Introduction – Domestic violence in the Health Sector

Over 1 in 5 women make their first disclosure of domestic violence to their general practitioner.

You may be the only person the victim will tell.

Your skills and sensitivity are essential.


Learning objectives

The aim is to give an overview on how patients and their children who are victims of domestic violence can be identified and how to respond to them appropriately. It also presents possible indicators of domestic violence and its physical and psychological consequences. The introduction also includes guidelines for patient care and some legal information relevant to medical sector. The learning materials are not tailored to the individual situation of different countries; they include rather generic cases that will need local adaptation.


IMPRODOVA: Domestic Violence in Health Services

The video describes the various steps on how to proceed in cases of domestic violence in the health sector.


Case Study: Disclosure of domestic violence to the primary care physician

Sabrina is an accountant, 30 years of age, married for 8 years to a construction worker. She presents to her primary care physician with low energy and headaches that have affected her for over a year. The headaches have worsened in the past month (since her husband was laid off), affecting her mostly at the end of the day. She has trouble sleeping and reports pains all over. She has been to several medical practices in the past year, but has found nothing to be helpful. She has had blood tests, been prescribed painkillers, been advised to get more exercise and change her diet. She desperately needs something to be done for her today as her husband is getting impatient with the lack of results. She is concerned he will become very angry with her when she returns home today. Sabrina’s doctor asks, ‘what happens when your partner becomes angry?’ She has not previously been asked this question and Sabrina hesitates to answer. Her doctor says, ‘I would really like to hear what is going on at home’. Sabrina bursts into tears and slowly the story of her experience with partner violence unfolds. After the doctor assessed the risk according the procedures defined for such cases, the doctor ascertains that Sabrina currently is not in danger of escalating violence and Sabrina confirms she feels she can manage what is happening for now. Right now, she does not want to go to a shelter or contact the police, what the physician suggests no matter how high the risk is. He wants her to have all the information available to make a good choice. They make a follow-up appointment for ongoing support and the doctor shares with her the number of a helpline if anything should happen until their next appointment.

For more case studies and scenario-based learning click here.


What is domestic violence?

Domestic violence is an abuse of power within a domestic relationship, between relatives or ex partners. It involves one person dominating or controlling another, causing intimidation or fear, or both. Domestic violence is often experienced as a pattern of abuse that escalates over time.

It is not necessarily physical and can include:

  • emotional or psychological abuse
  • verbal abuse
  • spiritual abuse
    • including taking part in their religious or cultural practice, misusing spiritual or religious beliefs and practices to justify abuse and violence
  • stalking and intimidation, including using technology
  • social and geographic isolation
  • sexual abuse
  • financial abuse
  • cruelty to pets
  • damage of property

Power and Control Wheel developed by the Domestic Abuse Intervention Programs (DAIP)

The Power and Control Wheel illustrates the most common abusive behaviors and tactics.

Understanding the Power and Control Wheel

Detailed information on the forms and dynamics of domestic violence is provided in module 1.

Indicators

The following are indicators associated with victims of domestic violence. Please note that none or all of these might be present and be indicators of other issues. This is where using these indicators as a guide can complement the practice of asking directly.

Physical indicators as being potentially a victim of domestic violence in adults:

  • Unexplained bruising and other injuries
    • especially head, neck and facial injuries
    • bruises of various ages
    • injuries sustained do not fit the history given
    • bite marks, unusual burns
    • injuries on parts of the body hidden from view (including breasts, abdomen and/or genitals), especially if pregnant
    • chapped lips
    • teeth knocked out
  • Miscarriages and other pregnancy complications
  • Chronic conditions including headaches, pain and aches in muscles, joints and back
  • Sexually transmitted infection and other gynaecological problems

Psychological indicators as being potentially a victim of domestic violence in adults:

  • Emotional distress, e.g. anxiety, indecisiveness, confusion and hostility
  • Sleeping and eating disorders
  • Anxiety / depression / pre-natal depression
  • Psychosomatic complaints
  • Self-harm or suicide attempts
  • Evasive or ashamed about injuries
  • Multiple presentations at the emergency room / client appears after hours
  • Partner or other family member does most of the talking and insists on remaining with the patient
  • Seeming anxious in the presence of their partner
  • Reluctance to follow advise
  • Social isolation / no access to transport
  • Frequent absences from work or studies
  • Submissive behaviour / low self-esteem
  • Alcohol or drug abuse
  • Fear of physical contact
  • Nervous reactions to physical contact/ quick and unexpected movements

Physical indicators as being potentially a victim of or witnessing domestic violence in children:

  • Difficult eating / sleeping
  • Slow weight gain (in infants)
  • Physical complaints
  • Eating disorders (including problems of breast feeding)
  • Fingertip injuries

Psychological indicators as being potentially a victim of or witnessing domestic violence in children:

