Chapter 118: Intimate partner violence and sexual assault

Intimate partner violence is defined by the World Health Organization as ‘any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship’. Domestic violence emphasises the setting of the violence, whereas family violence is a broader term that includes any violence or abuse that occurs in a family, e.g. elder abuse and adolescent violence against parents.¹

Intimate partner violence (IPV) is the most common form of violence against women. It occurs in heterosexual and homosexual relationships for both men and women; however, as intimate partner abuse is perpetrated more often against women, this chapter focuses on women (and their children) as victims of abuse.

GPs often say we do not see many patients that have experienced violence. However, it has been estimated that full-time GPs are seeing up to five women per week who have experienced some form of intimate partner abuse in the past 12 months.²

A major problem in dealing with IPV is that it is hidden and patients are reluctant to disclose violence when visiting medical practitioners. Another complicating factor is the fact that many patients experiencing abuse and violence may not even be aware that this is the case. Victims stress the importance of a trusting doctor–patient relationship including confidentiality and a non-judgmental attitude.

We usually think of domestic violence in terms of physical violence but it can take many forms.³ These include:

• physical abuse

• emotional and psychological abuse

• economic/financial abuse

• social abuse (e.g. isolation)

• sexual abuse

• stalking

• use of technology to abuse, e.g. sexting

• other controlling behaviour

In women:

• frequent presentations of non-specific symptoms (e.g. chronic pain, headaches, functional gastrointestinal disorders, sexual dysfunction)

• psychological problems (depression, somatiform disorders, anxiety disorders, panic attacks, PTSD, suicidal ideation)

• insomnia

• eating disorders

• drug and alcohol problems

• physical injuries: usually bruising caused by punching, kicking or biting; also fractures, burns, genital trauma

• pregnancy and childbirth (e.g. unintended pregnancies, forced terminations, miscarriage, poor antenatal care, low birth weight, premature labour)—it is recommended to ask all pregnant women about violence during antenatal care

In children:

• bedwetting, sleeping disorders, anxiety, stress, depression, withdrawal

• aggressive behaviour and language

• problems at school

• chronic somatic problems and frequent presentations

• drug and alcohol abuse

• suicidal ideation in adolescence

Diagnosis

Diagnosing the problem, which is usually ‘hidden’, can be a challenge to the GP. It is important to set aside common assumptions about the problem and have a high index of suspicion. If you suspect domestic violence—ASK! The doctor has to take the initiative because patients rarely complain about the violence.⁷ It is also the doctor’s responsibility to ensure the man leaves the room to talk to the woman alone. Possible questions include:

• How are things at home?

• How are things with your partner?

• Do you get scared or frightened of your partner?

• Is there a lot of tension in your relationship?

• Do you feel your views are respected?

• Has your partner ever physically threatened or hurt you?

• Have you ever felt unsafe?

It is advised to universally screen all pregnant women for intimate partner violence.

Assessment

• Delineate the problem: pattern of violence; effect on the woman and her children; resources available to women; social/cultural environment.

• Examine and investigate presenting symptoms.

• Check for coexisting injuries (common target areas are breast, chest, abdomen and buttocks). Inspect the ears, teeth and jaw.

• Check the patient’s general health status.

• Look for signs of alcohol or drug abuse.

• Keep accurate records and consider taking photographs.

• X-rays may show old fractures.

Women who have been subjected to violence come from all socioeconomic and cultural groups. As a rule they enter the relationship as normal, independent and intelligent women but gradually lose self-esteem and become increasingly compliant as a coping strategy. Unfortunately, many victims are led to believe that somehow they deserve their punishment.

Groups of women at greater risk include Aboriginal and Torres Strait Islander women, young women, pregnant women, women separating from their partners, women with disability, women experiencing financial hardship and women who witnessed or were subject to violence as children.⁴

Most women simply want the violence to stop rather than leave their relationships. They are usually constrained from leaving due to financial dependance, feeling they have nowhere to go or for concerns for their children. Often the reason they stay is fear of retaliation. Women may be at various stages of change in terms of taking action in accordance with Prochaska and Di Clemente’s model of change (see CHAPTER 21, FIG. 21.4) and the counsellor should be aware of this process.

