Domestic Violence and Abuse

Abstract

Domestic violence and abuse (DVA) is a violation of human rights, a major public health issue and a clinical problem that is increasingly recognised as a health care issue. It has been estimated that its cost to the UK is at least £5.7 billion a year. This article aims to cover the knowledge that GPs require about DVA, as described in the Royal College of General Practitioners curriculum. It is focused on women's health and also considers the care of children and young people, and sexual health. We shall define DVA and consider its causes, prevalence and health impact. The ideal primary health care response to DVA is described, alongside practical information about how GPs should respond to early presentation of sexual assault, including rape.

The GP curriculum and domestic violence

Clinical example 3.06: Women's health lists the learning objectives required for a GP to manage domestic violence. In particular GPs should be able to:

Demonstrate knowledge of domestic violence

Maintain patient records that are accurate, facilitate continuity of care and respect the patient's confidentiality in relation to domestic violence

Provide information to patients on possible local support services, referral services, networks and groups for women (e.g. domestic violence resources)

Recognise the prevalence of domestic violence and question sensitively where this may be an issue

Clinical example 3.04: Care of children and young people also draws attention to the importance of domestic violence

Be aware of the impact of parental problems, including domestic violence and abuse, on the welfare of the unborn baby. Be able to recognise the symptoms and presentations of such problems and to make a sensitive enquiry if concerned

Recognise the needs of children of parents with domestic violence and abuse problems

Clinical example 3.08: Sexual health includes a learning objective required for a GP to manage sexual violence

Manage sexual health emergencies, including responding to early presentation of rape and sexual assault

What is domestic violence and abuse?

Domestic violence and abuse (DVA) is threatening behaviour, violence or abuse (physical, sexual, emotional or financial) between adults who are, or who have been, intimate partners or family members, regardless of gender or sexuality (see Box 1). It forms a pattern of coercive and controlling behaviour. Family members can be from the extended family (e.g. a parent-in-law). In some cases, it may be teenagers or young adults who are violent or abusive towards family members, including their mothers. It is not necessary for the perpetrators to live in the family home.

Box 1.

What is DVA?

Physical violence: slapping, pushing, hitting, punching, kicking, choking, pulling hair, biting, cutting or scratching, withholding medication, burning or stabbing, pulling out hair, attempting to drown or strangle, attempting to murder and murder itself

Sexual violence: rape, using objects during intercourse against her will, forcing her to watch or engage in pornography or perform sexual acts in front of other people; forcing her to engage in any unwanted sexual act

Emotional abuse: humiliation in front of others, telling her she is useless, stupid or ugly, telling her she is a hopeless mother/housewife, making threats against her or her children, keeping her isolated from friends and family, preventing her from sleeping and making distorted ‘justifications’ for the abuse to make the woman feel it is her fault and that she deserves it

Economic/financial violence: denying her money for food, clothes, rent, for herself or her children, and stealing money from her

Reproduced with permission from Staffordshire Women's Aid

DVA is made up of different behaviours that can all potentially impact on health, though not all are illegal. The focus has traditionally been on criminal incidents of physical and sexual violence, such as physical assault, wounding, attempting to choke, sexual assault or rape. However, emotional abuse alone can also produce long-term adverse physical and mental health effects—greater awareness about the dimension of emotional abuse is needed among health professionals (see Box 2 for an example of the benefits of this awareness). Aspects of emotional abuse may also constitute a criminal offence, including threats to kill, harassment, stalking and putting people in fear of violence.

Box 2.

Case study of DVA, from the IRIS trial*

Catherine is a 49-year-old black Caribbean woman. She is disabled and has four adult children. Catherine's GP practice is ‘domestic violence aware’, having received “Identification and Referral to Improve Safety” (IRIS) training (see Box 5). Catherine saw an IRIS poster on display in the practice, and this prompted her to speak to her GP about domestic abuse. The GP subsequently made a direct referral to a domestic violence advocate as part of the IRIS programme. Catherine met with the advocate at the surgery and spoke about her ongoing experiences of abuse. Catherine's husband had verbally, emotionally and financially abused her for over 26 years. Catherine described feeling sad, low and said she felt unable to cope

