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White Book

Chapter 1

What is interpersonal abuse and violence?

‘GPs don’t need to be afraid that they don’t have enough training in DV, what is so important is to listen and ask questions like "what can I do for you" or "how can I help".’
Fiona, victim/survivor, The WEAVERs Group

Key messages

  • Interpersonal abuse and violence includes intimate partner abuse/violence (IPAV), the effects of child abuse for adult victims/survivors, sexual assault, child abuse, sibling bullying and elder abuse. Violence is not just physical; it includes emotional, sexual, economic and social abuse, in person or through technology.1
  • Interpersonal abuse and violence is very common, with the main perpetrators of such violence being men, but women can also use abuse and violence.2
  • Abuse and violence is an issue for the whole community. Health practitioners have a role in dealing with these issues and need to play their part in prevention, identification and response.3
Emotional and physical safety are concepts that should be foremost when working with patients experiencing abuse and violence.3 
(Practice point: Consensus of experts)
Health practitioners should have a system in place that includes the whole of practice and referral pathways to safety and healing.3
(Practice point: Consensus of experts)
It is important to receive training that includes reflecting on our own attitudes and assumptions about abuse and violence, as they can affect the way we respond to patients experiencing abuse and violence.3
(Practice point: Consensus of experts)

Welcome to the fifth edition of Abuse and violence: Working with our patients in general practice (White Book). We have added six new chapters since the fourth edition and updated all chapters with the latest evidence on abuse and violence, most of which occurs within the family or by someone the victim/survivor knows.

In this edition we use the term ‘victim/survivor’ for patients who experience abuse and violence and ‘perpetrator’ for patients who use abuse and violence (although we acknowledge these terms are not always preferred by some people).

Chapters are presented under six topics:

  • ‘domestic’ or intimate partner abuse/violence
  • trauma- and violence-informed care
  • children and young people
  • specific abuse issues for adults and older people
  • specific populations
  • system issues.

The World Health Organization (WHO) categorises interpersonal violence into that perpetrated by family, partners, community, acquaintances or strangers across the life course (Figure 1.1).

The White Book focuses on family violence across the life course, which is a broader term than IPAV or child abuse. Family violence also includes any violence or abuse occurring within a family – between, for example, siblings, uncles, aunts, cousins, grandparents and in-laws. The White Book does not address acquaintance or stranger violence to any great extent (apart from sexual assaults by acquaintances and strangers). It also does not cover the large burden of abuse and violence that occurs in global conflict zones, refugee camps and asylum-seeker detention centres.

Figure 1.1. Typology of interpersonal violence<sup>1</sup>

Figure 1.1. Typology of interpersonal violence1

Reproduced with permission from: Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: WHO, 2002. [Accessed 25 August 2021].

The White Book concentrates on the more prevalent form of interpersonal violence – that of violence against women by someone they know. A national survey conducted in Australia indicated both men and women were more likely to experience physical violence than sexual violence. Sexual violence was four times more common for women than men. Adult women were more likely to have experienced violence from someone they knew than by a stranger, while the reverse was true for men. Perpetrators of violence were more likely to be male than female, with one in three Australians experiencing violence by a male perpetrator compared to one in 10 by a female perpetrator.2

In particular, the White Book addresses specific populations, including women with disability, women from culturally and linguistically diverse (CALD) populations, and Aboriginal and Torres Strait Islander women, all of whom may be subjected to a higher prevalence of abuse and violence.2 The complex and cumulative way in which the effects of multiple forms of discrimination (eg racism, sexism and classism) combine, overlap or intersect – especially in the experiences of marginalised individuals or groups – should be acknowledged.

The White Book provides guidance on different types of abuse and violence, as discussed below.

‘Domestic’ or intimate partner abuse/violence

IPAV is any behaviour within an intimate relationship that causes physical, emotional, sexual, economic and/or social harm to those in the relationship.4 It may include a current or former intimate relationship and includes heterosexual, same-sex and gender-diverse relationships. Chapters on this topic are:

Trauma- and violence-informed care

Trauma- and violence-informed care enacts policies and practices that recognise the connections between violence, trauma, negative health outcomes and behaviours. These approaches increase safety, control and resilience for staff who are delivering care and people who are seeking care in relation to experiences of violence and/or have a history of experiencing violence.5 Chapters on this topic are:

