Interpersonal Violence in the Community
Scroll through Queensland’s Not Now, Not Ever. Putting an End to Domestic and Family Violence in Queensland and Queensland’s Domestic and Family Violence Prevention Strategy 2016—2026 and you will find 5 mentions related to ambulance and domestic and family violence (DFV). Visit Victoria’s Royal Commission into Family Violence and you will find a whole section on ambulance services and the “opportunities to strengthen and enhance their role”.
We have already visited to the topic of domestic violence in pregnancy. I’m returning to it now in its own right. In addition to domestic and family violence, I will revisit aspects of child maltreatment (CM), elder abuse (EA) and modern slavery (MS).
This topic is worthy of a chapter because not all victims of abuse are transported to hospital, not all victims of abuse realise they are victims of abuse  and abuse commonly takes place in the community, a place awash with paramedics (okay, maybe that was a hyperbolic indulgence, but paramedics are routinely found in all parts of Queensland).
All peoples can be victims of DFV. Disproportionally more women are victims of DFV. I acknowledge that men are also victims of DFV, and their experiences of DFV are different. However, many more women are killed by men known to them than are men killed by women known to them. The killings of Tara Brown, Karina Lock, Hannah Clarke and Karen Gilliland in the last half decade in Queensland are tragic and must not be forgotten. They encourage us to be better, to do better and to eliminate violence as a responsibility of health services in partnerships with social and legal services.
DFV can be characterised as but is not limited to:
- Physical violence
- Sexual violence
- Psychological violence
- Coercion and control
There are many additional examples of DFV that may not conform clearly to one of the above examples. They can relate to cyber-offences such as cyber-stalking and revenge pornography and abuse can take the form of economic abuse. According to section 8(1)-(3) Domestic and Family Violence Protection Act 2012 (Qld), domestic violence is defined in Queensland as:
(1) Domestic violence means behaviour by a person (the first person) towards another person (the second person) with whom the first person is in a relevant relationship that—
(a) is physically or sexually abusive; or
(b) is emotionally or psychologically abusive; or
(c) is economically abusive; or
(d) is threatening; or
(e) is coercive; or
(f) in any other way controls or dominates the second person and causes the second person to fear for the second person’s safety or wellbeing or that of someone else.
(2) Without limiting subsection (1), domestic violence includes the following behaviour—
(a) causing personal injury to a person or threatening to do so;
(b) coercing a person to engage in sexual activity or attempting to do so;
(c) damaging a person’s property or threatening to do so;
(d) depriving a person of the person’s liberty or threatening to do so;
(e) threatening a person with the death or injury of the person, a child of the person, or someone else;
(f) threatening to commit suicide or self-harm so as to torment, intimidate or frighten the person to whom the behaviour is directed;
(g) causing or threatening to cause the death of, or injury to, an animal, whether or not the animal belongs to the person to whom the behaviour is directed, so as to control, dominate or coerce the person;
(h) unauthorised surveillance of a person;
(i) unlawfully stalking a person.
(3) A person who counsels or procures someone else to engage in behaviour that, if engaged in by the person, would be domestic violence is taken to have committed domestic violence.
In addition to the offences above, s 315A Criminal Code Act 1899 (Qld) has created the offence of choking, suffocation or strangulation in a domestic setting:
(1) A person commits a crime if—
(a) the person unlawfully chokes, suffocates or strangles another person, without the other person’s consent.
Attempted strangulation is a feature of DFV. It is not only physically violent, it is psychologically violent. The perpetrator is enforcing control and influence over their victim. This is clinically relevant for HCPs as numerous signs and symptoms are associated with strangulation and they can all be missed. “The criminal offence of choking, suffocation or strangulation in a domestic setting is frequently the first form of physical altercation used against a victim of DV; it is an important red flag that can run the risk of being missed. Even a single episode can cause a stroke requiring medical intervention. Delayed death can be caused as a result of pressure placed on the vasculature on the victim’s neck. Attempted strangulation, along with pregnancy, is an important early indicator of homicide in women. Witnessing the choking, suffocation or strangulation of a parent has the potential to cause adversity to children and is therefore relevant to paramedics”.
Experiences of domestic and family violence in remote communities, including Aboriginal and Torres Strait Islander communities share similarities but there are substantial differences that need to be highlighted. The Australian Human Rights Commission identified key issues in relation to family violence and abuse in Aboriginal and Torres Strait Islander communities:
- “the relationship to substance abuse
- the interaction of Aboriginal customary law, violence and human rights
- the need for human rights education among Indigenous communities
- the significance of violence as a barrier to women achieving leadership positions and for women’s equality generally
- the significant role of violence and abuse as a causative factor in Indigenous women entering and then re-entering prison at alarmingly high rates
- international models for programs aimed at addressing inter-generational trauma and grief through healing
- the impact of violence on Indigenous youth in developing cognitive disabilities, in under-performance in schools and entry into the juvenile and then adult criminal justice processes
- its relationship to the high incidence of mental illness and youth suicide among Indigenous peoples and
- it being both a reflection of, and a cause of, poor health among Indigenous peoples”.
