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Guide for General Practitioners

Guide for General Practitioners

Guide for General Practitioners

Identifying and responding to family violence: a guide for general practitioners.

This guide was produced by the Victorian Community Council Against Violence (2004). It is based on a kit for general practitioners by the Domestic Violence Resource Centre Victoria and Women’s Health West (1999).

In 2009, the Royal Australian College of General Practitioners published a third edition of Abuse and violence: Working with our patients in general practice

What is family violence?

Family violence is coercive and controlling behaviour by a family member that causes physical, sexual and/or emotional damage to others in the family, including causing them to live in fear and threatening to harm people, pets or property. Family violence is most commonly perpetrated by one partner towards another (when it is sometimes called ‘domestic violence’ or ‘intimate partner abuse’) and/or by an adult towards a child or children. Other forms include elder abuse or sibling abuse. Whether the violence is physical, sexual or emotional, it may have long term detrimental effects.

Working with families experiencing family violence can be difficult work for general practitioners. This guide has been developed to provide general practitioners with information to assist them to identify and respond to family violence. General practitioners may see all members of families and family violence may affect all members of families. It is important to know what the effects of family violence might be.

While some men experience violent relationships, women and children are most likely to be the victims of family violence and this guide focuses on responding to these groups. The guide also provides information about responding appropriately to men who are those most likely to perpetrate family violence.

The incidence of family violence is high. A full-time GP is likely to be seeing one to two female patients each week who have experienced family violence (Hegarty & Bush 2002). The Women’s Safety Survey, conducted by the Australian Bureau of Statistics in 1996, found that nearly a quarter of all women who have ever been married or in a de facto relationship experienced violence by a partner at some time during the relationship (Australian Bureau of Statistics 1996).

‘The medical profession has key roles to play in early detection, intervention and provision of specialised treatment of those who suffer the consequences of domestic violence, whether it be physical, sexual or emotional (Australian Medical Association, 1998).

General practitioners are the major professional group to whom women experiencing family violence turn (Hegarty & Taft 2001). Responding effectively to family violence in a medical setting requires non-judgemental, supportive attitudes, a knowledge of the physical and emotional sequelae of the violence, an understanding of appropriate and inappropriate responses, and on having good networks with local family violence services.

Assessing women

Some signs of physical injuries may include:

  • bruising in chest and abdomen
  • multiple injuries
  • minor laceration
  • injuries during pregnancy
  • ruptured eardrums
  • delay in seeking medical attention
  • patterns of repeated injury.

Women do not generally present with obvious physical injury (Campbell 2002). Violence can include threats, coercion and insults, as well as social and economic control. She may not recognise this is abuse. Women are often reluctant to disclose abuse because of fear or shame, or because they think that they won’t be believed. More commonly, victims of family violence present with a broad range of symptoms such as:

  • anxiety, panic attacks, stress and/or depression
  • stress related illness
  • drug abuse, including dependency on tranquillisers
  • and alcohol
  • chronic headaches, asthma, vague aches and pains
  • abdominal pain, chronic diarrhoea
  • complaints of sexual dysfunction, vaginal discharge
  • joint pain, muscle pain
  • sleeping and eating disorders
  • suicide attempts, psychiatric illness
  • gynaecological problems, miscarriages, chronic pelvic pain.

Other indicators

The woman may:

  • appear nervous, ashamed or evasive
  • describe her partner as controlling or prone to anger
  • seem uncomfortable or anxious in the presence of her partner
  • be accompanied by her partner, who does most of the talking
  • give an unconvincing explanation of the injuries
  • have recently been separated or divorced
  • be reluctant to follow your advice
  • present with children, though little seems to be wrong with them.

Assessing children and young people

Children can be exposed to and affected by family violence; these experiences are harmful and may have long term physical, psychological and emotional effects. The longer family violence is experienced, the more harmful it is.

Ask about the impact of family violence on children because the realisation of harm to children can be a catalyst for both men and women to make beneficial change. Refer children to services to assist them.

Family violence and child abuse frequently co-exist. Remember that general practitioners are mandated to report child abuse. A general practitioner can assist in caring for children affected by family violence by supporting the woman in providing protection to her children and ensuring that responsibility for the violence remains with the perpetrator (Laing 2000).

