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Health Issues

Introduction

Health professionals have a vital role to play in tackling domestic violence and must have a basic working knowledge and understanding of domestic violence. Research has shown that abused women are more likely to approach a health professional than any other professional, yet previously health professionals have rarely raised the issue of domestic violence directly with their service users. National referral rates to specialist domestic violence services clearly reveal extremely low rates of referral from health professionals (only 2% in one study). Health professionals often seem reluctant to actually deal with the issue of domestic violence. Research on women’s experiences with both general practitioners and health visitors generally indicates that women are dissatisfied with the response they receive, for example, one woman stated: "I sat with my doctor and cried for about an hour telling him everything. At the end of it, he gave me some anti-depressants and sent me home."

The aim of this section of the Directory is to ensure that health professionals respond effectively to domestic violence. The health service may literally be a lifeline for women whose contact with the outside world is restricted by a violent partner, or who may not wish to become involved with the police or criminal justice system.

The Community Practitioners’ & Health Visitors’ Association writes: "There is evidence that women find health care workers add to their problems by not providing appropriate support. Health professionals may ‘re-frame’ the woman’s problem, labelling it as a mental health or a gynaecological issue, and so fail to recognise or acknowledge the cause of the problem."

On average women are assaulted 35 times before they seek external help and make 5-12 different contacts before receiving a supportive and appropriate response. Two thirds of women tell no one.

The BMA states: "Increased awareness of domestic violence is urgently required by all health care professionals…It is known that many women who experience domestic violence go undetected in health care settings…There is a need for the medical profession to take a more proactive approach and to do this at all levels of organisational responsibility. Health care professionals should recognise that they are responsible for managing violence against women and that they can make a difference."

The Greater London Association of Community Health Councils (GLACHC) believes that health care professionals and Primary Care Groups (PCGs) have a central role to play in tackling domestic violence as a health care issue.

Health professionals are probably seeing adults and children who are experiencing domestic violence every working day. Research has proven that 1 in 4 women experience domestic violence during their lifetime, whilst 1 in 9 will have experienced domestic violence in the last year with obvious effects on their health and well-being. One study found that 30% of women attending Accident & Emergency Departments do so due to domestic violence.

Impact of Domestic Violence on Health

Physical: As a result of domestic violence a significant proportion of women seek medical help for injury, chronic illness and pain: 27% of women suffer physical trauma, 10% are knocked unconscious, 7% have bones broken, 8% stay in hospital and 28% see a doctor for treatment, but only 25% of these women actually reveal that the cause of their injuries is domestic violence.

30% of female trauma victims are injured by a current or former male partner. Women assaulted by their partner or ex-partner are 13 times more likely to be injured in the breast, chest or abdomen, than women injured by other means. The American Medical Association has suggested that there is an association with delayed physical effects, particularly arthritis, hypertension and heart disease.

General medicine and surgery can encounter symptoms which can be associated with domestic violence, but which can be easily overlooked, such as irritable bowel syndrome, chronic pain and failure to recover from procedures.

Psychological: Post Traumatic Stress Disorder, flashbacks, nightmares, exaggerated startle response, anxiety, 40% experience difficulty sleeping, 46% feel depressed and 25% of all women who attempt suicide do so because of the psychological trauma caused by domestic violence. Women may also feel helpless, isolated, afraid, demoralised, ashamed, angry and/or experience panic attacks. Many abused women define the psychological effects of domestic violence as having a more profound effect on their lives than the physical violence, even where there has been life threatening or disabling physical violence. Domestic violence results in women being several times more likely to self-harm, be parasuicidal, suicidal, misuse drugs and/or misuse alcohol. A drug and alcohol project reported that 70% of women contacting them had experienced domestic violence. One study found that 50% of women referred for psychiatric consultation were in abusive relationships. Another study looking at women receiving in-patient psychiatric treatment found that 64% of them disclosed a history of physical abuse as an adult. And yet another study found that 59% of domestic violence survivors had been admitted to a psychiatric in-patient clinic, compared to 1% in the control group. 48% had attended psychiatric out-patient clinics, compared to 8% in the control group. Yet domestic violence is rarely recorded in the service user’s notes. Perpetrators of abuse are sometimes able to persuade professionals that the symptoms of domestic violence are in fact the result of mental health problems, thereby deflecting attention away from them on to the victim. Perpetrators use the mental illness label to threaten women with losing their children if they do not comply with the perpetrator’s wishes.

