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Domestic Violence

NHS Trust at a Child Health Surveillance Course run and organised by the London Care & Training Council, London.

Subsequent to being posted here on this website it has been extensively quoted in a training pack produced and distributed by Barnsley TV which is available from their website at www.barnsleytv.co.uk/btv/domestic.htm

Domestic violence refers to physical, sexual or emotional violence from an adult perpetrator directed towards an adult victim in the context of a close relationship.

The impact which domestic violence has will vary from person to person, but there is growing evidence to confirm that it does have serious and long lasting consequences on the health and well being of the individual.

Consideration must also be given to the wider consequences beyond the individual involved and could relate to children and other relatives.

1996 - The World Medical Association state that doctors have an important role in the PREVENTION and TREATMENT of family violence.

1996 - Annual Report - Chief Medical Officer for England and Wales states that domestic violence has considerable implications for the NHS in particular Accident and Emergency Departments, Primary Care and in specific settings such as Maternity Services and Child Adolescent Mental Health Services.

Effective intervention and support early on is crucial because the severity of the violence has been found to escalate over time.


Prevalence

Sadly many incidents of domestic violence are unreported, not recorded or not prosecuted; therefore domestic violence is often described as a 'hidden crime'.

British Crime Survey (BCS) 1996 - "Domestic violence accounted for one quarter of all violent crimes." Domestic violence is more likely to result in injury than any other violent crime.

BCS is believed to be a most reliable estimate of the prevalence of domestic violence, as information relates to experiences of crime over the last 12 months, including unreported crimes. The focus is however only upon physical violence rather than the broader experience of violence, abuse and sexual violence over the life span and therefore there is a tendency to underestimate the prevalence of the experience of domestic violence.

Other surveys for example, which include sexual violence and a broader range of abuse indicate that domestic violence affects 1 in 4 women at some time in their lives

   •    clear gender pattern to violent crime.
   •    90% male perpetrator assaults are on a female partner or ex-partner.
   •    Women most at risk of domestic violence are younger women below the age of 40yrs (44% of all violent attacks are the result of domestic violence).
   •    Women with children, especially women aged between 16-29 years are most at risk of domestic violence.
   •    Men who are victims of violence are most at risk from other men 'outside' the home.
   •    Male to male acquaintance violence accounts for 50% of all violent attacks on men.


Alcohol, drug dependency and domestic violence

The BCS found that apart from muggings, it was less likely for domestic violence offenders to be under the influence of alcohol or drugs than for other contact crimes.

   •    There is a lack of evidence to support the conclusion that these are the sole or primary causal factors for violent behaviour.


The Impact of Domestic Violence upon Health

Physical injury - Physical violence is typically ongoing and repeated and the range of injury wide. Sites of physical injury are 13 times more likely to be breast, chest or abdomen.

Pregnancy is a time when abuse may start or escalate. Estimates report from 0.9% - 20%.

Injuries in the Northern Ireland study included:
   •    Placental separation
   •    Foetal fractures
   •    Ruptured uterus
   •    Pre term labour
   •   Poor diet and restricted access to ante natal care

Women may be at even higher risk in the post partum period and also after a miscarriage.  Low birth weight babies are more common in abused women.


Sexual Abuse - Violence is often directed at the genitalia and can be accompanied by sexual acts and assault including rape and buggery. Health care professionals should be aware and recognize that rape victims may experience 'Rape Trauma Syndrome' after assault. i.e. short term disbelief and shock and longer term anxiety and depression.


Psychological effects - may include depression, anxiety, fear, shame, post traumatic stress disorder and suicide. These effects may be serious and have Long lasting consequences for the well being and self-esteem of women and children.

Stark and Flitcraft (1996) found that women who had been abused were:
   •    15 times more likely to abuse alcohol
   •    9 times more likely to abuse drugs
   •    3 times more likely to be diagnosed as depressed or psychotic
   •    5 times more likely to attempt suicide.



Identifying Domestic Violence in Health Care Settings

Why do many patients who experience domestic violence go undetected in health care settings?
Research in Canada, United Kingdom and Australia in Primary Health Care settings indicate that the reasons why doctors largely do not identify women who have experienced domestic violence include:

   •    Doctors' fears or experiences of exploring the issues of domestic violence
   •    Lack of knowledge of community resources
   •    Fear of offending the woman and jeopardising the doctor-patient relationship
   •    Lack of time
   •    Lack of time
   •    Lack of training
   •    Infrequent patient visits
   •    Unresponsiveness of patients to questions
   •    Feeling powerless, not being able to fix the situation

Also the medical model of care may well have a significant impact on how often domestic violence is identified as well as doctors' subsequent response. Patients are placed in a diagnostic category for which there is a defined treatment.

