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.
In 2006 the government agreed to define domestic violence as "Any incident of threatening behaviour, violence or abuse between adults who are or have been intimate partners or family members, regardless of gender or sexuality." In 2013 this was extended to include coercive behaviour, and the age of inclusion dropped to 16.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. The government further made it clear that it encompasses issues such as forced marriage, female genital mutilation, "honour" killings and elder abuse. Other terms used are intimate partner violence (IPV) and domestic violence and abuse (DVA).
It can include, but is not limited to, the following types of abuse:
Statistics: the scale of the problem
- In a 2012-13 survey 7.1% of women and 4.4% of men reported experiencing domestic violence.
- The lifetime risk of domestic violence (from age 16) is 30% in women and 16% in men.
- On average two women are killed every week by a male partner or ex-partner.
- 100,000 people are currently at risk of serious harm or murder due to domestic violence.
- 75% of cases of domestic violence result in physical injury or adverse mental health consequences to the victim.
- 4% of women experience stalking every year.
- Around 1,500 cases of forced marriage are reported each year.
- 66,000 women are living with the consequences of female genital mutilation.
- Women are more likely than men to experience all types of domestic violence.
- Domestic violence costs the taxpayer £3.6 billion a year.
Recognising domestic violence
There has been emerging recognition in recent years that GPs need training in identifying cases of domestic violence, and responding appropriately when it is disclosed. Clinicians tend to be reticent 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. It concluded this programme of training and support was effective in improving referral rates to specialist agencies, and improving the documentation in primary care records of abuse. It also found it to be a cost-effective intervention, reducing the social cost of domestic violence. 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.
When to suspect domestic violence
Often people suffering domestic violence have unnecessary investigations and medication for nonspecific or mental health symptoms. Consider asking about domestic abuse in patients with health markers of domestic abuse. These include:
- Unexplained symptoms/nonspecific symptoms.
- Chronic pain.
- Genital injuries.
- Sexually transmitted infections.
- Frequent attendance at surgery or A&E.
- Delay between injury and presentation.
- Injuries inconsistent with the explanation, or injuries at different stages of healing.
Risk factors for domestic violence
- Female gender.
- Young age.
- Pregnancy - 30% of domestic violence starts in pregnancy.
- Substance abuse.
- Mental ill health.
- Chronic illness or disability.
- Previous domestic violence or sexual assault.
- Cultural factors - for example:
- Living in a community which practices female genital mutilation or "honour" crimes.
- Immigration status.
- Language barriers.
- Leaving a violent partner. Many murder victims have recently ended a violent relationship.
If you suspect domestic violence, what do you do?
Explore your concerns with the patient in a sympathetic, non-judgemental manner. Ensure they feel safe, and reinforce the confidential nature of the discussion. See the person on their own, without their partner or children. Consider the need for an interpreter if appropriate.
Remember people may be reluctant to disclose they are suffering domestic violence. Reasons for this include:
- Fear of retribution from the perpetrator of abuse.
- Shame or embarrassment.
- Fear their children may be removed from their care.
- Fear of an unsympathetic response or not being believed.
- Cultural stigma.
- Not believing you can do anything to help.
The following may be helpful:
- "Is everything alright at home?"
- "Are you getting on with your partner?"
The four HARK questions were developed as a framework for helping identify people who have suffered domestic abuse, and found to be a sensitive tool.This stands for:
- 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?"
There is currently no evidence that screening for domestic violence is of benefit.
Responding to domestic violence disclosure
The GP's role is to:
- Establish if there is any immediate risk to safety for the person or any children. If so, consider contacting the local police. Initiate child protection procedures where relevant.
- Know who the designated person for domestic violence for the practice is. This can be a specialist person outside the practice, or a trained member within it.
- Arrange an appointment with the designated person responsible for initial assessment.
- Document domestic violence in the records, using the appropriate code. Document any injuries.
- Discuss and address the needs of any children involved.
- Be supportive and non-judgemental. Be aware there are many reasons people may not leave an abusive relationship, including:
- Worry about consequences for children, or that they may have their children taken away from them
- Loss of self-confidence
- Shame, embarrassment or stigma
- Cultural reasons
- They may still love their partner
The designated person responsible within the practice will:
- Make an initial risk assessment, using a recognised system - for example, the CAADA Risk Identification Checklist.
- Advise the person suffering domestic violence about the services available depending on the risk level. They may:
- Self-manage the person's support.
