Case study
A 28-year-old woman you have seen a number of times recently attends with vague abdominal pain and feeling tired all the time. When you review her notes, it becomes evident that she has been in with a number of complaints, all for vague symptoms. On examination the abdomen is soft and there is no guarding. There is no bruising and she has bowel sounds. She is passing urine normally and her bowels are regular. She has no history of abdominal surgery. You suggest that she brings in a urine sample, you confirm her last menstrual period and that she is not pregnant and ask her to schedule an appointment for bloods and then another appointment to see you. As she starts to leave, she tells you she does not feel safe at home.
It is important to recognise the possible range of domestic violence and abuse (DVA) presentations and their complexity. Not all presentations, for example as in the one mentioned above, will obviously be linked in the first instance to DVA.
DVA affects a significant number of individuals and families globally and intersects cultural, religious, gender and ethnic boundaries. It can be present in marital, cohabiting, heterosexual and same-sex relationships.1 Women can also perpetrate DVA against their male partners. However, the number of women abused and the intensity and frequency of DVA affecting women is much greater.2
Women who have experienced or are experiencing DVA may present to healthcare services with a range of symptoms that may not initially seem related to DVA. These may include but are not limited to gynaecological problems, pelvic pain, depression, anxiety and low mood, chronic headaches, fatigue, joint and muscle pain.3
Women who have experienced DVA are often unable to disclose their experiences to anyone through fear of harm or reprisal (to themselves or others) or because of the control that the perpetrator is exerting over them. Disclosure to a healthcare professional therefore will take a significant amount of courage. You will need to make a significant effort to develop trust and rapport.
Women who are experiencing DVA may present to a range of healthcare services. However, primary care services have been identified as a key point of access for women who disclose abuse.4 It has also been highlighted that women often feel that healthcare professionals do not understand their experiences, do not show concern and have a judgmental attitude towards women. These women also feel that health professionals often miss opportunities and cues during consultations to ask questions about DVA.5
Safety is paramount and a sensitive approach is essential. A GP practice or health centre can provide a safe space where a woman may talk to a healthcare professional without the perpetrator being present. You have a responsibility to offer support to someone who discloses DVA.
You should listen to the woman empathetically and offer support via referral mechanisms and support systems. You should respect women’s choices and help them make decisions for themselves rather than imposing them, unless the safety of the woman or children or any other vulnerable individual is at risk. You need to have an open and honest conversation. Remember that you are not working alone and a multidisciplinary approach is important, for example, involving midwives, health visitors, the safeguarding team and leads in your organisation along with outside agencies and specialist organisations.
The Royal College of Nursing (RCN) has an online resource page, including a risk assessment pathway and a list of possible questions to initiate a conversation.
Dr Julie McGarry is a registered adult and mental health nurse and an associate professor at the University of Nottingham
Dr Parveen Ali is a nurse and lecturer at the University of Sheffield, with an interest in gender-based violence
References
1 Ali P, Dhingra K, McGarry J. A literature review of intimate partner violence and its classifications. Aggression and Violent Behavior 2016 doi: dx.doi.org/10.1016/j.avb.2016.06.008
2 Caldwell J, Swan S Woodbrown V. Gender differences in intimate partner violence outcomes. Psychology of Violence 2012;2:42.
3 World Health Organisation 2013. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and nonpartner sexual violence. apps.who.int/iris/ bitstream/10665/85239/ 1/9789241564625 _eng.pdf?ua=1
4 Bradley F, Smith M, Long J et al. Reported frequency of domestic violence: cross-sectional survey of women attending general practice. BMJ 2002;324:271.
5 Feder G, Ramsay J, Dunne D et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technology Assessment (Winchester, England) 2009;13: iii-iv, xi-xiii, 1-113, 137-47
