA disclosure is a kind of unsafe and risky testimony. According to Dotson, as explained above, testimony is unsafe if it can easily be misunderstood by the hearer. Testimony is risky if misunderstanding it can lead to ‘social, political, and/or material harm’ (Dotson Reference Dotson2011: 244). If DVA disclosure is indeed a kind of unsafe testimony, we would expect to find evidence that it is easily misunderstood. Indeed, evidence from patients and practitioners alike supports this claim.

The evidence discussed in the following paragraphs will show that it is reasonable to suppose that DVA disclosure can easily be misunderstood and that its misunderstanding can have serious consequences for patients. To satisfy the first condition of Dotson's account of testimonial smothering, it only remains to show that DVA disclosure is risky and unsafe. We can find evidence of this in the fears reported by both patients and practitioners. McCauley et al. (Reference McCauley, Yurk, Jenckes and Ford1998) found that shame prevented women from disclosing their personal histories of DVA to healthcare practitioners. One woman interviewed in their study said:

Sexually transmitted infections are widely stigmatised and often prove to be a significant source of shame for many people, sometimes to such an extent that they prevent people from taking precautions or seeking medical treatment.Footnote ¹⁶ How then do shame and stigma lead women with personal histories of DVA to anticipate that disclosing their personal histories to their healthcare practitioners will lead those practitioners to form harmful beliefs? For a plausible explanation, let us briefly consider the nature of shame and the related attitude of contempt. We form these attitudes when we judge that someone has failed to live up to standards (Mason Reference Mason2003, Reference Mason2010). Contempt, Mason writes, ‘present[s] its object as low in the sense of ranking low in worth as a person in virtue of falling short of some legitimate interpersonal ideal of the person (Mason Reference Mason2003: 241). The same, I take it, may be said for shame: Mason writes that ‘to experience shame is to experience oneself as diminished in merited esteem on the ground that one has violated some legitimate ideal of character’ (2010: 417–18). Shame and contempt are thus closely related. While shame is what we feel towards ourselves when we fail to live up to standards, contempt is what we feel towards other people when they fail to live up to standards. Since shame and contempt both (ideally) respond to evidence of failing or deficiency, it is plausible that a person who feels ashamed may also believe that they deserve other people's contempt. Now, by equating domestic violence and sexually transmitted disease, the woman interviewed suggests how feelings of shame and stigmatisation associated with domestic violence may prevent women from seeking support, including disclosing DVA to healthcare practitioners. Moreover, it is reasonable to suppose that a patient who is ashamed of their personal history of DVA may fear that their testimony will provoke the contempt of the healthcare practitioner who attends them, where contempt arises from the mistaken judgement that the patient's victimhood is a consequence of their failure to live up to standards.Footnote ¹⁷

Related concerns about social class also prevent women from disclosing personal histories of DVA to healthcare practitioners. Indeed, McCauley et al. (1998: 552) note that women of all socio-economic backgrounds tended to associate domestic violence with lower socio-economic backgrounds than their own. In other words, most people thought domestic violence was ‘beneath them’. One woman interviewed by McCauley et al. said, ‘When I first came here, I thought it would be a group of low-lifes … You know, people that break beer bottles, scream and argue on Saturday nights’ (McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998: 522). The notion that domestic violence is a problem for members of supposedly ‘lower’ social classes appears to cause women who experience DVA to feel ashamed of their own histories of DVA, regardless of their social background. Shame and related attitudes thus present another barrier to DVA disclosure.

To be clear, what I have identified is probably best understood as a sympathetic extension of the view of testimonial smothering proposed by Dotson. Where Dotson focuses on harmful beliefs, I have suggested that other complex attitudes can contribute to testimonial smothering. In particular, I have suggested that it is possible that some women with personal histories of DVA withhold their testimony because they believe that it will provoke the contempt of the healthcare practitioner.

