Module 5: Risk assessment and safety planning

1. Risk Factors for Domestic Violence
2. Risk Assessment
3. Sex and Gender Aspect in Risk Assessment
4. Safety Planning
5. Communicating Safety Measures and Risk Assessment

Spotlight on Gynaecology/Obstetrics, Surgery/Emergency Room and Paediatrics
6. Gynaecology/Obstetrics
7. Surgery and Emergency Room
8. Paediatrics

Spotlight on Dentistry
9. Dentistry

Sources

Introduction to the topic

Welcome to Module 5: Risk Assessment and Safety Planning. In this module, you will explore the critical components of domestic violence risk assessment and safety planning. We will delve into identifying risk factors associated with domestic violence, how to conduct thorough risk assessments well, and the need to include sex and gender dynamics in risk assessment processes. Additionally, we will present strategies for safety planning and effective communication of safety measures and risk assessment. Moreover, in the spotlights, a special focus on Gynaecology/Obstetrics, Surgery & Emergency Room, Paediatrics, and Dentistry will be presented.

Learning objectives

+ How to conduct comprehensive risk assessments.

+ Recognising sex and gender dynamics in risk assessment and taking this into consideration.

+  Understanding and developing safety planning strategies to support victims.

Risk management involves a collaborative set of strategies and measures aimed at bolstering the well-being of the victim/survivor in all age groups while reducing or eliminating the likelihood of the perpetrator committing further acts of violence.1 Risk management can include facilitating access to support and services, seeking secondary consultations, and continuously assessing risk.2 Last, but not least, integral to all risk management efforts is the incorporation of safety planning after disclosure of domestic violence.

Activities related to risk management encompass addressing diverse risks and associated needs, such as…3

  • Addressing immediate risks promptly
  • Safety planning (including children or young individuals)
  • Engaging in conversations with victim/survivors regarding available alternatives and linking them to pertinent services
  • Continuously assessing and managing risks over time, monitoring for any shifts or escalations
  • Collaboration with other services by sharing relevant information.

Please remember: Victims of domestic violence come from all social, cultural, economic, and religious backgrounds with different age, gender and sexual orientation, including people with disabilities. It affects people from all socio-economic backgrounds and education levels. It is important to understand, that there is NO “typical victim”.

Even though many example videos depict a female as the victim in heterogenous relationships, please do not be misled. Victims can be anyone, including men, children, individuals with disabilities, or non-binary persons. The same applies to perpetrators. For more information on perpetrators, check out Module 1. Also, domestic violence can occur between couples, same-sex couples, parent and child, siblings, uncles, aunts, cousins, grandparents or even roommates.

1. Risk factors for domestic violence

“The man’s drunkenness (…) made him 3 1/2 times more likely to reassault his partner than a man who did not get drunk. If the man was drunk nearly every day, he was 16 times more likely to reassault than those who seldom or never drank.”4

It is important to identify the presence of those risk factors which increase the likelihood of escalating the violence and can lead to ‘reassault‘.5 These factors encompass the psychological and psychosocial traits of both, perpetrators and victims, as well as the dynamics within the victim-perpetrator relationship.6 It’s essential to emphasise that these factors are not causal factors.7 Understanding risk factors is an important part of responding appropriately to disclosures of domestic violence.8 Risk factors may not be direct triggers of domestic violence but rather play a role as contributing factors to domestic violence. It’s essential to remember that these factors can interact in various intricate ways. Nevertheless, even though certain factors often coincide with domestic violence, none of them directly causes it.

Risk factors associated with domestic violence are often analysed through the ecological model lens9, considering that factors vary between individual, relationship, community, and societal levels. Certain risk factors are consistently found across studies, while others are context-specific, varying between and within countries, such as in rural and urban settings.

General Risk Factors:

Possible indicators for high-risk: 10
· Sudden change in perpetrators’ behaviour: “he’s/she’s changed all of sudden”
· Victim tells you: “he/she gives me the creeps”, “He/she has that look in his/her eyes”
· Violence towards pets
· Substance abuse e.g. alcoholism, drugs etc.
· Strangulation
· Pregnancy
· Separation and divorce
· Victim is in a new relationship
· Perpetrator lost custody of children
· Violation of restraining orders

Challenges in high-risk cases of domestic violence 11

  • Perpetrator/victim have shared children
  • Close-knit family network is utilised by the perpetrator to gather information about the victim, to involve family members or friends to maintain pressure, etc.
  • Data protection regulations hinder involvement of additional professionals
  • Lack of information and problematic protection for the victim after conviction and imprisonment

While there are several common risk factors across various forms of domestic violence, specific risk factors may also exist for certain groups.

