‘Opening the door’ on domestic violence and abuse – the crucial role of medical professionals

Domestic violence and abuse will affect one in four women and one in six men in their lifetime and accounts for 16% of all violent crime in England and Wales. ¹ Typically, a single victim will have endured at least 35 assaults before seeking professional help (e.g. doctors, police, domestic violence and abuse advocacy agencies). ¹ Approximately two women are murdered each week by their partner or ex-partner. ² Are you adding to this statistic by unwittingly closing the consultation door on potential victims of domestic violence and abuse?

Domestic violence and abuse does not only encompass physical violence, but it also manifests as sexual, emotional, mental and verbal abuse which all relate to a spectrum of coercive control by an intimate partner or family/relative.^1,2 The face of domestic abuse can be reflected in any gender, social class, race, career or sexuality. ² A review by Hernandez et al. ³ even found that intimate partner violence was experienced by doctors too, who were then less likely to seek medical professional help for fear of stigmatisation by other professional colleagues.

Although domestic violence and abuse can affect anyone, there are certain risk factors that would place a patient in a higher-risk group to suspect possible abuse. Ferrari et al. ⁴ found that women with mental health disorders (e.g. depression, anxiety, post-traumatic stress disorder, substance abuse) are at greater risk of experiencing domestic abuse, and the vice versa, demonstrating evidence of a likely bidirectional effect. Therefore, medical professionals should consider prompting questions regarding domestic violence and abuse in patients with symptoms of mental illness, as recommended in the World Health Organization guidelines on intimate partner violence and sexual violence.^4,5 Staff in high-risk domestic violence and abuse specialties including antenatal, postnatal, reproductive care, sexual health, alcohol or substance misuse, mental health, paediatric and vulnerable adults’ services particularly should make it a part of routine good clinical practice to assess for abuse, irrespective of level of suspicion. ⁶

The National Institute for Health and Care Excellence (NICE) has issued an interactive NICE guidance pathway for domestic violence and abuse (updated August 2017) providing recommendations on ‘Identifying, preventing and reducing domestic violence and abuse’ and ‘training’, which should be read by any practising clinician. ⁶ The identification, prevention and reduction of abuse can only be widely practiced effectively if all medical professionals are provided with appropriate training. ⁶ Yeung et al. ⁷ performed a research study on the perceptions and experiences of general practitioners in responding to domestic violence in their patient cohort and found that apart from lack of time in the appointment clinicians felt they had a lack of appropriate training in medical school, inadequate experience in dealing with domestic abuse and a lack of awareness of effective postdisclosure interventions. This supports the NICE guidance’s emphasis on the need to integrate domestic violence and abuse training as part of the undergraduate and/or postgraduate curriculum and that it should remain part of continuing professional development for any health and social care professional, and delivered in partnership with local specialist domestic violence and abuse services.^4,6 If this training is not available, particularly in primary care, clinicians should seek out their clinical commissioning group to commission relevant training organisations (e.g. Identification and Referral to Improve Safety [IRIS]) that can provide training to the whole primary care team including how to provide immediate support after disclosure and, crucially, the referral pathway to a domestic violence and abuse advocacy agency/floating support/outreach support/refuges, or in a hospital setting – independent domestic violence advisors, tailoring care appropriately to the patient’s needs and referring them to other relevant services (e.g. alcohol or substance misuse, mental health) where appropriate.^4,6,8 Apart from patients/service users, there should also be support available for staff to address issues relating to their own personal experiences, as well as those that may arise after contact with domestic abuse patients. ⁶ If not already available in a clinician’s practice, clinical commissioning groups and local authorities should establish an integrated commissioning strategy to provide access to domestic violence and abuse and other relevant services to meet the health and social care needs of victims and their children, and perpetrators/abusers seeking help (e.g. behavioural intervention programmes [DVIP]).^2,6

The NICE guidance recognises that domestic violence and abuse victims have great difficulty in disclosing information to medical professionals regarding their circumstances and recommends measures to remove obstacles to better enable victims to disclose their experiences. ⁶ Information regarding domestic violence and abuse support services/advocacies/local or national helplines should be clearly displayed in waiting areas and other suitable places for easy access of domestic violence victims. ⁶ Given the sensitive nature of the information to be shared, all patients should be given maximum privacy; some examples include organising the clinical reception area to ensure patients cannot be overheard or ensuring that patients can be seen on their own. ⁶ A victim may have multiple abusers, and friends and family members who may be colluding in the abuse.^2,6 It is a frequent occurrence that abusers attend medical appointments with their victim as part of their spectrum of control.^2,6 The abuser attempts to lead the medical appointment, answering for the victim and inadvertently building a good rapport with the clinician while the victim is silent and withdrawn. ² In a time-constrained setting such as a medical appointment, discussing with the person who seems to be the more ‘sensible’ one appears to be the most time-efficient manner of completing the appointment and managing the ‘couple’s expectations’. This witnessed collusion or ‘gaslighting’ of the vulnerable victim, however, gives them a sense of helplessness, preventing them from seeking help again once they have been snubbed and losing confidence in both themselves and the medical profession. ²

Discussing with several general practice and radiology colleagues and lending from the experiences of fellow Freedom Programme trainers, it seems that more often than not, doctors do know when a situation does not feel quite right, but they ignore this intuition as they feel that they would not have time to address it at this appointment.^2,7 Although this is arguably understandable, it is unacceptable, as it perpetuates a culture which turns a blind eye on domestic violence. This goes against both NICE domestic violence and abuse guidance and the General Medical Council’s Good Medical Practice ‘Develop and maintain your professional performance’.^6,9 However, challenges in addressing domestic violence and abuse in a clinical setting must be recognised. Yeung et al.’s ⁷ study found that a lack of time in a clinical setting to deal with abuse was the greatest challenge. Clinical managers should address this and provide clinicians a suitably longer duration of time in suspected patient appointments, as administering effective care and safeguarding patients should always be the priority in any clinical practice. ⁶

Domestic violence is unacceptable in all its forms and should be a priority in healthcare assessment, being the first port of call for most victims. We, as doctors, need to be that helping hand to pull a victim up from their traumatising circumstances when they do reach out to us and support abusers who want to change their ways. Living in ignorance and feeling relief once the consultation door is closed is a degradation to the humanity and compassion we are meant to foster within medicine – a violation of the NICE domestic violence and abuse guidance and General Medical Council's Good Medical Practice’s code of ethics.^6,9 Silence itself is a form of collusion; ignorance or trivialisation of abuse would only allow and perpetuate domestic violence to continue in a conspiracy of silence. ¹⁰ Be a responsible physician and equip yourself with the widely available and accessible knowledge, training and guidance pathways on domestic violence and abuse which should always be a part of your ongoing professional development.^4,6 Help give a voice to those who feel they no longer have one – break the silence and open the door on domestic abuse.