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Clinical guidelines

Abuse and violenceWorking with our patients in general practice

Chapter 11. Aboriginal and Torres Strait Islander communities

Key messages

  • Aboriginal and Torres Strait Islander victims of violence include men, women and children. However, women are the predominant victims of intimate partner abuse46
  • The most vulnerable age group is 15–24 years followed by 25–34 years and 35–44 years. Your risk for being a victim of Aboriginal and Torres Strait Islander family violence decreases after age 4546
  • One factor alone cannot be singled out as the ‘cause’ of family violence, however, 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 are being removed from one’s family, single parent families and financial stress47

Recommendations

  • Health practitioners should raise the issue with any Aboriginal or Torres Strait Islander patient, no matter where they live, who is presenting with indications of being a victim of violence3 Level III A
  • At a community level, health practitioners need to show leadership through local organisations by advocating for provision of services that meet the needs of Aboriginal and Torres Strait Islander peoples experiencing family violence Practice point  

Introduction

Abuse and violence in Aboriginal and Torres Strait Islander communities across Australia has been the subject of intense media coverage over the past decade. These are not new issues. However, to address the health needs of patients, they need to be part of the care they will receive wherever they present to an Aboriginal and Torres Strait Islander medical service or general practice.

Prevalence

State-commissioned inquiries and government reports since 1999 have consistently reported that the occurrence of family violence in Aboriginal and Torres Strait Islander communities across Australia is disproportionately high in comparison to the Australian population as a whole. They have also highlighted that the main victims of family violence are women and children. However, men are also equally the victims of violence perpetrated often by other men.274–280 The 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS)46 confirms that:

  • of the 23.4% of Indigenous people reporting to be victims of physical or threatened violence in the 12 months prior to the survey, men and women had similar levels of victimisation47
  • a further, more in-depth study of the data, however, reveals that assaults by an intimate partner represented 41.7% of the most recent incidents reported. The largest proportion of incidents were against women46
  • 2.6% of Indigenous men reported being assaulted by a current or former partner, or date.46 This figure needs to be treated with some caution because the small numbers involved increase the risk of sampling error
  • men were most likely to be assaulted by someone outside of the family, either a person they knew by sight only or other known person (35.0%), friend, work colleague, fellow student or neighbour (22.8%).46

Children experiencing family violence

It should be recognised that family violence continues to be a significant risk factor for Aboriginal and Torres Strait Islander child abuse notifications to be substantiated in most states and territories. The data however is difficult to disaggregate and to obtain. In Victoria, for example, the police have reported that in Aboriginal and Torres Strait Islander family violence matters attended in 2005–06, children were present in 65% of the cases.281 These children are likely to have experienced and/or witnessed various forms of abuse and are intimately aware of its visible consequences for themselves and for their caregivers.282,283 Research evidence is widely available asserting that children living in homes in which violence occurs are vulnerable to physical, emotional and psychological abuse.282,283

Outcomes of this violence

As has been outlined in other chapters, exposure to violence puts children and adults at a greater risk of anxiety, depression and behavioural disorders. In addition, the experience of violence in childhood is a significant risk factor for being both a victim and a perpetrator of violence in adulthood.282,283 Thus, it is through children that a cycle of violence may take root and become intergenerational. This has been a significant concern for Aboriginal and Torres Strait Islander communities across the country and certainly in the many state inquiries that have been conducted over the past decade. There is copious evidence to illustrate the intergenerational transmission of violence. This is entrenched by the fact that many families have had little support in addressing the problems that led to the violence or indeed any assistance in healing from the violence.

