Identifying intimate partner abuse in practice
It is important to consider IPAV in all women, as it is a hidden epidemic that can happen to women from every socioeconomic status, postcode, race, religion and age. Refer to Risk factors for intimate partner abuse in this chapter.
Women can present in many ways, and GPs should have a high index of suspicion for signs and symptoms to inquire about the possibility of IPAV. A large number of health conditions and issues are strongly associated with IPAV (refer to Figure 2.3),5 including physical presentations such as chronic pelvic pain or chronic headaches, obvious injuries and bruises, psychological presentations such as depression or anxiety, and emotional presentations such as anger or irritability (refer to Table 2.2). It is possible that a victim/survivor may show no signs or symptoms at all.
Abuse during pregnancy
Abuse during pregnancy is associated with suboptimal weight gain, preterm delivery and having lower birthweight babies, kidney infections, as well as injuries to the mother and maternal mortality.16 Pregnant women experiencing abuse are twice as likely to miscarry than non-abused pregnant women. Pregnancy and the immediate postpartum period deliver new challenges for a household, including financial issues, stress and sexual pressures. Some partners may become jealous and possessive of their partners as they now have to ‘share’ them with the pregnancy and/or new baby. Often abuse starts in the first pregnancy and may lead to women avoiding antenatal visits. Women who do not seek antenatal care until late in the pregnancy should raise suspicion.
Given the high incidence of IPAV in pregnancy, it is recommended to routinely ask about violence at antenatal visits. GPs who provide antenatal care should inquire about IPAV.
Figure 2.3. Health outcomes associated with different types of intimate partner abuse
Source: World Health Organization.5
|Table 2.2. Clinical indicators of intimate partner abuse
- Obvious injuries
- Bruises at various stages of healing
- Sexual assault
- Sexually transmitted infections
- Chronic pelvic pain
- Chronic abdominal pain
- Chronic headaches
- Miscarriage and stillbirth
- Change in appetite
- Difficulty concentrating and making decisions
- Memory issues
- Anxiety and panic disorder
- Suicidal ideation
- Somatoform disorder
- Post-traumatic stress disorder
- Eating disorders
- Drug and alcohol use
- Poor self-esteem
- Feeling of overwhelm
- Hyper-alertness and hypervigilance
Depression and anxiety
IPAV, including physical, emotional and sexual abuse, is strongly associated with depression in women attending general practice, remaining significant when adjusted for sociodemographic variables and physical health.17 Mental health symptoms are among the strongest clinical predictors of IPAV, and all women should be asked about IPAV as part of a mental health assessment.
In addition to being more likely to experience psychological symptoms, women who are victims/survivors of domestic violence are more likely to experience a range of physical symptoms. In an Australian study in general practice, women who reported a greater number of physical symptoms, like tiredness, chronic headaches, diarrhoea and chronic abdominal pains, were also more likely to have experienced IPAV in the last 12 months.9
Women who experience violence may present with behavioural signs such as delays in treatment, inconsistent explanation of injuries, frequent presentations to general practice, non-compliance with treatment or attendances, and/or an accompanying partner who is overattentive and may answer for the woman.
Post-traumatic stress disorder and complex PTSD
Post-traumatic stress disorder (PTSD) and complex PTSD is a common outcome of being subjected to IPAV. In a 2001 systematic research synthesis, between 31% and 84% of IPAV victims/survivors were found to be experiencing PTSD.18 PTSD occurs when there is exposure to actual or threatened death, serious injury or sexual violence, either by directly experiencing the traumatic event or by witnessing a traumatic event. In many cases of domestic violence, women are repeatedly exposed to trauma, which puts them at risk of PTSD and complex PTSD. Because of this, it is vital that GPs universally respond with a trauma-informed approach to avoid retraumatising victims/survivors. Trauma-informed care focuses on understanding impacts of trauma and creating an environment that promotes emotional and physical safety for all patients.
Traumatic brain injury and family violence
Injuries to the head, neck (including strangulation) and face area are major causes for traumatic brain injury, especially for victims/survivors attending the emergency department.19 Over a decade, 40% of 16,000 victims/survivors of IPAV (including children) attending Victorian hospitals had sustained a brain injury.20 Victims/survivors can present with dizziness and headaches consistent with post-concussive syndrome.21
Presentation of children
Children may experience IPAV in a number of ways. They may see abuse, hear abuse or be aware of the abuse or potential abuse. In households where IPAV occurs it is common for children to witness violence or to be victims/survivors of abuse themselves.22 The ABS Personal Safety survey found that one in 10 men and one in eight women had witnessed violence towards their mother by a partner when they were children (before the age of 15).10 In addition, male to female IPAV has been shown to increase the potential for child abuse perpetrated by both fathers and mothers.11 Child abuse is discussed in Chapter 9: Child abuse and neglect.
Children who are exposed to IPAV may present in the following ways.22,23 Effects may be seen both at home and at school:
- chronic somatic problems and frequent presentations
- aggressive behaviour and language, problems at school
- drug and alcohol abuse
- lower self-worth
- suicidal ideation (adolescents)
- homelessness (adolescents)
- academic failure
- bedwetting, sleeping disorders, stress, behavioural problems (younger children).
