What is domestic violence?
Usually the term refers to spouse or partner abuse. Partner abuse is a complex pattern of behaviours that includes emotional, physical and sexual abuse, not just simple acts of violence. These behaviours are used to exert power and control over his female partner 1.
How common is domestic violence?
Lifetime prevalence figures vary depending on the definition but conservative estimates are that up to one in ten women suffer persistent emotional, physical and sexual abuse in an adult intimate relationship as opposed to one in five women who suffer occasional physical abuse at the hands of their partners2. Of women who present to general practices, one in twenty five women in current relationships over a twelve month period are experiencing severe combined abuse e.g. raped, used a knife or gun, kept from medical care, locked in bedroom, not allowed to work outside the home. Up to one in ten women experience emotional or physical or sexual abuse3. One in 50 women are presenting on average to the emergency department today for domestic violence4. Women are very much more likely to be victims of domestic violence than men4.
Why don't women disclose?
Women deal with the problem themselves and/or do not perceive the abuse as serious enough to disclose to a GP. Ideas of ‘family duty or norms’, are translated into beliefs about shame, self-blame, concern for her partner, responsibility for family cohesion and that abuse was ‘normal’. Pressure from outside on her capacity to disclose, include her fear of her partner’s revenge, coercion to keep quiet, blame from unsupportive family members, or her partner’s deliberate attempts to isolate her5.
How do patients present?
Most presentations are probably hidden and not the obvious black eye. Common hidden presentations are chronic pelvic pain, chronic abdominal pain or “functional gastrointestinal disorders”, multiple presentations at the surgery, anxiety, depression, eating disorders, suicide attempts, alcohol and drug abuse, post traumatic stress disorder, miscarriages, headaches, insomnia, noncompliance, lethargy, accompanying partners6,7,8,9. Victims of abuse are more likely to be younger (less than 40 years), separated or divorced, have a personal history of child abuse, or the perpetrator to have come from a violent family3,8. Up to a third of women who have been subjected to violence and abuse disclose abuse to their general practitioners. Abused women are 2.5 times more likely to disclose if asked by their GP3.
Why don’t GPs ask about domestic violence?
About nine in ten abused women have never been asked by their general practitioners about that abuse3. The reasons given by doctors include lack of time, lack of skills and in particular not knowing what to do once found. Further they believe it doesn’t occur, or believe women provoke abuse or that it is a private matter. The often feel she should just leave resulting in a belief that any intervention won’t change anything as the patient just goes back to the relationship5. GPs are one of the few providers who frequently know the perpetrator.
When and how should you ask about domestic violence?
In any situation that you suspect underlying psychosocial problems you can ask indirectly and then directly about partner abuse.
- Is there a lot of tension in your relationship? How do you resolve arguments?
- Sometimes partners react strongly in arguments and use physical force. Is this happening to you?
- Has your partner ever physically threatened or hurt you?
- Are you afraid of your partner?
- Violence is very common in the home. I ask a lot of my patients about abuse because no one should have to live in fear of their partners.
What should you do once you have found partner abuse?
Consensus from the literature (see RACGP Women and Violence manual)
- Believe them and state that no one deserves to be beaten. That it is common and that help is available.
- Ensure confidentiality and avoid reassuring that everything will be okay
- Discuss their options (including legal) and encourage decision making.
- Assess their current state - stay, about to leave, ready to leave. Need to inform them that the greatest risk is at the time they are leaving or thinking about leaving.
- Document injuries include history, frequency, severity, clear descriptions
- Assess safety of the woman and her children- What does she need in order to feel safe? Has frequency and severity increased? Weapons involved? Obsession?
- Devise safety plan with her
- Refer for domestic violence counselling in the community.
References
1. Sassetti MR. Domestic Violence. Prim Care 1993;20(2):289-304.
2. McLennnan W. Women’s Safety Australia:Australian Bureau of Statistics, 1996.
3. Hegarty KH, Measuring a multidimensional definition of domestic violence. The prevalence of partner abuse in general practice. PhD thesis, University of Queensland, 1999.
4. Roberts G, O'Toole B, Lawrence J, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1994;159:307-310.
5. Head C, Taft A. Improving general practitioner management of women experiencing domestic violence: A study of the beliefs and experiences of women victim/survivors and of GPs: Final Report, Department of Health, Housing and Community Service, Canberra, Australia, 1995.
6. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Int Med 1995;123:737-746.
7. Drossman DA, Talley NJ, Lesserman J, Barreiro MA. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Int Med 1995;123:782-794.
8. Stark E, Flitcraft A. Violence among intimates: An epidemiological review. In: Hasselt VV, Morrison R, Bellack A, Hersen M, ed. Handbook of Family Violence . New York: Plemun Press, 1988:293-316.
9. Mazza D, Dennerstein L, Ryan V. Psychotropic drug use by women: current prevalence and associations. Med J Aust 1995; 163, 86-89.
