22 October 2020
Article from October 2020 edition of INPractice
Shocking new revelations have emerged about the true ugliness of domestic and family violence with physical attacks on the torsos and wombs of pregnant women a frightening trend.
"Generally, the research is that one in four women would be experiencing domestic and family violence," said Dr Kristina Birchmore, manager of Women Safety Strategy at Adelaide's Women's and Children's Health Network (WCHN).
'When they look at research around hospital presentations and they compare pregnant versus non-pregnant women, pregnant women are more likely to have a trunk (torso) assault whereas non-pregnant women are more likely to experience assaults to their extremities, such as their hands," she says.
"For some women pregnancy will be the time they first experience physical violence. For other women who have a history of domestic and family violence, where there's pregnancy violence escalates as well."
An attack on the trunk is often an attempt to kill the foetus. And the sad statistical reality is a woman is killed by her partner every nine days in Australia.
According to the Australian Institute of Health and Welfare, there were 25,000 sexual assaults reported to police in 2017; and 2.2 million Australians have experienced physical or sexual violence from a previous or current partner. Indigenous people are 32 times more likely to be hospitalised through family violence than non-Indigenous people.
While domestic and family violence incidents against women is one in four, for men the figure is one in 16, with the perpetrator usually being another male.
The Institute of Health and Welfare also reports that up to 3.6 million Australians have experienced emotional abuse from a partner, and 2.2 million have experienced sexual violence since the age of 15.
The Women's Health Service also briefly saw a rise in strangulations during COVID, with 32 cases assessed, triaged and treated in May. This was up from t 4 cases in April and 18 in March. There were 36 cases in February.
Only five people presented for strangulation in both June and July.
Experts warn that even playful strangulation among mutually consenting partners can have serious consequences.
"Research from the US estimates it takes 20 pounds of pressure to open a can of Coca-Cola, just four pounds of pressure to block the jugular vein and 11 pounds of pressure to block the carotid artery in the neck, a consequence of this could be stroke, said WCHN Interpersonal Violence Forensic Nurse Practitioner Tracey Markham, of the Yarrow Place Rape and Sexual Assault Service.
The Family Court top judge Chief Justice Will Alstergren said in August household violence following the pandemic lockdown was at a 30-year high.
The other tragedy around domestic and family violence is only a very small proportion of victims report it to police.
As a consequence, the WCHN has adopted an international evidence-based training guideline centred on protecting abused women and the development of a screening tool, 'Ask, Assess, Respond to Domestic Violence, to identify at-risk women.
The tool, a specialised series of questions, Is embedded as routine practice to screen all women aged over 16 who present at the Women's and Children's Hospital for any reason, including pregnancy.
The Women's and Children's Hospital became an accredited White Ribbon Workplace in 2017, recognised for its efforts in taking active steps to stop violence against women.
The new WCHN push against violence forms part of an internationally acclaimed program, Best Practice Spotlight Organisation® (BPSO®}, which aims to drive nursing and midwifery education to ever higher levels and achieve greater health results.
The ANMF (SA Branch) is the Australian host of the Best Practice Spotlight Organisation® - a program founded by the Registered Nurses· Association of Ontario (RNAO) that leads the way for health providers to improve patient outcomes through the implementation of evidencebased best practice guidelines (BPGs).
"Woman Abuse is the third 'Best Practice· guideline implemented across the WCHN to complete the site transition to become an accredited International Best Practice Spotlight Organisation® (BPSO®). The program has already seen a substantial increase in women seeking help from appropriate services.
Dr Birchmore says the screening process has "absolutely" been successful in getting more and more women into appropriate services.
"Going out to outreach clinics in domestic violence accommodation, we have seen women who haven't had health care in years: said Ms Markham. ·one, they might not have been allowed (by their partner) to access or present alone to a GP or health service because or the risk they might tell someone what's happening or their life was too erratic and often health care wasn't first priority.
"And we've picked up breast changes, cervical changes, STIs (sexually transmitted infections) and symptom-related health issues from the impact of violence they weren't aware of.
There is a strong correlation between domestic and sexual violence and STls, namely because consent is often lacking.
"I think the other thing that has given us traction (in combating domestic and family violence) is changes in legislation. In January 31, 2019, the legislation changed where strangulation was considered a crime and can hold a maximum of seven years imprisonment ... in the context of domestic and family violence," said Ruth Steer, acting manager of the Port Adelaide based Women's Health Service, also part of the Women's and Children's Health Network (WCHN).