Research indicates that in A&E departments the problem of ongoing domestic violence was identified in the discharges of only 1 in 52 cases in which abuse was explicit or strongly indicated. In three-quarters of these cases the doctor failed to record the relationship of the assailant to the woman.


Women's views of doctors:
The numbers of women who approach their Doctor and disclose domestic violence varies from study to study.
helpful responses included
   •    Listening
   •    Being sympathetic
   •    Offering appropriate advice
 
Unhelpful responses included
   •    Not listening
   •    Unsympathetic, hurried attitude
   •    Prescribing antidepressants


A Gender Issue?
Studies indicate that it is the knowledge, understanding and sympathetic attitude shown by the doctor, rather than their gender that makes a difference in disclosing domestic violence.

Women attending GP's surgeries were more likely to disclose abuse to their health visitor, although it is unclear whether this was related to the fact that health visitors were more likely to be female, or to their different approaches to the woman.

Overall when a woman seeks help from statutory agencies, the GP is likely to be high up the list of those approached


Should all patients be asked about domestic violence?
A large number of American guidelines recommend that the doctor should routinely ask all women direct, specific questions about abuse. Recognition of the significance of domestic violence as a widespread, often hidden, health problem and evidence can justify this and also the important reason why women do not discuss the issue 'because they are not asked'.

British guidelines implemented in health care settings are not common and tend to shy away from recommending routine questioning, instead preferring to suggest that doctors and others should maintain a high level of awareness and ask if the clinical presentation is suggestive of violence.

The BMA's view is that until evidence can clearly point to the most effective practice, doctors should consider what is appropriate for each patient. There should be a greater focus on training and educating doctors.

1994 - 87% of US medical schools devoted some curricular time to dealing with adult domestic violence. In the UK a recent survey of 254 GPs in the Midlands found that 10% had received some training either as an undergraduate or postgraduate level on domestic violence.

More studies may show in time that women patients in the UK would not object to being asked routinely about violence if it is raised in an appropriate sensitive manner.


Communication and Confidentiality

 

Doctors may obtain advice on issues of confidentiality in relation to domestic violence from the BMA Ethics department on 0171 3836286.

No problem arises where patients give informed consent to their information being disclosed to a third party.

Nevertheless, statute, case law and professional guidance recognises that confidentiality may be breached in exceptional cases and with appropriate justification. The GMC in its guidance Duties of a doctor states:

"Disclosure may be necessary in the public interest where a failure to disclose information may expose the patient, or others, to risk of death or serious harm. In such circumstances you should disclose information promptly to an appropriate person or authority".

Ideally the doctor should first discuss this with the patient and explain his or her reasons for taking such action. Attempts should be made to seek the patient's approval and the doctor should ensure that the patient will not be put at risk if a disclosure is made.


Disclosure where a child or other vulnerable person is at risk
On occasions. doctors may become aware or suspect that somebody, such as a child or other vulnerable person, living with the victim is also at risk of abuse. In this situation, the interests of that person are of paramount consideration, but the confidentiality owed to the victim cannot be disregarded. Nevertheless, knowledge or belief of abuse and neglect of a child or incapacitated adult is one such exceptional circumstance that will usually justify disclosure to an appropriate, responsible person. The GMC states that:

"If you believe a patient to be a victim of neglect or physical or sexual abuse, and unable to give or withhold consent to disclose, you should usually give information to an appropriate responsible person or statutory authority".

It is particularly important in the context of domestic violence that the patient is involved in all stages of the decision making process, and that they retain as much control as possible over disclosures of information.


Advice on good practice for identifying and dealing with domestic violence


Suggested seven step approach features:

   •    Privacy and confidentiality
   •    Questioning
   •    Respect and validation
   •    Assessment and treatment (medical and of the safety of the individual)(With the patient's consent, making necessary referrals)
   •    Record keeping and concise documentation
   •    Information giving
   •    Support and follow tip

Examples of questions to assist in identifying and acknowledging that domestic violence is occurring could include:

   •    Do you ever feel afraid of your partner?
   •    Has your partner or ex-partner ever physically hurt or threatened you?
   •    Has your partner ever destroyed things that you cared about'?
   •    Has your partner ever threatened or abused your children?
   •    Has your partner ever forced you to have sex?
   •    Has your partner ever prevented you from doing things - for example leaving the house, seeing friends etc?

