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Internal Medicine Journal 45 (2015)
E D I TO R I A L
Domestic violence: it is time for the medical profession to play its part
Ignored for a long time, domestic violence is now recognised as one of the major public health issues in Australia. The financial cost of the problem to the community, estimated at $14.7 billion in 2013, is similar to that of obesity and far in excess of diabetes.1 However, beyond the monetary cost the personal and social damage associated with domestic violence is regarded by many as sufficient to constitute a national emergency. Intensifying public interest in the problem is reflected in the appointment as the 2015 Australian of the Year of Rosie Batty, a courageous victim of a tragic case of domestic violence, together with the establishment of a special Domestic Violence Task Force in Queensland and a Royal Commission in Victoria. While these initiatives are most welcome, they will not on their own provide a solution. What is needed is a national strategy that brings together diverse groups and individuals from the community around a multidisciplinary programme that includes information, support, education and research. Such a programme will require support and resources from government as well as active participation from the medical profession. Despite their potential influence and importance, medical professionals, with rare exceptions, have been strangely silent in this area. The Australian Medical Association has had an admirable policy on its books for 10 years and the Royal Australian College of General Practitioners has developed guidelines for family doctors.2 However, many other Colleges – including the Royal Australasian College of Physicians – appear not even to have developed policies on the subject, let alone effective action strategies. It is time that the wider medical profession contributed actively to addressing this scourge on Australian society.3 Any coordinated strategy on domestic violence will need to be informed by accurate and reliable data. Unfortunately, such data are, at the present time relatively limited. It is known that domestic violence extends to a vast array of abusive settings, covering physical, sexual, emotional and financial abuse among intimate partners, same sex couples, elders and children. It crosses all socioeconomic, cultural, ethnic and religious boundaries. The vast majority of victims are women, with 17% of all Australian women aged more than 18 years having experienced violence from a partner at some time, com-
pared with 5.3% for men,4 and that domestic violence is especially marked in pregnancy, during which up to 36% of all violence occurs,5 and when up to 20% of women experience it for the first time.6 More than 65 000 cases of domestic incidents are reported to police in Victoria each year,7 and nearly 35 000 intervention orders related to family violence are issued, both of these numbers are rapidly increasing.8 Sadly, even death is a not infrequent outcome, with 185 domestic homicides having been reported across Australia in the 3 years to 2010.9 It is known that, despite its frequent occurrence, domestic violence is recognised only rarely by medical practitioners. Indeed, the Bettering the Evaluation and Care of Health (BEACH) study,10 which monitors patterns of consultations in general practice, reported that in more than 95 000 consultations examined in 2013–2014, domestic violence was never cited as a reason for encounters by patients or a problem managed by general practitioners (GP). Similarly, an Irish study of women attending general practices showed that while 39% had experienced violent behaviour from their partner, only 12% were questioned about it by their doctors.11 There is much, however, that remains to be explained. In particular, it is not clear why doctors are doing so badly. Contributing factors no doubt include a reluctance of many patients themselves to volunteer that they have been abused. However, a lack of awareness by practitioners is also important. Sufferers of violence frequently make contact with GP, emergency medicine physicians, obstetricians, psychiatrists, specialist physicians or in other clinical settings. Indeed, full time GP may see up to five women per week who have experienced partner violence, of which two are severe.12 Patients may present with unexplained physical injury, bruising, chronic fatigue, anxiety, depression, insomnia or undifferentiated somatic symptoms.13 Although each of these should raise the possibility of domestic violence, very frequently the warning signs are missed. Nor is it well understood why victims are so reluctant to report abuse and seek help. Power differences within relationships, especially those between men and women, and an associated sense of shame among the victims are likely to be relevant here, perhaps leading women to believe that the attacks on them were provoked by their
© 2015 Royal Australasian College of Physicians
471
Editorial
