Identification and Management of Domestic and Sexual Violence in Primary Care in the #MeToo Era: an Update

What are the experiences and psychosocial needs of female survivors of domestic violence in Afghanistan? A qualitative interview study in three Afghan provinces

OBJECTIVES

This study aimed to qualitatively explore (1) the experiences of female survivors of domestic abuse and mental health problems in Afghanistan; (2) how female survivors of violence and abuse, male members of the community and service providers perceive and respond to mental health and domestic violence in Afghanistan and (3) the provision of mental health services for female survivors of violence and abuse in Afghanistan, including the barriers and challenges faced around accessing mental health services.

DESIGN

Qualitative interviews and framework thematic analysis.

SETTING

Kabul, Bamyan and Nangarhar in Afghanistan.

PARTICIPANTS

60 female survivors of domestic abuse, 60 male community members and 30 service providers who work with female survivors of domestic abuse.

RESULTS

Experiences of multiple and compounding traumatic experiences of violence, armed conflict, and complex and competing psychosocial concerns were common among the female survivor participants. All female survivor participants reported experiencing negative mental health outcomes in relation to their experiences of violence and abuse, which were further precipitated by widespread social stigma and gender norms. Support and service provision for female survivors was deemed by participants to be insufficient in comparison to the amount of people who need to access them.

CONCLUSIONS

There are many risks and barriers women face to disclosing their experiences of violence and mental health problems which restrict women's access to psychological support. Culturally relevant services and trauma-informed interventions are necessary to respond to these issues. Service providers should be trained to effectively recognise and respond to survivors' mental health needs.

[Addressing sexual violence in health services]

Sexual violence is a very underdetected public health problem, with important short and long-term consequences on physical, mental, social, sexual and reproductive health, which must be taken into account by health services. Health systems are part of the set of resources necessary for a comprehensive approach from the ecological model: prevention and promotion of healthy sexuality with equality, adequate and coordinated care in the event of sexual assault and subsequent support to prevent sequelae. All sexual violence has health consequences, even those that may seem less serious such as sexual harassment or sexual cyberviolence. We must know the needs of the victim and their possible emotional reactions. A risk assessment will be carried out, the victim will be referred to a hospital if necessary and comprehensive and integrated care will be provided. Care and follow-up must focus on the survivor and with professionals trained in trauma to understand the consequences of sexual violence, offer a safe and trusting environment and know how to reinforce their qualities and support.

The role of family doctors in the management of domestic violence cases - a qualitative study in Portugal

BACKGROUND

Domestic violence leads to multiple health problems in victims and their families. Family doctors are in a particularly privileged position to detect, follow up, refer and report cases of domestic violence. However, little is known about the perception of these physicians regarding their role in managing domestic violence cases.

METHODS

We conducted semi-structured interviews with family doctors from all regional health administrations of continental Portugal. Interviews were audio recorded, transcribed, and analysed using thematic analysis.

RESULTS

Fifty-four family doctors participated in this study (n = 39 women, n = 15 men). The themes and subthemes that emerged from the data analysis translated doctors' broad responsibilities when approaching victims and aggressors. These included: "Implement preventive measures", "Empower the victim leading them to recognize the violent situation", "Detect domestic violence cases", "Treat health problems related to violence", "Provide emotional support", "Refer victims to specialized services", "Register the episode on the victims and/or aggressor clinical records", "Incentivize the victim to report", "Report the case to the authorities", "Intervene with the aggressor", "Protect other individuals" and "Follow up the patient and the process".

CONCLUSIONS

The results of this study provide an overview of the current practical approaches being adopted by physicians and may provide a base for developing new interventions to support physicians to manage cases of domestic violence.

Risk factors of involuntary referral by police to ER psychiatric services for patients with a severe mental illness: A GEE analysis

This study aimed to identify risk factors for involuntary referral by police to emergency room (ER) psychiatric services for community-based patients with a mental illness via a generalized estimating equation (GEE) analysis. The analysis was based on data from the Management Information System of Psychiatric Care (MISPC) system for patients with a severe mental illness in Taipei, Taiwan and registered referral records of the police. Data on 6378 patients aged ≥20 years were used in this study, including 164 patients who were involuntarily referred to the ER by the police and 6214 patients who were not during the period of January 1, 2018 to December 31, 2020. GEEs were utilized to explore possible risk factors of repeated involuntary referral to ER psychiatric services for patients with a severe mental illness. The logistic regressions indicated that patients defined as "severe" according to the Mental Health Act of Taiwan (crude odds ratio (OR): 3.840, 95 % confidence interval (CI): 2.407-6.126), with a disability (crude OR: 3.567, 95 % CI: 1.339-9.501), with two or more family members with a psychiatric disorder (crude OR: 1.598, 95 % CI: 1.002-2.548), with a history of a suicide attempt (crude OR: 25.582, 95 % CI: 17.608-37.167), and with a history of domestic violence (crude OR: 16.141, 95 % CI: 11.539-22.579) were positively associated with involuntary referral to ER psychiatric services. However, age (crude OR: 0.971, 95 % CI: 0.960-0.983) and the MISPC score (crude OR: 0.834, 95 % CI: 0.800-0.869) were inversely associated with involuntary referral to ER psychiatric services. After adjusting for demographics and potential confounders, we found that patients defined as "severe" (Exp (β): 3.236), with a disability (Exp (β): 3.715), with a history of a suicide attempt (Exp (β): 8.706), and with a history of domestic violence (Exp (β): 8.826), as well as age (Exp (β): 0.986) and the MISPC score (Exp (β): 0.902) remained significantly associated with repeated involuntary referral to ER psychiatric services. In conclusion, community-based mentally ill patients with a history of a suicide attempt, with a history of domestic violence, with a severe illness, and with a profound level of disability were highly associated with involuntary referral to ER psychiatric services. We suggest that community mental health case managers identify significant factors associated with involuntary referral to ER psychiatric services to accordingly arrange case management plans.

