Volume 173 Issue 7

Research Diabetes-related lower-limb amputations in Australia Craig B Payne MJA 2000; 173: 352-354 For editorial comment, see Colman & Beischer; see also Campbell et al. Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Endocrinology Abstract Objective: To identify the prevalence of diabetes-related lower-limb amputations and its regional variations in Australia. Design and setting: Cross-sectional analysis of a hospital morbidity dataset in Australia. Methods: Analysis of the National Hospital Morbidity Database of all hospital separations for the ICD codes 84.10-84.19 (lower-limb amputations) and 250.0-250.9 (diabetes and its complications) for the financial years 1995-96 to 1997-98. Main outcome measure: Number of lower-limb amputations in people with diabetes mellitus in Australia, and in each State and Territory. Results: 7887 diabetes-related lower-limb amputations were reported during the study period, with a mean ± SD of 2629 ± 47 per year. The prevalence in Australia was 13.97 per 100 000 total population, and varied from 11.34 per 100 000 in the Australian Capital Territory to 20.68 per 100 000 in South Australia. Conclusion: Diabetes-related lower-limb amputation poses a substantial personal and public health cost in Australia. The loss of a limb is a frequent complication of diabetes mellitus, most commonly the result of diabetic foot problems such as ulcers and infection. The risk of amputation of the lower limb is increased up to 15-fold in people with diabetes. Contributory factors include the loss of sensation from the sensory neuropathy; deformity and gait abnormalities from the motor neuropathy; abnormal blood flow regulation from the autonomic neuropathy; ischaemia from the macrovascular disease; limited joint mobility from the increased glycolation of collagen; poor glycaemic control; and increased risk of infection. It is usually some trigger or traumatic event superimposed on these risk factors that causes a lesion such as ulceration or infection which starts a pathway leading to amputation.2,3 Inadequate and inappropriate self-care is also a major factor. The National Diabetic Foot Disease Management Program, as part of the National Diabetes Strategy and Implementation Plan,4 has called for a 50% reduction in lower-limb amputations by the year 2005. Data on diabetes-related lower-limb amputations in Australia are lacking.4 The aim of my study was to identify the prevalence of diabetes-related lower-limb amputations in Australia, as well as variations among States and Territories. Methods Approval for the study was given by the Faculty of Health Sciences Human Ethics Committee at La Trobe University (Victoria). The dataset for my analysis was obtained from the Australian Institute of Health and Welfare (AIHW) for the financial years 1995-96, 1996-97 and 1997-98. The AIHW obtained permission from the relevant State and Territory agencies to release the information, which did not include any personal identifying data. Information was obtained from the National Hospital Morbidity Database (compiled by the AIHW) on all separations from public and private hospitals in Australia for the International Classification of Disease (ICD)5 procedure codes 84.10 to 84.19 (amputations of the lower extremity) and diagnosis codes 250.0 to 250.9 (indicating diabetes and its complications) as the principal or secondary diagnoses. Information was also obtained on sex, age, ethnicity, duration of hospital stay, and State or Territory of residence of each patient who had an amputation. A spreadsheet was used to determine the number of amputations in each region and the duration of hospital stay. The data for each State and Territory were age- and sex-standardised6 to the estimated Australian population as at 30 June 1998.7 This information was then used to determine the rate for each State and Territory. Results A total of 7887 diabetes-related lower-limb amputations (68.2% in men) were recorded as occurring in the three-year period, with an annual mean of 2629 ± 47 (SD) (Box 1). Most occurred in the 65-79 years age groups (Box 2). The age- and sex-standardised prevalence of lower-limb amputation varied among the States and Territories (Box 3), from 11.34 per 100 000 total population in the Australian Capital Territory to 20.68 per 100 000 total population in South Australia. The duration of hospital stay (Box 3) also varied among the States and Territories. The shortest mean hospital stay was 20.0 (95% CI, 17.4-22.6) days in South Australia and the longest was 40.2 (95% CI, 23.1-57.3) in the Northern Territory. It was not possible to analyse the ethnicity data, as two States/Territories would not agree to the release of this information. Discussion The 2629 diabetes-related lower-limb amputations in Australia per year represent a significant personal burden on people with diabetes and on the healthcare system. The loss of a limb is a personal tragedy for those with diabetes,8 and is associated