‘Child abuse’ is a topic about which clinicians will be well informed. There are protocols relating to the management of patients suspected of having sustained non-accidental injuries and clinical staff will be expected, as part of mandatory training, to receive education in this area. Domestic abuse (DA) is an under-reported, but relatively common problem and has many implications in the management of traumatic injuries in adults. The objective of this paper is to discuss the aetiology, history and presentation of patients who have been subjected to domestic abuse, and to help provide a strategy for their management.
Clinical Relevance: Domestic abuse is a relatively common problem and, as such, dentists should be aware of this important area and how to manage patients they suspect of having been abused, or who inform them that they have been subjected to DA.
Article
Dentists have a pivotal role to play in the identification of domestic violence because dental and/or facial injury may provide the only contact point with professionals who could recognize the signs and intervene.1
Definition
The Government defines domestic abuse as ‘any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between partners (sixteen years and over) who have been in intimate relationships or between family members (eighteen years and over) regardless of gender and sexuality.2 Family members include close family, ie parents, siblings, grandparents, in-laws and step-family. It can involve a range of abusive behaviours, not all of which are seen as being individually violent.3
Domestic abuse is far ranging and can include forced marriages and ‘honour’ crimes.2 It can happen to a man or a woman, and be perpetrated by a man or a woman, with children often being affected as well. It creates a dynamic of power imbalance (Figure 1),4 the pattern of violence being all important; the victim is the person who is being controlled and living in fear. This may not be the same person who is the victim in a single incident.2
Figure 1. Power Wheel.4
Prevalence of domestic abuse
Domestic abuse affects millions of people per year; two women are killed every week by a current or former partner.5 A Home Office survey suggests that around one in four women and one in seven men have been victims of domestic abuse.2 There is a one in five chance of a woman being injured during an episode of domestic abuse and a one in ten chance for a man.2 It is the most common cause of non-fatal injury, and on average a victim will have received 35 assaults before he/she calls the police.2
There is, furthermore, increasing evidence of chronic, severe and often long-term adverse mental health and physical effects for both victims and their children.6 More than half of all child protection cases involve domestic abuse.5 Ninety per cent of children are in the same or next room when domestic abuse occurs.5
Causes
Domestic abuse can be caused by:
Physical attack either – Blunt Trauma, ie a fist, bottle, sticks, or Penetrative Trauma, ie a knife, or a Combination of the two;
Physical domination;
Sexual assault, through any kind of forced sexual contact of any kind;
Threats/pressure tactics – hurting the person or someone he/she cares about – this may be physical, emotional, sexual, etc;
Children having injuries that would be unusual for their stage of development;
Relationships with their children or partners may be different from other relationships, ie they may seem withdrawn.8
From reviewing the available literature on physical injuries caused by domestic abuse it can be seen that the majority of patients, 61–94%,9 who come through emergency departments suffering from some form of domestic abuse have some form of head, neck or facial injury.
Studies on injuries caused by domestic abuse suggest that the majority of patients, 61–89% (dependent on the research paper),10 receive a soft tissue injury. The majority of these, 67%,10 are caused by the fist. Facial fracture patterns are similar to those suffered in an assault, thus the left side of the face is more often affected, as most assailants are right-handed.10 From the literature, when a patient suffers a facial injury the most common area affected is the midface; especially common are nasal fractures, which account for 40%.8 Condylar process fractures are the most common mandibular fractures to occur.10
Case studies
In the last three years, Norfolk and Norwich University Hospital, which serves a catchment area of around 655,000 patients, have had a few explicit cases of domestic abuse causing facial fractures and several cases which could have been caused by domestic abuse, a couple of examples are included below.
Case 1
A 20-year-old female, who was drinking in a local nightspot and had been taking drugs, got into an argument with her boyfriend who head-butted her, leaving her with facial bruising, lateral subconjunctival haemorrhage, paraesthesia in the right infra-orbital nerve region and a right infra-orbital rim fracture (Figure 2).
Figure 2. OM view of fracture of the right infra-orbital rim.
Case 2
A 71-year-old female was assaulted by her schizophrenic son who had been out drinking. This left her with a right mandibular body fracture (Figure 3) and tender and swollen right ribs.
Figure 3.
(a, b) Fracture of the right angle of the mandible.
Importance to GDPs
As you can see, it is of the utmost importance to develop a practice protocol for domestic abuse. Table 1 gives useful helplines and websites that could be incorporated into practice policy.
Respect (for people who are abusive to partners and want to stop)
0808 802 4040
http://www.respect.uk.net
The Domestic Violence Forum will be able to direct you to local support available.
Dentists can help patients by providing information on how to contact the appropriate local services either:
Directly;
Via anti-domestic violence abuse posters in waiting areas;
Having information of national/local helplines in the toilets, eg posters on the back of the toilet door or leaflets by the hand-driers are useful.
All staff members who have direct patient contact should have training and education. To increase awareness and improve staff response by informing them what to do if:
They are concerned about a patient suffering from domestic abuse;
A patient tells them that they are a victim of domestic abuse.
This will improve the provision of support to those suffering from domestic abuse, ie both adults and children affected.11 Giving employees a copy of the Department of Health's Responding to Domestic Abuse: A Handbook for Health Professionals can help with this training.
Suggested management
It is not acceptable to assume that another service, eg social services, will be doing something. Dentists do not need to give direct advice, as those people who leave a relationship which has been subject to domestic abuse are at increased risk of assault; not only for themselves but also their children.12
If you are worried that a patient may be suffering from domestic abuse there is a Department of Health booklet5 to help you deal with this situation. You should:
Treat the physical injuries;
Ask about and document the history of any injuries and how they were sustained.
If you are worried that a patient is undergoing domestic abuse with no physical sign, this enquiry must be handled sympathetically, owing to the sensitivity surrounding domestic abuse. The patient will need to be in a comfortable, safe and private environment. It should take place at a time and place away from the suspected assailant or other family members, as the patient may be attending with the assailant. A more senior member of the clinical or nursing staff may have experience of these situations and thus be in a better position to obtain a full history of the events. Some patients may not be ready to tell someone initially; if this is the case then you should remain sympathetic. It may be at a later stage that the patient feels able to inform you of the real cause of his/her problems.6 The following factors should be considered:
Ensure the safety of the patient and any children involved;
Refer them to the correct agencies, eg if you suspect the patient has been raped or sexually assaulted they can call their local sexual assault referral centre for help;
Be non-judgemental;
Be supportive and reassuring.
Do not encourage a victim of domestic violence to leave an abusive relationship. This may escalate the frequency of violence and put the victim and his/her children at greater risk of harm.
In addition, the treatment of any physical injuries may be handled as follows:
Treat any lacerations and/or facial injuries; this may mean referral;
Ensure that you treat the patient without making them feel uncomfortable. This will help the victim feel safe and able to come back for reviews or further treatment.
These patients may have other social problems, ie alcohol and drug problems. You will need to ensure that:
They have capacity to consent for treatment. This may mean you have to wait to gain consent;
They may have psychological problems which may make them harder to treat and deal with. Remember, no matter what they have been through, they shouldn't make you feel uncomfortable or threatened doing your job;
They may be slow to heal and be at increased risk of infection, eg the need to stop smoking needs to be reinforced.
Summary
In summary, domestic abuse is present in the UK population, therefore, a general practitioner may well treat a patient who is affected by domestic abuse. The main concern is that the whole team is aware of how to deal with a patient suffering from domestic abuse or, if it is suspected, how he/she may be affected. The priority is providing a supportive and safe environment for both adults and children affected and to know where to refer these patients to for further assistance.
