Vasumathy Sivarajasingam is a GP in West London and an Honorary Clinical Research Fellow at Imperial College London. She is also the North West London Primary Care Clinical Lead (Ealing Borough) for Green Agenda, Adult Mental Health, and Patient Engagement. She is on Twitter: @vasu27765631
For the first time, a coroner in the UK declared domestic abuse (DA) as having a causal role in death by suicide,1 and sadly this is not an uncommon occurrence. The case highlighted the impact DA has on the state of mental health — the emotional stress causing alcohol dependence, leading to suicide. The coroner recommended a greater recognition of the link between DA and suicide, and raised concerns about the risks that future deaths could occur unless action is taken.
The 2021 Domestic Abuse Act in England and Wales defines DA as any incident of threatening behaviour, violence, or abuse towards someone to whom the perpetrator is personally connected.2 This includes coercive controlling behaviour, intimate partner violence, and harm perpetrated by others in the family or household. The Act also recognises children under the age of 18 years who see, hear, or experience the effects of the abuse as a victim of DA if they are related or have a parental relationship to the adult victim or perpetrator of the abuse.
According to the Crime Survey for England and Wales, around 1 in 5 adults aged 16 years and over had experienced DA at some time since the age of 16 years, equating to 10.4 million people.3 Nearly half a million survivors of DA seek assistance from medical professionals yearly,4 with an estimated total economic and social cost of over £66 bn in England and Wales for the year ending 31 March 2017.5 The highest expenditure (£47 bn) was attributed to victims’ physical and emotional harm. This is in addition to the lost labour yield along with the cost to health and victim and survivor services.
So what?
DA is a serious crime, though underdiagnosed by the medical community. Data published by SafeLives (a UK-wide charity dedicated to abating DA by conducting research, influencing policy, and training professionals and organisations) showed that typically victims experience abuse for an average of 3 years before getting effective help and visit their GP an average of 4.3 times during this time.6 Some victims of DA, including older individuals, Black, Asian, and minority ethnic people, and/or people with a disability, are likely to endure abuse for much longer before disclosure.
National Institute for Health and Care Excellence guidance encourages targeted enquiries during consultations in general practice, reiterating that addressing DA is a core responsibility of the primary care team.7 Following a disclosure, clinicians have a responsibility to identify immediate safety concerns (for the victim and dependents) and direct patients toward appropriate specialist support. Despite this mandate, conversations concerning DA rarely occur in primary care settings.
“Tackling domestic abuse is everyone’s business. Multilevel, sustained interventions need to be implemented to tackle domestic abuse in our society.”
Besides, identifying those experiencing DA can be difficult due to its vague initial presentation and issues with denial.8 This is particularly so in those experiencing emotional, economic, or coercive control. Often people suffering from DA have unnecessary investigations and medications to address a variety of physical and/or mental health symptoms, including chronic pain, and are frequent attenders to the healthcare service. Witnessing DA can lead children to develop an array of age-dependent negative effects including short- and long-term cognitive, behavioural, and emotional effects, in addition to direct physical consequences including injuries and even death. Children exposed to DA are more likely to either experience or perpetrate DA as adults.
Globally, primary care is identified as playing a key role in the healthcare response to DA as it is the access point to all health services for non-emergency care, and is well-placed to initiate discussions concerning DA. Often healthcare workers treat such victims without asking about abuse, therefore never recognising or addressing the underlying cause of their health concerns.
New legislation in the UK recommends raising awareness about the devastating impact of DA on victims and their families, while protecting and supporting victims.9 Studies have shown that routine enquiry of DA improves victim identification in healthcare settings, and plays a key role in reaching and supporting the victims, particularly those who may not engage with other services.10
What now?
So what now, given that we know that DA is a growing public health burden, often a cyclic phenomenon that escalates in frequency and severity, and with time increases morbidity and mortality? DA is preventable. We must protect individuals experiencing abuse (make the diagnosis and offer support early), root out the abusers, and make our society safer.
There is no ‘one size fits all’ approach to tackling DA in our society as the root causes are multifactorial. Tackling DA is everyone’s business. Multilevel, sustained interventions need to be implemented to tackle DA in our society. Offering adequate training for our health and social care professionals (including mandatory undergraduate and postgraduate training) coupled with integrated referral pathways and system-level support will undoubtedly increase detection, documentation, and referrals.
