The law and social policies in the UK have made it clear that domestic violence is unacceptable, but are health professionals lagging behind in their responses? Domestic violence 18-1

Philippa Sully MSc RN RM RHV RNT CertEd FPACert CC Relate
Senior Lecturer: Interprofessional Practice City and Community Health Sciences City University, London 
Domestic violence causes injury and death throughout the world. Women are most likely to be the victims. In the United Kingdom (UK) two women die each week and 30 men each year as a result of this multifaceted and common source of violent crime. It is a sign that children are at risk of abuse too, as they can be directly or indirectly caught up in the violence. A central tenet of domestic violence is power dynamics: the need for the abuser to control their partner and at times the children. Domestic violence is a health care as well as a social, ethical and legal issue.

This paper emphasises the importance of professional practitioners being aware of the signs and symptoms of abuse, its frequency, the risk factors for homicide from domestic violence, and the risks to children and the impact on them. It is likely that the violence is known about in the community and by professional practitioners. The paper explores the role of practitioners and how important it is for them to examine their own values and beliefs about domestic violence. It is imperative for responses to be interprofessional and interagency if practitioners are to meet the needs of survivors and their families and work in partnership with them. Fundamental to this approach is effective information sharing and the sensitive co-ordination of services for survivors. It is no longer acceptable to regard domestic violence, a cause of misery and loss of life, as a private matter and not to consider it as a health care or human rights issue. Clients and their families have a right to sensitive inquiry about their situations and the offer of services to themselves and their children.
Journal of Family Health Care 2008; 18(1): 9-13

Key points 
_ Domestic violence is common. In the UK it accounts for 16% of all violent crime and the deaths of two women every week and 30 men every year. Domestic violence is illegal in the UK
_ Health professionals working with families have a duty to be aware of the signs of domestic violence and how to respond effectively. It is no longer acceptable to regard it merely as a personal matter between the partners, and practitioners may need to examine their own attitudes to domestic violence
_ Pregnancy is a common trigger. Sound midwifery practice includes sensitive routine enquiry of all women in their care
_ Children are at risk, either directly or indirectly, when there is domestic violence, and child protection is a key consideration _ In delivering services, practitioners need to maintain their focus on the needs and safety of survivors and their children
_ Domestic violence can escalate and may result in serious harm or murder. Police services now routinely perform risk assessments for surviviors of domestic violence and are likely to have a realistic idea of the dangers
_ Information-sharing with other health professionals and other agencies such as the police service and social services is an important part of an interagency and interprofessional approach. The aim is to work as a team in partnership with the survivor
_ One sign of domestic violence is often cruelty to family pets. Disclosure of this may be the first sign that a child is living with domestic abuse

Domestic violence is defined by the Home Office as "any incident of threatening behaviour, violence or abuse between adults who are or have been in a relationship together, or between family members, regardless of gender or sexuality."1 Violence towards an intimate partner is a global phenomenon that causes misery, distress and loss of life in families and communities throughout the world2. According to the Home Office3 it causes more morbidity than war, motor vehicle crashes and cancer in women between the ages of 19 and 44 years. In the UK it accounts for 16% of all violent crime and the deaths of two women every week and 30 men every year3.
Several disciplines including psychology and sociology have attempted to explain this social and personal phenomenon. Dynamics of power and control seem to be central to intimate partner violence4,5,6 and the murder of an intimate partner7,8. The manifestation of these power dynamics can be brutal or subtle, with the majority of survivors and victims being women3. Violence towards a woman partner occurs in both heterosexual and lesbian relationships. A review of violence in same-sex partnerships found a high prevalence and many similarities to those identified in heterosexual relationships9. In a case study of five domestic homicides (four heterosexual and one lesbian)10, Sully and Greenaway found similarities of power and control between the heterosexual relationships and the lesbian relationship. In the latter, the woman was killed by her partner after the victim had said she was leaving the relationship. If, as practitioners, we are to address domestic violence with a view to protecting those in abusive relationships and their children, it is important to consider the contexts in which the violence occurs. It is crucial that practitioners maintain their focus on the diverse and very real needs of survivors and their children when delivering services. Malos11 identified that the involvement of feminists in statutory and voluntary agencies dealing with domestic violence was an important factor in helping to maintain this client-centred focus. Research across the world consistently shows that patriarchy contributes to femicide12. In a patriarchal society women are frequently disadvantaged, and this inequality is reflected in the way violence towards women is reported in the media or portrayed in films or on television13. Children may be influenced by this even though they may not necessarily be aware of it.