Specific Risk Factors: Post Separation Abuse

A common misconception is that when a relationship ends, the violence and conflict end too, but in many cases, it is the opposite. Instead of decreasing, violence can escalate and become more intense after separation. This means that many victims of domestic violence they still suffer repeated violence that continues also after separation. 12 That is in line with data showing that DV perpetrators often subject their victims to repeated violence and international research based on crime statistics shows varying results with a recidivism rate of 15-60%. 13,14

The term “post-separation abuse” delineates an enduring, intentional pattern of intimidation tactics directed towards a former partner after separation. In essence, it is about using various mechanisms to maintain and reinforce the power imbalance that already exists in the relationship. 15 Most of the research on post-separation abuse has so far focused on fathers’ violence against mothers, 16 but post separation abuse can happen to all DV victims.

Post separation can take many forms and key include:

  • Judicial or legal violence, which means that the perpetrator uses their legal rights to continue perpetrating violence in various forms. It can include initiating legal proceedings against the victim in order to control or intimidate or pursuing child custody or visitation rights with the intention of exercising dominance and control over the victim during or after separation. 17, 18
  • Financial abuse as a means of control within the legal system. 19 The perpetrator may seek changes in child support arrangements, pursue full custody to avoid financial obligations altogether, prolong court proceedings to negotiate payments excessively, or refuse to fulfil their financial obligations altogether. 20 Those who resort to this type of abuse may deceive about their financial situation, hide assets, or change employment to avoid sharing resources. 21 Prolonging legal proceedings can also put a financial burden on survivors, as the longer the negotiations last, the greater the cost to them.
  • Threats to children’s safety: Research has shown that there are often children involved in relationships with domestic violence 22, which means that many children live in a dynamic where there has been violence between the parents and where post-separation abuse is ongoing. As this enables the perpetrator to exert power and control through the children, by e.g. using children as weapons to control or manipulate the other party, this may lead to a variety of negative consequences regarding the child’s physical and mental health and quality of life. 23
  • Traumatising and social isolation: Among victims of DV violence, trauma symptoms often persist for many years after separation from the perpetrator 24. In this group a high proportion have been reported to develop post-traumatic stress disorder (PTSD). 25 It should be emphasised that different types of violence and seemingly milder violence can lead to traumatisation and not only severe physical or sexual violence. 26 In many cases, these symptoms can be interpreted as other types of psychiatric and somatic health problems, hindering adequate care and treatment. 27 In addition, people who have been exposed to repeated and prolonged traumatic events may develop more complex symptoms such as impaired affect regulation, somatization, dissociation and problems related to attention, memory, identity and relationships. 28 When the victim is met with a lack of support, for example through questioning, blaming and suspicion in meetings with professionals there is a risk that traumatisation and other negative consequences of the trauma deepens. 29
  • Character defamation: is not uncommon that victims are further victimised in various social processes following the primary victimisation 30 31 this is sometimes referred to as secondary victimisation. Research shows that secondary victimisation occurs as a sense of betrayal linked to “the victim’s expectations that she/[he] will be believed, validated and protected when she/[he]  is instead met with blaming attitudes and ignoring or minimising her/[his]  victimisation”. 32
  • Persistent harassment or stalking: Threats, harassment, intimidation, power, control, intrusion, imprisonment and omnipresence, i.e., the constant presence of the perpetrator, which can persist for a long time after separation. 33

Society’s response to post-separation abuse has crucial implications for victims 34, as life after separation from a violent partner can be characterised by plenty of hardships. There is an urge need for increased knowledge among front line responders on the signs, patterns and consequences of post-separation abuse in terms of mental and physical health and quality of life.

It is crucial that society takes post-separation abuse seriously and offers resources and support to those affected. This includes access to shelters, counselling, legal assistance and other resources that can help victims regain their independence and safety.

