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ABC of Domestic and Sexual Violence

Susan Bewley (Editor), Jan Welch (Editor)
May 2014, ©2014, BMJ Books
ABC of Domestic and Sexual Violence (EHEP003153) cover image

Description

ABC of Domestic and Sexual Violence is a practical guide for all health care professionals who are looking after abused individuals (whether knowingly or not) and who wish to learn more in order to help their patients. It employs a positive and hands on approach, emphasising simple history taking skills and clinical ‘tips’ and pitfalls to help demystify what is often considered a sensitive or difficult subject area.

This new ABC title covers background and epidemiology, including: international and cultural perspectives, common presentations, how to identify abuse, and guidance on subsequent acute and longer-term medical and psychosocial interventions. It provides guidance on legal perspectives including documentation and sources of help and advice. While focusing mainly on women, it will also cover aspects relating to children and men. It also incorporates victim testimonies and case scenarios throughout.

From a multidisciplinary team of contributors ABC of Domestic and Sexual Violence is ideal for all general practitioners, accident and emergency, practice nurses, health visitors, midwives, social workers, and other primary and secondary care health care professionals.

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Table of Contents

Contributors vii

Foreword ix
Sir George Alberti

Introduction xi
Susan Bewley and JanWelch

1 The Epidemiology of Gender-Based Violence 1
Gene Feder and Emma Howarth

2 ‘Culture’ and Violence 5
Marai Larasi

3 Domestic Violence and Abuse 9
Fiona Duxbury

4 The Impact of Trauma 17
Gwen Adshead

5 Children 21
Andrea Goddard

6 Sexual Assault of Men and Boys 27
Michael King

7 Identifying Domestic Violence and Abuse 30
Alex Sohal and Medina Johnson

8 Community-Based Responses to Domestic Violence 37
Nicole Biros

9 Sources of Referral and Support for Domestic Violence 41
Jackie Barron

10 Perpetrators 46
Colin Fitzgerald and Jo Todd

11 General Practice 50
Emmeline Brew-Graves

12 Emergency Medicine and Surgical Specialities 54
Lindsey Stevens

13 Elder Abuse 59
Finbarr C. Martin

14 The Dental Team 62
Tim Newton and Rasha Al Dabaan

15 Mental Health Services 64
Eleanor Turner Moss and Louise M. Howard

16 Women’s, Reproductive and Sexual Health Services 69
Maureen Dalton

17 Female Genital Mutilation 72
Sarah M. Creighton

18 Sexual Violence:What to Consider First 74
CatherineWhite

19 Rape and Sexual Assault: Medical and Psychosocial Care 82
Hannah Loftus and Karen Rogstad

20 Documenting in the Notes 87
Ali Mears

21 Law and Prosecuting Practice in Relation to Serious Sexual Assaults and Domestic Violence 90
Wendy Cottee

22 Writing a Statement as a ProfessionalWitness 93
Bernadette Butler

23 Going to Court 97
Bernadette Butler

24 Violation of Professional Boundaries 100
Fiona Subotsky

25 Moving Forward: Developing Care Pathways within the Health Service 103
Loraine J. Bacchus

26 Moving Forward: Pursuing a Career and Implementing Better Services 106
Maureen Dalton

Appendix A Useful Resources 109

Appendix B CAADA-DASH Risk Identification Checklist 111

Index 115

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Author Information

Susan Bewley is Professor of Complex Obstetrics, Division of Women's Health, King's College London, and Women's Health Academic Centre, King's Health Partners (KHP), St Thomas' Hospital, London

Jan Welch 
is Director, South Thames Foundation School, and Deputy Dean for Foundation Training, Sherman Centre, Guy's Hospital, London, UK

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Reviews

Domestic and sexual violence is becoming a more openly discussed and disclosed subject, however, not all health professionals are equipped with the knowledge to support and signpost the person(s) affected. Indeed, many may not feel confident in being able to identify individuals subjected to abuse.

