RCGP Safeguarding toolkit

What is domestic abuse?

Domestic abuse can include physical, sexual, economic, psychological, emotional abuse, violent or threatening behaviour, controlling or coercive behaviour. It does not matter whether the behaviour consists of a single incident or a course of conduct. It can occur between those aged 16 years or over and who are personally connected. This includes: those who are, or who have previously been, partners, in an intimate relationship; relatives; and those who have had a child together.

It includes coercive control, which is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Domestic abuse can also include stalking and harassment as well as technology facilitated abuse.

Domestic abuse is very common but is largely a hidden crime, occurring primarily at home.

It is very common – each year an estimated 2 million adults in England and Wales experience some form of domestic abuse but this is likely to be an underestimate as domestic abuse is under-reported.

Asking about domestic abuse

Every victim and survivor of domestic abuse is on their own individual journey. Some may not recognise that they are victims of abuse, others may recognise it but not feel ready to talk about it or ask for help, others may fear the consequences of speaking out – both from their abuser but also from statutory services, for example, a fear of having their children removed from them. Some may have spoken out before and the abuse just got worse.

Asking and talking about domestic abuse should be done sensitively in a private environment. If an interpreter is needed, do not use friends, family or carers. There is no single ‘right way’ to ask about domestic abuse. The key is to be able to identify when there are signs of possible domestic abuse and then have professionally curious conversations. Each practitioner will find their own way of asking and talking about domestic abuse, keeping in mind that this will need to be adapted to each individual patient depending on communication needs and preferences.

These are some examples of questions you could use:

• Has anyone ever made you feel frightened? What do they do that scares you?
• Has anyone hurt you or threatened to?
• Does anyone at home make you feel scared?
• Do you feel safe at home/in your family/in your relationship?
• Are you ever forced to do anything you are not comfortable with?

Responding to disclosures of domestic abuse

DO:

• Listen, be non-judgmental.
• Thank them for telling you, acknowledge how difficult this must be for them.
• Ask what you can do to help.
  • Signpost to agencies who can help, e.g. local domestic abuse agencies, police, National Domestic Abuse Helpline (freephone number 0808 2000 247 which is run 24 hours a day, 7 days a week). Domestic abuse agencies are the experts in supporting victims and survivors of abuse – knowing the contact details of your local agency and also what they do will help you to feel more confident in asking about domestic abuse and knowing how to help your patients.
• Consider what the current level of risk is, and respond appropriately.

DON’T:

• Minimise or dismiss the abuse.
• Tell them what to do.
• Ask ‘why don’t you just leave?’ – this is victim blaming. Leaving is also one of the highest risk times for victims.

Role of domestic abuse agencies

Domestic abuse agencies play a vital role in supporting victims and survivors of domestic abuse. They offer a wide range of services such as providing support in the community, helplines, refuges, independent advocacy, supporting children, and supporting victims through police, legal and court processes. They are the experts in all aspects of domestic abuse including safety planning and risk assessment.

MARAC

MARAC stands for ‘Multi-agency risk assessment conference’. A MARAC is a meeting where information is shared on the highest risk domestic abuse cases. MARACs operate across the four UK nations. MARACs are attended by representatives from police, health, child protection, housing, independent domestic violence advisors (IDVAs), probation and other specialists from the statutory or voluntary sectors.

They:

• share all relevant information they have about a victim
• discuss options for increasing the victim’s safety
• create a co-ordinated action plan.

The primary focus of the MARAC is to safeguard the adult victim. The MARAC will also make links with others to safeguard children and manage the perpetrator’s behaviour.

At the heart of the MARAC is the working assumption that no single agency or individual can see the complete picture of a victim’s life but they all may have insights that are crucial to the victim’s safety. The victim doesn’t attend the meeting but they are represented by an IDVA who speaks on their behalf.

Referral and information sharing processes between general practice and their local MARACs vary across different areas.

More information about MARACs, including specific guidance for each UK nation, can be found on SafeLives. 

Documentation of domestic abuse in the medical record

• Documentation of domestic abuse is very important. Use the patient’s exact words when recording what they have said. Where there is patient online access, make sure all entries about domestic abuse are marked not for online access.
• The RCGP has specific guidance on documenting domestic abuse in different scenarios, including whether to record information in perpetrator records.

Identifying, understanding and responding to different levels of risk in domestic abuse including safeguarding considerations

GPs and general practice staff are not expected to be experts in domestic abuse or in carrying out domestic abuse risk assessments. However, as with any other condition or situation that potentially can cause serious harm or a risk to life, in general practice we need to be able to identify, understand and appropriately respond to different levels of risk in a domestic abuse situation. It is important to keep in mind that risk can be dynamic and fluctuate over time. In addition, the understanding the level of risk in a situation can change over time when additional information becomes available. Our response therefore needs to be flexible and adapt to changing risk.