Frequency, Types, and Manifestations of Partner Sexual Violence, Non-Partner Sexual Violence and Sexual Harassment: A Population Study in Spain

Background: This study analyzes the frequency and sociodemographic characteristics associated with sexual violence by a partner/ex-partner (PSV), someone other than a partner or ex-partner (NPSV), or sexual harassment (SH). Methods: The study is based on the 2019 Macro-survey of Violence against Women conducted by the Spanish Ministry of Equality among a sample of 9568 women age 16 or more years. Odds Ratios were calculated and multinomial logistic regression analyses were performed. Results: Forty-four women had suffered some kind of sexual violence over their lifetime, 9.2% had experienced PSV, 6.5% NPSV and 40.4% SH. More than 7% of women had been raped by a partner and 2.2% by another man. In the three groups, violence was associated with lower age and having a certified disability. NPSV and SH were significantly associated with a higher education and internet use. In NPSV, 9.2% of cases were reported to the police and 3.9% were reported to the courts. In SH, 91.7% of women told a family member or a close friend and 4.2% reported it to the police or the courts. Conclusions: A greater emphasis needs to be placed on reporting sexual violence in its various forms. Rape within intimate partnerships ought to be investigated and studied in greater depth.

Women's intimate partner violence versus community violence: Comparing injuries as presented in Iceland's largest emergency department

BACKGROUND

Intimate partner violence (IPV) is a widespread, often unidentified and hidden public health problem, which has serious consequences. The purpose of this study was to describe and compare the clinical characteristics of women's violence inflicted physical injuries, as presented at Iceland's largest Emergency Department (ED). Three groups were created based on registered reason of injury: (1) IPV, (2) community violence (CV) with a history of IPV (HIPV), and (3) CV with no history of IPV.

METHODS

Data was collected retrospectively by using the Nomesco classification system of external causes of injuries. Participants were adult women, residing in the capital area, visiting the ED during 2005-2019.

RESULTS

IPV inflicted ED visits declined by 45% during the research period and CV visits declined by 61%. Women in the IPV group had the highest prevalence of repeated new ED visits per 1000 women in the capital area. The majority of IPV occurred in residential areas (86.4%), inflicted by a current partner (54.7%), and included only one perpetrator (95.3%). Women involved in CV were most likely to visit the ED on weekends (p = 0.003) and IPV women were most likely to visit between 08:00 and 16:00 (p < 0.001). Superficial injuries were the most common type of injury among all groups and IPV women were twice as likely (7.1%) to have injuries on their neck than CV women (3.5%). IPV women were most likely to be admitted (3.0%).

CONCLUSION

Time of ED visit, number of perpetrators and location of assault can be indicators of IPV inflicted injuries, as opposed to otherwise inflicted injuries. Repeated visits, superficial injuries and neck injuries might also be an indicator of IPV, however wounds and sprains and injuries on head and upper limbs are more likely to be non-IPV inflicted.

The Perceptions of Domestic Violence by a Family Member Who Uses Crack or Cocaine: A Secondary Retrospective Cross-Sectional Study

OBJECTIVE

To evaluate the relationship between crack/cocaine use and domestic violence perpetration from the perspective of substance users' families. A secondary retrospective cross-sectional study, with 3162 family members of crack/cocaine users seeking treatment in the Recomeço Família Programme in São Paulo/Brazil was undertaken. Family members of crack/cocaine users reported that their relatives were more involved in domestic violence such as stealing (money and objects) at home [Odds Ratio Adjusted ORA = 2.17 (CI 95% 1.87; 2.53)], the family gave money to the user to buy drugs [ORA = 1.27 (1.08; 1.48)], and having problems with the judiciary [ORA = 1.48 (CI 95% 1.28; 1.71)]. Relatives of snorted cocaine users reported that there was physical and interpersonal violence, such as fathers being assaulted [ORA = 2.50 (CI 95% 1.08; 5.82)], assaulted someone else [ORA = 1.86 (CI 95% 1.32; 2.60)], threats of violence fights, arguments when the family talk about problematic drug use [ORA = 1.50 (CI 95% 1.13; 1.96)] and threatened some family members [ORA = 1.52 (CI 95% 1.14; 2.04)]. In this sample, there was a connection between crack/cocaine use and the perpetuation of domestic violence, corroborating with important implications for public policies, substance use treatment and prevention of domestic violence interventions.

