APPENDIX 1
Memorandum submitted by The British Medical
Association
EXECUTIVE SUMMARY
— The impact of domestic abuse (DA)
can vary from person to person, but there is growing evidence
to confirm that it has serious and long-lasting consequences on
the health and wellbeing of the victim and their family members.
The British Medical Association (BMA) has a long-standing interest
in the health of the public and believes that the occurrence of
DA is a serious concern.
— The BMA defines DA as "any incident
of threatening behaviour, violence or abuse (psychological, physical,
sexual, financial or emotional) between adults who are or have
been intimate partners, or family members; regardless of gender,
sexuality, disability, race or religion". DA has been reported
to affect over 350,000 people in England and Wales annually.
— Victims of DA can include pregnant women,
lesbian, gay, bisexual and transgender (LGBT) individuals, minority
ethnic groups, older people and disabled people.
— There is a cost to services as a
consequence of DA—in England and Wales, the total cost of
DA to services amounts to £3.1bn, and a loss to the economy
of £2.7bn per annum. There can also be a serious health impact
to individuals as a result of DA.
— Identification of DA falls largely
to the Primary Healthcare Team (PHCT) and it is essential that
there is a joined up approach across the whole PHCT when dealing
with DA. Respect for confidentiality is essential for the preservation
of trust between patients and healthcare professionals.
— Dealing with DA is not the sole responsibility
of the PHCT as victims of DA will present in numerous healthcare
settings. DA is a multidisciplinary concern.
— The BMA commends the government's
move to develop a multi-agency approach to tackling DA. There
are roles to be played by voluntary and community services, local
authorities and legal agencies in dealing with DA.
— There are a number of recommendations
for the government, chief among these being that it must raise
general awareness of DA, including its prevalence, manifestation
and available support services for victims.
ABOUT THE
BMA
1. The BMA is an independent trade union
and voluntary professional association which represents doctors
from all branches of medicine all over the UK. It has a total
membership of over 139,000.
2. The evidence for this Home Affairs Committee
inquiry originates from the BMA report Domestic Abuse (June 2007)1.
WHAT IS
DA?
3. The BMA defines DA as "any incident
of threatening behaviour, violence or abuse (psychological, physical,
sexual, financial or emotional) between adults who are or have
been intimate partners, or family members; regardless of gender,
sexuality, disability, race or religion".
4. Children are not direct sufferers of
DA, because by definition it occurs between adults, but they are
commonly impacted upon in the family environment.
5. All types of domestic abuse are known
to have a long-term impact on the victims. Physical injury is
likely to be the most life threatening, but this does not mean
that the other types of abuse cause less harm.
HOW COMMON
IS DA?
6. DA has been (under) reported to affect
over 350,000 people in England and Wales annually.2 Recently reported
annual figures show 45,796 such incidents in Scotland3, and 8,565
in Northern Ireland.4
7. It has been estimated that approximately
half a million older people are being abused at any one time in
the United Kingdom (UK), although only a small proportion of victims
will be reported.5 The majority of perpetrators of elder abuse
are family members. The BMA calls for further research into the
true prevalence of elder abuse.
8. No accurate figures exist for the prevalence
of DA as it is grossly under reported to authorities, such as
the police, health service and social services. The British Crime
Survey found that 34 per cent of women, and 62 per cent of men
who had suffered DA at some point since they were 16 years of
age never told anyone other than the survey in question.6
9. Evidence shows that there is increased
prevalence of DA in areas with relatively lower levels of socio-economic
status.7 DA can, however, also occur within professional families,
and this includes healthcare professionals themselves.
Who are the victims of abuse?
10. In the UK, 80 per cent of reported DA
victims are women.8 It is estimated that one in four women and
one in five men have at some point experienced DA by a partner
since the age of 16.9 One in three women seeking emergency medical
care in UK inner city hospitals has suffered DA at some point
in their lives.10
Pregnant women
11. Around 30 per cent of DA begins during
pregnancy.11 Abuse is more common for pregnant women than gestational
diabetes or pre-eclampsia—both conditions for which pregnant
women are routinely screened.12
Lesbian, gay, bisexual and transgender (LGBT)
individuals
12. Partner abuse is as common among same-sex
couples as among heterosexual couples.13 LGBT individuals may
also experience DA perpetrated by family members on grounds of
their sexual orientation.14 The BMA recommends that further research
is carried out into the prevalence and lifetime experience of
gay male victims and transgender victims of DA.
Minority ethnic groups
13. The risk of DA does not differ significantly
by ethnic group.15 Women from black and other minority ethnic
communities experience the same forms of DA as those from all
other communities.