Violence in Aboriginal and Torres Strait Islander communities 

In most states and territories there is a general acceptance that Aboriginal and Torres Strait Islander violence encompasses:

A wide range of physical, emotional, sexual, social, spiritual, cultural, psychological and economic abuses that occur within families, intimate relationships, extended families, kinship networks and communities. It extends to one-on-one fighting, abuse of Indigenous community workers as well as self-harm, injury and suicide.279

The term ‘lateral violence’ has also grown in prominence in Aboriginal and Torres Strait Islander communities in recent years. It describes the way people in positions of powerlessness, covertly or overtly, direct their dissatisfaction inward towards each other, toward themselves, and towards those less powerful than themselves. Langton explains that those most at risk of lateral violence in its raw physical form are family members and, mainly ‘the most vulnerable members of the family: old people, women and children. Especially the children’.284

Lateral violence occurs worldwide in all minorities, but particularly among Aboriginal and Torres Strait Islander peoples where its roots lie in colonisation, oppression, intergenerational trauma and ongoing experiences of racism and discrimination. Lateral violence is the expression of rage and anger, fear and terror that can only be safely vented upon those closest to us when we are being oppressed. It has been argued that those who do the oppression do not adequately bear witness to or respond appropriately to Indigenous experiences of oppression and as a consequence oppressed peoples feel unsafe in seeking supports from them.285

Behaviours included under the spectrum of lateral violence range from gossiping, jealousy, bullying, shaming of others, backstabbing, family feuding, organisational conflict, attempts at socially isolating others and in extreme situations, physical violence.284,286 By recognising these actions as violence, you can better appreciate that this kind of assault can be just as damaging as the other forms of violence. You also need to appreciate that this type of violence can take place alongside the other forms of violence and as a consequence make the context of individual, familial and community experiences with violence all the more complex. It also can inhibit individuals’ choices and options when making decisions about responding to the violence being inflicted upon them.285

Violence in Aboriginal and Torres Strait Islander communities - specific contexts 

The violence occurring in Aboriginal and Torres Strait Islander communities happens across the country regardless of locality in proportions consistent with the disbursement of the population. For example, in the 2008 NATSISS, 26% of Aboriginal and Torres Strait Islander people living in major cities had experienced physical violence during the 12 months prior to interview, compared to 22% of Aboriginal and Torres Strait Islander people living in remote areas.46 While there has been a large focus in the media and by government on the occurrence of violence in the Northern Territory, the available evidence tells us that the violence occurs in all states and territories. Figure 5 provides data from the 2008 NATSISS that demonstrate this. The table also illustrates the significance of age in the reporting of violence in Aboriginal and Torres Strait Islander communities.  – those under the age of 35 are more likely to report being survivors of physical or threatened violence than those who are older.

Figure 5. Reporting of physical and threatened violence by location and age in 2008 NATSISS (expressed as percentages)

15–24 years25–34 years35–44 years≥45 yearsTotal
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
Major cities of Australia 30.7 30.3 30.5 24.3 23.4 23.9 30.0 24.8 27.2 15.7 14.5 15.1 25.3 23.7 24.5
Regional Australia 26.1 30.9 28.4 28.8 29.7 29.3 23.3 23.5 23.4 14.5 13.1 13.7 22.9 23.8 23.4
Total non remote 27.9 30.6 29.3 26.4 27.0 26.7 26.4 24.1 25.1 15.0 13.6 14.3 23.9 23.8 23.8
Remote/ very remote Australia 30.7 30.8 30.7 25.6 22.7 24.1 22.2 18.9 20.5 9.1 10.6 9.9 21.8 20.9 21.3

Source: Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: AGPS; 2010.

The proportion of victimisation decreased with age and this finding is consistent with other population groups.46 Older members of the community experience other forms of violence, including economic abuse.

It is also significant to note that, of the Aboriginal and Torres Strait women who reported in the 2008 NATSISS that they had experienced physical assault during the 12 months prior to the interview, almost all (94%) knew the perpetrator of their most recent incident of physical assault, with the categories most frequently recorded being a current or previous partner (32%), or a family member (28%). Aboriginal and Torres Strait Islander men on the other hand were significantly less likely to identify a current or previous partner as the perpetrator of their most recent incident of physical assault (2%). They were more likely to report being assaulted by a family member (20%), friend (16%), known person by sight (20%), or other known person (25%).46

Factors contributing to the violence

One factor alone cannot be singled out as the cause of violence. Often a multitude of interrelated factors are responsible. A useful way of understanding the multitude of factors is by categorising them into two groups, as demonstrated in Figure 6.