Patients’ fears are widely recognised in the empirical literature as one of the barriers to DVA disclosure in healthcare settings (McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998). These fears reveal some of the reasons why women with personal histories of DVA may withhold or truncate their DVA testimony in those (and other) contexts. These fears can be divided into general fears and specific fears. General fears are fears about DVA disclosure that apply to most women; specific fears are fears about DVA that are relevant for groups of women with particular characteristics such as age, social class, race, and immigration status.

I will first describe some of the general fears that are felt by patients towards DVA disclosure. Among the women surveyed by McCauley et al., women frequently mentioned that they worried that if they disclosed a personal history of DVA to a healthcare practitioner, the practitioner would blame them for the abuse they have suffered at the hands of their abusers (McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998: 553). Some women fear that if they disclose their personal histories of DVA to their healthcare practitioner, this will be passed on to the abusive party. Indeed, a third of the women interviewed by McCauley et al. (Reference McCauley, Yurk, Jenckes and Ford1998) indicated that they were prevented from disclosing their history of DVA to healthcare practitioners by fear of repercussions from their abusers. Reflecting on what would happen if she reported her abuse and her abuser found out, one woman commented: ‘I'll get beat up more. I mean, God forbid they're gonna give him something to be angry about. He's angry about nothing’ (McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998: 553). This is just an introduction to the dangers that are posed by DVA disclosure.

Now I will describe some more specific fears that prevent different groups of women from disclosing personal histories of DVA to healthcare practitioners in clinical contexts. These fears reveal both the risks incurred in disclosing DVA and the possibility of that disclosure leading to misunderstanding on the part of its recipient. First, women with children were prevented from disclosing DVA to their healthcare practitioners by concerns that doing so would have harmful consequences for their children: ‘They want to check your children for sexual abuse … I don't want my children up on nobody's table at the age they are with their legs spread’ (McCauley et al. 2018: 552). Second, immigration status also appears to be a barrier to DVA disclosure. The fear that DVA disclosure could lead to deportation prevents some immigrant women in the US Midwest from accessing outreach support organisations for DVA victims (Reina et al. Reference Reina, Lohman and Maldonado2014). This perceived risk prevents some women from disclosing their personal histories of DVA to healthcare practitioners. Third, race presents barriers to DVA disclosure too. Indeed, this is the very example that Dotson cites (2011: 245). To reiterate Dotson's point: many Black women refrain from disclosing personal histories of DVA because they are concerned that such testimony might be misunderstood in ways that bring about harmful consequences for Black people. Fourth, age appears to be a barrier to DVA disclosure: generational differences in norms regarding ‘privacy about domestic affairs’ may prevent older women from disclosing DVA to healthcare practitioners (Zink et al. Reference Zink, Jacobson, Regan and Pabst2004). Older generations, it is supposed, tend to place special value on maintaining the privacy of one's personal life. Sharing intimate details about one's private life, including (or, one imagines, especially) information about experiences of violent or abusive behaviour, is perceived to come at heightened social cost. So, in addition to the risks faced by all (or most) women who disclose personal histories of DVA, the specific fears described here indicate that other aspects of women's social identities may add further risks to DVA disclosure in clinical contexts. All of these concerns may contribute to the smothering of those women's testimony. The analysis here can be sharpened by highlighting a link between patients’ fears and what McKinney calls ‘unjust locutionary extraction’ (2016). McKinney explains that, while our speech is ideally a manifestation of our agency, our words can also be ‘used against us’ (2016: 259–60). One way in which a speaker can undergo unjust locutionary extraction is when they are made to make an utterance which licenses wrongs against them (McKinney Reference McKinney2016: 265). Given the patient fears enumerated in the preceding paragraph, we might think that when women withhold personal histories of DVA, they do so because they do not want their speech to be used against them. In particular, they may be concerned that disclosing DVA will unleash a cascade of negative consequences. We will return to this thought later. One way, then, to understand what is going on here, is that concerns about the risk of unjust locutionary extraction contribute to the testimonial smothering of women with personal histories of DVA.Footnote ¹⁸

