Identifying Domestic Violence and Abuse

Chapter 7
Identifying Domestic Violence and Abuse


Alex Sohal1 and Medina Johnson2


1Centre for Primary Care and Public Health, Queen Mary University of London, UK


2Next Link Domestic Abuse Services, University of Bristol, UK






OVERVIEW



  • Health care professionals can identify domestic violence and abuse (DVA) given practical guidance on how to ask directly about it, stressing the use of language and specific questions
  • Individuals who appear helpless and inactive may have complex reasons for their nondisclosure and perceived inertia
  • The skills to respond compassionately and effectively can be acquired




How to ask about domestic violence and abuse


Identification is achieved by directly asking women whether they are experiencing domestic or sexual abuse, encouraging spontaneous disclosure or asking other health care professionals to consider the issue. Asking can be by selective enquiry (on the basis of presentation), routine enquiry (habitual social history) or screening (universal).


Ideally, professionals should be encouraged to ask women directly and to promote spontaneous disclosure only as part of a DVA protocol, with local specialist services and referral pathways identified. Recent UK guidance ensures safeguards are in place in general practice to protect safety and confidentiality (see CAADA, 2012). Boxes 7.1–7.3 describe how to ask, giving practical tips.






Box 7.1 How to ask about DVA


Ask safely



  • Only ask when it is safe, when women are alone.
  • Do not ask about DVA when women are accompanied by third parties, including friends and family members (who should not be used to translate): third parties can report back to a controlling partner and disclosure can precipitate further abuse.
  • It may not be safe to ask all women.

Keep confidential



  • Ensure that information on computer screens is not visible to third parties.
  • Record DVA (if feasible, code on practice computer system).
  • Understand local principles for guidance on information sharing (e.g. Caldicott Guardian principles in the UK), for example with the police.

Ask sensitively



  • Use sensitively worded questions (examples are given later in the chapter).








Box 7.2 Case story: avoid compromising a woman’s safety


A 43-year-old woman presented with her teenage son as translator. She had multiple symptoms, including shakiness, total body pain and a 3-day history of dysuria (no frequency or nocturia). She wanted antibiotics, which had helped before. The GP asked who lived at home and the son said that Dad had left as his parents are separating. The GP decided not to ask why, as it might have compromised the woman’s safety if abuse was a factor.


The GP prescribed antibiotics for a possible urine infection. A follow-up appointment was suggested, including the urine culture result, using a professional advocate to interpret ‘so that [the son] does not have to translate complicated medical information’. The woman and son agreed.


The following week, a double appointment was arranged with the professional translator present. The woman reported that she felt better but that abdominal pain persisted. The urine culture was negative. The GP asked why she was separating. The woman disclosed that her husband had been physically violent for many years and was addicted to drugs. The police had been involved and her children were aware.


At a third appointment, the GP asked about a previous contraception prescription. The woman said her husband occasionally returned and wanted sex. She was worried he was putting her at risk of sexually transmitted infections (STIs) and was surprised to learn that previous antibiotics would not have treated STIs. On further explanation, she was keen to be tested.


Lesson


Had the GP asked the son why his parents were separating, he might have reported that Dad hit Mum. As he still saw his father, he might then have inadvertently mentioned the GP appointment and disclosure, which could have resulted in Dad challenging Mum or in another violent incident.





 






Box 7.3 Case story: how confidentiality can be broken


A 30-year-old woman confided that her new boyfriend did not like her going out with her colleagues. He had hit her after she got drunk at a work Christmas party, saying she needed to be taught a lesson. The GP recorded ‘domestic violence experienced’.


A few years later, the couple, now married, attended together for travel vaccinations. The nurse brought up the wife’s files on her computer screen, in view of the patients. The husband saw the entry on his wife’s summary medical record. The wife could not believe that what she had told her GP in confidence had been passed on to her husband. The husband was furious about the accusation and made a formal complaint, demanding the entry be removed from his wife’s notes.





What to ask


Once a DVA protocol is in place and it is safe to proceed, the subject can be broached using open questions and then further explored more directly (see Boxes 7.4 and 7.5). The open question, ‘How are things at home?’ invites the woman to talk unreservedly, preferably without interruption.






Box 7.4 Initial questions



  • ‘How are things at home?’
  • ‘Who lives at home with you?’
  • ‘Are things OK at home with your partner and family?’
  • ‘Are there any problems at home? Tell me about your relationship.’