  • Aggressive behaviour and language
  • Depression, anxiety and/or suicide attempts
  • Appearing nervous and withdrawn
  • Difficulty adjusting to change
  • Regressive behaviour in toddlers
  • Delays or problems with language development
  • Psychosomatic illness
  • Restlessness and problems with concentration
  • Dependent, sad or secretive behaviours
  • Bedwetting
  • ‘Acting out’, for example cruelty to animals
  • Noticeable decline in school performance
  • Fighting with peers
  • Overprotective or afraid to leave mother/father
  • Stealing and social isolation
  • Exhibiting sexually abusive behaviour
  • Feelings of worthlessness
  • Transience

Routinely check the patient’s medical history to see if there have been previous hospital visits with similar injuries or complaints.

Further information: Matoori, S., Khurana, B., Balcom, M.C. et al. Intimate partner violence crisis in the COVID-19 pandemic: how can radiologists make a difference?. Eur Radiol (2020)

Possible Indicators for sexual violence

  • injuries to the genitals, the inside of the thighs, the breasts, the anus
  •  irritations and redness in the genital area
  •  common infections in the genital area
  •  pain in the lower abdomen and/or pelvic area
  •  sexually transmitted diseases
  •  bleeding in the vaginal or rectal area
  •  pain when urinating or defecating
  •  pain when sitting or walking
  •  strong fears of examinations in the genital area; avoidance of examinations
  •  severe cramps in the vaginal area during gynaecological examinations
  •  sexual problems
  •  self-harming behaviour
  •  unwanted pregnancies / abortions
  •  complications during pregnancy
  •  miscarriages

Indicators of domestic violence are dealt with in more detail in module 2.

Stages of effective response
  1. Non-judgmental listening and validation
  2. Initial safety assessment
  3. Referrals, e.g. Police, Domestic Violence Line, legal advice, victim support (only with the victim’s consent)
  4. Note-taking for legal purposes if the victim wants to take legal steps
  5. Mandatory reporting – if required
  6. Continuing care
How to talk to your patient about domestic violence

In any situation that you suspect underlying psychosocial problems you can ask indirectly or directly about domestic violence. If you have concerns that your patient is experiencing domestic violence, you should ask to speak with them alone, separate from their partner or any other family members. It is important to understand that very often the victim blames herself/himself or tries to protect the perpetrator. At the beginning of a situation that makes you suspicious, you can always ask broad questions about whether your patient’s relationships are affecting their health and wellbeing. Listen to them non-judgmental and validate them.

For example:

  • ‘How are things at home?’
  • ‘How are you and your partner (or other family members) getting on?’
  • ‘How do you argue when you are at home?’/’Can you disagree with your partner?’
  • ‘Is anything else happening which might be affecting your health?’

It is important to realize that some victims who have been abused want to be asked about domestic violence, give hints and are more likely to disclose if they are being asked in a safe environment. If appropriate, you can ask direct questions about any violence.

For example:

  • ‘Are you afraid when you are at home?’/‘‘Are there ever times when you are frightened of your partner (or other family members)?’
  • ‘Are you concerned about your safety or the safety of your children?’
  • ‘Does the way your partner (or other family members) treats you make you feel unhappy or depressed?’
  • ‘Has your partner (or other family members) ever verbally intimidated or hurt you?`
  • ‘Has your partner (or other family members) ever physically threatened or hurt you?’
  • ‘Has your partner (or other family members) forced you to have sex when you didn’t want it?’
  • ‘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.’

If you see specific clinical symptoms and are sure about your suspicion, you can ask specific questions about these (e.g. bruising). These could include:

  • ‘You seem very anxious and nervous. Is everything alright at home?’
  • ‘When I see injuries like this, I wonder if someone could have hurt you?’
  • ‘Is there anything else that we haven’t talked about that might be contributing to this condition?’

If your patient’s fluency in your mother tongue is a barrier to discussing these issues, you should work with a qualified interpreter. Don’t use your patient’s partner, other family members or a child as an interpreter. It could compromise their safety or make them uncomfortable to talk with you about their situation.

How to talk to victims of domestic violence is the subject of module 3. For more information, please visit this module.

Responding to a disclosure

Your immediate response and attitude when your patient discloses domestic violence can make a difference. Victims require an initial response to disclosure, where they are listened to, validated and their own and their children’s safety is assessed. They also need to be assisted on a pathway to safety.

Listen

Being properly listened to can be an empowering experience for a victim who has been abused. The key aspect of proper listening is non-judgmental attitude. Acknowledge that the victim is the expert in his/her own life and his/her experiences. He/she should not be pushed into making decisions.

Communicate belief

‘That must have been frightening for you.’

Validate the decision to disclose

‘I understand it could be very difficult for you to talk about this.’

