How can general practitioners help all members of the family

Abstract

Domestic violence (ie physical, emotional and/or sexual abuse by a partner) has wide-ranging impacts on individuals, families and communities, including poor physical and mental health1 and intergenerational trauma on children.2 The COVID-19 pandemic’s effects on movement restriction and family finances appear to be exacerbating domestic violence incidence and creating barriers to help-seeking for women, men and children.3 Since COVID-19 restrictions, the national helpline, 1800RESPECT, has reported an increase in demand, while calls to the Men’s Referral Service have simultaneously increased for those men who use domestic violence.4 Social isolation of women and their children, a common tactic that some men use as part of coercive control over their partners, will likely be worse during COVID-19 pandemic–related physical isolation.4 Further, economic stress, increased alcohol use and the fact that families are forced to spend a long time together without other supports can also be a context for more domestic violence and child abuse.5

A patient’s general practitioner (GP) is the first professional person, after friends and family, told about domestic and sexual violence in Australia.6 There is a great opportunity for GPs to reach out to victims and perpetrators through face-to-face and telehealth appointments. However, this has to be done safely, by asking sensitively about experiences of feeling unsafe or afraid at home, and only doing so when the patient is definitely alone.

The World Health Organization recommends asking all patients with symptoms of domestic violence, including those in same-sex relationships, about feeling unsafe.7 This includes all patients in the antenatal period, those with mental health presentations (depression, anxiety, insomnia, suicidal ideation, post-traumatic stress disorder) or chronic pain, those presenting following reproductive events (miscarriage, termination, low birth weight) and those presenting with injuries. The recommended first-line response is to listen, inquire about needs, validate experience, enhance safety and offer support (LIVES).8 In the context of the COVID-19 pandemic, this best-practice guidance might be difficult to enact but is not impossible. Patients about whom GPs are concerned could have subsequent follow-up consultations, where a pre-arranged code word could be used to indicate that the patient is concerned about someone listening in (so the subject can be changed) or to indicate that the patient would like the GP to call the police.

However, it is difficult for victims to take responsibility for stopping violence. Rather, this may be a time where GPs could engage and support patients to stop using violence. For patients who are using violence, GPs could be asking how things are at home and whether patients want help with any unhealthy or negative behaviours in their relationship or family.9 People who use violence do admit to using such behaviours and may want to seek help during this pandemic. Motivational interviewing techniques to seek help show some promise, particularly for patients who voluntarily want to seek help (Box 1). Research shows that men who use violence in their relationships also see their health professional as a person to whom they might listen, and they are open to seeking help online.9 Finally, the impact of domestic violence exposure on children at this time when they may be studying at home is likely to be much higher. This will include social, emotional, physical and behavioural impacts that may impair educational opportunities.