The information should be clear and practical and this is where this book fits in. The ABC of domestic and sexual violence presents a practical guide suitable for all health care professionals, with contributors from a wide range of professions adding to the multidisciplinary remit of the publication. It is one in a series of ABC books all
aiming to provide knowledge and information on a variety of topics in a practical and easily understood format.

This book is of particular relevance to midwives and others working with women and with men being the perpetrator. However, this is not exclusive to women and can affect the whole age spectrum and as midwives we come in contact with a range of people, from newborns through to grandparents and even great grandparents. It is therefore our duty to be vigilant for signs of abuse and to be able to act upon such information.

The chapters within the book discuss the different ways people are affected, including same sex situations and female genital mutilation. It also gives guidance on how to identify domestic abuse and violence, varying types of abuse and the impact it has on the abused.

I particularly like the layout of the book with the inclusion of boxes with guidance of what to do, ask and consider in certain situations and the case studies give insight into real situations that the reader may come across in practice. Some of the case study scenarios may resonate with experiences already encountered by the reader – these are good to reflect upon and consider if the action taken was appropriate or whether situations could have been handled differently.

The final chapters discuss how we can move forward and develop care pathways within the health service and how to build these services into future careers. It is acknowledged that, although teaching on the subject of domestic abuse is not always integral to all undergraduate training, there are various ways of gaining this information at a later stage. The appendix contains some useful resources including a risk-identification checklist.

I would highly recommend this book to students and qualified professionals that are inexperienced in the knowledge of domestic abuse and sexual violence. It contains valuable
information in every chapter and once read should be kept as a useful resource to turn to when working in the field of health care. (Cathy Ashwin, Principal Editor, MIDIRS Midwifery Digest 26:1, 2016)

This excellent text skilfully addresses the topic of domestic and sexual violence, thoroughly yet concisely, within a slim A4 volume of 26 short chapters.

Domestic and sexual violence is a daunting area for most clinicians. It is ubiquitous yet concealed, requiring knowledge, skill, commitment and sensitivity to tackle it, based on awareness that it may underpin the patient’s presenting complaints. Written in an authoritative yet user-friendly style, this book deftly leads the reader through all aspects of the subject, anticipating and addressing the concerns faced by all clinicians, notably in the field of legal practice. Reference to the ‘burden of disease’ sheds new light on the topic, pointing out analogies to physical illness and injury, supported by scholarly references.

One particular strength of this book is its breadth of vision, including in its remit safeguarding, child protection and mental health, as well as topics less commonly-addressed, such as elder abuse and the role of the dental practitioner in recognising the significance of facial injuries.

Yet despite this, the book does not neglect its core areas, namely General Practice, Accident & Emergency, Sexual Health and Obstetrics & Gynaecology. It reminds us that abuse often starts or escalates in pregnancy, and that it is a major cause of maternal and fetal death, as well as premature labour, antepartum haemorrhage and fetal growth restriction. Likewise, chronic pelvic pain can be a manifestation of abuse.

I have found this volume to be a valuable and refreshing source of information and advice, and I would thoroughly recommend it to all clinicians, including trainees and medical students. (Brigid Hayden FRCOG, Consultant O&G, Bolton Hospital, Lancashire, UK, in The Obstetrician & Gynaecologist, Issue 2, Vol 17, 2015)

The ABC of Domestic and Sexual Violence complements the existing series of ABC books. Both the editors are passionate about this subject and with this book aim to improve health services to support families suffering domestic and sexual violence.

This book is targeted at all teams providing health care and aims to increase knowledge and confidence to enable the team to identify, question and act appropriately within this realm. It highlights when, where and how to achieve this most effectively within conventional health care settings.