Obstetrics: Domestic violence increases in frequency and severity over time. Pregnancy is often a time for violence to begin or to increase in severity and frequency, with the violence being directed at both mother and child. Domestic violence is a significant factor in maternal and perinatal mortality and morbidity. Injury to the abdomen, breasts and genitals is common during pregnancy. Violence during pregnancy can cause placental separation, foetal fractures, antepartum haemorrhage, rupture of the uterus and pre-term labour. Abusive relationships can lead to poor diet and restricted access to antenatal care, which can also impact upon the health of both mother and baby.

The prevalence of domestic violence in pregnancy is more frequent than pregnancy induced hypertension, placenta praevia, twins and gestational diabetes, yet domestic violence is not generally screened for but the other abnormalities are. Women experiencing domestic violence are 15 times more likely to have suffered a miscarriage and have much higher rates of stillbirth, premature labour, low birth weight babies and injuries to the foetus, including fractures. Researchers in the U.S. estimate that 23% of all obstetrical service users experience domestic violence. Another study showed that 36% of women who had experienced domestic violence had seen a doctor for at least one violent incident during pregnancy and 10% were hospitalised due to domestic violence.

The risk of domestic violence in the postpartum period is even greater.

Gynaecology: 45% of women with sexual problems and 47% of those with other gynaecological complaints have suffered domestic violence. There are links between chronic pelvic pain and domestic violence, resulting in women having unnecessary exploratory surgical procedures, such as laparoscopy.

For the health impact of domestic violence on children: see Chapter 10 entitled "Children".

The Cost to the Health Service of Domestic Violence

In just one London Borough the cost of domestic violence to the health service, excluding hospitalisation and medicines, was £590,000. Tackling domestic violence properly saves lives, improves health and saves the NHS time and money!

Research shows that, without intervention, there are increased attendances at Accident and Emergency Departments and GP surgeries. Further, the health problems caused by domestic violence can escalate, unless the underlying domestic violence is addressed in a positive, safe and supportive manner.

Why don’t women tell?

Many women feel embarrassed, fearful or distrustful about revealing the cause of their injuries/health problems. Health professionals that suspect that the woman they are seeing may be being abused should make clear to her that she can tell them about any abuse.

The fact that a woman denies violence does not mean she is not being abused. She may not trust the professional enough to expose her personal life. She may have been threatened by the man not to tell anyone. She may not define the abuse she is experiencing as domestic violence at this point. She may feel that no one can do anything that will change her situation. If she denies abuse, but the professional suspects abuse they should record this in their notes, as the health professional may later need to provide medical evidence to support her in relation to legal proceedings or rehousing.

Health professionals should be especially alert to the possibility of current or past abuse when a patient returns a number of times to the surgery with a set of vague and changing complaints. This may be her way of trying to make health professionals aware that the obvious health problems are not her main concern.

If professionals know that a client has experienced or lived with abuse, they must offer her referral to an agency that can give her specialised advice.

Why should health professionals encourage women to tell?

Even if the woman does not trust her doctor or is fearful of telling anyone the truth, there are several good reasons why she should disclose the abuse to them. For instance, in cases where a woman has external physical injuries, the doctor needs to know how these occurred so as to determine the most appropriate medical investigations, e.g. where there has been physical abuse to look for internal injuries. Similarly, seeing her GP about depression, without explaining why she is depressed, probably means she will be prescribed tranquillisers or anti-depressants. They may help temporarily, but if nothing is done about the abuse that is making her depressed, she may end up with two problems: an abusive partner and a dependence on drugs.

Another reason why a woman should tell is that the hospital staff can protect her, by putting her in contact with an agency that can find her alternative accommodation if she does not want to return to her home.

