Abuse and violence: Working with our patients in general practice


The White Book
Chapter 1.  What is interpersonal abuse and violence?
☰ Table of contents


Key messages

  • Interpersonal abuse and violence includes intimate partner abuse, adult survivors of child abuse, sexual assault, child abuse, bullying and elder abuse. Violence is not just physical; it includes emotional, sexual, economic and social abuse9
  • Interpersonal abuse and violence is very common, with the main perpetrators of such violence being men, but women can also be perpetrators10
  • 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 (refer to Tool 1. Nine steps to intervention – the 9 Rs)3
 

Recommendations

  • Safety is a concept that should be foremost when working with patients experiencing abuse and violence3 Practice point
  • Health practitioners should have a system in place that includes the whole of practice and referral pathways to safety and healing3 Practice point
  • It is important to receive training that includes our own attitudes and assumptions about abuse and violence as they can affect the way we respond to patients experiencing abuse and violence3Practice point


Introduction


In this manual, abuse and violence encompasses:

  • Intimate partner abuse (often known as domestic violence) – any behaviour within an intimate relationship that causes physical, emotional, sexual, economic and social harm to those in the relationship.9 An intimate relationship may refer to a survivor’s current or previous partner or living companion, including same sex relationships
  • Perpetrators of intimate partner abuse – a person who commits, or knowingly allows, acts of abuse, neglect or exploitation to occur
  • Children in violent families – children who are members of a family in which abuse and violence occurs, whether or not they themselves are abused
  • Child abuse – any type of abuse that involves physical, emotional, sexual, or economic abuse or neglect of a child under 18 years of age (16 years of age in New South Wales, 17 years of age in Victoria)
  • Adult survivors of child abuse – adults who experienced physical, sexual, or emotional abuse or neglect during their childhood or adolescence
  • Sexual violence – 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, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object3
  • Elder abuse – 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 (RACF), 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.11

Family violence is broader than intimate partner abuse or domestic violence and child abuse as it includes any violence or abuse that is occurring within a family – between, for example, siblings, uncles, aunts, cousins, grandparents and in-laws.

While it is acknowledged that not all survivors of abuse are women and not all perpetrators are men, research supports that men are the perpetrators in the majority of cases for child abuse, sexual assault and intimate partner abuse. Intimate partner abuse incidents that are reported show that the majority of those affected are women.12

The WHO categorises all of the above forms of violence within interpersonal violence (refer to Figure 1). This manual does not address acquaintance violence (apart from child and young person bullying) or stranger violence (apart from sexual assaults by strangers). It also does not cover the large burden of abuse and violence that occurs in global conflict zones, refugee camps and asylum detention centres.

 

Figure 1. Typology of interpersonal violence13

Typology of interpersonal violence

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 17 February 2014).


This manual includes guidance on intimate partner abuse (Chapters 25 ), child abuse (Chapter 6 ) young people and bullying (Chapter 7 ), adult survivors of child sexual abuse (Chapter 8 ), sexual assault (Chapter 9 ). It also addresses specific populations such as the elderly and disabled (Chapter 10 ), Aboriginal and Torres Strait Islander peoples (Chapter 11 ), and migrant and refugee communities (Chapter 12 ). It concludes with reference to legal issues (Chapter 13 ) and, importantly, doctor self-care (Chapter 14 ). There is an emphasis on particular issues for rural populations and same-sex populations throughout the manual.

 

Prevalence


The Australian Bureau of Statistics found that young people aged 18–24 are the most likely group to have experienced some form of violence over the past year.10 More than one in 10 young women, and nearly one in four young men had experienced some form of violence during 2012.

Both men and women were more likely to have experienced physical violence than sexual violence. However, sexual violence was four times more common for women than men: 19% of women had experienced sexual violence since the age of 15 compared to 4.5% of men.10

Since the age of 15, women were more likely to have experienced violence from someone they knew than by a stranger, while the reverse was true for men.10

This manual concentrates on the more prevalent form – violence against women by someone they know. The prevalence of different types of violence and abuse are detailed in individual sections of this manual.