The Best Practice DFV: AAR (Domestic and Family Violence: Ask, Assess and Respond) training entails empowering health care staff with the expertise and confidence to be alert to and respond to potential victims of abuse.
Domestic abuse isn't just about physical violence. It's also about emotional and psychological abuse, financial control, sexual assault/coercion and reproductive control. White Ribbon training highlighted that some WCHN staff didn't recognise they were in a DFV situation" said WCHN nurse consultant Anita Minkus.
"Chiefly thinking about the Women's and Children's Hospital. That is one of the risk factors, is that men might withhold contraception and get women pregnant on purpose ... therefore they have control. That's quite a huge thing," Ms Markham says.
"People don't always recognise their relationship could be characterised as domestic and family violence because they have a whole lot of community ideas that support what's going on, Dr Birchmore says.
"So, one of the things that can demonstrate that is this idea around 'Oh, he loves me so much he wants to know where I am all the time'.
'He loves me and he's just so jealous, that's just a sign of how much he really loves me.
"It's about behaviour that is to control and instil a sense of fear for that person that they're living with. It's so subtle and then you make excuses, 'Oh it's only because of that, it's something to do with me'."
Adds Ms Markham: "I know when I see women in the community for sexual assault and/or domestic violence, and you talk to them about it not being their fault, I often have to talk about vulnerability versus responsibility, so they understand it is not their fault. It's nice when you see that lightbulb moment and they realise they are not responsible and it was a crime committed against them.
"I hope when they leave they feel different and they feel a little bit more empowered and they feel a little bit more in control of the decisions they're making around their own health care."
"When we think about South Australia we're really lucky in that we've 901 some state-wide responses. One of those state-wide responses is the Family Safety Framework (a reporting tool) and the other is the Multi Agency Protection Service," Ms Markham says.
"Our division not only does training in our network, we do training all across South Australia for medical students, police, the schools, community workers and country areas. Next week I'm doing training for Whyalla, this will be done via Zoom due to COVID-19. Normally I would head out there."
"One of the things we are really clear about is there is significant domestic and family violence in the community and they need a health response. So we're there to provide that response, for sexual assault and domestic and family violence," Dr Birchmore says.
"I think we have tangible evidence of changes in understanding for health care professionals. People talking about their knowledge and confidence ... not feeling very confident and then post-training feeling confident and able to respond.
"You can't ask and you shouldn't ask about domestic and family violence unless you have a response. So in SA we have a stale-wide response and secondly we need to have a workforce that's confident. So that's where we are at the moment. is really building a confident workforce to be able to ask and then link services. We're one of the services that people can link to."
"We ask questions like has a partner or significant other ever made you feel afraid, hurt you physically, thrown something at you?'," Ms Markham adds. "We talk about emotional safety, 'has he ever humiliated you, called you names, put you down?'. If the answers are 'yes' then a further risk assessment is done: "They can come to Women's Health for domestic violence injury documentation or Yarrow Place (in the event of rape and sexual assault) and have injury documentation which includes photographs and a health assessment which can be used in court." Ms Steer says.
Another major issue facing women, and directly linked to domestic and family violence, ,s their own childhood trauma. "When we look now at what is the No.1 risk factor for women it's child abuse and neglect, and then it's illicit drug use and then it's domestic and family violence," Dr Birchmore says.
Children are also victims of violence within their own household and the long-term consequences for their psychological wellbeing can be devastating, even fatal.
"And it's one of the things that drives me utterly insane in health," Ms Markham adds.
"If you go to a hospital/GP or other health professional , in gathering health histories they ask you if you smoke. ask you about diseases and all sorts of health questions related to your history, but they never ask you about childhood trauma.
"Childhood trauma including sexual abuse, domestic violence and neglect is one of the leading causes of health issues that can last a lifetime and can increase the risk of drug and alcohol abuse, smoking, and can dramatically increase the risk of other health conditions such as heart disease, stroke. cancer, diabetes and mental health conditions.
"Every nurse, midwife and other health professionals I provide training to, I always encourage them to ask questions about past trauma that may have impacted someone's life. It may just provide more answers to the health history."
The WCHN is continuing to offer training on their Evidence-based Best Practice Domestic and Family Violence: Ask. Assess and Respond initiative to support development of the skills and confidence to ask women about domestic and family violence, assess risk and respond as appropriate.
To find out how to undertake the Ask. Assess and Respond' training or BPSO® contact: Anita Minkus, Nurse Consultant, of the WCHN's Nursing & Midwifery Clinical Practice Development Unit on:
[email protected].
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here to read the full October 2020 edition of INPractice.