with a deterioration of functional status and residential status,9 with a significant number requiring long term care.10 People with diabetes who have a lower-limb amputation have a higher mortality rate,1,11 especially perioperative mortality.12 Half the people with an amputation will require an amputation of the remaining limb within five years.13,14 This morbidity results in high medical and rehabilitation costs: about 10% of diabetes-related healthcare costs are associated with lower-limb amputations.15The sex differences in lower-limb amputation rates of about 2:1 for men to women reported here are consistent with previous reports,20 and may be related to the levels of adherence to advice, the amount of social support, psychological factors such as denial, or a higher prevalence of the physiological risk factors for amputation such as macrovascular disease.21 Ethnicity is a well-recognised risk factor for lower-limb amputation,22,23 but was not analysed in this project as two of the States/Territories would not release this information. The duration of hospital stay has been identified as one of the main determinants of cost associated with a lower-limb amputation.17 The mean number of bed-days reported here (24.7 days) is less than the mean in the Netherlands15 (42 days) and more than that in the United States16 (15.9 days). There was a large variation among the Australian States and Territories in the mean hospital stay; South Australia has the highest prevalence of lower-limb amputation, but the shortest mean stay. Regional variations have been reported previously in New Zealand for hospital admissions for diabetic foot complications.18 Such regional variations are most likely to be due to variations in clinical practice and access to services.19 A number of shortcomings are inherent in the type of dataset analysed here. Of primary concern is the accuracy of the recording of data. Diabetes has been reported as being under-recorded on discharge records,24,25 so the numbers reported here are most likely an underestimate. There is also concern that the dataset does not distinguish the number of multiple amputations in the same individual; this will bias the population towards the characteristics of these individuals. A number of modifiable risk factors for diabetes-related lower-limb amputation have been identified,26-28 including the lowering of blood pressure, improving glycaemic control and reducing or eliminating smoking. With proper foot care, patient education and provision of appropriate services, such as regular podiatric care, a reduction in the number of amputations can be achieved.4 A number of studies have shown the value of multidisciplinary teams in reducing amputations by up to 50%.29-32 A reduction of this magnitude has the potential to save up to $24 million (based on the assumption that the direct cost of diabetes-related lower-limb amputations in Australia is $48 million per year4). However, a significant proportion of this potential saving will need to be directed to programs to prevent the amputations. Acknowledgements Funding for this project was provided by the Australasian Podiatric and Education Foundation. References Nelson R, Gohdes DM, Everhart JE, et al. Lower extremity amputations in NIDDM: 12 year follow up study in Pima Indians. Diabetes Care 1998; 11: 8-16. Payne CB, Scott RS, Moir C. Trigger events for acute admission to hospital for diabetic foot disease. Australas J Podiatric Med 1998; 32: 57-64. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic amputation -- basis for prevention. Diabetes Care 1990; 13: 513-521. Colagiuri S, Colagiuri R, Ward J. National Diabetes Strategy and Implementation Plan. Canberra: Diabetes Australia, 1998. The International classification of diseases. 9th Revision. Clinical modification. Commission on Professional and Hospital Activities. Michigan, 1990. Beaglehole R, Bonita R, Kjellstrom T. Basic epidemiology. Geneva: World Health Organization, 1993. Australian Bureau of Statistics. Australian demographic statistics. Canberra: ABS, 1999. (Catalogue no. 3101.0.) Fitzpatrick MC. The psychologic assessment and psychosocial recovery of the patient with an amputation. Clin Orthop 1999; 381: 98-107. Frykberg RG, Arora S, Pomposelli FB, LoGerfo F. Functional outcome in elderly following lower extremity amputation. J Foot Ankle Surg 1998; 37: 181-185. Lavery LA, van Houtum WH, Armstrong DG. Institutionalisation following diabetes related lower extremity amputation. Am J Med 1997; 103: 383-388. Faris I, Duncan H, Young C. Factors affecting the outcome of diabetic patients with foot ulcers or gangrene. J Cardiovasc Surg 1988; 29: 736-740. Ebskov LB. Relative mortality in lower limb amputees with diabetes mellitus. Prosthet Orthot Int 1996; 20: 147-152. Silbert S. Amputation of the lower extremity in diabetes mellitus. Diabetes 1952; 1: 297-299. Ebskov LB. Diabetic amputation and long-term survival. Int J Rehab Res 1998; 21: 403-408 Van Houtum WH, Lavery