- Refer to, and liaise with, the local multi-agency risk assessment conference (MARAC) co-ordinator. A MARAC is a regular consultation between professionals to ensure the safety of those at high risk from domestic violence. The MARAC will co-ordinate resources between agencies in order to protect and support. This may include representatives from the police, probation service, victim support services, schools, social care, healthcare, women's aid/refuge, housing department, and substance abuse services. The person suffering abuse may be represented at this consultation by an independent domestic violence adviser (IDVA) who may be their primary source of contact. The MARAC may also be aware of local programmes for perpetrators, which are increasingly being commissioned under new National Institute for Health and Care Excellence (NICE) guidance.
- Provide a safety plan, and details of available resources if the person does not wish to engage at this time.
- Initiate child protection or adult safeguarding procedures where appropriate.
The whole general practice team should have specific training in what to do when domestic violence is disclosed, as well as when to suspect it.
Domestic violence and safeguarding children
There is a close link between domestic violence and abuse, and safeguarding children.
The Department of Health estimates that every year 750,000 children experience domestic violence.In houses with children where there is domestic violence, about three quarters of it is witnessed by children. Around half the children in these cases have suffered violence themselves.
Children living with domestic violence are at increased risk of behavioural problems and mental health difficulties in later life. Children living with domestic violence have a higher risk of sexual abuse.
Signs that children may be living with domestic violence:
- They actively disclose information about it.
- Injuries to themselves.
- Unexplained illness.
- Constant worry about family members and their safety.
- Insomnia or nightmares.
- Failure to thrive.
- Poor achievement at school, poor attendance.
- Behavioural difficulties.
- Speech and language delays.
- Substance misuse.
- Missed health appointments.
These are some of the resources available that you can make those suffering from domestic violence aware of:
- 24-hour National Domestic Violence Helpline: 0808 2000 247
- Police Domestic Violence Officers: 0845 3300 222 (999 in an emergency)
- Women's Aid: 0808 2000 247, www.womensaid.org.uk
- Refuge: 0808 2000 247 (in partnership with Women's Aid, refuge.org.uk
- Victim Support: 08453 030 900, www.victimsupport.org.uk
- Mankind (for male victims of domestic violence): 01273 911680, www.mankindcounselling.org.uk
- ManKind Initiative (for male victims of domestic violence): 01823 334244, www.mankind.org.uk
- Men's Advice Line: 0808 801 0327, www.mensadviceline.org.uk
- Childline. 0800 1111, www.childline.org.uk
- Respect Phoneline: (help for perpetrators of domestic violence) 0808 802 4040, www.respectphoneline.org.uk
Further reading and references
Protecting people promoting health. A public health approach to violence prevention in England; Dept of Health, October 2012
Buller AM, Devries KM, Howard LM, et al; Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis. PLoS Med. 2014 Mar 411(3):e1001609. doi: 10.1371/journal.pmed.1001609. eCollection 2014 Mar.
Improving safety, Reducing harm: Children, young people and domestic violence; Dept of Health, November 2009 (archived content)
Home Office: Policy. Violence against women and girls in the UK; GOV.UK, March 2013
Intimate personal violence and partner abuse - Chapter 4: focus on violent crime and sexual offences; Office for National Statistics (ONS), February 2014 (archived content)
Ramsay J, Rutterford C, Gregory A, et al; Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians. Br J Gen Pract. 2012 Sep62(602):e647-55. doi: 10.3399/bjgp12X654623.
Feder GS, Hutson M, Ramsay J, et al; Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med. 2006 Jan 9166(1):22-37.
Feder G, Davies RA, Baird K, et al; Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet. 2011 Nov 19378(9805):1788-95. doi: 10.1016/S0140-6736(11)61179-3. Epub 2011 Oct 12.
Devine A, Spencer A, Eldridge S, et al; Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial. BMJ Open. 2012 Jun 222(3). pii: e001008. doi: 10.1136/bmjopen-2012-001008. Print 2012.
IRIS (a general practice-based domestic violence and abuse training programme); Identification and Referral to Improve Safety
Trevillion K, Oram S, Feder G, et al; Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS One. 20127(12):e51740. doi: 10.1371/journal.pone.0051740. Epub 2012 Dec 26.
Sohal H, Eldridge S, Feder G; The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract. 2007 Aug 298:49.
Taft A, O'Doherty L, Hegarty K, et al; Screening women for intimate partner violence in healthcare settings. Cochrane Database Syst Rev. 2013 Apr 304:CD007007. doi: 10.1002/14651858.CD007007.pub2.
Responding to domestic abuse. Guidance for general practices; Royal College of General Practitioners (January 2013)
CAADA: Risk Identification Checklist (RIC) & Quick Start Guidance for Domestic Abuse, Stalking and ‘Honour’-Based Violence; Co-ordinated Action Against Domestic Abuse (CAADA)
Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively; NICE Public Health Guidance (February 2014)