Children and young people

Child abuse and neglect includes any type of abuse involving physical, emotional, sexual, economic abuse or neglect of a child under 18 years of age (16 years in New South Wales, 17 years in Victoria). It may include children exposed to IPAV. Chapters on this topic are:

Specific abuse issues for adults and older people

  • Adult survivors of child abuse are adults who experienced physical, sexual or emotional abuse or neglect during their childhood or adolescence. Refer to Chapter 13: Adult survivors of child abuse
  • Sexual violence is any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim/survivor, in any setting. This includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object.2 Refer to Chapter 14: Adult sexual assault
  • Abuse of older people is any type of abuse (physical, emotional, sexual, economic) or neglect of a person 65 years of age or over, either in a residential aged care facility, in private care, or living independently. It can be a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. Refer to Chapter 15: Abuse of older people

Specific populations

The White Book also provides guidance on abuse and violence in specific communities:

System issues

The White Book also provides guidance on system issues, notably the law, and education and training:

Abuse and violence can take many forms (Figure 1.2).

Figure 1.2. Forms of abuse and violence

Figure 1.2. Forms of abuse and violence

Source: World Health Organization.3
 

Using the example of domestic violence or IPAV, violence can be severe and leave obvious injuries, but many victims/survivors may be subject to more subtle abuse that may not leave physical injuries. This is sometimes called ‘coercive control’, which can be divided into tactics used to hurt and intimidate victims/survivors (coercion) and those designed to isolate and regulate them (control).6

Coercive control may be defined as an ongoing pattern of domination by which male abusive partners primarily interweave repeated physical and sexual violence with intimidation, sexual degradation, isolation and control. The primary outcome of coercive control is a condition of entrapment that can be hostage-like in the harms it inflicts on dignity, liberty, autonomy and personhood as well as to physical and psychological integrity.6

Women as well as men physically assault their partners. But coercive control is ‘gendered’ because it is used to secure male privilege and its regime of domination/subordination is constructed around the enforcement of gender stereotypes.

This pattern, which may include but is not limited to physical violence, has been variously termed ‘psychological’ or ‘emotional’ abuse, ‘patriarchal’ abuse or ‘intimate terrorism’.7 The major outcome is a hostage-like condition of entrapment that arises from the suppression of a victim/survivor’s autonomy, rights and liberties through coercive control.

Abuse and violence can take many forms in intimate relationships, and is often not recognised as such by the victim/survivor. For example:

‘At the time I felt that it was not really abuse but the longer I thought about it the more that I felt it was abuse. Emotional abuse is more severe than physical abuse as there are no outward marks or bruises. When this was realised by myself, I got out. Living alone is far better than what was happening in the relationship.’

Abuse can occur across all populations and ages, cultures, religious groups and socio-economic groups. What is common is that all of them involve an abuse of power. The next section illustrates how a partner uses power.

‘So if I argue with my partner and we push each other around, that’s intimate partner abuse?’

Not always. Some couples have arguments that may involve some physical contact without an imbalance of power in the relationship. Generally, IPAV occurs where one partner is being abused by the other partner and because of a power imbalance in their relationship, the victim/survivor lives in fear of being exposed to that abuse again (Figure 1.3). Fear experienced by the abused partner may be constant or episodic and is often used by the perpetrator to control the victim/survivor. Regardless of the frequency with which abuse occurs, it is still abuse.

Many IPAV victims/survivors say that arguments did not precede the violent episodes or that the perpetrator often provoked the confrontation deliberately.

Figure 1.3. Intimate partner abuse

Figure 1.3. Intimate partner abuse

Power imbalance in an abusive relationship

Abuse and violence more generally may be any of the following:

  • Physical abuse – injuries may range from minor trauma, which may or may not be visible, to broken bones and lacerations, non-fatal strangulation, head injuries and injuries to internal organs. For many victims/survivors, the abuse occurs regularly. Some are threatened with weapons, such as knives, or household items such as a hot iron, cigarettes or a length of rubber hose. Physical abuse can take many forms such as smashing property and killing or hurting family pets.
  • Emotional/psychological abuse – may include subtle or overt verbal abuse, humiliation, threats or any behavior aimed at scaring or terrorising the person experiencing the abuse. The victim/survivor may lose their confidence, self-esteem or self-determination. Emotional abuse can take many forms including threats of suicide, extreme jealousy, and stalking or harassment at work or through the use of technology. This may also include coercive control, a pattern of acts which aims to cause fear through manipulation and controlling behaviours.
  • Economic abuse – restricting access to money and essential needs, fraudulently using another’s money for personal gain, or stealing from the victim/survivor; the illegal taking, misuse or concealment of funds, property or assets.
  • Social abuse – isolating the victim/survivor from family and friends, and other contacts in the community. This may form part of coercive control.
  • Neglect – the persistent failure to meet the basic physical and/or psychological needs of a person for whom you are caring, such as failing to protect from physical harm or danger, or failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, the other person’s basic emotional needs.
  • Spiritual abuse – abuse related to a person’s beliefs; can include the misuse of power under the guise of religious belief.

