Family and Domestic Violence - 2016

Family and domestic violence refers to acts of violence between family members as well as people who are in, or have been involved in, an intimate relationship.  The violence may involve physical, sexual, financial, emotional or psychological abuse and include a range of controlling behaviours, such as the use of verbal threats, enforced isolation from family and friends, restrictions on finances and public or private humiliation.^[1]

Those who are victims of family and domestic violence, or are at risk, are overwhelmingly women and children, however the lack of research and information means the true situation is not known or understood.  Family and domestic violence is not always fatal or life threatening, but for those exposed to abuse and violence, the consequences can be lifelong.  

It is important to emphasise that it is not only the victims of violence that need support; all family members affected by family and domestic violence should be offered support and treatment from appropriately trained medical professionals.

One of the strongest risk factors for family and domestic violence is alcohol and drug use.  When alcohol and drugs are combined with behavioural issues, it increases the levels of aggression by perpetrators.  Research shows that those with alcohol and drug problems often inflict more violence on their partners.  Alcohol is a significant factor in many intimate-partner homicides.

Often the psychological consequences of family and domestic violence can be as serious as the physical effects.  The research tells us that victims of family and domestic violence receive more mental health treatment and have an increased ideation and incidence of attempted suicide.^[2]  

The Victorian Royal Commission into Family Violence (released March 2016) was the first ever inquiry in Australia to examine ways to prevent family violence, improve early intervention, support victims, make perpetrators accountable and better coordinate community and government responses.  The Royal Commission also evaluated and measured strategies, frameworks, policies, programs and services. 

The AMA welcomes the Commission’s findings as a landmark document.  The Commission report can be found at:  www.rcfv.com.au/MediaLibraries/RCFamilyViolence/Reports/RCFV_Full_Report_Interactive.pdf

Family and domestic violence is a national issue – it is widespread across all cultures, ages and socio-economic groups in Australia.  Attitudes towards family and domestic violence must be changed: through education, awareness, interventions and models of care that help victims and perpetrators. 

The AMA Position on Family and Domestic Violence

 1.  The medical profession has key roles to play in early detection, intervention and provision of specialised treatment of those who suffer the consequences of family and domestic violence, whether it be physical, sexual or emotional.

 2.  Medical practitioners must encourage attitudes and actions necessary to prevent family and domestic violence, identify women, men, families and children ‘at risk’, prevent further violence and assist patients to receive appropriate help and protection. 

 3.  Medical practitioners should understand their current State and Territory requirements for mandatory reporting on family and domestic violence. 

 4.  The role and extent of family and domestic violence, as a determinant of medical and psychiatric morbidity, should be included in all specialty undergraduate curricula and postgraduate training programs.

 5.  Continuing education of the profession is essential to emphasise the extent of family and domestic violence and the medical and psychiatric consequences for the victims.

 6.  Continuing education of the profession is also necessary to highlight the critical role of all primary health care providers in the early detection of victims of family and domestic violence.

 7.  Appropriate tools and resources should be utilised when dealing with family and domestic violence, with close collaboration and a coordinated approach with other community agencies. 

 8.  There is a need for continuing research into the emotional and social aetiology of family and domestic violence.

 9.  Development and evaluation of intervention programs for both offenders and victims should be significant components of research.  Strategies to prevent family and domestic violence must incorporate recognition, understanding, and management of the underlying problems of the perpetrator.  Adequate data and research is needed in order to fully understand the effectiveness of these programs. 

 10.  Immediate attention should be given to children who witness family and domestic violence.  Intervention is necessary to reduce the negative psychological effects, development of adjustment difficulties, and in turn modify the risk of those children subsequently becoming perpetrators of family and domestic violence. 

 11.  In addition to any legally-imposed penalty, perpetrators should be referred to experts knowledgeable in current methods of assessment and treatment of their problem. 

 12.  Doctors have a role in community-wide efforts to advocate and strengthen resources for victims and perpetrators, and to encourage preventive education programs through schools, the media and community organisations.

 13.  Employers have a role to play in flexibility and support when an employee is dealing with family and domestic violence. 

 14.  Continuous government funding is needed to establish, evaluate and continue effective family and domestic violence programs. 

