UEMO Statement on Family Violence

08/02/2011 1517 Views

Introduction

Over recent years, the disclosure and recognition of family violence has increased enormously in countries across Europe . The rates of injury attributable to family violence are now comparable with those caused by traffic accidents and suicide. While the prevalence of intimate partner violence in various studies globally varies from 20 to 50%, respectively, The researchers in the Unites states of America have made a numerical approximation (1,2) Each year, violence within intimate partnerships (IPV) results in an estimated 1,200 deaths, 2 million injuries to women and nearly 600,000 injuries to men. IPV is also associated with certain adverse health conditions and health risk behaviours (1).

Since general practice/family medicine (GP/FM) is generally a person’s first point of contact with the health care system, providing unrestricted access and dealing with all kinds of health problems, regardless of age, sex or any other characteristic of the person concerned, general practitioners/family physicians have a very important role to play in responding to the various presentations of IPV.

An adequate response to family violence poses complex problems which have specific social, moral, geopolitical, historical, economic and psychological dimensions. Violence perpetrated within the domestic environment distorts, and often breaks, family bonds with profound affective, psychological and social repercussions. Domestic violence disrupts the essential bonds of trust, which are the basis of family life, and affects family relationships and their meanings (1).

Definition

The World Health Organization defines violence as: the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation (2). This definition associates intentionality with the committing of the act itself, irrespective of the outcome it produces.

Family violence includes intimate partner violence, child abuse and elder abuse.

There are four main types of violence:

– physical violence
– sexual violence
– psychological violence
– deprivation or neglect

Intimate partner violence (IPV) is defined as threatened, attempted, or completed physical or sexual violence or emotional abuse by a current or former intimate partner. IPV can be committed by a spouse, an ex-spouse, a current or former boyfriend or girlfriend, or a dating partner (1). Intimate partner violence occurs at some point in the lives of one fifth to two fifths of women attending general practice.

Child abuse also includes physical, emotional, and sexual abuse, and neglect.

The signs of physical abuse are usually visible. Emotional abuse may take many forms, such as ignoring, belittling, or intimidation. It negatively affects the development and distorts the positive self-image of the child, leaves long-term consequences, and may lead to risky or aggressive behaviour in adolescence or adulthood. Abuse is defined as a chronic type of behaviour that “erodes and corrodes” the child’s integrity. In the strict sense, the term does not include occasional use of minor physical punishment. Fit mothers react inadequately 10% of the total time spent with the child, as opposed to unfit mothers who do so 80%-90% of the time (3).

Elder abuse is associated with physical and mental health problems, including physical injuries, depression, poor control of chronic diseases, and functional disability. The results of elder abuse can be devastating (4). Elder neglect and abuse have many clinical presentations, ranging from the overt appearance of bruises and fractures, to the subtle appearance of dehydration, depression, and apathy.

Detection

Family violence, neglect and abuse represent a common, widespread and largely unrecognised and undiagnosed problem. In addition to physical injuries, those living in violent relationships have higher than average rates of abdominal pain, urogenital problems, irritable bowel syndrome, chronic pelvic pain, gynaecological problems and psychosomatic problems. In pregnancy, the violence may escalate with higher than average rates of miscarriage, foetal damage and low birth-weight babies. Despite its high prevalence in general practice, GPs /family physicians detect less than 20% of those experiencing family violence, even when there is a physical injury present (5). Many governments are encouraging health professionals to engage in ‘routine enquiry’ for family violence but this remains controversial and the evidence of benefit is equivocal.

Factors contributing to misdiagnosis and underreporting include denial by both the victim and the perpetrator, clinicians’ reluctance to report victims, disbelief by medical providers, and clinicians’ lack of awareness of warning signs. Physical abuse is the most easily recognizable, but psychological abuse is the most common and, like neglect and financial abuse, is easily missed. The consequences of non-diagnosed family violence have an important impact on health services: consultation rates which are almost double the norm, 3-7-times more painkillers prescribed, 2.3-times more tranquilizers prescribed, many unnecessary referrals and diagnostic procedures.

UEMO understands that there are several barriers preventing the early diagnosis of family violence:

a. patient factors: feelings of shame and guilt, fear of consequences, fear of mockery, unresponsiveness, etc,

b. doctor factors: lack of knowledge and skills, lack of time, personal attitude, fear of opening the Pandora’s box, lack of control, infrequent visits, fear of jeopardizing the doctor-patient relationship, feeling powerless, cultural differences, etc.

The GP/FP should clarify the link between traumas suffered and symptoms experienced so that the patient is able to understand that the symptoms they are experiencing are explicable as a recognised human response to life-threatening trauma. The relevance of the patient’s experiences of violence is then clear to both professional and patient. Similarly, the role of intimate partner violence as a potent factor in the patient’s declining self-esteem and in the development of depression becomes clear to both doctor and patient once the doctor’s enquiry about types of trauma the patient may have experienced has elicited a confirmation of family violence from the patient. Again, making the connection with the patient between symptoms and causative trauma may help the patient to make choices about what they do next (5).