The twenty-six chapters are conveniently titled and penned by various authors. The authors provide a valuable picture of each topic and go on to identify noteworthy points and give very practical ideas of how to cope when faced with a domestic and sexual violence issue. Case examples are described in many chapters, including ‘The Dental Team’. These case scenarios provide real insight into what ‘survivors’ (classically termed ‘victims’) may be thinking and feeling. Signposts to online resources and descriptions of available services that patients may be referred to are included. To understand the evidence base of each topic further reading is recommended. A ‘Risk Identification Checklist’ provided as an appendix gives front line practitioners the basic tools to identify high risk cases.

However, ‘The Dental Team’ chapter is rather disappointing as it provides no additional information beyond what is learnt and understood by a recent graduate. Alone this chapter is a poor as a clinical tool but it identifies further chapters and this is where the real information can be found.

The book goes on to consider documentation and how clinicians may be involved in court proceedings. The points made and lessons learnt listed here can clearly be applied to many situations dental teams commonly find themselves in.

The book very effectively challenges traditions and viewpoints, including the very topical Female Genital Mutilation as well as questioning male circumcision. It also does not forget the less obvious groups involved in domestic and sexual violence: males, children, the vulnerable or elderly and the perpetrators themselves.

As a sometimes uncomfortable subject to research the book is thoughtful and non-apologetic throughout and, allows the reader to see the true value in its pages and not be put off by taboos. Overall the book achieves its aim of empowering health-care workers to ask searching questions at appropriate points whilst providing clear structured guidance and excellent signposts. (Charlotte Molyneaux BDS (Hons.))

A quick online search for ‘domestic violence statistics’ yields a glut of disturbing responses. Womens Aid lead with ‘one episode of domestic violence is reported to the police every minute’, the Crime Survey for England and Wales reports a lifetime prevalence of partner abuse of 31% for women, and two women a week in the UK are murdered by their partners. Domestic and sexual violence is common. It affects all genders and all ages, all ethnic backgrounds and those of all faiths and none. It affects the patients whom we see every day and its’ repercussions echo through their physical and psychological health.

Domestic and sexual violence are more prevalent than diabetes, inflammatory bowel disease and stroke, and yet teaching on domestic violence features little on undergraduate and postgraduate medical curriculae. How many of us can claim to feel comfortable asking about a history of sexual violence, would know where to refer a women in crisis, or how to advise her about basic safety precautions?  If you, like me, find your knowledge base wanting, then the ABC of Domestic and Sexual Violence may be the book for you.

Edited by Susan Bewley, Professor of complex obstetrics at Kings College London and Jan Welch, Consultant in HIV Medicine and Sexual Health, the ABC of Domestic and Sexual Violence is a one stop shop for information on this complex topic. With contributors ranging from GUM consultants to psychiatrists and from GPs to those working in the third sector the book is both wide ranging in its scope and practical in its approach.

Early chapters focus on the epidemiology and impact of abuse. The range of abusive behaviors is made clear, and the role of the health care professional is set out in the three R’s; recognise, respond and offer to refer. An important chapter from Michael King discusses the sexual assault of men and boys, busting common myths held by the public and health professionals alike that men cannot be forced to have sex against their will, that men can defend themselves when threatened and that a man experiencing an erection or who ejaculates during an assault must have been in some way complicit. Case studies throughout these chapters work through examples with the reader, reminding you of what you need to consider and of key learning points.

Despite being armed with the worrying knowledge of the prevalence of domestic violence and abuse within the communities we work in, many of us struggle to know how to identify patients who are affected. We may feel unsure of when to ask, how to do so sensitively and what to do with the information. Here the ABC really comes in to it’s own. A chapter is dedicated specifically to identifying domestic violence and abuse, and to the average registrar like me, it was invaluable. The do’s and don’ts of asking about abuse are made clear with helpful text boxes giving examples of questions to use, from the open ‘how are things at home’, to the more direct ‘are you afraid of anyone at home?’ The validated HARK questions were new to me, but are a take home point that I am incorporating in to my consultations (Humiliation; ‘have you ever been humiliated or emotionally abused by your partner/ex partner, Afraid; ‘have you ever been afraid of your partner/ex partner’? Rape; ‘Have you ever been raped or forced to have any kind of sexual activity by your partner/ ex partner’ Kick: ‘Have you ever been kicked, hit, slapped or otherwise physically hurt by your partner/ex partner’).

