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1. DOMESTIC VIOLENCE Your role as GP
Dr Hudson Munyira
2. Why this topic? Women’s Health
RCGP curriculum statement 10.1
Raise awareness among trainees
3. Aims of this talk Define domestic violence
Apply the information to help improve data gathering when dealing with domestic violence patients
Recognise the prevalence of domestic violence and question sensitively where this may be an issue
4. Definition Domestic violence is any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are in a relationship
It can occur between family members and children
Violence at home is as illegal as violence on the street
5. Forms of domestic violence
6. Level of the problem Predominantly affects women
(80% of reported cases are against women)
At some time in their lives, 1 in 4 women suffer violence
60% attacked by current partner, 21% by ex partner
50% suffer >1 attack, 1/3 are repeatedly abused
For women aged 19-44, domestic violence is the leading cause of morbidity
Can affect men, as well as people in the lesbian, gay, bisexual and transgender communities
8. Domestic violence and pregnancy “child abuse in the womb” Escalates in pregnancy
30% suffer 1st attack in pregnancy
=Repeated miscarriages, APH, PROM, low birth weight infants
(abuser focuses on abdomen, breasts and genitalia)
9. Cost of domestic violence £23 billion per annum
- £3.1 billion as the cost to the state , £1.3 billion as the cost to employers and human suffering cost of £17 billion. (Walby 2004)
The estimated total cost is based on the following:
Cost of physical healthcare treatment (hospital, GP, ambulance, prescriptions) is £1,2 billion, i.e. 3% of total NHS budget
Cost to the criminal justice system is £1 billion
Cost of treating mental illness and distress £176,000,000
Social services is £0.25 billion
Housing costs £0.16 billion
Civil legal services £0.3billion
12. Recognising domestic violence General practice is the 1st formal agency to which women present for help
(only 1:4 reveal an attack, takes up to 35 attacks before reporting)
Recent frequent consultations
Mental illness –in victim or partner
Ethnic and cultural background
13. What to do as a GP High level of suspicion
14. Ask the question stanko 1997 Evidence suggests that women who are being subjected to violence want to be asked, and that women who are not, do not mind being asked (Friedman et al., 1992)
It is important to ask direct questions in a gentle, non-threatening manner (Schei, 1989)
15. Examples I noticed you have a number of bruises. Could you tell me how they happened? Did someone hit you?
You seem frightened of your partner. Has he ever hurt you?
Many patients tell me they have been hurt by someone close to them. Could this be happening to you?
You mention your partner loses his temper with the children. Does he ever lose his temper with you? What happens when he loses his temper?
Have you ever been in a relationship where you have been hit, punched, kicked or hurt in any way? Are you in such a relationship now?
You mentioned your partner uses drugs/alcohol. How does he act when drinking or on drugs?
Does your partner sometimes try to put you down or control your actions?
16. Confidentiality The RCGP guidelines suggest the following:
If possible interview the patient alone
Remind her that anything she talks about is protected by doctor-patient confidentiality
Be aware that the patient may prefer to talk to a female health worker and this should be offered if available
The concept of medical confidentiality and the protection it offers may be unfamiliar to many immigrant women. This will need to be very carefully explained and emphasized
18. Children 60-80% presentations of domestic violence are also associated with child protection issues
Confidentiality may only be broken if the doctor believes that a child is at risk
Seek permission from the woman to disclose their information. If this permission is not given, you are advised to seek medico-legal advice before disclosure
19. Common sites for injury Side of the face
Around the eye
Throat or neck
Upper and lower arms and legs
In 76 % of the victims there is more than one type of injury
20. Keeping notes Time, date, place and witnesses to the assault or accident
If patient states that abuse is the cause of injury, preface patient’s explanation by writing: “Patient states…”
Avoid recording subjective data that might be used against the patient (for example, “It was my fault he hit me because…”)
If patient denies being assaulted, write: “Patient denies being assaulted”
Record the size, pattern, age, description and location of all injuries. Make a body map of injuries, including any signs of sexual abuse
Record non-bodily evidence of abuse, such as torn clothing
21. Photographs Photographs can convey the severity of injuries much more effectively than verbal description and, whenever possible, photographs should be taken of all patients with visible injuries.
Refer to RCGP for guidelines on taking photos
22. Explore the immediate risk Is the abuser verbally threatening her?
Is the abuser frightening friends and relatives?
Is the abuser threatening to use weapons?
Is the abuser intoxicated?
Does the abuser have a criminal record?
Are the children in danger?
23. Consequences Psychiatric disorders:
-panic attacks and anxiety
-drug and alcohol abuse
-low self esteem
-suicide and para suicide
Mental stress is worse than the physical beatings
Children affected and may perpetuate the cycle of violence as adults
24. Why women won’t be willing to leave care for partner
scared of the future
worry about money
low self esteem
isolated from family
where to go
sake of children
25. Decision Respect patient’s decision/ autonomy
DO NOT PRESSURISE THE VICTIM INTO ANY COURSE OF ACTION
Most women will remember the information given to them and will use it when they are ready
26. How you can help Provide written information about legal options and the help offered by:
Police domestic violence units
Women’s Aid national helpline (Tel: 0345 023468)
Women’s Aid refuges (Asian women’s refuges and services available for women from other ethnic minorities can usually be contacted through Women’s Aid)
Local authority social services departments
Department of social security
Offer any help in making contact with other agencies
27. Escape plan and kit Discuss a plan/escape route
Give contact numbers
Keep a separate mobile
Money, credit cards and accounts
Women’s refuges and shelters (location + numbers)
28. Prevention and stopping it Early detection
Educate-women, men, children
High index of suspicion
29. Useful contacts Kent Police 999 (in an emergency) 01622 690690 (non-emergency)
Rising Sun Domestic Violence Project 01227 452 852
Victim Support 0845 389 9527
Citizen’s Advice Bureau 0844 499 4128
Riverside Children’s Centre 01227 457 552/483 579
Home-start Canterbury and Coastal 01227 472 050
Family Action 01227 370 987
Women’s Aid 0800 200 0247
Canterbury and District Early Years Project 01227 786 420
Respect 020 7022 1801
Are you a man suffering from domestic abuse?
Mankind 01823 334 244
31. Resources www.womensaid.org.uk/domestic_violence_
RCGP curriculum women’s health
E-learning for health, e-gp-GPS_10-1a_014 Domestic Violence
Oxford Handbook of General Practice p122
34. Feedback Some of the things you may want to say……
Give this doctor a pay rise and a good job!