- The majority of intimate partner abuse victims are women in heterosexual relationships; however, intimate partner abuse also occurs in same-sex relationships22
- Intimate partner abuse is common. It is one of the leading contributors to death and disability for women of child-bearing age23 and has major effects on the health of children24
- Most women are open to enquiry about intimate partner abuse25 and the gender of a patient’s health practitioner does not affect disclosure of intimate partner abuse26
- Health practitioners should ask patients who are showing clinical indicators of the mental and physical effects of intimate partner abuse about their experiences of abuse3 Level II B
- Health practitioners should provide first line support – listening, inquiring about needs, validating women’s disclosure, enhancing safety and providing support – to women who disclose abuse3Practice point
Intimate partner abuse (or domestic violence) is the most common form of assault perpetrated against adult women in Australia today.10 Globally, one in three women experience physical or sexual violence at the hands of their partners.3 Because it occurs in the privacy of the home, and those involved are often reluctant to talk about it, intimate partner abuse remains a hidden problem in all strata of society. Intimate partner abuse occurs in heterosexual and homosexual relationships for men and women. However, as intimate partner abuse is perpetrated more often against women, this chapter focuses on women (and their children) as victims of abuse. That said, the overarching statements and recommendations in this chapter relate to both genders.
This chapter outlines an appropriate initial response by GPs and their practices to survivors of intimate partner abuse. Chapter 4 outlines the ongoing management and response for survivors. Chapter 3 provides an overview of documentation, risk assessment and mandatory reporting and Chapter 5, the response to perpetrators. In particular, doctors working in the Northern Territory need to be aware of the mandatory reporting requirements for domestic and family violence. Visit the 1800 respect website for further details.
Understanding and naming intimate partner abuse is the first important step in breaking the silence. This manual employs a broad definition that includes abuse of a physical, sexual or emotional nature (Figure 4).
Forms of violence
Violence used by partners can take many forms:
- punching, hitting, slapping, shoving, throwing objects, pulling hair, twisting limbs, choking and other forms of physical assault including use of weapons and homicide, threats to injure or otherwise harm adults, children or pets
- sexual abuse or assault
- harassment by telephone, email or at the workplace
- deprivation of finances and basic human needs (access to food, sleep, medical care)
- erosion of self-esteem through humiliation and verbal abuse
- social isolation through denial of outside contact with friends or relatives
- use of technology to abuse, for example, sexting.
Although many victims of intimate partner abuse experience physical abuse, most victims say that the constant fear of the next episode is as bad as the actual violence:
- You don’t know what the limit is when he’s attacking you. It is very frightening.
- Each time you think: This will be the last. He’s going to kill me.
Physical injuries heal. Emotional abuse, if not dealt with, can cause long-term suffering for the survivor:
- You’re lucky to have me, no-one else would have you.
- You’re a hopeless mother.
- I’ll smash your face in if you do that again.
- If you leave, I’ll kill you.
- If you leave, you’ll never see the kids again.
- If you leave, I will kill myself.
Many intimate partner abuse survivors also undergo forced sexual contact, but sexual abuse is rarely an isolated form of abuse. In most cases, it takes place within relationships where physical assaults and emotional abuse are occurring.
Figure 4. Types of abuse
When does it start?
People don’t enter relationships expecting that the relationship will become violent.
I’ll never forget when he hit me for the first time ... the pain of split lips and blackened eyes was outdone by the shock I felt. I just couldn’t believe it had happened.
Violence erupts in many relationships in the first year of that relationship, sometimes involving a pregnancy, and setting off a cycle of abuse that may last years.
Who are the victims of intimate partner abuse?
Survivors of intimate partner abuse (and their children) come from all social, cultural, economic and religious backgrounds. We know this from telephone and household surveys, as well as research conducted in hospital accident and emergency departments and general practice consulting rooms.3
One survivor of intimate partner abuse reported:
People say to me, ‘I just can’t believe an intelligent woman like you could be in such a situation. You just aren’t the type I picture tolerating such madness’. My answer is this: It can happen to anyone.
The Australian Bureau of Statistics 2012 Personal Safety Survey10 collected information about the nature and extent of violence experienced by men and women since the age of 15. It includes men’s and women’s experience of current and previous partner violence, lifetime experience of stalking, physical and sexual abuse before the age of 15 and general feelings of safety. The report shows that:
- women were more likely than men to experience violence by a partner:
- 17% of all women aged 18 years and over (1,479,900 women)
- 5.3% of all men aged 18 years and over (448,000 men)
- women were more likely than men to have experienced violence by a partner in the previous 12 months:
- 1.5% of all women aged 18 years and over (132,500 women)
- 0.6% of all men aged 18 years and over (51,800 men)
- 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
- men was at a place of entertainment or recreation
- the majority of male and female physical assaults are not reported to the police
- women were more likely than men to have experienced emotional abuse by a partner: 25% of women compared to 14% of men
- children frequently experience (hear or witness) the violence between their parents.