Group 1 factors have been experienced specifically by Aboriginal and Torres Strait Islander peoples and their communities. It should be noted that for many Aboriginal and Torres Strait Islander peoples, ‘our lived’ experiences would dictate that any or all of the factors in Group 1 could also be identified as contributing to current experiences of violence.

Group 2 factors are seen as contributing to high levels of distress and can occur separately or in multiples in any population impacting on one’s experience of violence. Sufficient research evidence is now widely available to support this contention.287–293

The NATSISS conducted in 2002 and 2008 have also demonstrated that there is a strong relationship between reported victimisation and being removed from one’s natural family.47,294 For Group 2 factors, Weatherburn and Snowball found that the strongest risk factor for being a victim of physical violence was alcohol use.47 In addition, they demonstrated that significant predicators of victimisation included substance use, lone-parent families and financial stress.

Figure 6. Factors contributing to Aboriginal and Torres Strait Islander family violence

Figure 6. Factors contributing to Aboriginal and Torres Strait Islander family violence

Sources: Cripps K. Enough family fighting: Indigenous community responses to addressing family violence in Australia and the United States. Melbourne: Monash University; 2004. Cripps K, Adams M. Family Violence: Pathways Forward. In: Dudgeon P, Milroy H, Walker R, editors. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. Canberra: Commonwealth of Australia; 2014:399–416.

The role of GPs

The issues around identifying family violence are covered in Chapter 2. Intimate partner abuse: identification and initial validation.

Management

If your patient identifies as being Aboriginal or Torres Strait Islander, is under the age of 45, lives in any location in Australia and is presenting with indications of being a victim of violence, you should attempt to raise the issue with the patient. For ways of asking about violence and ways of responding to disclosure refer to Chapter 2, Chapter 3, and Chapter 4.

At a community level, GPs need to show leadership, for example through local primary healthcare organisations and other local organisations, by advocating for provision of services that meet the needs of Aboriginal and Torres Strait Islander peoples. The case study below provides an insight into the experience of family violence in an Aboriginal and Torres Strait Islander context and identifies some key issues to be mindful of in your interaction with an Aboriginal or Torres Strait Islander survivor of abuse.

Case study: Lisa

Lisa, a 24-year-old Aboriginal woman with three children aged 6 months, 20 months and 3 and a half years, presents to the emergency department of a regional hospital at the weekend. This is the fourth time in 18 months. She has injuries related to family violence. You have a follow-up visit with her at your clinic in your small regional town of 2000 people, 30% of whom are of Aboriginal or Torres Strait Islander descent. As you review her file you note that this is not her first presentation at the emergency department, or indeed at the practice, for injuries consistent with family violence. The first was about 2 years ago and included a broken nose and facial bruising. Other presentations have included:

  • a broken wrist
  • facial bruising
  • broken ribs
  • bruising.

On this occasion she has had more broken ribs, and extensive bruising down one side of her body from being repeatedly kicked. She has come in today because the hospital told her she needed to see her GP on Monday to follow-up on the tests they did in the hospital last Friday night.

The context

As you are reviewing Lisa’s notes you are thinking about what you know about Lisa, her partner, her broader family and the community in which she lives. This is a community that has had a significant history of dispossession and cultural dislocation and many of the families, including Lisa’s, have had aunts, uncles, brothers and sisters forcibly removed both as a policy of the Stolen Generation but also as a consequence of recent Child Protection involvement.

This is a community and family who have not had opportunities to heal from the hurts they have suffered and they struggle with day-to-day living. You know this because you have seen the high incidence of chronic illness, alcoholism and mental health issues in some sectors of the community and it is not unusual for you to be patching up patients who have borne the brunt of violence.

There are also many related issues that confound the problems faced by these community members. These include the high unemployment in the area, because of seasonal work, and the low educational attainment levels related to the racism experienced at the local school. Further, the high turnover of staff at schools and community centres, and more broadly the high levels of both financial and personal stress experienced by most community members, also confound the problems.