The table below provides general principles for practitioners to help them identify, understand and respond safely to different levels of risk that might present in a domestic abuse situation.

A note on the DASH risk checklist

The SafeLives DASH (domestic abuse, stalking and honour-based violence) risk checklist is widely used by specialist domestic abuse workers to identify high risk cases of domestic abuse, stalking and ‘honour’ -based abuse. It is not expected or recommended for use in general practice as dedicated training, sufficient time and domestic abuse expertise are necessary to complete this with a victim/survivor.

Why is domestic abuse a health issue?

• 75% of domestic violence results in physical injury or mental health consequences to women.
• Domestic abuse is the leading cause of morbidity for women aged 19-44, greater than cancer, war and road traffic accidents.
• There is extensive contact between women and primary care clinicians with 90% of all female patients consulting their GP over a five-year period.
• 1 in 8 of all suicides and suicide attempts by women in the UK are due to domestic abuse.
• 80% of women in a violent relationship seek help from health services, usually GPs, at least once and this may be their first or only contact with professionals.
• 30% of domestic abuse starts/escalates during pregnancy.
• 1 in 4 women in contact with mental health services are likely to be experiencing domestic abuse.
• 51,355 NHS staff are likely to have experienced abuse in the past 12 months.

On average, victims will experience abuse for three years before getting effective help and will visit their GP on average 4.3 times. In England, children are now recognised in law as victims of domestic abuse in their own right if they see, hear or otherwise experience the effects of abuse.

Some victims may face additional barriers to help and disclosure such as those who are older, disabled, LGBTQ+, or from ethnic minorities.

Who are victims of domestic abuse?

Anyone can be a victim of domestic abuse, regardless of sex, gender reassignment, age, ethnicity, socio-economic status, sexuality, or background. It can occur within a wide range of relationships. In addition, domestic abuse can manifest itself in different ways within different communities.

While both men and women can be affected by domestic abuse, females are disproportionately the victims. The majority of domestic homicide victims are women.

Domestic abuse most commonly takes place in intimate partner relationships, including same sex relationships. Intimate relationships can take different forms, partners do not need to be married or in a civil partnership and abuse can occur between non-cohabiting intimate partners. As with all forms of abuse, abuse in intimate relationships can vary in severity and frequency, ranging from a one-off occurrence to a continued pattern of behaviour.

Abuse can continue or intensify when a relationship has ended or is in the process of ending. This can be a very dangerous time for a victim including an increased risk to their physical safety. It is a highly critical period for ensuring support for victims, as they may consider returning to perpetrators during the period immediately after fleeing or ending the relationship. Separation can raise both the likelihood and consequences of risk because of the perpetrator’s perceived lack of control.

Domestic abuse may also be perpetrated by a family member: by adult children, grandchildren, parents, those with “parental responsibility”, siblings, or extended families including in-laws. Abuse within a family set up can encompass a number of different harmful behaviours. Abuse may be perpetrated as a perceived means to protect or defend the ‘honour’ of an individual, family or community against alleged or perceived breaches of the family or community’s code of behaviour. It can therefore include ‘honour’-based abuse, forced marriage, female genital mutilation, and other harmful practices such as reproductive coercion (and as part of this, forced abortion).

Young people can experience domestic abuse within their relationships. Teenage relationship abuse often occurs outside of a domestic setting. Teenage victims may find it difficult to identify abusive behaviour, for instance, controlling or jealous behaviour may be misconstrued as love.

Teenage relationship abuse is not a term defined by the Domestic Abuse Act 2021. If the victim and perpetrator are at least 16 years old, abuse in their relationship can fall under the statutory definition of domestic abuse. Whilst young people under the age of 16 can experience abuse in a relationship, it would be considered child abuse. Abusive behaviours by one young person toward another, where each are aged between 16 and 18 could be both child abuse and domestic abuse as a matter of law. Ultimately, in responding to cases of abuse involving those under 18, child safeguarding procedures should be followed.

Domestic abuse in teenage relationships can be just as severe and has the potential to be as life threatening as abuse in adult relationships.

Child victims of domestic abuse

Domestic abuse always has an impact on children. Being exposed to domestic abuse in childhood is child abuse. Children and young people may experience domestic abuse both directly and indirectly. Young people aged 16 or over can also experience domestic abuse in their own relationships.

Domestic abuse undermines a child's basic need for safety and security. It can have a serious effect on their behaviour, brain development, education outcomes and overall wellbeing.