So far I have focused on patients’ fears about DVA disclosure. Practitioners’ fears about the risks associated with DVA disclosure are also informative. Healthcare practitioners are in a position of relative authority in the sense that, to some degree, how they respond to the patient's testimony can have major consequences for them. However, the institutional setting that grants practitioners their authority also truncates it in pernicious ways. It seems that practitioners have relatively little autonomy concerning how, or indeed, whether, their patients’ DVA disclosures will be followed up. Moreover, in recent work on the moral dispositions and agency of frontline public service providers in bureaucratic institutional settings, Zacka suggests that workers often adopt pathological reductive dispositions towards service users (2017) as a way of coping with the cognitive dissonance that arises from the difficulties involved in working with limited resources whilst remaining responsive to competing demands, among other factors (Zacka Reference Zacka2017: 123). Zacka identifies three such dispositions: indifference, enforcement, and caregiving. I will sketch these very roughly here. Indifference leads to withdrawal from the messiness of individual cases and allows workers to function as morally disengaged ‘people processors’ (Zacka Reference Zacka2017: 101–4). Enforcers and caregivers are both much more engaged with their institutional roles, but they have starkly contrasting priorities. Enforcers focus on and prioritise the upholding of rules and regulations to protect their organisations from abuse by service users, perhaps at the expense of some deserving service users (Zacka Reference Zacka2017: 106–9). Caregivers, by contrast, focus on and prioritise the particular circumstances and needs of their clients, perhaps at the expense of efficiency (Zacka Reference Zacka2017: 104–6). Which of these dispositions a service provider adopts makes a considerable difference to how they operate within the margin of discretion afforded to them in their institutional roles (Zacka Reference Zacka2017).Footnote ¹⁹

It seems plausible that the pressures associated with working in clinical settings can cause practitioners to adopt any of a variety of pathological dispositions towards their patients. These dispositions may shape how healthcare practitioners interact with patients and how they exercise their discretion. In particular, adopting certain dispositions in their roles may cause some practitioners to refrain from screening patients for DVA. Strikingly, it has been reported that some practitioners fear that screening their patients for DVA runs the risk of ‘opening Pandora's box’, that is, that so doing will set in motion a chain of negative consequences for the patient (Sugg and Inui Reference Sugg and Inui1992; McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998). This fear is compounded by concerns about the lack of resources to follow up DVA disclosure. Indeed, the lack of resources to adequately follow up DVA disclosure was reported as a barrier to DVA screening by 63.6% of the articles reviewed by Sprague et al. (2012: 596). If practitioners’ fears about following up on DVA disclosure cause them to withdraw from their patients and refrain from screening their patients or to avoid the topic (perhaps unconsciously), then an important opportunity for patients to disclose personal histories of DVA will be lost. Moreover, such reluctance may be interpreted by patients as a sign that they should not disclose, further contributing to testimonial smothering. This lends support to the claim in the previous paragraph: it seems that patients’ fears that their speech could be used against them are, at times, well-founded. These examples of practitioners’ fears may be evidence of pathological indifferent or caregiving dispositions. But frustration can cause practitioners to form more hostile dispositions too. Indeed, various frustrations, including frustrations about the lack of resources to help women who disclose personal histories of DVA, led one of the nurses interviewed by Robinson (Reference Robinson2010) to comment: ‘I don't have time to hear a 30-minute story about it. You're a grown person: get out of it. That's horrible, I shouldn't be saying that’ (2010: 574).Footnote ²⁰

It is reasonable, then, to conclude that DVA disclosure is a kind of unsafe and risky testimony. Testimony that discloses a personal history of DVA is easily misunderstood and carries with it the risk of serious negative consequences for the patient. When women refrain from making a DVA disclosure in clinical contexts because of the perceived risks involved in making such a disclosure, it is plausible that their testimony has been smothered.