Local information to be provided

   •    Branches of national organisations (London Women's Aid)
   •    Police Station (Domestic Violence Unit)
   •    Access to emergency housing (District Housing Officer)
   •    Organisations giving legal, advice/solicitors
   •    Citizens Advice Bureau (CAB)
   •    Department of Social Security
   •    Organisations willing to help children
   •    Community Health Councils
   •    Support/counselling groups
   •    Alcohol groups
   •    Organisations for specific community groups
   •    Organisations for men willing to receive help for their violent behaviour


Adopting An Inter-Agency Approach

Inter-agency initiatives on domestic violence have a great deal to offer GP's and health service providers, particularly in terms of training opportunities, information of support groups, resources and referral agencies, guidance on policy and best practices including anti-discriminatory methods of working.


Legal Advice:
It is recommended that primary health care teams should hold a brief, up to date contact list for referral purposes.


Court Orders' for personal protection and occupation of the home:
Part IV of the Family Law Act came into force on 1 October 1997. Adults who experience domestic violence can apply to the court for an order which prohibits any further violence or 'molestation' and in some cases, for an order regulating occupation of the family home.

Non-Molestation Orders prevent the perpetrator from molesting the partner and/or any relevant children. (Undertakings)

Occupation Orders can regulate occupation of the home by permitting a person who has been thrown out of the home re-entry or by excluding the perpetrator from the home temporarily or for a longer period of time.


Involving the Police:
If the police are called, the woman's main motive is often to stop the violence, rather than to prosecute her partner. Women may also be fearful that if the police become involved then social services will be notified and they may risk 'losing' their children. If the police are called to a domestic violence incident, their main responsibility is to protect the victim and any children from further violence and to arrest the assailant if there has been an offence.


Child protection and domestic violence:
GP's and other members of the primary health care team have an important role to play in the prevention, identification and subsequent management of child abuse. The links between domestic violence to the mother and abuse of the child are increasingly being acknowledged by child protection agencies and many local child protection manuals and procedures offer guidance on this matter. Support and protection to the mother is increasingly being recommended as a most effective child protection strategy where there is domestic violence.


Children and Domestic Violence

 

A Training Imperative!

   •    That domestic violence is also a child protection issue has been relatively slow in gaining professional acceptance, in spite of numerous inquiries.
   •    The Farmer and Owen (1995) study Child Protection Practice: Private Risks and Public Remedies found that in three out of five cases where children had suffered physical abuse, neglect or emotional abuse, the mothers' were also subject to violence from their male partners.
   •    Domestic violence was a feature of most of the cases with the worst outcomes and, most worrying of all, professionals were found to give little attention to the fact that children were witnessing and living with high levels of violence.
   •    There is also growing research evidence emerging from forthcoming study by Professor Skuse, Institute of Child Health, that boys who become abusers are highly likely to have been exposed to domestic violence in their early years.
   •    Why has it taken so long for the impact of domestic violence on children to be widely recognised?
   •    Why, when there is awareness, there still appears to be a reluctance to act?

The impact which domestic violence has upon children varies from child to child. Children will be affected differently because their own resources and capacities to cope will vary. Having a good relationship with one caring parent (usually the mother), a supportive relationship with other significant adults, friends or relatives may also help the child to cope with witnessing and living through domestic violence.

   •    Where there is domestic violence to the mother there is an increased risk that there will also be physical or sexual violence to the child
   •    In households where there are children present, most domestic violence incidents are witnessed by children (75-90%)and they are significantly affected by it
   •    Witnessing domestic violence can cause considerable short term and long term harm
   •    The parenting capacity of women who are intimidated and abused by their partners can he seriously impaired, and as a result they may be unable to meet their basic children's needs. The 1990's have seen a growing awareness of domestic violence and its impact on women thanks largely to the work of Women's Aid.
   •    In the short term both boys and girls may show a range of disturbed behaviour including withdrawal, depression, increased aggression,, fear and anxiety.
   •    The signs children show vary in relation to their ages, gender and development
   •    Children may blame themselves for the violence or take on responsibility to 'manage' the violence or to protect their mother and siblings
   •    Barriers may try to involve the children in the abusive behaviour, compounding the child's feelings of guilt and sometimes affecting the relationship between child and mother.
   •    Children are especially vulnerable to abuse or manipulation by the father during poorly supervised contact meetings after the parents have separated.
   •    Domestic violence may affect the mother's capacity to parent
   •    The poverty and residential insecurity many families living through domestic violence face can adversely affect children's welfare, social networks, education and emotional security.