The possibility of intimate abuse (in childhood or adulthood) should be considered by clinicians whenever patients have multiple, ill-explained complaints. Multiple injuries and bruising, (especially to face, arms, breasts and abdomen), loss of consciousness, and drunkenness are significant, but non-specific markers of domestic violence. Given that the physical signs of domestic violence have often faded before the victim presents to primary care, health professionals need to be able to detect the longer-lasting psychological scars, such as depression, low self-esteem and PTSD.

Some governments require primary care providers to report suspected violence and abuse but clinicians need to understand that such policies may make those exposed to violence more fearful of seeking help and that this may drive the problem further underground.

Three simple questions when used together can effectively identify lifetime IPV and will aid clinicians’ efforts to identify abuse in women. These questions are:

“Have you ever been in a relationship where your partner has pushed or slapped you?”

“Have you ever been in a relationship where your partner threatened you with violence?”

“Have you ever been in a relationship where your partner has thrown, broken or punched

things?” (6).

Prevention

The links between violence and the interaction between individual factors and the broader social, cultural and economic contexts suggest that addressing risk factors across the various levels of the ecological model may contribute to decreases in more than one type of violence (9).

As violence is a multifaceted problem with biological, psychological, social and environmental roots, it needs to be confronted on several different levels at once. This involves taking steps to modify individual risk behaviours, influencing close personal relationships and working to create healthy family environments, as well as providing professional help and support for dysfunctional families, monitoring public places (schools, workplaces and neighbourhoods) while also addressing the broader contextual problems that might lead to violence. The latter include gender inequality, adverse cultural attitudes and practices, and the larger cultural, social and economic factors that contribute to violence, which require measures to close the gap between the rich and poor and to ensure equitable access to goods, services and opportunities.

• Universal interventions – approaches aimed at groups or the general population without regard to individual risk; examples include violence prevention curricula delivered to all students in a school or children of a particular age and community-wide media campaigns.

• Selected interventions – approaches aimed at those considered to be at heightened risk of violence (having one or more risk factors for violence); an example of such an intervention is training in parenting provided to low income, single parents.

• Indicated interventions – approaches aimed at those who have already demonstrated violent behaviour, such as treatment for perpetrators of domestic violence.

Future steps

• Providing primary preventive measures, support problematic parenting, detecting early violence in the kindergarten, problematic behaviour etc.

• Health professionals playing a major role in recognizing family violence (doctors, nurses, community nurses)

• Action plan within the general/family practice: assure privacy and confidentiality, high index of suspicion, active questioning (vs. screening), respect and validation, using specific tools (Hopkins symptom check list 58, SCL-22), providing a network (existing organisations, social care, legislative demands), assessment and treatment, record keeping, giving support and information, referring when needed, following up.

• Raising public awareness, sensitising the media

• Education of health professionals, adjusting and improving skills, attitudes and knowledge

• Public campaigns

• Establishing networks, guidelines, according to the legislation

• Urge national organisations to take a standpoint on family violence, since as a pattern of behaviour it has broad repercussions in society in general

• Compare the legal situation in different countries and , if needed, campaign for a change in European legislation

UEMO states that a strong role in the detection and prevention of family violence has to be played by general practitioners/family physicians, academic institutions, nongovernmental organizations and international organizations.

UEMO is concerned with the health and wellbeing of European populations. Violence imposes a big burden on that well-being. The objective of all practicing physicians should be to contribute to safe and healthy communities, establish national plans and policies to prevent violence, building important partnerships between sectors and ensuring a proper allocation of resources to prevention efforts.

References:

1. Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence — United States , 2005. MMWR, URL:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm

2. World Health Organization Global Consultation on Violence and Health. Violence: a public health priority. Geneva : WHO; 1996.

3. Aberle N, Ratkovic-Blaževic V, Mitrovic-Dittrich D, Coha R, Stoic A, Bublic J, Boranic M. Emotional and Physical Abuse in Family: Survey among High School Adolescents. Croat Med J. 2007 April; 48(2): 240-248

4. Rodríguez MA, Wallace SP, Woolf NH , Mangione CM. Mandatory Reporting of Elder Abuse: Between a Rock and a Hard Place. Ann Fam Med. 2006; 4(5): 403-409.

5. Levine JM. Elder neglect and abuse. A primer for primary care physicians. Geriatrics. 2003;58(10):37-40, 42-4.

6. Duxbury F. Recognising domestic violence in clinical practice using the diagnoses of posttraumatic stress disorder, depression and low self-esteem .Br J Gen Pract. 2006; 56(525): 294-300.

7. Paranjape A, Liebschutz J. STaT: a three-question screen for intimate partner violence.J Womens Health (Larchmt). 2003;12(3):233-9.

8. Rosin AJ, van Dijk Y. Subtle ethical dilemmas in geriatric management and clinical research. J Med Ethics. 2005;31(6):355-9

Sofia, 1 November, 2008

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