Abuse and violence

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Abuse and violence can occur in many forms, including physical, psychological, financial, sexual and social, as well as neglect. In Australia, after the age of 15 years, one in six women and one in 16 men have experienced physical or sexual violence from a current or previous partner, with one in four women enduring emotional abuse by a current or previous partner.1 Child abuse and neglect have long-term impacts on health, including higher rates of diabetes, gastrointestinal problems, headaches and heart disease in adulthood, in addition to persisting mental health problems, eating disorders, obesity, and alcohol and substance abuse.2 Partner violence is the third leading risk factor for total disease burden in women aged 25–44 years, behind child abuse and neglect during childhood, and illicit drug use.1 While women are more likely to experience violence in their home from a known person, men are more likely to experience violence in a public place from a stranger.1

The most prevalent form of abuse and violence in Australia is bullying. One in four Australian children in years four to nine have been bullied, and approximately one in five Australian young people experience cyberbullying in a 12-month period.3 In a six-month period, 9.4% of Australian workers experience bullying, and one-third of these experience bullying at least weekly.4 Women are more likely to be bullied and to experience unwanted sexual advances, unfair treatment due to their gender, and to be physically assaulted or threatened by a client or patient.4

There are over 600 abuse-related hospitalisations per year for children in Australia.1 In 2017–18, there were more than 26,400 child protection notifications substantiated, with emotional abuse most commonly reported as the primary abuse type.5 Approximately 13% of Australian adults experienced physical and/or sexual abuse during childhood,6 while one in six women and one in 25 men have experienced at least one sexual assault since the age of 15.7 The rate of police-recorded sexual assaults against children aged 0–14 years is nearly twice that of people aged 15 and over.7

The prevalence of abuse of older people in Australian residential aged care is estimated to be almost 40%.8 In the Australian community as a whole, the prevalence of abuse of older people is estimated at between 2% and 14%.9 The abuse of older people can be financial, emotional, physical, sexual and/or neglect.10 Aboriginal and Torres Strait Islander peoples and people from culturally and linguistically diverse communities face additional barriers to reporting sexual assault, including communication barriers, lack of culturally appropriate services, and lack of trust in police and institutions.7

Due to the prevalence of abuse and violence in the community, it is imperative that general practitioners (GPs) understand abuse and violence-related presentations. GPs play an important role in recognising red flags that may indicate a patient is experiencing or has experienced abuse or violence. Individuals may present on one or several occasions with signs, such as recurrent injuries or unexplained bruising, that warrant further investigation. Depression is the most common presentation in Australian general practice for victims of family and domestic abuse and violence.11 Patients may also present with less specific symptoms and signs, such as mood changes, sleeping issues or substance misuse. Screening for abuse and violence should occur across the lifespan. The use of trauma-informed care is important to promote safety, empowerment and healing with patients. GPs may be called on by police to examine a person who has been physically or sexually assaulted, particularly in rural and remote areas, or may be asked by a patient for an examination following an assault. An understanding of forensic requirements, including chain of custody and writing court reports, are essential general practice skills, as well as knowing where and when to seek assistance. GPs need to be aware of their medico-legal requirements and mandatory reporting laws.