Catherine had been registered at her practice for over 16 years and had never before spoken to anyone about the abuse she was experiencing. The advocate provided practical support (with information and options for Catherine to consider), consistent emotional support and always discussed Catherine's safety. Catherine was seen for 12 months. For the first 2 months, this involved an appointment once every 2 weeks. The next 2 months involved an appointment once every month and, for the last 8 months, an appointment once every 2 months (each approximately an hour in length). Additional support included approximately five phone-calls and a monthly text

Over the 12-month period, Catherine remained with her husband and reported many positive changes in her life, including going out on her own, leaving the house at least once every day, meeting with a friend/family member each week, opening her own bank account, taking a holiday to visit family, setting career goals and beginning a degree. Catherine reported the feeling of ‘having her life back’ and ‘feeling stronger to cope’. She felt less anxious and stated she was happy and had self-belief

Catherine's doctor stated that since identifying domestic abuse, it is as if ‘a light switch has been turned on’ with Catherine's health and emotional well-being improving. Catherine previously visited the surgery around once a month, but now her visits have reduced by two-thirds to once every 3 months. Catherine has also reduced her use of medication for depression and sleeplessness. In Catherine's words: ‘Encouraging myself that I can do this … I feel empowered … I feel proud of me … thank you for believing in me’

The central feature of the different types of DVA is the power and control that a perpetrator covets over an intimate partner or other family member. This recurs, often gets worse with time, and is potentially life threatening. In this article, we have elected to use the term ‘domestic violence and abuse’ to try to capture that control can be exerted within a relationship in multiple ways. When describing particular studies or the work of other agencies, we have used the term utilised in their reports. For example, studies examining the prevalence and health impact of abuse are often specifically about ‘intimate partner violence’ (IPV), which excludes the violence committed by other adult family members. The World Health Organisation (WHO) definition of IPV focuses on the impact of behaviours. Behaviours are only defined as IPV if they cause harm:

Any behaviour within an intimate relationship that causes physical, psychological, or sexual harm to those in a relationship; it includes: physical aggression, psychological abuse, forced intercourse and other forms of sexual coercion, various controlling behaviours. (Krug, Mercy, Dahlberg, & Zwi, 2002)

DVA in its widest sense also includes harmful and illegal practices that affect women and children in different communities, including female genital mutilation, forced marriage and so-called ‘honour-based’ violence (see Box 3). These are important issues for health professionals to be aware of but should not detract from the knowledge that IPV is the predominant type of DVA seen in all communities and is thus the most likely to present in general practice.

Box 3.

Definitions

Female genital mutilation: ‘All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons’ (WHO, 2012)

Forced marriage: ‘A marriage in which one or both spouses do not consent to the marriage and duress is involved. Duress can include physical, psychological, financial, sexual and emotional pressure’ (Crown Prosecution Service, 2000)

‘Honour’-based violence: ‘So-called honour-based violence is a crime or incident, which has or may have been committed to protect or defend the honour of the family and/or community’ (Association of Chief Police Officer of England, Wales and Northern Ireland, 2008)

Gender matters

Repeated coercive, severe physical and/or sexual violence is more common in DVA against women (Tjaden & Thoennes, 2000), with 89% of those who have experienced four or more incidents of domestic violence being women (Walby & Allen, 2004). Women tend to experience DVA for longer periods of time than men. DVA that results in injury or death is also most likely to be experienced by women (AuCoin, 2005); they are more likely to need medical attention or hospitalisation and are more likely to fear for their lives. Crime statistics show that the vast majority of cases are committed by men. Hence, in this article, we refer to women as experiencing DVA while acknowledging that DVA can also affect men. We hope that future research will help articulate the needs of male victims and thus determine effective interventions.

Causes of DVA

DVA occurs in all societies regardless of ethnicity, age, class, religion, sexuality and disability. However, it is more prevalent in socio-economically deprived communities. Internationally, IPV has no consistent demographic associations other than relative poverty. Although it is prevalent across the socioeconomic spectrum, it is more common in families and communities that are relatively deprived. In the UK and North America, IPV is more common among younger women, and there is some evidence that women with disabilities are at increased risk (Mirlees-Black, 1999). Coercive control supported by patriarchal social structures has been put forward as the central cause of IPV.

Prevalence

Violence against women is a global public health issue affecting millions who have to live with its consequences (Watts & Zimmerman, 2002). The WHO's multinational Violence Against Women study found that the prevalence of lifetime physical violence and sexual violence by an intimate partner, among ever-partnered women, varied from 15 to 71% in urban and rural settings in 10 countries (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). In women attending UK general practice, 41% had experienced physical violence from a partner or ex-partner (Richardson et al., 2002).

