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Summary for primary care

Domestic Abuse

NICE

Overview

This Guidelines summary outlines NICE recommendations on recognising, assessing, and managing victims of domestic abuse in primary care. 

This Clinical Knowledge Summary (CKS) topic does not cover domestic abuse perpetrated on children by adults in detail, but includes recommendations on how to support children who are affected by domestic abuse. It also does not include detail on the recognition and management of suspected female genital mutilation.

All healthcare staff should be trained to recognise possible signs of domestic abuse at an early stage, to enquire sensitively and safely, be aware of patient confidentiality, and know how to respond to a disclosure.

Risk Factors

  • The risk of experiencing domestic abuse is increased if a person is:
    • Female — more women than men are affected by domestic abuse.
    • Age — aged 16–24 years (women) or 16–19 years (men).
    • Sexual orientation and gender identity — about 80% of 'trans people' (including cross-dressers, transgender and transsexual people, and other gender-variant people) experience emotional, physical, or sexual abuse from a partner or ex-partner, and 38.4% of bisexual, gay, and lesbian people class themselves as having experienced domestic abuse.
    • Affected by long-term illness, disability, or mental health problems — the odds of being a victim of domestic abuse were two-fold higher for those with a physical disability and three-fold higher for those with a mental illness. Mental health problems can be a risk factor for perpetration and victimisation of domestic abuse.
    • Separated or in the process of separating from a partner — there is a higher risk of abuse around the time of separation including increased risk to physical safety, due to the perpetrator's perceived lack of control.
    • Pregnant or has recently given birth — although pregnancy appears to offer protection for some women, it increases the risk for others.
    • Socio-economically disadvantaged — although domestic abuse is experienced across all socio-economic classes, there is increased risk if a person is low income or under financial strain, or has reduced access to social support.
  • The immediate risk of harm is increased if there is:
    • Escalating violence — previous domestic abuse is the clearest indicator that further domestic abuse will occur, and the number of police callouts to the victim in the past 12 months can indicate a risk of potential escalation.
    • Substance misuse — some studies have found a significant relationship between alcohol and drug use and intimate partner violence and risk of escalation.
    • Mental health problems of the perpetrator and/or the victim.
    • A history of stalking.
    • Credible threats to kill.
    • Assault or threatening with a weapon.
    • Controlling or excessive jealous behaviour.
    • Assault during pregnancy.
    • Strangulation.
For information on the consequences of domestic abuse, refer to the full CKS topic.

Recognition

  • Indicators of possible domestic abuse include:
    • Inconsistent health-seeking behaviour
      • Frequent attendances for vague symptoms.
      • Frequently missed appointments, including at antenatal clinics or children not brought to appointments.
      • Non-concordance with treatment or unplanned/early discharge from hospital.
      • Repeated health consultations with no clear diagnosis. The person may describe themselves as ‘accident prone’ or ‘silly’ and provide a vague explanation for injuries.
      • Delay in presentation of injuries. 
    • Physical symptoms and signs
      • Traumatic injury, especially if repeated, and with vague, inconsistent, or implausible explanations (for example bruises, burns, bites, lacerations, abrasions, or fractures).
      • Physical injuries may be inflicted on areas of the body that are covered by clothing, such as the neck, thorax, breasts, and abdomen. The person may try to hide or minimize the extent of injuries.
      • Functional disorders or stress-related conditions such as irritable bowel syndrome and other unexplained chronic gastrointestinal symptoms; fibromyalgia; chronic headache; and other chronic pain syndromes; unexplained fatigue; and unexplained cognitive problems.
    • Reproductive and sexual health symptoms and signs
      • Unexplained gynaecological symptoms, including chronic pelvic pain, sexual dysfunction, and genital injuries. 
      • Adverse reproductive outcomes, including multiple unintended pregnancies or terminations.
      • Delayed pregnancy care, miscarriage, premature labour, stillbirth, or concealed pregnancy.
      • Vaginal bleeding and recurrent sexually transmitted infections or urinary tract infections.
    • Emotional and psychological symptoms
      • Depression, fear, anxiety, post-traumatic stress disorder, eating disorders, and sleep disorders.
      • Adjustment difficulties, behavioural problems, risk-taking, aggression, sleep problems, and bed-wetting (particularly in children).
      • Self-harm, suicidal ideation, or suicide attempts.
      • Alcohol or drug misuse.
    • Intrusive ‘other person’ present in consultations:
      • Partner or spouse, parent, or grandparent (or, for elder abuse, a partner or family member or carer) always attending appointments unnecessarily.
      • The person is submissive or afraid to speak in front of the partner or relative, escort, or spouse.
      • The escort is aggressive, dominant, or over-attentive, talking for the person, or refusing to leave the room.
      • Note: the escort may intentionally present as charming, pleasant, and agreeable, which may make the person experiencing domestic abuse seem difficult and/or disordered in their thinking.