References
  1. Australian Institute of Health and Welfare. Australia's health 2020: in brief. Canberra: AIHW, 2020.
  2. Child Family Community Australia. Effects of child abuse and neglect for adult survivors. Canberra: Australian Institute of Family Studies; 2014 [Accessed 4 November 2021].
  3. Australian Institute for Teaching and School Leadership. Spotlight: Bullying in Australian schools. Melbourne: Australian Institute for Teaching and School Leadership, [date unknown] [Accessed 4 November 2021].
  4. Potter R, Dollard M, Tuckey MR. Bullying & Harassment in Australia Workplaces. Canberra: Safe Work Australia, 2016 [Accessed 4 November 2021].
  5. Australian Institute of Health and Welfare. Australia's children: in brief. Canberra: AIHW, 2020.
  6. Australian Bureau of Statistics. Personal safety, Australia. Canberra: ABS, 2017.
  7. Australian Institute of Health and Welfare. Sexual assault in Australia. Canberra: AIHW, 2020.
  8. Commonwealth of Australia. The Royal Commission into Aged Care Quality and Safety. Experimental Estimates of the Prevalence of Elder Abuse in Australian Aged Care Facilities. Canberra: Commonwealth of Australia, 2020.
  9. Australian Institute of Health and Welfare. Australia's welfare 2019 data insights. Canberra: AIHW, 2019.
  10. The Royal Australian College of General Practitioners. RACGP Aged Care Clinical Guide. 5th edn. East Melbourne, VIC: RACGP, 2020.
  11. Forsdike-Young K, Tarzia L, Hindmarsh E, Hegarty K. Family violence across the life cycle. Aust Fam Physician 2014;43:768–74.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • empathically and sensitively ask patients of all ages about exposure to abuse and violence
1.1.1, 1.1.2, 1.2.3, 1.3.1, AH1.3.1
  • clearly and respectfully communicate with family members and carers where abuse of children or older people is suspected
1.1.2, 1.1.3, AH1.3.1, 1.3.1
  • establish a therapeutic relationship with patients who have experienced abuse and violence that is based on respect and trust and has clearly defined boundaries
1.3.1, 1.4.1, 1.4.3, 1.4.4, 1.4.5, AH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify red flags that may indicate abuse or violence and respond appropriately, especially where there is an immediate risk to health and safety
2.1.3, 2.3.1, 2.3.3
  • assess an individual’s safety following disclosure of abuse or violence, and support them to develop a safety plan
2.1.1, 2.1.2, 2.3.1, 2.3.3, 2.3.4, AH2.3.1, RH2.3.1
  • provide trauma-informed care to an individual who has experienced abuse or violence
2.2.2, 2.3.1, AH2.3.1
  • refer patients who have experienced abuse or violence to appropriate support and specialised services
2.3.1, 2.3.2, 2.3.4, AH2.3.1, RH2.3.1
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • advocate for access to appropriate services and care for patients who have experienced, or are at risk of, abuse and violence
3.1.1, 3.1.2, 3.1.3, 3.1.4
  • identify and promote ways to contribute to positive messaging and changes to reduce risk of abuse and violence for individuals and communities
3.1.4, 3.2.2, 3.2.3, AH3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • manage personal health through self-care and setting professional boundaries when treating patients who have experienced abuse and violence
4.1.5, 4.2.2, 4.2.3, 4.2.5
  • explore and identify personal beliefs and views on abuse and violence that might impact on interactions with patientss
4.2.1, 4.2.2, 4.2.4
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • document evidence of abuse and violence in a manner that is appropriate to the medico-legal context and jurisdiction
5.2.1, 5.2.3
  • discuss duty-of-care obligations in regard to mandatory reporting
5.2.1, 5.2.3, 5.2.6

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. If you are finding a patient ‘difficult’; for example, they don’t turn up to appointments, always arrive late, or present frequently with headaches, abdominal pain or other somatic symptoms, consider that they may be current or historical victims of abuse and/or violence. Reframing our judgement and adopting a patient-centred approach, rather than dismissing the individual as a ‘difficult patient’, can be life-saving for that patient.
  2. Regression of development in young children can be a sign of abuse or violence.
  3. Working with people who have suffered abuse or violence can be challenging and affect your own health and wellbeing. Acknowledge that this is difficult work, and that the suffering of others does not lessen the intensity of your suffering. Remember to look after yourself.
  4. Abuse of older people is common and often insidious. A good understanding of the patient’s social relationships and resources is invaluable when assisting an older patient who is subjected to abuse.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Abuse and violence

Eva, a 23-year-old woman, presents with her four-year-old son, Tye. Tye had been dry at night for the past six months, but has been wetting the bed almost every night for the past two weeks. Eva tells you she is in a new relationship that started six months ago, and she is 14 weeks pregnant.

Questions for you to consider Clinical exam assessment area Domains

What techniques would you use to engage both Eva and Tye in the consultation?

What communication strategies would you use to sensitively ask Eva about exposure to abuse and violence?

How would you vary your approach to communication if Eva and Tye identified as Aboriginal or Torres Strait Islander? Which Aboriginal and Torres Strait Islander-specific services could you refer Eva and Tye to? What specific resources are available for Aboriginal and Torres Strait Islander peoples?

  1. Communication and consultation skills
1,2,5
 

What red flags may indicate abuse or violence?

How would you assess Eva and Tye’s safety?

Describe the elements of an appropriate physical examination.

  1. Clinical information gathering and interpretation
2   

How would you assess whether Eva and Tye have post-traumatic stress disorder (PTSD) or complex PTSD (CPTSD)? What are the diagnostic criteria? Are these criteria different in childhood and adulthood?

Would you consider any investigations in light of Tye's recent bedwetting?

  1. Making a diagnosis, decision making and reasoning
2   

What is a safety plan? What essential components of a safety plan would you discuss with Eva for her and Tye?

Which counselling techniques could you use to help Eva? What about for Tye?

