INTRODUCTION AND OVERVIEW

In the past decade, domestic violence has been recognised as a health problem resulting in significant morbidity and mortality. It is a serious and widespread problem that affects all economic, educational, ethnic and regional groups. This chapter outlines the nature and prevalence of domestic violence, how it presents in clinical practice, how to ask about it and how to respond to it holistically.

WHAT IS DOMESTIC VIOLENCE?

In the community, domestic violence is usually taken to mean physical violence between partners, usually perpetrated by the husband on the wife, although men may be victims and abuse does occur in same-sex relationships. Sometimes the term is used to refer to abuse that occurs in any relationship within households and thus would include child, elder and sibling abuse. This chapter concentrates on partner abuse (marriage, de facto relationship, boyfriend or girlfriend), which is a complex pattern of behaviours that includes emotional, physical and sexual abuse, not just simple acts of violence (Fig 59.1).

FIGURE 59.1 Types of abuse in partner violence

The World Health Organization uses the term intimate partner violence and defines it as:

From a health perspective, domestic violence is best understood as a chronic syndrome characterised not by the episodes of physical violence that punctuate the problem but by the emotional abuse that the perpetrator uses to maintain control over the partner. Furthermore, as most victims of partner abuse report, the physical violence is the least-damaging abuse suffered. It is the relentless psychological abuse that cripples and isolates the victim and results in fear of the partner. Domestic violence against women is the focus of this chapter, because most abuse with serious health and other consequences is committed by men against their female partners.²

BACKGROUND AND PREVALENCE

Abuse of women by their partners or ex-partners is a worldwide phenomenon.³ The World Health Organization World Report on Violence and Health revealed that in 48 population-based surveys around the world, 10–69% of women had been physically assaulted by their partners at some stage in their lives.¹ Clinical samples obtain higher rates than community surveys. For example, recent general practice studies in Australia, the United States, the United Kingdom and Ireland have found high lifetime physical abuse rates ranging from 23.3% to 41.0% of women, and 12-month rates from around 5% to 17%.⁴ A full-time general practitioner probably sees at least one abused woman each week, although she may not be presenting with obvious signs or symptoms. Similar rates are found in emergency departments, mental health clinics, antenatal care and drug and alcohol clinics. Today, on average, one in fifty women presenting to the emergency department do so because of domestic violence.

Thus women experiencing domestic violence present very frequently to healthcare services and require wide-ranging medical services. The societal economic impact is great, with an Australian study estimating that in 2002/03 the cost to the community of domestic violence was in the order of AUD$8.1 billion, with the main contributors being pain, suffering and premature mortality.⁵ The total cost of intimate partner violence to services and to the economy as a whole in the United Kingdom has been estimated at £3.1 billion and £5.7 billion a year, respectively.⁶

AETIOLOGY

Researchers have postulated that there are many causes of domestic violence at the individual, family, community and societal levels. Originally, people thought that abuse was caused by psychiatric illness. Once the prevalence of abuse in the community was recognised, however, it was realised that this explanation was unrealistic. Subsequently, researchers felt that conflict in the family was the major cause. Unfortunately for this theory, many women describe there being no conflict before abuse happening. Review of the evidence for societal risk factors shows that violence in the family of origin of victim and perpetrator, and unemployment of the perpetrator, were the only variables that had sound evidence of an association. It seems that the combination of environment, social and economic factors may contribute to domestic violence. However, feminist researchers have argued that patriarchy in today’s society underlies much of the abuse of women. The World Health Organization certainly places domestic violence in the context of violence against women, which includes such issues as rape and genital mutilation.

HEALTH CONSEQUENCES

Domestic violence can have short-term and long-term negative health consequences for survivors, even after the abuse has ended.⁷ Abused women experience many chronic health problems, with depression, post-traumatic stress disorder, chronic pain and gastrointestinal and gynaecological problems being the most common (Box 59.1). It is also a very common cause of femicide, with over 50% of all female murders being committed by their partners or ex-partners, in the United Kingdom and the United States. In Australia, a far higher percentage of Indigenous than non-Indigenous women are murdered by their partners.

EFFECT ON CHILDREN AND ADOLESCENTS

Up to 60% of children witness their mother’s abuse.⁸ This witnessing includes:

Children exposed to domestic violence in the home have a higher risk of physical, emotional, behavioural and educational problems that persist into adulthood. In adolescents, it may manifest as depression, running away from home, drug and alcohol abuse, criminal behaviour, self-harming and suicidal ideation.