own failures as mothers and wives.14 Victims may also feel that help is hard to obtain, based on the common perception, that police officers are reluctant to become involved in domestic violence, seeing the problem as one of interpersonal conflict outside their legitimate responsibilities.15 The courts have contributed to this sense of a lack of support by the application until recently of the so-called ‘doctrine of provocation’ as a formal basis for excusing violence against women.16 Doctors, frequently lacking training, skills, confidence and practical resources to enable them to respond effectively, are all too often caught up in this sad labyrinth of unconscious collusion. The final result of all these factors is that doctors mostly don’t ask and women mostly don’t tell. It is not known what social and psychological forces drive some people to commit acts of violence against the people who are closest to them and who trust them most. And most importantly of all, evidence is lacking about what interventions are effective for responding to domestic violence and for preventing its occurrence in the first place.17 Up until now, attempts by the medical profession to respond to the problem have largely focused on guidelines to assist in the detection, management and referral of patients experiencing domestic violence.2,18 It is apparent that more than broad guidelines are needed. Also required are society-wide approaches that mobilise individuals and groups within the community and draw on a wide range of resources. The response must incorporate support for victims to become empowered to speak out and accept help, and understanding and management of the underlying problems of those committing the violence. Here, a move away from the traditional approach based on shame, recrimination and blame to a recognition that domestic violence is usually a symptom of deep underlying social and psychological pathologies is more likely than existing strategies to bear fruit. It is clear from this formulation that there are many ways in which doctors can help. They can provide safe trusted spaces in which both the victims and their assailants can express their pain and explore options for change. They can play a key part in detection, intervention and provision of specialised treatment of the
References 1 KPMG. Cost of Violence against women and children. White ribbon international conference. Sydney Australia 13–15 May 2013. 2 The Royal Australian College of General Practitioners. Abuse and Violence:
physical, mental and emotional damage caused by domestic violence. They can provide support and, where appropriate, active treatment for the direct victims of the violence as well as for all those harmed by being drawn into its fatal web; this includes the child witnesses of the violence, who often carry the damaging effects into their own subsequent relationships. However, they cannot do all this without a well coordinated, locally driven multidisciplinary team-based approach. Doctors can participate in much-needed research into the emotional and social roots of domestic violence, and development and testing of intervention programmes for both offenders and victims. The methodologies required for such research are often complex, but the experience gained from the study of other major public health problems, such as obesity, will provide a fecund resource. Above all, they can help – along with many others – in action to prevent the violence occurring in the first place. This will involve work to change prevailing assumptions that narrowly stereotype women and impose unrealistic demands on all the parties in a relationship. Preventive work must start early, involve both boys and girls, and continue throughout school years. The media could play a positive and ongoing role in promoting awareness of the nature of the problem . The contribution of domestic violence to both physical and mental health problems should be included in undergraduate and postgraduate educational programmes, including continuing professional development, to enhance the possibility of effective responses. Doctors can play an important role in developing and implementing major changes in the social response to the problem of domestic violence. It is time this was recognised and it is time they started doing so. Received 28 February 2015; accepted 8 March 2015. doi:10.1111/imj.12738
L. Piterman,1 P. A. Komesaroff,2 H. Piterman3 and K. J. Jones4 1
Berwick and Peninsula Campuses, Monash University, 2Medicine, Monash University, 3School of Primary Health Care, Monash University, and 4Office of the Pro-Vice Chancellor, Peninsula Campus, Monash University, Melbourne, Victoria, Australia
Working with our Patients in General Practice. 4th edn. Melbourne: RACGP; 2014 [cited 2015 Feb 22]. Available from URL: www.racgp.org.au/your -practice/guidelines/whitebook 3 WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy
guidelines. Geneva WHO. 2013 [cited 2015 Feb 22]. Available from URL: http://apps.who.int/iris/bitstream/ 10665/85240/1/9789241548595_eng .pdf?ua=1 4 Australian Bureau of Statistics. Personal Safety, Australia, 2012. Cat No. 4906. Canberra: ABS. © 2015 Royal Australasian College of Physicians
472
Editorial
5 ABS. Personal Safety Survey, 2006. ABS Cat. No. 4906.0. Canberra: Australian Bureau of Statistics. 6 Walsh D. The hidden experience of violence during pregnancy: a study of 400 pregnant Australian women. Aust J Prim Health 2008; 14: 97–105. 7 Victoria Police. Family Incident Reports, Victoria Police Crime Statistics 2013–2014; 2015. 8 Magistrate’s Court of Victoria. Annual Report 2012/2013, 2013 [cited 2013 Dec 18]. Available from URL: http://www .magistratescourt.vic.gov.au/sites/ default/files/Default/MCV_Annual _Report_2012-13.pdf 9 Chan A, Payne J. Homicide in Australia: 2008–2009 to 2009–2010. National Monitoring Homicide Program annual report. Canberra. Australian Government, Australian Institute of Criminology, 2013. 10 Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y et al. General Practice activity in Australia 2013–2014.
