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Abstract

• Domestic violence is a complex issue at both an individual and public health level.
  
• Barriers to disclosure often lie with the doctor rather than the victim.
  
• Assessment of risk and devising a safety plan are important steps for the doctor to undertake with the victim.
  
• Recommendations for joint counselling or marriage guidance for the couple are usually not appropriate.
  
• The efficacy of population screening for domestic violence has not yet been demonstrated. More limited opportunistic screening is recommended, especially in the emergency department, mental health and obstetric settings, and general practice.
  
• Health professionals can be a bridge to resources within the community, but this requires knowledge of and liaison with those services.

There is increasing awareness of the benefits of taking a public health approach to domestic violence -- in considering it analogous to a chronic and complex condition, the burden of care on individual doctors can be lessened and the healthcare system can take a more constructive approach to this difficult issue.

We examine here the role of individual practitioners, healthcare institutions and government in managing domestic violence, and propose some preventive strategies.

What can individual doctors do?

It may be that some doctors who are aware of abuse experienced by their patients fail to document it. However, documentation is essential for the patient in case legal action ensues.

Easteal and Easteal⁵ surveyed 96 Australian general practitioners on their attitudes and practices towards victims of domestic violence. The most common reasons given for suspecting spouse abuse were physical signs and injuries (56.3%), excess alcohol consumption by the patient and/or partner (11.0%), and the patient's case history (11.5%). Only about a third of doctors reported that they look for emotional problems as "symptoms" when determining assault cases.

In a similar Canadian study of 505 physicians, respondents estimated that 14%-17% of their female patients had been victims of abuse, but over 70% of respondents believed that they identified fewer than half of these patients in their practice. The most common reasons given for failure to uncover domestic violence were patient unresponsiveness, lack of physician initiative and infrequent visits by the patients.⁶

Doctors perceive spouse abuse to be a complex and multifaceted problem.⁷ Many feel powerless to deal with domestic violence,⁸ and fear that in broaching the subject they are "opening Pandora's box".⁷

Barriers to instituting helpful intervention in cases of domestic violence include:

• close identification by doctors with patients of similar background, which may preclude the consideration of domestic violence as a differential diagnosis;⁹

• a perception, especially among female doctors, that dealing with patients' domestic violence issues will expose their own fear of vulnerability and lack of control;⁹

• a fear of offending patients by asking questions about a subject culturally defined as "private";⁹

• reluctance to accept a patient's claims of domestic violence without corroboration from an outside source;⁹

• time constraints in a busy practice that make it difficult to deal with complex problems such as domestic violence;^7,10

• lack of training of doctors in the area of domestic violence.^9,11

Abused women are more likely to disclose domestic violence to their GP than to other health workers and, when they do, the GP needs to be prepared. Useful advice for doctors on dealing with domestic violence, and an illustrative case scenario, are given in Boxes 1 and 2.

What can be done in the institutional or hospital setting?

The effectiveness of population screening of women for domestic violence has not been proven,²³ and at this stage the more limited goals associated with opportunistic screening are recommended. Routine screening should only be undertaken in situations where there is likely to be a high prevalence, such as among people attending hospital EDs, antenatal clinics and psychiatric services. Routine screening within the hospital setting will raise ethical and practical issues.

An important ethical issue is the acceptability of asking people directly about their experience of domestic violence. Studies conducted in EDs demonstrate high response rates to screening questionnaires by women and men.²⁴ The current pilot study being conducted by Queensland Health Domestic Violence Initiative to introduce routine screening in EDs and antenatal clinics has met with strong acceptance from the women being surveyed (Ms J Webster, Co-manager, The Domestic Violence Initiative, personal communication).

Screening will require the choice of appropriate tools and training of staff. Staff will need broader knowledge in the areas of documentation of history and injuries, photographs, safety of the victim, confidentiality, legal rights, and reporting of attempted or suspected criminal assault. (Reporting of violence is a controversial issue -- for example, several states in the United States have mandatory reporting of domestic violence, but there are concerns about patient autonomy and risk of retaliation for the victim.²⁵)

Training also needs to deal with the barriers to enquiry about domestic violence, including negative attitudes of health professionals towards victims. Staff who have themselves experienced domestic violence may require particular care. Knowledge of the dynamics of domestic violence is important -- staff need to understand that domestic violence can manifest as both mental and physical injury, and to accept that there is often no immediate solution to the problem (eg, a victim may return to a violent partner).

Hospitals need to assess their resources for dealing with domestic violence and devise policies and protocols for the use of those resources. Health professionals can be a bridge to services in the community if they are familiar with the appropriate referral services within the hospital and in the wider community.

For years, legal and community advocacy services have acted as community resources for women seeking help with domestic violence problems. A recent development in the United States has been to enlist the help of advocates in medical settings.²⁶ While this is not common practice in Australian hospitals, the service is worthy of consideration given the success of other services such as breast cancer volunteer visitors (ie, women who, having experienced the condition themselves, give support and comfort to other women with breast cancer). Advocates can assist victims with legal information and safety planning, and help them develop independence.

What can governments do?

Governments can enact policies aimed at prevention, supply resources for effective management of perpetrators and victims of domestic violence, and educate the community about domestic violence. Government policy can also target the training that medical, nursing and allied health personnel receive to ensure that all clinicians are aware of their role in managing domestic violence, know how and when to screen for domestic violence and know which management strategies are likely to be effective.²²

Governments could also ensure that the different departments dealing with domestic violence and child abuse are able to work together effectively and communicate information on cases they have in common. This is because the strategies for managing child abuse in this context are different from those required for dealing with other forms of child abuse.

When asked how government services relating to domestic violence could be improved, women have suggested improving the responsiveness of individual police members when dealing with domestic violence; ensuring that a wider range of organisations and professional services are aware of domestic violence issues and how to manage them; increasing awareness of how to access the domestic violence services that are available; increasing the services in remote and rural areas; and providing more practical support with housing, employment and the law.^15,27

Governments also need to address the continuing shortage of refuge accommodation,²⁸ and to examine the effect of recent changes to legal aid funding that have made it available only for cases going through the Family Court.

Conclusions

References

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Royal Australian College of General Practitioners, South Melbourne, VIC.
Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education.

Watkins Medical Centre, Brisbane, QLD.
Joan M Lawrence, AM, FRANZCP, Adjunct Professor of Psychiatry.

Research Unit, Department of Psychiatry, CYMHS, Fortitude Valley, QLD.
Gwenneth L Roberts, PhD, B Bus (Health Admin), Research Manager.

Department of General Practice, University of New South Wales, Kensington, NSW.
Sheila M Knowlden, MB BS, FRACGP, Senior Lecturer.

Reprints will not be available from the authors.
Correspondence: Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education, Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, VIC 3205.
danielle.mazzaATracgp.org.au

©MJA 2000
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