5.3. Testimonial incompetence, pernicious ignorance and DVA disclosure

There is considerable evidence that many women who withhold or truncate their testimony, do so because of concerns about the testimonial incompetence of their hearers in clinical contexts, that is to say, of their attending practitioners. Often, this incompetence is due to pernicious ignorance. Owing to the interrelatedness of these factors, I present them together. Beecroft's amendment to Dotson's account of testimonial smothering is relevant here (Reference BeecroftMs). The thought is that there are circumstances in which a would-be speaker can have their testimony smothered simply because their audience fails to demonstrate that they possess the relevant competencies. Indeed, where the speaker's testimony is unsafe and risky, it seems reasonable for a speaker to withhold or truncate their testimony until they receive some appropriate kind of assurance that the hearer is a competent recipient of their testimony.

DVA disclosure seems to fit this description well. I have argued that DVA disclosure is a kind of unsafe and risky testimony; unsafe, in that it is easily misunderstood, and risky, in that those misunderstandings can yield serious negative consequences. The influence of stereotypes about DVA, its victims, and its perpetrators, all stack the deck against women's testimony. It is plausible, I would suggest, that against this background, women would not be unreasonable in supposing that their healthcare practitioners lacked the relevant testimonial competence, at least unless they possess additional evidence to the contrary. Interestingly, it has been shown that women with histories of DVA are much more likely to disclose their experiences if there are some visible indications that their healthcare practitioners are minimally receptive to such testimony. For example, the presence of posters or brochures was enough to reassure half of the women surveyed by McCauley et al. that they could disclose their personal histories of DVA (McCauley et al. Reference McCauley, Yurk, Jenckes and Ford1998: 553). This may suggest that it is assumed that practitioners will not welcome DVA disclosure, but that this assumption can be overridden by evidence of receptiveness and competence on the part of healthcare practitioners.

How do testimonial incompetence and pernicious ignorance present barriers to disclosure in clinical contexts? In a systematic review of the literature on barriers to DVA screening, Sprague et al. (Reference Sprague, Madden, Simunovic, Godin, Pham, Bhandari and Goslings2012) identify a diverse range of factors which prevent healthcare practitioners from screening patients for DVA. It is notable that over two-thirds (68.2%) of the literature reviewed by Sprague et al. reports that factors such as a ‘lack of knowledge, education, or training regarding screening’ present significant barriers to DVA screening (2012: 596). We might interpret these finds as evidence that a significant proportion of healthcare practitioners refrain from screening their patients for DVA because they lack the relevant competencies or because they lack the relevant knowledge for dealing with DVA disclosure.

Women who do not fit certain stereotypes are at an epistemic disadvantage when it comes to disclosing personal histories of DVA. This thought is captured well by the criminological concept of the ‘ideal victim’. According to Christie, ‘ideal victims’ are people who ‘are most readily given the complete and legitimate status of being a victim’ when they are affected by crime (Christie Reference Christie and Duggan2018: 12). Christie outlines a number of attributes which are typically held by ‘ideal victims’ (2018: 12–13). Ideal victims are weak, they are engaged in respectable activities, and they are found in locations where they cannot be blamed for being. Think, for example, of an elderly person doing their shopping at the local greengrocers. Ideal-victim status also depends on the attributes of the perpetrator. For the victim to be an ideal victim, the perpetrator ought to be stronger than the victim and, significantly for this project, personally unknown to them. Non-ideal victims of crime are not given victim status. This can have the consequence that they are not provided access to appropriate support services. Presumably, it can also mean that when they report what happened to them, their testimony is not believed, either because they suffer a deficit of credibility, or because the perpetrator is granted a credibility-excess.Footnote ²¹ Thinking about how the construction of the ideal victim and the corresponding notion of the ideal perpetrator manifest themselves in relation to DVA may help us to understand the barriers to disclosure in clinical contexts.

