Domestic Violence

A Handbook for Health Care Professionals

Lyn Shipway

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781134459650
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

This Handbook provides a clear introduction to the theoretical debates surrounding the topic of domestic violence, and also offers practical advice on possible interventions. Focusing on improving the care of clients it covers:

• the causes and consequences of domestic violence
• personal and professional issues for the practitioner
• domestic violence and the law
• the process of effective intervention
• interventions in specific health care settings
• interventions where children are involved
• multi-agency approaches
• education and training.

Taking an evidence-based approach to practical problems, Domestic Violence is an invaluable resource for nurses, doctors and other health practitioners who deal with the consequences of domestic violence in their daily work.

Chapter 1

Domestic Violence – A Healthcare Issue

For many women and their families the effects of domestic violence will be catastrophic, the damage to their physical and psychological well being may be deeply damaging, and on occasions fatal.

(Department of Health [DoH] 2000a: 12)

Defining Domestic Violence

Domestic violence has been defined as:

a continuum of behaviour ranging from verbal abuse, physical, and sexual assault, to rape and even homicide. The vast majority of such violence, and the most severe and chronic incidents, are perpetrated by men against women and their children.

(Department of Health [DoH] 2000a: v)

While the term ‘domestic violence’ includes violence and abuse within same-sex relationships, violence by women against men and violence and abuse perpetrated by one family member against another, the focus of this book is on violence and abuse by men, against women. It seeks to explore the multiplicity of factors that collectively construct an ever-increasing and serious healthcare need for those being abused within their intimate relationships.

Intimate violence may take many forms, often combining physical, emotional, psychological, sexual and financial abuse. The degree of abuse and violence varies within each partnership, often occurring on a continuum of severity and effect. For some the abuse and violence are periodic with minimal long-term effects. However, countless women are so controlled and inhibited that they are unable to make even the simplest decision or act without permission, responding with complete obedience to every order given and every rule imposed. The violence becomes insidious, permeating every action, every thought and deed until eventually, for some women, suicide remains the only escape. Other women express their self-disgust and powerlessness through alcohol or drug abuse, or self-mutilation, exhibiting signs of severe depression and total dependency on the abuser. Intimate partners may demand and achieve, through physical and emotional violence, complete obedience to every order, using humiliation as an important strategy in obedience training in their women.

As stated above, abuse and violence may be physical, emotional, psychological, financial or sexual, may be constant or spasmodic, and are experienced by individuals from every class, race, religion and culture the world over (British Medical Association [BMA] 1999).

Key Point

The content of this book focuses in the main on the abuse in an intimate relationship of a woman by the man with whom she is having, or has had, an intimate relationship. However, it is important to note that when designing and developing procedures and protocols to deal with incidents related to domestic violence, a gender-neutral definition may be more effective in practice. To focus entirely on the needs of heterosexual females excludes other women and men, leaving them at risk.

Some of the Facts and Figures

One in four women experience violence in the home at least once during their lifetime.

(Women’s Aid Federation of England 2002)

Statistics reveal that one in four women experience violence in the home at least once in their lives, whilst many are subjected to long-term violence and abuse (British Medical Association [BMA] 1999; Department of Health [DoH] 2000a; Frost 1999a).

Domestic Violence and Abuse - A Healthcare Issue?

Historically the plight of women who are abused has largely been ignored by the majority of healthcare practitioners, often owing to a lack of understanding of either the problem or the potential solutions. However, in the 1990s, alongside other public services such as the police service, social services and local authorities, healthcare practitioners have increasingly recognized that violence and abuse in the home is an important, if not urgent, collective issue. In 1996, the World Medical Association, having recognized that doctors have a major role to play in the prevention and treatment of family violence, recommended that national medical associations should encourage and enable research to understand the prevalence, risk factors, outcomes and care needs for those experiencing family violence.

The Department of Health (2000a) summarizes the way forward for healthcare practitioners as follows:

Whether in general practice, dentistry, health visiting, nursing, maternity services, psychiatry and mental healthcare, general medicine and surgery, or in Accident and Emergency care, healthcare practitioners have daily contact with patients whose health is damaged by domestic violence, and who often face risks of further and more extreme injury. The NHS response must not be seen simply in terms of treating the consequences of abuse, without also addressing the underlying causes. This responsibility rests with all healthcare practitioners who have contact with patients including those who have an on-going relationship such as through General Practice, Health Visiting, or Midwifery, and those who may have only a fleeting contact with someone in crisis, such as in Accident and Emergency departments.