Society condones violence in overt and subtle ways by failing to recognise and acknowledge that IPAV, child abuse, sexual assault and elder abuse exist. We turn a blind eye to family abuse and violence, preferring not to be involved, believing it to be a private family matter. This has been described as a ‘conspiracy of silence’. Unfortunately, this has meant the problem often seems to be no-one’s responsibility.

Other factors influence community responses:

  • We expect the family to nurture, protect, guide and provide refuge for all its members.
  • Family violence forces us to acknowledge that for some families this is not the case and that, for many victims/survivors, the greatest danger lies in the home itself.8
  • As a community, we believe that the family is the building block of our community and our nation. The existence of family violence challenges our sense of security.
  • The high level of violence we tolerate as a society – for example, in some sports, in film and television – can be seen as normalising this behaviour.
  • The broader context of community gender norms of discrimination against women and men controlling women’s behaviour.

The WHO endorses an ecological multidimensional framework of risk factors for family violence (Figure 1.4). A society that endorses rigid gender roles or male entitlement and ownership of women, and communities that experience high rates of unemployment, poor health, overcrowding, alcoholism and few support services are most at risk. Male dominance within the family, male control of wealth, use of alcohol and marital conflict can be risk factors in relationships, while experiencing abuse as a child or witnessing abuse as a child can be individual risk factors.9

Figure 1.4. Factors associated with violence<sup>10</sup>

Figure 1.4. Factors associated with violence10

Reproduced with permission from: Heise LL. What works to prevent partner violence? An evidence overview. London: STRIVE Research Consortium, 2011. 

There has been an increase in understanding throughout the Australian community about violence towards women over time. Concerningly, young people within the Australian community have a lower level of understanding of violence against women than those aged 25 and over. The 2017 National Community Attitudes towards Violence against Women Survey11 explored attitudes towards violence in Australia. The strongest predictors for holding violence-supportive attitudes were having low levels of support for gender equity or equality, low levels of understanding about violence against women and high level of support for violence in general. Men were more likely to hold violence-supportive attitudes than women.

Attitudes regarding sexual assault:

  • 95% of people agreed that forced sex is violence against women.
  • 14% of men believed that women often say ‘no’ when they mean ‘yes’.
  • 28% of people believed ‘rape results from men being unable to control need for sex’.
  • 32% of men believed that women who had been raped had led a man on and then had regrets.

Attitudes regarding IPAV:

  • 34% of people believed that female victims/survivors were partly responsible for continuing abuse if they did not leave.
  • 19% of people believed domestic violence could be excused if the perpetrator later regretted what they had done.
  • 16% of people regarded domestic violence as a private matter.
  • 20% of men believed that domestic violence is just a normal reaction to day-to-day stressors.

In this community survey, women were more likely than men to be aware that IPAV could consist of both psychological and physical abuse. Women were much more likely to believe that violence towards women was common (78% compared with 57%).11

Any form of abuse and violence has implications for the health of our patients, both physically and emotionally. Health outcomes may also be affected by the quality of care received, which in turn will affect the health of the entire family. Recent research shows that children who live in abusive families experience negative effects on their health, wellbeing and ongoing relationships.12

Failure to acknowledge the reality of trauma and abuse in the lives of children, and the long-term impact this can have in the lives of adults, is one of the most significant clinical and moral deficits of current mental health approaches. Trauma in the early years shapes brain and psychological development, sets up vulnerability to stress and to a range of mental health problems.13,14 GPs need to understand the nature of violence and abuse so that they can help break this intergenerational cycle of abuse.

