Presentations and consequences of abuse and violence are common in Australian general practice. Unfortunately, it is not unusual for individuals attending general practice who have experienced family violence to not disclose these traumatic experiences to their general practitioner (GP). The reasons for this lack of disclosure are complex, but it is clear that every GP practising in Australia requires knowledge and skills in understanding, recognising, supporting and managing survivors of the many presentations and consequences of abuse and violence.
For the purpose of this unit, the term ‘abuse and violence’ includes that perpetrated on intimate partners, children and older people. Abuse and violence are not solely physical, but also include emotional (eg stalking, harassment and humiliation), sexual (eg non-consensual sex), economic (eg restricting access to money), neglect (eg to provide a dependant with what is required for normal physical and emotional wellbeing and/or development) and social (eg forced isolation from family and friends) abuse. Abuse incorporates elements of fear and control by one person over another and often has major impacts on an individual’s health, wellbeing and sense of self. For children, witnessing family violence can be considered a form of child abuse.1
Intimate partner violence (IPV) is prevalent in Australia, affecting approximately 17% of all women and 5% of men aged 18 and older.2,3 It is estimated that 25% of women and 14% of men have experienced emotional abuse from a partner.3
IPV is a significant cause of mortality and morbidity in Australia, particularly for women in the childbearing years (25–49), with an average of 129 family homicide victims each year (32–47% of all annual homicides) from 2001 to 2012. Most of these occurred at home and 75% of the victims of intimate partner homicides were women, with the majority aged 25–49.4 One third of the perpetrators had a recorded history of family violence, and the majority of cases involved the offender and/or victim having consumed alcohol or other drugs prior to the incident.4
Abuse of children is also common in Australia; the rate of notifications to child protection was 27.2 per 1000 children in 20135 (It is suspected that these figures are an underestimate of the actual number of children exposed to abuse and neglect.)
The consequences of abuse are often intergenerational. Evidence suggests ongoing impacts on individuals’ ability to form future relationships,6,7 and women who have experienced abuse and violence, and its perpetrators, are more likely to have experienced abuse in childhood.7,8 Family violence is also one of the leading causes of homelessness in Australia, accounting for 32% of individuals accessing specialised services.8
Family violence is pervasive throughout Australia and not confined to particular socioeconomic or cultural groups.2,9 Recognised correlating factors for risk of violence in women include exposure to abuse or violence as a child, issues of alcohol or drug dependency, financial or personal stress, and a lack of social support.9 Some women are also more vulnerable to violence, or less able to leave violent relationships, based on factors such as age, Aboriginal and Torres Strait Islander status, rural and remote location, disability, ethnicity, English language ability and pregnancy.2
An estimated 51,200 Australians aged 18 and older experienced sexual assault in 2011–12, and close to one third of those had the most recent incident reported to the police.10
It is likely that most GPs are not aware of the number of their patients who are experiencing family violence.
Full-time GPs may be seeing up to five women per week who are experiencing IPV, one to two of whom will have experienced severe violence.11,12 It is also important to note that only 14% of women experiencing intimate partner sexual violence and 16% of women assaulted by another male reported the assault to police.13 The majority of those who experience family and sexual violence don’t disclose for a number of reasons, including:
- fear of reprisal/worsening violence
- social isolation
- financial dependence
- decimated self-esteem as a consequence of the violence
- emotional dependence
- inability to recognise cycle of abuse and self-blame
- fear of losing custody of children
- cultural or religious issues.11
GPs are well positioned within high-quality therapeutic relationships to recognise red flags that indicate family violence may be occurring and take appropriate action to minimise patient risk. Individuals may present on one or several occasions with ‘suspicious’ signs, such as unexplained/inadequately explained bruising or recurrent injuries. GPs may also be presented with less specific symptoms among patients of all ages:
- children and adolescents – bedwetting, sleeping difficulties, changes in mood and behaviour (eg problems concentrating, deterioration in school work, social withdrawal, sexual and/or risky behaviours, anxiety symptoms and/or phobias)14
- adults for whom IPV is possible – mood and somatoform symptoms, eating disorders, post-traumatic stress disorder (PTSD), complex PTSD (formerly referred to as borderline personality disorder), substance misuse, suicidal ideation15
- older people – mood symptoms, insomnia, avoidance of eye contact and/or reluctance to talk.1
Questions that may be used to empathically and sensitively ask patients of all ages about exposure to abuse and violence can be found in the RACGP’s Abuse and violence: Working with our patients in general practice (the ‘White book’). For example:
- children and adolescents – ‘Some children get scared at home. What do you think makes them scared?’; ‘Where do you feel safe? Where do you feel not safe?’