Men who use violence come from all walks of life and social and ethnic groups. There are often no distinguishing characteristics to identify a man who will be violent towards his partner. Men who use violence tend to minimise responsibility for their use of violence, blame the victim or external factors and greatly under-report their use of violence.

Perpetrators use abuse and violence to maintain their power and control in a relationship. This is often based on community norms and expectations, along with risk factors including mental disorders, substance abuse, unemployment, poverty and coming from a family where intimate partner abuse occurred.³ It is important to note that these risk factors are not causal.

A predictable pattern that is referred to as the ‘cycle of violence’ has been identified in many intimate relationships. It is controlled by the perpetrator while the victim feels confused and helpless. The cycle repeats itself with a tendency for the violence to increase in severity (see FIG. 118.1).

Management

The key to management is initial recognition of the problem and establishment of empathic caring and support for the woman and family. It must be emphasised that men who use violence (as in most criminal activity) do not readily change their behavioural pattern and thus there is minimal prospect of the violence decreasing unless there is a dramatic reason to change. A management strategy is presented in TABLE 118.1. The immediate safety of women and any children is always the prime working rule.

Useful strategies¹⁰

Do:

• talk to the woman alone

• believe her

• validate the decision to disclose

• provide a strong statement that violence is never okay

• reassure her that it is not her fault

• enquire about and express concern for her safety

• give information (i.e. about the course of action available to her, contacts for legal advice)

• acknowledge the complexity of the issue

• respect her right to make her own decisions

• provide follow-up and continued support

Harmful strategies

Don’t:

• deny domestic violence

• minimise the importance of domestic violence

• blame the victim

• treat with tranquillisers

• refer to a psychiatrist

• refer to marriage guidance, but do refer to specialist counsellors

• set explicit criteria/rules (takes away victim’s power yet again)

Dealing with perpetrators

It is uncommon to get the cooperation of the perpetrator in the management process. The perpetrator has to admit that they have a problem before effective counselling can begin. If they do seek help they require counselling by a skilled and experienced practitioner, as treatment will be prolonged and complex. In early intervention, the GP’s role is to:⁹

• briefly assess men

• prepare them to accept a referral to a behaviour change program

• undertake alternative interventions to decrease the risk of violence if a referral is not taken up

Safety³

Women may not feel safe to go home and may require urgent crisis referral or an urgent safety plan. When assessing a woman’s immediate safety, it is important to take the following into account:

• the woman’s own assessment of her safety

• presence of risk factors in the perpetrator, including severity and duration of previous violence, history of arrest and incarceration, drug and alcohol use, access to weapons, and unemployment

• your own professional judgment

Where you reasonably believe a patient is in imminent threat of danger, you should seek their consent to report the matter to the police. Children at risk require mandatory reporting to child protection. If a violent incident develops or is imminent, it is important to assist the victim in developing a safety plan. One such plan is:

• Compile a list of emergency numbers.

• Identify family and friends who can provide support.

• Put aside emergency money.

• Pack a bag of clothing, medications and toiletries.

• Organise a safe place to store valuables and important documents.

• Identify a safe place for the woman to go to and how she will get there.

• Ask neighbours to call police if they hear any disturbance.

As a general rule the most effective intervention in arresting the violence is to arrest the violent person.⁷ Consider legal interventions such as intervention orders, protection orders (AVOs) and restraining orders.

Continuing care¹⁰

It is important to keep in mind that the woman’s ability to change her situation may be very limited. It is also important to:

• assess safety regularly, checking for escalating violence

• provide emotional support

• ensure confidentiality

• build her self-esteem by acknowledging the coping skills she has developed

• empower her to take control of decision-making: ask what she needs, explore options and present services available

• familiarise yourself with referral services and their processes:

  • – domestic violence resource centres

  • – relationship services

  • – legal aid

  • – social workers

  • – social services/police

  • – private counsellors and psychologists

• have information available for her to take if appropriate

• offer assistance in contacting referral services if this would be of help

According to Australian statistics, since the age of 15 years, 1 in 5 women and 1 in 20 men have been sexually assaulted and/or threatened.⁴ Sexual assault is defined broadly as any unwanted sexual contact that occurs without a person’s consent and which makes the victim feel uncomfortable, frightened or threatened. The behaviour can include any activity from sexual harassment through to life-threatening rape.

