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Domestic violence among female psychiatric patients: cross-sectional survey

  • John F. Morgan (a1) (a2), Gabriella Zolese (a3), Jane McNulty (a4) and Sharon Gebhardt (a5)
Abstract
Aims and method

To establish prevalence of domestic violence among female psychiatric patients, including risk factors, health professional attention and acceptability of routine enquiry. Participants were 70 adult women in an inner-city community mental health team who received questionnaire and case-note review. Main outcome measures were: lifetime/point prevalence of domestic violence; attitudes to routine enquiry; past disclosure and recording in psychiatric records; clinical and demographic risk factors.

Results

Lifetime prevalence was 60% for physical violence from partners, 27% during pregnancy and 40% receiving injuries. Point prevalence was not reported, as an insufficient number of participants were currently in a relationship. As many as 82% regarded routine enquiry as acceptable, but only 24% had ever been questioned. Logistic regression analysis showed prediction by presence of children, previous overdose, and experience of sexual abuse.

Clinical implications

Domestic violence in female psychiatric patients is common but undetected. Enquiry should be routine, but would require staff training.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
John F. Morgan (john.morgan@leedspft.nhs.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Garcia-Moreno, C, Jansen, HAFM, Ellsberg, M, Watts, CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet 2006; 368: 1260–9.
2 Richardson, J, Coid, J, Petruckevitch, A, Chung, W, Moorey, S, Feder, G. Identifying domestic violence: cross sectional study in primary care. BMJ 2002; 324: 274.
3 Sethi, D, Watts, S, Zwi, A, Watson, J, McCarthy, C. Experience of domestic violence by women attending an inner city accident and emergency department. Emerg Med J 2004; 21: 180–4.
4 Golding, JM. Intimate partner violence as a risk factor for mental disorders: a meta-analysis. J Fam Violence 1999; 14: 99132.
5 Cascardi, M, Mueser, KT, De Girolamo, J, Murrin, M. Physical aggression against psychiatric inpatients by family members and partners. Psychiatr Serv 1996; 47: 531–3.
6 Miller, LJ, Finnerty, M. Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders. Psychiatr Serv 1996; 47: 502–6.
7 Tham, SW, Ford, TJ, Wilkinson, DG. A survey of domestic violence and other forms of abuse. J Ment Health 1995; 4: 317–21.
8 Dobbs, J, Green, H, Zealey, L (eds). Focus on Ethnicity and Religion:5. Palgrave Macmillan.
9 World Health Organization. Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women. WHO, 2001.
10 Ramsay, J, Richardson, J, Carter, YH, Davidson, LL, Feder, G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002; 325: 314–25.
11 Royal College of Psychiatrists. Domestic Violence (Council Report CR102). Royal College of Psychiatrists, 2002.
12 Itzin, C, Bailey, S, Bentovim, A. The effects of domestic violence and sexual abuse on mental health. Psychiatr Bull 2008; 32: 448–50.
13 Straus, MA, Gelles, RJ. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. Transaction Publishers, 1990.
14 Coid, J, Petruckevitch, A, Feder, G, Chung, W, Richardson, J, Moorley, S. Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey. Lancet 2001; 35: 450–4.
15 Dearwater, SR, Coben, JH, Campbell, JC, Nah, G, Glass, N, McLaughlin, E, et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998; 280: 433–8.
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Domestic violence among female psychiatric patients: cross-sectional survey

  • John F. Morgan (a1) (a2), Gabriella Zolese (a3), Jane McNulty (a4) and Sharon Gebhardt (a5)
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eLetters

Routine enquiry for domestic violence is not enough

Louise M Howard, Professor of Women's Mental Health
15 November 2010

We read with great interest the paper by Morgan et al on the prevalence of domestic violence and acceptability of clinical enquiry of abuse among female psychiatric patients. This study is highly topical, as our own review of the academic literature identified a dearth of research on prevalence of domestic violence in psychiatric settings and low rates of staff detection in routine clinical practice , particularly in the UK. Morgan et al’s paper reported that the majority of patients sampled perceived clinical enquiry of domestic violence as acceptable. This finding, alongside high reported prevalence rates, led the authors to advocate routine enquiry of domestic violence by mental health professionals.

