Around 15 million people every year use UK emergency departments as their first point of contact with health services. This is particularly true of vulnerable patients whose social situations and psychological states militate against using planned care. Studies in the UK put the incidence of domestic violence presenting to general emergency departments at 1.2–4.2%. One in six rape cases present initially to emergency departments. Staff members therefore have a unique opportunity to identify and support patients who are suffering the results of domestic and sexual violence and to provide crisis intervention when invited. Sadly, such abuse often goes unsuspected; even where it is suspected, lack of confidence, protocols and time may mean that staff members sidestep the issue. Treating a patient with domestic or sexual violence is distressing for clinicians, particularly those with personal experience of abuse; staff members should be supported within the team and by staff counsellors.

The first pitfall is the assumption that domestic and sexual violence always present as trauma (Box 12.1). In fact, they present in a wide variety of ways, and the incidence and prevalence are far higher than is evident if only injury is considered.

Domestic and sexual violence, whether experienced as a child or an adult, are common underlying factors in ‘heartsink’ patients. Some patients turn to alcohol and drug abuse to cope with the violence, some somatise their distress and some turn to the emergency department again and again. Some patients present to the surgical specialties in the out-patient clinic (Box 12.2).

Teenaged and young women, the pregnant, those who self-harm, those seeking postcoital contraception and those who leave before treatment are particularly likely to be suffering domestic and sexual violence (Box 12.3).

There is a high association between child abuse, failure to thrive, child behavioural difficulties and domestic violence in the home; up to 90% of children who live in homes where domestic violence exist witness or are involved in it. Staff members must be highly suspicious of domestic and sexual violence affecting the mother whenever a child in these categories presents.

Although clinicians should routinely maintain a high level of suspicion of abuse, some presentations are good indicators of domestic and sexual violence (Boxes 12.4 and 12.5).

Many general medical disorders have also been associated with past experiences of domestic and sexual violence; violence should be considered when patients present with cardiovascular disease, liver disease, chronic lung disease/smoking, cancer or osteoarthritis.

Interview the patient alone. This may call for ingenuity, particularly if the suspected abuser is present and is unwilling to leave. Strategies include interviewing the patient in x-ray or a procedure room from which the accompanying person is excluded because of ‘radiation or infection control risks’. It may be necessary to admit the patient to an observation bed in order to get privacy and time for discussion. Where the patient does not speak English, use an independent translator rather than a family member or friend, who may be complicit.

Be nonjudgemental towards both the patient and the perpetrator. Believe patients and treat them with compassion and empathy. It is the rule, rather than the exception, for the patient to return to the abuser at some stage. They will be reluctant to seek help again if they feel criticised or if the perpetrator has been roundly condemned (Box 12.6).