The GP's role in assisting family violence victims

Domestic and family violence affects all types of people, regardless of gender, culture or sexuality.

It is complex and there is no quick-fix solution.

Health practitioners are the group of professionals most often told about family violence, even more than police.¹

It has been estimated that full-time GPs see up to five women per week who have experienced some form of intimate partner abuse — physical, emotional, sexual — in the past 12 months.

Healthcare providers are therefore key to helping women and children on a pathway to safety and good health.

In 2018, the WHO adopted a global plan of action to strengthen the role of the health system to address interpersonal violence, in particular against women and girls.

Australia was one of 44 member states to adopt the resolution, which aims to strengthen health service delivery and improve the capacity of health professionals to respond to violence.

Intimate partner abuse

Intimate partner abuse is one of the leading contributors to death and disability for women of child-bearing age, and has major effects on the health of children.

Most intimate partner abuse victims are women in heterosexual relationships, but abuse can also occur in same-sex relationships.

Domestic and family violence damages a person’s mental and physical health and can take the form of:

Intimidation or threats.
Physical, verbal, sexual or psychological abuse.
Neglect, control of money, stalking, harm to an animal or property.
Deliberately causing fear or control.
Restricting spiritual or cultural participation.

Doctors’ role

Broadly speaking, health practitioners can assist with:

Primary prevention approaches (stopping violence before it happens) by reinforcing the right to healthy and respectful relationships, in particular with young people.
Secondary prevention or early intervention, targeting at-risk populations and underlying risk factors for family violence at the earliest point in a family’s journey.
Tertiary prevention measures (stopping harm from ongoing violence), through a first-line response and integration of specialist services in health and support services.

Specifically, GPs can assist by identifying predisposing risk factors, noting early signs and symptoms.

They can then provide a response that includes assessing for violence and safety within families, managing consequences of abuse to minimise morbidity and mortality, being aware of and using referral pathways and evidence-based patient and services resources, and advocating for changes that promote a violence-free society.

The WHO suggests all health practitioners be trained in first-line support of LIVES — Listening, Inquiring about needs, Validating experience, Enhancing safety and providing Support.²

Consultation

Studies show abuse is associated with depression, anxiety, other psychological disorders, drug and alcohol abuse, sexual dysfunction, functional gastrointestinal disorders, headaches, chronic pain and multiple somatic symptoms.

Sexual abuse has also been linked with chronic pelvic pain.

Women are unlikely to take the first steps to disclose interpersonal violence, but evidence shows they are open to being asked about their safety at home.

So, if abuse is suspected, it is important to ask questions in a sensitive way.

Patients need to be encouraged to discuss abuse and to see it as affecting their health.

It’s important to remember that most women who disclose they are experiencing family violence are safe to return home that day, so unless there is an imminent threat, an initial discussion that flags an intention to follow-up at a later appointment is an appropriate response.

Some possible questions to ask and statements to make if you suspect intimate partner abuse include:

Are you afraid of your partner? Have you ever been afraid of any partner?
Has your partner ever controlled your daily activities or do they constantly put you down?
Has your partner ever physically threatened to hurt you?
Has your partner pushed, kicked, slapped or otherwise hurt you?
Sometimes partners react strongly in arguments and use physical force. Is this happening to you?
Have you ever felt unsafe in the past?
I ask a lot of my patients about abuse because no one should have to live in fear of their partners.

A woman may not wish to disclose for a variety of reasons, such as fear of reprisal from the partner, feelings of shame and humiliation, and not thinking she will be believed.

Therefore, disclosure is rarely immediate and often sporadic. Women may reveal partially, then get frightened by disclosing and disappear for some time and then disclose at another time and place.

Referral or connection to specialist services should be offered if disclosure occurs.

If a woman does disclose, she may not yet be ready to access services. In this case, it is important to validate her experience with statements such as:

Everyone deserves to feel safe at home.
You don’t deserve to be hit or hurt, and it is not your fault.
I am concerned about your safety and wellbeing.
You are not alone. I will be with you through this, whatever you decide. Help is available.

An initial assessment should also be made of the patient’s safety.

This may be as simple as checking if it is safe for her (and her children) to return home.

A more detailed risk assessment that can be done at a subsequent visit will include questions about escalation of abuse, the content of threats, and direct and indirect abuse of any children.

Practice Points

– Health practitioners are the professionals most often told about family violence, even more than police
– GPs can identify predisposing risk factors, noting early signs and symptoms of violence
– Evidence shows women are open to being asked about their safety at home
– GPs can provide a first-line response and offer referral pathways and evidence-based patient resources

Resources:

RACGP White Book: Abuse and Violence, Working with our Patients in General Practice
Melbourne Medical School learning module: Identifying and Responding to Domestic Violence
The Australian Department of Human Services — Family and domestic violence
- Phone: 132 850. (Information in different languages and translation services available)
National Sexual Assault Domestic Violence Counselling Service (includes translator services)
- 24/7 phone line: 1800RESPECT
White Ribbon’s list of hotlines
InTouch – Multicultural Centre Against Family Violence

Dr Kelsey Hegarty (PhD) is an academic GP who holds the joint Chair in Family Violence Prevention at the University of Melbourne and the Royal Women’s Hospital.

References on request from Dr Kate Kelso.

This column is supplied by Jean Hailes for Women’s Health – a national, not-for-profit organisation focusing on clinical care, innovative research and practical educational opportunities for health professionals and women.