If the woman’s GP knows about her situation, the GP may be better able to understand and help her and her children with any problems they might have. Not all doctors are sympathetic to women who have been abused. If a GP is not sympathetic, then the woman could try one of the other GPs in the practice or try talking to the practice nurse or a health visitor if she has one. Women can contact Find Doc 0207 655 6688 for a list of female GP practices in the borough.

Women are increasingly being asked by the courts and housing departments to ‘prove’ that they have been abused. Medical evidence can be very useful to strengthen their case. Women should tell their GP that they may need his/her evidence for court.In cases of physical injuries women may be able to claim compensation from the Criminal Injuries Compensation Board. The awards range from £500 to thousands depending on the injuries. Whilst claiming compensation can be complicated and time-consuming, women stand a much better chance if they can provide medical evidence.

"But I can’t talk to my doctor"

Not everyone develops a positive relationship with their local GP, for lots of different reasons. If English is the woman’s second language and her GP doesn’t speak her first language, then it will be additionally difficult for her to talk about these issues. The woman may feel uneasy if her GP is male. If the G.P. knows the whole family, this may raise issues of confidentiality and loyalty for the woman.

Women have a right to health care and a right to choose the right doctor or services. They can change doctors. For more details contact Find Doc on 0207 655 6688. There are also other health workers whom they might feel more at ease with, e.g. Health Visitors, practice nurse or the staff at the Well Women Clinic.

Identifying domestic violence

All health professionals must know how to identify domestic violence, as health professionals have a duty of care to identify service users whose health may be affected by domestic violence.

McWilliams and McKiernan found that: "Interviews with medical professionals showed how the violence could often be minimised and not diagnosed or identified [by health professionals]…this is the process which results in a double victimisation of women, once by the perpetrator and once by the system to whom she has turned for help".

All health professionals are expected to be able to recognise the possible signs and symptoms of domestic violence. This is important not only for adult victims of domestic violence, but it is also important for child protection purposes, as up to 60% of children living in households where there is domestic violence are also being abused by the perpetrator of the domestic violence. Likewise, domestic violence has been present in up to 60% of child protection cases.

When domestic violence is suspected it is vital that staff actively follow the procedures laid out elsewhere in this document for dealing with domestic violence, i.e. ask the service user if they are experiencing domestic violence, record findings and, with the woman’s consent, make referral to a specialist domestic violence agency.

There is no sure way of diagnosing domestic violence but the following factors may be indicative, especially if several apply:

Unexplained bruises, whiplash injuries consistent with shaking, areas of erythema consistent with slap injuries, lacerations, burns, multiple sites of injury or multiple injuries in various stages of healing.
Injuries to areas hidden by clothing.
Injuries to face, chest, breast and abdomen.
Evidence of sexual abuse, e.g. injuries to genitals.
Chronic pain problems, including pelvic pain, back pain, neck pain, psychogenic pain or pain due to diffuse trauma without physical evidence.
The explanation given by the service user, as to how her injuries have occurred, is inconsistent with those injuries.
Delay exists between time of injury and presentation for treatment.
The service user describes the alleged ‘accident’ in a hesitant, ashamed, embarrassed, frightened or evasive manner.
Service user, partner and/or family deny or minimise injuries/violence.
Exaggerated sense of personal responsibility for the relationship, including self-blame for partner’s violence.
Review of the medical records reveals that the service user has presented with repeated ‘accidental’ injuries.
Repeated visits to the surgery.
Service user presents repeatedly with vague complaints or symptoms for which no explanation can be found, e.g. abdominal pain, reduced foetal movements, ‘query UTI’, etc.
Non-compliance with treatment regimes. Not being allowed to obtain or take medication. Missed appointments. Lack of access to finances. Lack of ability to communicate by telephone.
Ill-defined symptoms.
The woman is accompanied by an ‘overprotective’ partner. The perpetrator of the violence will actively try to prevent health care professionals from obtaining an accurate picture of what is happening by:
- Doing all the talking: he will explain what the health problem is and will answer all the questions asked by the health care professional, thereby ensuring that only his explanation of what is wrong is heard.
- Refusing to allow the woman to be seen alone: he will always be present during all consultations and examinations.
- Speaking to health care professionals in the absence of the service user, e.g. discrediting her child care capabilities, presenting her as having mental health problems and/or claiming that she is the perpetrator of the violence (that he was only defending himself).
Intense irrational jealousy or possessiveness expressed by partner or reported by service user.
Service user may be reluctant to speak or disagree in front of her partner.
Service user is pregnant (domestic violence often begins in pregnancy). Injuries are most commonly to the breasts and/or abdomen.
Service user has a history of miscarriage, stillbirth, pre-term labour, intrauterine growth retardation, low birth weight babies and/or unplanned or unwanted pregnancies.
Postpartum, removal of perineal sutures.
Service user has persistent gynaecological complaints, e.g. pelvic pain, pain during intercourse, frequent urinary and/or vaginal infections.
Failure to use condoms and other contraceptive methods.
History of psychiatric illness, alcohol or drug dependence in service user or partner.
History of attempted suicide/parasuicide and/or self-harm.
History of depression, anxiety, panic attacks, inability to cope, social withdrawal, feelings of isolation and/or a sense of helplessness. One survey found that depression was the strongest indicator of domestic violence. The depression caused by domestic violence, when present after childbirth, can be misdiagnosed as postnatal depression.
Physical symptoms related to stress, anxiety and depression:
- Sleep & appetite problems.
- Fatigue, decreased concentration & sexual dysfunction.
- Chronic headaches.
- Abdominal & gastro-intestinal complaints.
- Palpitations, dizziness, parathesia & dyspnea.
- Atypical chest pain.
Frequent use of prescribed tranquillisers or pain medications.
Children: history of behaviour problems or unexplained injuries.