We see the concept of the ideal victim at work in nurses’ decisions whether to screen a patient for DVA. These decisions are sometimes guided by judgements about the demeanour of both the patients and the person(s) who accompany them to their appointments (Robinson Reference Robinson2010). One nurse interviewed in Robinson's study commented: ‘You have to look at the patient's demeanor and the demeanor of the person that is with them. Do they (the person accompanying the patient) have a dominating personality and is the patient shy and quiet?’ (2010: 574). This judgement, that victims of DVA are submissive and abusers are dominating, and the accompanying heuristic, seem to be based on the pervasive social constructions of the ideal victim and the corresponding ideal perpetrator. Women who match the profile of the ideal victim, or whose abusers match the profile of the ideal perpetrator may be detected and screened as a result of this heuristic. Nevertheless, this is concerning. It may be the case that many cases of abuse will fit this stereotype, but there is more than one way in which heuristics such as this one can mislead us. Relying on it as a way of determining whether a patient is at risk of DVA carries the significant risk of overlooking victims who do not fit the image of the ideal victim, upon which the heuristic is based.

Perceptions of social class have also been shown to guide healthcare practitioners’ judgements about the likelihood that a patient is a victim of DVA. In a study of 275 nurses conducted by Moore et al. (Reference Moore, Zaccaro and Parsons1998) 92% of respondents stated that women with middle- and upper-class social backgrounds were unlikely to experience DVA. This is another example of a barrier to disclosure that results from the social constructions of the ideal victim and the ideal perpetrator. Perhaps the thought is that people, in particular men, from middle- and upper-class social backgrounds are less likely to treat their intimate partners violently or abusively. In short, it may be the problem is not so much that middle- and upper-class women are non-ideal victims, but rather, that middle- and upper-class men are non-ideal perpetrators. Admittedly, this reading is speculative, but if it is correct, then it is evidence of another barrier to disclosure presented by pernicious ignorance.

This is evidence of situated ignorance on the part of healthcare practitioners. Of course, for it to be the case that these instances of situated ignorance contribute to the testimonial smothering of patients with personal histories of DVA, it must also be the case that those patients believe that they will not be recognised as genuine victims because they do not fit the stereotype of the ideal victim. Admittedly, this is harder to show, although it is plausible that some of the various patients’ fears mentioned above (e.g. especially fears regarding victim-blaming and other negative affective responses) are evidence that patients suspect that they will be stereotyped.

However, not all stereotypes about DVA can be understood as consequences of the social construction of the ideal victim. For instance, the influence of stereotypes about pregnancy and domestic violence also seem to lead to testimonial smothering. Due to the widespread but false belief that pregnancy can offer women a respite from abuse, domestic violence in pregnancy has been described as ‘the silent enemy’ (Scobie and McGuire Reference Scobie and McGuire1999: 259). This stereotype may prevent healthcare practitioners from screening for DVA. Given that pregnant women already face a heightened risk of testimonial injustice in healthcare contexts (Freeman Reference Freeman2015), it is not unreasonable to suppose that this is another example of situated ignorance about domestic violence that contributes to the smothering of women's testimonies in clinical contexts.

There is considerable evidence that women who do not disclose their personal histories of DVA to healthcare practitioners in clinical contexts are victims of the epistemic injustice of testimonial smothering. That being said, there are other possible explanations that ought not to be overlooked. In particular, there is empirical evidence that some women's nondisclosure of personal histories of DVA is the result of a lack of understanding on their part; in particular, some women do not recognise their abusers’ abusive behaviour as abuse (Francis et al. Reference Francis, Loxton and James2017). We might understand this as a form of hermeneutical injustice. It is also important to note that not all women's decisions not to disclose personal histories of DVA are the consequence of epistemic injustice. Nevertheless, it is clear that the testimony of many women with personal histories of DVA is smothered in clinical contexts.