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The impact of domestic violence on individuals | ||
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Jill Astbury, Judy Atkinson, Janet E Duke, Patricia L Easteal
MJA 2000; 173: 427-431 Abstract -
Children -
Pregnant women -
Elderly people -
Indigenous people -
People of non-English-speaking background -
The need for change -
References -
Authors' details
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| Abstract |
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If the idea of "home" implies physical and psychological safety and
security as well as shelter, then a child, adult or older person
affected by domestic violence experiences a hidden
"homelessness".1
Domestic violence occurs across the lifespan2 and across most cultures. Women are at a disproportionately high risk of physical, sexual and psychological violence from an intimate person such as a partner or ex-partner.3 Many children, too, are likely to experience violence from someone they know or be witnesses to violence within their families.4 Domestic violence may be physical, sexual or psychological, but all three can be present. What is subjectively defined and identified as "domestic violence" by victims can be strongly mediated by cultural beliefs, values and previous experience of abuse and may not coincide with standard clinical or research definitions. Domestic violence is always characterised by the use of coercive control and psychological abuse.5,6 Victimisation is associated with alterations in the perception of the perpetrator, especially a belief in his or her omnipotence, and alterations in the victim's perception of self. Feelings of self-blame, shame and loss of self-esteem are extremely common. At the same time, psychological defenses used to cope with violence include denial of its existence and minimisation of its severity.7 Acts of contrition and intermittent kindness by the perpetrator can maintain the relationship and give false hope to the abused person that the violence will end. In addition to the common features of domestic violence, there are important aspects of domestic violence that are characteristic of specific groups in society, such as children, pregnant women, the elderly, Indigenous people, and people of non-English-speaking background. Here we examine some of the specific problems of each of these groups in more detail. | |||||||||||||||||||||||||||||||||||||||||
| Children |
Children can be at risk of experiencing and witnessing violence
within the family or from those known to them.8 The perpetrator is usually
in a caring role or a position of trust in relation to the child.
Children can be the direct targets of physical violence or can get hurt when they try to protect another family member, often the mother, or try to stop their parents from fighting. It is becoming increasingly apparent that domestic violence results in a similar outcome for many children, whether they are direct victims or only witnesses of the violence. A number of authors have pointed to a clear link between domestic violence and child abuse, with one being a predictor of the other: it has been estimated that children living in domestic violence situations are up to 15 times more likely to be abused or neglected than children from non-violent homes.9-11 Behavioural and psychological consequences of childhood violence include poor school performance, bedwetting, aggression (particularly among males), temper tantrums, oppositional behaviour, self-blame, guilt for the violence between parents, isolation from peers, self-harming behaviour, running away, psychosomatic symptoms, stealing, over-eating, depression, sleep disturbances and excessive anxiety symptoms (see Box 1). Violence by a person in a position of trust impairs the child's ability to trust others and increases the risk of victimisation in later life.12 Recent research has shown that there are significant and possibly persistent neurobiological effects of trauma experienced in early childhood. Work by Perry and others13,14 has demonstrated the importance of critical periods of exposure to secure parenting: exposure to recurring traumatic experiences in early childhood places a child at much greater risk of long-term psychological, emotional and behavioural problems. The type of violence is not the primary factor determining long-term outcome. More important predictors are the duration of violence, its severity and frequency. The cumulative impact of exposure to multiple adverse experiences (eg, violence, psychological or sexual abuse, substance misuse) in childhood is predictive of adverse health outcomes in adult life. In a large US study it was found that exposure to four or more categories of adverse childhood experiences was associated with a 4-12-fold increased risk of alcoholism, drug abuse, depression and attempted suicide.15 Protective factors include a healthy relationship with a primary carer, good social support and positive subsequent life experiences.8,12 | ||||||||||||||||||||||||||||||||||||||||
Pregnant women | |||||||||||||||||||||||||||||||||||||||||
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The number of unwanted or unplanned pregnancies and terminations is
higher among women experiencing domestic violence.16,17 Pregnancy
itself is a time of heightened risk and the abdomen is targeted more
frequently and more severely in pregnant women.18,19 The
Women's Safety Australia survey4 found that, of all the women
who reported violence occurring at some time in their lives, 42% were
pregnant at the time. Twenty per cent reported that violence occurred
for the first time during the pregnancy, although the strongest
predictor of violence occurring during pregnancy is a prior history
of abuse.12 Furthermore, women
abused during pregnancy are at even greater risk of violence in the
postpartum period.19
Women experiencing violence during pregnancy often obtain minimal or late antenatal care.20 They are at increased risk of having poor weight gain, anaemia, infections, or preterm labour; of bearing a low birthweight infant; and experiencing postnatal depression.18,21-23 They are also more likely to engage in behaviours harmful to health, such as smoking, drinking excessive amounts of alcohol, and substance misuse.18,21-23 | |||||||||||||||||||||||||||||||||||||||||
Elderly people | |||||||||||||||||||||||||||||||||||||||||
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Abuse of elderly people is the most recent form of familial violence to
come to public attention but it remains a largely hidden problem. Most
community-based studies have shown that similar proportions of
older men and women are victimised (in contrast to the younger
population, in which the number of women experiencing
domestic violence is greater than the number of men).24 Close family
members (the victim's spouse, adult child or other relative)
constitute the majority of abusers and usually live with the
victim.25 The reasons for elder
abuse are often related to their dependence on others (due to physical
or mental impairment, particularly dementia), psychopathology in
the abuser, or a long history of family violence26 (see Box 2).
