Domestic Abuse

Question 1

what is domestic abuse?

Answer 1

The Police Definition:
• 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 and surveillance can be carried out easily online and this can be part of the abusive cycle of domestic abuse

Question 2

what are the types of domestic abuse

Answer 2

• Situational Couple Violence
○ Fighting or verbal aggression not involving control
○ Probably on a regular basis

• Coercive and Controlling Behaviour
○ Violence may also be a feature
○ Doesn’t have to involve violence
○ Invades every part of somebody’s life

Question 3

what is the domestic abuse (scotland) act 2018

Answer 3

• The Domestic Abuse (Scotland) Act 2018 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 ~ for the first time

Question 4

what is the leading cause of morbidity for women aged 19-44 globally

Answer 4

domestic violence

Question 5

what is the prevalence of domestic abuse in Scotland

Answer 5

1 in 5 women
1 in 6 men

However, women are much more likely to experience repeated incidents over time, have greater injuries and suffer more psychological and sexual violence than men

Question 6

where does domestic abuse happen

Answer 6

• victims home (most common)
• other house
• joint home
• street
• accused home
• licensed premises

Question 7

what is gender based violence

Answer 7

Violence directed against a person on the basis of their gender

Question 8

what is included in gender based violence

Answer 8

• domestic abuse
• rape and sexual assault
• childhood sexual abuse
• sexual exploitation and trafficking
• sexual harassment and stalking
• harmful traditional practices eg FPM

Question 9

what are teh different types of abuse

Answer 9

Verbal
Emotional
Physical
Sexual
Financial

Question 10

what is coercive control

Answer 10

• a pattern of behaviour
• isolation
• degradation
• micro-regulation of all aspects of life (money, dress ~ told what to wear etc, surveillance)
• abusers are often very charming to everyone else which serves to increase the isolation

Question 11

who is most at risk of domestic abuse

Answer 11

• Women
• Age 16-24 (women) or age 16-19 (men)

• Long term illness or disability = almost doubles the risk
○ Classed as vulnerable adults

• Mental health problem

• Women who are separated
○ There is an elevated risk of abuse around the time of separation
○ Dangerous time for people who are being abused

• Pregnancy
○ Domestic abuse sometimes starts during pregnancy or will escalate to violence at this time
○ Studies show that it can be because another person is coming into the relationship who may perhaps be more important than the abusive partner

but can affect anyone

Question 12

what are non-fatal outcomes of domestic abuse

Answer 12

• physical issues
• chronic conditions (TMJ dysfunction)
• reproductive health problems
• mental health
• health harming behaviours (such as smoking or drinking or taking drugs ~ ways patients try to self-medicate)

Question 13

what are fatal outcomes of domestic abuse

Answer 13

• femicide
• suicide
• maternal
• mortality

Question 14

how can domestic abuse impact children even if they are not physically harmed

Answer 14

• Anxiety or depression
○ PTSD

• Sleeping issues
• Nightmares
• Heightened startle response
• May develop physical symptoms
• Behavioural issues

• Lowered sense of self-worth, feelings of guilt
○ Believe the situation has been caused by them
○ Try and protect the partner who has been abused

• Health harming behaviours

• Truanting from school
○ Can become classroom disruptive to take this into account to help them

It is NOT inevitable that they will grow up to become abusers or victims BUT think ACEs
ACE = Adverse Childhood Experiences

Question 15

what are adverse childhood experiences

Answer 15

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

ACE’s change ow your brain responds to stress

• They make you more likely to get involved in health harming behaviours:
○ Smoking
○ Alcohol
○ Drug misuse

• They influence your social determinants of health things like:
○ Education
○ Employment
○ Income

Question 16

what are examples of ACEs

Answer 16

• abuse
  > physical
  > emotional
  > sexual
• neglect
  > physical
  > emotional

- household dysfunction
> mental illness
> incarcerated relatives
> mother treated violently
> substance abuse
> divorce
> domestic abuse

