Societal context

Domestic abuse (DA) against women has occurred throughout the ages with evidence from religious texts,1 literature2 and legislation suggesting it was often culturally, socially and legally acceptable.

Women in the 19th century were widely seen as their husband's possessions, with a wife's legal rights and obligations being subsumed by her spouse.3 Despite a mid-1800s Act of Parliament specifying the punishment a violent husband would receive,4 in practice, domestic violence (DV) was still accepted, as evidenced by a civic regulation in London forbidding wife beating after 21:00 because of noise disturbance.5

Women's status improved considerably in the 20th century. The Sexual Offences Act, 1956 set out the first legal definition of rape making incest, sex with a girl under 16 years old, sex without consent and drug-facilitated sexual assault, illegal. In 1991, marital rape was finally criminalised.

This century has seen continued progress. In 2013, the definition of DA was revised, lowering the age to 16 and widening the scope to encompass psychological, physical, sexual, financial or emotional abuse, as well as coercive control, stalking and harassment, so-called ‘honour-based’ crimes, female genital mutilation and forced marriages.6 In 2014, the DV Disclosure scheme (known as Clare's Law) came into effect (whereby police can share information about previous DA history with a partner, in response to a disclosure request) and DV Protection Orders give police power to prevent a perpetrator having contact with the survivor for up to 28 days following a DA incident. In 2015, the Serious Crime Act was amended to include DA as a criminal act in its own right.

Legislation has moved forward, but inevitably it takes longer for these changes to trickle through into social norms. There remains a high prevalence of DA occurring in all parts of our society, affecting women and men of all ages, sexual orientation and cultural and socioeconomic backgrounds.

Prevalence

In the UK, over one in four women (28.3%)7 has experienced DA at some point since the age of 16 and on average two women are killed by a partner or ex-partner every week in England and Wales8 (approximately 40% of all female homicides9). Worldwide, DA remains the leading cause of morbidity in women aged 19–44 years, greater than cancer, war and car accidents.10

Although the majority of DA is carried out by men on women, with 97% of perpetrators being male, we must not forget male survivors. Nearly one in six men (14.7%) in the UK have a lifetime experience of DA9 and the rates in men who have sex with men (MSM) are much higher, with 50% affected.11 The transgender population is the most vulnerable, with 66% having experienced DA at some point since the age of 16 years old.12

Why does DA matter to healthcare professionals?

The consequences of DA are far-reaching for the survivor, their families and for society.

DA is associated with high prevalence of mental health issues (including anxiety, depression, substance misuse and suicide), as well as physical injuries and many other health issues (including chronic pain syndromes, migraines, hearing loss and cognitive problems).13 Thirty per cent of DA in women starts during pregnancy and DA results in poor pregnancy outcomes.14

DA survivors have much higher usage of general medical and mental healthcare services with the cost to the National Health Service estimated at £2 billion annually.15 The National Institute for Health and Care Excellence (NICE) therefore states, ‘even marginally effective interventions are cost effective’.16

Why does DA matter specifically to GUM/HIV physicians?

DA is particularly relevant to GU/HIV professionals. Nearly one in two female genitourinary medicine (GUM) clinic attendees report a lifetime experience of DA, almost twice that of the general female population.17 Similar rates are seen in HIV-positive women,18 with even higher rates seen in HIV-positive MSM.19

Female DA survivors have 5 times higher rates of unintended pregnancies,20 3 times higher STI acquisition risk21 and a 1.5 times increased risk of acquiring HIV.13 This may be because fear of precipitating or escalating DA results in the loss of sexual decision-making capacity.22 The perpetrator may assert contraceptive control23 and there are higher rates of non-consensual sex. The fear of violence makes it difficult for a survivor to disclose an STI or HIV status to a partner, comply with medication or advice or attend follow-up appointments, which may ultimately result in poor sexual health outcomes.19 DA is also associated with recurrent urinary tract infections, chronic pelvic pain, sexual function issues, menstrual irregularities and cervical neoplasia, issues commonly affecting sexual health service (SHS) attendees.13 ,24

How do we identify DA?

There is a spectrum of DA identification approaches. At one end, spontaneous DA disclosures do occur, but very rarely.25 Targeted enquiry (where specific patient cohorts, eg, commercial sex workers, are asked about DA) is limited to the cohort. Case-based enquiry (where patients with DA risk indicators, eg, bruising, anxiety or frequently missed appointments, are asked) relies on staff being familiar with the many risk indicators and consistently vigilant, which is difficult under time pressure. Notably, a study reviewing practices by general practitioners (GP) using a case-based enquiry approach showed just 5% of female and 3% of male patients had ever been asked about DA by their GP.26

At the other end of the spectrum is routine enquiry (where all patients are asked about DA). The NICE 2014 DA guidance explicitly states that ‘routine enquiry is recommended in SHS’.21

Routine enquiry gives all patients the opportunity to discuss something normally perceived to be off-limits without feeling stereotyped or judged. It takes the guesswork out of DA identification as there is no need to look for risk indicators and there is a reduced risk that the window of opportunity to ask DA survivors will be missed. Studies have shown most patients would accept and even expect to be asked about DA, as long as this is done in a safe and confidential environment by trained professional staff.27

Despite the NICE guidance, doctors tend to be sceptical about routine enquiry. Some perceive DA to be a social care issue, but it has been suggested that DA identification may improve new-to-follow-up ratios by identifying the root cause of patients attending with recurrent STIs, multiple terminations of pregnancy, sexual function issues or non-compliance to medication.

Doctors' reservations may also reflect concerns about the time implications and feeling inadequately equipped to manage a DA disclosure. DA training can address these issues by demonstrating how to enquire and respond to a disclosure, clarifying that DA enquiry does not take long. There is no expectation that SHS will manage the chain of activity following DA disclosure; the key is to have established referrals pathways to services that can help.

DA enquiry in SHS can also provide ‘added value’ for commissioners, and contribute to local authorities' requirement to provide evidence they are addressing DA policies. This may benefit services coming up for retender.

Safe implementation

Given the prevalence of DA in SHS attendees, we are all seeing patients experiencing DA. Whatever our approach to identification, we need to ensure that the enquiry and management of a disclosure is carried out safely, by trained individuals.

Worryingly, only half the GU clinics responding to a 2012 national survey had provided any staff training on DA, while just one in five had DA guidelines.28 Departmental DA guidelines and a management flow chart, with clear onward referral pathways and good links with relevant services, are essential. Staff must receive DA training on how to safely enquire and respond to, document and manage DA disclosures. Staff also require regular training updates and ongoing support and supervision.

Recognising the challenges of implementing safe DA enquiry, the BASHH Sexual Violence (SV) group has compiled a BASHH-endorsed document ‘Responding to domestic abuse in sexual health settings, 2016’. This free resource is available on the SV group page of the BASHH website, providing information on how to roll out DA enquiry safely within SHS, for those services that want to do so.

Lastly, the BASHH SV group will be holding a BASHH Scientific Meeting, with the BASHH Sexual Function Special Interest Group, in October 2016 at the Royal Society of Medicine, London, where the SV group will focus on DA. We hope to see you there.

If you or someone you know is affected by DA, you can contact the 24 hours National DV helpline on 0808 2000 247 or access the BASHH SV group for more resources.