Domestic violence: can doctors do more to help?

One of the centrepieces of this week’s Primary Health Care Research Conference in Canberra will be a presentation, billed as “best paper” at the conference, on how general practitioners respond to women who fear violence at the hands of their partners.

Despite a long history of concern and policy action to reduce domestic violence, it remains common and continues to greatly affect the mental and physical health of survivors and their children.1 Just last month, changes to the Family Law Act 1975 (Cwlth) came into force, widening definitions of violence and abuse to include exposing children to violence, and a range of threatening behaviours causing fear (Family Law Legislation Amendment [Family Violence and Other Measures] Act 2011 [Cwlth]).

While general practice offers an accessible and confidential forum for disclosure, there are many barriers to communication about this complex problem.2 A meta-analysis of qualitative studies, published in 2006, found that women with experience of intimate partner violence wanted doctors to be non-judgemental, compassionate and sensitive, acknowledging complexity but not medicalising the problem or applying pressure to make quick decisions.3 Other analyses suggest doctors can facilitate disclosure with a few simple questions and can improve their response by validating the experience of domestic violence, affirming its unacceptability, expressing support and offering relevant referrals.1

One of the world’s leading researchers in this field is University of Melbourne Associate Professor Kelsey Hegarty, the academic GP who is delivering the “best paper” at this week’s primary care conference. “This issue is often in the back corner at medical conferences,” she told me last month, “so it’s very pleasing to see it front and centre”.

Hegarty will be presenting key results from a large National Health and Medical Research Council-funded randomised controlled trial that involved screening women for partner violence, training doctors and counselling women.4 While acknowledging that violence happens within same-sex relationships and against men, this study, like much of the research in this area, focuses on violence against women, as repeated and severe violence that causes fear is perpetrated largely by men against women.

The results from the initial screening stage of the trial were published earlier this year.5 A health survey of almost 6000 women found that more than one in 10 had felt fear of a partner or ex-partner in the previous year. Of all the health issues covered in the survey, including physical activity and smoking, women were least comfortable discussing their fear of partners, and least likely to seek help for it from a doctor or nurse in general practice. The survey also found significant associations between fear of partner violence and self-reported poor health.

The most important limitation to these findings was the low response rate; under 30% of almost 20 000 women who were sent the survey returned it. Similarly, only a very small number of GPs who were sent information about the study agreed to participate. Nevertheless, Hegarty and her coauthors concluded it is appropriate for health professionals to ask women about fear of their partners and to seek training in how to better communicate about it. The impacts of the training and counselling interventions — to be discussed at this week’s conference — will no doubt help to inform wider debate about how barriers to communication can be further broken down. Not only is this research highly relevant to an important social and health problem, it’s also an example of world-class Australian research in the field of primary care.

Clearly, general practice is just one pathway among broader social and cultural responses to the problem of family violence, and some doctors will be better suited than others to deal with the sensitivities and complexities. According to Hegarty, new research is already underway to help doctors better facilitate interventions for perpetrators.

Domestic violence casts long shadows over families, sometimes for generations. Attempts to find effective ways within the health care system to help break these dark cycles of fear may be long overdue, but are nonetheless extremely welcome.