- adults for whom IPV is possible – ‘Is there a lot of tension in your relationship? How do you resolve arguments?’; ‘Sometimes partners react strongly to arguments and get physical. Is this happening to you?’
- older people – ‘Has anyone made you feel afraid recently?’; ‘Have you felt upset because someone spoke to you in a way that made you feel ashamed or threatened?’
Assessment of safety is an essential role for the GP when a patient raises concerns in general practice. GPs should be familiar with state-based legislative criteria regarding mandatory notification of suspected child abuse and the process by which to undertake such a notification.
Important questions to assist with assessment of an individual’s safety can also be found in the White book. For example:
- ‘What do you need to feel safe?’
- ‘Has the frequency and severity of abuse and/or violence increased recently?’
- ‘How safe do you feel at the moment?’
- ‘Does the perpetrator have access to a weapon?’ (The majority of deaths due to partner violence are caused by stabbing or beating.)4,11
It is important for GPs to be able to provide patients:
- review and ongoing support
- referral for advocacy support and/or other specialised services (eg sexual assault services, respite care, home nursing, aged care assessment and/or admission)
- help in developing a safety plan (eg list of emergency numbers, identifying a safe place to go, ensuring access to money, valuables and important documents, having a packed bag to enable leaving quickly)
- counselling for PTSD
- empowerment counselling.
GPs play a key role in supporting those who have experienced sexual assault, guiding them with their available options. Unless a GP is trained in gathering forensic evidence, they should refer these patients to specialised services.16 Skills in the provision of counselling, emergency contraception and discussion regarding prophylactic treatment are also important for GPs.
Maintaining high-quality documentation is particularly important when working with those who have experienced family violence. Court proceedings may occur after a significant amount of time has passed, so writing clear notes to serve as a reference for future medico-legal reports and/or court appearances is very important. In taking these notes, it is useful for GPs to:
- not list events as fact, but phrase them as ‘patient stated that …’ or similar
- only document what they would be prepared to say in court proceedings
- use caution to not act as an advocate for the individual, but to rather document what has been stated and found during any consultation/examination
- understand appropriate terms to describe wound types that may assist in later determining causation (eg laceration, incision, bruise, abrasion, etc)
- avoid emotive language and seek advice from a medical defence organisation if concerned.17,18
The consequences of family violence are often ongoing and the long-term health impacts are beginning to be more broadly understood. For example, it has been found that the PTSD rates may be as high as 50% for survivors of rape.19 The mental health impacts of family violence, including on an individual’s confidence, capacity to form future relationships, sense of self and risk of substance misuse, are often significant.
Adult male and female survivors of child abuse are particularly at risk of developing long-term mental health issues, including depression and complex PTSD. Survivors of childhood sexual abuse constitute a significant proportion of those in the custodial justice system and who request services from the non-government organisational and mental health sectors, and research suggests that approximately 35–70% of female mental health patients report, if asked, a history of childhood of abuse.20–22
GPs can use simple strategies to assist in establishing a safe environment for individuals who have experienced such traumas and who demonstrate psychological symptoms, particularly those of complex PTSD. These strategies include:
- ensuring adequate time for consultations
- asking ‘What has happened?’ rather than ‘What is wrong with you?’
- developing actions plans if triggering events occur
- establishing a therapeutic relationship based on respect and trust, with clearly explained boundaries.15
There has also been increased recognition of the role of family violence in physical disease associations, including cardiovascular disease, type 2 diabetes, chronic pain syndromes (eg fibromyalgia and unexplained pelvic pain), gastrointestinal disorders (eg irritable bowel syndrome), chronic fatigue syndrome, somatoform disorders and migraines.19,21,23 The role of the GP is essential in not only recognising people who have experienced or are experiencing abuse and violence, but providing continuity of care, support and appropriate referrals in order to optimise long-term health and wellbeing and minimise the impacts of associated traumas.