What is happening in general practice?
GPs often say we do not see many patients who have experienced violence.27 It is true that violence doesn’t necessarily present in an obvious way, and it may not be identified by our patient as their reason for presenting.
Despite this, it has been estimated that full-time GPs are seeing up to five women per week who have experienced some form of intimate partner abuse – physical, emotional, sexual – in the past 12 months.22 One or two of these women will have experienced severe intimate partner abuse – for example, being raped, attacked with a weapon, locked in their home or not allowed to work. These figures are from a survey of 1836 consecutive women attending 20 randomly chosen Brisbane general practices (with a response rate of 78.5%). One in three women in current relationships attending routine general practice clinics had experienced partner abuse in their lifetime. Abused women were more likely to be younger, separated or divorced, have experienced child abuse and come from a violent family.28
It is important that we have an idea of the level of abuse and violence in general practice populations and the intergenerational transmission of abuse in families. This heightened awareness may help to identify health issues related to abusive episodes.
The role of GPs
GPs have a role in prevention, early identification, responding to disclosures of intimate partner abuse, and follow-up and support of patients and their children experiencing the health effects of violence and abuse.
Preventing intimate partner abuse requires culturally safe strategies involving community institutions and opinion leaders, including primary care.29 However, there is very limited evidence to guide healthcare organisations in primary prevention activities.30 Some examples of workplace-based strategies31 that a primary care organisation may choose include:
- training of staff in respectful relationships or bystander education to gain the skills and confidence required to identify, speak out about or seek to engage others in responding to specific incidents of violence, attitudes, practices or policies that contribute to violence32
- appointing practice or hospital champions who will assist with instituting prevention awareness activities across the workplace33
- acknowledging, as an organisation, significant days relating to the elimination of violence against women
- improving the workplace climate and peer support to work with this sensitive issue.
Identification of intimate partner abuse
Types of presentation
Studies show abuse is associated with depression, anxiety, other psychological disorders, drug and alcohol abuse, sexual dysfunction, functional gastrointestinal disorders, headaches, chronic pain and multiple somatic symptoms (Table 2).34 Sexual abuse has also been linked with chronic pelvic pain.3,34
Table 2. Potential presentations of intimate partner abuse35
- Suicidal ideation
- Anxiety symptoms and panic disorder
- Somatiform disorder
- Post-traumatic stress disorder
- Eating disorders
- Drug and alcohol abuse
- Obvious injuries (especially to the head and neck)
- Bruises in various stages of healing
- Sexual assault
- Sexually transmitted infections
- Chronic pelvic pain
- Chronic abdominal pain
- Chronic headaches
- Chronic back pain
- Numbness and tingling from injuries
Depression appears to be one of the strongest clinical predictors of intimate partner abuse. One in five currently depressed women attending Victorian general practices has experienced severe physical, emotional and sexual abuse by a partner or ex-partner in the past 12 months.36 Multiple physical symptoms are also a key indicator of abuse.28
Long-term consequences of intimate partner abuse include post-traumatic stress disorder (PTSD, refer to DSM criteria for PTSD, which is recognised as being likely to manifest itself following a ‘psychologically distressing event that is outside the range of usual human experience’. Intimate partner abuse and sexual assault are recognised as being events that can result in PTSD due to the abuse being experienced with feelings of terror, fear for one’s life, loss of control and a sense of helplessness. Abuse is also associated with other symptoms such as phobic avoidance of similar situations to where the abuse happened, anxiety, fear, withdrawal, isolation, depression, appetite and sleep disturbances, as well as problems with intimate and sexual relationships.
More general clinical indicators include a delay in seeking treatment or inconsistent explanation of injuries, frequent presentations to general practice, noncompliance with treatment or attendances, an accompanying partner who is over-attentive or identifiable social isolation.
What is the effect on children?
Child indicators24 include effects on school and home behaviour including:
- bedwetting, sleeping disorders, anxiety, stress, depression, withdrawal
- aggressive behaviour and language, problems at school
- chronic somatic problems and frequent presentations
- drug and alcohol abuse
- suicidal ideation in adolescence.
