Intimate partner abuse and violence: Identification and initial response

This chapter focuses on identifying IPAV and how to respond initially to a disclosure of IPAV. Safety and risk assessment are important parts of the initial response. Ongoing care, including counselling strategies, is covered in Intimate partner abuse and violence: Ongoing support and counselling.

Other forms of family violence, such as child abuse and neglect, abuse of older people, sibling abuse, and child/adolescent violence against a parent, are discussed in this volume; the principles outlined here can be used in these cases.

Globally, one in three women ever experience physical or sexual abuse by their partners.⁵ Women are much more likely to experience violence by their partners than are men.¹ Thus, this chapter focuses on women as victims/survivors and men as perpetrators of abuse; however, the overarching messages of the chapter can be applied to men and non-binary people. This chapter focuses on heterosexual relationships; IPAV also affects those in same-sex and gender diverse-relationships.

What is intimate partner abuse/violence?

The World Health Organization (WHO) defines IPAV as any behaviour within an intimate relationship that causes physical, psychological or sexual harm.⁵ It may involve either current or former partners. IPAV remains a silent epidemic, as it often occurs in the privacy of homes.

IPAV is an abuse of power. It is the domination, coercion, intimidation and victimisation of one person by another, by physical, sexual or emotional means, within intimate relationships. It is a pattern of behaviours, not just isolated incidents of physical violence, that is about power and control, rather than about conflict and anger. It stems from societal gender role ideologies that give men power and control over women. It can include physical or sexual violence, emotional abuse and other controlling behaviours that constitute coercive control (refer to Table 2.1).⁵

Coercive control is a pattern of acts that aim to cause fear and may include social control, whereby a survivor is isolated from friends or family, and technology-facilitated abuse, which could involve a survivor’s movements being tracked, their messages and emails being monitored, or sexting. Mental health coercion may involve threatening suicide to manipulate a victim/survivor. Migrant and refugee women may be manipulated by their partners based on their visa status.

Financial control occurs where the woman is not given access to money and may be deprived of basic necessities or prevented from accessing employment.

Emotional/psychological abuse includes intimidation, belittling and harassment. A woman may be blamed by her partner for the violence. Emotional abuse has significant long-term sequalae for survivors, with many survivors saying it is worse than physical violence.⁵

Physical violence may include slapping, hitting, kicking, beating or using a weapon. Women live in fear that the next violent episode may be the last. On average, one woman per week in Australia is killed by a partner or former partner.

Sexual abuse includes forced intercourse, sexual coercion and reproductive coercion. Forcing a woman to have sex may include forcing her to perform sex acts that she does not like or want to do. An example of reproductive coercion is where a man does not allow his partner to use contraception or forces her to have an abortion. Sexual abuse rarely happens in isolation and most often physical or emotional abuse occur concurrently.⁶

The Royal Australian College of General Practitioners (RACGP) Professional Development Program on Family Violence provides further information about types of IPAV in Module 1: The role of general practice in responding to family violence (from 2.46–3.23 minutes).

How common is intimate partner abuse?

The Australian Bureau of Statistic’s 2016 Personal Safety Survey collected information from men and women over the age of 18 about the extent of violence experienced since the age of 15 years.¹ An estimated 2.2 million had experienced physical and/or sexual violence from a partner, with one in six women compared with one in 16 men experiencing this form of IPAV. Figure 2.1 further shows how the prevalence of partner abuse is gendered.

When looking at a person’s most recent incident of physical assault by a male, the most likely location for women was in their home; for men, it was at a place of entertainment of recreation.⁷

Figure 2.1. Prevalence of lifetime intimate partner abuse

Source: Australian Institute of Health and Welfare.¹
 

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Risk factors for intimate partner abuse

Women from every race, religious group, age and socioeconomic status can experience IPAV. Those most at risk include:

• Aboriginal and Torres Strait Islander women, women from culturally and linguistically diverse (CALD) backgrounds, women with intellectual or physical disabilities and women who are in the process of separating from their partners⁵
• pregnant women – it is not uncommon for abuse to either commence or escalate during pregnancy. The incidence of IPAV during pregnancy has been reported to be 4–8% of all pregnant women⁸
• women who are recently separated or divorced, or who are on low incomes⁹
• women who are younger than 25 years¹
• women who have experienced child abuse or have come from a violent family.¹

Women don’t enter a relationship expecting it to become violent. One survivor of IPAV reported:

How does intimate partner abuse change in the time of COVID-19 and other natural disasters?

