Recognising intimate partner violence

GPs are well placed to help patients experiencing domestic violence, says Professor Gene Feder.

Domestic or intimate partner violence (IPV) is a common violation of human rights, with long-term consequences for the physical and mental health of those affected and for their children.

Women who suffer domestic violence need to be reassured that they are not to blame for the abuse

Defining IPV
IPV is any behaviour within a current or past intimate relationship that causes physical, psychological or sexual harm. Such behaviour includes:

  • Acts of physical aggression - such as slapping, hitting, kicking and beating.
  • Psychological violence - such as intimidation, constant belittling and humiliating.
  • Forced intercourse and other forms of sexual coercion.
  • Various controlling behaviours - such as isolating a person from their family and friends, monitoring their movements and restricting access to information or assistance.

Although the frequency of violent acts is comparable between men and women in relationships, sexual, repeated and severe physical violence is largely perpetrated against women, with consequent longer-term damage to their health.

Health consequences
Abuse of women is a significant public health issue with a prevalence similar to chronic diseases such as diabetes and asthma.1 About a quarter of women in the UK have experienced violence from a partner or ex-partner.

IPV can have short- and long-term negative health consequences, even after the abuse has ended. Unless there is an obvious injury, clinical manifestations are often hidden. IPV is strongly associated with mental health conditions such as depression, eating disorders, suicide attempts, insomnia, alcohol and drug abuse, anxiety and post-traumatic stress disorder.

The most consistent physical health difference between abused and non-abused women is the experience of gynaecological problems such as STIs, vaginal bleeding, genital irritation, chronic pelvic pain and UTIs.

Other conditions include chronic pain, particularly headaches and back pain, and CNS symptoms such as dizziness and fainting, functional GI disorders, particularly irritable bowel syndrome, and increased cardiovascular risk.

The health risks for abused mothers and their unborn children can be serious, including the death of the mother or the foetus. IPV in pregnancy is also associated with low birth weight.

Children exposed to IPV in the home have a higher risk of physical, emotional, behavioural and educational problems that persist into adulthood.

Potential clinical indicators in children may include aggressive behaviour and language, anxiety, difficulty adjusting to change, psychosomatic illness and bedwetting.

Identifying women at risk
General practice, where there is a long-term relationship between the woman and health professional, may be the only place where a woman feels safe to discuss partner abuse. Yet it is difficult for GPs to ask about and difficult for women to disclose.

To overcome these barriers, clinicians should funnel their questions about IPV into direct questions, for example:

  • Have you been afraid of your partner/ex-partner?
  • Have you felt humiliated or emotionally abused by your partner/ex-partner?
  • Have you been physically hurt by your partner/ex-partner?
  • Have you felt coerced by your partner/ex-partner to have any kind of sexual activity?

How to respond
Even if a woman does not choose to pursue any other intervention or engage with other agencies, validation of her experience by the GP is crucial, through statements like:

  • Everybody deserves to feel safe at home.
  • You don't deserve to be hit or hurt and it is not your fault.
  • I am concerned about your safety and well-being.
  • You are not alone; I will be with you through this, whatever you decide. Help is available.
  • You are not to blame. Abuse is common and happens in all kinds of relationships. It tends to continue.
  • Abuse can affect your health and that of your children in many ways.

In addition to offering support, the GP needs to check with the woman if it is safe for her and her children, if she has any, to return home.

A more detailed risk assessment will include questions about escalation of abuse, the content of threats, direct and indirect abuse to the children.

The greatest risk of serious assault or murder is at the time the woman is leaving or thinking about leaving.

Documentation
Writing down what your patient tells you about partner violence is an important aspect of management. It shows that you believe the woman and take violence seriously.

Your records may be critical in helping her access legal rights. Your duty of care may be examined after a domestic homicide review or required by the Domestic Violence, Crime and Victims Act 2004. Many housing agencies will accept a woman's application to be re-housed in a safe area if she can produce evidence from a health professional.

DOCUMENTATION

Records should ideally:

  • be made in an interview with the woman alone
  • include responses to questions
  • use the woman's own words when possible
  • briefly describe the nature of abuse and injuries sustained
  • include a detailed physical record, including sketches of injury sites on a body map or photographs scanned into the medical record
  • record and, if possible, keep any damaged, torn or stained clothing
  • include dates and times of incidents, if known
  • describe the client's psychological state, without interpretation/judgments
  • document behaviour of spouse, including spontaneous disclosures that may indicate abuse (but do not interview him)
  • note facts (including observations) rather than assumptions
  • record your action (e.g. information provided, referral to domestic violence service).

Domestic violence services
The needs of women experiencing partner violence are complex, ranging from the non-judgmental support that GPs can provide, to legal, financial, housing and safety needs.

Clinicians can offer referral for expert support and domestic violence advocacy, which can reduce abuse and increase social support and quality of life. Information about local domestic violence services is available from the Women's Aid Federation.

Specialist advocacy services are also starting to address IPV in heterosexual males and in gay and lesbian relationships.

A safe and effective response from general practice ultimately will require training of practice teams and the commissioning of advocacy services by PCTs. We are currently conducting a randomised controlled trial of a training and support programme, primary care Identification and Referral to Improve Safety of women experiencing partner violence (IRIS), at practices in two PCTs, which we hope will provide an evidence base for commissioning.

Child protection
Under the Adoption and Children Act 2002, living with and witnessing domestic violence is a source of 'significant harm' for children. However, there is no assumption that an automatic referral to social services should be made if domestic violence is disclosed.

If child protection procedures need to be followed, try to obtain the consent of the non-abusive parent. Women are often worried that any disclosure could lead to removal of the children. You might offer reassurance that you can report positive aspects of the non-abusive parent's care.

While the interests of the child are paramount, and initiating procedures does not depend on parental consent, women who experience domestic violence are rarely 'bad' parents. Never blame a woman for failing to protect her children - it is the abuser's violence that puts them at risk.

The most effective form of child protection is to empower and support the mother to make herself and her children safe.

  • Professor Feder is professor of primary health care at the University of Bristol
  • For further information or to become involved with the IRIS trial, contact Professor Feder at gene.feder@bristol.ac.uk

Resources
1. Hegarty K, Taft A, Feder G. Violence between intimate partners: working with the whole family. BMJ 2008; 337:a839.

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