Home is where the hate is.

The effects of domestic violence are catastrophic for many women and their families and friends. The impact on their physical and mental health and wellbeing can be deeply damaging and sometimes fatal.

The statistics are striking. It is the most common type of violence against women - one in four will experience domestic violence. Every year about 150 people are killed by a partner or former partner. The likelihood of assault is much higher during pregnancy or soon after giving birth.

Women's Aid, a charity working to end domestic violence against women and children, defines it as: 'Physical, psychological, sexual or financial violence that takes place in an intimate or family-type relationship and forms a pattern of coercive and controlling behaviour.'

Practical resources

In December 2005, the Department of Health (DH) published Responding to Domestic Abuse: A Handbook for Health Professionals, which supersedes the 2000 document Domestic Violence: A Resource Manual for Health Care Professionals. It offers guidance on working with those who have experienced or are experiencing domestic abuse. The key messages include:

• It is unacceptable; existing attitudes and perceptions need to be challenged.
• The stigma means that many victims are reluctant to seek help or do not know how to get help.
• Research shows that 30 per cent of the domestic abuse in the UK begins or intensifies during pregnancy.
• Healthcare professionals are uniquely placed to ensure that information is made available as early as possible.

The manual is intended to ensure that women have information and know that help is available.
Christine Mann was seconded to the DH in April 2004 to lead on the issue. She is involved in developing cross-government, national and local policies to address domestic violence, including the spread of good practice and improved service provision for victims. She has worked as a nurse, midwife and health visitor, and has a master's degree in psychotherapy. Research reveals that women who suffer domestic violence undergo on average 35 episodes of violence before they reveal the abuse.

Ms Mann says training is essential to help health professionals approach victims in a confident and sympathetic manner. 'Staff need to be confident in asking questions and giving information rather than advice,' she says. 'There is a fear that they could be opening a can of worms. But it is important to open up the topic. My vision is to ensure that everyone knows what to do and gives the appropriate information, such as refuge numbers and helplines. It is not our job to say "you must leave". Ours is not an interventionist role unless children are involved.'

Jealousy

Nancy Cartwright, a domestic violence specialist midwife at Calderdale and Huddersfield NHS Trust, is unable to pinpoint why abuse may start during pregnancy. 'Some victims say their partner developed a jealousy - even anger - towards the unborn child. Others have said: "He always did it, so why would he change?" Some suggest it is "business as usual".'

It is difficult to estimate the prevalence of domestic violence because women are reluctant to talk about it. They feel shame and are afraid of retaliation.

'Why a man should start confuses me. Some women say it began once they became pregnant and stopped around three months after the birth. I am not sure how accurate this is,' she says. 'It is as if their partner felt he had lost control of the relationship and needed time to adjust to the new responsibility. But some say it decreases, without going completely, and escalates again with a subsequent pregnancy.'

It is not that a woman wants to remain in a dangerous situation, suggests Ms Cartwright, but that the alternative may appear even more dangerous and unpredictable. A woman will go when she believes the time is right and when the risks of staying outweigh those of leaving. They are at greatest risk around the time they decide to leave, she adds.

It does not follow that people who have been abused will go on to abuse - extensive research refutes this. Some abusers may have grown up in violent homes, but many - much research even suggests the majority - do not.

Horror of abuse

This is not to say that children who grow up with an abusive parent are not affected - they are. But it is not as simple as repeating the behaviour. Many respond by developing a horror of abuse and a determination never to behave in the same way.

Generally, domestic violence is believed to be a gender issue. Home Office statistics reveal that 81 per cent of those who experience it are women and girls, and that the perpetrators are overwhelmingly male.

Domestic violence also happens in other groups, however. Abuse and violence occur in lesbian, gay, bisexual and transgender (LGBT) relationships too. Many LGBT people experiencing abuse and violence may feel too ashamed to tell anyone, or feel there is no one to turn to, especially if family and friends do not know about their sexuality. There may also be distrust of mainstream services.

A disabled woman may experience abuse in ways that non-disabled women do not. For example, an abuser may touch someone inappropriately while apparently 'assisting' her, or they may withhold assistance altogether or make her beg for it. They can also withhold medication or use it to distort her sense of reality. The abuser may capitalise on low self-esteem or the belief that a disabled person could not manage without their 'carer'.

Disabled men are vulnerable to abuse too. Tellingly, it is difficult to find information on the number of disabled people - women or men - who experience domestic abuse.

People experience domestic violence regardless of their social class, age, race, disability, sexuality or lifestyle. The abuse can begin at any time - in new relationships or after many years in a relationship. This situation is similar for older people who may be abused by partners or other family members.

In many instances, health professionals may be the first point of contact. It is therefore vital that they are equipped with the skills, knowledge and confidence to identify abuse and respond appropriately so as to help break this potentially damaging cycle

SUMMARY

Domestic violence and abuse are areas where health professionals often fear to tread, feeling that they have insufficient information and expertise to be able to help. But a Department of Health publication is there to provide guidance.