LA, Harkless LB. The costs of diabetes-related lower extremity amputations in the Netherlands. Diabetic Med 1995; 12: 777-781. Ashry HR, Lavery LA, Armstrong DG, et al. Cost of diabetes related amputations in minorities. J Foot Ankle Surg 1998; 37: 186-190. Solomon C, van Rij A, Barnett R, et al. Amputations in the surgical budget. N Z Med J 1994; 107: 78-80. Payne CB, Scott RS, Moir C. Hospital discharges for diabetic foot disease in New Zealand 1980-1993. Diabetes Res Clin Pract 1998; 39: 69-74. Sanders D, Coulter A, McPherson K. Variations in hospital admission rates: a review of the literature. London: King Edward's Hospital Fund, 1989. Armstrong DG, Lavery LA, van Houtum WH, Harkless LB. The impact of gender on amputation. J Foot Ankle Surg 1997; 36: 66-69. Vogt MT, Wolfson SK, Kuller LH. Lower extremity arterial disease and the aging process -- a review. J Clin Epidemiol 1992; 45: 529-542. Lavery LA, Ashry HR, van Houtum W, et al. Variation in the incidence and proportion of diabetes related amputations in minorities. Diabetes Care 1996; 19: 48-51. Simmons D, Scott D, Kenealy T, Scragg R. Foot care among diabetic patients in South Auckland. N Z Med J 1995; 108: 106-108. Williams DRR, Fuller JH, Stevens LK. Validity of routinely collected hospital admissions data on diabetes. Diabetic Med 1998; 6: 320-324. Phillips DE, Mann JI. Diabetes -- inpatient utilisation, costs and data validity. Dunedin 1985-9. N Z Med J 1992; 105: 313-315. Moss SE, Klein R, Klein BEK. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med 1992; 152: 610-616. Lehto S, Ronnemaa T, Pyorala K, Laakso M. Risk factors predicting lower extremity amputations in patients with NIDDM. Diabetes Care 1996; 19: 607-611. Hamalainen H, Ronnemaa T, Halonen JP, Toikka T. Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population based 7 year follow-up study. J Intern Med 1999; 246: 97-103. Edmonds ME, Blundell MP, Morris ME, et al. Improved survival of the diabetic foot -- the role of a specialised foot clinic. QJM 1986; 60: 763-771. Malone LM, Snyder M, Anderson G, et al. Prevention of amputation. Am J Surg 1989; 158: 520-523. Ebskov LB. Epidemiology of lower extremity amputation in Denmark. Int Orthop 1991; 15: 285-288. Larson J, Apelqvist J, Agardh CD, Stenstrom A. Decreasing incidence of major amputation in diabetic patients -- a consequence of a multidisciplinary foot care team approach. Diabetic Med 1995; 12: 770-777. (Received 25 Nov 1999, accepted 20 Jul 2000) Authors' details Faculty of Health Sciences, La Trobe University, Melbourne, VIC. Craig B Payne, DipPod(NZ), MPH, Lecturer, Department of Podiatry. Reprints: Dr C B Payne, Department of Podiatry, School of Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora, VIC 3083. c.payneATlatrobe.edu.au Make a comment 1: Number of diabetes-related lower-limb amputations in Australia Men Women Total1995-96 1996-97 1997-98 1729 1849 1804 851 824 830 2580 2673 2634 Mean ±SD 1795 ±61 834 ±14 2629 ±47 Total 5382 (68%) 2505 (32%) 7887 Back to text Click in box for larger versionBack to text 3: Age- and sex-standardised prevalence and duration of hospital stay for lower-limb amputations in Australia for 1995-1998 Mean ±SD lower extremity amputations per year Rate (95% CI) per 100000 total population New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Australian Capital Territory Australia 801 ±13 695 ±12 468 ±8 308 ±6 219 ±4 67 ±2 36 ±1 35 ±1 2629 ±47 12.59 (9.54-15.78) 14.87 (11.6-18.17) 13.48 (10.56-16.45) 20.68 (17.18-24.18) 11.89 (8.90-14.88) 14.21 (12.63-16.17) 18.86 (15.53-22.19) 11.34 (8.34-13.56) 13.97 (11.98-15.87) Duration of hospital stay Mean (95% CI) bed days Median (range) bed days New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Australian Capital Territory Australia 24 (23-26) 22 (21-23) 30 (28-33) 20 (17-23) 26 (22-29) 27 (19-35) 40 (23-57) 33 (18-47) 25 (24-26) 18 (1-210) 16 (1-183) 21 (1-283) 13.5 (1-176) 18 (1-183) 21 (1-197) 24 (1-224) 24 (1-223) 17 (1-283) Back to text

Craig B Payne

Abstract 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. In the past decade, domestic violence has been recognised as a major public health problem. It affects all people, irrespective of economic, educational, social, geographic or racial background,1 resulting in significant morbidity and mortality.2 However, lack of agreement about the basic features of domestic violence makes case identification difficult.3 In view of these uncertainties, we attempt to define "domestic violence" and explore how current attitudes influence measurement and estimated prevalence of domestic violence, and how it presents in clinical practice. How do we define "domestic violence"? The terms "violence", "abuse" and "battering" are frequently used interchangeably. In studies of the Australian community, "domestic violence" is usually taken to mean partner abuse, specifically physical violence between a male and female partner, most commonly perpetrated by the male partner.4 (A "partner" is a person who