It is essential that we raise public awareness and educate our society to break the code of silence on DA. Public awareness campaigns will contribute towards positive changes in social attitudes. This is not enough. Implementing routine enquiry in primary care would raise societal awareness repetitively and assist in primary prevention. Additionally, it would increase opportunities to identify those individuals presenting with symptoms not generally associated with DA and those struggling to disclose their experiences of abuse.
Screening for DA provides an opportunity for disclosure of DA and provides the person experiencing abuse or at risk of DA an increased chance to explore and develop a plan that would protect their safety and improve their wellbeing. Such interventions can lead to reduced morbidity and mortality.
Being proactive and utilising the already established screening tools would help with primary and secondary prevention of DA, especially since 90% of NHS patient contacts are via primary care.11 This would undoubtedly help tackle the prevalence and the health, social, and economic burden of DA. Asking all patients the same standard questions could help to legitimise the need for a conversation about DA and effectively communicate to a victim that they are not alone in their experiences. Clinicians would also find it easier to initiate conversations without resistance, especially during remote consultations. Education and training of healthcare workers on effective assessment, intervention, documentation, and referral are key.
Furthermore, self-administered DA screening is as effective as a clinician interview regarding disclosure, comfort, and time spent screening.12 There is room for incorporating DA screening tools as part of annual health checks. Tackling DA and saving people’s lives has enormous benefits to the individual, their family, friends, and society — and the NHS.
References
1. Harris L. Regulation 28: report to prevent future deaths (1). 2022. https://www.judiciary.uk/wp-content/uploads/2022/11/Jessica-Laverack-Prevention-of-future-deaths-report-2022-0344_Published.pdf (accessed 8 Feb 2023).
2. UK Government. Domestic Abuse Act 2021. 2021. https://www.legislation.gov.uk/ukpga/2021/17/section/1/enacted (accessed 8 Feb 2023).
3. Office for National Statistics. Domestic abuse in England and Wales overview: November 2022. 2022. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/domesticabuseinenglandandwalesoverview/november2022 (accessed 8 Feb 2023).
4. UK Government. Domestic Abuse Bill. 2020. https://publications.parliament.uk/pa/cm5801/cmpublic/DomesticAbuse/memo/DAB57.htm (accessed 8 Feb 2023).
5. Oliver R, Alexander B, Roe S, Wlasny M. The economic and social costs of domestic abuse. 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/918897/horr107.pdf (accessed 8 Feb 2023).
6. Department of Health, SafeLives. Pathfinder profile: general practitioners. Guidance for general practitioners responding to domestic abuse. 2019. https://safelives.org.uk/sites/default/files/resources/Pathfinder%20GP%20practice%20briefing.pdf (accessed 8 Feb 2023).
7. National Institute for Health and Care Excellence. Domestic violence and abuse. QS116. 2016. https://www.nice.org.uk/guidance/qs116 (accessed 8 Feb 2023).
8. Rath GD, Jarratt LG, Leonardson G. Rates of domestic violence against adult women by men partners. J Am Board Fam Pract 1989; 2(4): 227–233.
9. Home Office. Domestic Abuse Act 2021: overarching factsheet. 2022. https://www.gov.uk/government/publications/domestic-abuse-bill-2020-factsheets/domestic-abuse-bill-2020-overarching-factsheet (accessed 8 Feb 2023).
10. O’Doherty L, Hegarty K, Ramsay J, et al. Screening women for intimate partner violence in healthcare settings. Cochrane Database Syst Rev 2015; 2015(7): CD007007.
11. Goodwin N, Dixon A, Poole T, Raleigh V. The evolving role and nature of general practice in England. In: Improving the Quality of Care in General Practice. 2011. https://www.kingsfund.org.uk/sites/default/files/field/field_related_document/gp-inquiry-report-evolving-role-nature-2mar11.pdf (accessed 8 Feb 2023).
12. Chen P-H, Rovi S, Pan K-Y, Johnson MS. Costs effectiveness of domestic violence screening in primary care settings: a comparison of 3 methods. Journal of Community Medicine and Health Education 2013; DOI: 10.4172/2161-0711.1000253.
Featured photo by Cherry Laithang on Unsplash.