The prevalence of IPV tends to be higher in women attending health care services than in those participating in community surveys, even when these studies are set in the same geographic population. One study of women attending general practices in London, found that one in seven had experienced physical violence in the last year (Richardson et al., 2002). This is to be expected when one considers that health utilisation is higher among women who have a current or past history of abuse than no history of abuse. Women with a current or past experience of DVA use primary care and specialist outpatient services more frequently, are issued with more prescriptions and admitted to hospital more often than non-abused women (Campbell, 2002).

Health impact

DVA damages health. In the UK, two women are killed by their current or former male partner each week (Povey, 2004). The National Center for Injury Prevention and Control (2003) in the USA reports that 5.3 million episodes of domestic violence occur each year, causing 2 million injuries with 550 000 people requiring medical treatment as a result. However, most primary care presentations of DVA will be hidden and be neither an obvious injury nor an emergency. Instead, DVA is more likely to present with short- and long-term health problems that can persist after the abuse has ended.

In Australia, IPV is the top contributor to death, disability and illness for women of reproductive age (15–44 years) (Vos et al., 2006). In these women, IPV was the most important risk factor out of eight major risk factors for ill health, including high blood pressure, high cholesterol and body weight; IPV accounted for 8% of the disease burden in this age group, while high blood pressure accounted for just 1%. DVA can impact on the physical, gynaecological and mental health of women, as well as the health of children who witness it. The physical health consequences of DVA are surpassed by its 4–5 times increased risk of mental health effects, which can persist long after the violence has ceased (Golding, 1999). The possible presentations of DVA in primary care are listed in Box 4.

Box 4.

Possible presentations of DVA in primary care

Psychological

Insomnia; depression; suicidal ideation; anxiety symptoms and panic disorder; somatoform disorder; post-traumatic stress disorder; eating disorders; and drug and alcohol misuse

Physical

Chronic pain syndrome and chronic abdominal pain; chronic headaches; chronic back pain, irritable bowel syndrome, fibromyalgia, lethargy, medically unexplained symptoms, poorly controlled asthma and diabetes; STIs; and recurrent urinary tract infections, chronic pelvic pain and pelvic inflammatory disease

Injuries: with resulting numbness and tingling, bruises in various stages of healing and injuries from sexual assault, woman tries to hide injuries or minimises her extent

General indicators

Delay in seeking treatment of injuries; frequent appointments for vague symptoms; recent separation or divorce; history of child abuse; age less than 40; and abuse of a child in the family

Pregnancy related indicators

Miscarriages; unwanted pregnancy; antepartum haemorrhage; lack of prenatal care; intrauterine growth retardation, low birth weight of infant, premature labour and poor or non-attendance at antenatal clinics

Negative health behaviours

Smoking, alcohol and drug abuse, physical inactivity, over-eating, severe obesity, sexual risk taking and greater cardiovascular risk

Reproduced from BMJ, Hegarty K, Tat A, Feder G., 337: a839 (2008), with permission from BMJ Publishing Group Ltd

DVA has a damaging effect on the health of children. Its impact can include anxiety, depression, bedwetting, aggression, drug and alcohol misuse, self-harming and suicidal ideation. Children witnessing DVA have a higher risk of behavioural and educational problems, as well as physical and emotional ill health. IPV is an independent risk factor for deficit in gestational weight gain during pregnancy and is thus associated with low birth weight.

Health care response

The Identification and Referral to Improve Safety (IRIS) trial, the first European randomised controlled trial of a training intervention to improve the primary health care response to domestic violence, found that its use resulted in a 3-fold increase in the identification of DVA and a 6-fold increase in referral to specialist domestic violence advocacy services (Feder et al., 2011). To achieve this, the response of primary care to DVA needs to improve. Further information about the IRIS trial intervention can be found in Box 5.

Box 5.

IRIS—the identification and referral to improve safety trial

This was the first European randomised controlled trial of a training support and referral intervention to improve the primary health care response to domestic violence. The intervention comprised:

In-house training for the practice team regarding: how to make a clinical enquiry to identify DVA, appropriate response, referral, recording, data handling, confidentiality and safety.

