GPs are in a special position to pick up subtle signs in patients that could indicate family abuse and violence, particularly at the hands of controlling men.
By Eric Martin
While the nation grapples with the issue of domestic violence, Western Australia has faced a spate of family killings that have claimed the lives of nine women in the first half of 2024. After the Northern Territory with 3.97 per 100,000 women killed this year, WA has the highest number, at 3.1 per 100,000, more than double that of NSW at 1.31.
And while the role of WA Police and their response to family requests for protection has been thrust into the spotlight by the allegations of the latest perpetrator’s daughter, it is often GPs who have the first glimpse of potential family violence and struggle with how to tackle such a sensitive yet crucial subject.
Why are men choosing to use extreme violence against their partners?
Professor Donna Chung, from Curtin University’s Faculty of Health Sciences, has worked on numerous research projects investigating family violence and consults government on related policies and programs. She pointed out that in the 1990s and 2000s, as more women entered the workforce, more men started to engage with parenting and had to renegotiate their place in the world.
“Academics used talk about the ‘gender wars,’ yet it was not a war so much as everyone trying to work out their new identity,” she said. “While there is still an intergenerational pressure around masculine performance – such as my father was a good footballer or good surgeon – it’s quite different to, for example, young African men from the first generation born in Australia, who are struggling with everyday microaggressions in terms of racism and finding their place in an Australian community that isn’t necessarily that welcoming.
“Even though Australia is a very multicultural nation, our mainstream culture comes from that Western, Judeo-Christian breadwinner model where the man’s had economic dominance and been the primary breadwinner or main provider. And I think that’s been a challenge for some men.
“Everyone wants a good standard of living. But when it comes to the woman potentially earning more and being less available because of the hours she must work, that is often where there might be a tipping point, especially if there are children in the home.
“While the relationship dynamics might be split 50/50 when there are no kids, it often reverts to a more traditional role. That in turn is influenced by Australia having a very gender-segmented workforce, where the pay-gap is inherently skewed, such as plumbing getting paid more than hairdressing, for example.
“We saw the rise of the incel (voluntary celibacy) movement as a rejection of the dominant, sport-based, hyper-masculinity. But there’s also a myth that these men don’t have good communication skills, and that’s why they use violence. Many give a good account of themselves. When you meet them online, in bars, or at work it’s not, ‘hi, I’m John and I’ve got three VROs from three different women’. That’s not the story, it’s all their partner’s fault – ‘they’re horrible, nasty women.’
“Women are caught up in that grooming, and once groomed, they can believe those accounts, drawing on those stereotypes. ‘She took me to the cleaners’ or ‘I came from an abusive family and don’t have any contact with my family because of that.’ When in fact, years later, they discover the reason their partner has had no contact with the immediate nuclear family is because they’ve been deliberately ostracised.”
Professor Chung said that men with abusive tendencies would sometimes target people with low self-esteem or who have been through a tough time, enabling them to mark behaviours which could become the basis for coercive control.
“Much like a school bully will pick potential victims in the playground,” she said. “You target what you know will have the most crippling emotional effect. For example, ‘as a single mother for a long time you haven’t had a lot of money, but now that I’ve come along, we have more money as a couple’ – meaning that financial abuse could be a more effective lever for control. Another potential target is a woman’s body image, ‘no one else would want to be with you’.”
While some relationships were not particularly healthy and may be uneven in their power dynamics, an abusive relationship could be defined as when one person was being intimidated all the time.
“There are moments when the victim in the relationship will snap back, they’ve had enough, and they could even throw a glass themselves. But that will be interpreted as reciprocal violence, whereas it’s just an expression of helplessness – there is a disregard for consequences in that moment because they have been pushed to the edge,” Professor Chung said.
“In a normal argument people can get into who was wrong and who was right, but no one feels fearful and intimidated. But in coercive relationships the other person is always walking on eggshells, dancing around trying to minimise potential triggers.
“It’s not thoughtfulness so much as managing expectations: hyper-vigilance around keeping everything as calm as you can, which is exhausting. When women first leave and go to a refuge they will often sleep for the first few days. Their body takes over because they’ve been in overtime and probably haven’t slept properly for years.
“We also have a more complex way of negotiating intimate partnerships and relationships: people aren’t necessarily getting married at 20 and staying married till they’re 90, like they used to. Research shows that people are often having two or three big relationships over their life and each time, it’s generally a different type of negotiation.
“Paradoxically, many of our cultural rituals around courtship have changed as well and it’s also much easier to end up living together, which can be equally challenging for many older people entering relationships.
“Another exacerbating factor now is the housing crisis. Couples with separate houses and no plans to move in together can be suddenly forced to live together if one partner loses their rental property. There’s no sense of it being a stage of the relationship’s development and commitment, it’s a forced situation that brings its own associated stresses.
“Everything and everyone seem to be living on the edge and that can push people over the edge or hand an abusive partner another lever for control.”
While digital technology may have been a boon for communication, Professor Chung said it also provided an effective tool that people could use to put their partner under constant surveillance.
“For example, texting 30 times a day and expecting a response within a few minutes – that’s another sign that GPs can watch for during consultations. While you don’t want to jump to conclusions, as we’re all relatively addicted to our phones, a patient occupied with their partner’s texts during the consultation could be a red flag for coercive control,” she said.