14. Within the Asian community, some women
are expected to uphold the family honour and this may mean tolerating
DA rather than leaving the family home. In extreme cases "honour
crimes" can take place, either in the form of assault or
murder, and DA can occur within forced marriages.16,17
Disabled people
15. Disabled individuals can experience
the same forms of DA as non-disabled individuals but may be more
vulnerable. The BMA has called for research into the experience
of disabled people who are victims of DA.
WHAT IS
THE IMPACT
OF DA?
16. The total cost of DA to services in
England and Wales amounts to £3.1bn, and a loss to the economy
of £2.7bn per annum. Pain and suffering have been estimated
at a further £17bn.18
17. The direct health impact of DA can include
suffering from chronic pain, fractures, arthritis, hearing or
sight deficits, seizures or frequent headaches. The indirect health
outcomes are hypothesised to be caused through stress, and include
stomach ulcers, spastic colon, frequent indigestion and hypertension.19
Self-harm is an indirect health outcome for victims of DA.20
18. DA during pregnancy increases the rate
of miscarriage, low birth weight, premature birth, fetal injury
and fetal death.21 DA can have an indirect effect on the health
of the developing fetus, with an increased likelihood of maternal
smoking and alcohol consumption, in connection with maternal stress.
The fetus may also be indirectly harmed by women being prevented
from seeking or receiving proper antenatal or postpartum medical
care by their abusive partners.
19. A minimum of 750,000 children a year
witness DA, equivalent to about three-quarters of UK DA incidents.22,23
Approximately half the children in such families have themselves
been badly hit or beaten. The BMA has called for DA education
programmes to be implemented in all primary and secondary schools.
HOW CAN
VICTIMS OF
DA BE DETECTED
AND HELPED?
20. Doctors are required to identify signs
of possible abuse and alert the appropriate colleagues and agencies
in a timely fashion, as well as maintain a strong and consistent
focus on the needs of their patients.
21. Healthcare professionals report patient
non-disclosure and fear of offending the patient as two of their
key barriers to asking patients about DA.24 Doctors who have received
training are much more likely to ask patients about DA, and as
such are more likely to have patients who disclose abuse.25
22. Medical providers are well placed to
identify and intervene on behalf of patients who are experiencing
DA. All healthcare professionals should practise selective enquiry[1],
and routine enquiry[2]
should be considered in a number of different settings. The BMA
recommends that all healthcare professionals give the clear message
that DA is unacceptable and not the victim's fault and ensure
that they ask patients appropriate questions in a sensitive and
non-threatening manner. Healthcare professionals must recognise
that men can also be victims of DA and should therefore be questioned
if DA is suspected.
23. Victims of DA are most likely to have
told their own friends, relatives or neighbours. Only a minority
of victims approach the health service.26 Patients want their
doctor to offer referral to appropriate specialist services and
24-hour access to professional advocates who understand DA.27
24. Identification of DA falls largely to
the PHCT; which, as well as GPs includes practice nurses, midwives
and health visitors, all of whom may identify DA through their
contacts with families with young children. It is critical that
there is a joined-up approach to dealing with DA across the whole
PHCT.
WHAT ARE
THE ETHICAL
CONSIDERATIONS?
25. Respect for confidentiality is an essential
requirement for the preservation of trust between patients and
healthcare professionals. Providing that consent is gained from
the patient there is no problem in disclosing information to a
third party. The right to confidentiality, however, is not absolute
and may be overridden when the rights of others to be protected
from harm are jeopardised in a serious way. All healthcare professionals
must therefore understand and be honest with patients about the
limits to confidentiality.
26. While the safety of a domestic abuse
victim and their children is of primary importance in all cases
of domestic abuse, healthcare professionals also have a duty to
meet the healthcare needs of patients who are perpetrators of
abuse.
HOW CAN
SPECIALIST HEALTHCARE
SERVICES HELP
VICTIMS?
27. Dealing with DA is not the sole responsibility
of PHCT. Given that victims of DA will present in numerous different
healthcare settings, such as a hospital accident and emergency
(A&E) department, an obstetrician appointment, or a midwifery
home visit, it is a multidisciplinary concern. Staff working in
all areas of the health service who are likely to encounter DA
should be educated about it and trained to help victims. In addition
to meeting the specific medical needs of their patients the BMA
has called for all healthcare professionals to take a consistent
approach to the referral of patients to specialist DA services.
The accident and emergency department
28. Over one per cent of A&E department
visits are due to DA. To put this in context, an A&E department
with 55,000 patients of all ages attending during one year would
see over 500 adult patients suffering due to DA.28 It is important
that emergency doctors know how to create the opportunity and
environment for a patient to disclose DA, so that self-reported
victims can be offered help.