The woman can curtail the discussion if she wishes. Most are expert at hiding, and will not reveal information until they have assessed your likely reaction. Women should never feel pressured into disclosing current or historic DVA.






Box 7.5 Progressively more direct questions



  • ‘Does anyone try to control you or what you do?’
  • ‘Are you ever humiliated by anyone?’
  • ‘Are you afraid of anyone at home?’
  • ‘Are you having any problems with your husband/partner/anyone at home?’
  • ‘Has someone hurt you?’




Why ask whether anyone tries to control the woman or what she does?



  • 69% of women have reported controlling behaviour by their partner.
  • The UK cross-government definition of DV now includes coercive control.
  • This recognises the enormous impact of controlling behaviour (Box 7.6).





Box 7.6 Patient testimony


‘There were several incidents of violence over the six years… However, there were many more incidents of psychological and emotional abuse that went on even if there was no violence. These were about control and power and diminishing my self-esteem to the point of not being able to see what was going on or trust my own instincts.


‘Because there were fewer incidents of violence, I didn’t consider myself a victim of domestic violence. Only after the violence escalated, when divorce proceedings were started and my ex-husband started losing control over me, and the children witnessed the abuse, did I realise I was a victim and I must do something.


‘If I had been more aware that I was suffering the psychological abuse and emotional abuse, I may have been more able to see what was going on and get the help I needed for me and the children much sooner.’


Source: http://www.bbc.co.uk/news/education-19640257 (last accessed 12 February 2014).





Why ask whether the woman is ever humiliated by anyone?



  • Humiliation is defined as ‘injuring dignity or self-respect’.
  • Humiliation is plainer English, easier to understand and has more widespread usage than ‘emotional abuse’.
  • Emotional abuse alone can produce long-term adverse physical and mental health effects.
  • Emotional abuse may have greater health impacts than physical violence.

Why ask whether the woman is afraid of anyone at home?



  • Women who have reported DVA are 32 times more likely to be afraid of their partner than women who have not.
  • Women who have ever been afraid of a partner have higher depressive symptom scores than women who have not.
  • One-third of women reporting fear of a partner in the last 12 months have experienced severe combined physical, sexual and emotional abuse, 27% emotional abuse and/or harassment and 3% physical abuse alone.

The HARK questions (Box 7.7) are structured using a ‘funnelling technique’, starting with less direct questions and ending with more direct ones about physical and sexual violence. As well as facilitating disclosure, this structure emphasises the multiple dimensions of abuse: emotional, physical and sexual.


The HARK questions have been validated in a London primary care population and used internationally in research studies. In the UK, they are used in some sexual health and sexual assault services. They have been coded for installation on to many GP computer systems, with configuration of the HARK template as an electronic prompt triggered by specific conditions associated with DVA, such as headache (see Box 7.8).






Box 7.7 HARK questions



  • Humiliation: Have you been humiliated or emotionally abused in other ways by your partner or your ex-partner?
  • Afraid: Have you been afraid of your partner or ex-partner?
  • Rape: Have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
  • Kick: Have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?




In the IRIS study (see Box 7.8), questions were not recited exactly; instead the template was used as a mnemonic, reminding the clinician to:



  1. Lower their threshold to ask about DVA.
  2. Ask about DVA.
  3. Enquire about all abuse dimensions (emotional, sexual and physical).
  4. Remember safety.





Box 7.8 IRIS: the Identification and Referral to Improve Safety trial


IRIS is the first European randomised controlled trial of a training support and referral intervention designed to improve the primary health care response to DVA and comprises:



  • In-house evidence-based training for the practice team, on identifying DVA, appropriate responses, referral, recording, data handling, confidentiality and safety.
  • Use of electronic pop-up prompts (HARK) in patients’ medical records to remind professionals to ask about DVA.
  • HARKS = Humiliate, Afraid, Rape, Kick and Safety (‘Safety’ is currently under consideration as an extra HARK criterion).
  • Following a positive disclosure, asking whether it is safe for the woman to go home.
  • An advocate educator from a specialist DVA organisation, who provides training and is the named contact for referrals. The advocate provides emotional and practical support, assesses risk, plans safety and signposts patients to other services.

Results



  • Threefold increase in the identification of DVA.
  • Sixfold increase in referral to specialist DVA advocacy services.

The IRIS model can be commissioned for practices; see www.irisdomesticviolence.org.uk (last accessed 12 February 2014).




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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Identifying Domestic Violence and Abuse

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