Many instances of elder abuse are "victim-victim" situations in
which abusers may themselves be worn-out carers.
Physical consequences include the actual injuries inflicted (eg, bruising, lacerations, fractures, or burns) as well as the results of neglect, such as malnutrition, decubitus ulceration, and inappropriate use of medication. Older people who are frail may sustain major injuries from an apparently minor cause -- for instance, a shove leading to a fall may result in a fatal subdural haemorrhage. Abuse may also have psychological consequences: feelings commonly experienced are a sense of powerlessness, shame at having to admit that the abuse is occurring at the hands of close family members, fear of retaliation from the abuser, and particularly fear of institutionalisation if the abuse is reported. Such fears increase the victim's reluctance to report abuse,27 often causing a self-imposed isolation. Control by the abuser may be exercised financially through the improper use of an older person's property or finances or misuse of a power of attorney, or may take the form of neglect whereby the necessities of life (adequate food, clothing, medication, or other care) are withheld by a caregiver.28 | |||||||||||||||||||||||||||||||||||||||||
Indigenous people | |||||||||||||||||||||||||||||||||||||||||
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Domestic violence in Indigenous families and communities in
Australia is presently at a level for serious concern.29,30 In 1990, an
Aboriginal and Torres Strait Islander Commission briefing document
advised the Australian Aboriginal Affairs Council that "the
increasing injuries and fatalities as a result of interpersonal
violence have risen to levels which not only impair life but also
threaten the continued existence of Australian Indigenous
peoples".31
Physical assault is commonly associated with psychological abuse, and Indigenous victims of domestic violence (who are mainly women) may view themselves as being of little worth, incompetent, and deserving of abuse.32 The situation becomes more complex when racism and discrimination in social control structures are intertwined with domestic violence32 (see Box 3). Domestic violence in Indigenous communities can only be understood in the context of the historical, political, social and cultural environments in which it occurs.34 Colonisation has had a disastrous impact on the lives of Indigenous people: it has created complex and cumulative forms of traumatic stress that may be articulated as physical, emotional and spiritual distress; misuse of alcohol and other drugs; and violent behaviour arising from a rage that is directed towards the self and other close family members.35 With the breakdown of cultural lore, behaviours that were previously functional in conflict resolution processes have become unstructured and damaging when used under the influence of alcohol or other drugs.36 John Cawte, a psychiatrist and anthropologist, identifies Indigenous communities as suffering from "gross stress", a form of post-traumatic stress disorder in which individuals express their loss and bewilderment as emotional and behavioural disorders.37 Indigenous women are less likely than non-Indigenous women to report an assault, and less likely to seek medical help unless they have severe injuries.38 Historical interactions with police, who were used by the state to forcibly remove Indigenous children under government assimilation policies, and deaths of Indigenous people in custody continue to engender a deep mistrust of law enforcement officials.39 Indigenous women fear for their own safety40 and the safety of other family members if police or social welfare officials become involved. While some Indigenous women may call the police to intervene in violent situations, they are less likely than non-Indigenous women to want to lay charges, and there is a general belief that charging or incarcerating Indigenous men does not reduce male violence. Indigenous women are more likely to ask for other interventions in which their partner also receives help for his drinking and/or violent behaviour.32 People who have been traumatised through violence are more likely to be treated as if they are mentally ill or unstable than to be provided with programs that will meet their needs; however, recent program initiatives in Australia are beginning to respond to the specific and unique needs of Indigenous peoples.29 | |||||||||||||||||||||||||||||||||||||||||
People of non-English-speaking background | |||||||||||||||||||||||||||||||||||||||||
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The extent of domestic violence experienced in Australia by
people of non-English-speaking background has not been
extensively studied. However, research suggests that
overseas-born males are more likely to commit partner homicide than
would be expected from their numbers in the general
community.41 This may reflect a higher
rate of domestic violence among overseas-born women.