If Eva or Tye has PTSD or CPTSD, how would you adjust your counselling?

What are the local referral options for Eva and Tye?

  1. Clinical management and therapeutic reasoning
2   

Which groups of patients are at higher risk of intimate partner or family violence? At which stages of life are they more at risk?

  1. Preventive and population health
1,2,3      
 

What are the differences between the roles of medico-legal examiner and advocate, particularly with respect to the patient relationship?

How would you ensure that any personal biases don’t influence the consultation?

How do you practise self-care? What are the signs of vicarious trauma?

  1. Professionalism
4   

If either Tye or Eva has injuries on examination, do you know the medico-legal terms that describe specific injuries?

What is the legal difference between a request for information and a subpoena? How do patient confidentiality and the Privacy Act 1988 apply in each of these situations?

What is mandatory reporting?

  1. General practice systems and regulatory requirement
5   

If Eva had been sexually assaulted, what physical examination and specimen collection would you carry out if you were the only doctor working in a remote area? Where would you call for assistance to ensure that the correct protocol is followed?

What if Eva were an Aboriginal or Torres Strait Islander, would that change your approach? What resources could you use to assist?

Where could you refer Eva for further examination and management if working in a larger centre?

  1. Procedural skills
2   

How would you manage Eva and Tye if you suspected abuse, but Eva was unwilling or not ready to disclose? How would you manage the situation if your suspicions were incorrect?

  1. Managing uncertainty
2   

What findings on history or examination would indicate that urgent referral to hospital is needed?

In a rural or remote setting, when would you evacuate Eva and/or Tye to a larger centre?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify 10 patients from your practice software who are currently or were recently pregnant, and audit the notes to check for screening for abuse and violence.

  • Have these patients been screened for exposure to abuse and violence? Do any of the patients have documented higher risk? For those who have disclosed abuse or violence, is there a safety assessment and safety plan documented?
  • Can you sensitively present the results of this audit to your practice? What changes could you suggest to help ensure improved screening?

Using the Emerging Minds Pathways of care template, map the services available in your area for children, parents and families dealing with stressors, including abuse and violence. Extend the map to include services for sexual abuse/assault and abuse of older people.

  • Are there local services for children, adults and older people for physical, sexual and emotional abuse/trauma? For family violence? For victims of crime? For those experiencing vicarious trauma? For those subjected to bullying and/or harassment? Are there services for Aboriginal and Torres Strait Islander peoples?

Using a recent consultation in relation to abuse, harassment or assault, write a medico-legal report for submission as evidence in court. Ask your supervisor to review it with you.

  • Have you used the correct terminology, in the correct context; for example, laceration, incision and abrasion?
With a supervisor

Ask your supervisor to identify a consultation with a patient who has been subjected to abuse or violence, and discuss the case.

  • How did your supervisor identify the abuse or violence? How did they feel during the consultation/s? How did they manage the case? What advice do they have for you when you encounter similar situations?
  • What strategies did your supervisor use to debrief after the consultation?

Discuss vicarious trauma and self-care strategies to prevent/address it.

  • How does your supervisor prevent vicarious trauma?
  • What strategies could you use and how will you incorporate them into practice?

Review a recent ‘difficult’ consultation or patient.

  • Why was the consultation difficult?
  • What are common presentations for survivors of childhood trauma? Could childhood trauma or other trauma be a contributing factor as to why consultations with this patient are challenging?
  • How does your supervisor approach 'difficult’ consultations? Consider role-playing different approaches.
In a small group

Role-play a consultation with a patient who is exposed to abuse or violence; for example, a child with unexplained bruising, a woman with a controlling partner, an adolescent experiencing bullying at school/on social media or an elderly gentleman with an abusive carer.

  • How would you ask a patient about exposure to abuse or violence? What are the red flags that may alert you to abuse or violence?
  • What emotions did you note during this role play? What emotions did the role-player experience? How could you deal with these emotions? 
Role-play a scenario where you are giving expert witness testimony (as a Fellowed GP) in court related to one of the above scenarios.
  • Were the appropriate medico-legal terms used in the correct context? Was the information conveyed in a clear and concise manner, without emotive language?

Role-play a consultation with a very distressed patient.

  • What communication strategies did you use to de-escalate the situation, and how successful were they?
  • How did you feel during the consultation? How did the ‘patient’ feel?

As a group, create a fictional medico-legal report for a patient who presented with injuries from an alleged assault.

  • What details were needed? Were you surprised at how much detail was needed?
With a friend or family member

Ask a friend or family member if they are aware of abuse of older people and what it is. Educate them about it.