It is not unusual for members to be attending funerals at least once a month and this can have a great effect on individuals’ feelings of unresolved grief and powerlessness over their own circumstances.

Ongoing care

As you reflect on this context, you think about how you can draw on available resources to support Lisa and her children, to provide them with safety and then to begin the road to healing.

Lisa comes in with her sister Ella, whom she is staying with at the moment. Ella is well known in the community and works as an Aboriginal GP. She will be a great asset to you as you work with Lisa in developing both a safety and care plan for her.

Lisa’s children also attend the appointment. They have no obvious injuries and Lisa says that Rob has never hit them. The children, however, appear withdrawn – they are very quiet, appear scared, and are clingy to both their mum and their aunty.

Lisa says she hasn’t seen Rob since he got angry in the emergency department and they called security on him.

Rob will also need help. This should be provided by another GP, to assist with maintaining confidentiality. At this time the GPs responsibility is to Lisa and the children (refer to Chapter 3. Safety and risk assessment, and Chapter 5. Dealing with perpetrators in clinical practice).

Lisa’s safety

You may wish to discuss with Lisa and her sister what options are available to ensure her immediate safety. These might include:

  • staying with a family member or in a refuge – if available, a refuge specifically for Aboriginal and Torres Strait Islander women. Finding a refuge that has space can be challenging. Call the domestic violence line in your state
  • police assistance through the domestic violence liaison – remembering that many Aboriginal and Torres Strait Islander peoples have had bad experiences with the police
  • an Aboriginal Family Violence Prevention Legal Centre to obtain help or assistance with an intervention order.

If you are referring Lisa to the women’s refuge, or shelter, it is worth noting that they are in high demand, may not be able to cater for the number of children and can have quite strict rules that may be unsettling for Aboriginal and Torres Strait Islander clients. So the ‘fit’ may not always be the best option. It is, however, still worth trying.

Services for men

In terms of Lisa’s partner Rob, the number of Aboriginal and Torres Strait Islander men’s programs has grown significantly over the past decade, but there are still considerably fewer services available to address men’s needs than are available for women. GPs need to understand the context of Aboriginal and Torres Strait Islander men’s use of violence. Many men speak of their anger being related to colonisation. Colonisation, through its policies and practices, including dispossession and dislocation – for example, through the period of the Stolen Generations – often ‘constrain the control which people experience in their lives, and limit their personal choices under stress’.

Men’s ways of managing their trauma are too often, as Maggie White explains, seen as ‘bad’ or sometimes ‘mad’, but rarely as ‘sad’.296 Men are quickly seen as perpetrators but rarely as victims. Rex Wild and Pat Anderson’s Little Children are Sacred report of 2007 sheds more light on this underlying issue of men’s trauma and the intergenerational abuse that takes place in some communities as a consequence of little or no intervention for abused children.280 They provide the example of HG, reproduced here to exemplify Maggie White’s comments:

HG was born in a remote Barkly community in 1960. In 1972, he was twice anally raped by an older Aboriginal man. He didn’t report it because of shame and embarrassment. He never told anyone about it until 2006 when he was seeking release from prison where he had been confined for many years as a dangerous sex offender. In 1980 and 1990, he had attempted to have sex with young girls. In 1993, he anally raped a 10-year-old girl and, in 1997, an 8-year-old boy (ZH). In 2004, ZH anally raped a 5 year-old boy in the same community. Who will ensure that in years to come that little boy will not himself become an offender?

The above example clearly illustrates that Aboriginal men’s ways of coping tend to bring them into contact with the justice system and it is here that they may get their first court-ordered behavioural change type program, whether this occurs while incarcerated or on some form of bail or community-based order. In the event that no such program is ordered or offered through the criminal justice process, the GP may be in a unique position to offer other referrals to Rob should he visit your practice and this can be broached without confidentiality being breached (refer to Chapter 5). This will require some research in terms of what is available locally within Aboriginal and Torres Strait Islander medical services, via men’s groups or, again, via the Aboriginal Family Violence Prevention Legal Centres which may be able to refer you to legal service providers engaged in this work.