Here you can download the “Post Separation Power and Control Wheel”: https://www.theduluthmodel.org/wp-content/uploads/2017/03/Using-Children-Wheel.pdf

Specific Risk Factors: Domestic Violence Against the Elderly 35

Individual Risk Factors:

  • Being overburdened by the care duties due to poor or inadequate preparation or training for caregiving responsibilities
  • Inadequate coping skills for being stressed by the care
  • High financial and emotional dependence upon the  vulnerable elder
  • Past family conflict
  • Inability to establish or maintain positive prosocial relationships
  • Lack of social support
  • Lack of own´s financial resources

Specific Risk Factors for Re-Abuse 36

  • At the individual level there is evidence to suggest a significant negative relationship between the victim’s socioeconomic status and re-abuse.
  • At the interpersonal level, in exploring the type of relationship between the perpetrator and the victim, the length of time living together was a better predictor of re-abuse than marital status. The history of physical abuse in the relationship was an important predictor of re-abuse.
  • In considering the likelihood of re-abuse in DV relationships, medical professionals should consider the history of violence in the relationship, rather than focusing only on the severity of the offense.

2. Risk Assessment

“Women’s perceptions of safety and the likelihood of reassault [emerged as the] most consistent and strongest risk marker.” 37

Evidence shows that adult victim/survivors are often good predictors of their own level of safety and risk, and that this is the most accurate assessment of their level of risk.

Therefore, understanding and assessing risk begins with listening to the victim. Through listening, professionals can pick up on cues and ask questions about indicators of violence. Risk assessment helps to identify whether the risk is low or high. 38

When victims/survivors anticipate danger, it should be taken seriously. Psychological violence is a significant aspect of abusive relationships and should be considered in both contexts: as a potential precursor to future physical violence and as part of the spectrum of behaviours constituting domestic violence.

While the health sector isn’t solely responsible for risk assessment and safety planning, nor is it primarily tasked with creating safety plans, healthcare personnel should inform patients about these processes. Therefore, it’s crucial to gain a better understanding of the overall risk assessment and safety planning process, including its various steps.

For more information on the responsibilities related to risk assessment and safety planning among different frontline responders (such as police, healthcare professionals, social workers, and NGOs), please refer to the Country Reports and Cross-National Comparison on the Risk Assessment Tools and Case Documentation used by Frontline Responders.

Definition: Risk assessment39

Risk assessment is a point-in-time assessment of the level of risk. Risk is dynamic and can change over time. This means you should regularly reassess risk, and any changes should be part of future assessment and risk management. Your assessment should include the level of risk, as well as appropriate risk management actions and approaches. You should also take into account relevant information about a victim survivor or perpetrator’s circumstances.

Best-practice approaches to risk assessment with a victim/survivor enables them to share their story with you by you believing them about:

  • … their experience of violence
  • … the relationship
  • … how this has affected any children in the family (that is, understanding the risk experienced by children as victim survivors in their own right, which may also be informed by direct assessment of children)
  • … patterns of beliefs, attitudes and behaviours of the perpetrator.

Model of Structured Professional Judgement (Maram Practice Guides Foundation Knowledge Guide, State of Victoria, Australia, Family Safety Victoria, February 2021, p. 36, available at https://www.vic.gov.au/maram-practice-guides-and-resources)

Risk assessment means making a professional judgement about the risk factors that are present combined with the victims’ own assessment of risk to determine the likelihood of future violence, and the potential for harm, including serious injury or death, from future violence. 40

More information on risk assessment can be found in Module 7.

As the strongest indicator for future risks/violence is the perpetrator’s current and past behaviour. It is important that the patient is being asked about his/her risk perception as well as his/her security management in the past and his/her plans in the future. Often, victims may recognise when they are facing imminent danger and may feel apprehensive about returning home. It is crucial to acknowledge and take seriously any concerns they have about their safety. For other victims, assistance may be needed in assessing their immediate risk. Specific questions can be posed to determine whether it is safe for them to go back to their homes. The primary goal is to ascertain if there is a tangible and imminent risk of severe harm. 41

If there is an immediate high risk, you can express your concern for their safety and engage in a conversation about protective measures to prevent harm. You can say: “I’m concerned about your safety. Let’s discuss what to do so you won’t be harmed.” 42

This video shows a practitioner conducting a comprehensive risk assessment, using Structured Professional Judgement with an intersectional lens. It includes identifying evidence-based risk factors for the victim survivor, assessing children’s experience of risk, and conducting secondary consultations as required.