Domestic violence and children   
Domestic violence in a family should be regarded as a possible source of risk to the children14,15. Children are often witnesses when there is domestic violence and parents often underestimate how much children have seen, heard or understood16. McGee15 describes how mothers who had experienced domestic violence "expressed particular surprise at the level of awareness that very young children had regarding the violence and how the memories had remained." Children are hurt directly by being caught up in the violence17,18 or indirectly by seeing and hearing it. They may also be abused by the perpetrator as a means of abusing or controlling the non-abusing parent or carer18,15, or when on access visits to the abusing partner. There is an extensive literature on the effects these experiences have on children's development, achievements, relationships, education and social interactions19,18,15. Children have painful memories of these experiences16,20. When an abused parent flees, the upheaval to the children of suddenly having to leave school friends and social networks without being able to give an explanation can also be very distressing.
Domestic violence can affect the parents' ability to parent. Abusing male partners are reported to be more likely to be irritable, rarely affectionate and generally not much involved with child care21. The health of the abused parent may be significantly affected by the violence they experience. Abused mothers have higher incidences of mental and physical ill health21 and this in turn can affect their ability to care for their children as they would wish. If a child is conceived as a result of rape by the abusing partner or a means of controlling the mother through pregnancy, this may affect the mother's ability to relate to the child. Violence in pregnancy can increase the risk of miscarriage, and have a significant effect on infant morbidity and mortality2. Many abused survivors are socially isolated so their plight is not evident, and they feel shame because of what has happened. Some families may have fled persecution elsewhere only to find themselves caught up in family violence in their adopted countries. Survivors may not understand what services are available to help them and fear retribution if they seek help or try to leave an abusive relationship. These factors can contribute to the secrecy surrounding their situations. One sign of domestic violence is often cruelty to family pets22. Abusers can cause deep distress to children by threatening to harm their pets, or actually harming or killing them. They do this as means of controlling the child and the abused parent or carer. Disclosure of this type of situation at school or outside the home may be the first sign that a child is living with domestic abuse.

Professional practice   
I believe that the overriding focus of professional practice with children and their abused parents and carers should be to maintain their safety. The complexity of domestic violence and its manifestations means that any approach to working with survivors and their children should be across agencies and professions and across the voluntary and statutory sectors in the UK and abroad. Child protection is central to the care of children living in violent families. Although informationsharing and joined-up working are known to be significant factors in child protection, these remain difficult to implement23,24.

Listening to children   
Children's responses to living in abusive households vary according to their circumstances, age and developmental stage. Some settle down when they feel safe, others may demonstrate their distress in a range of behaviour across all the areas of development. Examples are being unable to express emotions, failure to thrive at school or regressing to an earlier stage of development19,25,18,15. In a study by Zink et al26, more than half the women were motivated to seek help because of their children's behaviour or comments. However, it is not solely the responsibility of the non-abusing parent to listen to children and seek to understand what they say and do. In my view it is the responsibility of all professional practitioners who work with children and families, regardless of their discipline or their position in the professional or management hierarchy, to be sensitive to children's distress. The Children Act "places a statutory duty on key people and bodies to make arrangements to safeguard and promote the welfare of children"27.
This duty also applies to parents' responsibilities towards their children. Listening to children and young people is integral to UK Government guidance on the development of services for children and their parents28. Children's disclosure of the abuse is likely to be affected by several of these issues and by their relationship with the person they choose to tell. Studies show that children may tell a trusted adult such as their teacher19,15. Alternatively, it may be a change in behaviour that alerts an adult to a child's distress. The Home Office has summarised best practice guidelines on how to respond if a child discloses violence or if their behaviour or appearance leads the practitioner to suspect abuse18.
The importance of listening to children cannot be overemphasised16,17,20. This may be the first occasion when someone has listened to the child's experience and tried to understand. The adult needs to do their best to enable the child to disclose in a safe and private place and to seek help for the child. Where there seems to be immediate danger, ensuring safe help as soon as possible is paramount. Unfortunately there is a risk that practitioners may not recognise what they are seeing, either in the child's behaviour or appearance. This seems to have happened with Victoria Climbié, the little girl murdered by her carers24, when practitioners saw the child but somehow her distress went unidentified.