Indicators in children

  • aggressive behaviour and language
  • anxiety, appearing nervous and withdrawn
  • difficulty adjusting to change
  • psychosomatic illness
  • restlessness
  • bedwetting and sleeping disorders
  • ‘acting out’, such as cruelty to animals.

Asking women about violence

The detail of your questions will depend on how well you know the patient and what indicators you have observed.

Broad questions might include:

  • ‘How are things at home?’
  • ‘How are you and your partner relating?’
  • ‘Is there anything else happening that might be affecting your health?’

Examples of specific questions linked to clinical observations include:

  • ‘You seem very anxious and nervous. Is everything all right at home?’
  • ‘When I see injuries like this I wonder if someone could have hurt you?’
  • ‘Is there anything else that we haven’t talked about that might be contributing to this condition?’

Some more direct questions include:

  • ‘Are there ever times when you are frightened of your partner?’
  • ‘Are you concerned about your safety or the safety of your children?’
  • ‘Does the way your partner treats you make you feel unhappy or depressed?’
  • ‘I think that there’s a link between your (insert illness) and the way your partner treats you. What do you think?’

When English is not the woman’s first language, use a qualified interpreter. Do not use her partner or a child as the interpreter. Be aware that both men and women tend to minimise the violence, particularly when seen together.

Responding to disclosures by women of violence against them

Listen

Being listened to can be an empowering experience for a woman who has been abused.

Communicate belief

‘That must have been very frightening for you.’

Validate the decision to disclose

‘It must have been difficult for you to talk about this.’
‘I am glad you were able to tell me about this today.’

Emphasise the unacceptability of violence

‘You do not deserve to be treated this way.’

What not to say

Avoid suggesting that the woman is responsible for the violence.

‘Why do you stay with a person like that?’

‘What could you have done to avoid the situation?’

‘Why did he hit you?’

Helping to assess her and her children’s safety

  • Speak to the woman alone.
  • Does she feel safe going home after the appointment?
  • Are her children safe?
  • Does she need an immediate place of safety?
  • Does she need to consider an alternative exit from your building?
  • If immediate safety is not an issue, what about her future safety? Does she have a future plan of action if she is at risk?
  • Does he have weapons?
  • Does she need to seek an intervention order?
  • Does she have emergency telephone numbers? (police, women’s refuges)
  • Help make an emergency plan. (Where would she go if she had to leave? How would she get there? What would she take with her? Who are the people she could contact for support?)

Document these plans for future reference.

Responding to disclosures by men that they are violent towards family members

Consider the safety of female victims and their children as foremost. Acknowledge the existence of violence by statements such as:

‘That was brave of you to tell me. Violent behaviour towards your partner and other family members is not acceptable. It not only affects your partner but your children as well. Did you know that there are services that may be able to assist you?’

If you are seeing both partners, do not ask a man about suspected family violence unless you have checked with his partner first to get her consent.

If violence is suspected and further information is needed, start with broad questions such as:

‘How are things at home?’

Then, if there is a disclosure of violence, ask more specific questions such as:

‘Some men who are stressed like you are, hurt the people they love. Is this how you are feeling? Is this happening to you? Did you know that there are services from which you can get assistance?’

Couples or marital counselling may not be recommended while physical violence is currently present in a relationship because of the threat to the woman’s safety.

(Adams 1996; Hamberger et al 1990; Mintz & Cornett 1997)

Working with family violence when both partners are your patients or within the same practice

  • The needs of female and male patients should be addressed independently.
  • When abuse is suspected or confirmed, a woman should be interviewed without the male partner being present.
  • Affirm to the woman that her health and safety are important and that her confidentiality will be protected, unless disclosure is required by law.
  • There should be no discussion about the suspected or confirmed abuse with the male partner unless the woman consents to it.
  • If a woman agrees to the general practitioner contacting the male partner it is important that a safety plan is in place.
  • It is not a conflict of interest to ask a woman about the possibility of abuse or to have an active management plan when it is suspected or confirmed if the male partner is also a patient.
  • Have in place staff protocols that ensure confidentiality of records.