Emphasize the unacceptability of violence but do not judge the perpetrator

‘Violence is unacceptable. You do not deserve to be treated this way.’

Be clear that the victim is not to blame

Avoid suggesting that your patient is responsible for the violence or that they are able to control the violence by changing their behaviour.

Do not ask questions that might raise victims’ stress and sense of powerlessness

  • ‘Why don’t you leave?’
  • ‘What could you have done to avoid this situation?’
  • ‘Why did he/she hit you?’

Aspects that should be considered after the disclosure of domestic violence such as medical assessment and securing of evidence are addressed in module 4.

Initial risk assessment

Assist your patient to evaluate their immediate and future safety, and that of their children. Best-practice risk assessment involves seeking relevant facts about their particular situation, asking them about their own perception of risk, and using professional judgment. You may need to refer your patient to a specialized domestic violence service. The strongest indicator of future risk/violence is current and past behaviours of the perpetrator. You may also advise the patient to go to the police.

It is essential that you engage the victim in a conversation about their perceptions of risk and how they have managed their safety in the past.

Document any plans made, for future reference!

For initial safety planning, you will at least need to:

  • Speak to the victim in private setting
  • Check for immediate concerns
    • Does the patient feel safe going home after the appointment?
    • Are his or her children safe?
    • Does he or she need an immediate place of safety?
    • Does he or she need to be assisted to do the next steps for their safety?
    • Does he or she need to consider an alternative exit from your building?
  • If immediate safety is an issue
    • Victims of domestic violence often feel isolated, depressed and helpless.  Thereby, it is extremely important to carefully identify the life situation and needs of the victim. If it is necessary
      • assist the victim to receive immediate crisis help and psychosocial support.
      • If there is an immediate risk to safety of the patient or any children, consider contacting police.
      • Initiate child protection procedures if not done yet
  • If immediate safety is not an issue, check your patient’s future safety
    • Has the perpetrator caused physical harm before? (e.g. by beating)
    • Has the perpetrator’s behaviour changed/ escalated recently?
    • Does the perpetrator have access to weapons or any other objects to cause serious physical harm?
    • Are there any additional current stressors in the perpetrator’s life or factors reducing the perpetrator’s self-confidence?
    • Does your patient need an assistance to make a referral to police or a legal service?
    • Does your patient have emergency telephone numbers?
    • Does your patient need a referral to a domestic violence service to help make an emergency plan?
    • Where would your patient go if he or she had to leave?
    • How would your patient get there?
    • What would your patient take with him or her?
    • Who could your patient contact for support?

Other elements in safety planning include usual scenarios (e.g. when victim keeps living with perpetrator, when victims wants to leave abusive relationship and when victim does no longer live with perpetrator).

Risk assessment is an ongoing process. You may need to check in on the victim to follow up on this initial safety plan.

Find more information on risk assessment and safety planning in module 5.

Note-taking for legal purposes
  • If the victim wishes to make a report to police: You can support the Police investigation and future legal proceedings by making detailed notes.
  • Describe physical injuries, including the type, extent, age and location. If you suspect violence is a cause, but your patient has not confirmed this, include your comment making it sure that their explanation accurately explains the injury. If there is an official form or template for documenting domestic violence injuries, please use it.
  • Record what the patient said (using quotation marks).
  • Record any relevant behaviour observed, being detailed and factual rather than stating a general opinion, e.g. rather than ‘the patient was distressed’, write ‘the patient cried throughout the appointment, shook visibly and had to stop several times to collect herself/himself before answering a question’.
  • Consider taking photographs of injuries, or certifying photographs taken of the injuries presented at the time of consultation. Your file notes must include the date and time and clearly identify the client. You must clearly identify yourself as the author and sign the file note. Do not include generalisations or unsubstantiated opinions. Correct and initial any errors, set out your report sequentially, and use only approved symbols and abbreviations.

International standards and legal frameworks in Europe are discussed in more detail in module 6.

Mandatory reporting

As a mandatory reporter, if a victim talks about experiencing or perpetrating violence, and you believe you have reasonable grounds to suspect that a child is at risk of significant harm, you need to report this to Community Services. You are not obliged to report violence experienced by adults. Reporting violence experienced by adults without their consent could put them at greater risk of harm.

Exposing children to domestic violence can have a serious psychological impact on children. In some cases, you may feel there is risk of significant harm to a child even though it seems unlikely that the violent person in their home would physically hurt them. Use your professional judgment about the individual circumstances and the nature of the violence.

Continuing care

Consider the victim’s safety as a paramount issue. You can help to monitor the safety by asking about any previous escalation of violence or physical harm.

Be familiar with appropriate referral services and their processes. The victim may need your help to seek assistance. Have information available for the patient to take with them if appropriate.

In module 7 you will find more information on inter-organisational cooperation and risk assessment in cases of domestic violence in multi-professional teams.

Toolkit for GPs