Domestic Violence and Abuse Dr Stuart Vas, Barnsley VTS, 2013

Learning Outcomes Be able to describe the various forms of DVA Be able to recognise the role of the GP in relation to victims of DVA Be able to describe important aspects of consulting with victims of DVA

What is our role as GPs in dealing with DVA? (clippings)

Why is it important? RCGP curriculum statement 3.06 Women’s Health: –“3.5 recognise the prevalence of domestic violence and question sensitively where this may be an issue” (RCGP, 2012 RCGP curriculum statement 3.06 Women's Health)RCGP curriculum statement 3.06 Women's Health Some facts: –1/4 women will face some form of violence (Council of Europe, 2002) –1 woman dies every 3 days as a result of DVA (DoH, 2005) –50% women murdered were killed by partner or ex-partner (Kay, 1989) –¼ women will suffer violence at the hands of men with whom they have intimate relationships (Mooney, 1994) –DVA is the greatest cause of injury to women under 60 years of age (DoH, 2010) –Significant mental health consequences including depression, PTSD, suicide and substance abuse (Golding, 1999) –Pregnancy may increase the risk of violence with the greatest risk in the post-partum period (Mezey, 1997)

Keira Knightley clip What constitutes DVA?

“Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality. An adult is defined as any person aged 18 years or over. Family members are defined as mother, father, son, daughter, brother, sister, and grandparents, whether directly related, in laws or stepfamily.” (DoH, 2009) This also includes: –Stalking: a feature in 40% of domestic murders (Metropolitan Police) –Honour-based violence –Forced marriage –Female Genital Mutilation

Any experiences of managing female victims of DVA? Any one wondered if a patient was a victim of DVA but did not ask (and why)?

Reasons for doctors not asking… “There wasn’t time to discuss it” “I didn’t know how to ask the right question” “I don’t know what to do if a patient reveals it” “there’s not much I can do about it” “DVA is a social problem not a medical one” “she doesn’t speak English” (Duxbury, 2006)

Bare in mind… Women are more likely to report to GP (29%) than Police (20%) (Kelleher, 1995) Many women believe that their doctor can be trusted with disclosure (Feder, 2006) Women want to be asked (Friedman, 1992) There are a number of reasons why women may choose not to disclose DVA…

Reasons for not disclosing DVA: Previous negative experiences of disclosure to friends, family or professionals Fear of being shamed or of disapproval Ostracism by the community Sadness that the family will split up or that the children will be taken away Fear that the perpetrator will find out and will harm or even kill her or her children (especially if they have previously made this threat) Fear that they will be given no choices after disclosure Fear that events will spill out of the survivor’s control after disclosure Fear that children will be taken away “ Giving information to the GP hands over some control from the patient to the doctor and this is daunting for the patient and potentially unsafe ” (RCGP, 2011)

Open disclosure Vs non-disclosure Women may present in a number of ways –Open disclosure of DVA –Non-disclosure but “patient’s behaviour, symptoms or injury patterns give rise to suspicions…you may need to ask the question” (ICGP, 2008) Physical conditions which may be due to underlying DVA include: –STIs, PID, unwanted pregnancies, miscarriage, IBS, chronic pelvic pain, chronic headaches and fibromyalgia (Campbell, 2002) Mental health problems include: –Depression, anxiety, suicidal ideation/attempts and PTSD (Golding, 1999)

Really important points! It is UNSAFE to ask a woman about DVA if she is with any one who can understand the discussion (including children) If translation is required use a professional, impartial translating services You may need to take control of the consultation in order to get the patient on their own

How to ask about DVA… Non-disclosure –Consider sensitive ways of exploring issue “How are things at home?” “You told me about… I haven’t found anything concerning during my examination, and I wondered whether you were having some worries?” “Sometimes people I see with panic attacks or anxiety have had traumatic experiences in their lives. As a result, their bodies prepare for flight or fight at the slightest prompt. Might that be happening to you?” Disclosure –If DVA is disclosed consider more specific question…

HARKS (Sohal, 2007) Humiliate –“does he make you feel bad about yourself ?” Afraid –“do you feel afraid of him?” Rape –“do you ever feel you have too sex even when you don’t want to?” Kick –“has he harmed you or your property?” Safety –“is it safe for you to go home?”

Your response is critical Key messages that need to be conveyed to the patient: –I believe you –It is not your fault –Thank you for telling me –Support is available for you –Your safety at home, and that of your children, is a priority for your health Assess the immediate risk to the woman and family with the questions –“Are you safe to go home?” –“Are either you or your children in danger?” –“Has violence become more severe or frequent recently?” –“Are there weapons in the home?” (IRIS Project) If the answer is “Yes” to any of the above then immediate contact with a specialist advocacy agency is required

Who can provide support? Local DVA support workers –Make risk assessments (using CAADA-DASH risk assessment tool ) –Provide information about other agencies: housing, police, solicitors, social services etc –Discuss options –Done by phone or in person Local Police DVU (Domestic Violence Unit) –Specialist police officer –Provide DVA alarms and prioritise 999 calls National DVA helpline

Duluth wheel and clip RCGP - Power and Control clip

In Summary DVA has a significant on our patients DVA is extremely common Don’t be afraid to ask women about DVA, but consider when and how Help is available