Domestic violence can refer to a wide range of physical, sexual, emotional and financial abuse of people who are, or who have been, intimate partners, whether or not they are married or co-habiting.Footnote 1 But what has domestic violence got to do with the dental team?

It's true that it's not the job of the dentist or dental care professional (DCP) to give advice to someone experiencing domestic violence on what direct action they could take. However, as the face is a common target in assault, the dental team has a part to play in identifying domestic violence. Their role is to identify domestic violence and provide information about where the individual can go for help. Dental professionals might assume that social services or the police will be doing something, but this isn't always the case, and the dental environment can provide an opportunity for the patient to reveal domestic violence and ask for help.

A proactive stance

It isn't easy to ask, or for a patient to be asked, about domestic violence, but DCPs should be proactive. If there are signs suggesting that a patient may be experiencing domestic violence, then the patient should be asked direct and specific questions. Vague questions are not helpful. Possible indicators of domestic violence which could arouse suspicion are listed in Table 1, although you should always be aware that there is a wide range of reaction to domestic violence. While some patients may appear withdrawn or depressed, others may be agitated or angry. Similarly, those who are carrying out the domestic violence may not fit stereotypes, and may appear concerned, charming and attentive.

The presence of a partner or relative may restrict discussion of domestic violence because, regrettably, the perpetrator of the violence may be a carer and discussion could place the woman in greater danger. Discussion should not take place in the presence of children either.

Patients are often unaccompanied during examination and treatment sessions as part of routine dental practice, and therefore dental staff are in a unique position to enquire about domestic violence. It may be possible to divert the partner to the reception to fill in forms, in order to see a patient on their own without arousing suspicion. A victim of domestic violence may telephone the practice to request an emergency appointment without wishing to provide any information about why they need the appointment. Reception staff are therefore ‘front-line’ and need to understand that this is acceptable and not press them for details. For these reasons, it is important that all team members are aware of the issues surrounding domestic violence.

Routine enquiry

An alternative approach is to ask all female patients about domestic violence rather than relying on signs observed in patients. All NHS Trusts in the UK are being encouraged by the Department of Health to adopt this ‘routine enquiry’ approach and to provide the necessary staff training. Training is essential before embarking on routine enquiry, as questioning by untrained staff can be unintentionally damaging and leave a woman vulnerable to further violence. Time could be a restriction on implementing this approach.

When undertaking routine enquiry the dental professional should be confident and supportive, expressing concern as necessary, but without accusation or being patronising. The appropriate time to ask is probably as part of taking the social history. Later, when examining the patient, if injuries do not appear to be consistent with the given cause, then the dental professional should explain this concern to the patient.

Open questions

The patient may be fearful of talking about her own experience, particularly if the abuse has taken place over a long period of time and has led to low self-esteem. Often women in this situation blame themselves, and the response of others to their situation may have reinforced this view. The dental professional should begin with some indirect questions to help establish a relationship with the patient and develop empathy, such as:

‘Is everything alright at home?’

‘Are you being looked after properly?’

‘Is your partner taking care of you?’

It may be helpful to explain why you are asking the questions by explaining, ‘I am sorry if someone has already asked you about this, and I don't wish to cause you any offence, but we know that throughout the country one in four women experiences violence at home at some time during their life and so we are asking all women about this issue.’ More direct questions may include:

‘Have you ever been in a relationship where you have been hit or hurt in any way?’

‘Are you currently in a relationship where this is happening to you?’

‘Has your partner ever destroyed or broken things you care about?’

‘Has your partner ever threatened or hurt your children?’

‘Does your partner get jealous of you seeing friends, talking to other people or going out? If so, what happens?’

If responding to dentofacial injury then it may be helpful to suggest:

‘Your partner seems very concerned and anxious about you. Sometimes people react like that when they feel guilty; was he responsible for your injuries?’

Respect and referral

How a patient suffering domestic violence is treated by health professionals will be significant in determining whether she will be able to disclose more and seek help, or whether she mistrusts professionals and faces the continued violence alone. When information is disclosed, it is essential that the response of health professionals is sympathetic, supportive and non-judgemental. Emphasise that confidentiality will be maintained. Criticising a woman who chooses to remain with an abusive partner must be avoided – there may be many reasons why such a decision is made.

Once domestic violence is identified it can be referred on to the appropriate agency, therefore this process must be considered prior to starting screening. The referral to agencies providing direct help may be made by providing leaflets and also discreet cards containing contact details to take away. Displaying posters in the waiting room with a contact telephone number is also useful and provides a signal to encourage patients to disclose their domestic violence experience. DCPs may also wish to help by offering to contact other agencies on behalf of the women. Written information should be available in a range of languages appropriate to the local area.

Specialist agencies provide help by supporting women to:

  • make sense of the violence and abuse they are experiencing

  • develop safety plans and assess the risks to both themselves and their children

  • be able to consider all of their available options

  • develop coping strategies

  • leave an abusive relationship.

Record-keeping

Documentation and record-keeping are very important because they can be used as evidence against the perpetrator of the domestic violence in the event that they are charged with assault. Evidence can also help an abused woman obtain protection through an injunction or court order, in opposing an immigration or deportation case, or in family courts to assess possible risks in granting access to children to a violent parent.

Any record of domestic violence should be kept separate from other patient notes to ensure confidentiality. Consent should be obtained from the patient if information needs to be shared with other agencies.

Despite this, when there are reasons to believe that the patient's children are at risk, then protection of the children must take precedence over patient confidentiality, and Child Protection Guidelines must be followed.

Training the team

The UK Department of Health published a manual called Responding to domestic abuse: a handbook for health professionals in 2005 (for information on ordering, see www.dh.gov.uk or telephone 020 7210 4850). This publication is designed to encourage all healthcare professionals, including those working in dentistry, to adopt the same approach to domestic violence, to ensure that the same standard of response is available to sufferers.

The UK National Domestic Violence Training Forum recommends that dentists and DCPs receive core training in responding to domestic violence. Even attending a lecture can increase knowledge and change attitudes in the dental team, but this should be followed by in depth practical training. The Forum recommends that training is incorporated into mandatory induction procedures when individuals take up NHS posts and as part of ongoing CPD.

Make sure you and your team know how to deal with domestic violence.

Table 1 Tell-tale signs