The role of primary care includes all the following points to address family violence across the lifecycle:

  • identifying predisposing risk factors
  • noting early signs and symptoms and asking directly
  • assessing for violence and safety within families
  • managing consequences of abuse to minimise morbidity and mortality
  • knowing and using referral and community resources
  • advocating for changes that promote a violence-free society.

Health practitioners need to understand the eight steps to intervention – the 8 Rs (Tool 1.1).
 

Tool 1.1. Eight steps to intervention – the 8 Rs

  • Be ready to identify and respond to intimate partner abuse
  • Recognise symptoms of abuse and violence, ask directly and sensitively
  • Respond to disclosures of violence with empathetic listening
  • Explore risk and safety issues
  • Review the patient for follow-up and support
  • Refer appropriately
  • Reflect on your own attitude, management and limitations to addressing abuse and violence
  • Respect your patients, your colleagues and yourself. This is an overarching principle of this sensitive work.

A recent systematic review15 exploring health professionals’ readiness to address domestic violence provides some insight into areas which you could concentrate on to enable this complex work. Five themes are identified in the CATCH (Commitment/Advocacy/Trust/Collaboration/Health system) model (refer to Figure 1.5):

  • having a personal commitment from human rights, child rights or a feminist lens or personal experience
  • adopting an advocacy or LIVES (Listen, Inquire, Validate, Ensure safety, Support) and CARE (Consider, Acknowledge, Respond, Empower) approach with feedback from patients to reinforce this approach
  • trusting the relationship in the health setting is the right place to address the issue
  • collaborating with a team such as the family violence worker – follow up with them recommended
  • being supported by the health system, including utilising Medical Benefits Schedule (MBS) item numbers such as those for mental health care treatment plans and antenatal attendance, booking double follow-up appointments, and secondary consults from family violence services and clear referral pathways.
Figure 1.5. CATCH model<sup>15 </sup>

Figure 1.5. CATCH model15

Reproduced from: Hegarty K, McKibbin G, Hameed M, et al. Health practitioners’ readiness to address domestic violence and abuse: A qualitative meta-synthesis. PLoS One 2020;15:e0234067.

Resources available nationally and in your state.

  1. Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet 2002;360:1083–88.
  2. Australian Bureau of Statistics. Personal Safety Survey. Canberra: ABS, 2017.
  3. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
  4. World Health Organization. Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO, 2013.
  5. Government of Canada. Trauma and violence-informed approaches to policy and practice. Government of Canada, 2018 [Accessed 25 August 2021].
  6. Stark E. Coercive control. New York: Oxford University Press, 2007. [Accessed 25 August 2021].
  7. Johnson M. A typology of domestic violence: Intimate terrorism, violent resistance, and situational couple violence. University Press of New England, 2008. [Accessed 25 August 2021].
  8. United Nations Office on Drugs and Crime. Global Study on Homicide: Gender-related killing of women and girls. Vienna: UNODC, 2018. [Accessed 25 August 2021].
  9. Heise LL. Violence against women: An integrated, ecological framework. Violence Against Women 1998;4:262–90. [Accessed 25 August 2021].
  10. Heise LL. What works to prevent partner violence? An evidence overview. Working paper 2.0. 2011 [Accessed 25 August 2021].
  11. Politoff V, Crabbe M, Honey N, et al. Young Australians’ attitudes to violence against women and gender equality: Findings from the 2017 National Community Attitudes towards Violence against Women Survey. Sydney: Australia’s National Research Organisation for Women’s Safety, 2019. [Accessed 25 August 2021].
  12. Kitzmann KM, Gaylord NK, Holt AR, et al. Child witnesses to domestic violence: A meta-analytic review. J Consult Clin Psychol 2003;71:339–52. [Accessed 25 August 2021].
  13. Felitti V, Anda R. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behaviour: Implications for healthcare. In: Lanius R, Vermetten E, Pain C, editors. The impact of early life trauma on health and disease. Cambridge: Cambridge University Press, 2010:77–87. [Accessed 25 August 2021].
  14. Kezelman C, Stavropoulos P. 'The last frontier': Practice guidelines for treatment of complex trauma and trauma informed care and service delivery. Sydney: Adults Surviving Child Abuse, 2012. [Accessed 25 August 2021].
  15. Hegarty K, McKibbin G, Hameed M, et al. Health practitioners' readiness to address domestic violence and abuse: A qualitative meta-synthesis. PLoS One 2020;15:e0234067. [Accessed 25 August 2021].
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