Domestic violence: the general practitioner's role
Dr Iona Heath MRCP FRCGP
Acknowledgements
I would like to thank Drs Jo Richardson and Gene Feder for
their help and advice.
For the purposes of this guidance, the term domestic violence
is used to describe the physical, emotional and mental abuse of
women by male partners or ex-partners. The impact of this violence
is felt strongly, but not always explicitly, in every general
practitioner's consulting room. The manner in which the general
practitioner responds to a woman's first tentative attempt to seek
help to change her situation can make an immense difference to that
woman's life and those of her children (Richardson and Feder,
1997).
The 1989 Home Office Research Study on Domestic Violence
(Smith, 1989) and a subsequent editorial in the British Medical
Journal (McIlwaine, 1989) highlighted the need for the medical
profession to develop codes of good practice in relation to
domestic violence. The 1992 report of the Victim Support Working
Party on Domestic Violence made the same recommendation.
What follows is an attempt to formulate guidance in relation
to the care of women who have been subjected to domestic violence
and who present to general practitioners and other health workers
in the UK primary health care setting. It has been freely adapted
from a hospital protocol used in the USA (Braham et al.,
1986).
At some time in their lives, as many as one in four women
suffer violence at the hands of the men with whom they have
intimate relationships (Mooney,1994). The 1992 British Crime Survey
(Mayhew et al., 1993) showed that violence against women by
partners, ex-partners and relatives is the most common form of
physical interpersonal crime. The total number of domestic assaults
in the twelve months covered by the survey was estimated at just
over 500,000. Those most at risk of violence were divorced or
separated women.
The 1996
British Crime Survey (Mirrlees-Black et al., 1996) found that sixty
per cent of domestic violence incidents involved current partners,
and twenty-one per cent involved former partners. Half of the
reported victims suffered more than one attack and a third had been
attacked three or more times. Domestic violence, occurring across
all social JUSTIFY">In many cases of domestic violence, general
practice is the first formal agency to which women present for
help. However, the possibility of violence is seldom raised
directly (Pahl,1979; Mehta and Dandrea, 1988) and it has been
estimated that only a quarter of women seeking medical help
actually reveal that they have been beaten. (Dobash and Dobash,
1979). Many use the 'calling card' an apparently unimportant
physical symptom to seek help indirectly.
In the past, general practitioners have often failed to
respond because of lack of confidence in their ability to intervene
effectively (Sugg and Inui, 1992), sharing the sense of
helplessness of the victims in the face of society's apparent
ambivalence (McWilliams and McKiernan,1993). However, attitudes
have altered considerably and society is now beginning to make
clear its determination to treat domestic violence as seriously as
any other form of violence.
In September 1991, Home Office Minister John Patten, speaking
one year after the Home Office issued advice to police forces on
their role in responding to violence in the home, said: 'We wish to
dispel for good any lingering notion that a man who attacks a woman
in the home is somehow automatically less deserving of society's
censure than one who assaults a woman he doesn't know in the
street. I hope that approach has been consigned to the dustbin of
social attitudes."
Without appropriate intervention, violence usually continues
and escalates in frequency and severity (Andrews and Brown, 1988).
By the time the woman's injuries are visible, violence may be a
long-established pattern. On average, a woman will be assaulted by
her partner or ex-partner 35 times before actually reporting it to
the police (Yearnshire,1997).
Women who have experienced domestic violence suffer a high
incidence of psychiatric disorders, particularly depression, and
various self-damaging behaviours including drug and alcohol abuse,
suicide and parasuicide (Jacobson and Richardson, 1987). However,
there is evidence that these present after the first exposure to
violence and should therefore be viewed as consequences of the
violence rather than causes of it (Stark et al., 1979).
Early detection and appropriate intervention can help to
prevent future violent incidents and the consequent psychiatric
morbidity, and can help to save and salvage lives. As with much
else in general practice, the most important aid to diagnosis is a
high index of suspicion. To ignore the offered 'calling card' is to
collude with the continuing concealment of domestic violence behind
closed doors. Much can now be done to protect women and empower
them to change their situation. Much still remains to be done, but
all general practitioners should be aware of what services are
available to their patients locally.
Finding oneself a repeated target of someone else's violence
is intensely demeaning and demoralising. Women attempting to
survive domestic violence tend to lose their self-esteem and begin
to accept the counter-accusation that they themselves are somehow
to blame (Harwin,1997). If a women is to extract herself from an
abusive situation she must often pay a high price in terms of
loneliness and disrupting her children's relationship with their
father. The violent relationship may be the only intimate
relationship that she has and this is a lot to lose. For many
women, there is also an economic price to pay with the decision to
leave a violent home bringing with it a substantial fall in income,
and even the risk of homelessness. All this goes some way to
explaining why so many women return again and again to face the
risk of repeated violence to the amazement and sometimes the
exasperation of the police, doctors and others trying to help.
Effective help must be directed towards enabling the woman to
retake control of her own life, to offer her realistic choices
while accepting that the decisions are hers alone and are always
valid in her particular situation. No woman should be condemned for
a decision to return to her abuser. It can take a very long time
for a woman, demoralised by years of violence, to find the
confidence and courage to choose a different life for herself and
her children.
Only in very exceptional and grave circumstances will it be
appropriate for this guidance to be followed in its entirety on a
single occasion in general practice. Much more commonly it can be
used to provide a framework for the care of patients over a number
of consultations over several weeks, months or even years as, in
common with many other conditions, the diagnosis of domestic
violence emerges and the care of the woman survivor is managed over
time.