A DIAGNOSTIC APPROACH

Intuitively, it would seem that early detection and intervention with women who have experienced domestic violence might improve health outcomes, but there is currently no empirical evidence for the effectiveness of routine screening. Although domestic violence is an important health problem, it fails to meet the most crucial criterion for screening—that early detection must enable early intervention, to reduce morbidity and/or mortality. Rather, opportunistic case finding in practice settings such as emergency departments, psychiatry clinics, antenatal clinics and general practices is appropriate with women who are presenting with the potential clinical indicators of domestic violence.⁹

HOW TO ASK ABOUT DOMESTIC VIOLENCE

Up to one-third of women disclose abuse to their GPs, particularly if asked in a non-judgmental, empathic way (Box 59.2). However, there are major internal and external barriers to women disclosing about domestic violence. Reasons given by women living in situations of domestic violence include fear, denial and disbelief, emotional bonds to partner, commitment to marriage, hope for change and staying for the sake of the children. Normalisation of violence (i.e. coming from a background where abuse was the norm) and women’s isolation, depression and stress play a major role in their non-disclosure. Feeling that they will not be believed by health practitioners and that available services will not be able to help or maintain confidentiality may reflect negative experiences in the past.

INTEGRATIVE MANAGEMENT

Managing partner abuse does not really follow the simple line of history taking, examination, diagnosis and referral. Rather, there are simple communication skills that the healthcare professional should exercise that women in situations of violence and abuse say they expect and hope for from their healthcare practitioner.¹⁰ Often women who feel supported see their GP as an advocate for them.

Women need emotional support from their healthcare practitioner, their multiple physical symptoms investigated and treated, their mental health issues managed, their injuries documented and their social and environmental situation acknowledged and validated. Apart from seeking help from doctors, many women in their attempts to heal look to alternative therapies (e.g. music therapy, art therapy), while others seek spiritual help from ministers and other religious leaders. Practitioners need to be aware that these are often a great source of comfort for women at times of stress from the abuse.

PREVENTION

Practitioners do not have a major role in primary prevention of domestic violence (e.g. community campaigns and school programs). They can, however, play a role in prevention by modelling non-abusive workplace practices, by early intervention with children who are witnesses of domestic violence and by speaking out in public forums about this common social problem. Education at the undergraduate and postgraduate levels across the disciplines is necessary to provide an educated healthcare workforce (Fig 59.2), which is essential for interventions in the domestic violence area. Healthcare practitioners need to actively intervene, with this social condition that affects the health of women and their families.

FIGURE 59.2 Clinical care pathway

SELF-HELP

Resilience is a commonly used concept to describe the ability to bounce back after encountering difficulties, negative events or hard times. For women who have experienced abuse, recovery is seen not as returning to normal, but rather as constructing a self built on the experience of having survived. Resilience can be seen to include a sense of self-esteem, the ability to adapt and a belief that problems can be solved. The central process involved in building resilience is the training and development of adaptive coping skills. An important aspect of this is socially focused, such as emotional support from others, which is when women may start to be able to break away from the abuse.

The literature identifies varying numbers of stages (Fig 59.3) that women undergo in dealing with domestic violence, and women may move in either direction along the path. For example, a woman often has to leave an abusive partner a number of times before the relationship is finally ended, and the abuse might not end when the relationship does. In the final stage, which is generally considered to be a lack of violence in a woman’s life, recovery is not returning to ‘normal’, but constructing a self built on the experience of having survived and left an abusive situation. Reclaiming the self may be a stage where women move from surviving to thriving. There are many self-help books, support groups and online support forums (chat rooms, bulletins and email groups) that women can access on this journey to recovery.

FIGURE 59.3 Stages of change¹²

The importance of relating to other women who have shared experiences in order to reconstruct a self where abuse is no longer part of a woman’s life cannot be underestimated. In Figure 59.3, the concept of a catalyst for change that propels women towards acting to end the violence is introduced. The ‘turning point’ moment connects the external and internal in a moment of change. It generally coincides with an environmental shift (e.g. children becoming teenagers, getting a job, taking up study) and leads to an adjustment to the woman’s sense of self.

IMPORTANT PITFALLS

The largest pitfall is that domestic violence is missed completely by the majority of practitioners. Practitioners need to be alert to the signs and symptoms of domestic violence and to train themselves in how to ask and respond appropriately.

PROGNOSIS

Allowing the woman to progress at her own therapeutic pace and understanding the chronicity of the problem is important in the ongoing relationship with the abused woman as the practitioner provides follow-up and continued support. Respecting the woman’s wishes, even if this means she does not follow up on your referral, shows that you understand the nature of the effects of domestic violence. Women who did not disclose initially may disclose at a later date. The likelihood is that the pathway to recovery and wellness is long for women who have experienced domestic violence. Practitioners need to be prepared to walk the journey with them, acting as support and advocate in a woman-centered, holistic way.