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Introduction
Domestic violence (DV) is defined as an incident or pattern of events that are abusive from one person, above the age of 16 years old, towards another, also above 16 years of age, and with whom they have an interpersonal relationship.1 It can also be referred to as ‘intimate partner violence’ when perpetrated by partners and ex-partners.
It often happens in secrecy and can happen both during and after a relationship. It can occur with all genders and in relationships of any race, sexuality or age, though it most commonly occurs to women in heterosexual relationships and transgender people.2-4
DV can include:
- Physical assault: involving hitting, punching, kicking, burning and choking
- Verbal assault: such as insulting or excessive yelling
- Sexual assault
- Controlling or coercive behaviour: including isolating them from their support system and regulating their everyday behaviour
- Emotional or psychological abuse: including humiliation, intimidation or manipulation
- Stalking or harassment
- Economic abuse or control: by not allowing the victim to access their own finances (stopping them escaping the abuser)
- Honour-based violence: including forced marriage and female genital mutilation
- Technology-assisted violence or intimate image abuse: including sending or creating pornographic images of the victim
Prevalence
1 in 5 adults will experience DV in their lives, and it affects 2.3 million adults in the UK per year. 5 It is highly likely this is underestimated, as DV is underreported.
A victim will experience abuse for an average of 3 years and visit their GP 4.3 times before getting effective help.6 Therefore, it is imperative that doctors and healthcare professionals assess risk opportunistically and support both victims and perpetrators if they disclose violence.
DV more commonly affects women, with 6.9% (1.7 million) of women and 3% (700,00) of men experiencing violence each year. 1 in 4 women will experience abuse across their lifetime, compared to 1 in 7 men.1 Women in heterosexual relationships are also more likely to experience repeated violence, sexual violence, and to be killed by their partner.3 Men are less likely to report being victims of abuse.7
Forms of domestic violence
Partner violence is the most common form of DV. Other forms of DV include:
- Elder abuse of older adults by their partners, family or carers
- Parental abuse by children (above the age of 16 years) to their parents, most commonly single mothers5
Risk factors
Risk factors for domestic violence can vary across the lifetime:
- Women are more likely to be victims than men
- 16 to 24-year-olds of both genders
- LGBTQ+ people
- Transgender people
- Disability and long-term health conditions
- Mental health conditions, with higher rates of being both a victim and a perpetrator
- Substance misuse
- Socioeconomic disadvantage
- Separating or undergoing divorce5
Risk factors of escalating violence
Some risk factors highlight that violence is escalating and therefore require immediate action. These include:
- Abuse while a partner is pregnant
- Strangulation or choking
- Threats to kill
- Weapon use or weapons found in the house
- Worsening symptoms of a mental health condition
- Multiple disclosures of violence
Clinical features
All patients should be screened for signs of DV, but these key factors are strong indicators that DV may be occurring.5
Physical findings:
- Bruises, burns, lacerations, fractures
- Describe themselves as “accident-prone” when asked about their injuries
- Delay in presentation of injuries
Recurrent attendance with vague symptoms:
- Headaches, fatigue, abdominal pain, pelvic pain, sexual dysfunction
Adverse reproductive health outcomes:
- Recurrent unplanned pregnancies, recurrent miscarriages, delayed pregnancy care, concealed pregnancy
- Recurrent sexually transmitted infections
- Genital injuries
Mental health symptoms:
- Anxiety, depression, sleep disorders, panic disorders, self-harm, suicide attempts, substance misuse
Variable engagement with healthcare:
- Frequently missing appointments
- Non-concordance with treatment plans
Never seen alone in consultations:
- The patient is quiet or appears afraid to speak
- The ‘other person’ is loud, aggressive, talks for the person or refuses to leave the room
- The ‘other person’ is very charming
Screening questions
Screening questions can be used within all consultations, but are especially important if any of the risk factors or clinical features mentioned above are present:
- “How are things at home?”
- “Are you getting the support that you need at home?”
- “Do you have concerns about your partner/family?”
Examples of further questions to determine the types of abuse:
- “Has your partner ever hurt you or your children, or threatened to do so?”
- “Has your partner ever forced you to have sex or perform sexual acts when you didn’t want to?”
- “Have you ever had to change your behaviour because you are frightened of your partner?”
- “Does your partner stop you from seeing your friends or family?”
- “Does your partner embarrass you in front of friends or family?”
- “Does your partner not allow you access to money when you need it?”
- “Are these behaviours getting worse, and are these incidents happening more frequently?”
Management
It is essential to recognise that both victims and perpetrators may find it challenging to discuss this topic, so starting with reassuring and open statements can help them feel safer and more likely to disclose information. Direct, proactive questions are needed to assess the risk after this.
First, explain the parameters of confidentiality: “We are in a private space, and everything you tell me is confidential, and I will not routinely share the information you tell me without your consent. However, if I feel that there is a risk of harm to you or someone else, I may have to share that information with other professionals.”