(Yvette Cooper, Parliamentary Under-Secretary of State for Public Health, the NHS Executive, foreword to Department of Health 2000)

Despite initiatives from the Department of Health (hereafter DoH in discursive text), the British Medical Association (hereafter BMA in discursive text), and professional nursing and midwifery and health visiting bodies, there is little evidence that the majority of healthcare practitioners can either distinguish or effectively manage care of clients presenting with health problems related to domestic violence (British Medical Association [BMA] 1999; Department of Health [DoH] 2000a: 2; Frost 1999a). However, in recent years important work related to domestic violence in health and social care has been accomplished by researchers and practitioners across the United Kingdom Much of this work is acknowledged in the ensuing chapters, and in the key resources in Appendix 1.

It is essential that all healthcare practitioners gain insight and expertise into the nature of domestic abuse including alternative explanations of the causes, contributory factors and local and national interventions. In this way, all levels of healthcare practitioners can unite with other professional and voluntary groups to provide a quality service which meets the needs of all those involved in abusive circumstances.

What’s in a Name?

Historically the term ‘battered woman’, or ‘battered wife’, has been acceptable terminology, but more recently it has come to be viewed by many in the field as an inappropriate term.

‘Battered’ conjures up an image of a woman lying beaten and bleeding, possibly in a state of physical exhaustion, and often in need of medical intervention, whereas the reality is that injuries may well be hidden and the damage virtually undetectable to the naked eye. Growing evidence confirms that countless women live their lives in constant fear and degradation, suffering severe psychological and emotional abuse perhaps without the accompanying broken bones and bruises. The abuse may be incessant whilst the physical violence is only periodic, but the results remain the same, a woman is being abused and therefore violated (Mayhew et al.1996).

Terminology becomes especially important when one considers the concerned professional on the alert for a ‘battered’ woman, looking for the signs of physical injury, unaware of the reality. It is not surprising, therefore, that the abuse of many women accessing health services with other injuries, conditions or related needs may go undetected. The term ‘battered’ ignores the significant and persistent psychological, sexual, emotional injury and financial deprivation experienced by many thousands of women on a daily basis for long periods of their lives. It is this type of abuse which may lead to mental illness and attempts at self-harm, including suicide attempts, and may never present in physical injury.

Victim or Survivor?

Continuing discourse relates to the use of the terms ‘victim’ and ‘survivor’. Whilst the former term symbolizes a woman crushed, beaten, helpless and powerless, the term ‘survivor’ signifies one who has overcome, or is currently overcoming, adversity. It is argued that being seen by others or seeing oneself as a ‘victim’ exacerbates the sense of powerlessness and resignation to one’s fate. It can also be argued that women who access healthcare services with injuries, or struggle with problems resulting from abuse, are in fact ‘victims’ of violence. However, where possible within this text the term ‘victim’ is avoided as it does little to move the discourse forward or serve the women we are endeavouring to support.

Women experiencing intimate violence and abuse are not a homogeneous group, neither are the men who abuse them. Therefore, one-dimensional accounts of cause and effect are manifestly inadequate if the care offered is to be of practical use. Understanding, for some, lies in explanations at the level of society as well as of the individual, whilst for others the cause lies within the pathology of the individual To disregard the wider political and social construction of domestic abuse is detrimental to the care that can be offered to the client. To do so leads to the ‘medicalization’ of domestic violence which ultimately structures the actual and potential approaches to care (Abbott and Williamson 1999).

Key Point

Healthcare practitioners need to acknowledge and accept that domestic violence has a multiplicity of causal relationships that can make survival on occasion impossible and intervention fraught with difficulty. To ignore this premise, may lead the healthcare practitioner to provide one-dimensional care in the belief that there is little else that can be done. Patching a woman’s wounds and sending her on her way ought not to be an option.

Domestic Violence and Abuse: The Size of the Problem

A Hidden Crime

Not only are domestic violence and abuse a hidden figure in the crime statistics, they are also concealed from friends, from family, from work colleagues and others. How do so many women live with abuse for years without ever speaking out? In 1983, a study by Hopayian revealed that 89 per cent of women in refuges had consulted their general practitioner (GP) but nearly half hid the fact that they were being abused. This raises the question of why so many abused women access healthcare services and yet so few are recognized as being abused (British Medical Association [BMA] 2000).

