Box 16.1 Checking that you are in a ‘safe space’ for a private conversation (all medical practice)

• Is the room/cubicle soundproof? Curtains are not! You must see the patient in a soundproof room to protect her privacy. If she is on a ward, insist on using a soundproof treatment room.
  
• Is the window open? If so, close it. Sound carries and the patient’s abuser or a relative of the abuser may be outside. We can all recognise friends’ and families’ voices over those of others, and from further away.
  
• Check your concerns: It may be appropriate to share your concerns with any other professional who is in the room.
  
• As the patient walks into the room, is she alone? If her partner is with her, is he clearly dominant/overbearing? Does he take the seat near you and leave her sitting to the side? Does he answer all the questions? Does she constantly look at him to check her answers? Does he make you feel uncomfortable? Does he avoid eye contact? We can pick up signals subconsciously; these instincts should not be dismissed out of hand.
  
• Has a member of the family offered to translate? You must use independent translators (preferably an anonymous one via telephone. If a patient comes from a country that has only a small community in your area, the translator may still know her even if they are employed independently).
  
• See the woman alone for some part of the consultation: Even having her mother or sister there will inhibit a discussion about domestic or sexual abuse.
  
• Try to examine the woman alone: If this fails, say you want to check her urine. Send the nurse or chaperone off with her and explain that while separated, she needs to be asked.
  
• It may be appropriate to ask the partner to leave: Say that while you appreciate the support they are giving, sometimes patients like the extra confidentiality of being seen alone for a few minutes with the doctor. Or say, ‘it’s a standard of care, and professional responsibility, to ensure a short confidential time alone’. Reassure the companion(s) that you will bring them back before you explain what you want to do about her presenting problem.
  
• Having a ‘red spot system’ in all toilets may also be useful: This involves putting a notice on the inside door of the toilet asking if a woman is a victim of abuse and would like to talk to someone about it, and pinning some red spots on the door. The victim can then put a red spot on her urine sample if she wants to talk to someone at a safe time.
  
• If you cannot get private time, do not endanger the patient or yourself: If the partner objects, this should raise further suspicion. Wait for another opportunity or pass your concerns on to the next carer, the midwife or the GP.
  
• Asking about abuse does not take long: You do have time. A video of the author, for a research project in an antenatal clinic that had nothing to do with abuse, timed how long it took to ask and receive an answer. On average, it took 26 seconds before the conversation could move on to other clinical parts of the history taking.
  
• Examine: Document any unusual bruises, burns or scratches that you find. Note their locations, shapes and colours. Abdomens and inner thighs are not common places for accidental bruises.