Domestic violence is a major health, legal, social and economic issue for our community. It is the leading preventable contributor to death, disability and illness in Victorian women aged 15–44 years old.1 The overwhelming majority of victim/ survivors are women and the highest risk times are during pregnancy or post separation. For women who experienced partner violence: 54 per cent reported experiencing violence by a previous partner during pregnancy and approximately 25 per cent for the first time while pregnant.2
Domestic violence is essentially an abuse of power by a family member that can take many forms, including intimidation, threats, coercion, control, isolation and emotional, physical, sexual, spiritual or financial abuse. Domestic violence is common. Victoria Police attend 385 incidents related to family violence per week.3
Domestic violence and the workplace
The International Violence Against Women Survey (IVAWS) found experience of domestic violence varied little according to education, status or household income.4 5 Up to two-thirds of women who report violence by a partner are currently in paid employment. Domestic violence can disrupt the economic lives of working women and can, therefore, serve to make women more dependent on the perpetrators of the violence and less financially independent.
Domestic violence can also occur in the workplace. The perpetrator may feel that he needs to assert control over the woman and make her dependent, thus her work is an impediment to his control. Attending work can make a woman particularly vulnerable, since there is a set location and work hours, often with easy public access for the perpetrator. Repeated unwanted attention that is intimidating and creates fear is commonly experienced at the workplace. In severe cases, murders within the context of intimate partner violence have occurred at work.6
An employee experiencing domestic violence is likely to struggle with decreased work performance. Controlling behaviour by the perpetrator may include monitoring the victim/survivor through phone calls, emails, texts and in person. The victim/ survivor may require increased leave, including sick leave and leave for medical, and legal consultations and court appearances. Perpetrators have been reported to interfere with women’s work efforts through sleep deprivation, inflicting injuries, reneging on agreements around childminding and physically preventing women from leaving their homes.
Of those surveyed, 25–50 per cent of victim/survivors report having lost a job partly owing to family violence.7 Victim/ survivors may be disadvantaged in the labour market owing to disrupted work histories and are more often employed in part-time and casual work.8
Domestic violence is one of the leading causes of homelessness, with up to 30 per cent of all Australians receiving assistance from homelessness services citing domestic violence as the reason.9
Health Justice Partnerships
The disease burden attributed to ‘unjust inequalities’ reaches at least 17 per cent in Australian studies.10 Our patients who present with a medical issue may also have underlying legal problems that need to be addressed in order to improve their health and wellbeing. Victim/survivors are particularly vulnerable to substantial and multiple legal problems and they often face barriers to accessing the legal system. Doctors can no longer ignore the importance of legal assistance in improving health outcomes for their patients. Australian research shows in the region of 27 per cent of people requiring legal services turn to a trusted healthcare or welfare provider for advice.11 Studies in the USA have found that increased provision of legal services was one of three key factors contributing to the decline of violence against women by their intimate partners.12
Boston-based paediatrician Dr Barry Zuckerman was the pioneer who, in 1993, created a model to integrate free legal advice into a medical clinic.13 This model has been replicated in 276 healthcare institutions in 36 states across the USA.14 He has unleashed a global phenomenon that has now been embraced by innovative Australian healthcare and legal providers: Health Justice Partnerships (HJPs).
Acting on the Warning Signs
Inner Melbourne Community Legal (IMCL) is a not-for-profit community organisation that has been a foundation player in the creation of HJPs in Australia. IMCL currently conducts several HJPs providing free legal advice to patients including one at the Royal Women’s Hospital (RWH), the Acting on the Warning Signs Project (AWSP). The great bulk of the legal work performed at RWH involves patients with family violence issues.
A major role of the AWSP is the education of health professionals to recognise and respond to patients who have been subjected to domestic violence. To date, more than 200 members of staff have been trained. Specific training for doctors has also been developed and received RANZCOG accreditation, with almost 30 doctors taking part to date.
From 1 July 2012 to 25 May 2015, IMCL provided 214 instances of legal advice onsite at the RWH. For over half of those, the lawyer considered that the client may have been affected by family violence.
The majority of issues arising at the onsite legal service include birth certificates, family law and child support, child contact and divorce, family violence, and fines. A number of other issues have also arisen, including: consumer complaints, credit and debt, discrimination, DNA testing, employment, government pensions/ benefits, criminal matters and tenancy. IMCL does not provide assistance to patients in relation to complaints against the hospital; medical negligence; business and commercial matters or personal injury matters such as TAC or WorkCover.
Many of the patients seen by IMCL lawyers are vulnerable and disenfranchised and a substantial number are unemployed or struggling in low income, casual or insecure employment. We have chosen a case to illustrate the complexity and difficulty of their personal and economic lives – see Box 1.
How can clinicians respond?
Doctors may feel impotent in helping women – whether they are patients, co- workers or employees – with domestic violence issues. They fear that they are involving themselves in a private matter that has no relevance to work or they do not have the skill set to handle the situation.
There are several ways in which we can make a practical difference to decrease the risks of domestic violence. The World Health Organization (WHO) identifies LIVES as a practical reminder of core elements of first response in situations where a clinician suspects that a woman may be impacted by violence.15
There are five core components of LIVES:
- Inquire about needs and concerns
- Enhance safety
The areas of response are relevant in the context of a patient-clinician response or, more broadly, for example, in interactions with a co-worker or employee.
It is important to actively inquire in situations where it is safe to do so (when a woman is on her own and in private). Be confident and comfortable asking questions about family violence and respect the woman’s wishes and decisions. Actively listen, including paying attention to body language. The doctor can, through empathy, demonstrate understanding of how the woman feels.