Create a feeling of safety and ask sensitively: “Sometimes, when people come in with these symptoms, they are also experiencing problems at home. This can be difficult to talk about, but given how common it is, we routinely ask questions to assess the risk of this happening.”
Reassure the patient that they are believed and that the abuse is not their fault. Explain they are not alone; they have a right to safety, and support is available.
Risk assessment
If they are at immediate risk of harm:
- Call the police and refer to the adult safeguarding teams in your local area, ideally with the person’s consent
If they are not at immediate risk:
- Manage any physical injuries
- Admit to hospital if needed
- Provide the patient with information about their rights and the support that they can access
- Share information with appropriate agencies and safeguarding teams, ideally with consent
- Add a note on the computer system that the patient must be seen on their own and that they are at risk
- Hide all online consultation notes from third parties, so the perpetrator cannot access these
- Arrange follow-up appointments to monitor mental health and risk, and be aware that the situation can change very quickly
Disclosure made by a perpetrator
Sometimes, you may suspect a patient is a perpetrator of domestic abuse. When reviewing patients with mental health issues, substance misuse or employment difficulties, always enquire how these issues are affecting their home life.
For these patients:
- Ensure your own safety before questioning
- Discuss the parameters of confidentiality
- Express empathy and use motivational interviewing skills
- If the patient discloses abuse, move to more direct questions to assess risk to partner/children
- Complete necessary safeguarding referrals for the victim(s)
- Refer to specialist support services for perpetrators of violence
- Document clearly and safely in the consultation notes, ensure documentation does not put the victim at further risk and ensure it is hidden from accessible online records
Screening questions
Screening questions can be used to explore concerns of a perpetrator of DV, with their directness increasing as appropriate:
- “Do you feel your drug use has an impact on your home life? When using drugs, what do you do/how do you behave towards your family?”
- “Thank you for speaking openly about this. I appreciate that this can be very difficult. What do you think would help? Would you like help?”
- “Have you ever assaulted your partner?”
Non-disclosure
Sometimes, victims of abuse do not disclose fully or do not want help. It is essential to ensure that safety netting is in place, and a follow-up appointment must be scheduled to monitor their situation.
Ensure they have a plan for if violence escalates:
- Remove risk from their home, e.g. remove knives from the kitchen
- Pack a hidden overnight bag in preparation for if they need to leave
- Ensure they have phone numbers for specific charities that can help should they need to leave
- Call the police if in immediate danger
Confidentiality
As a general rule, all adult patients have the right to confidentiality when accessing medical services, and this right must be upheld to ensure patients trust healthcare professionals and continue to seek help when needed.
Adults with capacity are allowed to make decisions that could be considered unwise, even if this decision leaves them (but no one else) at risk of harm. When a patient makes a decision, it is important to explore the reasoning behind it, provide them with all the necessary information (e.g. domestic violence charity contact numbers), and ensure that they understand they can change their mind at any time.
If required by law or if the patient lacks capacity, confidentiality can be broken. In such cases, inform the patient if it is appropriate to do so, and disclose only information relevant to the case.
If you are ever unsure whether or not you should break confidentiality, you should discuss the case with a senior colleague or your trust Caldicott guardian and document the rationale for the decision clearly in the notes.
Long-term consequences
Those who have experienced DV can be left with aftereffects. These can include mental health conditions, such as anxiety, depression and post-traumatic stress disorder. Women can also be left with the sequelae of recurrent STIs or termination of pregnancy, which can impact future fertility.
Those who experience financial abuse may be left with socioeconomic difficulties, such as becoming homeless or resorting to other ways to earn money (including sex work) if they leave the household.
Children can also be victims of domestic abuse. If children see, hear, or experience the effects of the abuse, they are likely to be significantly affected, even if they are not directly abused themselves. The most reported trauma for children is witnessing DV between their parents. For safeguarding reasons, it is extremely important to always ask if there are children in the house. 7
Child safeguarding
If you are concerned that a young person is suffering abuse, or at risk of abuse, then you must inform an appropriate body, local authority or the police. Though the principles of confidentiality still apply, there is a lower threshold for breaking confidentiality than with adults.
In most cases, the risk to the child far outweighs the potential harm that sharing concerns may cause.
Reviewer
Dr Josh Kadirgamar
General Practitioner
Editor
Dr Jamie Scriven
References
- Home Office. Domestic Abuse Statutory Guidance. 2022. Available from: [LINK].
- Keynejad R, Baker N, Lindenberg U, et al. Identifying and responding to domestic violence and abuse in healthcare settings. British Medical Journal. 2021. Available from: [LINK].
- Office for National Statistics. Domestic abuse prevalence and victim characteristics, England and Wales: year ending March 2024. 2024. Available from: [LINK].
- Peitzmeier SM, Malik M, Kattari SK, et al. Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates. American Journal of Public Health. 2020. Available from: [LINK].
- NICE CKS. Domestic abuse. 2023. Available from: [LINK].
- RCGP Learning. RCGP Safeguarding toolkit. 2025. Available from: [LINK].
- World Health Organization. Violence against women. 2024. Available from: [LINK].
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