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Domestic violence

Case

history

Marie is 25 and in her third pregnancy. She is 20 weeks pregnant and presents as an extra on Monday morning with a front tooth missing and bruising on her face. She 'tripped and fell down the stairs'. She is worried about the baby. Examination

reveals a healthy pregnancy but there are older bruises on

Marie's back and upper arms.

Dr Tanvir Jamil discusses.

I've only ever seen one case of domestic violence ­ how common is it?

Much more common than we doctors think. Two women a week are killed by a current or former partner and domestic violence accounts for 22 per cent of all recorded violent crime. Every minute in the UK the police are called to assist a domestic violence incident. In more than 50 per cent of cases children are also injured.

Women's Aid, the national domestic violence society, has come up with some very concerning figures for women who also have mental health issues and drug/alcohol-related problems: between 50-60 per cent will have experienced domestic violence and about a fifth will be experiencing current abuse.

The reason many doctors do not see much domestic violence is that we may simply be missing it. Some figures suggest that only one woman in 25 is correctly identified.

What are the reasons we miss these women?

There are many barriers that work together to make domestic violence difficult to diagnose, but the commonest reason is the 'lack factor': lack of time, training, control, knowledge.

Also an unwillingness to 'open a can of worms' and fear of offending the patient may contribute to doctors missing a lot of domestic violence. But it's important for all health care providers to be on the lookout for possible abuse.

Look for hidden agendas, unexplained bruises, co-existing drug/alcohol-related problems and of course a history of abuse (whether as a child or adult). Domestic violence exists in all socioeconomic, racial, religious and educational backgrounds. Violence exists in both homosexual and heterosexual relationships, across all ages.

Remember that battered women often feel great shame and fear for their safety if they confide in anyone. Some women have been abused for so long that they no longer see their spouse's behaviour as abnormal and may even feel they deserve abuse.

How do women find themselves in this awful position in the first place?

Domestic violence is about power and control. The batterer, typically a victim of abuse also, has low self-esteem and needs to control as much of his partner's life as he can, such as making all family decisions, financial decisions, controlling her time and movements, controlling her career and often deciding when and if she will be pregnant.

This control is achieved through threats (including emotional blackmail), intimidation and physical abuse. This is the beginning of the 'cycle of violence' which has three phases:

Phase I: tension-building ­ batterer becomes increasingly angry and irritable.

Phase II: battering ­ may include verbal/ emotional abuse, a slap or push, repeated beatings and/or rape.

Phase III: honeymoon phase ­ batterer is repentant, tells his partner he loves her and will never hurt her again. This phase gives the woman hope and so she stays with the batterer. This phase typically gets shorter and shorter while the abuse becomes more frequent and severe.

So how do I make sure I don't miss a woman who is being abused?

Many American guidelines suggest every woman should be asked about domestic violence. British guidelines instead suggest doctors should maintain a high level of awareness and ask the appropriate questions if the clinical presentation is suggestive of violence. Studies have shown victims of domestic violence prefer doctors who are listening, sympathetic and offer appropriate advice. They do not find it easy to talk to doctors who do not listen, seem hurried or who tend to prescribe antidepressants.

A 1998 article (Kamran Abbasi BMJ 316:7 January 3) suggested all pregnant women should be asked about domestic violence as up to one in five women seen in antenatal clinics may have experienced abuse.

Women should be assessed in private, not in the presence of a partner , other family members, or friends.

What are the most appropriate questions to ask a woman who may be a victim?

·Do you ever feel afraid of your partner?

·Has your partner or ex-partner ever physically hurt or threatened you?

·Has your partner ever destroyed things that you cared about'?

·Has your partner ever threatened or abused your children?

·Has your partner ever forced you to have sex?

·Has your partner ever prevented you from doing things ­ for example leaving the house, seeing friends etc?

In our case, Marie admits to domestic violence and wants to do something about it. What do I do next?

First take a complete history using as much of her own words as possible. Then document her injuries using drawings and/or photographs. The next steps are 'plan safety' and 'follow-up'. The sort of information that needs to be provided in the safety plan includes:

·Police station (domestic violence unit)

·Branches of national organisations (see right)

·Access to emergency housing (district housing officer)

·Organisations giving legal, advice/solicitors

·Citizens Advice Bureau (CAB)

·Department of Social Security

·Organisations willing to help children

·Community health councils

·Support/counselling groups

·Alcohol groups

·Organisations for specific community groups

·Organisations for men willing to receive help for their violent behaviour

Your health visitors may have a lot of this information already but it is always worth having an up-to-date list for your local area. Follow-up can be provided by you, a health visitor and a social worker.

Useful numbers:

Women's Aid Federations around the UK

(office numbers only)

England (0117) 944 4411

Northern Ireland

(028) 9024 9041

Scotland (0131) 475 2372

Wales (02920) 390874

Refuge is a National Domestic Violence Charity

Head Office

2-8 Maltravers Street

London WC2B 3EE

Tel: 0990-995-44324

24-Hour National Domestic Violence Helpline:

0870-599-5443

National helplines

Freephone ­ 24-hour National Domestic Violence Helpline 0808 2000 247

Northern Ireland 24-hour helpline (028) 9033 1818

Scottish Domestic Abuse Helpline (0800) 027 1234

Republic of Ireland 24-hour helpline (1800) 341900

Regional helplines

Manchester WA Helpline

0161 839 8574

Nottingham WA Advice Centre 0808 800 0340

SHE Helpline (East Anglia, Kent, East London)

01702 300006

Refuge Crisis Line (London-wide) (0870) 599 5443

Specialist helplines

Jewish Women's Aid

0800 591203

Women with learning difficulties 0208 522 0675

Tanvir Jamil

is on a sabbatical in Canada