Children and young people may experience:

• not getting the care and support they need from their parents or carers as a result of the abuse
• hearing the abuse from another room
• seeing someone they care about being injured and/or distressed
• finding damage to their home environment like broken furniture
• being hurt from being caught up in or trying to stop the abuse
• being denied access to parts of their home, such as rooms being locked
• being forced out of or losing their home.

The impact of domestic abuse on children and young people can include:

• aggression and challenging behaviour
• depression
• anxiety - including worrying about a parent’s or carer's safety
• changes in mood
• difficulty interacting with others
• withdrawal
• fearfulness, including fear of conflict
• suicidal thoughts or feelings
• not having a strong bond with their parents or carers
• hoping an abused parent will leave for safety reasons
• worrying about what might happen if their parents or carers separate
• being afraid of their parents or carers
• impact on executive functioning skills and brain architecture which can lead to overactive stress responses.

These impacts may present in general practice with problems such as:

• problems with school or with learning
• eating disorder
• anxiety and depression including separation anxiety
• alcohol and drug misuse
• nightmares or insomnia
• bedwetting
• tantrums
• antisocial behaviour
• aggression or bullying
• social withdrawal
• constant, regular sickness.

How might I know my adult patient might be experiencing domestic abuse?

There are some physical and mental health issues which have a strong link to being a victim or survivor of domestic abuse. Adult victims may present with:

• anxiety
• depression
• PTSD
• chronic pain
• difficulty sleeping
• facial or dental injuries
• alcohol/drug misuse
• chronic pain or fatigue
• pregnancy and miscarriage
• unexpected injuries, for example to breasts or abdomen
• genital injuries
• sexually transmitted infections
• urinary tract infections
• unprotected sex
• nipple lesions
• requests for a termination.

When patients, adults or children, present with any of the problems we have just identified, we should ask about domestic abuse. We also need to bear in mind that these problems can also be indicative of many different forms of abuse and neglect.

Coercive control

“Coercive control is an act or pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. This controlling behaviour is designed to make a person dependent by isolating them from support, exploiting them, depriving them of independence and regulating their everyday behaviour". Women's Aid. 

Coercive control is a criminal offence.

Some examples of coercive behaviour are:

• isolation from friends and family
• deprivation of basic needs, such as food
• monitoring how time is spent
• monitoring via online communication tools or spyware
• threatening to publish or share private information
• taking control over aspects of everyday life, such as where someone can go, who they can see, what they can wear and when they can sleep
• depriving access to support services, such as medical services
• preventing access to transport or work
• repeatedly putting someone down, such as saying they are worthless
• humiliating, degrading or dehumanising someone
• controlling finances
• making threats to hurt or kill someone, including their children or other family members
• sexual assault.

Honour-based abuse

Honour-based abuse is a crime or incident committed to protect or defend the 'honour' of a family or community.

If a family or community think someone has shamed or embarrassed them by behaving in a certain way, they may punish that person for breaking their 'honour code’.

People who carry out honour-based abuse are often close family members but also extended family or community members.

There isn't one specific crime of honour-based abuse. It can involve a range of crimes and behaviours, such as:

• forced marriage
• domestic abuse (physical, sexual, psychological, emotional or financial)
• sexual harassment and sexual violence (rape and sexual assault or the threat of)
• threats to kill, physical and emotional violence and murder
• pressure to go or move abroad
• being kept at home with no freedom
• not allowed to use the telephone, internet, or have access to important documents like your passport or birth certificate
• isolation from friends and members of your own family.

Support for victims of honour-based abuse

• Victim Support
• Southhall Black Sisters. Highlights and challenges violence against black (Asian and African-Caribbean) women. They offer a range of services.
• IKWRO. A charity providing advice and support in Arabic, Kurdish, Turkish, Dari and Farsi to women, girls and couples living in Britain, in particular helping women facing domestic violence, forced marriage and honour-based violence. 
• Karma Nirvana. Provides support and advice on protecting yourself if you are experiencing forced marriage or honour-based violence.

Forced marriage

A forced marriage is where one or both people do not or cannot consent to the marriage and pressure or abuse is used to force them into marriage. It is also when anything is done to make someone marry before they turn 18. It is a harmful practice that disproportionately affects women and girls globally, preventing them from living their lives free from all forms of violence. Forced marriage cannot be justified on either religious or cultural grounds, every major faith condemns it and freely given consent is a prerequisite of marriage for every religion.

A forced marriage is not the same as an arranged marriage. In an arranged marriage the families take a leading role in choosing the marriage partner, but the marriage is entered into freely by both parties.