Use of “HARKS” within the practice. This is an electronic pop-up prompt that appears in the patient medical record to remind health care professionals to ask about DVA. It is a mnemonic that stands for: Humiliate, Afraid, Rape, Kick and Safety. Its appearance is triggered by Read-coded symptoms and conditions associated with DVA.

An advocate educator from a specialist DVA organisation. The advocate trains practice team and is the named contact for patient referrals. They also provide support (emotional and practical), assess risk, devise safety plans and signpost patients to other services.

The IRIS model can now be commissioned for practices. For further information see www.irisdomesticviolence.org.uk.

The primary care response to DVA can be divided into the response required of individual GPs, who have a role in identifying and responding appropriately to DVA while facilitating access to specialist DVA services; required of the practices in which GPs work, who need to respond to DVA in order to ensure that the work of individual health professionals can be effective; and required from clinical commissioning groups, who will be commissioning services for women experiencing DVA. The different aspects of the response required by each of these agents are discussed below.

Role of the GP: ask women directly whether they are experiencing DVA

GPs should have a low threshold for asking about DVA when women present with conditions associated with current or historical violence. These conditions include mental health problems (e.g. depression), medically unexplained symptoms (e.g. tiredness), gynaecological conditions (e.g. chronic pelvic pain) and chronic conditions (e.g. irritable bowel syndrome). A potentially powerful way to achieve this is to install the Read coded ‘HARK’ questions (see Box 6) as an electronic prompt triggered by specific Read coded data that is known to be associated with DVA (e.g. headache). This was a central element of the intervention in the IRIS study. The HARK template functions as a useful mnemonic, reminding the clinician to ask about DVA and to consider the three dimensions of abuse (physical, sexual and emotional) and whether or not a woman is afraid of her partner. A useful initial question may be ‘How are things at home?’, followed by a more specific question like ‘Women with this symptom/condition may be suffering abuse from a partner or adult they live with; is that happening to you?’ Women should only be asked about DVA when it is safe to do so—in other words, when they are not accompanied by anyone who can understand what is being discussed. This may include young children who could report back to a controlling partner or a relative who is translating.

Box 6.

HARK questions

Humiliation: within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner?

Afraid: within the last year, have you been afraid of your partner or ex-partner?

Rape: within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?

Kick: within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?

Source: Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Family Practice 2007, 8:49 doi:10.1186/1471-2296-8-49

Role of the GP: respond appropriately—validate and assess immediate safety

If a woman discloses DVA, the clinician should validate her experience (see Box 7), assert that this is unacceptable behaviour and express support. GPs should always assess the risk of immediate harm by asking ‘Are you safe to go home?’ Other useful questions can be ‘Are either you or your children in danger?’ ‘Has violence become more frequent or severe recently?’ and ‘Are there weapons in the home?’ If the answer to any of these questions suggests risk of immediate harm, then the woman should be helped to urgently contact either a specialist DVA service or the police if it is not possible to speak to an advocate immediately. The practice needs a designated safe room where the woman can wait while the appropriate service is being contacted. This needs to be private so that the woman can speak without fear of the perpetrator being able to access her or of being overheard. The vast majority of cases of DVA seen in general practice are more akin to a chronic condition and the situation will not be urgent that day.

Box 7.

Possible validation statements if a woman discloses DVA

‘Everybody deserves to feel safe at home’”

‘You don't deserve to be hit or hurt. It is not your fault’

‘I am concerned about your safety and wellbeing’

‘You are not alone. Help is available’

‘You are not to blame. Abuse is common and happens in all kinds of relationships. It tends to continue’

‘Abuse can affect your health and that of your children in many ways’

Reproduced from BMJ, Hegarty K, Taft A, Feder G., 337: a839 (2008), with permission from BMJ Publishing Group Ltd.

Role of the GP: offer referral

Referrals to local specialist DVA advocacy services should be offered to all women who disclose DVA, regardless of the nature of the abuse or the timeframe over which it happened. Even if a woman declines the referral, she will know that her clinician is not ambivalent about discussing what is happening to her, and she may choose to be referred at another time.