Question 17

what happens if someone has 4 or more ACEs

Answer 17

○ Are more likely to have a range of medical problems
○ Are 2x more likely to binge drink
○Are 7x more likely to have been involved in violence in the last year

Question 18

why should clincians get involved in domestic abuse

Answer 18

• Violence is a public health issue; everyone has a role in prevention

• You have a duty of care to your patients
○ Need to make sure we are patient centred and we do our best for them regardless of the problem they are facing
○ We can refer / sign post

• 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
○ Clinical training helps

• You might be the only person they tell
○ Confidential relationship with the patient

• Many abused women (and men) will initially talk to someone they trust who is not a close friend or family member
○ Dynamics of domestic abuse mean that some of the other family members are witnesses to what is going on they may or may not believe what is going on

Question 19

how many attempts does it take someone to leave an abusive relationship

Answer 19

6-7 attempts

Question 20

how can you recognise abuse in a patient’s behaviour

Answer 20

○ Low self-esteem

○ Victims may appear fearful, anxious or sad

○ Constant phoning or texting by a partner while they are with you
§ Especially if the appointment runs late

○ Alcohol
§ Somebody you wouldn’t be expecting to be drinking during the day may smell like alcohol

○ If the partner is present he may do all the talking, patient may not speak while partner is present
§ He or she
§ Patients in an abusive situation may not be allowed to speak
§ Ask patient question but someone else is answering
§ Be suspicious of this especially if they can speak english

○ Partner may insist on female clinician
§ Can be other reasons for this eg cultural reasons

○ Missed or frequent appointments

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

Question 21

what are physical features of domestic absue

Answer 21

• Repeated injuries to the head and neck
• Bruises at different stages of healing
• Dental / maxillofacial injuries
• Unlikely explanations for injury

• Facial bruising, bruising or strangle marks around the neck, fingertip bruising on the arms or neck or behind the ears (BOS#)
○ If someone is wearing a scarf and won’t take it off ~ suspicious
○ Bruising behind the ears could indicate a base of skull fracture

• Delay in seeking help for injury
○ Had injury for a number of days before it gets so uncomfortable / painful they need to get pain

• TMJ problems
○ Chronic pain is common in victims
○ Can also get chronic back pain etc

• Orofacial pain ~ 69% had a history of abuse

• Think if asked about emergency contraception
○ Remember incidence of rape
○ Rape is common in domestic abusive relationships

Question 22

what is our role as clinicians

Answer 22

• We see victims at a different time frame from the police
○ Usually they are called in 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

Question 23

what is the gender based violence action plan

Answer 23

○ Priority health care settings ~ everyone working in these setting should ask about domestic abuse
§ Accident and emergency
§ Maternity services
□ Happens regularly and reliably in these services
§ Mental health
§ Sexual and reproductive health
§ Addiction
§ Primary care

○ Key deliverables
§ Routine enquiry
□ Doesn’t happen in every service - people are busy
□ Sometimes best to just ask when suspicious instead of asking everybody
§ Revised guidance on abuse
§ Employee policy on gender based violence
Multi-agency collaboration

Question 24

what is the rationale for routine enquiry

Answer 24

• Domestic abuse is common amongst particularly women using NHS services
• 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 25

what are the barriers to screening

Answer 25

• Patient accompanied (77%)
○ Need the person on their own
○ Don’t want the person with them to report back to the patient’s abuser / don’t want to ask in front of the abuser themself
• Lack of training (68%)
• Concern about offending the patient (66%)
• Patients’ cultural norms (53%)
• Embarrassment (51%)
• Lack of knowledge about where to refer (41%)
Lack of time (36%)