Initial Assessment

  • Allow the person to make a disclosure alone in private with no third parties present.
    • Ensure that the person feels safe, is given time and space to talk, and questions are asked in a kind, sensitive manner. Listen closely, with empathy, and without judgement.
    • Use gender-neutral terms such as partner/ex-partner.
    • Ask the person for safe contact details.
    • Ask about where the perpetrator and any children are.
    • Ask about who they are frightened of, and who they are frightened for.
    • Ask what they would like to happen.
    • Use a professional interpreter or an advocate from a local specialist domestic violence and abuse service. Do not use the person's child, relative, or friend as an interpreter.
  • Advise the person that any discussion is confidential and that the information provided will be shared only with their consent, subject to practice policy on adult and child safeguarding.
    • If it is believed that withholding information puts a child or another adult at risk of significant harm, then disclosure may be justified in the public interest and/or in order to protect the vital interests of the third party.
    • If there is any uncertainty about ongoing management, discuss with colleagues or seek specialist advice.
  • Ask open or direct questions about domestic abuse, depending on clinical judgement.
    • Consider asking open questions, such as 'How are things at home?', 'Sometimes symptoms can be triggered by stressful events in our relationships, has anything like that happened to you?', 'We know violence at home can be a problem, is there anyone who is hurting you?'.
    • Consider asking direct questions, such as 'Do you feel safe at home?', 'Does anyone make you feel afraid?', 'Do you feel safe in your relationship?', 'Is there anything that worries you about your relationship?', 'These injuries are more than I would expect following a fall, I'm wondering if someone else might have hurt you?'.
    • Try and establish the range of abuse, if the abuse is getting worse, or happening more often, or the incidents themselves are getting more serious.
      • Suggest the person keeps a diary of incidents or threats, when and where they happen, if anyone else was with them, and if they were frightened.
    • Try and establish if the abuse is affecting other people in the household or elsewhere, such as children (including ages, school or nursery), siblings, or relatives.
    • Ask about emotional, physical, social, and practical needs and concerns, and any risk factors for domestic abuse.
  • Consider asking specific questions relating to different forms of domestic abuse, depending on clinical judgement. These may include:
    • Emotional or psychological abuse
      • Does your partner, or former partner, repeatedly belittle you, put you down, or say you are worthless? Blame you for the abuse or arguments? Deny that abuse is happening, or play it down? Isolate you from your family and friends? Stop you going to college or work? Make unreasonable demands for your attention? Accuse you of flirting or having affairs? Tell you what to wear, who to see, where to go, and what to think? Control your money, or not give you enough to buy food, medication, pay bills, or pay for other essential things?
    • Threats and intimidation
      • Does your partner, or former partner, ever threaten to hurt or kill you? Destroy things that belong to you? Stand over you, invade your personal space? Threaten to kill themselves or the children? Read your emails, texts, or letters, monitor your internet or social media use, or limit your use of technology? Harass or follow you? Threaten to deny access to medical aids or equipment?
    • Controlling or coercive behaviour
      • Does your partner, or former partner, ever control or monitor your daily activities and behaviour? Control your access to finances and how you spend your money? Control who you see or isolate you from family, friends, and professionals? Refuse to interpret or hinder your access to communication including preventing you learning a language or making friends? Prevent you from taking medication or prevent access to medical aids or equipment? Threaten to expose sensitive information?
    • Physical abuse
      • Does your partner, or former partner, threaten to or ever slap, hit, punch, scratch, or pinch you? Push or shove you? Bite, spit on, or kick you? Burn or scald or poison you? Choke or strangle you or hold you down? Throw things at you or in the direction of you? Use or threaten to use weapons including knives or irons? Harm pets or damage furniture?