Aimed across the spectrum of health care professionals, the ABC of Domestic and Sexual Violence is both a practical guide and a springboard for further learning (chapters are well referenced, and useful websites and phone numbers are made available). A whole chapter is dedicated to how to manage a primary care consultation on domestic violence and, crucially, another chapter details how to document those consultations. A brief chapter on Female Genital Mutilation may well be expanded in future editions, but its’ presence is important and timely. Sections on the law in relation to sexual assault and domestic violence, and on the ethics of professional boundaries help to provide a thorough overview of a large topic.

The ABC of Domestic and Sexual Violence is both an eye opening read, and a practical handbook. It is brief, concise and always relevant. With the police receiving one domestic violence call a minute in the UK, and almost one in three teenagers already having experienced domestic or sexual violence, the real question is whether this a book you can afford not to read? (Dr R Fisher, GP ACF ST3, Oxford)


On the face of it, the ABC series seems an unlikely place for a book about domestic and sexual violence. Wiley’s ABC guides comprise a collection of some 80 titles, all highly illustrated, packed with diagrams, case histories, colour photographs and easily-digested text, written by specialists for non-specialists in primary care and covering subjects such as dermatology, kidney disease and resuscitation. But domestic violence, a complex, psychosocial issue that is often not even included in the training of health care professionals? Well, it seems to me that the publishers are to be congratulated for taking the bold step of putting some new and potentially life-saving skills into the hands of primary care-givers.

The scale of the problem and its impact on health services alone justifies this subject being included in the series. According to the Crime Survey for England and Wales, the most reliable source of estimates of prevalence within the community, 31% of women and 18% of men will experience abuse from a partner in their lifetime. Intimate partner violence is not a private matter. A burden-of-disease
analysis (in Australia) reported that interpersonal violence contributed 8% of the total disease burden in women aged between 15-44, making it the main cause of death, disability and illness in this age group, way ahead of harms resulting from drug-taking, smoking or obesity [1].

But most importantly, this book’s intended audience of primary caregivers—GP’s, nurses, health visitors, midwives, social workers, paramedics, even dentists—have unique and privileged opportunities
to be able to identify abuse and so have a chance to begin to help this vulnerable group of patients, if only they could know how and, crucially, have the confidence to ask the difficult questions. This slim volume applies the ABC series’ approachable and userfriendly format to a series of essays by a multidisciplinary range of contributors which take an evidence-based and practical look at a wide range of aspects of gender-based violence, including that within intimate relationships but also covering forms of violence linked to particular ethnic or social groups, for example, female genital mutilation, prostitution and sex-trafficking. The focus is not exclusively on women—there is a chapter on the sexual assault of men and boys; violence in same-sex relationships is also considered.
However the greater emphasis on women reflects evidence showing that the most consistent risk factor for domestic and sexual violence is being a woman; most severe domestic violence and most sexual
violence is perpetrated by men.

Each essay is broken into digestible sections, with diagrams, checklists, myth-busters, and case histories with “what would you do?” exercises. The section on identifying abuse, for example, includes sample questions, suggestions for when and where to ask, and practical tips for ways to overcome barriers to disclosure. Elsewhere there is clear guidance on subsequent medical and psychosocial
interventions. Legal issues are explained, including how to document cases; care pathways, professional boundaries, emergency medicine, and where to go for help and advice.

As you would hope from a guidebook, it does not shy away from being prescriptive. To the obstetrician: “You must ask every pregnant woman about domestic abuse; do not make the mistake of thinking that someone else (e.g. the midwife or GP) will have asked.” No misunderstanding there—now you know where your responsibilities lie there’s no way to justify looking the other way, whether from a disinclination to offend or embarrass or through fear of getting involved in an unpleasant situation.

