Domestic Abuse

Question 1

police definition

of domestic abuse

Answer 1

• Any form of physical, verbal, sexual, psychological or financial abuse which might amount to criminal conduct and which takes place within the context of a relationship.
• The relationship will be between partners (married, cohabiting, civil partnership or otherwise) or ex-partners.

The abuse can be committed in the home or elsewhere, including online (stalking; surveillance)

STRESS: partners/ex-partners (Scotland) - intimate partner relationship is the defining issue

Question 2

2 types of domestic abuse

Answer 2

• Situational couple violence-fighting or verbal aggression not involving control
• Coercive and controlling behaviour-violence may also be a feature (invasive - every part of the victims life)

Both are wrong and unacceptable, but they are different. Maybe a chance to think about the dangers associated with both

Question 3

the domestic abuse (scotland) act 2018

Answer 3

created a specific criminal offence of domestic abuse

• It recognised that it can be a course of conduct which takes place over a sustained period of time.
• The Act covers physical violence, and psychological and emotional abuse. It criminalised coercive control.

Question 4

main victims of Domestic abuse globally are

Answer 4

women are the main victims (does occur to men to)

WHO: 10 facts about women’s health worldwide - No3 VIOLENCE

• Violence has serious health consequences for women
• Between 15% and 71% of women worldwide have suffered physical or sexual violence committed by an intimate male partner at some point in their lives

Domestic violence is the leading cause of morbidity for women aged

• 1greater than cancer, war and motor vehicle accidents

The abuse cuts across all social and economic backgrounds – different from youth violence etc which is predominately deprived backgrounds

health related consequences are huge

Question 5

prevalence in scotland

Answer 5

60,000 reported cases annually

• Domestic abuse affects 1 in 5 women in Scotland at some point in their lives
• It also affects up to 1 in 6 men, however,
  
  • women are more likely to experience repeated incidents over time, have greater injuries and suffer more psychological and sexual violence (Scottish Crime & Justice Survey , 2009)

There are about 60,000 reported cases every year, this doesn’t vary much but we know domestic abuse is underreported to the police

• Scottish Women’s Aid One Day Census
  
  • On one day in 2019 Scottish Women’s Aid were contacted by 1235 women children and young people for support
    
    • This helps demonstrate that 60,000 cases recorded by the police annually is likely to be an underestimate
      
      • Statistics only as good as data entered

53% of women murdered in Scotland between 1997 and 2007 were killed by a partner or ex-partner

In 54% of rape cases the perpetrator is a current or ex-partner

reported incident but no crime recorded

• Arguments with no reference to physical or threatening behaviour
• Disagreements around communication

Question 6

why would people not report domestic abuse

Answer 6

Cascade of events – negative impact, meaning less likely to report as intimidating

Question 7

where does domestic abuse occur

Answer 7

Private residence – house

• unlikely in public or licensed premiseded

difficult to police, often a crime with no witnesses which makes it difficult to prove and bear in mind that abusers tend to be very charming to outsiders the police included

This has implications during the current COVID-19 pandemic as lockdown means that perpetrators have more opportunity to control their victim – have them where they want them 24/7 – home not always a safe place

Question 8

when does domestic abuse occur

Answer 8

weekend more

• sunday most common (inc overnight from saturday)

Question 9

what is gender based violence

Answer 9

spectrum

• Violence directed against a person on the basis of gender.
• Gender-based violence reflects and reinforces inequalities between men and women
• Some in spectrum are components in domestic abuse*
• Rape, stalking etc

Question 10

6 points of gender based violence specturm

Answer 10

• rape and sexual assault;
• childhood sexual assault
• sexual exploitation and trafficking
• sexual harrasment and stalking
• harmful traditional practices e.g. FGM
• domestic abuse

Question 11

key points on gender based violence

Answer 11

In line with the UN definition, and as established in the previous exercise on gender, many inequalities still exist between men and women and being female is a key risk factor for GBV.

• umbrella term for a spectrum of various forms of abuse, which are not discrete, but are often interconnected.
  
  • For example sexual violence, including rape, stalking, harassment and forced marriage, is often experienced within the context of domestic abuse.
• GBV is the term used to explain the context in which such violence occurs.
  
  • highlights the most important fact that cuts across all forms of abuse - that they stem from or reinforce gender inequality.

GBV is primarily experienced by women and mostly perpetrated by men.

• Many women will experience more than one form of abuse during her lifetime.
  
  • Although most abusers are men, most men are not abusers.
• Mental health and substance misuse services have a significant number of male and female survivors of abuse.

Question 12

signs of trafficking

Answer 12

sometimes you just get a bad feeling about a relationship and it may not be domestic abuse it may be related to trafficking.