    • Sexual abuse
      • Does your partner, or former partner, ever touch you in a way you don't want to be touched? Make unwanted sexual contacts or demands? Hurt you during sex including non-fatal strangulation? Pressure or trick you to have unsafe sex – for example deception over the use of contraception such as condoms? Intentionally expose you to STIs? Threaten, intimidate, or pressure you to have sex, or sexual acts, including with other people? Force you to to make or watch pornography? Restrict your access to contraception or refuse to use contraception? Force you to get a termination or pregnancy, or assisted reproductive procedure?
    • Economic abuse
      • Does your partner, or former partner, ever control the family income or not allow you to earn or spend money unless 'permitted'? Refuse to contribute to household income or costs? Prevent you claiming welfare benefits or interfere with your training, employment, or career so you are economically dependent on them?
  • If talking to a child about possible domestic abuse:
    • Talk sensitively, and ask simple and direct questions to allow opportunities for a disclosure.
      • Do not interrogate the child. Ask questions such as 'Is there something you are sad or worried about?'.
      • Be aware that some children may not want to talk at all, whilst others disclose indirectly (not sharing the details without being prompted) or in a roundabout way, for example 'Sometimes my stepdad upsets my mum'.
  • If the person is unwilling or unable to disclose domestic abuse at this time:
    • Assess whether the person (and any other adults or children) are at immediate risk of harm. See the section on Responding to a disclosure by the victim if there is an immediate risk of harm.
    • Offer follow-up and continuity of care, where possible. Advise that you are available to talk if and when they are ready.
    • Be aware of possible reasons for non-disclosure, such as:
      • Fear of the perpetrator; fear of retribution from the perpetrator; or fear of not being believed.
      • Pressures from family or the community. Fear of causing a family breakdown or bringing dishonour to the family; fear that the children will be taken into care; fear of an unsympathetic response; or fear of repercussions related to insecure immigration status.
      • Shame or embarrassment, cultural stigma, economic barriers, or communication difficulties.
      • Not identifying their experience as abuse.
      • Not believing that anything can be done to help them; believing that the experience is ‘too trivial’ to mention; or having had a negative past experience of services.
  • Document any discussion with the person clearly, accurately, and safely in the primary care health record, even if the person is unwilling or unable to disclose domestic abuse at this time.
    • Explain the need to document the consultation. Explain that, as a duty of care, healthcare professionals have a responsibility to record a disclosure or the findings of an examination (including any injuries).
    • Record any health problems, symptoms, and signs, including a description of any injuries, whether this is a first disclosure, or any previous disclosures, timescales, and actions taken.
      • Use the person's own words (with quotation marks) rather than your own. Describe exactly what happened, for example, patient states 'my husband kicked me twice in the stomach' rather than 'patient assaulted'.
      • It may be helpful to note the cause or suspected cause of injuries or other conditions, including the person who caused the injury.
      • Consider taking photographs of any physical injuries. Drawings or body maps can also be used.
    • Ensure that the medical record can only be accessed by those directly involved in the person’s care.
      • Make use of the online visibility function in the electronic medical record, and consider use of a code or special mark to indicate cases of (or suspected) domestic abuse in the person's (and children's) medical notes. Ensure that documentation of domestic abuse is hidden from accessible online records.
      • Do not document anything where it can be seen by those who do not need to know, for example, on an X-ray request or in hand-held notes (such as maternity notes).

