Domestic Violence (DV)

Intimate Partner Abuse and Violence (IPAV)

Global Statistics on IPAV:

• 1 in 3 women globally experience physical or sexual abuse from partners.
• Women are significantly more likely than men to be victims of intimate partner violence.
• Focus is on heterosexual relationships, with principles also relevant to men and non-binary individuals.

Definition of IPAV:

• Defined by WHO as behaviours causing physical, psychological, or sexual harm within intimate relationships.
• Involves abuse of power, coercion, control, and victimization.
• Stems from societal gender role ideologies.

Prevalence of IPAV:

• Survey data shows significant gender disparity in IPAV experiences.
• Women most frequently experience IPAV at home, while men more often experience violence in public settings.

Risk Factors for IPAV:

• Common across all demographics but particularly affects:
  • Indigenous women
  • culturally and linguistically diverse (CALD women)
  • those with disabilities
  • younger women
  • pregnant women
  • recently separated or divorced
  • women who are younger than 25 years
  • women who have experienced child abuse or have come from a violent family

IPAV During Crises (e.g., COVID-19):

• IPAV increases during large-scale crises.
• COVID-19 lockdowns isolated women with their abusers.
• Increase in severity and frequency of violence during the pandemic.
• Emergence of new psychological abuse tactics during COVID-19.

Types of intimate partner abuse
Type of abuse	Example behaviours
Physical	Slapping, hitting Kicking, beating Using knives or guns Strangulation
Emotional	Intimidation Constant belittling Harassment
Sexual	Forced intercourse Sexual coercion Reproductive coercion
Coercive control	Isolating from family and friends Monitoring movements Obsessive jealousy and possessiveness Controlling daily activities (eg where they go and what they do)Threats to harm victim/survivor, their children, pets or themselves Deprivation of basic necessities such as food, employment, health services, finances, liberty Mental health or substance-use coercion such as convincing others that the victim/survivor is crazy, controlling medication and drug use Visa abuse

Identifying Intimate Partner Abuse in Practice

• IPAV as a Hidden Epidemic:
  • Affects women of all backgrounds (socioeconomic, racial, age, religion).
  • Important to consider IPAV in all women.
• Clinical Indicators of IPAV:
  • Many health conditions are associated with IPAV, including:
    • Physical Symptoms: Chronic pelvic pain, headaches, injuries, fatigue, sexually transmitted infections.
    • Psychological Symptoms: Depression, anxiety, PTSD, suicidal ideation.
    • Emotional Symptoms: Anger, irritability, low self-esteem.
  • Symptoms may overlap or may not be present at all.

Physical	Psychological	Emotional
Obvious injuries Bruises at various stages of healing Sexual assault Sexually transmitted infections Chronic pelvic pain Chronic abdominal pain Chronic headaches Fatigue Miscarriage and stillbirth Nausea Change in appetite	Insomnia Difficulty concentrating and making decisions Confusion Memory issues Anxiety and panic disorder Depression Suicidal ideation Somatoform disorder Post-traumatic stress disorder Eating disorders Drug and alcohol use Poor self-esteem Nightmares	Anger Irritability Feeling of overwhelm Hyper-alertness and