Whilst many abusive acts are abhorrent they are not always deemed to be criminaL Nevertheless, domestic violence accounted for one-quarter of all violent crimes shown in the 1996 British Crime Survey (BCS). This is explored in further detail later in the chapter. Historically, even when women spoke out and reported violence, police responding to domestic incidents did little to intervene unless they absolutely had to. Today the police service is playing an important and changing role in addressing domestic violence and this will be explained in more detail in Chapter 8.

Violence Against Women is a Crime: Some of the Statistics

In the United Kingdom, two women every week are killed by a man with whom they have had, or are having an intimate relationship.

(Home Office 2001a)

Statistics related to domestic violence must always be viewed with caution. Apart from rapes and sexual assault, the hidden crime figure for domestic violence is probably larger than for any other category of crime. For various reasons, either the crime is not reported to the police or, alternatively, it is not recorded and thus statistics related to the prevalence and nature of domestic violence are dependent upon who is collecting the data (Dobash et al. 1996; Home Office 2000a; Stanko 1998).

Mullender (1996), summarizing the debate on criminal statistics related to domestic violence, acknowledged that only from two to 27 per cent of incidents are reported to the police. She emphasizes that the ‘constant terrorizing that goes on between each assault is equally a part of living with male abuse, but is not measurable in the same way’. Exploring the dilemma of how to quantify the magnitude of domestic abuse, Mooney (2000: 25), states that: ‘levels of non-reporting are thought to be considerable for various reasons: fear of reprisals (the perpetrator may be near to the interview situation), embarrassment, psychological blocking and so on’. These findings are not dissimilar to an earlier study undertaken by Walklate in 1989. Walby and Myhill (2000: 1) acknowledge that current statistics related to violence against women generally are limited, as they use a relatively narrow definition of violence and do not include women outside of the home.

Furthermore, as domestic violence is recorded only in terms of physical and/or sexual assault, the numerous women subjected to emotional and psychological abuse almost certainly do not appear within criminal, social, or healthcare statistics. Mooney warns that the on-going paucity of substantive statistics on domestic violence in effect limits the ability to take appropriate preventative and remedial action. More realistic data, according to Mooney (2000), has been collected as a result of victimization studies such as that carried out by Mirlees-Black et al. (1999) and Mooney (1993).

Various studies have identified the reasons for under-reporting. These include:

• fear of further or escalating violence should the victim report an incident
• hopes that the relationship can be salvaged
• mistrust of agencies
• lack of knowledge about what most agencies could do to help.

Measures to identify victims of domestic violence form an important part of any domestic violence strategy. Studies highlight the importance of equipping workers in a range of agencies to detect domestic violence and take appropriate follow-up action, both through training (including multi-agency training) and through developing protocols (Mooney 2000).

Statistics from the United Kingdom

The incidence of all categories of violence has increased since 1981, particularly domestic violence (240 per cent) and that by acquaintances (120 per cent).

(Shepherd 1998)

In 1992 the British Crime Survey reported that 11 per cent of women living with their partner experienced some degree of physical violence within their relationship. Later, in 1996, the British Crime Survey (Mirrlees-Black 1999) provided what is probably the best available data for domestic violence in England and Wales (Walby and Mayhill 2000) showing that:

• At least one in four women in the UK experience varying degrees of violent assaults from an intimate partner, at some point during their life. (Many of course endure it for a significant part of that life.)
• Domestic violence accounts for one-quarter of all violent crimes reported in England.
• Criminal stati...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgements
• 1 Domestic Violence – A Healthcare Issue
• 2 The Impact of Domestic Abuse on Health
• 3 Abuse in Other Intimate Relationships
• 4 The Response of Health Professionals to Domestic Violence
• 5 A Critique of Existing Healthcare Provision
• 6 Domestic Violence in a Variety of Clinical Settings
• 7 Domestic Violence and Children
• 8 Domestic Violence and the Legal System
• 9 Multi-Agency Approach to Domestic Violence
• 10 Existing Challenges and Future Opportunities
• 11 Making a Difference – The Way Forward
• Appendices
• References
• Index