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General practice series no. 36. Cat. no. GEP 36.Canberra: AIHW, 2014. Bradley F, Smith M, Long J, O’Dowd T. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002; 324: 271–8. Hegarty K. What is intimate partner abuse and how common is it? In: Roberts G, Hegarty K, Feder G, eds. Intimate Partner Abuse and Health Professionals: New Approaches to Domestic Violence. London: Elsevier; 2006; 19–40. Hegarty K, Gunn J, Chrondos P, Small R. Association between depression and abuse by partners of women attending general practice: descriptive cross sectional survey. BMJ 2004; 328: 612–24. Australian Institute of Family Studies. The many facets of shame in intimate partner sexual violence. 2014 [cited 2014 Nov 24]. Available from URL: http://www.aifs.gov.au/acssa/pubs/ researchsummary/ressum1/rs1a.html Fagan J. The Criminalisation of Domestic Violence: Promises and Limits. National
Institute of Justice Research Report. Washington, DC: National Institute of Justice; 1996. 16 The Law Institute of Victoria. Under the Crimes (Homicide) Act 2005 provocation as a defence to murder has been abolished and a new defence, ‘defensive homicide’, has been created. 2010 [cited 2015 Feb 22]. Available from URL: http://www.lawreform.vic.gov.au/all -projects/defences-homicide#sthash .moy7bzwe.dpuf 17 Breckenridge J, Hamer J. Traversing the maze of ‘evidence’ and ‘best practice’ in domestic and family violence service provision in Australia. Australian Domestic and Family Violence Clearinghouse; 2014. 18 National Institute for Health and Care Excellence (NICE). Domestic violence and abuse: how services can respond effectively. 2014 [cited 2015 Feb 22]. Available from URL: www.nice.org .uk/guidance/ph50/chapter/ recommendations
© 2015 Royal Australasian College of Physicians
473
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Internal Medicine Journal 45 (2015)
E D I TO R I A L
Domestic violence: it is time for the medical profession to play its part
Ignored for a long time, domestic violence is now recognised as one of the major public health issues in Australia. The financial cost of the problem to the community, estimated at $14.7 billion in 2013, is similar to that of obesity and far in excess of diabetes.1 However, beyond the monetary cost the personal and social damage associated with domestic violence is regarded by many as sufficient to constitute a national emergency. Intensifying public interest in the problem is reflected in the appointment as the 2015 Australian of the Year of Rosie Batty, a courageous victim of a tragic case of domestic violence, together with the establishment of a special Domestic Violence Task Force in Queensland and a Royal Commission in Victoria. While these initiatives are most welcome, they will not on their own provide a solution. What is needed is a national strategy that brings together diverse groups and individuals from the community around a multidisciplinary programme that includes information, support, education and research. Such a programme will require support and resources from government as well as active participation from the medical profession. Despite their potential influence and importance, medical professionals, with rare exceptions, have been strangely silent in this area. The Australian Medical Association has had an admirable policy on its books for 10 years and the Royal Australian College of General Practitioners has developed guidelines for family doctors.2 However, many other Colleges – including the Royal Australasian College of Physicians – appear not even to have developed policies on the subject, let alone effective action strategies. It is time that the wider medical profession contributed actively to addressing this scourge on Australian society.3 Any coordinated strategy on domestic violence will need to be informed by accurate and reliable data. Unfortunately, such data are, at the present time relatively limited. It is known that domestic violence extends to a vast array of abusive settings, covering physical, sexual, emotional and financial abuse among intimate partners, same sex couples, elders and children. It crosses all socioeconomic, cultural, ethnic and religious boundaries. The vast majority of victims are women, with 17% of all Australian women aged more than 18 years having experienced violence from a partner at some time, com-