• May feel intimidating or off about a relationship, something doesn’t add up (e.g. no health data for healthy pregnant women – trafficking)
• Complex but remember

To remember also that trafficking is not limited to people who come from overseas, people especially younger people can be trafficked in the UK for sexual exploitation or as part of a county lines issue for drug dealing

Question 13

men and domestic abuse

Answer 13

• Although most perpetrators of domestic abuse are men, most men do not abuse
• Men can be victims, but women tend to experience repeated incidents over time, have greater injuries and suffer more psychological and sexual violence.

Really important not to alienate men - Most men do not abuse and men are just as able as women to recognize domestic abuse and get someone the help they need.

Another important aspect of male involvement is being a good role model to other men and in challenging worrying behaviors

Question 14

5 types of abuse

Answer 14

• verbal
• emotional
• physical
• sexual
• financial

Question 15

coercive control

Answer 15

a pattern of behvaiour

aims to:

• Isolation (only see abuse)
• Degradation (put down on regular basis – fat, ugly, unwanted = low self-esteem)
• Micro-regulation of all aspects of life
  
  • Money
  • Dress
  • Surveillance

Abusers are often very charming to everyone else which serves to increase the isolation

Question 16

who is affected by domestic abuse

Answer 16

• Gender
  
  • 82% female victim
  • 16% male victim – underestimate – not reported
  • 2% same gender

Question 17

who is most at risk of domestic abuse

Answer 17

• Women
• Age 16–24 (women) or 16–19 (men)
• Long-term illness or disability – this almost doubles the risk vulnerable adult
• Mental health problem vulnerable adult
• Woman who are separated
  
  • there is an elevated risk of abuse around the time of separation.
• Pregnancy
  
  • Start or escalate during pregnancy – theory that another person coming into the relationship that will be of higher importance than abusive partner

Important particularly for health to draw out that some groups may be more at risk and they are often people who are more vulnerable.

Question 18

domestic abuse cannot affect

Answer 18

no one

goes across all boundaries

anyone can be affected

Question 19

health consequenes of domestic abuse/sexual assault/child sexual abuse

Answer 19

non fatal outcomes

• physical issues
• chronic conditions - facial pain - TMD
• reproductive heatlh
• mental health - anxiety, depression
• health harming behaviours - smoking, drinking, drugs

fatal outcomes

• femicide
• suicide
• maternal mortality

80 women were killed in UK by a partner/ex in 2019

Question 20

physical harm to children in domestic abuse

Answer 20

• 33 children in the UK were murdered by their parents in 2007. (Home Office, 2008)
• 2 reports from Women’s Aid that looked in detail at some of these cases in 2004 and 2016 highlight some of the issues

One mother stated that her ex-partner phoned to tell her that he had killed their child and when she asked him why, he replied: “If I can’t have you, you can’t have [the child].”

Another mother stated that her ex-partner phoned to let her know that he had killed the children and commented: “You’ve hurt me. Now I’m going to hurt you.”

Rare – but can happen e.g. murder suicide scenario may feel lost control of situation and want to take away the one thing the victim loves

Question 21

effect on children that is not physical harm

Answer 21

• Anxiety or depression (PTSD)
• Sleeping issues
• Nightmares
• Heightened startle response
• May develop physical symptoms
• Behavioural issues
• Lowered sense of self-worth, feelings of guilt
• Health harming behaviours
• Truanting – important that school are aware of home scenario so can support

It is NOT inevitable that they will grow up to become abusers or victims BUT think ACEs

Question 22

adverse childhood events (ACEs)

Answer 22

People to whom certain things happened in childhood had a higher risk of various health (mental and physical) and social issues later in life

• Association very significant

ACEs change how your brain responds to stress

• They make you more likely to get involved in health harming behaviors -smoking, alcohol and drug misuse etc
• They influence your social determinants of health-things like education, employment and income

70% of the population have one ACE (common)

9% have 4 or more ACES

• Among other things people with 4 or more ACES are more likely to have a range of medical medical problems
  
  • Are 2x more likely to binge drink
  • Are 7x more likely to have been involved in violence in the last year

ACES are a risk factor for violence-both being a victim and a perpetrator

• However, they can be overcome by the development of resilience (constant supportive adult, school, friend circle)

Question 23

cost of domestic abuse

Answer 23

The cost of domestic abuse to Scotland in 2013 was £2.3 billion

This includes

• ‘Human and emotional’ costs
• Criminal justice system, civil legal services, healthcare, social services, housing and refuges
• Costs to the economy due to time off work for injuries.

The cost of domestic abuse to England and Wales in 2017 was £66 Billion

• The largest element is the physical and emotional harm suffered by victims (£47 billion).
• The next highest cost is for lost output relating to time taken off work and reduced productivity afterwards (£14 billion).

