Abuse and Violence
Recognition, response and respect
Author: Amanda Lyons
Family abuse and violence is a major public health issue and, with support, GPs can make a real difference in patients’ lives.
According to Australia’s National Research Organisation for Women’s Safety, one in four women in the country has been affected by violence from a partner or boyfriend since the age of 15. Of these women, 61% had children in their care when the violence occurred.1
These numbers suggest that every general practice waiting room in Australia is likely to contain women (and men, but in far smaller numbers1) who are experiencing some form of family abuse and violence.
However, this may not often be immediately evident to many GPs. This was certainly once the case for Prof Kelsey Hegarty, GP and academic who is joint Chair in Family Violence Prevention at the University of Melbourne and the Royal Women’s Hospital.
When alarming research results about the prevalence of family abuse and violence in Australia were released in the 1990s, Prof Hegarty felt she couldn’t see those numbers reflected in her practice. She conducted her own research into the matter, ultimately uncovering confronting information.
‘I did a survey in the waiting rooms of randomly selected Brisbane general practices across the socioeconomic spectrum and found that domestic violence was very prevalent,’ she told Good Practice.
Prof Hegarty repeated her research in the ensuing decades and has found the figures remain comparable today.
‘There is a group of women sitting in general practice waiting rooms, around 5%, who have had quite severe combined abuse in the last 12 months,’ she said. ‘For example, have been forced to have sex, had a knife or gun used against them, kept from medical care, or locked up in a bedroom.
‘There is another group of women, also around 4% or 5%, who have had lesser physical violence, such as being pushed and shoved, and not so much sexual violence, but controlling behaviours with the physical violence. And then there’s other groups of women who experience physical or emotional abuse alone.
‘There’s certainly 10% of women who, in the last 12 months, have experienced combined physical and emotional abuse, and underpinning that is controlling tactics.
‘[These types of figures] have major health implications for women and their children.’
While the ‘traditional’ image of abuse and violence may involve obvious signs such as black eyes and broken bones, these sorts of serious physical effects are more likely to present in emergency rooms, often leaving GPs with less visible symptoms.
‘The problem is that it presents in hidden ways,’ Dr Elizabeth Hindmarsh, GP and co-Chair, with Prof Hegarty, of the RACGP Specific Interest Abuse and Violence network, told Good Practice. ‘Patients rarely walk through the practice door saying, “I’m involved in family abuse and violence”.
‘They come with anxiety or depression, insomnia, pain, drug and alcohol problems, eating disorders, non-specific symptoms.’
Another complicating factor is the fact that many patients experiencing abuse and violence may not even be aware that this is the case.
‘The fact that we have traditionally thought about domestic violence as “the black eye” is one of the trickiest things our counsellors, and doctors and frontline workers, would deal with. “He didn’t hit me, so it’s not violence”,’ Gabrielle Denning-Cotter, General Manager of the 1800 RESPECT national sexual assault, domestic family violence counselling service, told Good Practice.
Dr Hindmarsh agreed, citing other forms of abuse and violence that can be equally harmful.
‘People often think that family violence is only physical. They don’t see the psychological, the financial, the isolation, and the stalking and technological abuse that goes on,’ she said.
Recognising abuse and violence
Prof Hegarty believes the first step in recognising and assisting patients who are experiencing family abuse and violence is to set aside the more common assumptions about the phenomenon.
‘I think people tend to have in their heads that it’s [restricted to] lower socioeconomic groups, or people who drink, or this that or the other when, in fact, it’s across all of these areas,’ she said. ‘It’s people who drink and people who don’t, and people in different cultural groups.
‘Of course, there are some populations that are more vulnerable to it because they are generally vulnerable, like people with disabilities. And women are more vulnerable than men.
‘Men are the main people who use violence and abuse, and women are the main people who survive violence and abuse and are more likely to be injured or killed.’
Dr Hindmarsh acknowledged that it can be difficult for healthcare practitioners to come to terms with the idea that patients’ home lives may be abusive.
‘We all would like to believe that families look after each other, so it’s quite difficult to accept that in some families that is not happening,’ she said.
The nature of family abuse and violence means it can also be particularly difficult to elicit and identify.
‘I think there is something very unique about a situation in which the person who uses violence and abuse is someone that you love,’ Prof Hegarty said. ‘It really affects the survivor’s, or victim’s, sense of trust or identity.
‘That also creates the ability for it to be recurrent, as opposed to a stranger committing sexual assault. Most sexual violence actually occurs within a family situation.’
Prof Hegarty offered examples of ways in which abuse and violence might be seen in consultations.
‘In general practice, the most common presentations would be emotional health issues: depression, not sleeping, anxiety, sometimes eating disorders if there has been sexual abuse, often chronic pain, chronic headaches, and what we sometimes call psychosomatic-type illnesses,’ she said. ‘So unexplained symptoms, presenting frequently.
