Identifying and responding to domestic violence and abuse in healthcare settings
BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1047 (Published 07 May 2021) Cite this as: BMJ 2021;373:n1047Linked Opinion
Intimate partner violence as a public health problem
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Dear Editor,
We Can Do More – NICE guidelines need updating
General practice has a central role to play in identifying and responding to domestic violence and abuse.
GPs are not specialist domestic abuse workers and are not expected to provide a specialist service. Nevertheless, we are in a unique position to identify and support victims.
Many people go to their GP’s because it is a familiar route to seek help. We are often the main point of contact for majority of patients in the community. Victims experience abuse for an average of 3 years before getting help, and visit their GP an average of 4.3 times during this time (1). Some victims of abuse, including older individuals, Black, Asian, and minority ethnic people, and/or people with disabilities, are likely to endure abuse for much longer before disclosure (1).
Patients are often at different stages in their readiness to open up about their experiences of domestic abuse. General practice is well placed to have a frank conversation with most of the patients. We frequently are able to cultivate a sound relationship with a patient over time, increasing the chance of them disclosing abuse and seeking help - potentially saving lives.
It is challenging for clinicians to know how best to phrase questions, especially during remote consultations (video, email and telephone) and in a busy clinic. With video and telephone consultations, it is hard to assess who is present while the call takes place. Victims may struggle to say what is happening to them at home because the perpetrator might be present. Also, the impersonal nature of remote consultations might affect their willingness to say anything.
A webinar on family violence during the COVID-19 pandemic by the World Organization of Family Doctors in May 2020 emphasized that any contact between the patient and the healthcare system is a window of opportunity to diagnose abuse or neglect (2). Asking all patients about their experiences of domestic abuse during daily routine clinics, will aid early identification and we can offer appropriate support to victims (and perpetrators), before the problem getting worse. In addition, it also highlights to victims that they are not alone in their experiences.
Routine screening improves levels of victim identification of domestic abuse in primary healthcare settings (3). However, there is insufficient evidence to justify screening in health care settings; no head-to-head trials of screening versus clinical inquiry, so we do not know which is more effective (3, 4). Nonetheless, screening programmes are not all that different from targeted inquiry approaches (4).
By routine screening of patients who contact the surgery, we not only identify victims, but also raise public awareness of abuse which in turn may encourage people to talk about the issues more openly and combat potential reasons for unreported cases (e.g. taboo, fear of reprisal, financial implications, and perceptions that help and support is not available). In addition, this may even prompt perpetrators of abuse to recognise and accept support.
NICE guidance, which was published in 2016, does not recommend routine screening for or making inquiries about domestic abuse (5). However, the Pathfinder Toolkit developed by SafeLives recommends that GPs make inquiries, setting a low threshold for asking questions (1).
Digital and remote consultations will continue in general practice beyond the pandemic. NICE guidance was based on an era where the majority of patient contacts and modes of consultations were face-to-face. It is no longer fit for purpose. Therefore, it is vital that NICE guidelines on domestic abuse be reviewed and updated, with recommendations for routine screening in general practice.
Routine screening of domestic abuse on all patients who contact the surgery, in addition to sharing the accessible local supportive domestic abuse services with patients is the step towards reducing the detrimental effects of abuse, the ‘urgent public health priority’, and potentially reducing the financial burden of the country.
References
1) safelives.org.uk/health-pathfinder
2) https://www.globalfamilydoctor.com/News/WONCAWebinaronFamilyViolence.aspx
3) https://pubmed.ncbi.nlm.nih.gov/26200817/
4) Beyond Identification of Patients Experiencing Intimate Partner Violence.
5) https://www.nice.org.uk/qs116
Competing interests: No competing interests
Re: Identifying and responding to domestic violence and abuse in healthcare settings
Dear Editor,
Why can DVA have such a pervasive and lasting impact on victims and their children? The answer lies deeper than the superficial bruises, cuts, headaches, and chronic pain. In his perceptive exploration of the effects of trauma, Bessel van der Kolk, describes some of the unseen changes which trauma can produce. He terms the amygdala, which, at times of danger, unconsciously triggers the secretion of hormones like cortisol and adrenalin, as the brain’s “smoke detector”.1 The medial prefrontal cortex (MPFC), which he labels the brain’s “watchtower”, contributes the emotional response to potential threat. Trauma, including DVA, may alter the amygdala’s and MPFC’s abilities to interpret correctly whether a situation is truly safe or dangerous. Disproportionately high levels of stress hormone can, in turn, impair memory retrieval and working memory.2
Using fMRI, Bessel van der Kolk visualized some of the profound effects of reliving traumatic events. He showed that when remembering distressing experiences, the activity in Broca’s speech area may reduce (consistent with speechless horror) while that in Brodmann area 19 of the visual cortex intensify (perhaps explaining visual flashbacks); in some patients the right side of the brain diffusely lit up, in another the whole brain showed decreased activity (possibly representing dissociation from the trauma).
The ratio of CD45RO-positive to CD45RA-positive lymphocytes (CD45RO/CD45RA), an index of lymphocyte activation, can be higher in patients with a history of childhood sexual abuse.3 This is consistent with the finding that childhood traumatic stress increases the likelihood of hospitalization due to an autoimmune disease in adulthood.4
Why can it be so hard to leave a DVA situation? Seligman and Maier’s 1960s dog-study (replicating inescapable trauma) may give some insight into the complexities of an attempted escape.5 Dogs which had an electric shock applied to them while constrained by a harness appeared to develop learned helplessness, which impaired their ability to flee when physically able to do so. Similarly, after suffering years of DVA, leaving can be a difficult decision to make.
Why can DVA have such a major, life-long effect on individuals? Because, as van der Kolk says, the body keeps the score.
1. Bessel van der Kolk. THE BODY KEEPS THE SCORE (Penguin Random House, UK, 2015)
2. Roozendaal B, Barsegyon A, Lee S. Adrenal stress hormones, amygdala activation, and memory for emotionally arousing experiences. Progress in Brain Research 2008; 167: 79-97.
3. Wilson SN, van der Kolk B, Burbridge J, Fisler R, Kradin R. Phenotype of blood lymphocytes in PTSD suggests chronic immune activation. Psychosomatics 1999; 40(3): 222-5.
4. Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative Childhood Stress and Autoimmune Diseases in Adults. Psychosomatic Medicine 2009; 71 (2): 243-250.
5. Seligman ME, Maier SF. Failure to escape traumatic shock. Journal of Experimental Psychology 1967; 74 (1): 1–9.
Competing interests: No competing interests