• Abuse During Pregnancy:
  • Linked to complications like suboptimal weight gain, preterm delivery, low birthweight babies.
  • Pregnant women experiencing abuse are more likely to miscarry.
  • Abuse may commence or escalate during pregnancy; late antenatal care may be an indicator.
  • GPs should routinely ask about violence during antenatal visits.
• Risk Factors and Behavioral Signs:
  • Risk Factors: Low income, young age, disability, pregnancy, recent separation.
  • Behavioral Signs: Delayed treatment, inconsistent explanations, frequent visits, partner controlling appointments.
• PTSD and Trauma-Informed Care:
  • PTSD in IPAV Victims/Survivors:
    • PTSD or complex PTSD common due to repeated trauma exposure.
    • Rates between 31% and 84% of survivors.
  • Trauma-Informed Approach:
    • Focus on avoiding retraumatization.
    • Create an environment promoting emotional and physical safety.
• Traumatic Brain Injury (TBI):
  • Head, neck, and facial injuries are major causes of TBI in IPAV victims.
  • Presentation can include dizziness, headaches (post-concussive syndrome).
• Children and IPAV:
  • Children may witness, hear, or be victims of abuse.
  • Effects may be seen both at home and at school:
    • chronic somatic problems and frequent presentations
    • anxiety
    • depression
    • withdrawal
    • aggressive behaviour and language, problems at school
    • drug and alcohol abuse
    • lower self-worth
    • suicidal ideation (adolescents)
    • homelessness (adolescents)
    • academic failure
    • bedwetting, sleeping disorders, stress, behavioural problems (younger children).
  • Link between parental IPAV and child abuse.
• Inquiring About Abuse:
  • Women are more likely to disclose abuse if asked directly.
  • Insufficient evidence for universal screening, but inquiry is essential for those with psychosocial and physical symptoms.
  • Ensure patient privacy—woman should be alone without an accompanying partner.
  • Use general questions to lead into more specific questions (e.g., “Do you feel safe at home?”).
  • Telehealth considerations: Start with yes/no questions to assess safety; establish a code word for emergencies.
  • Confidentiality: Northern Territory requires mandatory reporting; other states have different guidelines.
• Effective Communication for Disclosure:
  • GPs should avoid attitudes that discourage disclosure (e.g., “It’s not my role to ask”).
  • The gender of the doctor does not impact disclosure if communication skills are good.
  • Statements normalizing abuse questions can make patients feel more comfortable.

 Questions and statements to make if you suspect:

General Well-Being and Home Environment:

• “How are things in your relationship with your partner?”
• “Is there anything going on at home that’s been hard for you recently?”
• “Have you felt supported and safe in your relationships lately?”

Assessing Physical Safety and Past Experiences:

• “Have you ever felt unsafe or scared in your relationship or at home?”
• “Is there anything in your relationship that makes you feel uncomfortable or afraid?”
• “Has anyone ever made you feel unsafe or threatened at home or in a relationship?”

Exploring Emotional and Psychological Safety:

• “Sometimes people feel pressure or tension in their relationships. Have you felt that way?”
• “Has your partner ever tried to control things like who you see, where you go, or what you do?”
• “Is there anything you’d like to change about how things are going in your relationship?”

Support and Normalization:

• “It’s common for people to feel pressured or hurt in relationships. If that’s happening to you, we can talk about it here.”
• “Many people in relationships face situations that don’t feel right, and you don’t have to handle it alone.”
• “I’m here to listen and help, and no one should ever feel threatened or unsafe in their relationships.”

Physical and Emotional Health Concerns:

• “Often, when people have symptoms like these, it’s related to stress or feeling unsafe. Has that been the case for you?”
• “Sometimes these types of health problems are linked to things happening in personal relationships. Has that been a concern for you?”

Normalizing the Discussion of Violence:

• “Violence is unfortunately quite common, and I ask about it because no one should have to live with fear or harm from someone they care about.”
• “I often talk to patients about feeling safe in their relationships because it’s something that affects many people.”

Encouraging Disclosure and Offering Help:

• “I’m here to support you, and there are ways to make things safer if you’re experiencing any trouble at home.”
• “If you’re feeling uneasy, we can talk about ways to ensure your safety and well-being.”
• “Is there anything you’d like to share with me about how things are going at home or with your partner?”

Strategies to increase disclosure and engagement in women who experience IPAV
Component	Aim	Strategy
Healthcare worker characteristics	Ensure helpful GP attitudes, judgements and behaviours	Be non-judgemental, empathetic, use active listening, be respectful and compassionate. There must be development of trust Recognise/support patient autonomy
Raising the issue	Setting the agenda, communication and counselling skills	Use open questions, reflection and active listening, sensitivity, non-judgemental inquiry, express empathy
Inquiry	Ask about emotions and safety	Ask about the woman’s fears and concerns Anxiety, shame, self-blame, loneliness, humiliation and embarrassment are commonly associated with a reluctance to disclose Assess safety (woman and any children) What does she need in order to feel safe? How safe does she feel? Has the violence been escalating?
Reluctance to disclose	Explore links to the presenting complaint	Increase awareness of how IPAV is a contributor to the woman’s presenting complaintHave a suspicion of IPAV when women present with anxiety, depression, substance abuse and chronic pain
Complexity	Insight	Women want GPs to have a deeper understanding of the complexities of their situation and circumstances GPs need to gain an understanding of how the woman views IPAV and what are their identified supports
Validation	Legitimisation of experiences	Affirm experiences – address misconceptions. For example: – Woman: ‘It’s my fault, I deserve it. – ’GP: ‘You do not deserve this and it is not your fault.’