Useful abuse and violence resources and tools
- Adults Surviving Child Abuse (ASCA), useful resources to assist in understanding complex trauma, www.asca.org.au/WHAT-WE-DO/ Resources
- Never Alone Luke Batty Foundation
- The Royal Australian College of General Practitioners, Abuse and violence: Working with our patients in general practice (the White book)
- The Royal Australian College of General Practitioners, gplearning online learning platform featuring several resources dedicated to abuse and violence, including ‘Domestic violence: Why women stay’, ‘Responding to and understanding domestic violence’ and ‘Domestic violence in refugee and migrant communities’
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), national list of forensic services
- Royal Children’s Hospital Melbourne, guidelines for determining and recording abuse and violence injuries
- White Ribbon Foundation, list of national, state and territory resources for abuse and violence survivors and perpetrators
- Forsdike K, Tarzia L, Hindmarsh E, Hegarty K. Family violence across the life cycle. Aust Fam Physician 2014;43(11):768–74.
- Phillips J, Vandenbroek P. Domestic, family and sexual violence in Australia: An overview of the issues. Research paper series, 2014–15. Parliament of Australia: Canberra, 2014.
- Australian Bureau of Statistics. Personal safety, Australia, 2012. ABS cat. no. 4906.0. Canberra: ABS, 2013.[Accessed 4 February 2016].
- Cussen T, Bryant W. Domestic/family homicide in Australia. Australian Institute of Criminology: Canberra, 2015.
- Australian Instititute of Family Studies. Mandatory reporting of child abuse and neglect. [Accessed 4 February 2016].
- Kitzmann KM, Gaylord NK, Holt AR, Kenny ED. Child witnesses to domestic violence: A meta-analytic review. J Consult Clin Psychol 2003;71(2):339–52.
- Hegarty K, Gunn J, Chondros P, Taft A. Physical and social predictors of partner abuse in women attending general practice: A cross- sectional study. Br J Gen Pract 2008;58(552):484–87.
- Australian Institute of Health and Welfare. Specialist homelessness services 2012–13. Canberra: AIHW, 2013.
- Smith N, Weatherburn D. Personal stress, financial stress, social support and women’s experiences of physical violence: A longitudinal analysis. Crime and Justice Bulletin 2013;168:1–20.
- Australian Bureau of Statistics. Crime victimisation, Australia, 2011–12. Cat. no. 4530.0. Canberra: ABS, 2013. [Accessed 4 February 2016].
- The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice. 4th edn. East Melbourne, Vic: RACGP, 2014. [Accessed 4 February 2016].
- Hegarty K. What is intimate partner abuse and how common is it? In: Roberts G, Hegarty K, Feder G, editors. Intimate partner abuse and health professionals: New approaches to domestic violence. Churchill Livingstone: Edinburgh, 2006.
- Mouzos J, Makkai T. Women’s experience of male violence: Findings from the Australian component of the international violence against women survey (IVAWS). Research and Public Policy Series. Canberra: Australian Institute of Criminology, 2004.
- Al Odhayani A, Watson WJ, Watson L. Behavioural consequences of child abuse. Can Fam Physician 2013;59(8):831–36.
- Kezelman C, Stavropoulos P. The last frontier: Practice guidelines for treatment of complex trauma and trauma informed care and service delivery. Sydney: Adults Surviving Child Abuse, 2012.
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Sexual assault support services. East Melbourne, Vic: RANZCOG, 2011. [Accessed 4 February 2016].
- Royal Children’s Hospital Melbourne. Clinical practice guidelines: Child abuse diagrams. Parkville, Vic: Royal Children’s Hospital Melbourne. [Accessed 4 February 2016].
- Bird S. How to write a medico-legal report. Aust Fam Physician 2014;43(11):777–79.
- Breslau N, Peterson EL, Poisson LM, Schultz LR, Lucia VC. Estimating post-traumatic stress disorder in the community: Lifetime perspective and the impact of typical traumatic events. Psychol Med 2004;34(5):889–98.
- Briere J. Treating the long term effects of childhood maltreatment: A brief overview. Psychotherapy in Australia 2004;10(3):12–18.
- Cashmore J, Shackel R. The impact of child sexual abuse on mental health. The long-term effects of child sexual abuse. Canberra: Australian Institute of Family Studies, 2016. [Accessed 18 February 2016].
- Mental Health Coordinating Council. Reframing responses – Supporting women survivors of child abuse. Lilyfied, NSW: MHCC, 2010. [Accessed 4 February 2016].
- Campbell J, Jones AS, Dienemann J, et al. Intimate partner violence and physical health consequences. Arch Intern Med 2002;162(10):1157–63.