Question 26

what is a vulnerable adult

Answer 26

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

Question 27

what act protects vulnerable adults

Answer 27

Adult Support and Protection (Scotland) Act 2007

Question 28

what is AVDR

Answer 28

Ask
Validate
Document
Refer

Question 29

Why do we use AVDR

Answer 29

· AVDR [Ask Validate Document Refer] was 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 ways to do this and is tried and tested
· We use it with all the groups that we train
Dentists, doctors, vets, pharmacists, the fire service etc

· The AVDR intervention is quick and easy 
· Limits the enquirers involvement to very simple tasks, devolving them of the responsibility to get too involved in the often complex circumstances surrounding the abuse
	○ Not complicated
· Allows professionals to work within their comfort zone
	○ And signpost the victim to get help If bystanders know that their involvement is limited they are more likely to undertake the intervention

Question 30

explain ask

Answer 30

• Is everything okay?
• I’ve noticed you’ve got some bruises on your neck, is everything okay? Has someone hurt you?
○ Not being confrontational or labelling them as a victim of domestic abuse - just asking
• I’m worried that you don’t see your usual self, is everything okay?
• Do you feel safe?
○ Give the patient the opportunity to say if they don’t feel safe

Question 31

explain validate

Answer 31

• This is just a way of showing someone that you are concerned about them
○ Removes blame
○ Shows them that you believe them
○ Shows 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 32

explain document

Answer 32

• 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 records could end up in court many years later
○ If the victim reports the domestic abuse to the police
○ May need to give evidence
○ All you have to go on the day is your notes so they need to be accurate
• Domestic abuse often happens in private with no witnesses and corroboration is still a requirement
○ While you haven’t witnessed the actual abuse your records are still important because you did see the injuries and you did see the patient distressed and the patient did tell you what happened

Question 33

explain refer

Answer 33

(Signpost)
• Referral in this case means ‘signposting’
• Your patient needs to take action rather than you.
• Signpost to appropriate services
○ Give details of services that can help the patient
• 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.
○ Still offer to do this
○ You may never know what comes of this but at least you know you have provided the information needed to help the patient if they decide they want to do anything
• Do not attempt to deal with the problem yourself
• The core Scottish organisation is the Scottish Domestic Abuse Helpline: 0800 027 1234
Gives access to a range of other services including legal help

Question 34

what can you give to someone you are concerned is experieincing domestic abuse

Answer 34

• A small card with contact details for domestic abuse organisations
○ Be careful as the handbag can be searched and the phone might be checked and then this can lead to more trouble for the victim
• A small gift with the domestic abuse helpline number concealed on it
○ (this is not something you should publicise)
• REMEMBER immediate threat to life or safety Police 999
If an instance happens in your practice then you should c

covert items

Question 35

what else can you do to support people suffering domestic abuse

Answer 35

• Put
○ Put cards in toilets and posters in waiting areas to let patients know you are able and willing to talk about domestic abuse
○ This is very useful if the victim is not ready to disclose
• Have
○ Have your staff where ASC badges
• Allow
○ Allow patients to use the phone in the surgery or pharmacy to contact agencies if they need to
○ Useful because the number they phone won’t show up on their phone if they are searched when they go home
• Link
○ Link with local domestic abuse agencies and have their materials available
○ This can help you let the community know that you are trained and willing to help
• Develop
○ Develop a protocol to allow you to get people on their own if partners are present and to alert others in the practise to the issue
○ You may want to have code words that you use
X-ray machine is a great excuse to get people out of the room

Question 36

what is not expected from clinicians

Answer 36

• It is not your role to provide specific advice about if, how or when to leave the home
• If a victim decides to leave a domestically violent / abusive relationship this has been shown to be the most dangerous time for them and the time when the abuse often escalates
○ Better to have a planned exit than an emergency exit
• Provision of advice about leaving is best left to the professional organisations who deal with domestic violence
○ Gives advice on documentation, passports, pictures of the abuser (so someone cannot pick the kids up from school if you don’t want them to be able to do this)
○ These professionals are trained to help victims leave so leave it to them to give the help as they know best
• You should provide the contact details of these organisations