  • Ask your friend or family member for feedback on your explanation. Did they understand what you were saying? Did you use any emotive or confrontational language? If so, how could you change your explanation to exclude any emotive or confrontational language?

Visit the local women’s refuge, domestic violence service, or sexual assault service.

  • What processes does the service have in place to keep their clients physically and psychologically safe? What is the range of ages, genders and ethnicities of clients using the service?
  • How can this information help you in your practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

Communication
  • Identify and manage barriers to communication.
  • Understand the specific considerations when communicating and managing patients who identify as Aboriginal or Torres Strait Islander, and adjust communication accordingly.
  • Manage distress.
  • Use de-escalation techniques to de-escalate the person in crisis.
  • Apply appropriate counselling techniques for patients with post-traumatic stress disorder (PTSD) or complex PTSD (CPTSD).
  • Identify and manage trauma, including intimate partner violence, victims of violent crime, exposure to torture and trauma, occupational trauma, bullying and harassment, and vicarious trauma (in those who support victims of trauma).
  • Identify those at risk of abuse, violence and trauma, including by age, gender and situation.
Abuse and violence in children and adolescents
  • Recognise symptoms and signs of abuse and violence in children and adolescents.
  • Identify the red flags for exposure to abuse and/or violence in children and adolescents.
  • Conduct and document the physical examination of a child exposed to abuse and/or violence.
  • Assess for exposure to abuse and violence at every developmental assessment and at every vaccination appointment.
  • Understand the impact of adverse childhood experiences and the importance of early intervention.
  • Formulate a management plan and safety plan for a child with suspected or confirmed exposure to violence and abuse.
  • Understand mandatory reporting requirements.
  • Understand the essential elements of informed consent, particularly with respect to sexual activity.
  • Refer appropriately to specialist services and community support services.
Abuse and violence in adults
  • Screen for exposure to abuse and violence, particularly at times of increased vulnerability, such as pregnancy.
  • Identify the red flags that may indicate exposure to abuse and/or violence.
  • Take a history and conduct an examination, and appropriately document the findings, for an adult who has been abused or assaulted.
  • Understand the different roles of medico-legal assessor versus advocate, and apply those roles appropriately.
  • Understand the legal requirements of a request for information or report versus a subpoena.
  • Understand the application of the Privacy Act 1988.
  • Prepare a medico-legal report using correct terminology that relates to mechanism of injury, and using non-emotive language.
  • Practise in a trauma-informed manner.
  • Conduct an initial assessment after a sexual assault and refer appropriately for further assessment.
  • Consider the need for post-exposure prophylaxis, emergency contraception and testing for sexually transmissible infections for a patient who has been sexually assaulted.
  • Recognise the impacts of adverse childhood events on adulthood and manage/address those impacts.
  • Recognise and manage PTSD and CPTSD.
  • Engage with, assess and develop a management plan for a person who identifies that they are a perpetrator of violence and/or abuse.
  • Refer appropriately to specialist services and community support services.
Abuse and violence in the elderly
  • Identify the red flags for abuse of older people.
  •  Screen for exposure to abuse and violence in a culturally appropriate and sensitive manner.
Vicarious trauma and self-care
  • Recognise that all healthcare workers are susceptible to vicarious trauma and may experience occupational trauma.
  • Recognise the signs and symptoms of vicarious trauma within self and colleagues.
  • Identify adaptive coping strategies and strategies to relieve stress.
  • Practise self-care and encourage colleagues to practise self-care.
  • Engage in self-reflection.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
A succinct and up-to-date overview of CPTSD and the long-term sequelae of childhood trauma. An overview of screening tools and how to incorporate them into practice.
Online resources
Evidence-based guidance on identifying and responding to patients experiencing abuse and violence. This chapter in the White book provides guidance on self-care.  An online teaching and learning resource that includes identifying and responding to victims and survivors of family violence, and working in a multidisciplinary healthcare team. Information about trauma-informed care and links to resources and further education.
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:  
Five modules covering the role of general practice, risk assessment, management and self-care.
    • Family abuse and violence learning path
Signs and symptoms, management, risk assessment and referral options.
    • Intimate partner violence
The role of GPs in diagnosing and managing abuse and violence.
    • check, unit 546, Jan/Feb 2018: Abuse and violence
  • Webinars:
Practical guidance on working with parents and children.
An introduction to family violence in Aboriginal and Torres Strait Islander communities.
An excellent overview of elder abuse.
Guidance on working with perpetrators of violence.
A practical and concise resource to guide management of patients who disclose sexual abuse.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/abuse-and-violence 6/10/2022