Inquiry and disclosure of abuse
Although the majority of female patients attending general practices state that they would not object to being asked about abuse, it is only a minority who are asked.25
Women do disclose abuse to their GPs in significant numbers, particularly if they are directly asked. In a Brisbane study, one-third of abused women had told a GP about the abuse, while only 13.2% had been asked by a doctor.27 GPs from this study said they did not inquire about abuse because of lack of time and appropriate skills, and a perception that they were unable to help abused women. The GP may communicate attitudes, directly or indirectly, that discourage disclosure – for example, ‘it’s the woman’s fault’, ‘it’s unlikely’, ‘it’s not my role to ask’, ‘women don’t want to be referred’, ‘most will stay with the abuser anyway’. The GP may worry about invading the woman’s privacy despite women wanting to be asked.
Women are significantly more likely to disclose if they are asked by their doctor about the abuse. The gender of the GP does not affect disclosure if communications skills are good.26 Barriers to disclosing sexual and physical violence include women not identifying the act as sexual violence or a crime, not thinking that they will be believed, fearing how they will be treated by the doctor or criminal justice system, and fearing reprisals from the partner. They may consider that they can handle it themselves and don’t want family and friends to know because of the humiliation and shame. They often tend to minimise or normalise the violence and, if the abuse is mostly emotional, they may see it as not serious enough.37
This failure to identify an act as abuse at the time may also be a ‘survival strategy’ for some women, particularly those who have been sexually assaulted by an intimate partner.
One interview study revealed:
Women told us that it was not until they were no longer in the relationship and sometimes not until many years later that they had the perspective to recognise they were being raped within their relationship. While they were in the relationship, they struggled to make sense of what was happening to them, and were caught in our society’s demand to make the marriage work. While in the relationship, they minimised the rapes, they blamed themselves or they feared even worse consequences if they didn’t comply.38
Thus, there are many reasons why disclosure is not immediate and is often sporadic. It has been called the ‘dance of disclosure’, where women reveal only partially, often get frightened after they disclose and disappear for some time and then disclose at another time and place.
In relation to same-sex relationships, additional barriers to disclosure of intimate partner abuse include:39
- internalised homophobia – the internalisation of negative attitudes and assumptions about homosexuality
- declaration – the fear of being ‘outed’ to friends, family and/or work colleagues
- emasculation – men declaring abuse at the hands of another man may be disempowering
- police heterosexism – a number of studies indicate that homophobic behaviours and violence are both permitted and committed by the police
- societal homophobia – society tends not to promote disclosure, whether this be due to homophobia or a tendency to view the world in terms of heterosexuality.
Studies show that there is a need for patients to be encouraged to discuss abuse and to see it as affecting their health. We need to have a high level of suspicion and to be able to ask direct questions in a sensitive way. There is insufficient evidence for screening in clinical settings,3,2 with the possible exception of antenatal care. However, there should be a low threshold for asking about abuse, particularly when underlying psychosocial problems are suspected. Possible questions to ask and statements to make are listed in Table 3.
Table 3. Questions and statements to make if you suspect intimate partner abuse
- Has your partner ever 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?
- 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.
Why don’t women report the abuse?
Most people do not report their partner to the authorities for intimate partner abuse because of fear of reprisals or counter charges from their partner. Abused women are often:
- too terrorised to be able to always protect their children, and too worn down by repeated violence to seek help
- living in fear of violence with the use of weapons
- in real fear of losing their children to authorities whom they fear will disapprove of their home life and take the children into care
- at greater risk themselves of abusing their children
- unable or reluctant to recognise the cycle. The patient continues to see each episode as a discrete event ‘caused’ by another specific event.
Box 3. Myth – abused women can always leave if they wish
Abused women are usually constrained from leaving home by a number of factors. These include:
Fear of reprisals – many women are subjected to threats of injury and violence to themselves or their children if they leave. Approximately 40–45% of women killed by their spouse are separated or in the process of separating40,41
Social isolation – a number of social factors contribute to why women feel they cannot leave; having dependent children, being deliberately isolated from friends and family by the perpetrator, and shame relating to injuries. Abused women often have no-one to turn to and are unaware of available services
Financial dependence – women generally do not have equivalent earning capacity to men. To leave their partner condemns many women, and their children, to a substantial decline in their standard of living42
Emotional dependence and fear – many abused women are committed to their relationship, love their partner and are hoping for a change in the relationship. Some abused women are fearful that their partner will not cope with a separation and/or the partner may be threatening to suicide if she leaves
Poor self-esteem – after years of physical violence and verbal abuse, many victims lose their self-confidence and doubt their ability to cope on their own.
