MJA
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The impact of domestic violence on individuals

Jill Astbury, Judy Atkinson, Janet E Duke, Patricia L Easteal, Susan E Kurrle, Paul R Tait and Jane Turner
Med J Aust 2000; 173 (8): 427-431.
Published online: 16 October 2000
Domestic Violence Icon Medicine and the Community

The impact of domestic violence on individuals

Jill Astbury, Judy Atkinson, Janet E Duke, Patricia L Easteal
Susan E Kurrle, Paul R Tait and Jane Turner

MJA 2000; 173: 427-431
See Articles 1, 3 and 4 of this series

Abstract - Children - Pregnant women - Elderly people - Indigenous people - People of non-English-speaking background - The need for change - References - Authors' details
- - More articles on Aboriginal health

Abstract
  • There is extensive evidence of the adverse effects of domestic violence across all age groups and cultural backgrounds.
  • The impact of domestic violence may be long-term, affecting emotional adjustment, physical health and subsequent relationships.
  • Health professionals should be aware of the confounding effect of youth, age and cultural diversity on presentation.
  • Shame and isolation militate against disclosure.
  • Specific, sensitive questioning that incorporates awareness of cultural and social issues is essential to detect domestic violence and initiate appropriate assistance.

 
  If the idea of "home" implies physical and psychological safety and security as well as shelter, then a child, adult or older person affected by domestic violence experiences a hidden "homelessness".1

Domestic violence occurs across the lifespan2 and across most cultures. Women are at a disproportionately high risk of physical, sexual and psychological violence from an intimate person such as a partner or ex-partner.3 Many children, too, are likely to experience violence from someone they know or be witnesses to violence within their families.4

Domestic violence may be physical, sexual or psychological, but all three can be present. What is subjectively defined and identified as "domestic violence" by victims can be strongly mediated by cultural beliefs, values and previous experience of abuse and may not coincide with standard clinical or research definitions. Domestic violence is always characterised by the use of coercive control and psychological abuse.5,6 Victimisation is associated with alterations in the perception of the perpetrator, especially a belief in his or her omnipotence, and alterations in the victim's perception of self. Feelings of self-blame, shame and loss of self-esteem are extremely common. At the same time, psychological defenses used to cope with violence include denial of its existence and minimisation of its severity.7 Acts of contrition and intermittent kindness by the perpetrator can maintain the relationship and give false hope to the abused person that the violence will end.

In addition to the common features of domestic violence, there are important aspects of domestic violence that are characteristic of specific groups in society, such as children, pregnant women, the elderly, Indigenous people, and people of non-English-speaking background. Here we examine some of the specific problems of each of these groups in more detail.

 
Children Children can be at risk of experiencing and witnessing violence within the family or from those known to them.8 The perpetrator is usually in a caring role or a position of trust in relation to the child.

Children can be the direct targets of physical violence or can get hurt when they try to protect another family member, often the mother, or try to stop their parents from fighting. It is becoming increasingly apparent that domestic violence results in a similar outcome for many children, whether they are direct victims or only witnesses of the violence. A number of authors have pointed to a clear link between domestic violence and child abuse, with one being a predictor of the other: it has been estimated that children living in domestic violence situations are up to 15 times more likely to be abused or neglected than children from non-violent homes.9-11

Behavioural and psychological consequences of childhood violence include poor school performance, bedwetting, aggression (particularly among males), temper tantrums, oppositional behaviour, self-blame, guilt for the violence between parents, isolation from peers, self-harming behaviour, running away, psychosomatic symptoms, stealing, over-eating, depression, sleep disturbances and excessive anxiety symptoms (see Box 1). Violence by a person in a position of trust impairs the child's ability to trust others and increases the risk of victimisation in later life.12

Recent research has shown that there are significant and possibly persistent neurobiological effects of trauma experienced in early childhood. Work by Perry and others13,14 has demonstrated the importance of critical periods of exposure to secure parenting: exposure to recurring traumatic experiences in early childhood places a child at much greater risk of long-term psychological, emotional and behavioural problems.

The type of violence is not the primary factor determining long-term outcome. More important predictors are the duration of violence, its severity and frequency. The cumulative impact of exposure to multiple adverse experiences (eg, violence, psychological or sexual abuse, substance misuse) in childhood is predictive of adverse health outcomes in adult life. In a large US study it was found that exposure to four or more categories of adverse childhood experiences was associated with a 4-12-fold increased risk of alcoholism, drug abuse, depression and attempted suicide.15

Protective factors include a healthy relationship with a primary carer, good social support and positive subsequent life experiences.8,12

 