 15.  The AMA supports initiatives undertaken by Federal and State Governments which recognise and address issues relating to family and domestic violence within the community.  

 16.  The AMA calls on governments to provide continuous and adequate funding for family and domestic violence supports and services, including housing and crisis accommodation.

 17.  Models of care should align with the needs of victims of family and domestic violence.

Background

Family and domestic violence encompasses varying degrees of severity and can take many forms.  It is most commonly experienced by women, but it is important to acknowledge that men and same-sex relationship partners also experience family and domestic violence.  When we use the term family and domestic violence, it does not refer only to physical violence; it can also involve:

• sexual abuse;
• emotional or psychological abuse;
• verbal abuse;
• spiritual abuse;
• stalking and intimidation;
• social and geographic isolation;
• financial abuse;
• cruelty to pets; or
• damage to property.

The research on family and domestic violence shows that a major factor is the imbalance of power and unequal rights and opportunities in society, combined with the controlling behavioural patterns of perpetrators.^[3]  This type of violence is often experienced as a pattern of abuse that escalates over time.  

All the evidence and data available highlights the fact that family and domestic violence involves violence against women, sometimes tragically leading to death and serious physical and emotional injury.  However, violence also occurs within same-sex relationships, by women on men and by children on parents.  It is difficult to know the true extent of the problem in Australia as most incidents of domestic, family and sexual violence are unreported.^[4] 

Family and Domestic Violence in Australia

• Two women are killed nearly every week in Australia due to family and domestic violence.^[5]
  
• In 2014, there were 95 victims of family and domestic violence-related homicide offences recorded by police. 40 per cent of women who experienced violence reported that they received injuries as a result of family and domestic violence.^[6]
  
• Intimate partner violence is the leading contributor to the preventable death, disability and illness burden in women aged 15-45.^[7]
  
• One in six Australian women had experienced physical or sexual violence from a current or former partner; while one in three women have experienced physical and/or sexual violence perpetrated by someone known to them.^[8]
• The Australian Bureau of Statistics’ Personal Safety Survey estimates that 5.3 per cent of men (that is, one in 19) and 16.9 per cent of women (one in six) have experienced physical or sexual violence perpetrated by a current or previous partner since the age of 15.^[9]
  
• The ABS survey estimates that 14 per cent of men and 25 per cent of women aged 18 or over have experienced emotional abuse by a partner since the age of 15.
• A woman is most likely to be killed by her male partner in her home;^[10] while an estimated 62 per cent of women and eight per cent of men experienced their most recent incident of physical assault in their home.^[11]
  
• It is most common for women to experience violence from a male ex-partner. Perpetrators of family violence against adult males tend to be both male and female, whereas perpetrators of family violence against adult females are mostly male.^[12]
  
• 61 per cent of women who experienced domestic violence had children in their care when the violence occurred.^[13]
• Aboriginal women are 34 times more likely to be hospitalised because of family violence than other women.^[14]
  
• More than one million children in Australia are affected by family and domestic violence.^[15]
  

 The AMA acknowledges that better data collection and statistical analysis is needed to identify those at risk of family and domestic violence.

Medical Practitioners

Medical practitioners have a key role in dealing with abuse and violence.  All medical and health practitioners need to do their part in prevention, identification and response to family and domestic violence.  

The ABS 2012 Personal Safety Survey confirms that women who have experienced, or are at risk of family and domestic violence, prefer to seek support from those they feel will understand and validate their experiences, such as a friend or family member, or their doctor.  Women will talk with someone they trust, rather than tell police or a specialised agency.  The reality is that about 80 per cent of women who experience some type of domestic violence by their current partner do not report this to the police.^[16]

Women want doctors to be non-judgemental, compassionate and sensitive; they want to talk with someone who acknowledges the complexities but does not necessarily medicalise the problem, or apply pressure to make quick decisions.^[17]  Women who have been abused want to be asked about domestic violence, and are more likely to disclose if they are asked.^[18]

Sometimes there are no visible signs of physical or sexual assault in family and domestic violence presentations.  This does not mean that the emotional or psychological effects of assault are any less devastating to the victim.^[19]

Medical practitioners should have systems in place to help them deal with family and domestic violence in their practice, and understand the different referral pathways to help patients find safety and begin healing.  This is why it is so important that medical practitioner training includes personal attitudes and assumptions about abuse and violence, as they can affect the way medical practitioners respond to patients experiencing abuse and violence.^[20]

The role of medical practitioners in addressing family and domestic violence includes:^[21]

• identifying predisposing risk factors;
• noting early signs and symptoms;
• assessing violence and safety within families;
• managing consequences of abuse to minimise morbidity and mortality;
• knowing and using referral and community resources; and
• advocating for changes that promote a violence-free society.