has been or is having an intimate relationship with another person -- ie, a married or de facto partner, a boyfriend or girlfriend). However, "domestic violence" (or "family violence") may also be used to refer to abuse that occurs in any relationship within households (ie, including abuse of children, elders or siblings). Much of this article deals with partner abuse against women, as women are most commonly the victims,5-7 but this is not to deny that there are rare cases of men being beaten by women.8 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. How common is domestic violence in Australia? It is now accepted that domestic violence is very common in Australia. An estimate of the magnitude of the problem can be obtained from public records (police reports, hospital records, applications for protection orders, lists of refuge positions, and spousal homicides), clinical samples and community surveys. Although public records have inherent bias in their non-random selection and under-reporting of samples, they do show that women are the main victims of domestic violence: 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 surveys12,13 or prevalence studies in clinical samples6,7,16-19 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. How does domestic violence present in practice? There are major barriers to women disclosing situations of domestic violence.21,22 Reasons given include fear, denial and disbelief, emotional bonds to their partner, commitment to marriage, hope for change, staying for the sake of the children, "normalisation" of violence, social isolation, depression, stress, and feeling that they will not be believed or that services will not be able to help.22,23 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. Screening for domestic violence Researchers have developed several scales to measure domestic violence (see Box 4). Although the American Medical Association has suggested routine screening, this is not recommended for a general population, as tested and proven interventions to reduce morbidity and mortality are lacking.43 Nevertheless, opportunistic screening in practice settings such as emergency departments, psychiatric clinics, antenatal clinics and general practice is still considered worthwhile.43 Health professionals need to use a variety of questions to elicit women's experiences of domestic violence, taking into account different types of women (eg, women with disabilities, Indigenous women, women in lesbian relationships and women of non-English-speaking background). Examples of questions doctors could ask a patient if they suspect domestic violence are given in Box 5. ConclusionsDomestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse, such as social isolation and financial deprivation. 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. References Australian Public Health Association. Domestic violence. Canberra: Australian Public Health Association, 1990. Centers for Disease Control and Prevention. Emergency department response to domestic violence - California, 1992. JAMA 1993; 270: 1174-1175. Knowledge and social change. In: Dobash RE, Dobash RP. Women, violence and social change. London: Routledge; 1992: 251-283. ANOP Research Services. Community attitudes to violence against women. Canberra: Office of the Status of Women, 1995. Candib LM. Violence against women: no more excuses. Fam Med 1989; 21: 339-341. Roberts G, O'Toole B, Lawrence J, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1994; 159: 307-310. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20: 364-368. Johnston JR, Campbell LE. A clinical typology of interparental violence in disputed-custody divorces. Am J Orthopsychiatry 1993; 63: 190-199. Alexander R. Wife-battering - an Australian perspective. J Fam Violence 1993; 8: 229-251. Sassetti MR. Domestic violence. Prim Care 1993; 20: 289-304. Australian Medical Association. Position statement on domestic violence. Canberra: AMA, 1998. Ferrante A, Morgan F, Indermaur D, Harding R. Measuring the extent of domestic violence. Sydney: Hawkins Press, 1996. Womens Policy Unit. Women's experience of crimes of personal violence. A gender analysis of the 1991 Queensland crime victims survey. Brisbane: Office of the Cabinet, 1992. Sherrard J, Ozanne-Smith J, Brumen IA, et al. Domestic violence: patterns and indicators. Melbourne: Monash University Accident Research Centre, 1994. Hegarty K, Roberts G. How common is domestic violence against women? The definition of partner abuse in prevalence studies. Aust N Z J Public Health 1998; 22: 49-54. Hegarty KL. Measuring a multidimensional definition of domestic violence: prevalence of partner abuse in women attending general practice. Brisbane: Department of Social and Preventive Medicine, University of Queensland, 1999. Bates L, Redman S, Brown W, Hancock L. Domestic violence experienced by women attending an accident and emergency department. Aust N Z J Public Health 1995; 19: 293-299. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. Webster J, Sweett S, Stolz T. Domestic violence in pregnancy: a prevalence study. Med J Aust 1994; 161: 466-470. McLennan W. Women's safety survey. Canberra: Australian Bureau of Statistics, 1996. Brown JB, Lent B, Brett P, et al. Development of the Woman Abuse Screening Tool for use in family practice. Fam Med 1996; 28: 422-428. Head C, Taft A. Improving general practitioner management of women experiencing domestic violence: a study of the beliefs and experiences of women victim/survivors and of GPs. Canberra: Department of Health, Housing and Community Services, 1995. Keys Young. Against the odds: how women survive domestic violence. Canberra: Office of the Status of Women, 1998. Roberts G. Domestic violence victims in the emergency department. Brisbane: University of Queensland, 1995. Friedman L, Samet J, Roberts M, et al. Inquiry about victimisation experiences: a survey of patient preferences and physician practices. Arch Intern Med 1992; 152: 1186-1190. Eisenstat S, Bancroft L. Domestic violence. N Engl J Med 1999; 341: 886-892. Straus MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. New York: Doubleday/Anchor, 1980. 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. 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. DeKeseredy W, Hinch R. Woman abuse: sociological perspectives. Toronto: Thompson Educational Publishing, 1991. Tolman R. The development of a measure of psychological maltreatment of women by their male partners. Violence Vict 1989; 4: 159-177. Hudson W, McIntosh S. The assessment of spouse abuse: two quantifiable dimensions. Journal of Marriage and the Family 1981; 43: 873-888. 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. Yegidis BL. Abuse Risk Inventory for women. Palo Alto, California: Mind Garden, 1989. 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. 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. 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. 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. Headey B, Scott D, Vaus D. Domestic violence in Australia: are men and women equally violent? Australian Social Monitor 1999; 2: 57-62. Candib LM. Naming the contradiction: family medicine's failure to face violence against women. Family and Community Health 1990; 13: 47-57. Johnson MP. Patriarchal terrorism and common couple violence: two forms of violence against women. Journal of Marriage and the Family 1995; 57: 283-294. 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. Lawler VA. Routine screening for domestic violence: a review of the literature. Melbourne: University of Melbourne, 1996. Authors' details Department of General Practice and Public Health, University of Melbourne, VIC. Kelsey Hegarty, MB BS, PhD, Senior Lecturer. 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 Make a comment 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. 1: Potential clinical indicators of domestic violence26 Psychological Insomnia Depression Suicidal ideation Anxiety symptoms and panic disorder Somatoform disorder Post-traumatic stress disorder Eating disorders Drug and alcohol abuse Physical Obvious injuries, especially to the head and neck or multiple areas Bruises in various stages of healing Sexual assault Sexually transmitted diseases Chronic pelvic pain Chronic abdominal pain Chronic headaches Chronic back pain Numbness and tingling from injuries Lethargy Pregnancy and childbirth Miscarriages Unwanted pregnancy Antepartum haemorrhage Lack of prenatal care Low birthweight of infant Back to text 2: Presentation of domestic violence to a general practitioner Jane*, aged 38, has two children aged 5 and 9, and is now 20 weeks' pregnant. She is well dressed, slightly overweight, and presents for review of her blood pressure, which was high on a previous visit to the obstetrician the week before. She has been married nine years to Theo*, a plumber. She is not in paid work. Background: No previous history of hypertension with pregnancies. One previous miscarriage and an antepartum haemorrhage with her last pregnancy. Recurrent presentations for vaginal discharge to a GP in the past few years. Multiple presentations with the children for behavioural problems. Consultation: Her blood pressure was again slightly raised, which she explained was because she had been a bit busy. GP:How are things at home? Jane: [angrily] Fine, thanks. GP:It must be hard at home with two other children. Does your husband help? Jane:He only makes things worse. GP:Can you tell me more about it? Jane:Look, after years of putting up with him I moved out, and last week, on my son's birthday, I let Theo come around to give the boy his present and he became angry and abusive again. He smashed a plate glass window and it fell onto the boy's head. GP:This is serious. Are you and the children safe? Jane: I'm not sure. How was abuse recognised? Looking back through the patient's notes, there was mention of "matrimonial disharmony" - direct questioning