Role of the practice: find out about existing local and national DVA services

DVA services can help assess risk to women and their children, provide advocacy and broker access to housing, criminal justice and social care support. Understanding the scope of provision of these services, and how best to refer women, helps to develop a simple pathway for your patients to gain access to them. Most are provided by third-sector agencies, but the local authority may have a domestic violence coordinator who coordinates the local response to DVA and can provide information about local services. The contact details for local and national DVA services and how best to access them should be documented in the practice handbook and/or on intranet services with easy accessibility for all locum doctors and other temporary staff. Each member of the primary health care team should at least be aware of the free phone 24-hour national domestic violence helpline run in partnership between Women's Aid and Refuge (0808 2000 247). This can give confidential support, help and information to women experiencing DVA, as well as their family, friends, colleagues and others calling on their behalf, including health professionals.

Role of the practice: engage with local services in order to develop an effective working partnership

Ideally, the practice should identify a contact person at a local DVA service who can directly liaise with clinicians and provide care for patients, including the provision of full risk assessments and safety planning. A named health professional—preferably the safeguarding lead for the practice—should be identified to act as the practice's DVA lead. This person would liaise with the local specialist agencies and have more specific face-to-face DVA training.

Role of the practice: encourage spontaneous disclosure of DVA

Spontaneous disclosure is only likely to occur if a woman feels that she can trust the doctor and practice. Having information about DVA in the practice, including telephone numbers for national help lines and local services (e.g. posters in waiting rooms, leaflets at reception and small discreet easily hidden credit cards in the toilets), may help women feel more able to trust a practice. Posters stating that the practice is ‘domestic violence aware’ and that the staff have received training about DVA can increase a woman's confidence that health care professionals will respond effectively and compassionately to her disclosure of DVA.

Role of the practice: ensure staff members know how to safeguard children and vulnerable adults exposed to DVA

In families with children, in 90% of DVA incidents, the children are in the same or next room (Hughes, 1992). In each case of DVA, the GP needs to enquire whether children are present in the household and assess the level of risk for each child. The child is at greater risk if they are under 7 years old, the mother is pregnant or the mother or child has special needs. Liaison with a health visitor and/or school nurse may help to gain further information, allowing a more complete assessment of the family and determination of the impact of DVA on a child's health and development.

Safeguarding procedures need to be initiated when there are concerns about the welfare of children or vulnerable adults. A judgment about whether the exposure of children to DVA requires safeguarding intervention is complex and should be discussed with the safeguarding clinical lead. If parental or patient consent is not given for sharing information, confidentiality may need to be broken in this context. It is useful to discuss dilemmas about breaking confidentiality with colleagues within the practice. The safety of a child is a GP's first concern; if a child comes to harm, the GP may need to justify why other agencies were not informed.

Role of the practice: record and keep DVA information confidential

There should be a consensus within practices on how to record DVA using agreed Read codes and on how to ensure that this information is kept confidential so that it is not visible on the computer screen to third parties within consultations. Recording DVA allows DVA quality audits to be undertaken, including auditing the proportion of women identified as having experienced DVA and its dimensions.

Clear medical notes are also important, as they can be helpful for police obtaining a future conviction. They are also useful if a patient has been referred to a Multi-Agency Risk Assessment Conference (MARAC), at which information will be shared between local agencies. MARACs are intended for domestic abuse victims who are thought to be at risk of murder or serious harm, with the aim of constructing and implementing a coordinated safety plan to protect these women. Over 260 MARACs are operating across England, Wales and Northern Ireland, managing over 55 000 cases a year. A MARAC coordinator may contact a general practice for information about a case. Practical guidance is available on the application of Caldicott Guardian Principles when trying to decide whether it is appropriate to share health information with a MARAC (Fincken, 2012).

Role of the practice: hold regular practice meetings involving the whole primary health care team

Gathering the knowledge of the whole team at regular meetings (for example, at existing critical incident meetings) will increase the identification of DVA. Inviting health visitors and other community-based professionals (e.g. midwives and district nurses) to these meetings is helpful, as they are often aware of when DVA is occurring within vulnerable families. Administrative staff may also have concerns about vulnerable families in their local community, which they should be able to share with the clinical team.

Role of the practice: provide face-to-face training on DVA for the whole practice

Few GPs have had face-to-face training about DVA, either once qualified, as undergraduates, or, until recently, during postgraduate training. There is evidence of an inappropriate poor-quality response to women disclosing DVA to health professionals in primary care (e.g. being judgmental, dismissive, breaking confidentiality and/or offering couple counselling; Feder, Hutson, Ramsay & Taket, 2006). Specific evidence-based DVA training and support programmes for general practice are available, and these can be commissioned for the whole practice team.