Tasks for reflection

(1) List the evidence-based risk factors that the practitioner identifies for the victim survivor in the video.
(2) Reflect on the importance of evidence-based approaches in risk assessment.
(3) Explore how the practitioner applies an intersectional lens during the risk assessment. See module 1 for further information on intersectionality.
(4) Examine how the video addresses the assessment of risk concerning children.

Download: IMPRODOVA-Domestic Violence Risk Assessment Checklist (PDF, 0.3 MB)

Immediate risk of suicide and self-injury

Some people fear that the question of suicide might provoke the victim to commit it. On the contrary, talking about suicide often reduces the victim’s fear of suicidal thoughts and helps him or her to feel understood. The findings of a study demonstrated a clear correlation between documented cases of domestic violence and a heightened likelihood of self-harm. During the study period, almost a quarter of individuals who experienced domestic assault engaged in self-harming behaviour. 43

Further it is important to provide documentation indicating an immediate risk of suicide and self-injury, to facilitate effective communication among colleagues and ensure consistency.

Example: Suicide Risk Screening Tool (asQ) https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit_1.pdf

In cases where there is an imminent danger of self-harm or suicide, it is crucial that the patient not be left alone, particularly if…

  • … the victim has current thoughts or plans to commit suicide or to harm himself/herself or
  • … there is a history of thoughts or plans for self-harm in the past month or a record of self-harm in the past year, and the patient now appears extremely agitated, violent, desperate, or uncommunicative,

In these cases, the victim should be sent to a psychiatric hospital immediately. You should call an ambulance for transfer. In case of non-compliance ask for an immediate psychiatric consultation or involve the police. Breaking confidentiality is not a legal issue in this case; reporting acute self-endangerment is obligatory.

3. Sex and Gender Aspect in Risk Assessment 44

Image by Marek Studzinski on Unsplash

The majority of risk assessments do not explicitly consider sex/gender aspects. Often, these instruments either lack provisions for both sexes in their checklists or exclusively use the masculine form when referring to perpetrators. Consequently, if health care professionals harbour gender bias, they may overlook men as victims of domestic violence.

The perception and assumptions about one ́s own and the other sex and gender are important for specific aspects regarding risk assessment as well. For example, the perception of a female health care professional can be influenced by her sex (being female), her gender (e.g., how she sees her own role as a woman) and her own mind-set and expectations (e.g. woman can be very aggressive, too). This may have an impact on how she speaks with other women and with men (e.g. strong voice, holding eye contact). This can also influence how she assesses the risk, the aspects recognised as significant (e.g. who started the incident), and how she perceives the victim (what cues are most important to her e.g. outward appearance). Moreover, it also affects how she is perceived by the victim (male or female) and other frontline partners. For instance, a female health care professional could be seen as less threatening by a female victim who may then more willingly share information.

Furthermore, biased communication may arise when frontline responders perceive women as the “weaker sex” needing protection. In this scenario, gendered perception runs the risk of re-victimizing the victim through using derogative words and not considering the victim as an autonomous individual for example. This might be responsible for victims not sharing all information that are relevant for the risk assessment because they do not feel as being taken seriously. Alternatively, a health care professional may not take male victims’ complaints seriously and may downplay the incident, because in this frontline responder’s worldview, it is almost impossible to conceive those men can also become victims of domestic violence, which might end in an escalation of violence because the health care professionals do not intervene to end the violence against the man.

Another scenario is that the health care professional may not ask a male victim if he is financially dependent of his wife because in this socio-cultural context it is assumed that men are breadwinners and earn more money than women. Therefore, they might not be aware that the male victim is financially dependent on his wife, and this is not reflected in the risk assessment of the victim.

Hence, integrating sex and gender aspects into risk assessment instruments is imperative for health care professional. They must acknowledge legislative and ethical requirements on gender equality, reflecting on their behaviour and judgment to mitigate biases that could affect risk assessment outcomes. Even if sex/gender aspects are included, health care professionals must be trained to consider them during assessments, ensuring that questions are asked and interpreted appropriately. For further insights, refer to module 8.

