Domestic abuse can be defined as any violence between current or former partners in an intimate relationship, wherever and whenever it occurs. The violence can include physical, sexual, emotional or financial abuse. It is a criminal offence that results in two women being murdered by their partner or former partner every week in Britain (Jay and Straw, 1998).

The motivating factor of the abuse is the gaining of power and control over another individual. Most cases of domestic violence, and the most severe, are perpetrated by men against women. Stanko et al (1998) calculated the financial cost to the health service, including employees’ sick leave and absenteeism, was over £5m in 1996.

Prevalence
It is acknowledged that the prevalence of domestic abuse is under-reported because of shame and fear of retaliation, but it is estimated that a quarter of all violent crimes in England and Wales are the result of domestic abuse (Mayhew et al, 1996). Research suggests that 25 per cent of women will experience domestic violence during their lifetimes (Lovendski and Randall, 1993).

The British Crime Survey (Mirlees-Black, 1999) found that housewives and unemployed women were at a higher risk of domestic abuse than women who worked outside of the home, and that women aged 16-24 years had higher reported rates of domestic violence than a correlated older group of women.

Effects on health
Domestic violence is responsible for significant health and social disturbances. There is growing evidence that domestic abuse has long-term implications on the health of women. Abused women often complain of somatic complaints such as low self-esteem and suffer from anxiety, depression, passivity and learned helplessness (Stewart and Cecutti, 1993).

A multitude of physical symptoms may suggest that a woman is being abused (Stanko et al, 1998), including:

– Burns, which may lead to permanent disfiguration;

– Bites;

– Wounds inflicted by an implement such as a knife;

– Fractures of the jaw, arm, leg or ribs;

– Joint and internal injuries.

Sexual violence includes forced anal, oral and vaginal sex and enforced prostitution. Chronic abuse can often result in post-traumatic stress disorder and suicide.

Domestic violence has only recently come on to the agendas of the government and health professionals. The Department of Health acknowledges that almost every woman will access the health care system at some stage in her life, providing an opportunity for any woman who has experienced domestic abuse to receive help and support.

Stenson et al (2001) state that domestic abuse encompasses all aspects of women’s health and suggest that related research involving women should be encouraged. They also add that most women find it entirely acceptable to be asked, in private, about their experiences of domestic abuse. However, there is a paucity of research looking at the effects and prevalence of domestic abuse in general and community medicine.

Gynaecologists can make a significant contribution when it comes to identifying women who are suffering from domestic violence. Abused women may present with persistent gynaecological complaints or with multiple, vague symptoms.

The most common gynaecological disorders are seen more frequently in women who have been physically abused. These symptoms include recurrent urinary tract infections, pelvic inflammatory disease, dyspareunia and pelvic pain. An increase in sexual dysfunction has also been reported.

Abuse in pregnancy
Pregnancy is often the time when violence begins or escalates. Estimates of its prevalence during pregnancy range from 4-20% (Amaro et al, 1990). Obstetric care providers should, therefore, be systematically screening for domestic abuse in all pregnant women.

A number of symptoms may suggest that the woman is experiencing domestic abuse and encourage further investigation. Common injuries in pregnancy include recurrent urinary tract infections, foetal fractures, intrauterine growth retardation, premature labour, placental abruption and stillbirth.

Postnatal complaints may include dyspareunia and pelvic pain, removal of perineal sutures by partner and postnatal depression. Furthermore, the latest maternal mortality report of The Royal College of Obstetricians and Gynaecologists (2001) states that 12 per cent of the women who had died, had previously self-declared that they were victims of violence in the home.

Sociological signs may include the woman being constantly escorted by her partner, several missed appointments, the woman appearing frightened or subservient, self-harm, smoking, and alcohol and substance abuse.

Physical abuse often includes blows to the abdomen, breasts and genitalia. Such violence in pregnancy can have a significant effect not only on the woman but on her developing foetus. The effects can include miscarriage and placental abruption. Babies born to abused women may have a low birthweight, have sustained foetal injury or be stillborn (Morey et al, 1981).

Friends and family often fail to recognise the problem, or ignore it. Consequently the woman enters a cycle of abuse that is difficult to break. It may be some time before the woman feels able to take definitive action and actively seek help to escape from her violent relationship. It is not uncommon for women to suffer decades of domestic abuse without detection.

The coordinator’s responsibilities
The domestic violence coordinator’s role is broad and complex: its remit may include child protection issues as well as mental health issues. Domestic abuse against a female partner is often accompanied by physical and/or sexual abuse of the child and health professionals therefore have a duty under the Children Act 1989 to report any concerns about a child’s safety to social services or the police.

The coordinator’s responsibilities also include education, training and development, multiagency collaboration and the support of health professionals and those affected by the abuse.

The educational priority should be to raise awareness amongst health professionals of the impact that domestic abuse has on health, and to outline the appropriate referral procedures to follow when abuse is encountered. Training can be undertaken with large or small groups, or individually, depending on the organisational structure.

Strategies for the documentation of abuse, referral pathways and staff support should be identified and implemented. The coordinator needs to support and assist health care professionals who will in turn empower and support those women who are experiencing domestic abuse.

Training on the subject of domestic violence is encouraged by most of the professional organisations. The Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Department of Health advocate education and training for all health professionals, and routine investigation for domestic abuse.

However, personal experiences of abuse will have a direct effect on the health professional’s ability to make a clinical decision. Research has found that in order to be able to ask women about their experiences of domestic abuse, health professionals need to have in place a clear and identified system to assist the abused women. Moreover, the system must be both compassionate and effective.

Part of the domestic violence coordinator’s role is to establish multiagency collaboration to facilitate access and referral to the voluntary and statutory agencies within the community so that the immediate needs of a woman and her family are addressed after the disclosure. The coordinator will then be able to disseminate information to all clinical areas and health professionals to promote an autonomous response.

The health service may be the first agency the abused woman contacts and it is imperative that she is believed and receives the appropriate care and protection. The woman is likely to be feeling ashamed and humiliated and health care professionals must be sensitive to this. Some studies have highlighted a need for an identifiable coordinator to offer that initial support.

The impact of domestic abuse on a woman’s mental and physical health is immeasurable, while the financial cost to the NHS is substantial. The government and health care professions have produced guidelines that advocate a proactive approach to domestic abuse. The employment of a domestic violence coordinator is not only cost effective, but is also essential for the implementation of an effective education and training programme that will underpin these professional guidelines.

Conclusion
Domestic abuse has significant long-term health implications. A proactive approach to the detection and prevention of domestic violence needs to be adopted by all health care professionals (see Key Points left). A referral strategy and support network for staff must be in place prior to health professionals asking clients about their past or present experiences of domestic abuse. Indeed, this is essential if professionals are to avoid becoming emotionally burdened by the situation.

Ideally health professionals should be able to address their individual anxieties and concerns in a private and supportive environment. It is recommended that all hospitals have a designated domestic violence coordinator to establish protocols, provide support and coordinate an effective response for all survivors of domestic abuse.

To date there is no ‘gold standard’ for the identification of domestic violence, nor any acknowledged system of data collection or documentation. With a unified approach to domestic abuse and funding available for research, the much-needed best practice guidelines will no doubt be developed.