One option is the Identification and Referral to Improve Safety (IRIS) course (see Box 5). This training should include practical experience on how to ask sensitively about current or past abuse and how to provide an empathic and safe first response to a disclosure of DVA. Whole practice training on safeguarding children, including its link to DVA, is required at least every 3 years for all National Health Service staff.

Role of clinical commissioning groups

Clinical commissioning groups will also need to respond to ensure effective commissioning of services for women experiencing DVA. The person who has strategic responsibility for safeguarding children and vulnerable adults may be ideally placed to also strategically lead and coordinate services for women experiencing DVA across the local health economy. This may include accident and emergency, mental health, drug and alcohol, and maternity services, as well as primary care. The role of commissioning services will be increasingly important in the current economic climate in which funding of third-sector organisations is being squeezed.

Managing sexual health emergencies

Most sexual abuse occurs within pre-existing intimate relationships. Sexual assault can range from inappropriate touching, assault by penetration (intentional penetration of the vagina or anus with a part of the body, or anything else, without consent), to rape (intentional penetration by the penis of the vagina, anus or mouth, without consent). Though sexual assault may not involve any external physical injuries, it is still a crime and remains thus, no matter who commits it or where it happens.

Patients may present to GPs following a recent sexual assault, including rape. If there are acute medical needs these must take priority (e.g. patients with significant injuries may require referral to accident and emergency or gynaecology). The risk of pregnancy and sexually transmitted infections (STIs) should be considered, and GPs may need to provide emergency contraception if appropriate. GPs should not undertake examination or testing prior to a forensic examination. Instead, all patients should be encouraged to attend a sexual assault referral centre (SARC), whether they wish to have a forensic examination or not. The 40 SARCs in the UK provide a one-stop service where specially trained doctors and nurses provide forensic services as well as medical, emotional and practical support. They will ensure patients understand all forensic and care options available. Patients should be informed that they can self-refer to SARCs by telephoning at any time of day or night. They are then given an appointment to attend, as a walk-in service is not provided. For patients who decline further referral, GPs may need to consider how they can manage the care needs listed in Box 8.

Box 8.

Health care needs to consider following recent sexual assault (British Association for Sexual Health and HIV, 2012)

Management of pregnancy risk

Levonorgestrel (Levonelle)—should be given as soon as possible as efficacy declines over time. Although efficacy has been demonstrated up to 96 hours, between 96 and 120 hours efficacy is unknown, and its use beyond 72 hours is outside the product licence. May be given repeatedly in the same cycle

Ulipristal acetate (EllaOne)—efficacy has been demonstrated up to 120 hours and it can be offered to all eligible women requesting emergency contraception (EC) during this time period. It is the only oral EC licensed for use between 72 and 120 hours. Efficacy does not appear to decline over time

The copper-bearing intrauterine device can be inserted up to 120 hours after a first episode of unprotected sexual intercourse or within 5 days of the earliest expected date of ovulation. Efficacy does not decline over time

Management of STI risk

Immediate treatment comprises a combination of 400mg cefixime, 1g azithromycin and 2g metronidazole, all as one-off oral doses

After 10 to 14 days of assault patients should undergo STI screening, due to the risk of re-infection from a partner and emerging problems with cefixime-resistant gonorrhoea

Management of blood-borne infection risk

Offer baseline testing for Hepatitis B and C, syphilis and human immunodeficiency virus

Hepatitis B prevention should be given if the patient is not immune or known to be HBV positive

Offer an accelerated course of Hepatitis B vaccination. The first dose should be given within 6 weeks of the incident, with the GP/genitourinary medicine clinic or SARC administering further doses at 1 and 3 weeks after the first dose. A final dose should be given 6–12 months after the first dose. Suitable preparations for adults and adolescents (over the age of 16 years) are 1ml intramuscular injections of Engerix B® 20 mcg or HBvaxPRO® 10 mcg

Hepatitis B immunoglobulin should be considered within 48 hours, and no later than 7 days, after a known or strongly suspected infectious contact

Human immunodeficiency virus post-exposure prophylaxis

If indicated, this should be started as soon as possible, but can be considered up to 72 hours after the incident