 

Types of abuse and violence


Abuse and violence can take many forms. Violence can be severe and leave obvious injuries, but some victims may be subject to more subtle abuse that may not leave physical injuries. Abuse and violence 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, head injuries and injuries to internal organs. For many victims, 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, or killing or hurting family pets.
  • Emotional abuse – may include subtle or overt verbal abuse, humiliation, threats or any behaviour aimed at scaring or terrorising the person experiencing the abuse. The victim 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.
  • Child sexual abuse – for children, sexual abuse may involve forcing or enticing them to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative or non-penetrative acts. The abuse may include non-contact activities such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.
  • Adult sexual assault – involves any type of sexual activity to which there is no consent. This may or may not involve penetration or physical contact with the victim (for example, exposure). It is important to note that people with a disability or the elderly may not have consented, or they may have lost their ability to consent (for example, those with dementia).
  • Economic abuse – restricting access to money and essential needs, fraudulently using another’s money for personal gain, or stealing from the victim; the illegal taking, misuse, or concealment of funds, property or assets.
  • Social abuse – isolating the victim from family and friends, and other contacts in the community.
  • 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.

Types of abuse are across populations and ages, however, all of them involve an abuse of power. The next section illustrates how a partner uses power.

Abuse and violence can take many forms in intimate relationships, and is often not recognised as such by the victim. 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."

 

Intimate partner abuse – not just an argument


"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, intimate partner abuse occurs where one partner is being abused by the other partner and lives in fear of being exposed to that abuse again (Figure 2). Fear experienced by the abused partner may be constant or episodic. Regardless of the frequency with which abuse occurs, it is still abuse.

Many intimate partner abuse survivors say that arguments did not precede the violent episodes or that the perpetrator often provoked the confrontation deliberately.

Figure 2. Intimate partner abuse: power imbalance in an abusive relationship

Intimate partner abuse

 

The role of GPs


The role of GPs includes all of the following to address family violence across the lifecycle (refer to Tool 1. Nine steps to intervention – the 9 Rs):14

  • identifying predisposing risk factors
  • noting early signs and symptoms
  • 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.

 

What part does the community play?


Society condones violence in overt and subtle ways by failing to recognise and acknowledge that intimate partner abuse, child abuse, sexual assault and elder abuse exist. We turn a blind eye to family violence, preferring not to be involved. 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 some, the greatest danger lies in the home itself.
  • As a community, we believe that the family is the basis of a good community and a strong 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 (refer to Figure 3). 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.15


Figure 3. Factors associated with violence13

Factors associated with violence

 

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 17 February 2014).

This manual particularly addresses vulnerable populations, including disabled women, women from culturally and linguistically diverse populations and Aboriginal and Torres Strait Islander women, all of whom may be subjected to a higher prevalence of abuse and violence. Rural populations, which may have less access to services and information, are also highlighted.

 

Attitudes in society


Attitudes within the Australian community regarding family violence have been improving over time, although there are some gender differences. A 2009 survey16 by the Victorian Health Promotion Foundation explored attitudes towards violence in Australia. The strongest predictors for holding violence-supportive attitudes were being male and having low levels of support for gender equity or equality. There is a developing awareness that interpersonal abuse and violence is a crime and is not acceptable.

Attitudes regarding rape

  • 93% of people agree that forced sex is a crime.
  • 1 in 20 people believe that ‘women who are raped ask for it’.
  • 34% believe ‘rape results from men being unable to control need for sex’.
  • 1 in 4 agree that ‘women make false claims of being raped’.
  • 13% agree women ‘often say no when they mean yes’.
  • 1 in 6 agree that a woman ‘is partly responsible if she is raped when drunk or drug‐affected’.

Attitudes regarding intimate partner violence

  • 1 in 5 people (22%) believe that domestic violence can be excused if the perpetrator later regrets what they have done.
  • 22% of people believe that domestic violence is perpetrated equally by both men and women.
  • 14% of Australians regard domestic violence as a private matter.
  • 4% of Australians condone the use of physical force by a man against his wife.