Inquiring about abuse
The majority of victims/survivors of IPAV would not object to being asked about domestic violence, but only a minority of women are actually asked. In a Brisbane study, 28% of abused women had told a GP about the abuse, while only 13% had been asked about it by a doctor.14
Raising the issue can be challenging, but women are significantly more likely to disclose if they are asked by their doctor about abuse.24 There is insufficient evidence to support screening for all women (with the exception of antenatal domestic violence screening), so GPs should ask women who present with the psychosocial and physical conditions as outlined in Identifying intimate partner abuse in practice.3
There should be a low threshold for asking about abuse, especially with some typical presentations. For example, in a patient you have seen for years for depression or anxiety, persistent headaches or vague somatic complaints, begin to explore the possibility that they are experiencing abuse or have experienced abuse in the past with general and then specific questions. It may be important that you simply suggest the possibility of a connection between what may be happening at home or in the past and their presenting symptoms.
The gender of a doctor does not affect disclosure, provided communication skills are good.
Health practitioners may inadvertently discourage disclosure by communicating attitudes like, ‘It’s not my role to ask’, ‘Asking will invade her privacy’ or ‘She will not want to leave anyway’.
When asking about possible abuse, ensure that the woman is alone. If she is with her abuser, she will either not disclose, or if she does disclose, it could put her in danger. Ask a woman’s accompanying partner to wait in the waiting room and explain that it is usual for a health practitioner to spend time alone with their patients.
Telehealth has increased the accessibility of health professionals for victims/survivors of IPAV; however, it is not always possible to be certain who is present at the other end of the telephone or video call. It is advisable to start with yes/no questions to ensure the safety of the telehealth consult, for example, ‘Is it safe for me to ask you how you are going?’ or ‘Are you alone at the moment?’ If the answer is ‘No’, tell them that you will call back the next day, and give them some times that they can answer ‘Yes’ or ‘No’ to in order to find a safe time to call. If they are alone, establish a code word or phrase for if they need to suddenly end the call (eg if they think they will be overheard), such as ‘Thanks, but I’m not interested’.
It is important to explain confidentiality and information-sharing procedures, which differ across states/territories. The only state or territory to require mandatory reporting of domestic violence is the Northern Territory. In other states and territories, the doctor could explain that ‘I don’t routinely share information without your consent. However, if you tell me that you or someone else is at a serious risk of harm, I can’t always keep that information to myself’ (refer to Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment.
When inquiring about abuse, start with general questions that will then lead into more specific questions. ‘How are things at home?’ or ‘Do you feel safe at home?’ may then lead into ‘Are you afraid of your partner?’ and ‘Has your partner ever physically harmed you?’
Another approach is to say, ‘Violence is very common in the home. I ask a lot of my patients about abuse because no-one should have to live in fear of their partners’. The benefit of such a statement is that will allow the woman to see that this is a common presentation that the health professional has seen before and that the health professional won’t be shocked or judgemental when disclosing to them. For further examples of questions to ask if you suspect IPAV, refer to Box 2.1.
Box 2.1. Questions and statements to make if you suspect IPAV
- ‘How are things at home?’
- ‘Do you feel safe at home?’
- ‘Often people who have these types of health problems are experiencing difficulties at home. Is this happening to you?’
- ‘Sometimes these symptoms can be associated with having been hurt in the past. Did that ever happen to you?’
- ‘Has your partner physically threatened or hurt you?’
- ‘Is there a lot of tension in your relationship? How do you resolve arguments?’
- ‘Sometimes partners react strongly in arguments and use physical force. Is this happening to you?’
- ‘Are you afraid of your partner? Have you ever been afraid of any partner?’
- ‘Have you ever felt unsafe in the past at home?’
- ‘Violence is very common in the home. I ask a lot of patients about abuse because no-one should have to live in fear of their partners.’
- ‘Has your partner ever controlled your daily activities?’
- ‘Has your partner ever threatened to physically hurt you?’
To hear a GP inquire about abuse using some of the above questions, visit the RACGP Professional Development Program on Family Violence − Module 2: Identifying and responding to family violence (from 9.03–13.52 minutes).
Note: If the physical harm was to the head, face or neck, ask the following questions:
- ‘Have you ever been hit in the head or face?’
- ‘Have you ever been pushed or shoved and banged your head against something?’