4. Safety Planning

While the health sector isn’t solely responsible for risk assessment and safety planning, nor is it primarily tasked with creating safety plans, healthcare personnel should inform patients about these processes. Therefore, it’s crucial to gain a better understanding of the overall risk assessment and safety planning process, including its various steps.

Creating a safety plan can be approached in various ways, tailored to individual circumstances. It should address immediate safety concerns and remain adaptable to changes in circumstances. While a victim cannot control their partner’s abusive behaviour, they can implement measures to safeguard themselves and their children. A safety plan is a personalised and practical strategy that identifies specific actions a victim can take to enhance their protection and minimise the risk of harm.

Many victims who have been subjected to violence have fears about their safety. Other victims may not think they need a safety plan because they do not expect that the violence will happen again. Explain that domestic violence is not likely to stop on its own: it tends to continue and may escalate over time and may happen more often. 45

When making a safety plan with someone experiencing violence, it’s important to start by listening. First, listen for, and ask questions about, what has been happening. Find out what they already do to increase safety and use this as a basis for helping them to think about what else might increase their safety. 46

Assessing and planning for safety is an ongoing process – it is not just a one-time conversation. You can help them by discussing their particular needs and situation and exploring their options and resources each time you see them and as their situation changes. Discuss whether it is safe for them to return home.

All plans that have been made must be documented in the medical record for future reference! Copies should be given to the victim, if possible. At the same time, they should be made aware that there is a risk that the perpetrator might find the document and that the violence will escalate.

5. Communicating Safety Measures and Risk Assessment

“This video shows how to conduct an intermediate risk assessment with a person using violence, including how to observe and ask questions to identify patterns and level of risk, whilst always ensuring the victim survivor is kept in mind. It also shows how conducting a secondary consultation can support risk management.”

This video is a follow-up on the previous one. It introduces the various elements to risk management planning https://youtu.be/tDPFIw5IwHI

For an initial risk assessment talk to the victim in a private setting and assess immediate concerns. For further information on how to communicate with victims, see Module 3.

Questions to assess immediate risk of violence 47, 48

  • Is it safe for you to go home?
  • What are you afraid might happen?
  • What has the perpetrator threatened?
  • What about threats to the children?
  • Has physical violence happened more often or gotten worse over the past 6 months?
  • Has he/she had a weapon and has he/she ever used a weapon or threatened you or other family members with a weapon?
  • Has he/she ever tried to strangle you?
  • Do you believe he/she would kill you?
  • Has he/she ever beaten you when you were pregnant?
  • Is he/she violently and constantly jealous of you?
  • Has the perpetrator threatened to commit suicide? (risk for femicide!)

Victims who answer “yes” to at least 3 of the questions may be at especially high immediate risk of violence.

Making a safety plan 49

Even a victim who is not facing immediate serious risk could benefit from having a safety plan. If they have a plan, they will be better able to deal with the situation if violence suddenly occurs. The following elements are part of a safety plan and questions you can ask to help them make a plan.

Safe place to go“If you need to leave your home in a hurry, where could you go?”
Planning for children“Would you go alone or take your children with you?”
Transport“How will you get there?”
Items to take with you“Do you need to take any documents, keys, money, clothes, or other things with you when you leave? What is essential?”
Financials“Do you have access to money if you need to leave? Where is it kept? Can you get to it in an emergency?”
Support of someone close by“Is there a neighbour you can talk to about the violence, who can call the police or come help you if they hear sounds of violence coming from your home?”

Be realistic: You can help by discussing the victim’s needs with them, telling him/her about other sources of help, and assisting him/her to get help if they want it. It will usually not be possible to deal with all their concerns during the first meeting. Let the victim know that you are available to meet again to talk about other issues.
Do not expect the victim to make decisions immediately. It may seem frustrating if you think he/she will not take any steps to change their situation. However, the person will need to take it’s time and do what he/she think is right for them. Always respect the wishes and decisions of the other person.

Discuss how to stay safer at home 50

If the victim finds it challenging to avoid discussions that might escalate with their perpetrator, it’s advisable to suggest having those conversations in a space where they can easily exit if needed. Emphasise the importance of avoiding rooms where weapons may be present for added safety.

