GPs involved in obstetric or shared antenatal care need to be aware that pregnancy is a risk factor for intimate partner abuse. Evidence suggests that four to nine women in every 100 pregnant women are abused.44
We ask pregnant patients about smoking, alcohol and breastfeeding, and we also need to screen for intimate partner abuse.3,2
For many women, pregnancy and the post partum period exacerbates the violence and threats within their relationship.45 For some, pregnancy may even provoke it. A violent and jealous partner may resent the pregnancy because he is not prepared to ‘share’ her. There may be financial or sexual pressures, which are compounded by the pregnancy.
Abused pregnant women are twice as likely to miscarry than non-abused pregnant women. An abusive partner will often target the breasts, stomach and genitals of their pregnant partner.3 Often the abuse will start with the first pregnancy, and as a result the woman may avoid prenatal check-ups. Women who do not seek antenatal care until the third trimester should raise suspicion.
Consider asking about intimate partner abuse in the antenatal period.3
Aboriginal and Torres Strait Islander peoples
Aboriginal and Torres Strait Islander victims of violence include men, women and children, but women are the predominant victims of intimate partner abuse.46 The most vulnerable age group is 15–24 years followed by 25–34 years and 35–44 years – the risk for being a victim of Aboriginal and Torres Strait Islander family violence decreases after the age of 45.46 One factor alone cannot be singled out as the ‘cause’ of family violence, but research has found that the strongest risk factor for being a victim of violence as an Aboriginal and Torres Strait Islander person is alcohol use. Other factors include being removed from one’s family, single parent families and financial stress ( refer to Chapter 11 ).47
Gay, lesbian, bisexual and transgender people
Diverse sexual orientations and gender identities require specific knowledge and skills of the GP.48 It is particularly important for us to understand the impact of societal homophobia, biphobia and transphobia (prejudice against gays and lesbians, bisexual, and transgender people respectively) on this group of people. Homophobia, biphobia and transphobia commonly manifest in abuse and violent outbursts towards gay, lesbian, bisexual and transgender (GLBT) people. This ranges from victimisation of same-sex-attracted young people at school, to harassment in the workplace and violence in public places. In an Australian population-based sample, 63% of lesbian and bisexual women reported lifetime abuse as compared with 37% of heterosexual women.49 Experiences of such violence, and the pervasive fear of assault, have a negative impact on the mental and physical health of GLBT people. It can lead to the need to conceal their sexual orientation or gender identity to reduce the risk of violence. It can also lead to non-disclosure within consultations, as the patient cannot predict the attitude of the health practitioner.
There is a predominant assumption in society that violence within same-sex relationships does not exist, or that it is not as confronting as violence within heterosexual relationships. Also present is the assumption of ‘mutual combat’, implying that violence is reciprocated or, at the very least, the victims are able to defend themselves because they are of the same gender. These statements are sometimes true, but if so, victims may question their victim status if they responded with violence, and may feel guilty for having participated in a violent way. Conversely, they may berate themselves for not defending themselves.
Emerging evidence from population-based studies indicates that there are no differences in the prevalence, type or severity of abuse between same-sex and opposite-sex couples; and in one study women survivors of same-sex domestic violence were twice as likely than those with male perpetrators to have poor self-perceived health status.50 This poor health status may be due, in part, to a reluctance to report the violence due to fears of triggering a negative response from services.51 The result of the relative invisibility of same-sex intimate partner abuse is that GPs do not consider it, and do not ask about it.
Cultural sensitivity can encourage disclosure of sexual orientation and gender identity, and therefore related experiences of violence. This can be communicated to GLBT people within the general practice setting in the following ways:52,53
- waiting areas – displaying materials specific to GLBT people including a rainbow flag sticker and specific information pamphlets on local services and support groups
- staff training – ensuring that all staff are trained not to make assumptions about the gender of patients and their partners, and to be aware of other forms of heterosexism
- practice policy – including anti-discrimination statements specific to sexual orientation and gender identity
- communication within the consultation – the use of gender-neutral language when discussing partners, being openly non-judgemental about different lifestyles, and being willing to ask direct questions about the possibility of abuse and discrimination.
Culturally and linguistically diverse women
The problems for women from a non-English speaking background are often compounded by social isolation, language barriers, the migration experience, cultural differences and for some, their religious beliefs. They may be less aware of the resources that exist within the community and how to access them. They may also need help in their own language and support that is culturally appropriate. Migrant women often feel economically and socially marginalised and need support to seek services and to understand the Australian legal system (refer to Chapter 12 ).