Addressing the needs of children

It would be worth keeping a watchful eye on Lisa’s children. In this chapter, the significant concern of the intergenerational transmission of violence and the need to break this cycle in these communities was discussed. Lisa’s children are very young but have potentially already witnessed a lot in their short lives. They will need to be monitored to ensure that their development is appropriate and that they do not continue to be exposed to violence. In the event that the latter occurs, as a GP you would need to carefully consider your mandatory reporting requirements and how you were going to communicate them to Lisa (refer to Chapter 6).

If available in your area, specific services for children experiencing family violence can be very helpful. A discussion with the family and a referral for Lisa and the children may help to deal with what has happened and contribute to their safety.

Conclusion

The consequences of violence within Aboriginal and Torres Strait Islander communities continue to be felt long after the bruises fade. A therapeutic response to the problem means thinking about the complexities that are often inherent in these contexts, as the above case study highlights. A decade of reports and research clearly articulates that any response or intervention must fundamentally engage with the multilayered factors that are contributing to the violence. These interventions need to take place and engage with the factors on an individual, familial and community basis for healing to be successful.

Resources

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

Further information

References

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
  2. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: AGPS, 2010.
  3. Weatherburn D, Snowball L. Is there a cultural explanation for Indigenous violence? A second look at the NATSISS. In: Hunter B, Biddle N, editors. Survey Analysis for Indigenous Policy in Australia: Social Science Perspectives. Canberra: ANU E Press, 2012.
  4. Gordon S, Hallahan K, Henry D. Putting the picture together: Inquiry into response by government agencies to complaints of family violence and child abuse in Aboriginal communities. Perth: State Law Publisher, 2002.
  5. Mow KE. Tjunparni: Family violence in Indigenous Australia. Canberra: ATSIC, 1992.
  6. Mullighan EP. Children on Anangu Pitjantjatjara Yankunytjatjara (APY) Lands Commission of Inquiry. A report into sexual abuse. Adelaide: South Australian Government, 2008.
  7. NSW Aboriginal Child Sexual Assault Taskforce. Breaking the silence: Creating the future. Addressing child sexual assault in Aboriginal communities in NSW. Sydney: NSW Government, 2006.
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  10. Wild R, Anderson P. Ampe Akelyernemane Meke Mekarle: Little Children are Sacred. Report of the Northern Territory Government Inquiry into the Protection of Aboriginal Children from Sexual Abuse. Darwin: Department of the Chief Minister, 2007.
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  15. Cripps K, Adams M. Family Violence: Pathways Forward. In: Dudgeon P, Milroy H, Walker R, editors. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. Canberra: Commonwealth of Australia, 2014:399–416.
  16. Australian Human Rights Commission. Social Justice Report 2011. Sydney: Australian Human Rights Commission, 2011.
  17. Cripps K. Enough family fighting: Indigenous community responses to addressing family violence in Australia and the United States. Melbourne: Monash University, 2004.
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  23. Raphael J, Tolman R. Trapped by poverty/trapped by abuse: New evidence documenting the relationship between domestic violence and welfare. Chicago: Taylor Institute and the University of Michigan Research Development Center on Poverty, Risk and Mental Health, 1997.
  24. Cripps K, Bennett C, Gurrin L, Studdert D. Victims of violence among Indigenous mothers with dependent children. Med J Aust 2009;191:481–5.
  25. Day A, Howells K, Nakata M, et al. The development of culturally appropriate anger management programs for Indigenous people in Australian prison settings. Int J Offender Rehab Comp Criminol 2006;50:520–39.
  26. White M. Pathways to a good life well lived: Community-owned recovery plan for overcoming suicidal despair in the Fitzroy Valley. Fitzroy Crossing: Marninwarntikura Fitzroy Women’s Resource and Legal Centre, Marra Worra Worra Aboriginal Corporation, Nindilingarri Cultural Health and Kimberley Aboriginal Law and Cultural Centre, 2011.
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