Pregnant women
  The number of unwanted or unplanned pregnancies and terminations is higher among women experiencing domestic violence.16,17 Pregnancy itself is a time of heightened risk and the abdomen is targeted more frequently and more severely in pregnant women.18,19 The Women's Safety Australia survey4 found that, of all the women who reported violence occurring at some time in their lives, 42% were pregnant at the time. Twenty per cent reported that violence occurred for the first time during the pregnancy, although the strongest predictor of violence occurring during pregnancy is a prior history of abuse.12 Furthermore, women abused during pregnancy are at even greater risk of violence in the postpartum period.19

Women experiencing violence during pregnancy often obtain minimal or late antenatal care.20 They are at increased risk of having poor weight gain, anaemia, infections, or preterm labour; of bearing a low birthweight infant; and experiencing postnatal depression.18,21-23 They are also more likely to engage in behaviours harmful to health, such as smoking, drinking excessive amounts of alcohol, and substance misuse.18,21-23

 

Elderly people
  Abuse of elderly people is the most recent form of familial violence to come to public attention but it remains a largely hidden problem. Most community-based studies have shown that similar proportions of older men and women are victimised (in contrast to the younger population, in which the number of women experiencing domestic violence is greater than the number of men).24 Close family members (the victim's spouse, adult child or other relative) constitute the majority of abusers and usually live with the victim.25 The reasons for elder abuse are often related to their dependence on others (due to physical or mental impairment, particularly dementia), psychopathology in the abuser, or a long history of family violence26 (see Box 2). Many instances of elder abuse are "victim-victim" situations in which abusers may themselves be worn-out carers.

Physical consequences include the actual injuries inflicted (eg, bruising, lacerations, fractures, or burns) as well as the results of neglect, such as malnutrition, decubitus ulceration, and inappropriate use of medication. Older people who are frail may sustain major injuries from an apparently minor cause -- for instance, a shove leading to a fall may result in a fatal subdural haemorrhage.

Abuse may also have psychological consequences: feelings commonly experienced are a sense of powerlessness, shame at having to admit that the abuse is occurring at the hands of close family members, fear of retaliation from the abuser, and particularly fear of institutionalisation if the abuse is reported. Such fears increase the victim's reluctance to report abuse,27 often causing a self-imposed isolation.

Control by the abuser may be exercised financially through the improper use of an older person's property or finances or misuse of a power of attorney, or may take the form of neglect whereby the necessities of life (adequate food, clothing, medication, or other care) are withheld by a caregiver.28

 

Indigenous people
  Domestic violence in Indigenous families and communities in Australia is presently at a level for serious concern.29,30 In 1990, an Aboriginal and Torres Strait Islander Commission briefing document advised the Australian Aboriginal Affairs Council that "the increasing injuries and fatalities as a result of interpersonal violence have risen to levels which not only impair life but also threaten the continued existence of Australian Indigenous peoples".31

Physical assault is commonly associated with psychological abuse, and Indigenous victims of domestic violence (who are mainly women) may view themselves as being of little worth, incompetent, and deserving of abuse.32 The situation becomes more complex when racism and discrimination in social control structures are intertwined with domestic violence32 (see Box 3).

Domestic violence in Indigenous communities can only be understood in the context of the historical, political, social and cultural environments in which it occurs.34 Colonisation has had a disastrous impact on the lives of Indigenous people: it has created complex and cumulative forms of traumatic stress that may be articulated as physical, emotional and spiritual distress; misuse of alcohol and other drugs; and violent behaviour arising from a rage that is directed towards the self and other close family members.35 With the breakdown of cultural lore, behaviours that were previously functional in conflict resolution processes have become unstructured and damaging when used under the influence of alcohol or other drugs.36 John Cawte, a psychiatrist and anthropologist, identifies Indigenous communities as suffering from "gross stress", a form of post-traumatic stress disorder in which individuals express their loss and bewilderment as emotional and behavioural disorders.37

Indigenous women are less likely than non-Indigenous women to report an assault, and less likely to seek medical help unless they have severe injuries.38 Historical interactions with police, who were used by the state to forcibly remove Indigenous children under government assimilation policies, and deaths of Indigenous people in custody continue to engender a deep mistrust of law enforcement officials.39 Indigenous women fear for their own safety40 and the safety of other family members if police or social welfare officials become involved. While some Indigenous women may call the police to intervene in violent situations, they are less likely than non-Indigenous women to want to lay charges, and there is a general belief that charging or incarcerating Indigenous men does not reduce male violence. Indigenous women are more likely to ask for other interventions in which their partner also receives help for his drinking and/or violent behaviour.32

People who have been traumatised through violence are more likely to be treated as if they are mentally ill or unstable than to be provided with programs that will meet their needs; however, recent program initiatives in Australia are beginning to respond to the specific and unique needs of Indigenous peoples.29

 

People of non-English-speaking background
  The extent of domestic violence experienced in Australia by people of non-English-speaking background has not been extensively studied. However, research suggests that overseas-born males are more likely to commit partner homicide than would be expected from their numbers in the general community.41 This may reflect a higher rate of domestic violence among overseas-born women. Alternatively, these women may be less likely to leave violent situations, and therefore experience escalating violence.

