Abuse and violence - Working with our patients in general practice


The White Book
Section 10.2  People with disabilities
☰ Table of contents


Key messages

  • Health practitioners have a role in preventing, detecting and managing abuse in their patients with disabilities3,264
  • People with disabilities need appropriate education, care and protection to ensure that violence and abuse are minimised and that responses are adequate when they do occur265
 

Recommendations

  • Health practitioners should be aware that people with disabilities, particularly those with a mental illness, are at a much greater risk of violence – physical, sexual, or intimate partner – than those without a disability266 Level I C

 

Introduction


People with disabilities are a vulnerable group within our society and among our patients. They are at increased risk for neglect and for multiple forms of abuse including verbal, psychological, physical and sexual.3

 

Prevalence of disability


The Australian Bureau of Statistics research in 2009 identified 18.5% of the community as having a disability. Of these, 2.9% of people had a ‘profound core limitation’, indicating the need for assistance with daily tasks such as self-care, mobility or communication. About 1.86% of the population has an intellectual disability.267

 

Abuse and people with disabilities


People with disabilities, especially those with intellectual disability or mental illness, are at high risk of violence perpetrated against them,266 especially sexual exploitation. Children with disabilities are more likely to be victims of violence than are their peers who are not disabled.144 Research suggests that 50–99% have been sexually exploited by the time they reach adulthood.267,268,269 Abuse may include intimate partner abuse, violence and sexual, emotional and financial exploitation.

People with intellectual disability (especially men) are also at risk of being accused of abuse due to their sometimes-poor understanding of appropriate behaviour and poor social and relationship skills.

Abuse of people with disabilities is most likely to be perpetrated by family members, support workers or co-clients of support services. It can be difficult to differentiate between ‘passive’ abuse such as rough handling, inattention and withholding of care information, and more purposive abuse, such as sexual and physical assault. Poor screening of support workers and drug and alcohol abuse by family members or support workers increase the risk of abuse.

Research has been undertaken to explore the issue of sexual abuse in women with intellectual disabilities and ways of helping family members and support workers develop skills to help in the prevention of abuse of people with intellectual disability.264,265

Other research has demonstrated that it is possible to teach people with intellectual disability skills in decision making and identifying the difference between healthy and abusive interactions. People have also been assisted to use these skills in their own life situations.270–272

 

The role of GPs


GPs and other health practitioners have a duty of care to patients with disabilities, as to all patients. However, access to and provision of appropriate healthcare for people with disabilities may be difficult due to physical access problems, communication difficulty or lack of awareness of the need for care on the part of patients and their carers.269 Research has shown that people with disabilities have greater health needs and less access to healthcare. Good general practice care has the potential to greatly improve the health and welfare of people with intellectual disability. GPs need to be mindful of the possibility of abuse.

 

Identification


A person with a disability may:

  • lack support to deal with violence and abuse
  • live in a group home or other supported living situation with little privacy
  • experience abuse from those responsible for his or her care
  • not understand his or her rights
  • need appropriate support to communicate effectively
  • be ‘not believed’ or told it is their fault
  • believe it is their fault even if not directly told this
  • fear that if they speak up the abuse will escalate.

People with disabilities can experience the same effects of family violence and sexual assault as the elderly (refer to Table 15) or people without disabilities (refer to Chapters 267 and 9 ). Patients with intellectual disability in particular may have limited or no verbal communication, and may present with changes in behaviour such as sudden excitability or withdrawal, challenging behaviour and/or mental illness as a result of abuse.

 

Management


GPs can assist by:

  • listening in a non-judgemental manner
  • seeing the patient alone for some of the time if they are able to communicate independently (keeping in mind that the accompanying person may be the perpetrator of abuse)
  • giving permission to speak about sensitive issues, especially sexual abuse
  • helping the patient understand the effects of abuse on their health and welfare
  • helping the patient to find ways to be safe
  • reassuring the patient that they are not to blame
  • reinforcing that everyone has the right to live without violence
  • being aware of services in the community such as counselling, advocacy, police and legal services
  • allowing time for the patient to make their own decisions.

 

Changes in the disability system: The NDIS


In 2013 there was major shift in the structure of disability funding. The Australian Government passed legislation to replace the current separate state-controlled systems with the National Disability Insurance Scheme (NDIS, also referred to as DisabilityCare Australia). The NDIS aims to individualise funding and allow more choice of service provider and use of available funds. Disability advocates have hailed it as a breakthrough in fairness, choice and control for people with disabilities. However, as with any system, care will need to be taken to ensure that as the system is rolled out, it meets its potential to reduce harm, abuse and neglect.273

 

Conclusion


The elderly and those with disabilities are at increased risk of experiencing abuse and violence. However, these particular patient groups may find it difficult to disclose such abuse because of their situation or even an inability to verbally communicate. Some patients may not understand that what they are experiencing is abuse or what their rights are because of potentially limited intellectual capacity. GPs should consider the possibility of abuse and identify and appropriately care for patients to ensure their safety.

Where the patient has lost the capacity to make decisions, help may need to be sought from the person legally responsible for giving consent for their healthcare. If this person is the abuser, then seek help from the appropriate advocacy source in your state or territory (refer to Resources).

 

Resources


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

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013. 
  2. Jones L, Bellis MA, Wood S, et al. Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet 2012;380:899–907. 
  3. Eastgate G, van Deil M, Lennox N, Scheermeyer E. Women with intellectual disabilities – study of sexuality, sexual abuse and protection skills. Aust Fam Physician 2011;40:226–30. 
  4. Eastgate G, Scheermeyer E, van Driel M, Lennox M. Intellectual disability, sexuality and sexual abuse prevention – a study of family members and support workers. Aust Fam Physician 2012;41:135–9.
  5. Hughes K, Bellis MA, Jones L, et al. Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies. Lancet 2012;379:1621–9. 
  6. Australian Bureau of Statistics. Disability, ageing and carers. Australia: summary of findings 2009. Canberra: Commonwealth of Australia, 2011. 
  7. Intellectual Disability Rights Service. Legal Advice, 2014. 
  8. Jenkins R, Davies R. Neglect of people with intellectual disabilities. J Intellect Disabil 2006;10:35–45.
  9. Khemka I, Hickson L, Reynolds G. Evaluation of a decision-making curriculum to empower women with mental retardation to resist abuse. Am J Ment Retard 2005;105:193–204. 
  10. Barger E, Wacker J, Macy R, Parish S. Sexual assault prevention for women with intellectual disabilities: a critical review of the evidence. Intellect Dev Disabil 2009;47:249–62. 
  11. Johnson K, Frawley P, Hillier L, et al. Living Safer Sexual Lives: Research and Action. Tizard Learning Disability Review 2002;7.
  12. National Disability Insurance Scheme Launch Transition Agency (National Disability Insurance Agency). National Disability Insurance Scheme