In situations where immediate leaving is considered the best option, encourage the victim to plan and execute their departure to a secure location before informing their perpetrator. This approach is crucial to minimising the risk of violence towards themselves and any children involved.

Avoid putting the victim at risk 51

Minimise the risk to the victim’s safety by addressing violence concerns only in private settings, ensuring that no one can overhear the conversation. Avoid discussing it if the partner, family members, or anyone accompanying the victim may be within earshot, even friends. Create opportunities for private conversations, perhaps by sending someone on an errand or assigning a task. If children are present, arrange for a colleague to supervise them during your discussion.

Maintain the confidentiality of her/his health records by storing them securely, away from public view. Discuss how she/he will explain her/his whereabouts and, if necessary, determine the plan for any paperwork she/he needs to take with her/him, like documentation for the police.

This video shows risk management including safety planning at a comprehensive level. It demonstrates how to lead collaborative case coordination and how to centre a victim survivor in risk management planning.

Tasks for reflection

(1) List the key risk management strategies and safety planning techniques presented in the video.
(2) Consider how the video emphasises centring the victim in the risk management planning process.
(3) Reflect on the importance of empowering and involving victims in decision-making.
(4) Identify potential challenges or barriers to effective risk management and safety planning.

Taking care of your own needs 52

Recognise that your needs are just as significant as those of the person you are assisting. Engaging in discussions or hearing about violence may evoke strong reactions or emotions, particularly if you have personally endured violence in the past, or if you are currently facing such challenges. Acknowledge and understand your emotions, using this as an opportunity for self-reflection. Seek the necessary help and support to address your own needs and ensure your emotional well-being. Further information can be found in Module 9: self-care (soon available)

IMPRODOVA D2.3: Risk Assessment Tools and Case Documentation of Frontline Responders

Factsheet: Risk Assessment and Safety Planning (VIPROM)Download

Spotlight on Gynaecology/Obstetrics, Surgery & Paediatrics

6. Gynaecology/Obstetrics

Specific Risk Factors: Sexual Violence 53

Individual risk factors for perpetrators:

  • Alcohol and drug use
  • Delinquency
  • Lack of concern for others
  • Aggressive behaviours and acceptance of violent behaviours
  • Early sexual initiation
  • Coercive sexual fantasies
  • Preference for impersonal sex and sexual-risk taking
  • Exposure to sexually explicit media
  • Hostility towards women
  • Adherence to traditional gender role norms
  • Hyper-masculinity
  • Suicidal behaviour
  • Prior sexual victimisation or perpetration
  • Association with sexually aggressive, hypermasculine, and delinquent peers
  • Involvement in a violent or abusive intimate relationship

Relationship risk factors:

  • Family history of conflict and violence
  • Childhood history of physical, sexual, or emotional violence
  • Emotionally unsupportive family environment
  • Poor parent-child relationships, particularly with fathers

Societal risk factors:

  • Societal norms that support sexual violence, male superiority and sexual entitlement
  • Societal norms that maintain women’s inferiority and sexual submissiveness
  • Weak laws and policies related to sexual violence and gender equity
  • High levels of crime and other forms of violence

“This video depicts simulation scenario of a health professional at an antenatal clinic screening a patient for Family and Domestic Violence.”
“In this video, Marta P. Chadwick, Director, Violence Intervention and Prevention Programs at the Brigham and Women´s Hospital Center for Community Health and Health Equity reviews the risk assessment tool used by Passageway and describes how it has been used to successfully help patients in abusive relationships.”
High risk Situation: Pregnancy

Pregnancy can be one of the triggers for violence within a couple. 30 % of physical partner abuse begins in pregnancy, and in 13 % of the cases it aggravates and intensifies previously initiated episodes of violence.

Specific risk factors during pregnancy include:

  • the fact that it is an unwanted pregnancy, especially if it arises at a young age
  • isolation and poor supportive relationships by the family and friends during pregnancy

For general risk factors (applicable also in the case of pregnancy), please click here.

The consequences of domestic violence in pregnancy may include an increased risk of miscarriage, preeclampsia, preterm births and stillbirth. It is also possible for the partner to coerce the woman to carry the pregnancy (known as “reproductive coercion“). In such cases, issues like self-induced, amateurish termination and the absence of prenatal bonding may arise.