Patient Consultation

All health professionals must develop the necessary skills to carry out effective consultation with service users when domestic violence may be a factor. It is essential to create an environment that encourages disclosure by those experiencing domestic violence.

Health care professionals are in a privileged position as:

It is much easier for a health professional to ask to see the service user alone to ask direct questions about domestic violence.
Health professionals more often see the resulting injuries and therefore are able to ask very specific questions and relate the health of the service user to the wider issue of domestic violence.
It is, therefore, vital during service user consultations to:
Have someone independent of the woman doing any language interpreting, i.e. do not use the woman’s children, relatives or partner.
See the woman alone.
Ensure that the environment is confidential, i.e. that no one can overhear the conversation.
How she is treated will be significant in determining whether she is able to disclose domestic violence and seek help, or whether she mistrusts professionals and is left to face continued violence alone. The fear of not being believed or of being blamed for what has happened may stop women from talking about their experience of violence. When a disclosure has been made it is essential that the response of the health professional is sympathetic, supportive and non-judgmental.
Do not rely on what family members report as to the reason for injuries or as to the state of mind of the service user.
Remember that the presenting complaint is only part of the picture. It is important to deal with the underlying cause of the health problems (i.e. the domestic violence) as a priority, rather than merely focussing on the symptoms. It is easy to lose sight of the cause of health problems whilst focusing on symptoms, such as depression, asthma, alcohol abuse and physical injuries. Many health problems can greatly improve once the victim is away from the domestic violence.
Listen to what the woman wants — do not decide that you know what is best for her. Remember perpetrators of violence frequently tell their victims that the violence is for their own good! Do not become another oppressor in her life. The perpetrator of the violence tells her what to do all the time, don’t simply become someone else who tells her what to do. Instead give her options. Encourage and empower her to make her own decisions.
Some women are not comfortable divulging incidents of domestic violence to a man, so male health care professionals should offer consultation with a female colleague, wherever possible, when domestic violence is suspected. Likewise suspected male victims of domestic violence should be offered consultation with a male colleague.

If the service user lives in a safe house, e.g. a refuge or with friends:

Do accept a post office box number or a different address as her address for the purpose of her notes and correspondence.
Do NOT under any circumstances write her actual address on the notes, or input it onto any computer system. Should she require a home visit, she will provide her actual address at that time. After the home visit has taken place, the actual address should be destroyed and must not at any time be written on her notes.
BEWARE of simply writing a prescription for anti-depressants or tranquillisers, as this can compound the problem. Anti-depressants and tranquillisers can actually do more harm than good, as they can make the service user less able to think clearly and take action to tackle the underlying problem (i.e. the domestic violence). They may limit the service user’s alertness, leaving her more vulnerable to assault. They help the service user to stay in a situation that is physically dangerous, bad for her health and not meeting her emotional needs.