In this community survey,16 women are more likely than men to be aware that intimate partner abuse can consist of both psychological and physical abuse. Women also tend to attach a greater degree of seriousness to such abuse. Both men and women identify men as more likely to be perpetrators.

Many myths (refer to Box 1 and 2) however, are still held as beliefs by health practitioners, despite more training on family violence being available to clinicians in the last decade.

Box 1. Myth 1 – Alcohol misuse causes violence

In reality …

Alcohol appears to be involved in about 45% of incidents of intimate partner violence.17

However, 55% of cases involve sober perpetrators. Abuse of alcohol is a risk factor that contributes to intimate partner abuse by lowering inhibitions, but alcohol does not cause intimate partner abuse, sexual assault, child abuse or elder abuse, nor is it an excuse for these behaviours.

 

Box 2. Myth 2 – Abuse and violence only occurs in certain groups, for example only poor women are abused

In reality …

Numerous studies, in Australia and internationally, show that both victims and perpetrators are found in all social classes and across all ethnic groups.18 The abuse may be more hidden in higher socioeconomic groups, even among GPs themselves.

These myths and GPs’ own experience of abuse (refer to Chapter 14) may impact on their work with patients experiencing family violence.

 

 

Impact on people’s lives and the role of GPs


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.19

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.20,21

GPs need to understand the nature of violence and abuse so that they can help break this intergenerational cycle of abuse.

 

Resources


Please refer to Tool 7 for resources nationally and in your area.

 

Further information


The further reading and information listed below will assist GPs in this role.

Refer to Tool 1. Nine steps to intervention – the 9 Rs in the PDF version

1800RESPECT is a phone line and website providing information, advice and connection to resources in your area

Australia’s National Research Organisation for Women’s Safety (ANROWS) is an independent, not-for-profit company. ANROWS delivers research evidence to drive policy and practice aimed at reducing violence against women and children.

The National Survey on Community Attitudes to Violence Against Women 2009 – this report presents findings from a community survey conducted by VicHealth. It provides an interesting insight into community attitudes towards violence and how this has changed over the past decade.

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013. 
  2. Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet 2002;360:1083–8. 
  3. Australian Bureau of Statistics. Personal Safety. Canberra: ABS, 2012. 
  4. World Health Organization. A global response to elder abuse and neglect: building primary health care capacity to deal with the problem worldwide: main report. Geneva: WHO, 2008. 
  5. Taft A, Hegarty K, Flood M. Are men and women equally violent to intimate partners? Aust NZ J Public Health 2001;25:498–500. 
  6. Krug EG, Dahlberg LL, Mercy JA, et al, editors. World report on violence and health. Geneva: WHO, 2002. 
  7. Reilly JM, Gravdal JA. An ecological model for family violence prevention across the life cycle. Fam Med 2012;44:332–5. 
  8. Heise LL. Violence against women: an integrated, ecological framework. Violence Against Women 1998;4:262–90. 
  9. Victorian Health Promotion Foundation. National Survey on Community Attitudes to Violence Against Women 2009. Changing cultures, changing attitudes – preventing violence against women. A summary of findings. Carlton: Victorian Health Promotion Foundation, 2009. 
  10. Mouzos J, Makkai T. Women’s experience of male violence: Findings from the Australian component of the International Violence Against Women survey. Canberra: Australian Institute of Criminology, 2004. 
  11. O’Donnell C, Smith A, Madison J. Using demographic risk factors to explain variations in the incidence of violence against women. J Interpers Violence 2002;17:1239–62. 
  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. 
  13. Newman L. The last frontier: Practice guidelines for the treatment of complex and trauma informed care and service delivery: ASCA, 2012. 
  14. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behaviour: Implications for healthcare. In: Lanius RA, Vermetten E, Pain C, editors. The Impact of Early Life Trauma on Health and Disease. Cambridge: Cambridge University Press, 2010. p. 77–87.