Inquire about needs and concerns
This process can enhance the woman’s control over all decisions relating to her care. The healthcare professional should outline the limits of confidentiality – for example, in situations where children are at risk.16
Box 1. May’s story
May* first came in contact with the police when she called to ask them to stop her boyfriend, Troy*, from assaulting her and damaging her property. When the police arrived, May was concerned her boyfriend would be charged with a criminal offence and did not assist with their enquiries. The police then applied for family violence intervention orders for both May and her boyfriend and they were advised of the upcoming court date.
An intervention order is made if the Court is satisfied, on the balance of probabilities, the respondent has committed family violence against the affected family member and is likely to continue to do so or do so again. The conditions of an intervention order can be broad or narrow. Breach of an intervention order is a criminal offence and the penalty for a breach can be imprisonment, a fine or both.
Because neither May nor Troy wanted intervention orders to be made, they did not attend Court and interim orders were made that prevented May and Troy from contacting or seeing each other. May and Troy still wanted to be together and they arranged to meet up. During the meeting they had another argument and Troy was concerned that May would report him to the police and he would be charged with breaching the intervention order, so he went to the police and made a false report that May had slapped him when they had met.
As a result of this false report, May was charged with assault and they were both charged with breaching court orders. May and Troy both still had limited intervention orders protecting them from each other, but these had now been revised so they could continue to communicate. The day before May was due to go to court in relation to the criminal charges, May saw a lawyer from IMCL at RWH. May had just given birth to a daughter and was now engaged to Troy. Troy had stopped drinking and they were attending couples counselling.
IMCL helped May to adjourn her matter and then started to negotiate with the police on her behalf. IMCL argued that the issuing of intervention orders for both parties against each other by Victoria Police is in breach of their Code of Practice for the Investigation of Family Violence and, on this basis, IMCL requested that the charges be withdrawn. By this stage, Troy had been charged with assault and property damage from the initial night when May called the police. Troy had also made a statement of no complaint regarding the false report he had made to the police about May slapping him.
After IMCL negotiating and attending court on May’s behalf, both charges against her were withdrawn. This means that May does not have a criminal record and will not face any problems in the future in gaining employment or travelling overseas.
*Names have been changed.
It is important to provide a response that is both supportive and educative. Part of this is emphasising that she is not to blame for the situation of violence that she finds herself in.
The first step is to assess immediate risk. Engage the woman in developing a plan to protect herself from further harm if violence reoccurs. Connect (with consent) women in crisis or in fear of their lives to specialist family violence services. The doctor should document interactions and safety plans.
Refer (with the woman’s consent) her to specialist support services such as: psychologist, crisis centres, social worker and legal services. The doctor should document this referral.
Domestic violence has a significant impact on women. It may be an issue for our patients, our colleagues or our co- workers. Responses for our patients include integrating legal services into the medical care setting.
Healthcare professionals and lawyers can make powerful allies with significant political clout when they have a common purpose. The collaborative Health Justice Partnerships make good sense for improving the health and working lives of our patients. In order to best target our resources, good-quality research in this area needs to be encouraged.
Box 2. Dr Olivia’s story
My only experience with violence was at a particularly vulnerable time of my intern year when I was making a career choice to step into obstetrics and gynaecology training. The perpetrator, sadly, was none other than my own husband, the one person I should have been able to trust fully. It started off in small ways as passive aggression at first, then expressions of uncontrollable rage, belittling words about my long hours or extreme tiredness on occasion. This quickly progressed to rough handling, often knocking me around. With time, threatening me with sharp weapons became commonplace and I became terrified to share a home with him.
I felt too ashamed to talk to anyone about it at work and did not engage in any work-related social occasions for fear that others would see my cuts. I became very good at covering up his behaviour with excuses to my family as well. My personality changed, I avoided friends; my work suffered, I could not concentrate and every sign of patient distress would dissolve me into tears as my own tears were always very close to the surface. My husband never came to my work or harassed me in the workplace. He always picked me up in the car after work though. My self-esteem was at its worst and I could not see any future beyond my sad life.
As I transitioned from internship into a resident obstetrics rotation, I found great joy in what I did on one hand, but the rapidly deteriorating home situation came to a head, making me need to pull away from work for a period of time. It was a very difficult time as I finally faced up to the increasingly violent behaviour from my husband and made the hard decision to quit the marriage. I was very concerned about a disruption in my career, particularly how the gap would be viewed in my curriculum vitae. I considered my legal options, including an intervention order, but instead one day went to my parents’ house and finally told them the whole story. I never went back to the house I had shared with my husband.
My family was very supportive, their love was unconditional and they helped me to see a future. I took an extended period of leave from work during that time and moved away, leaving all my familiar surroundings. Serendipitously, my travels found me working in an unaccredited job in obstetrics. Instinctively, I knew then this was what I would do for the rest of my life. I got a fresh lease of life in this new world; I found new purpose, which helped heal many of the recent wounds. As the months rolled by, I could not stop learning and every day had again begun to be joyful for me. I decided to enrol in a new research study in obstetrics overseas in this unexpected gap year. I finally had something to look forward to beyond this failed marriage. Slowly my personality and confidence returned, I came back to my hometown and applied into RANZCOG training, knowing that I had a purpose and a destination.
As I write this today, I still carry a few visible physical scars, but they are more a show of strength for me now, as I know that the bully is the coward. I have been fortunate that I did not become embittered, or fearful for the rest of my life as a result of those difficult experiences. I am a consultant obstetrician and doing what I have always wanted to do. Joy, compassion and self-confidence are mine again. My career in obstetrics saved me and restored me.
Olivia is a pseudonym.
The authors would like to thank ‘May’ and ‘Olivia’ for their consent to publish their stories and Prof Kelsey Hegarty for her advice. Finally, thank you to Ms Anne Dive (social worker FMU) for inspiring Dr Woodrow to write the article on domestic violence and HJPs for her medical colleagues.