Factors Associated with Family and Domestic Violence

While there is no single cause that leads to family and domestic violence, there are a number of situations and causes that can be associated with both perpetrators and victims that increase the risk of violence.  For example, it is known that pregnancy, separation, a perpetrator’s alcohol and drug use, and previous abuse or witness to abuse as a child may influence and increase the chances of family and domestic violence occurring.

The influence of alcohol and drugs was documented in the ABS 2012 Personal Safety Survey, which found that an estimated 53 per cent of women who experienced physical assault by a male reported that alcohol or drugs had been involved; and between 2008-09 and 2009-10, alcohol consumption occurred in 47 per cent of all homicide incidents.

Women

One in three patients presenting at medical practices, emergency departments and hospitals will be women affected by violence.^[22]  While not all of these presentations will be because of family and domestic violence, the evidence that women comprise the vast majority of victims of family violence is overwhelming.

The ABS Survey found that approximately 1.5 million women had experienced violence at the hands of their partners since the age of 15.  More than 25 per cent of women who experienced this violence never told anyone; 39 per cent sought advice or support; and 80 per cent never contacted police.  Of the 536,900 women who did contact police in relation to a previous partner’s violence, half of them had a restraining order against the partner; however 58 per cent of the women experienced further violence.^[23]

For medical practitioners, it is of the highest concern that women’s vulnerability to violence may increase during pregnancy or separation from their partner.  25 per cent of women who had experienced violence from a partner during a relationship, experienced it for the first time during pregnancy.^[24]  For women who experienced partner violence since the age of 15, 22 per cent reported experiencing violence by a current partner during pregnancy and 54 per cent reported experiencing violence by a previous partner during pregnancy.^[25]

While younger women understand the criminal nature of family and domestic violence, they have more difficulty than older women in understanding the complex aspects within relationships which underpin domestic violence.^[26]

Men

The Victorian Royal Commission into Family Violence^[27] discussed the challenges faced by male victims of family violence.  The Commission found that men are also victims of violence inflicted by an intimate partner, a parent, a sibling, adolescent or family member.  

The Royal Commission found that:

• Men make up around one quarter of victims of violence by intimate partners within heterosexual relationships.
• Violence by women towards male partners is generally less severe than that of men towards their female partners.
• There is a lack of information and services for male victims, which can create barriers to men seeking help.
• Interpreting data is complicated by the possible under-reporting of family violence by both male and female victims.
• 2.1 per cent of men (since the age of 15) have experienced violence perpetrated by a parent against them, compared with 3.5 per cent of women—with men making up 37 per cent of victims of parent-on-child violence.
• Women are most likely to be victims of intimate partner violence perpetrated by male partners (rather than by any other family member); when men are victims, they are likely to be victims of violence either perpetrated by female partners, or by another male family member (brother, son, father).

Elder Abuse

A less well covered form of family and domestic violence is elder abuse.  It too can be physical, but also involves psychological and financial abuse.  Elder abuse is mostly perpetrated by a son or daughter, grandchild or partner, but is also known to be perpetrated by other family members and friends.

As with women in general, it is overwhelmingly older women who experience violence and abuse, at a rate two and a half times higher than older males.  Somewhere between one-fifth and one-quarter of reported incidents of elderly abuse are committed by the victim’s spouse or partner.^[28]

It is estimated that about four to six per cent of older Australians (generally considered 60 and over) experience elder abuse.  As Australia’s population is ageing, this form of family and domestic violence in likely to increase. And, as with all cases of family and domestic violence, it occurs in all cultural backgrounds and lifestyles and women and men are both victims and perpetrators.^[29]

Children

Children are victims and witnesses to family and domestic violence.