Earlier reviews on the book’s Amazon page show that this guide is roundly welcomed by professionals, but it is difficult to ignore a couple of critical comments from patients. Clearly it is one thing for clinicians to ask questions, but that alone doesn’t guarantee they will ask them sensitively and in a way that engenders the trust of the patient and result in a positive outcome in every case. These are
very complex and difficult situations, the stakes can be terrifyingly high for the parties involved (including the health professional), and this is only a book. But a book that empowers and compels practitioners to look harder and ask those questions, has got to be a positive step. There may be only one chance to ask a difficult question and ensure the safety of a patient, and it should always be taken.
(Mandy Payne, HealthWatch Newsletter, Issue 96, Jan 2015) [Ref 1: Vos et al. Bulletin of the World Health Organization 2006;84(9):739-744.]

ABC of Domestic and Sexual Violence is a long overdue practical guide to assist health professionals to help survivors of domestic violence.

With a lifetime prevalence of 31% for women and 18% for men (pp. xi–xii), this subject is relevant to all of us, but it receives little attention in undergraduate or postgraduate training. Consequently, when we suspect domestic violence we may not know how to react, or wrongly conclude that it is not our problem. Or else we may miss overt signals altogether as we are not equipped to recognise them.

A whole book on the subject seemed overwhelming at first, but on reading it I realised that this was just a reflection of my own ignorance. Each chapter is an approachable and manageable summary of the complex different facets of this epidemic. As well as ignorance, there may also exist apathy and confusion as to what the role of a doctor should be in this setting. We are wisely recommended to “recognise, empathise and witness and to refer to appropriate multi-agency services” rather than to try and fix or medicalise the problem (pp. 1–4).

This new ABC title, edited by Susan Bewley, a Professor of Complex Obstetrics, and Jan Welch, a Consultant in HIV Medicine and Sexual Health, covers epidemiology and the diverse disease burden that violence creates. There is practical advice for health care workers in obstetrics and gynaecology, genitourinary medicine, general practice, emergency medicine and dentistry, on how to screen for and ask about domestic violence. It describes the current services available and how to access them, as well as other practical legal and documentation advice.

The ABC can act as a reference for which type of injuries and behaviours ought to raise concern, as well as providing example questions and statements to fall back on during difficult conversations. The language of domestic and sexual violence is a recurring theme, with many contributors advocating precision with the words we choose, to avoid implying blame or judgement while remaining accurate and objective.

Another strength of the book is the editors’ consideration of the issue of violence from all perspectives. The contributors identify groups at particular risk of violence such as children, the elderly and people in same-sex relationships, and debunk myths around sexual assault to men. The chapter on culture and violence examines how to remain sensitive to diversity whilst being willing to ask difficult questions. There is even a chapter on how to recognise and respond to perpetrators of violence.

The disadvantage of reading this book was the uncomfortable sinking feeling I experienced as it exposed the missed opportunities I have encountered in practice. Hopefully, if this book can find its rightful place on the reading lists of undergraduates, trainees, specialists, and all those working in primary care, this can be rectified. (Helena Watson, The Journal of Family Planning and Reproductive Health Care, Vol 41, Issue 1)

Case histories blend with medical personnel insights with contributions coming from a multidisciplinary team of experts to make for a basic reference for a wide range of practitioners, from emergency workers to nurses, midwives, social workers and more. (Midwest Book Review, Nov 2014)

This thorough, evidence based, diligently created book deserves to be on hand for all doctors who are faced with these complex, difficult problems. This book answered all my questions - including some I didn't know I needed answers to. (Margaret McCartney, GP)

The health and care professions have long needed an evidence-based reference text on domestic and sexual violence. This compilation of high-quality review chapters is highly readable and a rich resource of evidence on what works, as well as offering (sometimes harrowing) detail on the different kinds of domestic and sexual trauma. (Trish Greenhalgh, Professor of Primary Health Care and Dean for Research Impact, Barts and the London School of Medicine and Dentistry)