The WHO LIVES model of first-line response to IPAV

• Listen: Listen to the person closely, with empathy, and without judging
• Inquire: Assess and respond to their various needs and concerns – emotional, physical, social and practical
• Validate: Show that you understand and believe the person − assure them that they are not to blame
• Enhance safety: Discuss a plan for the person to protect themself from further harm if violence occurs again
• Support: Support the person by helping them connect to information, services and social support

Consultation

1. Prepare for the Consultation
   • Be ready to identify and respond to signs of intimate partner and family violence (IPAV).
   • Reflect on personal biases to ensure a non-judgmental approach.
2. Opening the Consultation
   • Create a safe and supportive environment for the patient.
   • Ask open-ended questions to encourage discussion, especially if signs of abuse are present.
3. Recognize Signs of Abuse
   • Look for physical, emotional, or behavioral signs of abuse.
   • Ask directly and sensitively about abuse if there are concerns.
4. Validation and Initial Response
   • Everybody deserves to feel safe at home 
   • No-one deserves to be hit or hurt in relationships 
   • I am concerned about your safety and wellbeing. 
   • Let’s work together on this 
   • Abuse is common and happens in all kinds of relationships. 
   • It tends to continue. 
   • You are not to blame 
   • Abuse can affect your health and that of your children
5. Assess Safety and Risks
   • Enquire about the immediate safety of the patient and their children.
   • Assess risks: Is it safe for the patient to return home?
   • Compile a list of emergency contacts, including police, shelters, and helplines.
6. Safety Planning
   • Help the patient identify a safe place and how to get there if needed.
   • Compline a list of emergency numbers
   • Help to identify a safe place and how to get there
   • Identify a safe place to store valuables and important documents
   • Identify family and friends who can provide support
   • Ensuring cash available
   • Safety of children
   • Safety to go home
7. Providing Information and Resources
   • Offer information about available services, such as counseling, legal aid, and shelters.
   • Offer/recommend police involvement if appropriate.
   • Offer access to an Aboriginal health worker if culturally appropriate.
   • Reassure the patient about confidentiality and explain its limits.
   • Explain available legal options and pathways for support.
8. Review and Follow-Up
   • Schedule follow-up appointments to provide ongoing support and reassess the situation.
   • Continue to listen empathetically and respect the patient’s choices.
9. Reflect and Respect
   • Respect the patient’s decisions and recognize the complexity of their situation.
   • Maintain a non-judgmental and respectful attitude.
   • Reflect on the approach taken and adjust strategies as needed for future consultations.
10. Conclude the Consultation
    • Reinforce that the patient is not to blame for the abuse and that they deserve to feel safe.
    • Validate their courage in seeking help.
    • Provide reassurance that you will be there for ongoing support.

Summary of Key Messages to Communicate

• Abuse is never the patient’s fault.
• Everybody deserves to feel safe at home.
• Let’s work together to ensure your safety and wellbeing.
• Abuse can affect both your health and the wellbeing of your children, but support is available.

• Ready: Be prepared to identify and respond to IPAV.
• Recognize: Look for symptoms and ask directly and sensitively about abuse.
• Respond: Listen empathetically to disclosures of violence.
• Risk: Assess safety and risks.
• Review: Follow up and provide ongoing support.
• Refer: Direct patients to appropriate resources.
• Reflect: Consider personal biases and the approach taken.
• Respect: Prioritize respect for patients, colleagues, and oneself.

Sexual assault

• Offer support
• Assess mental health risks
• Offer emergency contraception if within 72 hours
• Offer STI investigation/ prophylaxis/ treatment as appropriate
• Offer option police report
• Forensic exam preferably within 72 hours
• Refer sexual assault resources
• Follow up STI checks 2,6,12 weeks
• Consider if likely immune hep B – may give vaccine