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Editorial
Domestic violenceThe healthcare sector could become agents of change
MJA 2000; 173: 513-514
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The recent series of review papers on domestic violence in the Journal
has dealt with a number of important themes: the impact of domestic
violence on individuals;1 characteristics of
perpetrators;2 presentation of domestic
violence in clinical settings;3 and what can be done about
domestic violence.4 The prevalence of domestic
violence is difficult to estimate because of the variability of
definitions and ways of measuring it and the lack of systematic
epidemiological studies. Rates tend to be high among patients
presenting to general practitioners,5 antenatal
clinics,6 emergency
departments7 and mental health
services,8 but in each of these settings
detection is poor.
While studies are often developed within a feminist frame of reference and have mostly emphasised the impact on women, men may also be subject to violence from women, as may partners in same-sex relationships. Its impact on children is also substantial, both through witnessing violence and experiencing the effects of abused and abusing parents.9 Focusing on physical abuse as the key indicator may fail to identify far more damaging emotional abuse. There are major health and economic costs of domestic violence.10 Both physical and mental health are affected, increasing the risk of suicide-related behaviours, the drain on healthcare resources and negative perceptions of health status.8,10 | |||
Domestic violence in a cultural context | |||
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Cultural factors have an important impact on the prevalence of
domestic violence. These include stereotyped attitudes about
"ownership" of women and their value and place in the family and in
society; attitudes that define social status in terms of power over
others; and the belief of some people that violence is a normal and
acceptable way to resolve conflict. The phenomenon of psychological
"splitting" is relevant in many situations of domestic violence:
people in relationships may unconsciously separate their own good
and bad qualities, projecting the hated parts of themselves onto
their partner, who is then abused.
Understanding violence in families should always encompass an understanding of the importance and complexity of intimate relationships, the making and breaking of affectional bonds and the basic human needs they reflect. These attachments are central to human well-being. It is also vital to take into account social determinants and the particular adversities of social disadvantage that will add cumulative risk. | |||
Domestic violence and clinical care | |||
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Patients are more likely to disclose domestic violence if they
receive clear signals that their doctor does not condone violence and
will approach the problem in a sensitive way.3,4 A number of
questionnaires, including one that has been tested in Australian
general practice,5 have been developed to
screen for domestic violence. However, they tend to focus only on
women, and some are too long to serve as a practical screening tool. In
some cases, a single question or a few queries may be all that is
required to bring about disclosure of domestic violence if the
clinician is alert to its possibility.
A high index of suspicion is appropriate if a patient presents with low self-esteem, vague somatic complaints, signs of bruising or other injury and a level of defensiveness. The doctor should question the patient about fear, abuse, depression, and suicidal thoughts. Some victims of domestic violence may even be suffering from a form of post-traumatic stress disorder.11,12 Support, protection, and treatment of acute problems are the first priorities. Effective mental health interventions are available, but should not be provided until the person is in a safe situation. It is also important to remember that children are often traumatised by domestic violence, even if not directly subject to abuse. Feelings of powerlessness, helplessness, and shame often make it difficult for victims of violence to speak of their experience, and they may feel that they are somehow to blame or have "deserved" the abuse. The review of perpetrator issues2 highlights the complexity of this behaviour, the lack of adequate data and the need for evidence of effective interventions. Joint counselling for the couple is usually not recommended because of the late recognition of most cases of domestic violence, the entrenched damaging behaviours and the critical requirement for safety. However, partner programs involving early intervention to reduce negative interaction and interpersonal hostility in relationships could be beneficial.13 Barriers to effective clinical identification and management of domestic violence by health professionals include lack of training, fears for the safety of the victim, or even of the self, identification with victims or perpetrators from the doctor's own social group and, above all, deeply entrenched social attitudes about the privacy of the family.4 | |||
Health services and social policy | |||
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Health services have responded to domestic violence with a range of
policies.14 The highest priority for
health services is to ensure that victims are protected from further
harm. Health professionals need to know about the relevant State
legislation, contact details for refuges, and local protocols for
appropriate responses when domestic violence is suspected or
confirmed. They must be well informed about how to make timely and
appropriate referrals.15 The effectiveness of
current and proposed programs needs to be evaluated.
There are a number of social and health-related policies and programs that could potentially influence the prevalence of and response to domestic violence. Policies that focus directly on domestic violence include:
Other, more general initiatives that may have an effect on domestic violence include National Crime Prevention's "Pathways to Prevention",18 the National Action Plan for Mental Health Promotion and Prevention,19 the Stronger Families and Communities Strategy,20 national policies on alcohol and other drugs, and policies aimed at preventing child abuse and neglect. The complex interface of social policy and health is very relevant in this field. Social variables may far outweigh other factors in the aetiology of domestic violence, but the healthcare sector could become the driving force for change. Beverley Raphael
©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. | |||