Richard Smith: Why is the health service so hopeless with domestic violence?

Richard SmithI’ve always thought that death, although universal, was the great taboo for health services, but now I’ve discovered something that seems to cause even greater difficulty for clinicians – domestic violence.

Domestic violence is not quite as common as death but it’s not far off. The prevalence of domestic violence is terrifying and almost unbelievable – except that it’s supported by many studies.

The prevalence is obviously sensitive to the definition but domestic violence is usually defined as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm” -and can take many forms. Several studies in general practice have found a life time prevalence of physical abuse among women of 23% to 41%. In other words, at least one in four women is likely to experience physical abuse and it may be almost one in three. A study in East London found that one in six women had been physically abused by a partner or ex-partner in the past year.

Abused women usually do not report being abused. I spent an hour recently talking to a woman who had experienced more than 10 years of the most savage abuse, which had often necessitated medical treatment. But she saw the abuse as her fault and kept hoping against hope that she could recreate a loving relationship with her husband. She saw her GP, whom she likes, again and again, often with clear signs of injury, but he never asked about abuse – and she never said anything.

This seems to be a typical pattern. Abused women have very high consultation rates – perhaps five times higher than non-abused women – but doctors rarely ask about domestic violence. They can ask comfortably about bowel movements, drinking habits, and even check for sexually transmitted infections, but asking about domestic violence seems a step too far for most doctors and nurses.


We don’t know, but we can guess. Perhaps domestic violence never enters their minds. Many clinicians are unaware of the high prevalence – and find it hard to believe when they are told about it. Perhaps doctors are fearful of opening a Pandora’s box and being unable to control the consequences. Perhaps there is a persistent cultural belief that what a man and his wife do in the privacy of their bedroom is nobody’s business but theirs – or,  worse, that it’s almost a man’s privilege to “correct” his wife as he might his children. Or maybe doctors just don’t know what to do if they do identify abuse. Sympathise? Call the police? Refer to a psychiatrist?

The best thing that doctors can do when a woman discloses abuse to them, is to refer her  to domestic violence advocacy services that can provide support and help with legal, financial, housing, and safety issues. Such referral is known to be beneficial.

But how to get doctors to identify domestic violence and refer the women? I couldn’t help thinking that you could ask every woman: those who weren’t being abused would just say “Oh no,” while at least some of those who were – and remember we’re talking at least one in four women with a lifetime history of domestic violence – would be forever grateful. But this is a step too far for most clinicians.

So a group from Hackney and Bristol led by Gene Feder, professor of primary care in Bristol, has devised a comprehensive  intervention to try and encourage primary care clinicians to ask about domestic violence and refer women to advocacy services when appropriate. The intervention comprises training for the practices, continuing support and feedback from a named advocate attached to the practice, identification of a “champion” within the practice, and a pop up template to encourage doctors to ask about domestic violence.

This intervention is being tested in a randomised trial funded by the Health Foundation, and the protocol of the study has just been published in BMC Public Health ( The results should be available in the summer. Perhaps the group will have at last found a way to get health services to engage with the huge numbers of women who experience domestic violence. The present performance is shameful for the health service.

Richard Smith is a former BMJ editor.