For those who are migrants, the strain of migration may compound the problem. However, in most cases in which a couple migrated together, the abuse preceded migration.42 Once in Australia, however, the migrant family may undergo further stresses as traditional gender roles shift. This may encompass unemployment or downward shifts in employment status for men, and paid employment for women. Assimilation of the younger generation into the broader Australian culture may further erode traditional hierarchies based on age and sex. Women who may be at particular risk include Asian women sponsored by non-Asian men,43 and Middle Eastern women brought to Australia for arranged marriages to Middle Eastern men already residing here.42 Such women have not only left behind their family and supports, but have joined partners whose established community networks may not recognise their needs. In some instances, their partner's extended family may collude in the violence, overtly or indirectly, by not offering support.42

Disclosure of domestic violence towards women of non-English-speaking background is inhibited if they have poor command of English (Box 4). For some women, however, the issue is more fundamental -- their concept of sexual assault within marriage may be very different from current Australian values and norms.44 Over 70% of migrant women have minimal knowledge of the legal rights of victims of domestic violence,45 which further inhibits disclosure, and many know little about support services or refuges. Women from Middle Eastern and Latin American cultural backgrounds who experience domestic violence are often reluctant to contact police, in part because they have witnessed oppression or torture at the hands of police in their country of origin.42

Domestic violence often creates a feeling of shame. There may be considerable pressure for a woman to maintain a marriage, and she may fear being deported.46 She may feel the burden of providing financial support for family in her country of origin,47 and consider that their plight outweighs any consideration of personal needs. The erosion of self-esteem accompanying domestic violence is compounded if the woman is isolated by virtue of limited English and lack of family and friends in whom to confide. The adverse health effects are similar to those experienced by abused women in the broader Australian society, although they may be exacerbated by longer delay in disclosure.

 

The need for change
  Each of the specific groups examined has characteristic issues related to their experience of domestic violence. Nevertheless, the need for change applies equally to all groups. Patients are reluctant to disclose violence if not asked,48 but sensitive questioning can legitimate and encourage disclosure. As the Council on Scientific Affairs of the American Medical Association has observed, knowledge of a history of abuse can provide "the starting point from which to disentangle a confusion of presenting complaints and symptoms".49

Clinical practice and medical education programs in Australia have been slow to respond to the large body of research confirming the harmful health effects of domestic violence. Failure by healthcare providers to detect and treat those affected by domestic violence exacerbates the harm done in several ways. Firstly, the complexity of violence-related negative health outcomes increases if abuse remains undetected. Secondly, the drain on healthcare resources increases as victims present repeatedly to primary and emergency healthcare providers. (Conversely, victims' uptake of preventive healthcare is considerably lower than average, and the role of violence in their "non-compliance" with preventive health behaviours can easily be missed.) Thirdly, non-detection ensures that treatments are necessarily directed at the symptoms rather than the cause.1

A thorough understanding of the multiple adverse health effects and high rate of physical and psychological comorbidity associated with domestic violence must be acquired by all healthcare professionals. Training is required in every aspect of treatment, including initial questioning, counselling and responding to those who do disclose violence, and providing appropriate assistance, including safety plans and advocacy on behalf of patients. A number of our medical colleges have begun this necessary task. In clinical care, the concept of meaningful assistance to patients with health needs associated with domestic violence deserves to be strongly promoted.

 
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Authors' details
  Key Centre for Women's Health in Society, University of Melbourne, Carlton, VIC.
Jill Astbury, MEd, PhD, Associate Professor.

Cooperative Research Centre for Rainforest Ecology and Management, Cairns, QLD.
Judy Atkinson, PhD, Senior Research Officer, Aboriginal Liaison.

Harley Medical Chambers, Fitzroy, VIC.
Janet E Duke, FRANZCOG, FRCOG.

Faculty of Law, Australian National University, Canberra, ACT.
Patricia Easteal, PhD, Visiting Fellow.

Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby, NSW.
Susan E Kurrle, MB BS, DipGerMed, Director and Senior Staff Specialist.

Child Protection Unit, New Children's Hospital, Westmead, NSW.
Paul R Tait, MB BS, FRACP, Head.

Department of Psychiatry, Royal Brisbane Hospital, Herston, QLD.
Jane Turner, MB BS, FRANZCP, Senior Lecturer.