GPs should provide information to support patients in considering whether they wish to proceed to forensic examination. These are undertaken if the patient presents within 7 days of the incident. The purpose of the examination is to collect evidence, including DNA evidence, to support a court case. It involves a top-to-toe examination, with careful documentation of any injuries. Samples of hair, nails and body fluids may be taken, including swabs from genital and extra-genital sites. Qualified forensic medical staff carry out the forensic examinations, normally in a SARC or a police suite. They can be arranged by referral to a SARC or can contact the police by calling 999. Patients should be advised to keep relevant clothing or bedding, toothbrushes or tampons; and to not shower, wipe, change or wash clothes, smoke or chew gum. This is in order to preserve forensic evidence.

If a patient is unsure about pressing charges, the SARC can arrange informal contact with specially trained police officers who will explain the process involved if they wish to report a sexual assault to the police. SARCs can also collect and store evidence until a patient decides whether they want to press charges. If they prefer, patients are able to disclose evidence anonymously. So-called ‘anonymous disclosure’ is also known as third-party reporting and allows police to collect intelligence that may be relevant to other cases, which may help to identify a serial offender.

Conclusion

DVA is a diverse subject that provides both clinical and public health challenges. For further information about DVA, including more detail on how to respond to a disclosure of DVA, and the topics of female genital mutilation, forced marriage and so-called ‘honour based violence’, you may find it useful to complete the Violence Against Women and Children e-Learning course in the Royal College of General Practitioners online learning environment (see Box 9). This provides practical information about these issues, as well as serving as a platform for high-quality practice-based training.

Box 9.

Royal College of General Practitioners e-Learning course on violence against women and children

Designed to complement domestic violence training, this course familiarises practitioners with how to recognise and respond to patients experiencing violence

First session: Recognising Violence—helps practitioners to understand how to identify patients who may be suffering, or have suffered from, violence

Second session: Asking About Violence—considers the issues around asking about violence in the consultation, including when and how to approach it and the immediate response to disclosure

Third session: Responding to Violence—gives further detail on the problems facing women experiencing different forms of violence and the support available to them

Final session: Improving your Practice—explores how the practice organises and manages the issues relating to violence against women and children

A self-assessment exercise at the end of the course enables the practitioner to test their knowledge, attitudes and decision-making skills and provides the opportunity to earn a certificate for continuing professional development credits to use towards appraisal and revalidation

Reproduced from RCGP Online Learning Environment (http://elearning.rcgp.org.uk/). ©Royal College of General Practitioners 2012.

Key points

Most primary care presentations of DVA will be hidden; patients often have no obvious injury

If a patient discloses that they experienced DVA respond non-judgmentally and offer ongoing support

Offer all women referral to specialist advocacy DVA services

Face-to-face quality training on DVA for the whole practice team is strongly recommended

Responding to a sexual assault involves considering emergency contraception and STIs (including blood-borne infections such as hepatitis B and human immunodeficiency virus), as well as consideration of the need for forensic examination

Footnotes

*

This anonymous case study was taken from the training and commissioning guidance that arose following the IRIS trial. For more information, please see

References

Association of Chief Police Officer of England, Wales and Northern Ireland (2008) Honour based violence strategy. Retrieved from www.acpo.police.uk/documents/crime/2008/200810CRIHBV01.pdf

AuCoin

(2005) Family violence in Canada: A statistical profileStatistics Canada89

British Association for Sexual Health and HIV (2012) UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault 2011Retrieved from www.bashh.org/documents/4450

Campbell

JC.

(2002) Health consequences of intimate partner violence. Lancet 359(9314)1331–1336. doi:10.1016/S0140-6736(02)08336-8

Crown Prosecution Service (2000) Honour Based Violence and Forced Marriage. Retrieved from www.cps.gov.uk/legal/h_to_k/honour_based_violence_and_forced_marriage/#a01

Faculty of Sexual and Reproductive Healthcare Clinical Guidance (2012) Emergency Contraception, Clinical Effectiveness Unit. Retrieved from www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf

Feder

Davies

R.A.

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Dunne

Eldridge

Griffiths

Sharp

(2011) Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: A cluster randomised controlled trial. Lancet 378(9805)1788–1795. doi:10.1016/S0140-6736(11)61179-3

Feder

G.S.

Hutson

Ramsay

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