Reasons for 'In action'

The perpetrator's behaviour may fluctuate between extremes
   •    Domestic violence is difficult to report due to the emotional relationship between the victim and the perpetrator
   •    The perpetrator's behaviour may fluctuate between extremes
   •    Fear of reprisals
   •    A tendency to minimise rather than exaggerate the violence and hide it from families and friends
   •    Pressure from the family/local community to remain in the relationship
   •    Worry about the effect on their children whether they stay or leave
   •    Worry about the effect on their pet(s) whether they stay or leave
   •    Financial dependence upon their partner
   •    Not knowing of a safe place to go or the sources of help and advice available
   •    A less than helpful response from those agencies to whom they may have turned to for help
   •    Repeated abuse may undermine a woman's confidence in her ability to take decisions and act


Further Reading

Domestic Violence: A resource Manual For Health Care Professionals
Domestic Violence: A Resource Manual for Health Care Professionals has been launched by the Department of Health to give health care professionals the skills, knowledge and confidence to identify domestic violence and to respond appropriately to help break the cycle of repeat victimisation.

The manual offers a foundation for local work and provides factual information to help raise awareness about domestic violence, including a listing of useful national contacts, support agencies and websites. It also offers a good practice approach for dealing with domestic violence and for developing a local multi­agency response which should be adopted and supported by managers throughout the health service: in hospital, community and primary care settings.

Loose-leaf copies (which enable local material to be inserted) are available free of charge from: OH Publications, PO Box 777, London SE1 6XH Fax 01623 724 524; Email doh@prologistics.co. uk

The manual is available on the DH website at www.doh.gov. uk/domestic.htm, linked website www.homeoffice.gov.uk/domesticviolence

For further information contact: Elizabeth Connell, Room 514, Wellington House, 133-155 Waterloo Road, London SE1 8UG. Telephone: 020 7972 4633, Email: elizabeth.connell@doh.gsi.gov. uk

 

Domestic Violence Education Series
Barnsley Television has a produced a series of videos on domestic violence.

'The Domestic Violence Series' is accompanied by a 40-page Domestic Violence Series learning pack, which will be available shortly.

The videos are suitable both for training and raising awareness of the issues surrounding domestic violence which affects one-in-four women in Britain at some stage in their lifetime, as well as one-in-seven men. In the past few years, parts of the statutory sector and the voluntary sector have adopted a multi-agency approach to tackle domestic violence where agencies such as the police, social services and the National Health Service (NHS) among others, are increasingly working together.

The Domestic Violence Series of videos is professionally produced and aims to give an overview of the work of statutory agencies and other professionals who are working at the forefront of domestic violence, as well as give an understanding not just of the scale of the problem but practical solutions on how it is being dealt with.

Whilst the Domestic Violence Series of training videos is aimed principally at those living and working in the United Kingdom, several of the interviews are relevant anywhere in the world. Please contact Barnsley TV for further information if you are not based in the United Kingdom.



Resources

Women's Aid
Women's Aid is the national domestic violence charity that co-ordinates and supports an England-wide network of over 500 local services working to end domestic violence against women and children.

Women's Aid websites for women and children:

www.womensaid.org.uk
www.thehideout.org.uk


Refuge
Refuge is the country's largest single provider of specialist accommodation and support to women and children escaping domestic violence. Refuge provides safe, emergency accommodation through a growing number of refuges throughout the country and offers individual and group counselling for abused women and children, and community based outreach services for women including specialist services for minority ethnic communities.

www.refuge.orq.uk


Specialist help lines

Jewish Women's Aid

Southall Black Sisters
A not for profit organisation established in 1979 to meet the needs of black (Asian and African-Caribbean) women.

Imkaan
National charity specialising in domestic violence, especially asian women.

www.stoplookqo-everqreen.orq.uk


Other useful numbers

Samaritans

The National Child Protection Helpline
This is a free, confidential service for anyone concerned about children at risk, including children themselves run by the NSPCC. The service offers counselling, information and advice