Forced marriage is illegal in the UK. It is a form of domestic abuse and a serious abuse of human rights and for those under 18, child abuse.

In the majority of cases of forced marriage, the marriage takes place abroad. Forced marriage is a global issue that affects many different cultures and nationalities.

The pressure put on people to marry against their will may be physical, emotional, psychological or financial.

Child marriage is any marriage where at least one of the parties is under 18 years of age. Child marriage is considered to be a form of forced marriage. Child marriage is also often accompanied by early and frequent pregnancy and childbirth, resulting in higher than average maternal morbidity and mortality rates.

The Forced Marriage Unit (FMU) is a joint Foreign, Commonwealth and Development Office (FCDO) and Home Office unit which leads on the government’s forced marriage policy, outreach and casework. It operates both inside the UK (where support is provided to any individual) and overseas (where consular assistance is provided to British nationals, including dual nationals). The FMU operates a public helpline for victims, potential victims and professionals.

SafeLives has a useful practice briefing “Identifying and engaging with young people at risk of forced marriage ” which outlines warning signs, aggravating factors, best practice and safety planning.

Non-fatal strangulation

Strangulation is defined as asphyxia by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck. There are three main categories: hanging, ligature strangulation and manual strangulation. Non-fatal strangulation (NFS) is where the patient has not died.

Non-fatal strangulation is common, especially in domestic and sexual abuse/rape and suicide attempts. NFS can have serious consequences such as carotid artery dissection, stroke and acquired brain injury.

A trauma informed approach is required and patients are unlikely to spontaneously give a history of strangulation. Intercollegiate guidance has been developed for clinical management of non-fatal strangulation.

Domestic abuse during pregnancy

Pregnancy is a particularly high-risk time for domestic abuse. For Baby’s Sake (an organisation who work with parents experiencing domestic abuse) highlights:

• 30% domestic abuse begins during pregnancy.
• 40-60 % of women experiencing domestic abuse are abused during pregnancy.
• 82% of health visitors reported an increase in domestic violence and abuse during Covid-19.
• 50,000 children aged 0 – 5, including 8300 babies under one, are living in households where all three of domestic abuse, alcohol or drug dependency and severe mental ill-health were present.

Exposure to domestic abuse in the first 1001 days of life is associated with adverse outcomes for babies and mothers:

• Potential antenatal and postnatal depression.
• Poor obstetric outcomes.
• Disrupted neurodevelopment.
• Poor mental and physical health.
• Lower academic achievement.
• Impaired social development and emotional regulation.

It is therefore vitally important that everyone in general practice is aware of this high-risk period and clinicians proactively ask about domestic abuse during this time so that families can receive the support and help they need.

Resources for parents

• The Baby Buddy app is for mums, dads and caregivers during pregnancy, birth and the baby’s first year. Safer Beginnings (a joint programme of work by Best Beginnings and the White Ribbon Alliance UK) content has been embedded into the Baby Buddy app on themes such as ‘safer care’ and ‘safer relationships’. The resources offer support, guidance and practical tools for parents and parents-to-be, particularly those who have experienced trauma or harm. Topics include self-advocacy in maternal care, emotional safety, stress responses, FGM/FGC, sexual abuse and domestic abuse.

Stalking

The four warning signs of stalking are:

• fixated
• obsessive
• unwanted
• repeated.

It is behaviour that makes the victim feel pestered and harassed. It includes behaviour that happens two or more times, directed at or towards the victim by another person, causing them to feel alarmed or distressed or to fear violence might be used against them.

Stalking can go on for a long time, making the victim feel constantly anxious and afraid. Cyber-stalking and online threats and harassment can be just as intimidating. Stalking is a crime in all four UK nations and must be taken seriously. Stalking is a warning marker for violent behaviour.

Stalking can happen to anyone. A stalker can be a current of former partner, an acquaintance, work colleague or a stranger. Professionals, including healthcare staff, can be stalked by clients/patients.

Stalking may include:

• regularly following someone
• repeatedly going uninvited to their home
• checking someone’s internet use, email or other electronic communication
• hanging around somewhere they know the person often visits
• interfering with their property
• watching or spying on someone
• identity theft (signing-up to services, buying things in someone's name).

Social networking sites, chat rooms, gaming sites and other forums are often used to stalk and harass someone, for example:

• to get personal information
• to communicate (calls, texts, emails, social media, creating fake accounts)
• damaging the reputation
• spamming and sending viruses
• tricking other internet users into harassing or threatening
• identity theft
• threats to share private information, photographs, copies of messages.

The National Stalking Helpline is a service set up to provide advice and advocacy to residents from across the United Kingdom.