Approximately 10 per cent of all homicides in Australia involve children as victims.  In 2009-10, among children aged 0-14, there were 24 deaths due to homicide and the rate of homicide was highest among infants less than 1 year old.  The Australian Institute of Criminology reported that across the period 2008–2010, 22 domestic homicides were sub-classified as filicides and seven further domestic homicides were sub-classified as infanticide.^[30]

Between July 1997 and June 2008, 468 children (under 18) were killed, with the overwhelming majority of these child deaths (62 per cent) perpetrated by a parent.  Data and research on the motives behind filicide (death of a child attributed to a parent or step-parent) is limited.  We do know from filicide research that men and women kill children in different circumstances and for different reasons, however understanding these gender differences is complex and the findings contradictory.^[31]

One report on filicide in Australia found that fifty-two per cent of the child victims of filicide were killed by their fathers/stepfathers, while 48 per cent by their mothers, however it must be stressed that there are gaps in the data and research and overseas evidence indicates a higher proportion of mothers are responsible for filicide.^[32]

Indigenous children are considerably more likely to witness physical violence against their mother or stepmother than the ‘average’ child with 42 per cent of Indigenous children reporting that they witnessed violence against their mother or stepmother, compared with 23 per cent of all children.^[33]

Family and domestic violence has negative effects on the victim’s mental health.  With violence often occurring for the first time during pregnancy, there is a need for perinatal mental health services for both men and women. 

The Royal Children’s Hospital Melbourne’s Australian Child Health POLL rated family and domestic violence seventh among child health problems.  When comparing household income and perception of child health problems, adults from households with income less than $1000 per week identified higher ratings for ‘big problems’ such as family violence, child abuse and neglect.

For further information regarding children and violence please refer to the AMA Position Statement Child Abuse and Neglect 2005. 

Aboriginal and Torres Strait Islander People

The statistics on family violence amongst Aboriginal and Torres Strait Islander families are deficient, what is certain however, is that Indigenous women in particular are far more likely to experience violent victimisation, and suffer more serious violence, than non-Indigenous women.^[34]

The evidence that is available shows that:

• Indigenous people are two to five times more likely to experience violence than non-Indigenous people, and
• Indigenous women are five times more likely to be homicide victims than non-Indigenous people.^[35]
  
• Indigenous women experience up to 38 times the rate of hospitalisation of other women for spouse/domestic partner inflicted assaults.^[36]
  
• Violence in some Indigenous communities is so prevalent that it is now regarded as a normal occurrence in life.^[37]
  

Homelessness

Family and domestic violence is a main contributor to, and cause of, homelessness in Australia.  Women and children escaping family and domestic violence are the largest group of homeless people in Australia.^[38]

Research shows that over one third of adults and children using homeless services sought help due to family and domestic violence, with 48 per cent of all clients assessed as homeless when they presented.^[39]

Housing is critical for women fleeing family and domestic violence.  In a study of women’s economic wellbeing during and after episodes of violence, women said that finding affordable, safe accommodation post leaving was their biggest concern.  Women and children escaping family and domestic violence often need homelessness services, and frequently experience Australia’s chronic shortages of crisis accommodation.^[40]  

In fact, only nine per cent of families seeking housing assistance due to family and domestic violence were provided long term accommodation.  In 2013-2014, a staggering 77,992 women and children sought the safety of women refuges.  Although there is little documentation for men, three in ten experiencing family and domestic violence were looking for housing assistance due to mental health.^[41]

In 2015, the Women’s Electorate Lobby (WEL) asked the Government to support their proposal for long term secure Commonwealth/State funding for women’s refuges, related services and transitional accommodation.  WEL’s proposal was for $1.982 billion over five years, funded 50/50 by the Commonwealth/State.  The WEL proposal fits within the fourth outcome outlined within The National Plan to Reduce Violence against Women and their Children 2010-2011.

Culturally and Linguistically Diverse Groups

Women and children from culturally and linguistically diverse (CALD) communities are less likely than other groups of women to report violence.  These groups may face particular barriers to reporting family and domestic violence including language barriers, cultural stigma, financial insecurity and concerns about visa and residency.^[42]

Consequences of Family and Domestic Violence

Family and domestic violence has severe and long lasting effects on physical and mental health.  In terms of physical injury, the most common types seen by medical practitioners are bruises and swelling, cuts, scratches and burns.  However, in 10 per cent of cases, women have suffered from broken bones or noses; six per cent suffered head or brain injuries and six per cent sustained internal injuries.^[43]

It is well known that the health impacts of family and domestic violence persist long after the violence ceases.  Women who experience family and domestic violence report a higher prevalence and severity of mental disorders, increased rates of physical disorders and impaired quality of life.  They also have higher rates of suicide attempts. 