In a meta-analysis of 25 interview studies of women’s expectations and experiences when they encounter clinicians, there were consistent messages about how GPs can respond appropriately to the issue of partner violence (Table 4).43
Table 4. What abused women say they want from GPs
Before disclosure or questioning
- Understand the issue, including knowing about community services and appropriate referrals
- Ensure that the clinical environment is supportive, welcoming, and non-threatening
- Place brochures and posters in the clinical setting
- Try to ensure continuity of care
- Be alert to the signs of abuse and raise the issue
- Use verbal and non-verbal communication skills to develop trust
- Assure abused women about privacy, safety and confidentiality issues
- Be compassionate, supportive and respectful towards abused women
When the issue of intimate partner abuse is raised
- Be non-judgemental, compassionate and caring when questioning about abuse
- Be confident and comfortable asking about intimate partner abuse
- Do not pressure women to disclose; simply raising the issue can help them
- Consider asking about abuse at later consultations because patients may disclose at another time
- Ensure that the environment is private and confidential, and provide sufficient time
Immediate response to disclosure
- Take time to listen
- Respond in a non-judgemental way, with compassion, support and belief of experiences
- Validate experiences, challenge assumptions and provide encouragement (Table 5)
- Acknowledge the complexity of the issue, respect the patient’s unique concerns and decisions
- Put patient-identified needs first, making sure social and psychological needs are addressed
- Address safety concerns
- Provide information and where appropriate offer referral for more specialised help
- Assist patients to make their own decisions
Response in later interactions
- Be patient and supportive; allow the patient to progress at their own pace
- Understand the chronicity of the problem and provide follow-up and continued support
- Respect the patient’s wishes and do not pressure them into making any decisions
- Be non-judgemental if patients do not take up referrals immediately
Even if a woman does not choose referral to specialist intimate partner abuse services, our validation of her experience (Table 5) and the offer of support is an act that may contribute to her being able to change her situation. These questions and responses are applicable for both male and female victims. The readiness to action model can be very helpful in understanding a patient’s current position within the journey of change (refer to Chapter 4).
Table 5. Possible validation statements if a patient discloses intimate partner abuse
- Everyone deserves to feel safe at home
- You don’t deserve to be hit or hurt and it is not your fault
- I am concerned about your safety and wellbeing
- You are not alone; I will be with you through this, whatever you decide. Help is available
- You are not to blame; abuse is common and happens in all types of relationships
- Abuse can affect your health (and that of your children).
In addition to offering support, we need to make an initial assessment of the patient’s safety (Table 6). This may be as simple as checking if it is safe for her (and her children) to return home. A more detailed risk assessment (refer to Chapter 3) will include questions about escalation of abuse, the content of threats, and direct and indirect abuse of any children.
Table 6. Assessing the safety of patients experiencing intimate partner abuse
- What does the patient need in order to feel safe?
- Has frequency and severity increased?
- Is the perpetrator obsessive about the patient?
- How safe does she feel?
- How safe does she feel her children are?
- Has the patient been threatened with a weapon?
- Does the perpetrator have a weapon in the house?
- Has the violence been escalating?
GPs involved in obstetric or shared antenatal care need to be aware that pregnancy is a risk factor for intimate partner abuse. Evidence suggests that four to nine women in every 100 pregnant women are abused.44
We ask pregnant patients about smoking, alcohol and breastfeeding, and we also need to screen for intimate partner abuse.3,2
For many women, pregnancy and the post partum period exacerbates the violence and threats within their relationship.45 For some, pregnancy may even provoke it. A violent and jealous partner may resent the pregnancy because he is not prepared to ‘share’ her. There may be financial or sexual pressures, which are compounded by the pregnancy.
Abused pregnant women are twice as likely to miscarry than non-abused pregnant women. An abusive partner will often target the breasts, stomach and genitals of their pregnant partner.3 Often the abuse will start with the first pregnancy, and as a result the woman may avoid prenatal check-ups. Women who do not seek antenatal care until the third trimester should raise suspicion.
