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Domestic violence is a challenge to general practice

GPs are in a unique position to help protect women’s health, write RCGP clinical champions Dr Alex Sohal and Professor Gene Feder

Domestic violence is a violation of human rights – and it's also a major public health and clinical problem.  More than one in four women in the UK experience physical or and sexual violence during their lifetime, and one in 10 will have done so in the past year.  Although it is more prevalent in socio-economically deprived communities, domestic violence and abuse (DVA) occurs in all communities, regardless of ethnicity, age, class, sexuality and region. 

DVA can have severe health consequences for women who, compared to men, experience more sexual violence, more severe physical violence and more coercive control from their partners.  Whatever the general population prevalence, it is consistently found more frequently among women seeking healthcare. 

A study of women attending London general practices found that one in seven had experienced physical violence in the last year.  Survivors suffer more long-term health problems including gynaecological conditions, chronic pain, neurological symptoms, gastrointestinal disorders and greater cardiovascular risk.  DVA may start in pregnancy and is associated with miscarriage and low birth weight.  The physical health consequences are over-shadowed by its impact on mental health, including a 4 to 5-fold increase in risk of persistent PTSD, depression, anxiety and substance abuse.  Children exposed to DVA are more likely to have developmental delay, mental health problems and educational difficulties.

Abused women are more likely to be in contact with general practice than any other agencies.  The isolation that survivors of DVA experience as a direct result of their abuser's control over their relationships with friends, family and professionals means that their GP may be one of the few people to whom they can turn.  The magnitude of the health consequences of DVA contrasts with its virtual invisibility within general practice; in one study, only 15% of women with a history of DVA had any reference to violence in their GP record.

General practice manages the long-term consequences of DVA such as depression, chronic pain and substance abuse.  Yet it is likely that while treating many of these common consequences, the role of either historical or current domestic violence is not recognised.  This is neither appropriate nor safe.  This invisibility of DVA can only result in suboptimal management of these conditions and denies women an important pathway for accessing further care from specialist DVA services.

If a woman discloses domestic violence to a clinician there can be an inappropriate, poor quality response as doctors and nurses  seldom receive any training about domestic violence.  Nevertheless, abused women identify doctors as the professionals from whom they would most like to seek support and there is growing evidence for the effectiveness of domestic violence advocacy and psychological treatments for survivors of DVA.

Not asking about domestic violence and ignoring its impact on our patients is not compatible with effective and compassionate general practice. 

For further details see http://www.irisdomesticviolence.org.uk/, and the accompanying Pulse CPD and download on domestic violence

Dr Alex Sohal and Professor Gene Feder are RCGP Clinical Champions for domestic violence

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