This is an excellent, desperately needed book, written and presented in a clear and accessible way that will be of vital use for any health care professional. Too often, this area is neglected in the training of health care professionals and yet doctors, nurses, midwives and social workers are often the first people that victims of domestic and sexual violence confide in. Those in the healthcare setting are in a unique position to identify victims and intervene, yet without adequate understanding and knowledge of this topic, there is a real risk that we profoundly let our patients down. This book is the answer to this. Bringing together world renowned experts in the field, this is an instant classic and compulsory reading for every healthcare professional. (Dr Max Pemberton, Doctor and Daily Telegraph columnist, author of The Doctor Will See You Now)

This book is aimed at General Practitioners, Accident & Emergency Workers, Health Visitors, Midwives, Social Workers and other primary and secondary care professionals. There are 26 chapters: some chapters relevant to a particular medical specialty or distinct age groups but there are excellent chapters on epidemiology of gender based violence, the relationship between culture and violence, documentation (which is very important for successful engogement with the criminol justice system), the Law, statement writing and attending court, that are pertinent to all Health Care Professionals.
The editors ... have a collective experience of Domestic and Sexual Violence spanning at least six decades! Prof. Bewley has written several published papers on Domestic Violence and Dr Jan Welch MBE was instrumental in the birth of The Havens, The Sexual Assault Referral Centre (SARC) that serves London and supports the out-of-hours rotas for acute Paediatric CSA (Child Sexual Abuse) cases for several of the Home Counties. The Havens are funded jointly by the NHS and the Metropolitan Police Service.
This book is comprehensive and demonstrates the advance that has been made with recognising the impact Domestic and Sexual Violence has on children, individuals and society in general. Like all books in the ABC series, it would be of immense interest to students and practitioners of nursing, medical and paramedical specialities, it would definitely be a very useful addition to the library of every General Practice. (Dr Brew-Graves, The Family Doctor, Autumn 2014)

The first edition of ABC of domestic and sexual violence complements the existing series of ABC books. Both the editors are passionate about this subject and, with this book, aim to improve health services to support families suffering domestic and sexual violence.

This book is targeted at all teams providing healthcare, and aims to increase knowledge and confidence to enable the team to identify, question and act appropriately within this realm. It highlights when, where and how to achieve this most effectively within conventional healthcare settings.

The 26 chapters are conveniently titled and penned by various authors. The authors provide a valuable picture of each topic and go on to identify noteworthy points and give very practical ideas of how to cope when faced with a domestic and sexual violence issue. Case examples are described in many chapters, including 'The Dental Team'. These case scenarios provide real insight into what 'survivors' (classically termed 'victims') may be thinking and feeling. Signposts to online resources and descriptions of available services that patients may be referred to are included. To understand the evidence base of each topic, further reading is recommended. A 'Risk Identification Checklist' provided as an appendix gives front line practitioners the basic tools to identify high risk cases.

However, 'The Dental Team' chapter is rather disappointing as it provides no additional information beyond what is learnt and understood by a recent graduate. Alone, this chapter is poor as a clinical tool, but it identifies further chapters and this is where the real information can be found.

The book goes on to consider documentation and how clinicians may be involved in court proceedings. The points made and lessons learnt listed here can clearly be applied to many situations dental teams commonly find themselves in.

The book very effectively challenges traditions and viewpoints, including female genital mutilation, as well as questioning male circumcision. It also does not forget the less obvious groups involved in domestic and sexual violence: males, children, the vulnerable or elderly and the perpetrators themselves.

Despite the distressing subject, the book is thoughtful and non-apologetic throughout and allows the reader to see the true value in its pages and not be put off by taboos. Overall, the book achieves its aim of empowering healthcare workers to ask searching questions at appropriate points, whilst providing clear structured guidance and excellent signposts. (C. Molyneaux, British Dental Journal 220, June 2016)

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