Recognising domestic violence

A GP's role is to recognise, respond and offer to refer patients who disclose abuse, explains Dr Fiona Duxbury.

Acknowledge the bravery of the patient for disclosing DVA (Photograph: SPL)
Acknowledge the bravery of the patient for disclosing DVA (Photograph: SPL)

Domestic violence and abuse (DVA) is common. Almost one in six of the women (and some men) sitting in GP waiting rooms may have experienced DVA in the previous year.1

Women experience more sexual violence, more severe physical violence and more coercive control from their partners than men.2 This article focuses on male perpetrators and female victims.

DVA is disproportionately common in populations who have: medically unexplained symptoms, chronic pelvic pain, recurrent UTIs, STIs, poorly controlled asthma and diabetes, fibromyalgia, chronic fatigue, depression, post-traumatic stress disorder (PTSD), substance misuse, alcoholism and low self-esteem. 3,4

Domestic abuse in pregnancy is associated with intrauterine growth retardation, miscarriage and premature labour.

Women who reported DVA were 32 times more likely to be afraid of their partner than women who did not.5

Recognising DVA
A DVA patient may develop PTSD, the anxiety disorder most commonly caused by DVA.

PTSD alters the allostasis of serotonin and cortisol. Decreased serotonin is associated with depression and aggression. Cortisol affects development of the brain and the immune system.

The DVA survivor may attend the surgery frequently. If living in fear, she may not concentrate well. She may miss appointments. Avoiding DVA takes priority over other concerns. Regularly humiliated, she may become depressed, with low self-esteem.

 

She may not look after herself well. She may present as an obese person who cannot lose weight, who fails to exercise, who cannot stop smoking (even in pregnancy), who cannot look after her diabetes or asthma. Non-consensual sexual acts may result in recurrent UTIs, pelvic pain and unplanned pregnancies.

The role of the GP is to recognise, respond and offer to refer patients who disclose DVA.

Recognising abusive relationships
In abusive relationships, dynamics of power and control, using psychological and physical methods, dominate over mutual respect. Abusive relationships are characterised by undue possessiveness and isolation of the woman, perhaps explained as concern and love. The partner limits her freedom. Those in their first relationship may not recognise their relationship as abusive and assume it is the norm.

The Duluth wheels (see resources) were devised in the 1980s during focus group-based qualitative research with women survivors of DVA.

Modern day addenda would include harassment by stalking, texts and humiliation using social media and would incorporate same-gender and female-against-male abuse. Nevertheless, I find patients still instantly recognise the behaviour patterns when looking at the wheels in surgery.

Questions to ask

Asking 'How are things at home?' becomes part of the differential diagnosis of the aetiology of the above conditions.

HARKS is a helpful mnemonic for asking questions about DVA.6

Have you ever been ...

  • Humiliated (emotionally and verbally abused including put-downs).
  • Afraid.
  • Raped (made to have non-consensual sex).
  • Kicked (physically assaulted).

... by your partner?

Ask these questions in situations that are safe, not when the partner is present, or others from the community who might break the patient's confidentiality. Disclosure of DVA can be an excuse for further abuse.

Responding to DVA
Acknowledge the bravery of the patient for disclosing DVA. Explain the resources that are available in your area. Health visitors can usually supply the practice with posters, leaflets and discreet 'credit' cards (easily hidden) listing the main resources and helplines. Keep a stock in all surgery rooms. Put the cards in toilets in the surgery.

Explain that domestic abuse support workers will discuss options with her. Choices about what to do remain hers, unless children are being harmed.

Referral
There are domestic abuse support workers throughout the country, although the title varies. The support workers are able to discuss injunctions, non-harassment law, housing options, finances and strategies for keeping safe.

They can draw up a 'safety plan' with the patient to aid planning for eventualities. Lawyers, police, social services, housing officers, multi- agency risk assessment committees (MARAC) and an independent domestic violence adviser (IDVA) may become involved depending on her risk assessment.

Changes in the law enable police to arrest and prosecute perpetrators of DVA. Most forces have a domestic violence unit with specialist officers. Police can arrange alarm systems and flag up a survivor's telephone number to ensure they respond to her 999 call within minutes. Her home can be made safer.

Outcomes
There is evidence that support workers helping survivors of DVA reduce risk of further physical violence, improve quality of life and can improve mental health outcomes.2

GPs who are trained to ask about DVA improve the diagnostic detection and response and referral rates sevenfold compared with controls.2

  • Dr Duxbury is a GP principal in Oxford and a clinical tutor and author of the RCGP e-learning modules on violence against women and children 2011.

    Resources

    Click here to take a test on this article and claim a certificate on MIMS Learning

    CPD IMPACT: EARN MORE CREDITS

    These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

    • Find out about the local resources in your area for managing DVA.
    • Discuss responses to DVA in a primary healthcare team meeting. You could ask your local named doctor for child protection to facilitate and it could count towards child protection training too.
    • Try a course, such as the e-learning course on the RCGP e-learning website, Violence Against Women and Children, to find out more about recognising and then responding to DVA. It is available for free at: www.elearning.rcgp.org.uk

      References
      1. Richardson J, Coid J, Petruckevitch A et al. Identifying domestic violence: cross sectional study in primary care. BMJ 2002; 324: 274-7.

      2. Feder G, Agnew Davies R, Baird K et al. Identification and referral to improve safety of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378: 1788-95.

      3. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331-6.

      4. Golding J. Intimate partner violence as a risk factor for mental disorders: a meta-analysis. J Fam Violence 1999; 14(2): 99-132.

      5. Bradley F, Smith M, Long J et al. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002; 324: 271-4.

      6. Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract 2007; 8(49).

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