Improving the mental health of women intimate partner violence survivors: Findings from a realist review of psychosocial interventions

BACKGROUND

Intimate partner violence (IPV) is highly prevalent and is associated with a range of mental health problems. A broad range of psychosocial interventions have been developed to support the recovery of women survivors of IPV, but their mechanisms of action remain unclear.

METHODS

Realist review following a prospectively published protocol in PROSPERO (CRD42018114207) and reported using the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMSES) guidelines.

RESULTS

Evidence was extracted from 60 reviews and triangulated in expert consultations. Mechanisms of action were categorised as either associated with intervention design and delivery or with specific intervention components (access to resources and services; safety, control and support; increased knowledge; alterations to affective states and cognitions; improved self-management; improved family and social relations).

CONCLUSIONS

Findings suggest that psychosocial interventions to improve the mental health of women survivors of IPV have the greatest impact when they take a holistic view of the problem and provide individualised and trauma-informed support.

Should domestic violence be or not a public crime?

BACKGROUND

Domestic violence has been addressed in public policies and law reforms in many countries to target its identification and provide increased support to those affected. In some countries, reporting domestic violence is mandatory, which means that anyone not only 'can' but also 'must' file a report, which is enough to progress the criminal proceedings, even against the victim's will. This article provides an overview about the importance of the clinicians' duty of care, debating whether or not domestic violence should be a public crime.

METHODS

A narrative review on the subject of mandatory reporting of domestic violence, conducting a search of PubMed.

RESULTS

Twenty studies were retrieved. Commonly victims agree with mandatory reporting. However, there are still several concerns voiced by both victims and health care workers that need to be further addressed.

CONCLUSION

This article addresses the importance and limitations of mandatory reporting while acknowledging the impact of these measures in both the victim and the accused.

Persistent Suffering: The Serious Consequences of Sexual Violence against Women and Girls, Their Search for Inner Healing and the Significance of the #MeToo Movement

This paper uses the method of theory synthesis, primarily from our own previous studies and psychoneuroimmunology research, with the aim of exploring and better understanding the consequences of sexual violence for women and their search for inner healing. The impact of the #MeToo movement is also examined. The main finding is that sexual violence causes persistent suffering for women and girls. In childhood and adolescence, the main consequences include a feeling of unbearable secrecy, threat and humiliation; disconnection of body and soul; great fear and constant insecurity; damaged self-image, self-accusation and guilt; experiencing being compelled to take full responsibility for the crime; as well as various physical and mental health problems, e.g., suicidal thoughts. In adulthood, the consequences are also multifaceted and varied, including vaginal problems, recurrent urinary tract infections, widespread and chronic pain, sleeping problems, chronic back problems, and fibromyalgia, eating disorders, social anxiety, severe depression, and chronic fatigue. In conclusion, sexual violence has these extremely negative and long-term consequences because of the interconnectedness of body, mind, and soul. The seriousness of the consequences makes a trauma-informed approach to services essential to support the healing and improved health and well-being of survivors.

Usability of two brief questions as a screening tool for domestic violence and effect of #MeToo on prevalence of self-reported violence

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Domestic violence is a major public health problem that violates human rights.

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In long-lasting and frequent violence, the victim is usually a woman.

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Being a victim of domestic violence is a highly intimate and stigmatising experience and thus difficult to screen.

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Even broad social media movements such as #MeToo do not necessarily facilitate screening.

Objective

Domestic violence is a hidden epidemic. We used a two-question screening tool to explore the prevalence of domestic violence among gynaecological outpatients. We also retrospectively assessed whether there was a change in the prevalence rate of self-reported violence after the launch of the #MeToo movement.

Study design

Over an 11-month period, all gynaecological first-time visitors to our outpatient clinic were asked two dichotomous questions that screened for domestic violence and examined whether the violence had an ongoing impact on the respondent’s everyday life. We used logistic regression models to assess whether the launch of #MeToo was associated with the answers to these two questions.

Results

Of the 6,957 screened women, 154 (2.2 %) tested positive for domestic violence. Among the screen-positive women, 87 (56.5 %) reported that the violence affected their health and well-being. Of these 87 women, 52.9 % wanted further support and 72.4 % had already contacted psychiatric care. Out of all of the patients, the proportion of screen-positive respondents was 2.3 % before and 2.2 % after #MeToo. We did not detect increased odds of self-reporting domestic violence (odds ratio 0.97, 95 % confidence interval 0.70–1.36) or its ongoing impact on the victim’s everyday life (odds ratio 1.05, 95 % confidence interval 0.53–2.07) after #MeToo.

Conclusions

Our two-question screening tool detected a lower prevalence of domestic violence among gynaecological outpatients than previous reports examining the general population. Our results illustrate the dire challenges in screening for domestic violence that persist even in the post-#MeToo era. Domestic violence remains a highly intimate, stigmatising, and underreported health issue, and systematic measures to screen for and prevent it should be advocated, both in gynaecological patients and the general population.