Once upon a time a young girl told her story:
"I was aware of the violence at home since I was about three years old, and it made it difficult for me to sleep at night. I thought that if I was at home, it was less likely that my dad would be violent towards my mum. If I was out playing with friends, I would make sure I came home frequently to check and see if my mum was ok. The violence lasted eight years and sometimes I got caught in the middle. As the eldest child, I grew up quickly and felt responsible for my younger siblings, who I had to parent. My mum experienced both emotional and physical abuse, with my dad saying things like 'No-one else would have you', which lowered her self-esteem."
This is no fairy tale. Some advocates have used the medium of traditional fairy tales for telling these powerful stories such as 'Beauty and the Beast' and 'The Frog Prince', but there is no sugar-coated Hollywood ending for these women, and women are more likely than men to experience all types of domestic violence. Domestic violence is an enormous problem with far-reaching consequences. It is an abuse of human rights, causes physical and mental ill health and frequently death, and incurs vast cost to the NHS and beyond. Because of its close link with physical and mental health disorders, and with children's safety and well-being, it is an issue of vital importance for primary care.
Domestic violence involves a pattern of abusive and controlling behaviour by which the abuser obtains power over their victim, and is seen throughout society, irrespective of age, race, gender, sexuality, area or social class. In England and Wales the 2012-13 survey showed that on average two women are killed every week by a male partner or ex-partner.
Recently it has become apparent that GPs need training in identifying cases of domestic violence, and responding appropriately when it is disclosed. Clinicians tend to be reluctant about asking about domestic violence directly. However, women experiencing abuse often have frequent contact with healthcare professionals, and surveys have shown they consider it appropriate that doctors and nurses ask direct questions about domestic violence.
Identification and Referral to Improve Safety (IRIS) was set up initially as a randomised controlled trial to investigate the cost-effectiveness of setting up a general practice-based training programme in the field of domestic violence, to improve the response of health professionals. IRIS has now become a national commissionable training and support programme. Co-ordinated action against domestic abuse (CAADA) is a national charity which also provides training and support.
If you suspect your patient may be experiencing domestic violence, the four HARK questions were developed as a framework for helping identify people who have suffered domestic abuse, and have been found to be a sensitive tool.
• Humiliation: "In the last year, have you been humiliated or emotionally abused in other ways by your partner?" "Does your partner make you feel bad about yourself?" "Do you feel you can do nothing right?"
• Afraid: "In the last year have you been afraid of your partner or ex-partner?" "What does your partner do that scares you?"
• Rape: "In the last year have you been raped by your partner or forced to have any kind of sexual activity?" "Do you ever feel you have to have sex when you don't want to?" "Are you ever forced to do anything you are not comfortable with?"
• Kick: "In the last year have you been physically hurt by your partner?" "Does your partner threaten to hurt you?"
We have recently added patient and professional content on domestic violence to the site. For further advice and support read the professional article here. Other recently updated content includes End of Life Care and the updated QOF for 2014-15. For the full list of updated content see http://patient.info/content-updates.