Consider asking about intimate partner abuse in the antenatal period.3
Aboriginal and Torres Strait Islander peoples
Aboriginal and Torres Strait Islander victims of violence include men, women and children, but women are the predominant victims of intimate partner abuse.46 The most vulnerable age group is 15–24 years followed by 25–34 years and 35–44 years – the risk for being a victim of Aboriginal and Torres Strait Islander family violence decreases after the age of 45.46 One factor alone cannot be singled out as the ‘cause’ of family violence, but research has found that the strongest risk factor for being a victim of violence as an Aboriginal and Torres Strait Islander person is alcohol use. Other factors include being removed from one’s family, single parent families and financial stress (refer to Chapter 11).47
Gay, lesbian, bisexual and transgender people
Diverse sexual orientations and gender identities require specific knowledge and skills of the GP.48 It is particularly important for us to understand the impact of societal homophobia, biphobia and transphobia (prejudice against gays and lesbians, bisexual, and transgender people respectively) on this group of people. Homophobia, biphobia and transphobia commonly manifest in abuse and violent outbursts towards gay, lesbian, bisexual and transgender (GLBT) people. This ranges from victimisation of same-sex-attracted young people at school, to harassment in the workplace and violence in public places. In an Australian population-based sample, 63% of lesbian and bisexual women reported lifetime abuse as compared with 37% of heterosexual women.49 Experiences of such violence, and the pervasive fear of assault, have a negative impact on the mental and physical health of GLBT people. It can lead to the need to conceal their sexual orientation or gender identity to reduce the risk of violence. It can also lead to non-disclosure within consultations, as the patient cannot predict the attitude of the health practitioner.
There is a predominant assumption in society that violence within same-sex relationships does not exist, or that it is not as confronting as violence within heterosexual relationships. Also present is the assumption of ‘mutual combat’, implying that violence is reciprocated or, at the very least, the victims are able to defend themselves because they are of the same gender. These statements are sometimes true, but if so, victims may question their victim status if they responded with violence, and may feel guilty for having participated in a violent way. Conversely, they may berate themselves for not defending themselves.
Emerging evidence from population-based studies indicates that there are no differences in the prevalence, type or severity of abuse between same-sex and opposite-sex couples; and in one study women survivors of same-sex domestic violence were twice as likely than those with male perpetrators to have poor self-perceived health status.50 This poor health status may be due, in part, to a reluctance to report the violence due to fears of triggering a negative response from services.51 The result of the relative invisibility of same-sex intimate partner abuse is that GPs do not consider it, and do not ask about it.
Cultural sensitivity can encourage disclosure of sexual orientation and gender identity, and therefore related experiences of violence. This can be communicated to GLBT people within the general practice setting in the following ways:52,53
- waiting areas – displaying materials specific to GLBT people including a rainbow flag sticker and specific information pamphlets on local services and support groups
- staff training – ensuring that all staff are trained not to make assumptions about the gender of patients and their partners, and to be aware of other forms of heterosexism
- practice policy – including anti-discrimination statements specific to sexual orientation and gender identity
- communication within the consultation – the use of gender-neutral language when discussing partners, being openly non-judgemental about different lifestyles, and being willing to ask direct questions about the possibility of abuse and discrimination.
Culturally and linguistically diverse women
The problems for women from a non-English speaking background are often compounded by social isolation, language barriers, the migration experience, cultural differences and for some, their religious beliefs. They may be less aware of the resources that exist within the community and how to access them. They may also need help in their own language and support that is culturally appropriate. Migrant women often feel economically and socially marginalised and need support to seek services and to understand the Australian legal system (refer to Chapter 12).
In 2013, the WHO released clinical and policy guidelines for GPs responding to intimate partner violence and sexual violence.3
The guidelines recommend that GPs ask women about intimate partner abuse as a part of assessing the conditions that may be caused or complicated by intimate partner abuse. These include mental health symptoms, alcohol and other substance use, chronic pain or chronic digestive or reproductive symptoms.
Minimum requirements for GPs to ask women about violence include that it is safe to do so – that the abusive partner is not present, for example – and that they have training and systems in place. Domestic violence posters and pamphlets should also be available in women’s bathrooms within the practice or service.
GPs should provide immediate first-line support to women who disclose violence including:
- being non-judgemental and supportive, and validating what the woman is saying
- providing practical care and support that responds to her concerns, but does not intrude
- asking about her history of violence, listening carefully, but not pressuring her to talk
- helping her to access information about resources, including legal and other services that she might think helpful
- assisting her to increase safety for herself and her children
- providing or mobilising social support.
GPs are often the only health practitioners seeing the victim, the perpetrator and the children, which can create difficulties for doctors. The major principles of management are safety and confidentiality within legal limits. Chapter 3 outlines documentation, safety and risk assessment issues, Chapter 4 ongoing follow-up and management of patients and Chapter 5 management of perpetrators.
Please refer to Tool 7 in the pdf version for resources nationally and in your area.
Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
When she talks to you about the violence – a tool kit for GPs on domestic violence that was developed in NSW.
Management of the whole family when intimate partner violence is present: Guidelines for primary care physicians – this guide outlines information relating to management of the whole family. Developed by an international group, it explores the evidence surrounding identification and management of patients experiencing intimate partner abuse.
For more information on implementing change at a practice level, refer to the RACGP’s Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting (the Green Book).