Studies have consistently shown that IPAV increases after large-scale disasters or crises. IPAV escalates as catastrophic events destroy social networks that usually provide safety nets, and this escalation often continues post-disaster.¹⁰

In response to the COVID-19 pandemic, governments all over the world instituted lockdowns of their citizens to contain the virus. In this situation, women may be isolated at home with their abusers for prolonged periods of time, with factors such as economic instability, unemployment and uncertainty serving to increase the violence. Isolation makes it more difficult for women to call for help and hides abuse from friends, family members and services who may have previously noticed it.⁹

The Australian Institute of Criminology conducted survey-based research of 15,000 female respondents. Of those who had previously experienced physical or sexual violence, 65% reported an increase in either the frequency or severity of violence during the COVID-19 pandemic.¹¹ Among the women who had experienced physical and sexual violence, one in three said that this was the first time their partner had been violent to them.¹¹

The COVID-19 pandemic has also brought about new forms of psychological abuse: perpetrators telling their partner they have the virus so they can’t leave the house, increases in surveillance and control, withholding essential items such as cleaning equipment and hand sanitiser, and deliberately giving partners misinformation about quarantine measures.¹² Women have reached out to helplines and services in increased numbers; however, this is likely to be the tip of the iceberg, and many services are concerned that social distancing has made it difficult to engage with women who need their help.¹¹

The role of general practice

The majority of current IPAV is disclosed to a GP or other health practitioner and is not reported to the police (refer to Figure 2.2).¹⁰

Figure 2.2. Victim/survivors’ disclosures of intimate partner abuse to services and people

Based on: Australian Institute of Health and Welfare ¹
 

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The role of the health practitioner is important, as IPAV is the leading contributor to poor health in women of childbearing age, more than smoking, alcohol use and increased body weight.² GPs often say that they do not see many cases of IPAV in their clinics. It is much more common than many GPs realise.

It is estimated that a full-time GP sees around five women per week who have experienced IPAV in the last 12 months.¹³ One in three women have ever experienced IPAV in their lifetime.¹⁴ This is more common than the prevalence of rheumatoid arthritis, diabetes or asthma. However, only around one in 10 women have ever been asked by their GP about IPAV.

There are many barriers to GPs identifying people experiencing IPAV, including:^14,15

• lack of time or skills
• belief it is not common
• fear of offending the patient or belief it is a private matter
• fear of the perpetrator
• belief that it won’t change anything, as the patient is returning to the relationship anyway.

Despite these barriers, GPs are in a unique position to be able to identify and support women who are experiencing IPAV. They have a duty of care to identify situations of abuse so they can intervene early.

GPs are accessible, are often the first port of call for their patients and are in a position to have continuity of care with them. Because of this, they are able to build a trusting long-term supportive relationship with victims/survivors. An Australian study revealed that women feel comfortable disclosing to their GP, whether they are male or female, provided they have good communication skills and a patient-centred approach.⁴ Although some consider communication skills to be innate, it is possible to learn and improve these skills to facilitate an environment in which a woman is more likely to be able to disclose.

GPs need to understand the eight steps to intervention – the 8 Rs:

• Be ready to identify and respond to IPAV
• 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 their 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

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

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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.

Physical signs

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

Behavioural signs

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
• anxiety
• depression
• withdrawal
• 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.

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

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.

• See what you made me do: Power, control and domestic abuse – book by Jess Hill, Black Inc Books, 2019.
• See what you made me do: Power, control and domestic abuse – documentary series by Jess Hill, SBS, 2021.