Family and domestic violence impacts particularly on children, who often witness the violence between parents.  According to the research, children display a range of negative impacts as a result of experiencing or witnessing violence in the family and may display one or more of the following psychological and/or behavioural impacts:^[44]

• depression;
• anxiety;
• trauma symptoms;
• increased aggression;
• antisocial behaviour;
• lower social competence;
• low self-esteem;
• mood problems;
• school difficulties;
• impaired cognitive functioning; and/or
• increased likelihood of substance abuse.

Studies have shown that children with a violent upbringing and home life may be more likely to exhibit attitudes and behaviours that reflect their childhood experiences of domestic violence.

Economic Costs

A PricewaterhouseCoopers (PwC) report on domestic violence found that violence against women costs Australia $21.7 billion each year, with governments carrying more than a third of the cost burden.  Additionally, PwC estimates that if no further action is taken to prevent violence against women, the costs will accumulate to $323.4 billion by 2045.  This report shows the major economic benefits from investing in primary prevention.^[45]  While it is important to understand the economic cost of family and domestic violence, it is imperative to know that the physical and mental harm resulting from family and domestic violence is the true cost. 

Prevention

Primary prevention offers a way to address the link between gender inequality and violence against women.  A range of prevention activities are essential in addressing the stereotypes and gender imbalances that are deeply embedded within our society.  The 2015 PwC report shows that the benefits of improving equality between men and women would not just be felt by the victims but the community as a whole, ensuring a more positive and respectful future.

Government Response to Family and Domestic Violence

In September 2015, the Turnbull Government announced a $100 million, Women’s Safety Package to Stop the Violence, which aims to provide practical measures to help keep women safe, provide better front line support and services, and to provide resources to parents, teachers and students to bring awareness and alter their attitudes towards domestic violence.  $21 million was committed to helping Indigenous women and communities in regards to domestic violence.

The Council of Australian Governments (COAG) created an advisory panel on Reducing Violence against Women and their Children.  The National Plan has established a framework that sets out six national outcomes to be delivered over a 12 year period.  The six outcomes are: communities are safe and free from violence; relationships are respectful; Indigenous communities are strengthened; services meet the needs of women and their children experiencing violence; justice responses are effective; and perpetrators stop their violence and are held to account.  The National Plan is set up in a series of four three-year action plans over a total of twelve years.  There have been two action plans produced so far.^[46]

The Commonwealth Government is responsible for the over-arching programs designed to reduce violence against women nationally.  However, it is state and territory governments that have law enforcement responsibilities in relation to policing and prosecuting instances of domestic, family and sexual violence.

Resources

1. Royal Australian College of General Practitioners (RACGP) Abuse and violence: Working with our patients in general practice (white book). http://www.racgp.org.au/your-practice/guidelines/whitebook/
2. Australian Medical Association (AMA) Supporting Patients Experiencing Family Violence: A Resource for Medical Practitioners. https://ama.com.au/article/ama-family-violence-resource
3. The Period of PURPLE crying is an infant abuse prevention program which educates caregivers and parents about normal infant crying. http://purplecrying.info/ 

Crisis Lines

1. 1800 RESPECT:  1800 737 732 (National Line – 24 hours)
2. Victoria: 1800 015 188 (24 hours)
3. Western Australia:  (08) 9325 1111 or 1800 007 339 (24 hours)
4. Australian Capital Territory:  (02) 6280 0900 (24 hours)
5. New South Wales:  1800 656 463 (24 hours)
6. Northern Territory:  1800 019 116 (24 hours)
7. Queensland:  1800 811 811 (24 hours, local only)
8. South Australia:  1300 782 200 (Mon-Fri, 9:00 -4:00), (08) 8203 0424 (after hours/ weekends)
9. Tasmania:  1800 633 937 (Mon- Fri 9:00-midnight; Sat, Sun & Public Hol 4:00pm to midnight)

References