INTRODUCTION AND OVERVIEW

In the past decade, domestic violence has been recognised as a health problem resulting in significant morbidity and mortality. It is a serious and widespread problem that affects all economic, educational, ethnic and regional groups. This chapter outlines the nature and prevalence of domestic violence, how it presents in clinical practice, how to ask about it and how to respond to it holistically.

WHAT IS DOMESTIC VIOLENCE?

In the community, domestic violence is usually taken to mean physical violence between partners, usually perpetrated by the husband on the wife, although men may be victims and abuse does occur in same-sex relationships. Sometimes the term is used to refer to abuse that occurs in any relationship within households and thus would include child, elder and sibling abuse. This chapter concentrates on partner abuse (marriage, de facto relationship, boyfriend or girlfriend), which is a complex pattern of behaviours that includes emotional, physical and sexual abuse, not just simple acts of violence (Fig 59.1).

FIGURE 59.1 Types of abuse in partner violence

The World Health Organization uses the term intimate partner violence and defines it as:

Any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, includes: physical aggression, psychological abuse, forced intercourse & other forms of sexual coercion, various controlling behaviors.¹

From a health perspective, domestic violence is best understood as a chronic syndrome characterised not by the episodes of physical violence that punctuate the problem but by the emotional abuse that the perpetrator uses to maintain control over the partner. Furthermore, as most victims of partner abuse report, the physical violence is the least-damaging abuse suffered. It is the relentless psychological abuse that cripples and isolates the victim and results in fear of the partner. Domestic violence against women is the focus of this chapter, because most abuse with serious health and other consequences is committed by men against their female partners.²

BACKGROUND AND PREVALENCE

Abuse of women by their partners or ex-partners is a worldwide phenomenon.³ The World Health Organization World Report on Violence and Health revealed that in 48 population-based surveys around the world, 10–69% of women had been physically assaulted by their partners at some stage in their lives.¹ Clinical samples obtain higher rates than community surveys. For example, recent general practice studies in Australia, the United States, the United Kingdom and Ireland have found high lifetime physical abuse rates ranging from 23.3% to 41.0% of women, and 12-month rates from around 5% to 17%.⁴ A full-time general practitioner probably sees at least one abused woman each week, although she may not be presenting with obvious signs or symptoms. Similar rates are found in emergency departments, mental health clinics, antenatal care and drug and alcohol clinics. Today, on average, one in fifty women presenting to the emergency department do so because of domestic violence.

Thus women experiencing domestic violence present very frequently to healthcare services and require wide-ranging medical services. The societal economic impact is great, with an Australian study estimating that in 2002/03 the cost to the community of domestic violence was in the order of AUD$8.1 billion, with the main contributors being pain, suffering and premature mortality.⁵ The total cost of intimate partner violence to services and to the economy as a whole in the United Kingdom has been estimated at £3.1 billion and £5.7 billion a year, respectively.⁶

AETIOLOGY

Researchers have postulated that there are many causes of domestic violence at the individual, family, community and societal levels. Originally, people thought that abuse was caused by psychiatric illness. Once the prevalence of abuse in the community was recognised, however, it was realised that this explanation was unrealistic. Subsequently, researchers felt that conflict in the family was the major cause. Unfortunately for this theory, many women describe there being no conflict before abuse happening. Review of the evidence for societal risk factors shows that violence in the family of origin of victim and perpetrator, and unemployment of the perpetrator, were the only variables that had sound evidence of an association. It seems that the combination of environment, social and economic factors may contribute to domestic violence. However, feminist researchers have argued that patriarchy in today’s society underlies much of the abuse of women. The World Health Organization certainly places domestic violence in the context of violence against women, which includes such issues as rape and genital mutilation.

HEALTH CONSEQUENCES

Domestic violence can have short-term and long-term negative health consequences for survivors, even after the abuse has ended.⁷ Abused women experience many chronic health problems, with depression, post-traumatic stress disorder, chronic pain and gastrointestinal and gynaecological problems being the most common (Box 59.1). It is also a very common cause of femicide, with over 50% of all female murders being committed by their partners or ex-partners, in the United Kingdom and the United States. In Australia, a far higher percentage of Indigenous than non-Indigenous women are murdered by their partners.

BOX 59.1 Potential presentations of domestic violence in clinical practice