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• Domestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse.
  
• Women experience domestic violence at far greater rates than men do, and women and children often live in fear as a result of the abuse that is used by men to maintain control over their partners.
  
• Domestic violence is a major public health problem and is very common in women attending clinical practice.
  
• Women present most commonly with a range of chronic symptoms to unsuspecting general practitioners, emergency department doctors or medical specialists.
  
• Women who have experienced partner abuse want to be asked about it and are more likely to disclose if asked in an empathic, non-judgemental way. Doctors can make a difference.

Under Australian law, use of the term "domestic violence" refers exclusively to violence committed by a heterosexual partner and includes physical injury, intimidation or serious harassment, wilful damage to property, indecent behaviour without consent, or a threat to commit any of these acts.⁹

However, from a health perspective, domestic violence can be better understood as a chronic syndrome characterised not only by episodes of physical violence but also by the emotional and psychological abuse that perpetrators use to maintain control over their partners -- ". . . most women experiencing partner abuse report that the physical violence is the least damaging suffered: it is the relentless psychological abuse that cripples and isolates the woman".¹⁰

The Australian Medical Association recently produced a position statement asserting that

"Domestic violence is an abuse of power. It is the domination, coercion, intimidation and victimisation of one person by another by physical, sexual or emotional means within intimate relationships."¹¹

The Australian Public Health Association employs a comprehensive definition of "domestic violence", outlining examples of abusive behaviour:¹

• Physical abuse, causing pain and injury; denial of sleep, warmth or nutrition; denial of needed medical care; sexual assault; violence to property or animals; disablement; and murder;

• Verbal abuse, in private or in public, designed to humiliate, degrade, demean, intimidate, subjugate, including the threat of physical violence;

• Economic abuse, including deprivation of basic necessities, seizure of income or assets, unreasonable denial of the means necessary for participation in social life; and

• Social abuse, through isolation, control of all social activity, deprivation of liberty, or the deliberate creation of unreasonable dependence.

• Police figures reveal that women are over eight times more likely to be victims than males;¹²

• Crime surveys show that a third of all assaults on women are by partners, whereas the number of assaults on men by their partners is too small to produce reliable estimates.^12,13

• Victorian public hospital figures show that 1.3% of women and 0.14% of men admitted to emergency departments are there as a result of partner-inflicted injury.¹⁴

• Each year, more than 20 000 women in Australia seek shelter in women's refuges and take out protection orders.⁹

A recent review in Western Australia showed that the incidence per 100 000 adult women of injury from domestic violence varied according to the source of public records used: 1.6 (police-recorded homicides), 129.2 (hospital admissions data), 183.5 (recorded crime), and 248.1 (restraining order data).¹²

In Australian survey research, women are three times more likely than men to experience an episode of physical violence by their partners.^6,7

Domestic violence rates vary depending on the definition used¹⁵ and whether the data are from community crime victim surveys^12,13 or prevalence studies in clinical samples^6,7,16-19 or community samples.²⁰ Clinical studies in emergency departments and antenatal clinics indicate that between 19.3%⁷ and 25.0%¹⁷ of women will be subjected to domestic violence over their lifetime. Surveys of women attending general practice in Australia reveal varying partner abuse rates of 8.0%¹⁶ and 28%¹⁸ in a 12-month period. The only population-based study that investigates physical and sexual violence, the Women's Safety Survey,²⁰ found that 2.6% of women who currently had partners had experienced an incident of violence in the previous 12 months, and 8.0% had experienced violence at some stage in their relationship.

When women come to the realisation that they can not change the situation however hard they try, and that they need help, relatively few present to domestic violence services or the police in the first instance.²⁴ They may seek help from family or friends, general practitioners, personal and relationship counsellors, child specialists, psychiatrists, teachers, hospital staff, solicitors, family support services, self-help groups, church representatives or charity organisations.²³

It is important to realise that women who have been abused want to be asked about domestic violence and are more likely to disclose if asked.^15,25 However, most women present to doctors with a variety of complaints without disclosing that there is a background of domestic violence. The wide range of potential clinical indicators of domestic violence (see Box 1) can make it difficult to detect, but if women present frequently with some of these problems over time the clinician should be alert to the possibility of domestic violence. While some abused women report that they specifically sought help for such symptoms, others say that they sought help for the perceived underlying cause of the abuse (eg, marital conflict, their partner's mental health, a drug and alcohol or gambling problem) or wanted information about how to deal with the violence.²³

Women may present with overt physical injuries, but more commonly with a range of chronic symptoms, to unsuspecting GPs, emergency department doctors or medical specialists.