Action Required from Health Professionals:

Ask
Record
Refer
Display posters in the waiting rooms, toilets and consulting rooms.
Have leaflets available in waiting areas, toilets and consulting rooms.

See Chapter 6, Section 7 for more information on the action required from all professionals when dealing with domestic violence.

Confidentiality

All health professionals must understand confidentiality in relation to domestic violence.

Both the British Medical Association (BMA) and General Medical Council (GMC) advocate disclosure of service user information in certain specific circumstances:

"It is essential that confidentiality is discussed in detail with the service user on each occasion that the issue of domestic violence is raised. The doctor should explain that any information provided by the service user relating to domestic violence will be treated as confidential. However, the doctor should also explain that secrecy cannot always be guaranteed and that there may be rare and exceptional circumstances when the doctor may be required to breach confidentiality, for example, where children are potentially at risk or where the doctor considers that the service user, herself, may be at risk of serious harm or death." (BMA)

"Disclosure may be necessary in the public interest where failure to disclose information may expose the service user, or others, to risk of death or serious harm. In such circumstances you should disclose information promptly to an appropriate person or authority." (GMC: Duties of Doctors)

Respect for confidentiality is an essential requirement for the preservation of trust between service user and health professional. There is a strong public interest in maintaining confidentiality, so that individuals will be encouraged to seek appropriate treatment and share information relevant to their health and well-being. No problem arises where service users give informed consent to their information being disclosed to a third party.

If the health care professional does decide that there is an over-riding duty to disclose the abuse to an appropriate third party, they should ideally discuss this with the service user first and explain their reasons for taking such action. Attempts should be made to seek the service user’s approval and the health professional must ensure that the service user is not put at increased risk of violence if a disclosure is made. Information disclosed without consent must be the minimum necessary to achieve the objective.

Children/Young Person’s Confidentiality:

Where a child is directly affected by domestic violence, through physical and/or psychological abuse used against the child, then the child protection procedures must be used.
When the child/young person discloses domestic violence within their family, the health professional will need to make a decision and request advice regarding breaking confidentiality.

The child/young person must be informed at all times when confidentiality is broken.

In any situation where confidentiality is breached without the consent of the adult or young person, health professionals must be prepared to justify their actions to their disciplinary bodies. The nature of, and reasons for, disclosure must be clearly documented.

Sharing information with other members of the primary health care team: the criteria governing such disclosure, as with all health information, is that the receiving health professional has a demonstrable ‘need to know’ a particular piece of information in the interests of the service user’s care. The sharing of identifiable information for the convenience or interest of health workers or administrators cannot be justified. Where the disclosure of relevant information between health care professionals is clearly required for the treatment to which a service user has agreed, the service user’s explicit consent is not required. However, if the service user does not wish the health professional to share particular information with other members of the team, those wishes must be respected. It is particularly important in the context of domestic violence that the service user is involved in all stages of the decision making process, and that they retain as much control as possible over the disclosure of information. Service users may cease to disclose information if they feel that what they are saying is being repeated.

The woman is at increased risk of violence when she attempts to leave, so it is vital that information regarding where she is living or which agencies she has been referred to are kept securely and are not disclosed to her partner. When a woman is living in a refuge, only the P.O. Box of the refuge should appear on the service user’s notes (if the woman requires a home visit, then she can give the actual address to the visiting health professional, who should destroy the actual address once the home visit has been done). The woman’s address must not be given to other professionals without her consent. 30% of women killed by their partners/ex-partners are killed after they have left the violent situation. Confidential adress should be recorded on all electronic databases.

End note:

Leaving domestic violence tends to be a process and so it should not be assumed that an interaction with a woman, which does not lead to any changes, was a waste of time. Any contact with a woman, which empowers and provides information, is useful. Slowly professionals can build up women’s self-esteem, confidence and determination to live without violence.