The majority of perpetrators of sexual assault are known to their victims and a high proportion of perpetrators are current or ex-partners. For this reason, it is important to assess whether the patient is safe to return to their accommodation. Stranger assaults only make up approximately 15% of sexual assault cases.¹¹

Survivors of sexual assault should be allowed to accept or decline various assessment or treatment options offered by the practitioner. Many victims do not report sexual assault to police because of fear, humiliation or shame.

Medical practitioners dealing with alleged sexual assault should familiarise themselves with the laws applicable in their state/territory. Self-care for clinicians is also of particular importance when dealing with this distressing problem.

Disclosure of sexual assault

Offer and provide privacy, safety and emotional support. Take the time to explain confidentiality and its limits, so that the patient is aware that the assault will not be discussed with the police or their family without their consent. Believe them, listen to them and be non-judgmental.

Five important things to say:

• I am sorry this happened to you.

• This is a crime—it was not your fault.

• It’s good that you have talked to me about this.

• I will do what I can to help you.

• You are safe now (if applicable).

History

Most jurisdictions require that the first person who hears an allegation of sexual assault must give evidence if the complaint comes to trial, so document the exact words used.

If the patient presents following recent sexual assault, the following information will help guide management:^12,13

• time and place of assault

• brief description of the assault (i.e. what went where)

• condom use

• details of the assailant

• preceding drug or alcohol use

• violence used and any injuries

• current contraception

• risk assessment for patient and any children

• accommodation issues

When patients disclose sexual assault that took place in the past, it is not necessary or advisable to ask all the details about what happened at the first disclosure. The patient may not be ready to tell you details and doing so may easily take them back to their trauma, leading them to decompensate. Let the patient know that you are ready to listen to more details if or when they are comfortable telling you.¹⁴

Management

A patient may disclose sexual assault immediately or years after the event. Management depends on when the assault occurred.

Recent sexual assault³

Management options include:

• forensic examination by a specialist sexual assault service, preferably within 72 hours of the assault—this is still advised if the patient is undecided about reporting the assault

• assessment and treatment of physical injuries

• emergency contraception if indicated

• testing for pregnancy or STIs according to need

• urine or blood drug testing if suspected drugassisted sexual assault, i.e. when the patient has no memory of events and time or other suspicious circumstances—seek specialist advice

• address safety and supports at home—alternative accommodation may be required

• follow-up—patients may need to return for follow-up at 2 weeks and 3 months following STI checks

• sexual assault counselling and support groups

• ongoing support and monitoring of symptoms of trauma

STI testing and prophylaxis

• take swabs and/or first-pass urine for testing gonococcus and chlamydia (PCR)

• take blood for HIV, syphilis and hepatitis B

• collect swabs from the oropharynx or rectum if indicated

• give STI prophylaxis (see TABLE 118.2)—depends on type of assault and assailant; azithromycin for chlamydia prophylaxis is the most commonly used

• at 2 weeks test for chlamydia, gonorrhoea and trichomonas (depending on risk)

• at 6 and 12 weeks, test for HIV, hepatitis B and syphilis

Past sexual assault

The long-term physical and psychological consequences of sexual abuse are many, often somatic or psychological, and can have devastating consequences for the victim. Disclosure to a trusted health professional may be the first step in the healing process. A sensitive response to disclosure can be critical in this process. Offer referral to an experienced therapist or sexual assault specialist counselling service, with access to up-to-date knowledge about relevant reporting and legal processes.¹⁴

Hindmarsh E, Roberts G (eds). RACGP Manual: Abuse & Violence, Working with Our Patients in General Practice (The White Book) (PDFIMB).

National Sexual Assault, Domestic Family Violence Counselling Service. 1800 RESPECT (call 1800 737 732). <www.1800respect.org.au>, accessed April 2018.