Responding to a Disclosure by a Victim

  • Reassure the person that they have made an important step by making the disclosure.
    • Tell them you believe them, that the abuse is not their fault, and that they (and any children) have a right to safety.
  • Assess whether the person (and any other adults or children) are at immediate risk of harm.
    • If there is an immediate risk, ring 999 and refer to the local adult and/or child safeguarding teams and/or IDVA (Independent Domestic Violence Advisors) service, ideally with the person's consent.
    • If there is no immediate risk, provide a basic safety plan.
      • Manage any presenting physical injuries and arrange admission or referral, depending on clinical judgement.
      • Do not advise the person on what action they should take, such as to leave their partner if they are not ready and without appropriate support in place.
      • Be aware that a person's situation and risk are dynamic and can change quickly.
  • Advise the person that any discussion is confidential, and that the information provided will be shared only with their consent, subject to practice policy on adult and child safeguarding.
  • If there is a significant risk to the person (or other adults or children), share information with other agencies and services appropriately, depending on clinical judgement.
    • If it is believed that withholding information puts a child or another adult at risk of significant harm, then disclosure may be justified in the public interest and/or in order to protect the vital interests of the third party.
  • Advise on sources of information and support to enable the person to make their own decisions.
  • Arrange referral, liaise with, or signpost to local agencies and services, depending on clinical judgement.
    • These may include specialist services for domestic abuse; maternity services; sexual health services; a sexual assault referral centre (SARC) and the police for medical and legal investigations if there is reported sexual abuse; mental health services and/or substance misuse services; housing support; financial advice; counselling; and advocacy, depending on the level of risk.
    • Ensure that children and young people affected by domestic abuse are offered referral to age-appropriate specialist domestic abuse services, which may include psychoeducational support, counselling, specialist children's victim support workers, or an Independent Domestic Violence Adviser (IDVA).
  • Provide ongoing support and follow-up for the person (and other adults or children) with continuity of care, where possible.
    • Ensure the person is seen alone at future appointments. 
    • Monitor for possible indicators of further, or increased, domestic abuse.
    • Follow existing safeguarding, risk assessment, and referrals processes and procedures for vulnerable adults and children. See the CKS topic on Child maltreatment - recognition and management for more information.
    • Monitor their physical, mental and/or emotional wellbeing and need for ongoing support, treatment, and/or referral.
For recommendations on responding to a disclosure made by a perpetrator, refer to the full CKS topic.

Sources of Victim Support

  • Useful sources of information and support for people experiencing domestic abuse include:
    • General
      • Police — 999 in an emergency.
      • National Domestic Abuse Helpline — 0808 2000 247 (www.nationaldahelpline.org.uk), a freephone, 24-hour, non-judgemental, and confidential advice run by Refuge to keep victims safe and provide information to make informed choices.
      • Bright Sky mobile app and website provide practical support and information on how to respond to domestic abuse.
      • Samaritans — 116 123 www.samaritans.org (available 24 hours a day to provide confidential, emotional support for people who are experiencing feelings of distress or despair).
      • Victim Support — 0808 1689 111 www.victimsupport.org.uk (free and confidential support for victims and survivors of any abuse or crime, regardless of when it occurred or if the crime was reported to the police).
    • Women
    • Men
      • Men’s Advice Line run by Respect — 0808 801 0327 www.mensadviceline.org.uk.
      • Men’s Aid — 0333 567 0556 www.mensaid.co.uk (provides practical advice and support to primarily men, but also seeks to represent the views and support anyone, regardless of gender or sexual orientation).
      • Mankind — 01273 911680 www.mkcharity.org (a specialist organisation for men in England and Wales affected by unwanted sexual experiences, including self-help resources, counselling, and other forms of therapy).
      • ManKind Initiative — 01823 334244 www.mankind.org.uk (provides a confidential helpline for male victims of domestic abuse, as well as information, support, and a signposting service).
      • Respect — 0808 802 4040 www.respectphoneline.org.uk (offers information and advice to male victims of domestic abuse, their partners, ex-partners, friends, family, and front-line workers).
      • Survivors UK — 0203 598 3898 www.survivorsuk.org (provides support and advocates for men and non-binary people who have been affected by rape or sexual abuse).
    • Children
    • Specific groups
      • Galop — 0800 999 5428 www.galop.org.uk (provides the national LGBT domestic abuse helpline, and can also advise on other issues such as hate crime, so-called conversion therapies, and sexual violence).
      • There are multiple additional resources on the GOV.UK website section on specialist support services including for lesbian, gay, bisexual, trans+ people; older people; refugee groups; disabled people, and ethnic minority groups.
    • Legal advice
      • National Centre for Domestic Violence — 0800 970 2070 www.ncdv.co.uk (provides a fast, free emergency injunction service to survivors of domestic abuse, regardless of their financial circumstances, race, gender, or sexual orientation).

For recommendations on confidentiality and information sharing, refer to the full CKS topic.

References

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