pared with 5.3% for men,4 and that domestic violence is especially marked in pregnancy, during which up to 36% of all violence occurs,5 and when up to 20% of women experience it for the first time.6 More than 65 000 cases of domestic incidents are reported to police in Victoria each year,7 and nearly 35 000 intervention orders related to family violence are issued, both of these numbers are rapidly increasing.8 Sadly, even death is a not infrequent outcome, with 185 domestic homicides having been reported across Australia in the 3 years to 2010.9 It is known that, despite its frequent occurrence, domestic violence is recognised only rarely by medical practitioners. Indeed, the Bettering the Evaluation and Care of Health (BEACH) study,10 which monitors patterns of consultations in general practice, reported that in more than 95 000 consultations examined in 2013–2014, domestic violence was never cited as a reason for encounters by patients or a problem managed by general practitioners (GP). Similarly, an Irish study of women attending general practices showed that while 39% had experienced violent behaviour from their partner, only 12% were questioned about it by their doctors.11 There is much, however, that remains to be explained. In particular, it is not clear why doctors are doing so badly. Contributing factors no doubt include a reluctance of many patients themselves to volunteer that they have been abused. However, a lack of awareness by practitioners is also important. Sufferers of violence frequently make contact with GP, emergency medicine physicians, obstetricians, psychiatrists, specialist physicians or in other clinical settings. Indeed, full time GP may see up to five women per week who have experienced partner violence, of which two are severe.12 Patients may present with unexplained physical injury, bruising, chronic fatigue, anxiety, depression, insomnia or undifferentiated somatic symptoms.13 Although each of these should raise the possibility of domestic violence, very frequently the warning signs are missed. Nor is it well understood why victims are so reluctant to report abuse and seek help. Power differences within relationships, especially those between men and women, and an associated sense of shame among the victims are likely to be relevant here, perhaps leading women to believe that the attacks on them were provoked by their
© 2015 Royal Australasian College of Physicians
471
Editorial
own failures as mothers and wives.14 Victims may also feel that help is hard to obtain, based on the common perception, that police officers are reluctant to become involved in domestic violence, seeing the problem as one of interpersonal conflict outside their legitimate responsibilities.15 The courts have contributed to this sense of a lack of support by the application until recently of the so-called ‘doctrine of provocation’ as a formal basis for excusing violence against women.16 Doctors, frequently lacking training, skills, confidence and practical resources to enable them to respond effectively, are all too often caught up in this sad labyrinth of unconscious collusion. The final result of all these factors is that doctors mostly don’t ask and women mostly don’t tell. It is not known what social and psychological forces drive some people to commit acts of violence against the people who are closest to them and who trust them most. And most importantly of all, evidence is lacking about what interventions are effective for responding to domestic violence and for preventing its occurrence in the first place.17 Up until now, attempts by the medical profession to respond to the problem have largely focused on guidelines to assist in the detection, management and referral of patients experiencing domestic violence.2,18 It is apparent that more than broad guidelines are needed. Also required are society-wide approaches that mobilise individuals and groups within the community and draw on a wide range of resources. The response must incorporate support for victims to become empowered to speak out and accept help, and understanding and management of the underlying problems of those committing the violence. Here, a move away from the traditional approach based on shame, recrimination and blame to a recognition that domestic violence is usually a symptom of deep underlying social and psychological pathologies is more likely than existing strategies to bear fruit. It is clear from this formulation that there are many ways in which doctors can help. They can provide safe trusted spaces in which both the victims and their assailants can express their pain and explore options for change. They can play a key part in detection, intervention and provision of specialised treatment of the
References 1 KPMG. Cost of Violence against women and children. White ribbon international conference. Sydney Australia 13–15 May 2013. 2 The Royal Australian College of General Practitioners. Abuse and Violence:
physical, mental and emotional damage caused by domestic violence. They can provide support and, where appropriate, active treatment for the direct victims of the violence as well as for all those harmed by being drawn into its fatal web; this includes the child witnesses of the violence, who often carry the damaging effects into their own subsequent relationships. However, they cannot do all this without a well coordinated, locally driven multidisciplinary team-based approach. Doctors can participate in much-needed research into the emotional and social roots of domestic violence, and development and testing of intervention programmes for both offenders and victims. The methodologies required for such research are often complex, but the experience gained from the study of other major public health problems, such as obesity, will provide a fecund resource. Above all, they can help – along with many others – in action to prevent the violence occurring in the first place. This will involve work to change prevailing assumptions that narrowly stereotype women and impose unrealistic demands on all the parties in a relationship. Preventive work must start early, involve both boys and girls, and continue throughout school years. The media could play a positive and ongoing role in promoting awareness of the nature of the problem . The contribution of domestic violence to both physical and mental health problems should be included in undergraduate and postgraduate educational programmes, including continuing professional development, to enhance the possibility of effective responses. Doctors can play an important role in developing and implementing major changes in the social response to the problem of domestic violence. It is time this was recognised and it is time they started doing so. Received 28 February 2015; accepted 8 March 2015. doi:10.1111/imj.12738
L. Piterman,1 P. A. Komesaroff,2 H. Piterman3 and K. J. Jones4 1
Berwick and Peninsula Campuses, Monash University, 2Medicine, Monash University, 3School of Primary Health Care, Monash University, and 4Office of the Pro-Vice Chancellor, Peninsula Campus, Monash University, Melbourne, Victoria, Australia
Working with our Patients in General Practice. 4th edn. Melbourne: RACGP; 2014 [cited 2015 Feb 22]. Available from URL: www.racgp.org.au/your -practice/guidelines/whitebook 3 WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy
guidelines. Geneva WHO. 2013 [cited 2015 Feb 22]. Available from URL: http://apps.who.int/iris/bitstream/ 10665/85240/1/9789241548595_eng .pdf?ua=1 4 Australian Bureau of Statistics. Personal Safety, Australia, 2012. Cat No. 4906. Canberra: ABS. © 2015 Royal Australasian College of Physicians
472
Editorial
5 ABS. Personal Safety Survey, 2006. ABS Cat. No. 4906.0. Canberra: Australian Bureau of Statistics. 6 Walsh D. The hidden experience of violence during pregnancy: a study of 400 pregnant Australian women. Aust J Prim Health 2008; 14: 97–105. 7 Victoria Police. Family Incident Reports, Victoria Police Crime Statistics 2013–2014; 2015. 8 Magistrate’s Court of Victoria. Annual Report 2012/2013, 2013 [cited 2013 Dec 18]. Available from URL: http://www .magistratescourt.vic.gov.au/sites/ default/files/Default/MCV_Annual _Report_2012-13.pdf 9 Chan A, Payne J. Homicide in Australia: 2008–2009 to 2009–2010. National Monitoring Homicide Program annual report. Canberra. Australian Government, Australian Institute of Criminology, 2013. 10 Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y et al. General Practice activity in Australia 2013–2014.
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General practice series no. 36. Cat. no. GEP 36.Canberra: AIHW, 2014. Bradley F, Smith M, Long J, O’Dowd T. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002; 324: 271–8. Hegarty K. What is intimate partner abuse and how common is it? In: Roberts G, Hegarty K, Feder G, eds. Intimate Partner Abuse and Health Professionals: New Approaches to Domestic Violence. London: Elsevier; 2006; 19–40. Hegarty K, Gunn J, Chrondos P, Small R. Association between depression and abuse by partners of women attending general practice: descriptive cross sectional survey. BMJ 2004; 328: 612–24. Australian Institute of Family Studies. The many facets of shame in intimate partner sexual violence. 2014 [cited 2014 Nov 24]. Available from URL: http://www.aifs.gov.au/acssa/pubs/ researchsummary/ressum1/rs1a.html Fagan J. The Criminalisation of Domestic Violence: Promises and Limits. National
Institute of Justice Research Report. Washington, DC: National Institute of Justice; 1996. 16 The Law Institute of Victoria. Under the Crimes (Homicide) Act 2005 provocation as a defence to murder has been abolished and a new defence, ‘defensive homicide’, has been created. 2010 [cited 2015 Feb 22]. Available from URL: http://www.lawreform.vic.gov.au/all -projects/defences-homicide#sthash .moy7bzwe.dpuf 17 Breckenridge J, Hamer J. Traversing the maze of ‘evidence’ and ‘best practice’ in domestic and family violence service provision in Australia. Australian Domestic and Family Violence Clearinghouse; 2014. 18 National Institute for Health and Care Excellence (NICE). Domestic violence and abuse: how services can respond effectively. 2014 [cited 2015 Feb 22]. Available from URL: www.nice.org .uk/guidance/ph50/chapter/ recommendations
© 2015 Royal Australasian College of Physicians
473
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
