• women
• prevention
• health serv research

Domestic violence and abuse (DVA) destroys lives. It can take many forms, including physical, sexual and psychological abuse, but at its heart is the use of power and control to deprive survivors of the right to their own bodies and futures. DVA exacts a heavy toll on the mental and physical health of survivors and their families, and for an average of two women a week, it is fatal.1

DVA is highly prevalent, particularly among women.2 It accounts for 11% of all crimes reported to police in England and Wales, and more than one in four women and around one in six men have experienced DVA since the age of 16.2 However, official figures are likely to be an underestimate, because much DVA remains hidden.2 Survivors may not disclose or report DVA out of fear for their own or their family’s safety, but also out of feelings of self-blame or fear of stigma.3 The isolating nature of DVA (often a deliberate tactic) can further reduce the likelihood of a survivor disclosing abuse or seeking help unprompted, but receiving information about DVA and support options or making contact with professionals from DVA services—if that is what the survivor wants—can be life-changing.

Sexual health practitioners have a key role to play in supporting DVA survivors to access advocacy services. Three-quarters of women would welcome being asked about DVA by a healthcare professional,4 and gynaecological and sexual health problems are the most consistent and long-lasting physical health differences between DVA survivors and other women.5 Survivors are more likely to experience STIs, including HIV, urinary tract infections and unintended pregnancy, to name but a few examples.6

The National Institute for Health and Care Excellence identifies sexual health services as a setting in which all service users should be asked about DVA, regardless of whether indicators of abuse are present or not.7 Guidance developed by BASHH similarly recommends DVA enquiry, but acknowledges that this is not without its challenges.5 Sexual health professionals receive little training in DVA8 and staff may be uncomfortable about asking, uncertain about responding to disclosure and lack knowledge about management and referral. There are also time and cost implications for the recommended routine enquiry. An intervention that could help to overcome these challenges and optimise outcomes for survivors is therefore welcome and is the subject of two papers published in this issue of the journal.

Sohal and colleagues8 report on the feasibility of adapting an existing model used in general practice, Identification and Referral to Improve Safety (IRIS). IRIS is an intervention including all staff training, patient information materials, an enquiry prompt added to the electronic patient record and a simple referral pathway to a DVA advocate employed by a local service. In a randomised controlled trial,9 IRIS helped to identify three times as many women and resulted in six times as many referrals compared with usual practice. IRIS has been endorsed by the Royal College of General Practitioners and is commissioned at more than 1000 General Practice surgeries.8

The adapted model IRIS Assessing for Domestic Violence in Sexual Health Environments (IRIS ADViSE) shows promising potential in sexual health services. The pilot study conducted at two female walk-in services found it was feasible to develop an intervention based on IRIS, which increased the rate of enquiry, identification of survivors and referral to specialist support. This increase in enquiry rate was marked (from 10% up to 61%) when it was made mandatory to record whether or not DVA had been asked about.8 As well as having a favourable effect on clinician behaviour, this measure was generally positively received by clinicians participating in the pilot, as reported in the accompanying qualitative analysis by Horwood et al. 10 Participants also responded favourably to the training, and felt more confident, both around asking about DVA and managing disclosures.

However, the challenge of the additional time needed to enquire and manage disclosure, particularly in ‘high-risk’ cases or those involving children, was felt strongly by participants. Some responded to this challenge by using their clinical judgement to selectively enquire about DVA, and while this approach may seem to be the only pragmatic option under increasing time pressures, it is not recommended practice.7 Anyone can be subject to DVA regardless of race, ethnicity, class or lifestyle, and routine enquiry is therefore the ideal strategy to identify survivors. However, this must be supported by policymakers and within service level agreements, as Horwood et al argue. Funding is a key consideration for the sustainability of IRIS ADViSE, both for training of sexual health staff and for the provision of linked DVA advocates. DVA funding from local authorities is increasingly precarious, and the most recent data show that a third of DVA organisations are running an area of service without dedicated funding.11

As Sohal et al point out, further research is required to fully confirm the applicability of IRIS ADViSE for specific sexual health settings. In the meantime, services wishing to implement some form of routine DVA enquiry may consider the Ask–Validate–Assess–Action model (as recommended by BASHH)5 which is described by Pathak et al in an article published recently in this journal.12

Sexual health practitioners are particularly adept at working in diverse populations and with vulnerable groups and are thus well placed and well qualified to identify and support survivors of DVA. The studies published in the current edition of this journal will contribute to ongoing efforts to help survivors regain control of their lives — but a sustained commitment from commissioners and employers to support front-line clinicians in this work will be the key to maximising the huge potential benefit of such interventions.