Tackling partner violence in families

In July 2006, new international consensus clinical guidelines — Management of the whole family when intimate partner violence is present: guidelines for primary care physicians — were launched simultaneously in Melbourne by the Victorian Community Council on Crime and Violence and at the General Practice and Primary Health Care Research Conference in Perth (Box).1

Partner violence is prevalent globally, exacerbated by poverty, war and gender inequality.2 In Australia, while 3% of women in the community report partner violence in the previous 12 months, the proportion among primary care patients is 8%.3 Men can also be victimised, but the evidence suggests that women suffer most of the significant harm, especially in the early child-rearing years, affecting the health of the whole family. Partner violence is no less prevalent among gay and lesbian families, and Indigenous families are particularly at risk of harm from partner or family violence, including murder of female partners.4

Abused women are more likely than non-abused women to experience physical and psychological symptoms and seek health care for stress-related and chronic ailments.5 There is also evidence of the damaging effect partner violence can have on children’s emotional, behavioural and cognitive development, as well as on their physical and mental health.6 Perpetrators can exhibit significant comorbidities, especially drug and alcohol misuse, and there is growing concern about early childhood development in this context. Increasing rates of depression and mental illness focus attention on the contribution partner violence makes to adverse social and economic circumstances.7

With a pattern of poor health and increased health care attendances by victims, perpetrators and their children, there are potential opportunities for health care providers to intervene. However, barriers to identification and management include lack of training, time and effective interventions.8 Advice for general practitioners in the medical literature focuses mainly on victims; there is a little on abusive male partners, but children or the wider dilemmas of whole-family management are rarely included.9 As recent systematic reviews concluded that there was inadequate evidence to guide clinical care,10 a Melbourne group of primary care researchers brought together, in a rigorous consensus process, an international collaborative team of clinical experts in partner violence.

A systematic review of existing guidelines identified those of best quality, when assessed according to the Appraisal of Guidelines Research and Evaluation (AGREE).11 AGREE helps readers assess, firstly, whether the potential biases of guidelines development are adequately addressed; secondly, whether the recommendations are externally and internally valid; and finally, whether they are feasible for practice. Recommendations endorsed by more than three guidelines were supplemented by those addressing key gaps. These gaps included advice about investigating harm to children and adolescents, and parenting issues (addressing any parenting difficulties that the victim faces as a consequence of the abuse). Further gap recommendations deal with clinic management, including training of all staff in safety protocols when doctors are seeing different members of the family. With each recommendation, further narrative offers clarification and practical advice to strengthen the recommendation’s applicability.

The controversial issue of screening had experts in Europe, the United Kingdom, Canada and Australia arguing that the guidelines should recommend case finding only. This was based on the need to obtain evidence that intervention does not harm women and children in the longer term, and the available evidence that practitioners are largely untrained and unsupported. In contrast, participants from the United States believed that, in view of the prevalence of the problem, screening was still vital, and that not screening was bordering on unethical. The majority recommendation resolved that physicians should routinely ask all pregnant women and girls about partner violence, because of their particular vulnerability and the association between partner violence and adverse pregnancy outcomes; they should undertake case finding with all other women and with men.

While primary care intervention trials are only just underway, these guidelines offer the best current advice. Clinicians need to be mindful of the range of issues within the family that they may face. Many doctors continue to feel that asking about partner violence is “opening Pandora’s box”.8 There is increasing evidence that partner abuse is an underlying issue in many serious, recurrent symptoms in primary care, and that the damage to the family’s health creates continuing harm. Consequently, federal and state governments should ensure that doctors are provided with sustainable and effective training, support and resources to play their part in society’s efforts to prevent ongoing generations of damaged families.

The partner violence whole-family guidelines are endorsed by the Royal Australian College of General Practitioners and available on the College’s website.1