(Ferris et al 1997)

Documentation

Describe physical injuries. This includes the type, extent, age and location of any physical injuries sustained. If you suspect violence is a cause, but your patient has not confirmed this, it may be relevant to include your comments as to whether her explanation accurately explaining the injuries.

Consider taking photographs of injuries.

Record what the patient has said (using quotation marks) and any relevant behaviour you have observed.

This information may be required as evidence, should charges be laid against the perpetrator.

Guidelines for continuing care

  • Consider your patient’s safety as a paramount issue.
  • Monitor the woman and her children’s safety by asking about any escalation of violence.
  • Empower her to take control of decision making; ask what she needs and present her with choices.
  • Respect the knowledge and coping skills she has developed. You can help build on her emotional strengths, for example, by asking ‘How have you dealt with this situation before?’
  • Provide emotional support.
  • Be familiar with appropriate referral services and their processes. Patients may need your help to seek assistance.

How to show your clinic’s awareness of family violence and willingness to help

  • Display posters in the waiting area.
  • Have pamphlets available in the surgery (where women can take them without being seen by other patients).
  • Put a folder of health articles, including some of family violence, in the waiting room.
  • Have your appointment cards printed with the phone numbers of domestic violence and sexual assault services on the reverse side.

All women, regardless of race, age, ability or sexual preference, are entitled to live in a safe environment. If you live in an area where services are not readily available, or the woman does not feel comfortable accessing specialist services, you can still let her know you are concerned for her safety and assist her to consider her options.

References

Adams, D., ‘Guidelines for doctors on identifying and helping their patients who batter’,JAMWA, vol. 51, no. 3, 1996, pp.123-126.

Australian Bureau of Statistics, Women’s Safety Australia, Catalogue No. 4128.0, 1996, p. 50.

Australian Medical Association, AMA Position Statement on Domestic Violence, Canberra, AMA, 1998.

Campbell, J.C., ‘Health consequences of intimate partner violence’, The Lancet, vol. 359, 2002, pp. 1331-1336.

Ferris, L.E., Norton, P.G., Dunn, E.V., Gort, E.H. & Degani, N., ‘Guidelines for managing domestic abuse when male and female partners are patients of the same physician’, Journal of the American Medical Association, vol. 278, no. 10, 1997, pp. 851-857.

Hamberger, L.K., Feuerbach, S.P. and Borman, R.J., ‘Detecting the wife batterer’, Medical Aspects of Human Sexuality, September 1990, pp.32-39

Hegarty, K.L. & Bush, R., ‘Prevalence and associations of partner abuse in women attending general practice: A crosssectional survey’, Australian and New Zealand Journal of Public Health, vol. 26, no. 5, 2002, pp. 437-442.

Hegarty, K. & Taft, A., ‘Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice’, Australian and New Zealand Journal of Public Health, vol. 25, no. 5, 2001, pp. 433-437.

Laing, L., ‘Children, young people and domestic violence’, Australian Domestic and Family Violence Clearinghouse Issues Paper 2, 2000, pp. 15-17.

Mintz, H.A. & Cornett, F.W., ‘When your patient is a batterer: What you need to know before treating perpetrators of domestic violence’, Postgraduate Medicine, vol. 101, no. 4, 1997, pp. 219-228.

Acknowledgment & disclaimer

This guide is substantially based on Domestic Violence Resource Centre Victoria (DVRCV, formerly DVIRC) and Women’s Health West, ‘Identifying Family Violence: A Resource Kit for General Practitioners in the Western Suburbs of Melbourne’, 1999, part of a project funded through Partnerships Against Domestic Violence.

The information contained in this publication is intended as a guide only, and is not intended to cover all aspects of the issues dealt with herein. Practitioners are advised to contact the relevant services and agencies for more detailed information and advice about responding to those who are experiencing or are at risk of experiencing, family violence. Information about services was correct at the time of going to print.

This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without permission in writing from the Victorian Government.

Referrals

Our website has a list of national and state-based services.

Training and resources

We have:

  • Specialist library of written and video resources relating to violence in the home including books, kits, articles, manuals and protocols, studies and research
  • Professional education and training for those working with people affected by family violence
  • Publications including flyers, small booklets, Quarterly Newsletter, blog, Fact Sheets and Discussion Papers on family violence and sexual abuse.

More resources