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  2. DFV Primary Care Toolkit

Spot the Signs

Last updated May 15, 2023

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Recognising domestic and family violence (DFV) is a whole of practice responsibility. All staff need to be trained to identify clinical indicators of DFV, with clear lines of communication between non-clinical and clinical staff to ensure any suspicion of DFAV is responded to appropriately.

Recognising DFV is a three-part process:

  1. Understanding what DFV is

  2. Identification of clinical indicators or DFV

  3. Supporting disclosure of DFV

What is DFV?

Domestic and family violence (DFV) is the use of harmful behaviours to control another person within the family or home. These behaviours include emotional abuse, psychological abuse, financial or economic abuse, physical abuse, sexual abuse, and stalking. Women are more likely to be victim/survivors of DFV. However, DFV occurs throughout all age, socio economic, and demographic groups.

Emotional abuse
  • Constant criticism
  • Belittling, name calling, and verbal abuse
  • Humiliation Jealousy
  • Controlling the way the victim/survivor spends their time
Physical abuse
  • Pushing, slapping, biting, kicking, or choking
  • Actual or threatened harm with a weapon
  • Damage to property
  • Placing the victim/survivor in dangerous positions
  • Forced drug and/or alcohol use
Sexual abuse
  • Using physical force in sexual situations
  • Using coercion or manipulation to have the victim/survivor engage in sex acts they do not want to do
  • Taking sexual photos or videos without consent
  • Being forced or coerced to engage in sexual acts with other people
Psychological abuse
  • Intimidation
  • Threats to the victim/survivor, their children, family, friends, , or pets
  • Threats of suicide
  • Isolation from friends and family, or controlling which people the victim/survivor can have contact with and at what frequency
Financial or economic abuse
  • Controlling finances
  • Restricting access to money
  • Not allowing the victim/survivor access to income through work or government benefits
Stalking
  • Repeated calls and messages
  • Sending unwanted gifts or letters to a victim/survivor’s home, work, or other place they frequent
  • Tracking the victim/survivor’s movements

Clinical Indicators of DFV

Depression is the most significant clinical indicator of the presence of DFV. One in four women who present to their GP with symptoms of depression are also currently impacted by DFV (Hegarty, O'Doherty, Astbury, & Gunn, 2012).

Additional clinical indicators in adults may be caused by to physical trauma, psychological trauma and stress, or fear and control.

Physical trauma

Injury
  • Musculoskeletal
  • Soft tissue
  • Genital/anal trauma
  • Other

Fear and control

Sexual and reproductive health
  • Lack of contraception
  • Unsafe Sex
  • Unwanted pregnancy
  • Abortion
  • HIV and other sexually transmitted infections
  • Gynaecological and/or anal problems
Health care seeking
  • Lack of autonomy
  • Difficulties seeking care and other services
Perinatal and maternal health
  • Low birth weight
  • Prematurity
  • Pregnancy loss

Psychological trauma and stress

Mental health problems
  • Post-traumatic stress disorder (PTSD)
  • Anxiety
  • Depression
  • Eating disorders
  • Suicidality
Substance use
  • Alcohol
  • Tobacco
  • Other drugs
Non-communicable diseases
  • Cardiovascular disease
  • Hypertension
Somatoform
  • Irritable bowel
  • Chronic pain

(World Health Organisation, 2013)

Identifying Strangulation

Strangulation has been described as a "last warning shot" before death. Risk of fatality increases by 750 per cent for victim/survivors who have been strangled previously compared to those who have never been strangled.

Signs of strangulation are not always obvious; often in fatal cases there are no external signs of injury. About 35 per cent of women who are strangled will have very minor marks, and 15 per cent will have enough injury to be photographed (Training Institute on Strangulation Prevention, 2019).

Practice point

Consider using the DFV Primary Care Action Plan's Risk Assessment upon patient disclosure of DFV, it will provide guidance around how to ask if your patient has experienced strangulation.

Examination

A range of respiratory, vascular, neurological, and musculoskeletal signs and symptoms may indicate strangulation-related injury.

Red flags include neurological signs or symptoms including:
  • Amnesia
  • Incontinence
  • Severe headache
  • Near or complete loss of consciousness
  • Changes in vision or sight
  • Petechial haemorrhages
  • Neck bruises or ligature marks
  • Neck swelling or tenderness
  • Dysphonia
  • Odynophagia
  • Inability to clinically clear cervical spine
  • Dyspnoea
  • Subcutaneous emphysema
  • A mechanism suggestive of significant force
  • The presence of any red flag is an indication for imaging. For facial, cranial or neurological red flags, most centres will include a computerised tomography (CT) stroke protocol (non-contrast CT brain and CT arch-Circle of Willis (COW) to assess for ischaemic, watershed or haemorrhagic stroke and carotid or vertebral artery dissection. For neck-related red flags, CT cervical spine and/or neck is indicated and a CT chest for subcutaneous emphysema (ACI, 2022).

Investigations

Computed tomography angiography (CTA) of the head and neck is highly sensitive and specific (>95%) for assessing penetrating and blunt trauma of the neck.

Cervical spine injury is uncommon in non-fatal strangulation (NFS)without a supporting mechanism of injury involving hanging from a height. In these instances, a CT cervical spine is indicated.

Magnetic resonance imaging (MRI) may be indicated for assessment of long-term hypoxic damage resulting from NFS, however it is not routinely indicated in the ED assessment. MRI or magnetic resonance angiography (MRA) may be considered in younger patients as an alternative to CTA if concerns are raised regarding radiation exposure.

Patients with significant vocal changes or swallowing difficulties may require further specialty input to assess and document laryngeal injury (including significant oedema or bruising not visible externally) and advise on management (ACI, 2022).

Supporting Disclosure

Studies show that women are twice as likely to disclose Domestic Family Violence and Abuse if asked by their GP or a nurse in the general practice. There are several ways a practitioner may be able to support a person to disclose that they are being impacted by DFV.

  • Never raise the issue of partner violence unless a woman is alone, even if she is with another woman. That woman could be a friend or family member of an abuser.
  • If you do ask her about violence, do it in an empathic, non- judgmental manner.
  • Use language that is appropriate and relevant to the culture and community you are working in. Some women may not like the words “violence” and “abuse”. Cultures and communities have ways of referring to the problem with other words. It is important to use the words that women themselves use (WHO, 2104).

Responding to Disclosure

The LIVES Model

The White Book

Abuse and violence: working with our patients in general practice, 5th edition (the White Book), was developed by General Practitioners and subject matter experts to create a valuable and useful document for health practitioners. The guideline is a practical resource and is based on the best-available current evidence about recognising and responding to abuse and violence, including DFV.

View the white book

References

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