- ‘Have you ever lost consciousness?’
|Table 2.3. Strategies to increase disclosure and engagement in women who experience IPAV
|Healthcare worker characteristics
||Ensure helpful GP attitudes, judgements and behaviours
- Be non-judgemental, empathetic, use active listening, be respectful and compassionate. There must be development of trust
- Recognise/support patient autonomy
|Raising the issue
||Setting the agenda, communication and counselling skills
- Use open questions, reflection and active listening, sensitivity, non-judgemental inquiry, express empathy
||Ask about emotions and safety
- Ask about the woman’s fears and concerns
- Anxiety, shame, self-blame, loneliness, humiliation and embarrassment are commonly associated with a reluctance to disclose
- Assess safety (woman and any children)
- What does she need in order to feel safe? How safe does she feel? Has the violence been escalating?
|Reluctance to disclose
||Explore links to the presenting complaint
- Increase awareness of how IPAV is a contributor to the woman’s presenting complaint
- Have a suspicion of IPAV when women present with anxiety, depression, substance abuse and chronic pain
- Women want GPs to have a deeper understanding of the complexities of their situation and circumstances
- GPs need to gain an understanding of how the woman views IPAV and what are their identified supports
||Legitimisation of experiences
- Affirm experiences – address misconceptions. For example:
- Woman: ‘It’s my fault, I deserve it.’
- GP: ‘You do not deserve this and it is not your fault.’
Barriers to women reporting abuse
Many women do not report abuse because they fear reprisals from their partner if they found out that they had disclosed, or they may feel that the abuse is normal. There are many other barriers to disclosure.12 They may fear judgemental attitudes by the doctor or that they will not be believed. There may be particular barriers to disclosure for women in small, rural or remote communities, such as not wanting the GP to think badly of the perpetrator or fear of repercussions and consequences in communities where anonymity cannot be maintained. Other barriers include:
- a lack of access to services
- concerns about maintaining confidentiality and anonymity
- the stigma attached to the (public) disclosure of violence
- a lack of transport and telecommunications.25,26
Further, as Judith Herman says in her book, Trauma and recovery:27
‘People who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner that undermines their credibility and thereby serves the twin imperatives of truth-telling and secrecy. When the truth is finally recognized, survivors can begin their recovery. But far too often secrecy prevails, and the story of the traumatic event surfaces not as a verbal narrative but as a symptom. The psychological distress symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it. This is most apparent in the way traumatized people alternate between feeling numb and reliving the event.’
If the violence is mainly emotional, they may not see it as serious enough and may minimise the violence, particularly if they come from families where IPAV might have occurred.
For these and other reasons, disclosure may not be immediate, and is often sporadic. This is called the ‘dance of disclosure’, where a woman partially discloses, then becomes reluctant to disclose for a while, then discloses again later.
Women experiencing abuse may be unable to recognise the cycle of violence that they are in. They may feel that each act of violence is a discrete event ‘caused’ by a specific event. Women may also often be too terrorised to protect their children or too worn down by repeated violence to seek help. They may live in fear that if they report to authorities, their children will be taken away. Further, some children who are exposed to IPAV grow up to also be more likely to experience or use IPAV.
Responding to disclosure, including validation
One of the many barriers to GPs asking about IPAV is that they do not know what to do if a woman discloses abuse. The WHO ‘LIVES’ (Listen, Inquire, Validate, Ensure safety, Support) model is a useful tool to guide doctors in their response (see Box 2.2).28
The immediate response to disclosure should be to listen empathetically and hear the woman’s story. The response should be non-judgemental, supportive and believing of her experiences.
Following this should come an inquiry as to her current needs and concerns. These may be quite different to what the health professional thinks are her needs. Health professionals should put the patient-identified needs first, especially ensuring social and psychological needs are addressed.
Validation will assure her that violence is never okay and that it is not her fault that the violence is occurring. Again, it is vital that she is believed. It is also important to acknowledge the complexity of the situation and respect the patient’s choices, even if that means going back to her abusive partner.
It is ineffective at this point to suggest leaving the relationship, but any message of support and identifying that alternatives exist, may be a trigger for action.23,29 Remember that women are at greatest risk of being a victim of homicide around the time of leaving. Therefore, planning when, and how, to leave needs to be done carefully to maintain safety.
Validation statements include:
- ‘What is happening to you is not okay, and it is not your fault.’
- ‘Everyone deserves to be safe at home.’
- ‘I am concerned about your safety and wellbeing.’
- ‘It took you a lot of courage to discuss this with me.’
- ‘You are not alone. I will be with you through this, whatever you decide.’
- ‘You are not to blame; abuse is common and happens in all types of relationships.’
Elsewhere in this resource we discuss enhancing safety and providing ongoing support according to the LIVES model.
When a woman returns for a subsequent visit, it is important to recognise the chronicity of the problem, and, as with any chronic condition, to offer ongoing follow-up and support. Continue to believe and validate the woman. Be patient and supportive and respect her wishes.
Never say, ‘Why don’t you just leave your partner?’ Never pressure her into making decisions. Allow her to progress at her own pace. The supportive space that we are making may well contribute to her being able to change her situation in the future. The readiness to action model can be very helpful in understanding a patient’s current position within the journey of change.
Box 2.2. The WHO LIVES model of first-line response to IPAV
Listen: Listen to the person closely, with empathy, and without judging
Inquire: Assess and respond to their various needs and concerns – emotional, physical, social and practical
Validate: Show that you understand and believe the person − assure them that they are not to blame
Enhance safety: Discuss a plan for the person to protect themself from further harm if violence occurs again
Support: Support the person by helping them connect to information, services and social support