Assessing Domestic Abuse in Women

Elements of the risk assessment

Key aims of your initial clinical assessment are to build rapport with the woman, estimate the current risk to her physical and psychological health (Box 2) and identify and assess physical injuries. Try to find out whether any other household members such as children are also at risk. Offer support and consider referral to relevant agencies. You may be the first person that the women has ever told about her abuse. Talk to her alone without other people present.

Establishing her story

Use open questions and encourage the woman to talk freely. Explore her ideas, concerns and expectations about the consultation early on, which will help to focus your further assessment. Gently explore any reasons for her abuse (e.g. alcohol problems, pregnancy or financial issues). Find out whether she has any immediate concerns about her own and her children's safety (if she has any). What does she feel would help her most in her current situation?

Allow plenty of time for the woman to answer and try not to interrupt—it may take her a while to formulate her thoughts. Be aware that she may deny what is going on at home or play things down because of shame and embarrassment. Find out exactly what has happened, but remember that she may not reveal the whole story in the first consultation. Be sympathetic, gentle and direct, and assure privacy and confidentiality, as she may feel humiliated, ashamed and frightened. She may also blame herself for what has happened to her. Try to identify what type of abuse has taken place, and how this fits into the context of the woman's life. Ask her about any additional injuries that she has not mentioned yet. When and how exactly did these occur? Establish whether she is currently pregnant or has had a child recently, as domestic abuse can lead to pregnancy and birth complications. Check if she has a history of termination of pregnancy.

Relationship with the perpetrator

What is the nature of the relationship between the woman and her abuser? Is separation—or threat of separation—a current issue? Check whether abuse has escalated lately and whether her abuser keeps any dangerous weapons (e.g. guns) in the house. Ask details about the person who has caused the injuries, including his current whereabouts, convictions for drug misuse or violence and whether he is controlling or jealous.

Social issues

Find out whether she feels lonely or isolated. Does she have a supportive social network? Does she have financial problems? What has been the impact of the abuse on her children (if she has any)? Has her partner hurt or threatened to hurt her children? Are any outside agencies (such as Social Services or the Child Protection Lead) already involved? Ask whether she drinks any alcohol or uses drugs.

Examination and documenting injuries

Limit the first assessment to a general screening examination and leave more detailed examination (particularly in cases of sexual abuse) to an examiner with special training and expertise in assessing victims of domestic abuse.

First impressions are valuable. Does she appear anxious, depressed, frightened or distressed? Is she suicidal? She may try to conceal any injuries or minimize their extent (e.g. with clothing). Multiple injuries at various stages of healing suggest ongoing abuse over a period of time. In particular, look for burns, bruises and slap injuries. Be suspicious if injuries that are unexplained are inconsistent with the woman's story.

Taking action

Offer ongoing support and referral to relevant agencies while making sure that you follow local procedures (Department of Health, 2005). Provide advice about involving the police and how she can access locally available places of safety. Be aware that abused women for various reasons (such as fear, still loving the abuser or cultural issues) may sometimes make decisions that can be hard to understand, and so do not let any frustrations get in the way of providing support for her. Encourage the woman to speak to a specialist domestic violence agency about what support is currently available (such as the 24 hour National Domestic Violence Helpline on 0808 2000 247, which is run in partnership between Women's Aid and Refuge). You should avoid asking the woman to leave her partner because this may increase the risk of injury. Try not to make decisions for the woman.

Conclusion

Domestic abuse is common, and you may be the first and only contact for the woman being abused. In many cases, you need a high index of suspicion. Consider both physical and psychological consequences of domestic abuse in your initial assessment. Be tactful and sensitive when approaching this difficult issue. Managing domestic abuse effectively requires excellent communication skills.