Sharing information and co-ordinating responses   
Working in partnership with the survivors, to help them explore their options while remaining safe, is central to effective help. Services must be co-ordinated, make the safety of the survivor and their children the priority, and be flexible in meeting the survivors' needs29. It is important that survivors are allowed to make their own decisions and have time to reflect on their options15. They should not, for example, be pressured into courses of action as a consequence of practitioners' anxieties. Children need practical care and help in their distress17. They need space to express their experiences, and meeting other children with similar experiences helps them to realise that they are not alone29,18.
They may need help to understand that they are not responsible for the abuse. The abuse is the responsibility of the abuser. I strongly believe that co-ordinated services are by their nature interagency and interprofessional, as opposed to multi-agency and multi-professional. Interagency and interprofessional approaches help to ensure that practitioners work as a team, in partnership with the survivors and with a shared focus and remit that is responsive to the families' needs. The danger with multi-agency and multi-professional approaches is that practitioners work in parallel but in isolation. There is, therefore, a risk that a shared purpose and explicit partnership will not be clarified and vulnerable people may slip through the net. A central element of an interagency and interprofessional approach is information sharing30,31. In a small study of police officers working with domestic violence42, the police reported that health care practitioners were the least likely to share information with them. The explanation practitioners gave was that they could not breach confidentiality or share information without the survivors' consent. It is crucial that the family is regarded as an entity, as opposed to the survivor, the children and the abuser. Considering the family as a whole is more likely to ensure a joined-up approach, with practitioners from the statutory and voluntary sectors working together with families to provide them with services that meet their needs. Police services now perform risk assessments for surviviors of domestic violence and are therefore likely to have a realistic idea of the dangers in the situation.

Some barriers to receiving effective services 
Ideally, sharing information should lead to working in partnership with the families or abused parent. Negotiated approaches to promote family safety and protect children should lead to effective interventions, preferably with the active involvement of the abused parent. However, this can be extremely difficult for survivors because of the disempowering nature of domestic violence and the terror in which many of them live. (For suggestions of sources of Journal of Family Health Care Vol 18 No 1 11 help for survivors, see Resources.) Some women who have been abused by men may find it difficult to trust male professionals who are working in this area of practice.

Ethnic and cultural aspects   
Seeking help can be difficult for survivors from some ethnic minority groups, particularly if they are isolated or in close-knit communities, or they do not know the language and services available18.
Their lives may be under more scrutiny and, in some communities, seeking help from outside may be perceived as bringing shame on them and their families15,18. Services, support groups and refuges exist for some ethnic minority groups, e.g. the Newham Asian Women's Project and the Southall Black Sisters in London, but survivors may not know about them or be able to gain access to them. Abuse and forced marriage of young women is not the sole preserve of any one religion or culture. According to the Foreign and Commonwealth Office32, "the majority of cases in the UK involve South Asian families, and cases have also occurred in the East Asian, Middle Eastern, European and African communities".  When exploring clients' cultural backgrounds and affiliation it is important to be sensitive to how this might influence their behaviour. In some communities, such as those originating in the Asian sub-continent, honour is held to be manifest by the women's behaviour. Women or girls perceived as having transgressed norms set by their communities may well be shunned, abused or even killed for reasons of "so-called honour"33. Young girls may be removed from school to be forced into marriage or to undergo genital mutilation. School nurses, teachers and others in the education services should be aware of the potential risk to girls and young women in their establishments. Mothers may be forced to collude with their children's abduction and forced marriage if they know that they themselves risk violence by refusing to comply. Communities may maintain a conspiracy of silence about these human rights abuses. Some mothers (who may well have been victims of violence themselves) have failed to protect daughters who are perceived as bringing shame to the family or community, or may even have actively participated in their murder34. Living in a rural area can also be a barrier to gaining access to services35. Service providers need to be sensitive to the needs of families who are geographically isolated. Establishing effective professional relationships with vulnerable people can take a long time. When people have had their trust broken and live in fear, it can be difficult for them to make and maintain partnerships with professionals. This is particularly so if they face possible retribution and more violence if the abuser finds out they have sought help. In these situations, offering empathy and respect, and making the boundaries of confidentiality explicit, can go a long way to enabling survivors and their children to begin to share their distress.