Women are at higher risk if they

• are less than 40 years of age;

• have a past history of child abuse or have a child who is currently being abused;

• have undergone recent separation or divorce;

• are socially isolated;

• have an accompanying partner who is overattentive;

• present frequently;

• delay in seeking treatment or are non-compliant.²⁶

The diagnosis of domestic violence is an important challenge to all doctors in clinical practice²⁶ because patients increasingly point to positive interactions with medical professionals as one of the important elements in their recovery. The stories in Boxes 2 and 3 (based on actual cases) illustrate situations that clinicians may encounter.

In spite of the lack of agreement on definitions, domestic violence is clearly a very common, hidden problem for many patients attending clinical practice. Doctors need to be aware of the many potential indicators of domestic violence²⁶ and should ask about abuse in an empathic, non-judgemental way.²⁵ At an individual level, domestic violence can cause physical and emotional ill health; the underlying abuse needs to be recognised and dealt with directly if women and their children are to be safe. Domestic violence is clearly a significant public health problem that all clinicians need to be aware of to enable them to act as advocates for their patients.

1. Australian Public Health Association. Domestic violence. Canberra: Australian Public Health Association, 1990.
2. Centers for Disease Control and Prevention. Emergency department response to domestic violence - California, 1992. JAMA 1993; 270: 1174-1175.
3. Knowledge and social change. In: Dobash RE, Dobash RP. Women, violence and social change. London: Routledge; 1992: 251-283.
4. ANOP Research Services. Community attitudes to violence against women. Canberra: Office of the Status of Women, 1995.
5. Candib LM. Violence against women: no more excuses. Fam Med 1989; 21: 339-341.
6. Roberts G, O'Toole B, Lawrence J, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1994; 159: 307-310.
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20. McLennan W. Women's safety survey. Canberra: Australian Bureau of Statistics, 1996.
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28. Straus MA, Smith C. Family patterns and primary prevention of family violence. In: Straus MA, Gelles RJ, editors. Physical violence in American families. Risk factors and adaptations to violence in 8145 families. New Brunswick, New Jersey: Transaction Publishers, 1990: 507-525.
29. Yllo K. Through a feminist lens: gender, power and violence. In: Gelles RJ, Loseke DR, editors. Current controversies in family violence. Newbury Park, California: Sage Publications, 1993: 47-63.
30. DeKeseredy W, Hinch R. Woman abuse: sociological perspectives. Toronto: Thompson Educational Publishing, 1991.
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32. Hudson W, McIntosh S. The assessment of spouse abuse: two quantifiable dimensions. Journal of Marriage and the Family 1981; 43: 873-888.
33. Rodenberg F, Fantuzzo J. The measure of wife abuse: steps toward the development of a comprehensive assessment technique. J Fam Violence 1993; 8: 203-217.
34. Yegidis BL. Abuse Risk Inventory for women. Palo Alto, California: Mind Garden, 1989.
35. Hegarty KL, Sheehan M, Schonfeld C. A multidimensional definition of partner abuse: development and preliminary validation of the Composite Abuse Scale. J Fam Violence 1999; 14: 399-414.
36. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992; 267: 3176-3178.
37. Sherin KM, Sinacore JM, Li X, et al. HITS: A short domestic violence screening tool for use in a family practice setting. Fam Med 1998; 30: 508-512.
38. Straus MA, Gelles RJ. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. Journal of Marriage and the Family 1986; 48: 465-479.
39. Headey B, Scott D, Vaus D. Domestic violence in Australia: are men and women equally violent? Australian Social Monitor 1999; 2: 57-62.
40. Candib LM. Naming the contradiction: family medicine's failure to face violence against women. Family and Community Health 1990; 13: 47-57.
41. Johnson MP. Patriarchal terrorism and common couple violence: two forms of violence against women. Journal of Marriage and the Family 1995; 57: 283-294.
42. Saunders DG. Wife abuse, husband abuse or mutual combat. A feminist perspective on the empirical findings. In: Yllo K, Bograd M, editors. Feminist perspectives on wife abuse. Newbury Park, California: Sage Publications, 1988: 91-113.
43. Lawler VA. Routine screening for domestic violence: a review of the literature. Melbourne: University of Melbourne, 1996.

Women's Health, Royal Australian College of General Practitioners, Sydney, NSW.
Elizabeth D Hindmarsh, MB BS, FRACGP, Chairperson.

Public Health Unit Gascoyne, Carnarvon, WA.
Marisa T Gilles, BSc, MB Chb, MPH, Director.

Reprints will not be available from the authors.
Correspondence: Dr K Hegarty, Department of General Practice and Public Health, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053.
k.hegartyATgpph.unimelb.edu.au

©MJA 2000
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