at the time might have resulted in an earlier disclosure. However, it may be that Jane was only ready to disclose after she had left Theo. Breaking the silence breaks the isolation and provides a way out for when the woman decides to take it. * Actual names have been changed. Back to text 3: Presentation of domestic violence to a general practitioner Rebecca*, aged 30, attractive and well dressed, presents requesting a referral for breast enlargement. She has been married eight years to John*, a busy lawyer. She does some secretarial and accounting work for him. Background: A number of previous referrals for plastic surgery. Consultation: GP: Can you tell me what concerns you about your breasts? Rebecca:I hate them. I have nothing there and I look ugly. GP:Do you really believe that? Rebecca:My husband does. GP: What does he say to you about it? Rebecca:He doesn't like the way I look now even though he used to. I try so hard to please him and I've had operations before but he is still not happy with me [in tears now]. It's horrible - he tears off my clothes in front of the mirror and says "Would you sleep with this?". GP: What else does he do that makes you upset? Rebecca:He tells me frequently that I am stupid and ugly. GP:That must be difficult for you. Do you feel in control of your life? Rebecca:No, he controls all the finances and tells me what to wear every day. He throws my clothes on the fire if he doesn't like them. GP:Has he ever physically hurt you? Rebecca:He has never hit me, although he has kicked the wall, smashed things and threatened to punch me a few times. GP: What is the worst thing that has happened to you? Rebecca:He forced me to have sex on several occasions against my will, but the worst was when he poisoned my dog because I had grown too fond of the dog. GP:Are you afraid of him? Rebecca:Yes ... She had tried to leave him on a number of occasions but had returned each time, as she had few economic resources of her own and little confidence in her own abilities to survive without him. She had few people to confide in. How was abuse recognised? Abuse was recognised because of a high level of suspicion, followed up by direct questioning. * Actual names have been changed. Back to text 4: Measuring domestic violence The Conflict Tactics Scale Researchers in family violence have defined "violence" as "an act carried out with the intention of, or perceived intention of, causing physical pain or injury to another person".27 To measure "violence" they have developed the Conflict Tactics Scale (CTS). Although the CTS is the scale most commonly used,28 it has been widely criticised for measuring conflict tactics (ie, overt actions used by persons in response to a conflict of interest) rather than coercive tactics, and for concentrating on physical violence alone and not eliciting information about the intensity, context, consequences or meaning of the action.3,9,29,30 Other scales Several other scales (eg, the Psychological Maltreatment of Women Inventory, the Index of Spouse Abuse, the Measure of Wife Abuse, the Abuse Risk Inventory for Women31-34) have been developed to broaden the definition of domestic violence to include emotional and sexual abuse. Apart from the Composite Abuse Scale,35 which has been validated across three Australian clinical populations,16 these scales have only been validated on small samples. All of these scales are long and would be difficult to use as a screening tool in a busy clinical setting. Several researchers16,21,36,37 have trialled shorter screening tools to measure domestic violence in clinical settings on small, selective samples. Quantitative v qualitative research Each researcher and practitioner appears to define "domestic violence" according to his or her own perspective. Quantitative research using the CTS utilises the physical abuse concepts outlined by Straus,38,39 while qualitative research uses a broader definition of domestic violence.3,40 Not all violent behaviour between partners may constitute domestic violence. Johnson41 argues that some families suffer from occasional outbursts of violence from either husbands or wives ("common couple violence"), while other families are terrorised by systematic male violence ("patriarchal terrorism").42 Back to text 5: Suggestions for how the subject of domestic violence could be raised with a patient Has your partner ever physically threatened or hurt you? Is there a lot of tension in your relationship? How do you resolve arguments?21 Sometimes partners react strongly in arguments and use physical force. Is this happening to you? Are you afraid of your partner?16 Violence is very common in the home. I ask a lot of my patients about abuse because no one should have to live in fear of their partners. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Or has anyone forced you to have sexual activities?36 Back to text

Kelsey Hegarty MB BS, PhD · Elizabeth D Hindmarsh MB BS, FRACGP · Marisa T Gilles BSc, MB Chb, MPH