Obstetrics and gynaecology
29. Obstetricians are the key healthcare
professionals in contact with women with, or at high risk of,
complications during pregnancy, and are therefore in an opportune
position to identify victims of DA. All pregnant women should
have at least one consultation with the lead healthcare professional
during the pregnancy which is not attended by the partner or any
family member.29
30. Gynaecologists are likely to encounter
women suffering from STIs and, due to the association between
STIs and DA, are in an important position to identify cases of
DA.
Midwifery
31. Pregnancy may trigger or exacerbate
DA;30,31 hence midwives should play a pivotal role in its detection
and management. All Trusts should be working towards routine enquiry
in maternity services and midwives should acknowledge their key
role to play within it.
Psychiatry
32. DA can have long-term consequences on
the mental health of its victims. Over a third of female victims
of DA and a tenth of male victims are likely to suffer (self-defined)
emotional problems as a result.32
33. Psychiatrists are in a key position
to not only treat the mental health disorders caused as a result
of DA, but also to spot the warning signs. Understanding the psychology
of both the perpetrator and the victim is critical for effective
treatment, and additionally psychiatrists must be aware of the
potential impact of DA on children's mental health.
Nursing and health visiting
34. Nurses may often be the first people,
outside of the family to discover that DA is occurring. Community
nurses are ideally placed to deal with cases of DA mainly due
to their ongoing relationship with their patient.33 Practice nurses
within GP surgeries are largely involved with well-women care
and are therefore in a position to see a female patient without
the presence of a family member or partner. School nurses must
be aware of the impact DA can have on children.
WHICH SERVICES
HELP VICTIMS
AND HOW
DO THEY
COLLABORATE?
35. The BMA commends the government's move
to develop a multi-agency approach to tackling DA. Due to this
approach, however, the numerous services available to support
a victim may be difficult to navigate. The Home Office promotes
the importance of DA advocates who should be independent and act
on behalf of the victim.34 Healthcare professionals have a responsibility
to refer patients disclosing DA to an expert DA agency which can
offer specialised help and support.
Voluntary and community services
36. The voluntary and community sector is
a major provider of specialist services to victims and perpetrators
of DA. Voluntary and community organisations can provide helplines
as well as advocacy and outreach responses to DA.
Local authorities
37. An individual may be considered homeless
if they live in accommodation where it is probable that living
there will lead to abuse. A local authority is obliged to provide
advice about finding somewhere else to live, and the DA victim
may be entitled to emergency accommodation.
38. Following disclosure of DA, a GP may
refer the case to social services with (or sometimes without)
the consent of the patient. Social services primarily become involved
in cases of DA when children are at risk.
39. As part of a local authority's DA preventive
strategy they may provide programmes for perpetrators of DA. Such
programmes are designed to help change the behaviour of the perpetrator
and to enable them to develop respectful, non-abusive relationships.
The BMA has called for research into the effective treatment and
interventions for perpetrators of DA.
Legal agencies
40. Prosecutors striving to gain protection
for DA victims may rely heavily on a doctor's medical records.
Such medical reports must be written promptly and must contain
all the facts. Doctors must record what they saw, observed and
heard.35
RECOMMENDATIONS
41. The BMA recommends that the government
should:
— raise general awareness of DA, including
its prevalence, manifestation and available support services for
victims
— ensure strategies to address DA are
explicitly highlighted in public health strategies
— develop a more structured and statutory
basis for addressing DA at the local level in a similar manner
to the policies in existence for child protection
— recognise that men are also victims
of DA and take this into consideration when developing policy
to address this concern
— work to identify and combat the barriers
to reporting DA.
— promote a "zero-tolerance"
attitude to DA.
42. The BMA recommends that the rights afforded
to transgender individuals by the Gender Recognition Act 2004
should be proactively implemented, for example refuges must be
more accessible to transgender individuals.
43. The BMA calls for further work in order
to:
— ensure that information about support
services is readily available in healthcare settings such as GP
surgeries, A&E units and maternity departments
— raise awareness of the scale of DA
among LGBT individuals
— break down the barriers for such
individuals to access the services and protection they need
— empower victims to report the abuse
to the police.
3 September 2007
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1 Selective enquiry involves asking women directly
about their experiences, if any, of DA where there are concerns
or suspicions, including visible signs/symptoms. Back
2
Routine enquiry about DA (within vulnerable groups), commonly
known as "screening", may help increase the rates of
identification. Back
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