Summary

Intimate partner abuse is a worldwide problem. Victims may present themselves to a doctor with vague symptoms. Apart from the police and social workers, general practitioners may be another point of contact with the victims. This article gives an overview of partner abuse in Hong Kong, the impact of the problem on victims, their children and the society. As majority (over 90%) of intimate partner violence is battering of the female partner,^1,5 this discussion will focus on partner abuse against women. The role of doctors on this issue is also discussed.

摘要

虐待親密伴侶是一個世界性問題。在求診時，受虐者可能會提出一些不明確的症狀。除了警務人員和社會工作者外，家庭醫生也可能是受虐者的接觸人。本文概述香港虐待伴侶的情況，及其對受虐者、子女和社會的影響。鑒於大多數（九成以上）親密伴侶間的暴力都以女性為受虐者，本文將重點討論受虐女性的問題，以及醫生在此問題中的角色。

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Introduction

According to the WHO, intimate partner violence includes acts of physical aggression, psychological abuse, forced intercourse and other forms of sexual coercion, and various controlling behaviours such as isolating a person from family and friends or restricting access to information and assistance.²

Magnitude of the problem

In large national studies, 10-34% of women reported being physically assaulted by an intimate male partner at some point in their lives, partner violence accounts for a significant number of deaths among them; and 40-70% of females who had been murdered were killed by their husband or boyfriend, often during an ongoing abusive relationship.² The pervasiveness of domestic violence is so great that it cuts across social, ethnic, sexual orientation, economic, cultural, religious, race and geographical boundaries.³

A local study on pregnant women reported 17.9% lifetime prevalence for domestic violence and 4.3% of pregnant women had suffered from domestic violence during their pregnancy.⁴

In another study done at one Accident and Emergency Department, the authors reported that over 95% of victims of domestic violence were assaulted by their husbands and the remainders were assaulted by their ex-husbands or boyfriends.⁵ All the victims sustained physical injuries. The study also showed that 70% of the victims were battered more than once and 39% had been battered for more than three years. The Harmony House reported that 53.6% of abuse against women involved psychological abuse.⁶

This problem was often under-reported and the data only showed the tip of the iceberg especially for psychological abuse and forced sexual intercourse. In the Chinese culture, violence within the family were regarded as a family secret and should not be disclosed.

On the other hand, Chinese tend to suppress their feelings and express their psychological trauma as somatic symptoms. Health professionals may not be alert enough to identify and respond appropriately to partner abuse. It may either be underestimated or even be overlooked. The somatic symptoms could easily be mistaken as physical illnesses.

The development of partner abuse

Most victims of physical aggression are subjected to multiple acts of violence over extended periods of time.^1,5 The cycle of domestic violence⁷ would probably continue if no intervention is done to break the cycle.

There are many factors that shape the nature and consequences of violence. At the individual level, young age and low income were consistently found to be factors linked to the likelihood of a man committing physical violence against a partner.⁸ Violence in the family of origin, low self esteem and mental disorders are shown to be related to partner abuse. With regards to substance abuse, Fals-Stewart W. found that the odds of severe male-to-female aggression were more than 11 times higher on days of men's drinking than on days of no drinking, and this supported the proximal effect model of alcohol use and partner violence.⁹

Birth outcome was once a cause of domestic violence in Hong Kong and elsewhere. But this has changed recently, at least in our community. At the interpersonal level, marital conflict and male control of family wealth are considered main risk factors for partner abuse.¹⁰ At the community level, lower socioeconomic status of women, cultural acceptance of violence to settle disputes, rigid gender roles are main factors leading to partner violence.

The consequences and impact of intimate partner violence

Impact on the victim

The impact of domestic violence may be long term, affecting emotional adjustment, physical health and subsequent relationship.¹¹ During the acute episode, physical injuries such as multiple brain injuries¹² may be serious or even life threatening. Emotionally, there may be suppressed anger, extreme fear, anxiety and sadness. Physical injuries are easily assessed, but psychological trauma may be more detrimental, and difficult to measure especially when the acute episode is over.

Impact on mental health

Abused women are more likely to suffer from depression, anxiety, psychosomatic symptoms, eating disorders and sexual dysfunctions.¹⁰ They may be chronically fatigued but unable to sleep. They may have nightmares, turn to alcohol and drugs to numb their pain, or become isolated and withdrawn.¹³ For those who had sustained brain injury, they were negatively associated with measures of memory, learning, and cognitive flexibility.¹² Other psychological and behavioural consequences include feelings of shame and guilt, poor self-esteem, phobias, panic disorder, posttraumatic stress disorder, and suicidal behaviour. These influences can persist long after the abuse itself has stopped, and the impact over time of different types of abuse and of multiple episodes of abuse appears to be cumulative.⁸ A study on adolescents also showed an increased level of risk behaviour including substance abuse, antisocial behaviour and suicidal behaviour among females.¹⁴

Impact on reproductive health:

Violence may affect the reproductive health of women through:

• the increase of sexual risk-taking amongst adolescent
• the transmission of sexually transmitted diseases, including HIV/AIDS
• unplanned pregnancy
• precipitating various gynaecological problems including pelvic pain and painful intercourse.¹⁰

A recent study¹⁵ showed that partner violence during pregnancy is significantly associated with an increased risk of adverse birth outcomes. They were more likely to have low birth weight or very low birth weight infants, preterm birth, very preterm birth, and neonatal death.