Very costly for something that is entirely preventable

Question 24

why should clinicians get involved in domestic abuse cases

Answer 24

• Violence is a public health issue – everyone has a role in prevention
  
  • You have a duty of care to your patients
• As a group you can have a role in advocating for social change and in changing attitudes
• You are in a good position to spot the signs – both physical and behavioural
  
  • Confidential, clinical training
• You might be the only person they tell
  
  • Many abused women (and men) will initially talk to someone they trust who is not a close friend or family member

Question 25

how HCP asking about domestic abuse can help

Answer 25

• It takes many incidents before someone being abused will speak to anyone about the abuse
• It takes 6-7 attempts before someone will finally leave an abusive relationship
• Evidence shows that if someone trusted askes about abuse this will make those being abused start to think about their situation
• This may encourage them to take action

Question 26

behavioural signs of domestic abuse

Answer 26

• Low self-esteem
• Victims may appear fearful, anxious or sad
• Constant phoning or texting by a partner while they are with you
• Alcohol
• If the partner is present he may do all the talking, patient may not speak while partner is present
• Partner may insist on female clinician
• Missed or frequent appointments

It is important to realise that some of these issues may be due to other things which is why it is important to give people room to speak

Question 27

dental signs of domestic abuse

Answer 27

• Repeated injuries
• Bruises at different stages of healing
• Dental/maxillofacial injuries
• Unlikely explanations of injury
• Facial bruising, bruising or strangle marks around the neck, fingertip bruising on the arms or neck or behind the ears (BOS fracture)
  
  • intensify with time since injury
• Delay in seeking help for injury
• TMJ problems
• Orofacial pain
  
  • 69% had a history of abuse
• Think if asked about emergency contraception – remember incidence of rape common in domestic abuse relatiosnships

Question 28

problems after attempted strangulation

Answer 28

now crime in england

amage around neck,

microinfarcts in brain due to deficit of O₂

Can be little to large extend – memory issues

Question 29

physical abuse prevalence in domestic abuse

Answer 29

• In about 40% of cases
• Most victims suffer injuries to the head or neck
  
  • Facial injuries in 50-90% of victims

Question 30

facial trauma in women

Answer 30

32 times more likely to be due to domestic abuse than any other cause – red flag

• Health professionals often form long term relationships with patients so can spot changes in appearance or behaviour

Question 31

role as dental clinicians

Answer 31

• We see victims at a different time from the police
  
  • usually they are called at crisis point
• we have a different window of opportunity
  
  • we can provide a lifeline
• healthcare professionals not trained to identify domestic violence and abuse may mislabel and misdiagnose people’s problems, resulting in unnecessary treatment and investigation
  
  • facial pain – antidepressants wrongly – but need help with abuse

Question 32

The Gender Based Violence Action Plan

NHS Scotland

Answer 32

Priority healthcare settings

• Accident and Emergency; maternity services; mental health; sexual and reproductive health; Addictions; primary care
  
  • Doesn’t always happen – busy
    
    • Sometimes better time management to target who you ask to match suspicions
• Key deliverables
  
  • Routine enquiry
  • Revised guidance on abuse
  • Employee policy on gender-based violence
  • Multiagency collaboration

Question 33

rationale for routine enquiry on domestic abuse

Answer 33

• Domestic abuse is common amongst (particularly women) using NHS
• People find it acceptable to be asked
• Abuse is a key contributory factor in many presentations
• Knowing about a person’s experience of abuse will help inform assessment and care
• Potential for increasing safety

Question 34

barriers to domestic abuse screening

Answer 34

• patient accompanied
• lack of training
• concern about offending pt
• patient’s cultural normal
• embarrassment
• lack of knowledge about where to refer
• lack of tie

may think its personal issue - it is not - its a major health issue

Question 35

do victims want to be asked?

Answer 35

yes

• 70% of pts presenting to their dentist with signs of abuse wished they had been asked
  
  • 88% were not asked (2008)
• If a pt present with obvious injuries and nobody askes about the abuse they will go away wondering why not, this will likely reinforce their belief that somehow they are in the wrong and that nobody believes them

Question 36

will offence be taken?

Answer 36

Generally, people are not offended and will often say they are glad someone finally asked them about the violence

• Those who do disclose abuse to someone typically describe a history of a long-standing and escalating violence and also remark on how much they wanted to be able to talk about what was going on, if only someone had asked them

Question 37

vulnerable adult

Answer 37

“unable to safeguard their own interests through disability, metnal disorder, illness or physical or mental infirmity, and who is at risk of harm or self-harm, including neglect”

• Adult support and protection (Scotland) Act 2007
• Consider whether a referral needs to be made on their behalf

Question 38

AVDR

Answer 38

• ask
• validate
• document
• refer

JADA 2006

Question 39

why we use AVDR

Answer 39

• Developed for use with dentists to help them reach out and offer help
• Asking about domestic abuse is difficult
  