“Another flag, particularly if the relationship is abusive and is reaching its end is that the patient might need something to deal with a high level of anxiety but could be reluctant to engage with treatment because of the fear that a mental health diagnosis could be used against them in the family court.”
Professor Chung said one of the particularly important factors for GPs to be aware of was the reluctance of perpetrators to have their children diagnosed with any sort of learning difficulties, disability, or stigmatised condition.
“Rather than support for the child, it’s used as another weapon in the relationship – ‘that’s because you’re a bad mother,’ or ‘that’s from your side of the family, and I’m not supporting any treatment for that’,” she said.
“Even when a GP has referred the child to a paediatrician or a clinical child psychologist, the response is, ‘I’m not paying for any of that. There’s nothing wrong with that kid. They need a kick up the arse and to go back to school.’
“Sometimes kids that seem overly socially withdrawn have been told to shut up all the time, ‘don’t upset your father – everyone shut up.’ Other kids can be quite outspoken or seem overly familiar in social situations because they’ve worked out quickly that it’s safe to actually push boundaries – like pushing a teacher to the limit because they know that adult can’t hit them.
“However, even if GPs have a good relationship with the child or mother, they may still feel reluctant to talk about domestic violence as the source of the patient’s anxiety or depression. Unhealthy dynamics are built up in a relationship over time and it’s hard for GPs to get to what the problem is in 15 minutes, it’s like opening Pandora’s box and is easily put in the too-hard basket.
“GPs can feel helpless, opening a conversation where there is a risk that the patient might go home and dwell on it, or leave the surgery in tears. But sometimes there are basic cues, and GP consultations often offer a brilliant entry point for wider discussions about relational issues.
“So, if it’s about contraception, if it’s about their sexuality or their gender identity, GPs can use that to initiate a conversation to discuss consent and equality in relationships in an informative manner.”
Professor Chung highlighted that the most recent guideline for GPs was the White Book, Abuse and violence – Working with our patients in general practice, published by the RACGP Vic and last updated with a fifth edition in 2022 by Dr Kelsey Hegarty, from the University of Melbourne’s Safer Family Centre.
“Dr Hegarty’s research has been some of the most forward thinking and it’s really the go-to-resource in Australia. It has webinars GPs can access and because it’s NHMRC funded, everything must be publicly available,” she said.
“There is past and current research, and they are always adding to it. And as Dr Hegarty is still involved with general practice, she has firsthand experience to ensure the White Book is thoroughly grounded for GPs. She has been working alone for a long time on this topic before getting the funding for a team of people to pull it together and really amp up the volume of work.”
ED: The 430-page resource is divided into six topics, with levels of evidence and recommendations included: Domestic or intimate partner abuse/violence; Trauma- and violence-informed care; Children and young people; Specific abuse issues for adults and older people; Specific populations; System issues.
The White Book is available online at
https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/preamble
Legal and health join the DV campaign
A new partnership between a community legal service and St John of God Midland Hospital is aimed at providing early responses to family and domestic violence.
Midland Information Debt and Legal Advocacy Services (MIDLAS), a not-for-profit centre which has been supporting victims and survivors of domestic violence for 35 years, has formed a health justice partnership with St John of God Midland public and private hospitals.
Supported with a $100,000 Impact100 WA grant, the partnership provides an early intervention response to the escalating family and domestic violence crisis as well as elder abuse in Western Australia.
Working in close liaison with health professionals, the partnership between Midlas and the Midland hospital provides onsite free legal support in a safe setting to victims and survivors of domestic violence.
Midlas chief executive officer Gaelle Gouillou said that with the potential to be replicated in other parts of WA, the initiative between the only community legal centre in the region and a major hospital provided an evidence-based early and primary prevention response to reduce rising rates of FDV.
According to figures reported in an Australian Bureau of Statistics Personal Safety Survey (2016), two out of five Australians would not know where to get help for a domestic violence issue and as few as 20% of victims contacted the police for assistance.
But people experiencing FDV were known to be more likely to disclose abuse to healthcare providers.
Ms Gouillou said with the sharp rise in FDV-related deaths and WA Police reporting a 35% increase in family-related offences in 2022 and a 15% increase on that figure in the first nine months of 2023, early intervention solutions were needed more than ever.
The Midland Health Justice Partnership, which complemented screening by clinicians for FDV, had already provided help with 23 separate legal issues.
Midlas lawyer Anne-Marie Ricciardi said a high priority was to create greater awareness among victims and survivors of the options and types of support they could access.
“We can assist people to put legal protections in place to help keep them safe. We provide advice and assistance in relation to restraining orders, family law, criminal injuries compensation and tenancy matters,” she said.
Along with providing an early intervention response for the FDV crisis in WA, the service also offered an early intervention and prevention strategy for elder abuse and the protection of older people’s rights.
SJOG Midland chief executive officer Paul Dyer said the service would fill an identified gap, and health justice partnerships had a long history of delivering outcomes for the community across Australia.
The Midland program complements a similar service launched in October 2023 by the East Metropolitan Health Service.