Alternatively, these women may be less likely to leave violent
situations, and therefore experience escalating violence.
For those who are migrants, the strain of migration may compound the problem. However, in most cases in which a couple migrated together, the abuse preceded migration.42 Once in Australia, however, the migrant family may undergo further stresses as traditional gender roles shift. This may encompass unemployment or downward shifts in employment status for men, and paid employment for women. Assimilation of the younger generation into the broader Australian culture may further erode traditional hierarchies based on age and sex. Women who may be at particular risk include Asian women sponsored by non-Asian men,43 and Middle Eastern women brought to Australia for arranged marriages to Middle Eastern men already residing here.42 Such women have not only left behind their family and supports, but have joined partners whose established community networks may not recognise their needs. In some instances, their partner's extended family may collude in the violence, overtly or indirectly, by not offering support.42 Disclosure of domestic violence towards women of non-English-speaking background is inhibited if they have poor command of English (Box 4). For some women, however, the issue is more fundamental -- their concept of sexual assault within marriage may be very different from current Australian values and norms.44 Over 70% of migrant women have minimal knowledge of the legal rights of victims of domestic violence,45 which further inhibits disclosure, and many know little about support services or refuges. Women from Middle Eastern and Latin American cultural backgrounds who experience domestic violence are often reluctant to contact police, in part because they have witnessed oppression or torture at the hands of police in their country of origin.42 Domestic violence often creates a feeling of shame. There may be considerable pressure for a woman to maintain a marriage, and she may fear being deported.46 She may feel the burden of providing financial support for family in her country of origin,47 and consider that their plight outweighs any consideration of personal needs. The erosion of self-esteem accompanying domestic violence is compounded if the woman is isolated by virtue of limited English and lack of family and friends in whom to confide. The adverse health effects are similar to those experienced by abused women in the broader Australian society, although they may be exacerbated by longer delay in disclosure. | |||||||||||||||||||||||||||||||||||||||||
The need for change | |||||||||||||||||||||||||||||||||||||||||
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Each of the specific groups examined has characteristic issues
related to their experience of domestic violence. Nevertheless, the
need for change applies equally to all groups. Patients are reluctant
to disclose violence if not asked,48 but sensitive
questioning can legitimate and encourage disclosure. As the Council
on Scientific Affairs of the American Medical Association has
observed, knowledge of a history of abuse can provide "the starting
point from which to disentangle a confusion of presenting complaints
and symptoms".49
Clinical practice and medical education programs in Australia have been slow to respond to the large body of research confirming the harmful health effects of domestic violence. Failure by healthcare providers to detect and treat those affected by domestic violence exacerbates the harm done in several ways. Firstly, the complexity of violence-related negative health outcomes increases if abuse remains undetected. Secondly, the drain on healthcare resources increases as victims present repeatedly to primary and emergency healthcare providers. (Conversely, victims' uptake of preventive healthcare is considerably lower than average, and the role of violence in their "non-compliance" with preventive health behaviours can easily be missed.) Thirdly, non-detection ensures that treatments are necessarily directed at the symptoms rather than the cause.1 A thorough understanding of the multiple adverse health effects and high rate of physical and psychological comorbidity associated with domestic violence must be acquired by all healthcare professionals. Training is required in every aspect of treatment, including initial questioning, counselling and responding to those who do disclose violence, and providing appropriate assistance, including safety plans and advocacy on behalf of patients. A number of our medical colleges have begun this necessary task. In clinical care, the concept of meaningful assistance to patients with health needs associated with domestic violence deserves to be strongly promoted. | |||||||||||||||||||||||||||||||||||||||||
| References |
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Authors' details | |||||||||||||||||||||||||||||||||||||||||
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Key Centre for Women's Health in Society, University of Melbourne,
Carlton, VIC.
Jill Astbury, MEd, PhD, Associate Professor. Cooperative Research Centre for Rainforest Ecology and Management,
Cairns, QLD.
Harley Medical Chambers, Fitzroy, VIC.
Faculty of Law, Australian National University, Canberra, ACT.
Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai
Hospital, Hornsby, NSW.
Child Protection Unit, New Children's Hospital, Westmead, NSW.
Department of Psychiatry, Royal Brisbane Hospital, Herston, QLD.
Reprints will not be available from the authors. ©MJA 2000
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia. We appreciate your comments. | |||||||||||||||||||||||||||||||||||||||||
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