Health care: midwives and health visitors   
Survivors and their children often seek help from health care services in the first instance. In the UK all mothers of newborn babies are normally in contact with midwives and health visitors. Health professionals working with families have a duty to be aware of the nature and manifestation of domestic violence and its effects on survivors and their children. Sound midwifery practice includes sensitive routine enquiry at the antenatal booking appointment and later appointments. This should be done for all women, not only where the midwife suspects domestic violence. An enquiry can be helpful when the mother and her midwife have built a relationship of trust. Sometimes midwives may notice that mothers are never allowed private time alone with with the midwife without their partners being present. The midwife may also notice tensions at a home visit that were not evident at the hospital. The demands of a new baby may escalate tensions that could lead to violence. Midwives may notice abdominal and breast injuries36 and perineal injury (Opoku D, personal communication) and should be aware that these are often signs of domestic abuse. These observations need gentle exploration with the mother, away from the potential abuser and/or their families. There is some evidence37 that practitioners are reticent about enquiring into what is still seen in many quarters as a private matter. The Royal College of Midwives' position is that "Midwives may also need to examine their own beliefs and attitudes toward domestic abuse"38. My view is that this is a responsibility for all practitioners who work with families. Richards31 identified six factors that indicate a high risk of homicide by domestic violence (see Table). These include pregnancy and a new birth, escalating physical violence, sexual assault, cultural

Table 1: Factors indicating a high risk of murder by domestic violence31_ Separation
_ Pregnancy
_ Escalation of the violence
_ Cultural issues and isolation
_ Sexual assault
_ Stalking issues and isolation.

The first three are issues that may well bring a woman into contact with the health services, so it is vital that practitioners are aware of the extent and manifestation of domestic violence and its effects on women and children. They must also know what services are available and how to intervene appropriately so that clients gain the care they need. Just to make a note in the person's records is not enough - something must be offered to survivors, even if only the telephone number of a domestic violence helpline. The client can then choose whether or not to take up the offer of help. (For comprehensive guidance on how to inquire about domestic violence and offer help to survivors, see Szaroleta39.) In her study of domestic violence murders, Richards31 recommends that health care practitioners should be taught to include early warning signs of domestic violence in their observations, particularly health visitors as they visit mothers in the early postnatal period.

Practitioners' anxieties 
It is understandable that working with survivors of domestic violence raises anxieties in practitioners. Unconscious responses to this anxiety can lead us to avoid dealing with the matters in hand by adopting strategies that deflect us from our task40. Another possible response is that in our desire to help survivors to be safe, we may try to take charge and direct the person's course of action. This is counterproductive to working in an effective partnership with survivors, who often find it difficult enough to manage everyday demands, let alone to make new, life-changing and possibly even lifethreatening decisions. Some survivors are caught up in an overwhelming problem of family violence that has been a long-standing pattern. When faced with this, practitioners too can feel overwhelmed, mirroring the feelings of helplessness and powerlessness experienced by the family (this process has been explored by Hawkins and Shohet41).

Family violence is a complex human problem that causes misery and distress worldwide. It is morally unjustifiable and, in the United Kingdom, illegal. There is evidence that family violence is known about in the community and by service providers31,10. Enabling the abused parent to be free of the abuse is one of the most effective ways of ensuring their children's safety21.
If professional practitioners in all the human services are to protect children and help their abused parents or carers, we need to be sensitive and open to their needs. We also need to be willing to address our ignorance and fears of family violence. Educating practitioners has been recommended in several reports18,31,10,2.
It is no longer acceptable for practitioners to argue that family violence is a private issue and it is therefore inappropriate for the state or professionals to intervene. Practitioners who take this attitude choose to remain in ignorance of its terrible toll in human misery.
Richards31 points out that "domestic violence is a primary health care issue as well as a social and human right issue". We need to work in partnership with and for those affected by this profoundly disturbing human problem.

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The author gratefully acknowledges the assistance of Daphne Berkovi and of Yvonne Rhoden, Detective Constable, Metropolitan Police Service, in the preparation of this paper.

Some sources of advice and help
English National Domestic Violence Helpline
0808 2000 247
Northern Ireland Women's Aid 24-Hour Domestic Violence Helpline 028 9033 1818
Scottish Domestic Abuse Helpline 0800 027 1234
Wales Domestic Abuse Helpline 0808 80 10 800
The Dyn Wales/Dyn Cymru Helpline 0808 801 0321. (new window)
Forced Marriage Unit (FMU) Foreign and Commonwealth Office, London +44 (0)20 7008 0151
Male Advice and Enquiry Line 0845 064 6800
Newham Asian Women's Project Works with women from the Asian communities  
Police Services Most police services in the United Kingdom have dedicated teams to deal with domestic violence. These are known as Community Safety Teams or Domestic Violence Teams. In an emergency, telephone 999
Refuge A national organisation that provides services to women and children survivors of domestic violence
Southall Black Sisters Services for black women in West London 020-8971 9595
Turning Point Offers help for people in England and Wales with substance misuse difficulties
Women's Aid Provides services to women and children survivors of domestic violence. Operates in England but has links to services in the rest of the UK