Even in the Wake of the Rahimi Case, Domestic Violence Still Threatens Our Patients

Welcome to “The Hypocritical Oath,” my MedPage Today series where I explore professional, educational, and ethical failures in medicine, from shortcomings in medical culture to abuses of power and patient harm. I try to give a voice to those that have been dismissed in an effort to inspire better doctors, committed to upholding our stated values.

Thankfully for domestic violence victims nationwide, the Supreme Court recently upheld a federal law that temporarily disarms people who are under protective orders for domestic violence.

I didn’t realize just how anxious I was about the U.S. v Rahimi decision until I entered our morning treatment team meeting and noticed my heart racing while live SCOTUS [short for the Supreme Court Of The United States] updates appeared on my phone. My attendings, aware of my personal investment in the case and ever supportive, smiled as I breathlessly announced the 8-1 decision.

I had hoped desperately that the justices would appreciate the enormity of the case. The T.H. Chan School of Public Health at Harvard has published data indicating that homicide is now the leading cause of death among pregnant women in the U.S., superseding hypertensive disorders, hemorrhage, and sepsis, historically the leading causes of maternal mortality in this country. In 68% of pregnancy-associated homicides, a gun was involved. Meanwhile, Surgeon General Vivek Murthy, MD, MBA, just declared gun violence a public health crisis; its intersection with domestic violence is a fraught, fatal one.

Rahimi isn’t so much a “win” as a “not-loss.” Within the context of a society that has a longstanding tradition of dismissing or shaming abused women, who are disproportionately affected by domestic violence, the ruling that a victim’s right to live safely outweighs an alleged abuser’s right to firearm ownership is a barely-adequate preservation of the status quo.

For the time being, the ruling affords us some measure of legal protection, but the medico-legal system’s understanding of domestic violence remains inadequate, with dire consequences for victims. As follows, I outline three distinct situations that exemplify these shortcomings.

Concern A: Misogynistic Myths About Abuse Persist and Cost Lives

The Rahimi decision, which I hoped would be regarded unilaterally as a common-sense measure to protect vulnerable victims, did not escape criticism. Many gun rights advocates proposed arming victims over restricting perpetrators’ access to firearms, despite public health evidence that the former actually increases the victim’s risk of dying. However, the most common counter-argument I see is predicated on misogyny and poor understanding of domestic violence: that the victim is lying.

This claim arose during oral arguments in Rahimi, when Justice Samuel Alito suggested that family courts issue unjustified “mutual” orders of protection on a “he said, she said” basis. Solicitor General Elizabeth Prelogar immediately addressed this as a mischaracterization of court activity. In other words, this counter-argument posits that women seek frivolous restraining orders with false abuse claims, unduly depriving the accused of their firearms under the federal law in question.

While I acknowledge there will always be bad actors in reporting any crime and certainly do not condone fabricated claims of abuse, physicians are tasked with making informed risk/benefit analyses leading to sound clinical decisions. Thus, we should consider the worst possible outcomes objectively, and assess risk accordingly regarding the value of this federal law as a matter of public health.

This argument inappropriately equates the right to firearm ownership with the right to live safely. If we take the stance of believing the alleged victim, but they are lying, the accused loses their guns temporarily. But if we take the stance of assuming that the alleged victim is lying about abuse when they are telling the truth, the victim could die. Firearm access by domestic abusers increases the risk of intimate partner homicide by more than 1,000%. Do we really want to take that risk?

Furthermore, the vast majority of us are neither lying about abuse nor overreacting to gender-based violence. Handling (rather, mishandling) our cases on the assumption that women who misrepresent their abuse costs lives.

Earlier this year, Audrey Peterson, a nurse at Johns Hopkins All Children’s Hospital, was fatally shot by her abusive former partner 2 days after Pinellas-Pasco Circuit Judge Doneene Loar denied her petition for a protective order. Dismissing women’s pleas for protection is not uncharacteristic of Judge Loar, who in 2021 denied Rep. Anna Paulina Luna (R.-Fla.) a temporary stalking injunction against her former GOP primary rival, William Braddock. Braddock allegedly threatened to have Luna murdered.

Both situations were preventable, but for a system that tends to protect alleged abusers over victims and often re-traumatizes the latter. Judge Loar remains on the bench, ironically presides over a community violence division, and was even honored by the St. Petersburg Bar Association a week after Peterson’s murder.

Based on these cases, I’m inclined to believe that the legal system, contrary to Justice Alito’s concern, rarely, if ever, issues restraining orders for domestic violence capriciously. And, as I’ve tried to highlight, failure to protect proactively has grave consequences.

The Rahimi decision, informed by sound public health evidence, is overall positive: removing the most predictive risk factor for intimate partner homicide from an imminently dangerous situation.

Concern B: A Lack of Accountability for Abusers

I dealt with the consequences of failing to hold domestic violence perpetrators appropriately accountable firsthand on a rotation with the child abuse team. My 6-year-old patient’s mother had repeatedly raised abuse concerns about the child’s father and half-brother. The perpetrators were never held accountable and family court gave the parents joint custody, dismissing the warning signs and the mother’s cries for help. By allowing her father and brother continued access to her, the court placed the little girl in an imminently dangerous situation, whose fallout I would witness in a painfully intrusive interview with the child.

My little patient recounted in a whisper how her brother had orally and vaginally raped her the week prior. I held back tears, fighting the urge to run to her and hold her, as though I could absorb her pain and return the light to her eyes.

I remember that child’s face with alarming clarity, and I never remember her without an accompanying sense of powerless rage. To this day, I cannot touch child psychiatry; I lack sufficient emotional resilience.

I tell this story to highlight the unspeakable damage inflicted when our systems won’t hold domestic abuse accountable. Intervening only when a child is raped, after her mother persistently raised the alarm about her father’s and brother’s potential to cause harm, means we have failed and continue to fail victims.

Concern C: Inadequate Physician Understanding of Domestic Violence

“It’s not abuse, it’s just harassment,” said one attending on a prior rotation as we discussed a patient who had repeatedly called his ex-girlfriend, leaving increasingly concerning messages, and had appeared uninvited at her home, shattering some of her belongings in a rage before fleeing.

Peterson’s abuser “just harassed” her, too, in the week preceding her murder.

Physicians must appreciate domestic violence and gun violence as significant public health threats. No matter where you stand on these issues, the terrifying combination has critical implications for survivors, who often look to doctors for guidance. It falls on our shoulders to be well-informed for our patients’ sake.

For now, I dare to breathe a sigh of relief at this latest Supreme Court decision that has mercifully not endangered us further. Hope — that fleeting thing with fragile wings — stirs within me, and I am cautiously, marginally optimistic for myself and for women like me.

Chloe Nazra Lee, MD, MPH, is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.

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