Victims of domestic violence and coercive control are more likely to disclose their experience to a healthcare practitioner than to any other service provider. Health and social care professionals can play a role in detecting intimate partner violence and raising the alarm. Ruth Geraghty looks at the research, and summarises six key messages.
In January 2021, the first Irish conviction under new coercive control legislation resulted in a 10½ year jail sentence for the perpetrator. Coverage of this landmark case highlighted the key role played by an emergency medicine consultant in detecting the abuse and raising the alarm. Research has consistently found that victims of domestic violence and coercive control are more likely to disclose their experience to a healthcare practitioner than to any other service provider. Health and social care services therefore present a key opportunity to detect and respond to domestic violence.
What we mean by Intimate Partner Violence
Intimate Partner Violence (IPV) refers to any behaviour within an intimate relationship that causes physical, sexual, psychological or financial harm to those in the relationship. The legislation applies to all types of intimate relationship, regardless of marital status, sexual orientation, whether the couple are cohabiting, and is applicable to either a current or previous relationship. In 2020, CES undertook a rapid review of the evidence on intimate partner violence as part of our Access Evidence series of evidence briefs for frontline practitioners in health and social services.
The role of frontline practitioners
Health and social care practitioners play an important role in recognising the signs and symptoms of IPV. They may want to have a greater understanding of some of the risk factors in order to recognise the warning signs, and to determine what they can do to support someone experiencing IPV. Practitioners should also have a good knowledge of local agencies, services and networks for domestic violence, so that a person experiencing IPV can be referred to the support and services they need wherever possible.
Our review of the evidence, which includes guidance materials from statutory and voluntary agencies, highlights the following six messages.
1. The victim may find it hard to seek help:
Estimates for help seeking are very low, ranging from 4% to 27% and many victims never disclose their experience of IPV to anyone. The reasons include fears about social stigma, retaliatory violence, and fear of setting in motion a process they will no longer have control over, such as the involvement of social services. Public discourses about IPV frequently depict victims as young, heterosexual females. People who do not fit this profile (male victims, older victims, victims from same sex couples, for example) can find it especially difficult to seek help. Safe Ireland provides information for professionals on recognising and responding to IPV.
2. The strongest determinant of disclosure is clinician inquiry:
While universal screening for domestic violence is not recommended or evidenced by the research, it has been found that most women do not object to being asked about domestic violence. The guidance literature recommends asking simple, direct questions. The HSE Practice Guide on Domestic, Sexual and Gender Based Violence provides guidance on asking about IPV.
3. The victim may not be thinking of leaving their abuser:
A victim may have very practical reasons for remaining in an abusive relationship, and what might be interpreted as inaction may in fact be the result of a calculated assessment. They may fear for their safety or that of their children and other dependents. They may not want to break up the family, or may be under pressure from extended family or their community to stay in the abusive relationship. They may be hopeful that the abuse will resolve on its own over time. Minority groups are particularly vulnerable due to social isolation, their dependence on the perpetrator and restricted access to support services.
4. Help seeking is a journey:
Help seeking involves a series of judgments and actions, rather than a single event. A victim may leave and return to the abusive relationship a number of times. Abuse tends to be cyclical in nature, where violent episodes are followed by periods of perpetrator remorse. Once in a ‘cold state’, the victim may feel overwhelmed or unable to engage in a drawn out criminal justice procedure, causing them to retract their statement. Many victims do eventually leave, often after a trigger, excuse or an opportunity arises, such as the need to protect a child, or a particularly severe incident of abuse.
5. The victim is best placed to know when the time is right to act:
The research highlights the victim’s sense of risk as an important factor in determining the likelihood of re-assault. A risk assessment provides a framework by which a practitioner can identify the signs of escalating violence and take the appropriate response. A risk assessment should also take account of whether there are children or other vulnerable adults in the household, and whether any of the abuse has been extremely physical or life threatening. The HSE National Domestic, Sexual and Gender-Based Violence Training Resource Manual provides guidance to front line practitioners on conducting a risk assessment. If the victim and family members, are not in immediate danger, the health and social practitioner, as a social prescriber, can refer the victim to support services for domestic violence. COSC provides a list of local and national domestic violence services and general support services.
6. The most dangerous time is when the victim is about to leave and the 12 months following separation:
There can be an intensification of abuse during the period of separation, particularly if the perpetrator feels they are losing control of the victim. Digital technology can provide the perpetrator with a means of terrorising their ex-partner, such as sending threatening messages, stalking, and posting, or threatening to post, sexually explicit visual material online. The behaviours associated with IPV typically precede intimate partner homicide. In the UK, between 2009 and 2015, 76% of women who were killed by their ex-partner or ex-spouse were killed within the first year of their separation; a third were killed within a month. According to the Australia study, Just to Say Goodbye (2013), children are at a particular risk at the time of separation, especially in relation to ‘retaliatory filicide’ where “children are killed by abusive fathers as an act of revenge against the mother after separation”.
The way in which a health or social care practitioner responds to a disclosure of IPV is of vital importance as it can influence the next steps the victim takes. Even providing information on domestic violence support services (or the victim's local refuge) is a good outcome, with due care for confidentiality and protection from retaliatory violence. In recent years, a number of training materials have been created for practitioners and for other settings where domestic violence may become apparent, such as the workplace. In-person training can often be provided from domestic violence support services, on request. Domestic Violence Advocacy Service (DVAS) and Safe Ireland have created a short film called Help her To Tell which illustrates how a health professional can support a person experiencing IPV to contact a dedicated domestic violence service.
Download the full tip sheet below. The evidence review on Intimate Partner Violence will be available on the CES website in 2021. Other Access Evidence resources are available here.