However, although our review found that the introduction of routine clinical enquiry into mental health services is associated with an increase in clinician identification of domestic violence, we do not believe sufficient evidence currently exists to justify its implementation, unless it is introduced with training on how to ask, and is carried out with a referral and care pathway that can address the domestic violence. We, and Morgan et al, have highlighted that research onthe effectiveness of screening for domestic violence to date has not foundevidence for enquiry leading to reductions in patient morbidity. Furthermore, routine enquiry is not a benign intervention and can lead to adverse consequences (see www.kcl.ac.uk/content/1/c6/05/72/39/Evaluationsummaryleaflet.pdf). The Royal College of Psychiatrists’ policy statement on domestic violence, and the recent Department of Health Violence Against Women and Children (VAWC) NHS taskforce report (see ttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113727)have also stressed the importance of prior clinical training and care pathways for domestic violence in ensuring efficacy of routine clinical enquiry. This year the Department of Health is delivering an NHS awarenessraising campaign to coincide with End Violence Against Women Day on 25 November 2010. This will support PCTs and NHS Trusts to participate in thecampaign and raise the profile of VAWC locally. We hope all Mental Health Trusts will take advantage of this campaign and associated resources to raise awareness among staff and their local communities to address this highly prevalent issue for our patients.

Yours sincerely

Kylee Trevillion

Professor Louise M Howard

Declaration of interest The authors receive funding for a project on domestic violence and mental health from the NIHR Research for Patient Benefit programme. Professor Howard is a member of the DH Implementation Group on Violence Aganist Women and Children. Neither of these organisations was involved with this letter at any stage.
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Conflict of interest: None Declared

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Domestic violence is most commonly reciprocal

Daniel McQueen, Consultant Adolescent Psychiatrist
08 November 2010

Morgan et al. (1) highlight the high incidence of being a victim of intimate partner violence among female psychiatric patients in the UK. This is in keeping with a historic approach that has conceptualised domestic violenceas something that men do to women and has only sought evidence for violence by men against women.

Partly this may be that women are more likely to report intimate partner violence than men. One study found that in the same sample of couples 28% of the women, but only 19% of their male partners, reported that their relationships were violent, suggesting underreporting of one third by men.(2) A study of non-consensual sexual experiences in men found that fewer than three percent of these experiences were reported to police. (3)

In recent years researchers have approached populations without preconceptions as to the direction of violence. Large epidemiological studies have demonstrated that domestic violence is most commonly reciprocal, and that when only one partner is violent there is an excess of violent women.

Whitaker et al (4) in a study of 14,000 young US couples aged 18-28 years, found that 24% of relationships had some violence, and 50% of those were reciprocally violent. In 70% of the non-reciprocally violent relationships

women were the perpetrators of violence. Reciprocal violence appears to be

particularly dangerous, the highest rate of injury (31.4%) was in reciprocally violent relationships. This may be because reciprocal violence is more likely to escalate.

The International Dating Violence Study (5) found that among studentsat 31 universities worldwide male and female students had similar rates of physically assaulting a partner (25% of men and 28% of women at the median

university). There was parity (9% of male and female students at the median university) for perpetrating severe assaults (used a knife or gun, punchedor hit my partner with something that could hurt, choked my partner, slammed my partner against a wall, beat up my partner, burned or scalded my partner on purpose, kicked my partner). For severe injury (passed out, required medical attention or broke a bone) the perpetration rate was higher for males (median rate 3.1% by men and 1.2% by women).

A review of 62 empirical studies of female perpetrated intimate partner violence (6) found rates of physical violence of 4-79% among adolescent girls, 12-39% among female college students and 13-68% among adult women. They concluded that a significant proportion of females seeking services for victimisation are also perpetrators of intimate partner violence, and that those who treat battered women may need to consider addressing the perpetration of violence with their female clients.

