The Health Service contribution to tackling Domestic Violence

1. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology The Health Service contribution to tackling Domestic Violence Prof. Ann Taket Head, School of Health & Social Development, Deakin University, Australia

2. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Outline • Scale and nature of intimate partner abuse • Health consequences • Routine and selective enquiry • Women’s experience • Health professional views • Models for enquiry • Training, support and other needs

3. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Nature of intimate partner abuse • IPA defined as: “the exercise of control by one adult person, usually a man, over another adult, usually a woman, within the context of an intimate relationship [current or past]. Such abuse may manifest itself in a variety of ways including physical violence, emotional or psychological abuse, sexual violence and abuse, financial control and abuse and the imposition of social isolation or movement deprivation,” (from Greater London Domestic Violence Strategy, 2001) • exercise of coercive control

4. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Scale of the problem – frequency and reach • In most countries, IPA will affect at least one in four ever-partnered women at some time during their adult life • found in all socio-demographic groups in all societies

5. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology WHO Multi-country Study1 • 15 sites in 10 countries (Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand and the United Republic of Tanzania), • where possible urban and rural setting in each • 24,000 women in total • range of lifetime prevalence of physical or sexual violence, or both, between 15% and 71% • WHO multi-country study on women’s health and domestic violence against women: summary report of initial results on prevalence, health outcomes and women’s responses. Geneva, World Health Organization, 2005.

6. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Scale of the problem - impact • major societal costs, annually • Australia1, IPA $8.1 billion, $408 per person • UK2, cost to the NHS for physical injuries alone, £1.2 billion, £20 per person • IPA is the leading cause of death and disability among women of age 15-44 in Victoria, Australia3 1. Access Economics (2005) The cost of domestic violence to the Australian economy: Part 1. Canberra. 2. Walby S (2004) The Cost of Domestic Violence. Women and Equality Unit, Department of Trade and Industry, http://www.womenandequalityunit.gov.uk/research/cost_of_dv_Report_sept04.pdf, last downloaded 21/3/2008 3. VicHealth 2004, The Health Costs of Violence: Measuring the Burden of Disease Caused by Intimate Partner Violence, A summary of findings, Victorian Health Promotion Foundation, Melbourne.

7. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Health consequences - physical • Injuries from assault • Chronic health problems such as irritable bowel syndrome, backache, and headaches1 • Increased unintended pregnancies, terminations2, and low birthweight babies3 • Higher rates of sexually transmitted infections, including HIV4 1. Campbell JC. Health consequences of intimate partner violence. Lancet 2002;359:1331-6. 2. Gazmararian JA, et al. Violence and reproductive health: current knowledge and future research directions. Maternal Child Health J 2000;4(2):79-84 3. Murphy CC, et al Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. Can Med Assoc J 2001;164:1567-72. 4. Garcia-Moreno C, Watts C. Violence against women: its importance for HIV and AIDS. AIDS 2000;14(suppl): S253-65.

8. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Health consequences - mental • Compared to women who have not experienced partner violence, those who have are: • 4 times as likely to have depression • 4 times as likely to have PTSD • 6 times as likely to abuse alcohol • 4 times as likely display suicidality Golding J. (1999) Intimate partner violence as a risk factor for mental disorders: a meta-analysis. Journal of Family Violence 14(2):99-132

9. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Routine and selective enquiry Routine enquiry: asking all [possible]women in setting direct questions about experiences, if any, of domestic abuse, regardless of whether there are signs of abuse or whether abuse is suspected Selective enquiry: asking women directly about their experiences, if any, of domestic abuse where there are concerns or suspicions, including in the presence of particular signs/symptoms

10. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology ‘Nicki’ – a case study • In her early 30s • 2 children • Relatively long history (years) of abuse • Initially kept isolated at home • Once children were at school realised “something was wrong”

11. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology ‘Nicki’: coordinated service response • Visits GP about injuries • GP tells her about specialist outreach worker who does sessions at the practice • Saw outreach worker the next day • Enters refuge with children a few days later • Relatively quickly offered suitable property by the local authority • Leaves refuge for new home after 3 months

12. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology ‘Mary’: a case study • In her early fifties • No children • Emotional abuse for over 20 years • Intensified over time • Physical abuse started 3 years ago • Enters refuge after contacting Samaritans

13. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology ‘Mary’ - missed opportunities • Abortion counselling • Visits GP with psychological distress • Psychiatric inpatient • Police • Visits GP for help for husband

14. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology From women’s own words – on needing direct questions “Told him [her GP] I’d fell. … He didn’t quiz me about it. He didn’t say anything more about it. I just said I fell and the look he gave was, ‘well, I don’t think you have, but…’. I remember sitting there and thinking ‘quiz me, quiz me, ask me’, and he never did. … because he didn’t, I didn’t tell.” [‘Kerry’, Salford] “I don’t know what to say to them actually. What they might think, this pathetic person, why do I put up with all this?” [‘Mary’, Birmingham]

15. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Asking – professional views “If you ask people – don’t pussyfoot around … I remember when I first plucked up the courage to ask on an antenatal visit. I had never seen this woman before. She wasn’t in this particular relationship but she had previously. She gave me the reasons to carry on because she said, “You must ask everybody. Because I just wanted somebody to come out and ask me.” She lived in a nice house, partner, everything hunky dory, and she were really depressed, and her health visitor kept saying, “I can’t see why you’re depressed.” She just wanted someone to ask her. That gave me the reason to carry on asking. I think we need to keep on asking, because they might not tell you the first time you ask them. I don’t think I would. So I tell them not to be surprised if I ask them again.” [Health visitor, Wakefield]

16. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology From women’s own words – on needing direct questions “I just wish somebody would of come right out and asked me. I always hope they’ll do that. Then it wouldn’t really be like me tellin’ on nobody. I’m scared to tell first.” Quoted in Drake 1982

17. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Asking – professional views “It’s like taking care of someone’s bad knee and not taking any notice of the fact that they weigh 25 stone and don’t do any exercise. If you ignore it, you can’t manage your patient effectively. I felt [IPA] was a huge undiagnosed problem. I felt uncomfortable about what to do, so it [the training] was a good opportunity to go and find out. I’ve got this lady who is a victim of abuse, but it is emotional and financial; it used to be physical, but not anymore. … And because we both know, we can talk about it; we don’t pretend that I can make her better. She has been offered help, and she’s refused, she copes the way she can. … I don’t beat myself up that I can’t get her better. At least I know I have been able to offer the help. … we can keep talking about it until she decides to deal with it in a more formal way. That is going to take time.” [GP, Wakefield]

18. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Asking – professional views “I think (the training) gave me insight into why people don’t leave, because I think your initial reaction when somebody tells you is “Leave” and if they don’t leave then it is their fault. But things aren’t that simple. It’s taught me a little how to support people if they decide to stay in that situation because you can’t just wash your hands of them. You need to provide on-going support and advise them how to stay safe while in that situation.” [Health visitor, Wakefield]

19. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Asking direct questions in health care settings • Asking is acceptable to majority of women • Asking uncovers significant numbers of previously hidden cases of IPA • Repeated enquiry at a number of consultations increases likelihood of disclosure • Many women will not disclose abuse without being directly asked • Trained staff find asking acceptable and helpful

20. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Advantages of routine enquiry • contributes to changing social attitudes to IPA • less likely to make women experiencing abuse feel stigmatised • less likely to compromise safety of women experiencing abuse • health professionals report that their perceptions about which women were free from abuse were often incorrect

21. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Health professionals’ views “It was quite a shock to me that people don’t talk to me about it unless they’re asked. Some patients where I was rather sniggering to myself and knowing the answer would be ‘no’, I heard, ‘Yes, I’ve dealt with it, I was abused….’ It has made me routinely ask about it.”[GP, Wakefield]

22. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Training for enquiry • At least one day • Include: • nature and extent of health problems • how to ask questions • how to respond appropriately to disclosure • safety planning AND safe documentation • Provide information on local availability of specialised services • Recognition of trainees’ own needs regarding any personal experience of abuse

23. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Models of routine enquiry ----Needs to be implemented flexibly---- A: GP asks one woman each surgery session B: Practice runs a well-woman clinic, women are invited once every 3 years C: Practice nurse before/after GP consultation D: During routine home visit following childbirth E: During antenatal sessions F: At A&E/Minor injuries unit/Walk in centre

24. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology Conclusions • scope for tackling IPA through health service is enormous • many missed opportunities: • changing attitudes about IPA • giving information about specialised services • using routine and selective enquiry • importance of training • importance of expert specialised non-statutory agencies like Women’s Aid

25. Stopping Domestic Violence: What Works? 28th to 30th May 2008, Waterford Institute of Technology In women’s own words…… “And sometimes you still get down, but I know when I'm down without a shadow of a doubt, I'm going to come back. I'm happier now. ….. In one of my things I wrote at college - … I [wrote] 'I was somebody's wife, I was somebody's mother and then I was somebody's possession and, now, I'm me'[emphasised]. That you should put down because that I feel is relevant.” [‘Jean’, Wakefield]