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.
- Many health conditions are associated with IPAV, including:
| 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)
- Mandatory Reporting and Legal Obligations
- Understand Legal Requirements: Be familiar with your legal obligations regarding mandatory reporting in cases involving children or imminent danger to the patient or others.
- Discuss Mandated Actions: Clearly explain any mandatory actions you must take, maintaining a supportive and empathetic approach.
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
- Opening the Consultation
- Private Setting: Ensure discussions occur in a private, confidential space where the patient feels safe and protected from possible eavesdropping or interruptions.
- Non-Judgmental Listening: Use empathetic and non-judgmental language to encourage openness. Show genuine concern and validate their feelings.
- Confidentiality: Reassure the patient that discussions are confidential unless there is a risk of immediate harm to themselves, children, or others (in which case mandatory reporting laws may apply).
- Validation: Let the patient know that abuse is not their fault, and they do not deserve to be treated this way.
- Active Listening: Allow them to share their story at their own pace, without rushing or pressuring them for details.
- Cultural Considerations
- Culturally Appropriate Support: For culturally diverse patients, including Aboriginal and Torres Strait Islander communities, offer referrals to culturally sensitive and community-specific support services.
- Respect for Traditions: Be aware of and respect cultural norms while ensuring that the patient’s safety and well-being remain a priority.
- Empowerment and Decision-Making Support
- Respect Autonomy: Respect the patient’s decisions and understand that leaving an abusive situation is complex and may take time. Do not pressure them to act before they are ready.
- Encourage Self-Efficacy: Provide resources that empower them to make informed decisions about their situation.
- Recognize Signs of Abuse
- Look for physical, emotional, or behavioral signs of abuse.
- Ask directly and sensitively about abuse if there are concerns.
- 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
- Assess Safety and Risks
- Immediate Danger:
- Ask the patient if they or their children are in immediate danger. If they are, work with them to develop a safety plan or contact emergency services
- Enquire about safety of their children.
- Assess risks: Is it safe for the patient to return home?
- Compile a list of emergency contacts, including police, shelters, and helplines.
- Immediate Danger:
- Safety Planning
- Identifying safe places to go if they feel threatened (friends’ houses, shelters).
- Preparing a bag with essentials (ID, money, medications, important documents) for quick escape.
- Setting up a code word with trusted people to signal if they are in danger.
- Compline a list of emergency numbers
- 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
- Addressing Mental and Physical Health Needs
- Counseling: Offer a referral to trauma-informed counseling or therapy for emotional support and coping strategies.
- Medical Care: If there are any physical injuries or health concerns, provide immediate care and document injuries accurately and thoroughly for any potential legal needs.
- Ongoing Support: Schedule follow-up appointments to monitor their physical and mental well-being.
- Providing Information and Resources
- Offer information about available services, such as
- counselling
- crisis hotlines = Provide the numbers for crisis support services, such as police, 24-hour domestic violence hotlines, and emergency shelter options.
- legal aid = Provide information on free or low-cost legal aid services if they require assistance navigating the legal system
- 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.
- Offer information about available services, such as
- 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.
- 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.
- 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