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1. DOMESTIC VIOLENCE Your role as GP Dr Hudson Munyira 16/02/2011

2. Why this topic? Women’s Health RCGP curriculum statement 10.1 CSA 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

7. 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 Ask Empathise Reassure confidentiality Document

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

17. Children

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: -depression -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 feel ashamed scared of the future worry about money too exhausted 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 Legal documents keys Women’s refuges and shelters (location + numbers)

28. Prevention and stopping it Early detection Educate-women, men, children Sign post 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 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!

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