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Editorial
Domestic violence
The 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
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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.
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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
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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:
- The National Campaign Against
Violence and Crime.16 This has programs aimed at
preventing violence in schools, rural communities and domestic
settings, and programs for dealing with perpetrators.
- Partnerships Against Domestic Violence.17 This is an agreement
between the Federal Government and the States and Territories to work
together to prevent domestic violence across Australia.
- Legislation relating to child protection, family law and orders
against violence.
- Specific policies of States and Territories relating to women's
services and the provision of care and protection for women and
children who are victims of violence.
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
Professor, and Director, Mental Health Services
New South Wales Health Department, Sydney, NSW
- Astbury J, Atkinson J, Duke JE, et al. The impact of domestic
violence on individuals. Med J Aust 2000; 173: 427-431.
-
Romans SE, Poore MR, Martin JL. The perpetrators of domestic
violence. Med J Aust 2000; 173: 484-488.
-
Hegarty K, Hindmarsh ED, Gilles MT. Domestic violence in
Australia: definition, prevalence and nature of presentation in
clinical practice. Med J Aust 2000; 173: 363-367.
-
Mazza DM, Lawrence JM, Roberts GL, Knowlden SM. What can we do about
domestic violence? Med J Aust 2000; 173: 532-535.
-
Hegarty K. Measuring a multi-dimensional definition of domestic
violence: prevalence of partner abuse in women attending general
practice. Brisbane: Department of Social and Preventive Medicine,
University of Queensland, 1999: 246.
-
Webster J, Sweett S, Stolz T. Domestic violence in pregnancy: a
prevalence study. Med J Aust 1994; 161: 466-470.
-
Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence
victims in a hospital emergency department. Med J Aust 1993;
159: 307-310.
-
Roberts GL, Lawrence JM, Williams GM, Raphael B. The impact of
domestic violence on women's mental health. Aust N Z J Public
Health 1998; 22: 796-801.
-
Campbell JC, Lewandowski LA. Mental and physical health effects of
intimate partner violence on women and children. Psychiatr Clin
North Am 1997; 20: 353-374.
-
Resnick HS, Acierno R, Kilpatrick DG. Health impact of
interpersonal violence. 2: Medical and mental health outcomes.
Behav Med 1997; 23: 65-78.
-
Kemp A, Green BL, Hovanitz C, Rawlings EI. Incidence and
correlates of posttraumatic stress disorder in battered women:
shelter and community samples. J Interpersonal Violence
1995; 10: 43-55.
-
Herman JL. Complex PTSD: a syndrome in survivors of prolonged and
repeated trauma. J Trauma Stress 1992; 5: 377-391.
-
Halford WK. Marriage and the prevention of psychiatric disorder.
In: Raphael B, Burrows G, editors. Handbook of studies on preventive
psychiatry. Amsterdam: Elsevier, 1995: 121-137.
-
Review of NSW Health domestic violence policy. Discussion paper.
NSW Health Department, 1999.
-
Roberts GL, Lawrence JM, O'Toole BI, Raphael B. Domestic violence
in the emergency department. 2: detection by doctors and nurses.
Gen Hosp Psychiatry 1997; 19: 12-15.
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National Campaign Against Violence and Crime (NCAVAC).
Canberra: Attorney-General's Department, 1998.
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Partnerships Against Domestic Violence. Information available
at: <http://padv.dpmc.gov.au>. Accessed 11 October 2000.
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Pathways to prevention. Canberra: National Crime Prevention,
Attorney General's Department, 1999.
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Mental Health Promotion and Prevention National Action Plan.
Canberra: Commonwealth Department of Health and Aged Care, 1998.
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Stronger Families and Communities Strategy. Canberra:
Commonwealth Department of Family and Community Services, 2000.
©MJA 2000
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