Reprints will not be available from the authors.
Correspondence: Associate Professor J Astbury, Key Centre for Women's Health in Society, 720 Swanston Street, Carlton, VIC 3053.
j.astburyATkcwh.unimelb.edu.au

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1: Illustrative case of domestic violence involving children

Nine-week-old baby "Lee" was taken to the family's general practitioner by her mother, "Anna", who stated that Lee was waking throughout the night and hard to settle. The GP noted some old and new bruising on Lee's head and trunk and asked Anna about these. She stated that Lee had tipped out of a bassinet down some stairs and also tended to bruise easily. Concerned about the possibility of child abuse, the GP referred Lee to the local hospital emergency department and notified the Department of Community Services. Lee was found to have skull and rib fractures and a subdural haematoma. Coagulation studies were normal. Anna was depressed and tearful on presentation. She admitted to the social worker that on several occasions she had "lost it" with Lee and thrown her down into her cot. She said her husband was away for long hours at work and she felt isolated. She later disclosed a long history of verbal, physical and sexual assault by her husband. He was often short-tempered and verbally intimidating towards her and their two-year-old son (who was described as being "very scared" of his father). She had had postnatal depression following the delivery of her first child. It was later learned that Anna had grown up in a family where domestic violence had occurred regularly.
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2: Illustrative case of domestic violence involving an elderly person

"Mrs Jones" is an 84-year-old widow with moderate Alzheimer disease. Until recently, she had been living alone, and was managing quite well with assistance from community services and regular visits from her general practitioner. Then her daughter moved in with her, ostensibly to care for her. Her daughter cancelled all services and suggested to the GP that his regular visits were unnecessary. Three months later, one of Mrs Jones' neighbours contacted her GP. He was concerned that Mrs Jones appeared to have lost a lot of weight and was often seen in her backyard crying. The GP visited and was reluctantly admitted to the house by Mrs Jones' daughter. The GP noted that Mrs Jones had indeed lost weight, and she appeared unkempt and had facial bruising. Her mental state had markedly deteriorated. Arrangements were made for Mrs Jones to be admitted to hospital, where she was found to be malnourished, to have an untreated wrist fracture and to have bruising over her trunk and face.
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3: Illustrative case of domestic violence involving Indigenous people

"Eva" has been married for nearly 25 years and has been beaten many times and subjected to different forms of abuse by her husband. She has seven children, and prides herself on being a strong Aboriginal woman, a "survivor". She stays in the relationship because "all kids need a father". Calling the police has therefore never been an option when she is being assaulted. Nor would calling the police be of any help. They are already constantly involved in her life, and judge her as being "a bad mother", "a troublemaker" and "emotionally unstable". Her sons are all in trouble with the law for their public behaviour, which is often violent. They are either in jail or in juvenile detention centres, on remand or parole. On release from jail they go back into a family environment that provokes distress and anger. Her eldest son has just served his second jail term for assault, after stabbing a person who said something against his father. He unsuccessfully attempted suicide in jail. He grieves for the loss of relationship with his father and continually attempts to establish some nurturing communication. He says he wants to get married and have a happy life, but all his relationships with young women have ended because of his violence. His mother, whom he has seen bashed many times, is angry at the juvenile justice system, Corrective Services and other state agencies because they just lock her children up without helping them to stop their offending behaviours. She is more involved with her own day-to-day survival than being able to think through how she can help them "break their cycle".33

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4: Illustrative case of domestic violence involving a woman of non-English-speaking background presenting in general practice

"Ruziye" is a Turkish migrant sponsored by her Turkish-Australian husband, to whom she has been married for 18 months. She presents to a general practitioner with a complaint of rectal bleeding and extreme pain. Her husband enters the surgery with her.

Background
Ruziye's file indicates that she has seen the doctor for vaginal bleeding on several prior occasions.
   
Consultation  
GP: Mr Amir, I would prefer to see your wife alone.
Husband: Her English is not good. I can do translating.
GP: That's OK. I have learned to talk to patients from non-English-speaking backgrounds and require that the consultation takes place between Ruziye and myself. [Husband reluctantly leaves the office]
GP: When did the bleeding and soreness begin?
Ruziye: A few days ago.
GP: How did it start?
Ruziye: My husband he likes to, you know, that part of me. This is hard to say. Where I come from, we do not talk about these things.
GP: I understand that it is not easy for you. To help you though I do need to have an understanding of what has happened.
Ruziye: Yes, I see. He does push hard and it hurts.
GP: Do you ask him to stop?
Ruziye: I tried once but he said it is my duty as his wife.
GP: Well, Ruziye, in Australia, it is actually not your duty. In fact, we have laws that say you can say "no" to your husband and if he still does it, he is breaking the law.
Ruziye: I did not know this. But in my family, you have to stay married and I have nowhere to go anyway.
GP: There is help for you, Ruziye. If you decide that he is hurting you and that you want to leave, I can give you a pamphlet that lists places and people that will help you.
Ruziye: Thank you doctor.
   
Ruziye returned to the doctor several times over the next year with similar problems. Each time, the doctor gently talked to her about marital rape and other types of violence.
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