Impact on children:

Children in violent families may also be victims of abuse. They are frequently injured while trying to defend their mothers.¹³ Children who witnessed partner abuse in their families have an increased chance of developmental delay. They show under achievement in academic work and behavioural problems.¹⁶ Children brought up in a violent environment were more likely to become abusers and being abused when they grew up.¹⁷

Impact on the society:

Battered women who are unidentified or do not receive appropriate interventions have increased health problems compared with women who are not battered.¹ They are more likely to be long-term users of health services. In addition, they utilise the social service more especially for counselling service, home shelters and financial assistance. Therefore early prevention may decrease public expenses on social problem.

Management in Hong Kong

As partner abuse usually takes place behind closed doors, only members within the family are aware of it. No intervention can be offered if the victims keep their mouths shut. Even if the incidents are reported by a third party, little can be done to the abusers if the victims refuse to ask for help and refuse to be witness against their partners. As shown in our local study,⁵ only 50% of victims presented themselves to the medical social services after attending the Accident and Emergency Department for treatment of physical injuries.

Currently, there is a hotline service of the Social Welfare Department (SWD). Victims or witnesses of abuse can report it through this hotline. Other sources of reporting are from the police, hospital emergencies department, social workers and other healthcare workers when the victims approach these services for assistance.

Once an incidence is reported, the Family and Child Protective Services Units (FCPSUs) of the SWD would provide "one stop" service for victims of domestic violence and their families to help them to overcome the trauma. These units provide outreaching services to conduct initial assessment upon receiving report on suspected domestic violence case, and to arrange the victims to receive medical examination, psychological assessment and/or temporary care at hospital or other institutions if battering or abuse is suspected.

There are four refuge centres providing residential services for abused women free of charge. They admit cases on 24-hour-basis, usually by referrals from social workers at the FCPSUs and the police. Applications for admission can also be made directly or through casework service units of SWD.

Follow-up services provided include counselling service, coordinating follow-up services such as clinical psychological service, financial assistance, compassionate rehousing, legal services referral, school arrangement and job placement provided by other government departments and non-governmental organisations.¹⁸

Immediate help and shelters are available. However, many victims are reluctant to obtain help through proper channels, or they are still unaware of these services. Many partner abuses remain unnoticed. Counselling services are also available to the abusers through the workers at FCPSUs or other voluntary agencies such as the Hong Kong Family Welfare Society.

The role of family physicians in partner abuse

Prevention

Family physicians have an educational role in teaching their patients skills to resolve conflicts with non-violent means when patients express the tendency to settle disputes with violence. Many people intending to get married would consult their family physician for premarital health check. This is a golden opportunity for these people to receive premarital counselling in order to enhance future relationship. Even though doctors may not provide such services, these clients should be advised to attend premarital counselling services run by other institutions.

Screening

Routine screening for partner abuse by health workers when women attend for contraception, perinatal care, child care services etc., can be carried out for identification of abuse, providing support and devising safety plan against such abuses.^8,19 Such screening is also regarded as effective in detecting domestic violence, and increases the rate of referrals to community resources, resulting in improved quality of life and fewer violence-related injuries.²⁰

Victims presenting to the family physician with physical symptoms may not acknowledge abuse and are reluctant to discuss this issue. In suspected cases, a family physician should be able to put the victims at ease to talk about it. By validating their fears and concern, by "normalising" the situation, and by using "funnelling" technique to assess the present situation, a family physician would be able to help the victims to face the situation.

Interventions

Many family physicians who may be the first contact with the victims are not trained to provide trauma and crisis intervention. Therefore, interventions during acute crisis may not be as effective as professional counsellors. To improve the service for partner abuse victims, family physicians should equip themselves with such intervention skills. As many psychologically abused women may prefer to attend their doctors rather than seeking help from the SWD, doctors should ideally be trained to provide simple and supportive counselling service or to make use of the trusting doctor-patient relationship to persuade these clients to seek appropriate help.

Many victims would also develop depression subsequently. Early detection and management are possible if their family physicians can screen for such a condition when they attend the clinic for whatever reasons. As some abusers have drug and alcohol abuse as well, a family physician has a role to help the abusers to adopt alternative ways to cope with stress and emotions instead of using these means.

Conclusion

In conclusion, to improve management of partner abuse, family physicians should better equip themselves with necessary knowledge and skills. They can assess risks and devise safety plan for victims during the acute stage, to follow up for any complications, to help the abusers to get rid of their unwanted behaviour, and to collaborate with other disciplines in the management.

Key messages

1. Partner abuse is an important social problem in Hong Kong.
2. Family physicians need to equip themselves with necessary skills to identify the victims and assess their risks.
3. Ideally, family physicians should know crisis intervention techniques.
4. Abusers need to be helped to get rid of their unwanted behaviours.
5. Collaboration with other disciplines is required to ensure proper care.

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References