Guidelines for preventive activities in general practice

Injury prevention

Intimate partner abuse and violence

      1. Intimate partner abuse and violence

Injury prevention | Intimate Partner Abuse and Violence

Intimate partner abuse and violence (IPAV) is not only physical; it can also be sexual, psychological, social, cultural, financial and spiritual. IPAV can be in-person or technology facilitated. IPAV is a pervasive public health problem with short- and long-term impacts on the health of all members of the family, particularly women and children.1 In Australia, 1 in 4 women and 1 in 17 men since the age of 15 years have experienced physical, sexual, emotional or economic abuse from a cohabiting partner.2 IPAV often commences and escalates in pregnancy. Most survivors are women in heterosexual relationships; however, men and non-binary people can experience IPAV, in same-sex and gender-diverse relationships.3 It is estimated that one-half to two-thirds of women survivors have children in their care at the time of the violence, which results in behavioural, cognitive and health issues for their children in later life.3 IPAV is a leading contributor to ill health and premature death among women, mainly due to mental health issues.1 Social impacts include economic insecurity, isolation and homelessness.4 Women who have experienced IPAV use healthcare services more than women not experiencing IPAV.5
 

Screening

Recommendation Grade How often References
Screening for IPAV in the general population is not recommended, because of insufficient evidence (to assess the balance of benefits and harms). Not recommended (Strong) N/A 3
Routinely screen for IPAV in pregnancy. Recommended (Strong) As part of antenatal care 3

Case finding

Recommendation Grade How often References
Ask all patients who present with clinical indicators, particularly psychological symptoms, about possible experiences of IPAV (see Box 1).

See Box 2 below for questions to ask and statements to make if you suspect IPAV.
Recommended (Strong) Opportunistically  3

Women survivors identify healthcare providers as the professionals they would most trust with disclosure of abuse.5 Therefore, consider asking all pregnant adult and adolescent women about IPAV during antenatal care, because this is a time of high risk and there are interventions that have been shown to work in this setting.3 However, there is insufficient evidence for screening the general population attending general practice;6,7 there should be a low threshold for asking about IPAV, particularly when the GP suspects underlying psychosocial problems.3

Provide first-line support to women who disclose IPAV. This includes the LIVES approach:8

  • Listening
  • Inquiring about needs
  • Validating women’s disclosure
  • Enhancing safety
  • Providing support/referrals.

This first-line response should be in the context of a CARE approach of providing:9

  • Choice and control
  • Action and advocacy
  • Recognition and understanding
  • Emotional connection with the patient.

People can experience IPAV regardless of race, religious group, age, gender and socioeconomic status. 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
  • LGBTIQA+ people
  • pregnant women
  • women who are recently separated or divorced, or who are on low incomes
  • women who aged <25 years
  • women who have experienced child abuse or come from a family where abuse and violence occurred.3

Risk assessment in migrant and refugee people needs to assess language proficiency, immigration status and the individual’s eligibility for support services. Many will experience marginalisation from the wider community through racism, as well as dislocation from their ethnocultural heritage.

Box 1. Clinical indicators where practitioners should think about asking patients directly about intimate partner abuse and violence3


Psychological
  • Insomnia, nightmares
  • Difficulty concentrating and making decisions
  • Confusion, memory issues
  • Irritability, feeling overwhelmed
  • Anxiety and panic disorder
  • Depression
  • Suicidal ideation
  • Somatoform disorder
  • Post-traumatic stress disorder – hyperalertness and hypervigilance
  • Eating disorders
  • Drug and alcohol use
  • Poor self-esteem

Social

  • Isolation from family and friends
  • Homelessness
  • Financial and food insecurity

Physical

  • Injuries, including strangulation
  • Bruises at various stages of healing
  • Sexual assault
  • Sexually transmissible infections
  • Chronic pelvic and abdominal pain
  • Chronic headaches
  • Fatigue
  • Miscarriage, premature labour and stillbirth
  • Nausea, chronic diarrhoea and change in appetite

Box 2. Questions to ask and statements to make if you suspect intimate partner abuse and violence3

  • ‘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?’

In Aboriginal and Torres Strait Islander communities across Australia, family violence (abuse by any family member, including partners) is disproportionately high in comparison with the non-Indigenous Australian population.3 In addition, Aboriginal and Torres Strait Islander women are more likely to experience serious forms of violence, such as physical assault. This high prevalence is attributable to the many interrelated elements that are associated with colonisation, kinship disruption, disconnection from land and culture, including trauma, racism, unemployment and poverty.3

Refer to the Family abuse and violence chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people for specific recommendations and advice.

  1. World Health Organization (WHO), Department of Reproductive Health and Research London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women. Prevalence and health effects of intimate partner violence and non-partner sexual violence. WHO, 2013 [Accessed 1 November 2015].
  2. Australian Bureau of Statistics (ABS). Personal safety, Australia. ABS, 2023 [Accessed 9 May 2023].
  3. The Royal Australian College of General Practitioners (RACGP). Abuse and violence – working with our patients in general practice. 5th edn. RACGP, 2021 [Accessed 22 February 2024].
  4. Boxall H, Doherty L, Lawler S, Franks C, Bricknell S. The ‘Pathways to intimate partner homicide’ project: Key stages and events in male-perpetrated intimate partner homicide in Australia. Research report 04/2022. ANROWS, 2022 [Accessed 22 February 2024].
  5. Australian Institute of Health and Welfare. Family, domestic and sexual violence. Australian Government, 2023 [Accessed 8 May 2023].
  6. World Health Organization (WHO). Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. WHO, 2013 [Accessed 1 November 2015].
  7. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. BMJ 2014;348:g2913. doi: 10.1136/bmj.g2913.
  8. World Health Organization (WHO). Health care for women subjected to intimate partner violence or sexual violence: A clinical handbook. WHO, 2014 [Accessed 8 May 2023].
  9. Tarzia L, Bohren MA, Cameron J, et al. Women’s experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis. BMJ Open 2020;10:e041339. doi: 10.1136/bmjopen-2020-041339.
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