The British Crime Survey, in England and Wales, indicates that one infour women and one in six men will be a victim of domestic violence at some point in their lives. (7)

A meta-analysis of 82 studies of sex differences in physical aggression to heterosexual partners found that men were more likely to inflict an injury; 62% of those injured by a partner were women. However women were slightly more likely than men to use one or more act of physical aggression and to use such acts more frequently. Younger aged couples showed more female perpetrated aggression. (8)

The US National Comorbidity Survey demonstrated severe physical aggression against 6.5% of women and against 5.5% of men. (9) Among couples seeking marital therapy, 64% of wives and 61% of husbands were classified as aggressive.(10) In 272 engaged couples, 44% of women and 31% of men reported physical violence towards their partners. (11)

Among women, risks of domestic violence do not differ significantly by ethnic origin. The risk of domestic violence to men does however vary by ethnic group. White men are more likely to be assaulted by their partner than menin other ethnic groups. Asian men are significantly less likely to be assaulted than Asian women. Black men are intermediate. (12)

People of all sexual orientations experience domestic violence in a similar proportion to the rest of the population. In a study of lesbians and gay men 22% of lesbian women reported domestic violence from a previous female partner and 29% of gay men from a previous male partner. (13)

Only examining rates of violence perpetrated against women risks perpetuating an inaccurate stereotype of women as victims and men as aggressors. This may hinder women from receive support to reduce their own

perpetration of violence, and may contribute to the underreporting of violence perpetrated by women against men.

1Morgan JF, Zolese G, McNulty J, Gebhardt S. Domestic violence among

female psychiatric patients: cross-sectional survey. The Psychiatrist 2010; 34: 461-464.

2Whitaker DJ. Haileyesus T. Swahn M. Saltzman LS. Differences in Frequency of Violence and Reported Injury Between Relationships With Reciprocal and Nonreciprocal Intimate Partner Violence. American Journal of Public Health 2007; 97(5): 941-947.

3Coxell A. King M. Mezey G. Gordon D. Lifetime prevalence, characteristics, and associated problems of non-consensual sex in men: cross sectional survey. British Medical Journal 1999; 318: 846-850.

4Whitaker DJ. Haileyesus T. Swahn M. Saltzman LS. Differences in Frequency of Violence and Reported Injury Between Relationships With Reciprocal and Nonreciprocal Intimate Partner Violence. American Journal of Public Health 2007; 97(5): 941-947.

5Strauss M. Prevalence of Violence Against Dating Partners by Male and Female University Students Worldwide. Violence against women 2001; 10(7):

790-811.

6Williams JR, Ghandour RM, Kub JE. Female perpetration of violence in heterosexual intimate relationships. Trauma, Violence, & Abuse, 2008: 9(4); 227-249.

7Nicholas S. Povey D. Walker A. Kershaw C. (2005) Crime in England and Wales 2004/2005. Home Office Statistical Bulletin. London.

8Archer J. Sex differences in aggression between heterosexual partners. A meta-analytic review. Psychological Bulletin 2000; 126: 651–680.

9Kessler RC. Molnar BE. Feurer, ID. Appelbaum M. Patterns and mental

health predictors of domestic violence in the United States. Results from the National Comorbidity Survey. International Journal of Law and Psychiatry 2001; 24:487–508.

10Langhinrichsen-Rohling D. Vivian J. Are bi-directionally violent couples mutually victimized? A gender-sensitive comparison. Violence and Victims 1994; 9: 107–124.

11O’Leary KD. Barling J. Arias I. Rosenbaum A. Malone J. Tyree A. Prevalence and stability of physical aggression between spouses. A longitudinal analysis. Journal of Consulting and Clinical Psychology 1989; 57:263–268.

12Mirrlees-Black C. (1999) Findings from a new British Crime Survey self-completion questionnaire, Home Office Research Study 191. Home Office. London.

13Henderson L. (2003) Prevalence of Domestic Violence among Lesbians

and Gay Men. Data Report to Flame TV Portsmouth.
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