‘Those sorts of things are often where a GP could be thinking, “I wonder if there’s some anxiety or depression”.’
Prof Hegarty recommends that GPs do not hesitate to raise the issue if they suspect a patient is in an abusive situation.
‘GPs definitely shouldn’t wait, because the patient might wait a very long time [to raise the issue themselves],’ she said.
Although GPs may be wary of the potential embarrassment for themselves and the patient if they are wrong, Prof Hegarty has found that patients are likely to disclose if the subject if asked directly about abuse and violence in a sensitive and respectful manner.
For GPs who are uncertain as to how to proceed in the event they suspect an abusive situation, Prof Hegarty cites LIVES, a helpful mnemonic developed
by the World Health Organization that health professionals can use when they’ve established a patient is experiencing family abuse and violence.2
‘First Listen, and that’s most important,’ she said. ‘Inquire about their needs, Validate their experience; say that this is something that does happen to people and it is not acceptable. Then assist them to Enhance their safety, and ensure Support by offering follow-up.
‘That’s within the realm of every GP.
‘The part I find that GPs know less about is how to assess a woman’s safety and carry out safety planning, but I often find they pick that up very quickly.’
While not all abuse involves children, Prof Hegarty emphasised that, where this is the case, it is an additional reason for intervention.
‘We know that part of family violence is child abuse,’ she said. ‘And we know that the more adverse childhood experiences children have – and that can be exposure to their parents’ violence and abuse, rather than directly to them – has as much effect as direct child abuse.
‘So we really need to intervene in these families, for prevention of children growing up and becoming victims, and also people who use violence.’
Boundaries in treatment
Once a situation involving family abuse and violence has been determined, a GP may find a conflict in that the person who uses violence and the person who is experiencing it are both patients.
‘You can’t provide care for both of those parties,’ Dr Hindmarsh said. ‘You are likely to get entrapped in what’s going on; the perpetrator tends to minimise anything that’s happening and it’s easy to collude.
‘But both people do need care, as well as the children. That’s why it’s very important that practices have talked about how they’re going to manage this as a whole-of-practice matter.
‘They need to have discussed it and to know what the resources are, and they also need to know how to keep themselves safe.’
Prof Hegarty highlighted that family abuse and violence is often corrosive to the health of those who inflict it as well as those who experience it.
‘Often [people who use violence] are depressed or using alcohol or other substances, or have chronic pain,’ she said. ‘Some of them know this isn’t what should be happening, but really need someone to ask them about it.’
According to Prof Hegarty, GPs can use the same motivational interviewing techniques with those who use abuse and violence as they would for those who experience it.
‘You can ask them, “Is this happening at home? Do you think that what you’re doing is affecting your partner and your children? What happened to you when you were a child? What do you think your children think of it?” There’s a whole series of questions you can utilise.
‘It’s certainly important not to condone the violence; often there’s a lot of minimising and excusing and saying that it’s her fault. Be clear that this isn’t what should be happening, but you can be a conduit for sending off to referral.’
GPs should also keep their own care in mind when treating patients for issues of family abuse and violence. This is a difficult, intractable problem and dealing with it in consultations can take a toll on healthcare professionals, particularly in terms of vicarious trauma.
For GPs, practising self-care can involve a balance between providing support to patients and maintaining firm boundaries within the doctor–patient relationship. This balance, however, can be difficult to manage.
‘I know people who have worked in this area and found they fall into breaking those boundaries,’ Prof Hegarty said. ‘If they have never given their mobile phone number, they’re suddenly giving it. Or whatever rule they have normally got for their general practice, they find themselves breaking it because they feel so much angst about what’s going on.
‘But it’s good to have clear boundaries, because sometimes the patients who have been abused don’t have them.’
GPs who are helping patients with issues of abuse and violence often need support themselves.
‘GPs’ mental health can sometimes be affected by patients,’ Prof Hegarty said. ‘It’s the [self-care] principle of ensuring you’ve got people to talk to.’
Denning-Cotter believes that although it can seem daunting, GPs have a key role in helping people who are experiencing abuse and violence.
‘It’s a really powerful position that GPs have, because they come into contact with people every day,’ she said. ‘We know a high percentage of the women who come into a GP’s surgery are in a circumstance of violence, or at risk of being in a circumstance of violence.
‘So a GP’s response can be the key to a person being able to successfully work through and ultimately move out of a circumstance of risk, or a circumstance of violence.’
- Australia’s National Research Organisation for Women’s Safety. Violence against women: Key statistics. Sydney, NSW: ANROWS. Available at: http://anrows.org.au/sites/default/files/Violence-Against-Australian-Women-Key-Statistics.pdf [Accessed 28 February 2017].
- World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: A clinical handbook. Geneva: WHO, 2014.