Domestic abuse
Exam Tips
- In OSCEs, prioritize privacy, immediate safety, and child safeguarding over exhaustive history-taking.
- Use validating language: believe, support, and avoid victim-blaming; ask both open and direct questions.
- Know high-risk escalation markers: separation, stalking, strangulation, threats to kill, weapon use, pregnancy.
- State confidentiality boundaries clearly and document injuries/history verbatim with time/date and body map.
- Children are victims if they witness or experience effects of abuse; this mandates safeguarding assessment.
- Domestic abuse is managed with multi-agency safety planning; medicines treat sequelae, not the abuse itself.
Definition
Domestic abuse is a pattern of physical, sexual, psychological, emotional, controlling/coercive, economic, or technology-facilitated behaviour between people aged 16 years or older who are personally connected (for example partners, ex-partners, or family members). In child health, a child is also considered a victim if they see, hear, or experience the effects of abuse in the household, even if they are not directly assaulted.
Pathophysiology
Domestic abuse is a repeated trauma exposure rather than a single-event illness. Perpetrator control, intimidation, and isolation produce chronic stress activation (autonomic and HPA-axis dysregulation), which contributes to anxiety, depression, PTSD symptoms, sleep disturbance, somatic complaints, and substance misuse. In children, ongoing exposure disrupts attachment security, emotional regulation, and neurodevelopmental stress responses, increasing behavioural problems, school difficulties, and later risk of revictimization or perpetration. Physical injury burden can escalate over time, especially around separation, stalking, strangulation, and threats to kill.
Risk Factors
- Female sex (higher burden of severe/repeated abuse), though all genders can be affected
- Young age (especially women 16-24 years; men 16-19 years)
- Separation or attempted separation from partner
- Pregnancy or recent postpartum period
- Mental health problems (victim and/or perpetrator)
- Long-term illness or physical disability
- Socioeconomic disadvantage, financial strain, social isolation
- LGBTQ+ status, including bisexual, gay/lesbian, and trans people
- Substance misuse in victim or perpetrator
- Escalating prior abuse, stalking history, coercive jealousy, weapon threats, strangulation
Clinical Features
Symptoms
- Fear of partner/ex-partner or family member; reports of feeling unsafe at home
- Anxiety, low mood, panic, PTSD symptoms, sleep disturbance, nightmares
- Recurrent unexplained pain (for example abdominal pain, headache), fatigue, poor concentration
- Sexual and reproductive concerns: unintended pregnancy, delayed antenatal care, recurrent STIs
- Child symptoms: bedwetting, abdominal pain, anxiety, behavioural regression, school refusal/truancy
Signs
- Injuries inconsistent with explanation, repeated attendances, injuries at different healing stages
- Bruises, abrasions, lacerations, burns, bite marks, fractures, facial/neck injury
- Indicators of coercive control: partner speaking for patient, restricted access to money/phone/transport
- Psychological distress, hypervigilance, dissociation, self-harm marks
- Child safeguarding red flags: developmental/behavioural change, poor school performance, aggression or withdrawal
Investigations
Management
Lifestyle Modifications
- See the NICE domestic abuse pathway figure (Sept 2023) for a stepwise response: ask privately, listen non-judgementally, validate, and document clearly.
- Ensure private consultation without partner/family present; use professional interpreter only (never child, friend, or relative).
- Agree safe contact method and timing; do not leave voicemail/text/email unless confirmed safe.
- Create a personalised safety plan (emergency exits, code word, essential documents, phone access, child safety arrangements).
- Explain confidentiality limits: information may be shared without consent if a child or vulnerable person is at risk of significant harm.
- Refer to IDVA/specialist domestic abuse services, social care safeguarding, and MARAC for high-risk cases; arrange close follow-up.
Pharmacological Treatment
Emergency contraception after sexual assault/coercive sex
- Levonorgestrel 1.5 mg orally as a single dose (as soon as possible, within 72 hours)
- Ulipristal acetate 30 mg orally as a single dose (within 120 hours)
No medication treats abuse itself; treat consequences. Safety warnings: ulipristal is unsuitable in severe asthma treated with oral glucocorticoids and interacts with enzyme inducers; avoid starting progestogen for 5 days after ulipristal. Check pregnancy risk and safeguarding needs.
HIV post-exposure prophylaxis (if sexual exposure risk per local protocol)
- Tenofovir disoproxil 245 mg/emtricitabine 200 mg orally once daily plus raltegravir 1200 mg once daily for 28 days
Start ideally within 24 hours and no later than 72 hours after exposure. Check renal function, drug interactions, adherence support, and specialist sexual health/HIV follow-up.
Mental health symptom treatment when indicated
- Sertraline 50 mg orally once daily initially, titrated to response (usual adult range 50-200 mg daily)
Use alongside trauma-informed psychological support, not as a substitute for safeguarding. Monitor for increased suicidal ideation early in treatment, especially in younger people.
Surgical / Interventional
- Treat traumatic injuries as indicated (for example wound closure, fracture management, maxillofacial/orthopaedic intervention)
- Forensic medical examination in sexual assault pathway where appropriate and consented
Complications
- Escalating violence, serious injury, or homicide
- Depression, PTSD, self-harm, suicide attempts
- Substance misuse and chronic pain syndromes
- Adverse pregnancy outcomes (miscarriage, preterm birth, stillbirth, delayed antenatal care)
- Recurrent STIs and sexual health morbidity
- Child emotional/behavioural disturbance, poorer educational attainment, intergenerational trauma patterns
- Homelessness, poverty, and prolonged economic dependency
Prognosis
Prognosis improves when abuse is identified early, risk is actively managed, and specialist advocacy/safeguarding support is sustained. Without effective intervention, recurrence is common and harms often accumulate across physical health, mental health, child development, and social functioning.
Sources & References
✅NICE Guidelines(1)
- Domestic abuse[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1072)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1831)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1716)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1696)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1715, 1716)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1716)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1695, 1696)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 217)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 208, 209)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 322, 323)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 322, 323)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3309, 3310)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3298, 3299)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3290, 3291)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2787, 2788)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2786, 2787)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3299, 3300)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2797, 2798)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3289, 3290, 3291)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3291, 3292)[context]