Precisely pregnancy and childbirth can foster greater contact between the woman and health care personnel, thus can provide her with an opportunity to bring out the suffering related to domestic violence and to be able to formulate a request for help.

Possible indicators that should lead doctors and midwives to suspect situations of violence  can be found in module 2.

7. Surgery and Emergency Room

In the surgery and emergency room setting, risk assessment is particularly crucial as physical violence has already occurred, placing these cases in the high-risk category.

Case study – Risk assessment and safety planning the emergency room

In module 4, you read the case study of Robin, a 36-year-old man, who arrived at the emergency department with a head injury and multiple hematomas on his left arm, as well as bruises in various stages of healing. He was accompanied by his sister, who assumed a controlling role during the examination, answering questions on his behalf and closely monitoring interactions with the physician. Robin avoided eye contact and appeared hesitant to share information independently.

Further inquiry revealed inconsistencies between the story provided by Robin’s sister and the observed injuries. Robin displayed submissive behaviour and exhibited a palpable fear of physical contact. These signs raised concerns about potential domestic violence. During a private conversation with the attending physician, Robin opens up.

Doctor: Robin, I want you to know that you’re in a safe space here, and anything you tell us will be kept confidential. It’s important for us to understand the full picture so we can provide the best care for you.

Robin: (after a pause) Well, um, actually… I’ve been having some problems at home.

Doctor: I’m sorry to hear that. It’s not easy to talk about, but it’s important to address these issues. Are you feeling safe at home?

Robin: (shakes his head) Not really. I’m afraid things might escalate.

Doctor: Okay, thank you for sharing that with me. We’re here to support you. Let’s talk about some safety planning strategies we can put in place to help keep you safe. Have you thought about where you could go if you need to leave the house quickly?

Robin: (nods) Yeah, I have a friend I could stay with for a while.

Doctor: That’s a good start. It’s important to have a plan in place so you know where to go if you need to leave quickly. Next, let’s talk about who you can reach out to for support. Do you have someone you trust, like a friend or family member, who you can confide in?

Robin: Yeah, I can talk to my brother.

Doctor: That’s great. Having someone to talk to can make a big difference. Now, Robin, I need to ask you some questions to better understand what happened. Can you tell me about the events leading up to your injuries?

Robin: Um, it’s kind of complicated. I got into an argument with my sister, and things escalated…

Doctor: I see. Can you tell me more about the argument? Was there any physical violence involved?

Robin: Yeah, my sister got angry and started hitting me. It’s not the first time it’s happened.

Doctor: I’m sorry to hear that, Robin. It’s important for me to understand the frequency and severity of these incidents. How often does this kind of violence occur, and have you sustained any injuries in the past?

Robin: It’s been happening on and off for a while now. Sometimes it’s just yelling, but other times it gets physical. I’ve had bruises and cuts before.

Doctor: Thank you for sharing that with me, Robin. It’s crucial for us to assess the level of risk you’re facing and determine the appropriate support and resources. Are there any specific triggers or patterns that seem to lead to these incidents?

Robin: It’s hard to say. It’s like walking on eggshells sometimes. Anything can set my sister off.

Doctor: I understand. It sounds like you’re dealing with a lot of stress and uncertainty. I want you to know that you’re not alone, and there are people who can help you navigate through this difficult situation. Have you considered reaching out to any support services or counseling resources in the past?

Robin: Not really, but I’m open to it.

Doctor: That’s good to hear, Robin. I can provide you with information about local support services and counseling options that specialise in domestic violence. It’s essential to have a support system in place as you navigate through this challenging time. Would you like me to connect you with these resources?

Robin: Yeah, I think that would be helpful.

Doctor: Okay, I’ll make sure to provide you with that information before you leave today. In the meantime, if you have any questions or concerns, please don’t hesitate to let me know. Your safety and well-being are our top priorities.

Tasks for reflection:

(1) Think about the safety planning strategies discussed by the doctor. Evaluate their effectiveness in empowering Robin to take steps to protect himself from further harm.
(2) Consider the doctor’s use of open-ended questions to encourage Robin to share his experiences. Reflect on how this approach helps to uncover important details about the situation.
(3) Evaluate the importance of assessing the frequency and severity of domestic violence incidents in determining the level of risk faced by the victim. Consider how this information informs the development of safety plans and access to support services.