  • We all worry about getting it wrong
• AVDR gives us a simple way to do this and is tried and tested
• We use it with all the groups that we train
  
  • Dentists, doctors, vets, pharmacists, fire services etc

Question 40

benefit clincian of using AVDR

Answer 40

• Quick and easy
• Limits the enquirers involvement to very simple tasks, devolving them of responsibility to get too involved in the often complex circumstances surrounding abuse
• Allows professionals to work within their comfort zone
  
  • If bystanders know that their involvement is limited they are more likely to undertake intervention

Question 41

A

in AVDR

Answer 41

ask

• Ask about abuse
• Try and ask in as private a setting as you can
• Don’t ask in front of other family members and nerve ask family members to translate if English not first language
• Use non-judgemental language
• Many studies show that victims want to be asked
• Sometimes people may not be ready to talk
  
  • Even if they are not you can still support them and be there when they are ready
• Remember the perpetrator may be an ex-partner
• Ways of asking:
  
  • Is everything OK?
  • I’ve noticed you’ve got some bruises on your neck, is everything OK? Has someone hurt you?
  • I’m worried that you don’t seem your usual self, is everything OK?
  • Do you feel safe?

Question 42

V

in AVDR

Answer 42

• This is just a way of showing someone you are concerned about them
  
  • Removes blame
  • Shows them that you believe them
  • Show them that you are taking this seriously
• ‘you do not deserve to be hurt or hit no matter what happened’
• ‘I am concerned about your safety’
• Even if your patient denies abuse you should still do this
• It may provide some relief or comfort
• It may help them to realise that they are in a serious situation and need to get help

Question 43

D

in AVDR

Answer 43

• Be specific and detailed
• Use the person’s own words as well as clinical notes
• Describe injuries in as much detail as possible or take photographs if able
• Remember your record could end up in court
• Domestic abuse often happens in private with no witnesses and corroboration is still required

Question 44

R

in AVDR

Answer 44

• Referral in this case means ‘signposting’
  
  • Your patient needs to take action rather than you
    
    • Signpost to appropriate services
    • Do not attempt to dealt with the problem yourself
• Even if your patient doesn’t seem keen or denies any abuse you should still offer, they may go away and think about it and take action later
• The core Scottish organisation is the Scottish Domestic Abuse Helpline
  
  • 0800 027 1234
  • What to give – small card with contact details for domestic abuse organisations (e.g. small gift with domestic abuse helpline concealed on it – not to be publicised – risk for victim)
• Remember – immediate threat to life or safety
  
  • POLICE 999
  • Non urgent police 101
• Police Scotland anonymous website report https://www.scotland.police.uk/domestic-abuse/

Question 45

core scottish organisation for domestic abuse referrals

Answer 45

• Scottish Domestic Abuse Helpline
  
  • 0800 027 1234

use of Covert Items – lip salves, phone screen cleaner

Question 46

what else clinicians can do to help stop domestic abuse

Answer 46

• Put cards in the toilets and posters in the waiting areas to let patients know you are able and willing to talk about domestic abuse – this is very useful if they are not ready to disclose
• Have your staff where ASC badges
• Allow patients to use the phone in the surgery or pharmacy to contact agencies if they need to
• Link with local domestic abuse agencies and have their materials available. They can help you let the community know that you are trained and willing to help
• Develop a protocol to allow you to get people on their own if partners are present to alert others in the practice to the issue – may want to have code words that you use

Question 47

what is not expected of clinicians in domestic abuse cases

Answer 47

It is not your role to provide specific advice about if how or when to leave the home

• If a victim decides to leave this has been shown to be the most dangerous time for them and the time when the abuse often escalates
• Provision of advice about leaving is best left to the professional organisations who deal with domestic violence

You should provide the contact details of these organisations

Question 48

how to speak to pt alone

Answer 48

x-ray

code words with nurse - so they take accompanier to sign a form

Question 49

vulnerable adult needs what form completed

Answer 49

AP1

to inform social services

• Physical, mental disability
• Need assistance in taking care of themselves

Question 50

what to do if someone is unwilling for help in domestic abuse sitution but not at risk of significant harm

Answer 50

need to leave the ball in their court

they have been under control for a long time so intimated and cannot control them too – damaging – give information and let them take action themselves

Question 51

do clinicians have obligation to report domestic abuse

Answer 51

No obligation to report if told in confidence – provide them with contact information for places they can get help Scottish Domestic Abuse Helpline

• Include in clinical notes – record that they disclosed, can be used as cooberation in court case

Question 52

if worried about a child in a domestic abuse household

Answer 52

child protection services - seek advice

Question 53

ASC

Answer 53

ask

support

care

The main thing is keep it simple

• Have the skill to do this: communication, empathy, concern, knowledge

We all worry about asking and getting it wrong, but better that than not giving someone the chance to get help