Child to parent Abuse

Child-to-parent abuse is where a child displays harmful behaviours towards parents/caregivers. Child-to-parent abuse can involve children of all ages, including adult children, and abuse toward siblings, grandparents, aunts, uncles as well as other family members such as those acting as kinship carers. If the child is 16 years of age or over, the abuse falls under the statutory definition of domestic abuse in the 2021 Act.

There is currently no agreed definition for this type of harm of abuse. The harmful behaviour can be physical, verbal, economic, digital, coercive or sexual. Behaviours can encompass, but are not limited to, humiliating and belittling language, violence and threats, jealous and controlling behaviours, damage to property, stealing and heightened sexualised behaviours. Child-to-parent abuse appears gendered, with the majority of cases being perpetrated by sons against their mothers, although men and boys are victims too.

These situations are often complex, difficult to identify and talk about. Parents/caregivers will often feel ashamed, disappointed, humiliated and blame themselves for the situation meaning they are less likely to report the abuse to the police. There can also be an element of denial. It can cause parents to feel fearful and isolated and can have a profound and devastating impact on families. In addition, Parents may fear being blamed, disbelieved, or conversely having their child taken away from them or criminalised leaving them reluctant to seek help.

There are often no simple solutions to these situations. Victims should receive appropriate domestic abuse response and support. As part of any professional response, it is important that any child who displays harmful behaviour receives a safeguarding response and steps taken to understand the child’s behaviour.

Domestic homicide reviews

Domestic homicide reviews (DHRs) are done when the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by either:

• a relative
• a spouse, partner or ex-partner
• a member of the same household.

This includes deaths by suicide.

The purpose of a domestic homicide review is to:

• help identify lessons we can learn from the death
• prevent further domestic abuse
• improve services for victims of domestic abuse.

GPs and general practice may be asked to contribute to domestic homicide reviews when it involves one of their patients. The GMC in their guidance, ‘Confidentiality: good practice in handling patient information (paragraph 71)’, state:

“You must also consider seriously all requests for information needed for formal reviews (such as inquests and inquiries, serious or significant case reviews, case management reviews, and domestic homicide reviews) that are established to learn lessons and to improve systems and services.”

References

• For Baby’s Sake. Domestic abuse and baby’s first 1001 days. 2021.
• SafeLives. Pathfinder Profile: General Practitioners. Guidance for General Practitioners responding to domestic abuse. 
• Women’s Aid. What is coercive control? 2024.
• Refuge. Coercive control. 2017.
• ManKind Initiative. Statistics on Male Victims of Domestic Abuse. 2024.
• Karma Nirvana. What is Honour Based Abuse? 2023.
• Metropolitan Police. What is honour-based abuse? 2024.
• Home Office. Guidance: Forced Marriage. Updated 2023. 
• United Nations Human Rights. Office of the High Commissioner. Child and forced marriage, including in humanitarian settings. 
• HM Government. Forced marriage factsheet and guidance. 
• SafeLives. ‘Honour’-based violence and forced marriage spotlight. 
• Institute for Addressing Strangulation. Guidelines for clinical management of non-fatal strangulation in acute and emergency care services. 2024. 
• NSPCC. Protecting children from domestic abuse. 2024. 
• Barnado's. Children affected by domestic abuse. 2024.
• Women's Aid. What isdomestic-abuse? 2024.
• SafeLives. Resources for identifying the risk victims face. 
• SafeLives. Multi-Agency Risk Assessment Conference (Marac) Guidance for GPs.
• GMC. Confidentiality: good practice in handling patient information. 2024.
• Best Beginnings. Safeguard Beginnings content to enable, educate and support people on maternity journeys.
• Best Beginnings. The Baby Buddy App.
• Victim Support. Stalking. 
• Metropolitan Police. What is stalking and harassment. 2024.
• Suzy Lamplugh Trust. National Stalking Helpline. 2019.
• SafeLives. Responding to Counter allegations: Guidance – A review of practice. 2023. 
• Home Office. Consultation: Defining child to parent abuse. Consultation description. 2023.
• Home Office. Domestic Abuse. Statutory Guidance. 2022. 
• Respect. Child and Adolescent to Parent Violence and Abuse. 
• PEGS (Parental Educational Growth Support). Child to Parent Abuse: Supporting parents and professionals. 2021.
• Home Office. Domestic Homicide Review Library. 2023.

The RCGP would like to thank Professor Gene Feder (Professor of primary health care, Bristol Medical School, University of Bristol) and Medina Johnson (CEO, IRISi) for their invaluable input into the development of this section on domestic abuse.