8. Paediatrics

Children and adolescents with disabilities have a 3- to 7-fold increased risk of neglect, abuse, and sexual violence

42

Higher risk of becoming a victim of domestic violence: 54

  • Children with motor developmental delays and only mild intellectual developmental delays.
  • Children and adolescents with sensory perception impairments thus have a 7.5-fold increased risk.
  • Children with behavioural problems such as Attention Deficit Hyperactivity Disorder (ADHD) have an increased risk. Particularly affected are children under six years old from low-income families.
  • Chronically ill children have a 2- to 3-fold increased risk.
  • Children and adolescents with disabilities have a 3- to 7-fold increased risk.
  • Children younger than 4 years of age 55
  • Children with special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses) 56

It is crucial to have sensitive conversations about domestic violence with children and youth because they are often deeply affected by such experiences, whether directly or indirectly. By providing age-appropriate information and support, we can empower them to understand what domestic violence is, recognise unhealthy behaviours, and seek help if needed. For further information see module 3.

Please click on the crosses in the illustration to see further information:

Sources: 57, 58,59, 60, 61, 62

Spotlight on Dentistry

9. Dentistry

It is important for dentists to have skills in risk assessment and safety planning in order to better assess the risk of those affected by DV and provide adequate support.

Case study – Risk assessment and safety planning in the dental practice

You already met Mrs. Miller in module 3 and module 4.

We recall that she came to the dental practice because of toothache. During treatment, the dentist noticed several haematomas and periorbital petechiae. When an X-ray was taken, a fracture of the jaw was also diagnosed. Mrs Miller subsequently agreed to the forensic documentation and explained how the injuries had occurred. As the treatment of the broken jaw included several treatment and check-up appointments, Mrs Miller built up a relationship of trust with her dentist.

When Mrs Miller came for her final check-up several months later, the dentist noticed new injuries. She documents the new injuries and uses them as an opportunity to talk to Mrs

Dentist: “Mrs Miller, how are you doing? A few months ago, we had talked about your situation at home. Is everything better at home now? I can see new injuries on your ear and forehead.”

Mrs Miller (hesitating): “It’s… complicated. The situation hasn’t really improved. The arguments with Martin keep coming back.”

Dentist: “I’m sorry to hear that you’re still having issues at home. Are there circumstances that seem to trigger the violence?”

Mrs Miller: “Yes…Martin always gets angry when I try to make contact with others, whether I’m talking to our neighbour or on the phone.”

Dentist: “What happens when your partner gets angry?”

Mrs Miller: “He can no longer control his own anger and sometimes gets violent.”

Dentist: “Has he been getting angrier and angrier more often recently and are the outbursts of anger becoming more violent?”

Mrs Miller: “Yes, when I think about it… it’s been happening more often recently. It’s getting more violent too… He even threw a plate at me once and it gave a big bruise in my face.”

Dentist: “I’m worried about you, because from what you’ve told me, the frequency and extent of the violence against you is increasing. Do you have a trusted person you can talk to?”

Mrs Miller: “After I had moved to another house, I lost contact with almost all my friends and family. I only speak to my sister regularly on the phone, for example when Martin is at work. She lives 30 minutes away from here.”

Dentist: “That’s good to hear. I would now like to talk to you about what you can do if you no longer feel safe at home. It is important that you have a place where you can go if the situation escalates. This could be your sister, for example. You should also consider leaving a rucksack with copies of your most important documents, such as your birth certificate and passport, with her.”

Mrs Miller: “I have to let that sink in first, because I don’t feel unsafe at home at all. Martin just gets very angry with me sometimes and it’s always my own fault.”

At the end of the conversation, the dentist emphasises once again that it is never okay to hurt someone else, even if you are angry, and that Mrs Miller is not to blamed for the situation. She tells her that it is very important to think about where she could go if she gets scared at home and that Mrs Miller can contact her at any time with further questions. She gives her a special business card, which contains important telephone numbers for such situations.

Tasks for further reflection:

(1) What communication strategies does the dentist use?
(2) What specific risk factors can the dentist identify that might point towards a further increase in the severity of violence?
(3) Why is it important for dentists to have skills in risk assessment and safety planning?
(4) How could the dentist continue to help her patient?

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