Current research supports the disparity between take up of services between first peoples and non-indigenous groups. An issue highlighted in the research appears to conform with DFV hiding in plain sight. This is not limited to anyone community. There is a stigma attached to DFV, and this can allow violence and abuse to continue without opportunity for interventions taking place. Discussed in chapter 5 was children’s exposure to domestic violence. I want to repeat that children require additional cognisance from HCPs responding to DFV. Their relationship to the victim and the scene must be considered. It is important to know that parent victims may be reluctant to seek help, out of fear child services may remove vulnerable children based on DFV.
The World Health Organisation (WHO) offers a suggested response for health services delivering health care for women subjected to intimate partner violence or sexual violence. This is the L.I.V.E.S. acronym. I believe it is applicable in any circumstance, irrespective.
- Listening is the most important part of good communication and the basis of first-line support
Inquire about needs and concerns
- Physical needs, emotional needs, or economic needs, safety concerns or social support
- Validating another’s experience means letting the person know that you are listening attentively … without judgment or conditions
- Partner violence is not likely to stop on its own; it tends to continue and may over time become worse and happen more often
- Find out what support and resources are available in the community
In closing this section on HCPs and DFV, I am going to speak to the paramedic group in the cohort. Not every victim of DFV is transported to hospital. If paramedics aren’t prepared to talk about domestic violence with their patients, then people are at risk of being no better off than they were before an ambulance turned up. The days of that’s not my job need to be confined to history and not be allowed to form part of current paramedic practice. I maintain that if paramedics can ask a patient about erectile dysfunction medication then they can ask about domestic and family violence. HCPs need to be aware of the barriers they believe prevent them from reaching out to victims and recognise that any perceived barriers to intervention are built on shallow foundations. HCPs must also consider whether they share a responsibility with other services to respond to perpetrators and encourage them to rethink their relationship with violence. There is a great deal to be done by paramedics to intervene and prevent DFV and CM. As the next generation of HCPs, it’s up to you to contribute to that change that removes DFV and CM from our communities.
9.2 Elder Abuse
The internet informs me reliably that it was Bette Davis who famously stated that becoming “old is no place for sissies”. The quote is pithy and sardonic, and a balanced snapshot that shares themes with Dylan Thomas’s poem, Do not go gentle into that good night. (I love the word that in the title.) To me, it means we can’t lose our sharpness and our burn. It is not a calumny to say we become increasingly vulnerable as we age. Youth has us bullet proof. Then something changes. It’s imperceptible at first. You begin to realise you don’t know everything. In fact, you realise you know quite little. It opens us up to new things with a better perspective. But it also exposes vulnerabilities. Vulnerabilities that can be used by others to their advantage. Remind me to show you a clip of the challenges people have negotiating user agreements in the tutorial. Every day we sign up to things with screeds of small print we never read. Imagine being bombarded by emails, cold calls all designed to separate you from your hard-earned cash. Many aspects of our lives are regulated to prevent malpractice, and we hope that whomever we contract for services respects the fiducial agreement and doesn’t fleece us. This is a burden faced by many elderly people who struggle to keep pace with ordinary daily living. Add the constantly changing landscape of cyber literacy into the mix it isn’t any wonder people give into demands to share personal details under the pretext someone is doing someone else a favour. Then add into all this the aging process. Anyway, I’m going to take a short break from writing and catch up with some emails I received from a Nigerian Prince. I discovered the emails recently in a folder that incorrectly identified them as junk (bah, paternalistic email application. What do you know?). Fingers crossed, if I am an heir to the apprehended fortune it looks like I might be able to retire early.
The Australian Institute of Family Studies published a paper describing understanding issues, frameworks and responses related to elder abuse. Like DFV, elder abuse is rooted in physical abuse, emotional abuse, financial abuse and other controlling influences. The report published these findings:
“Evidence about prevalence in Australia is lacking, though if international indications provide any guidance, it is likely that between 2% and 14% of older Australians experience elder abuse in any given year, with the prevalence of neglect possibly higher. The available evidence suggests that most elder abuse is intra-familial and intergenerational, with mothers most often being the subject of abuse by sons, although abuse by daughters is also common, and fathers are victims too. Financial abuse appears to be the most common form of abuse experienced by elderly people, and this is the area where most empirical research is available. Psychological abuse appears slightly less common than financial abuse, and seems to frequently co-occur with financial abuse. The problem of elder abuse is of increasing concern as in the coming decades unprecedented proportions of Australia’s populations will be older: in 2050, just over a fifth of the population is projected to be over 65 and those aged 85 and over are projected to represent about 5% of the population. Our federal system of government means that responses to elder abuse are complicated as they are contained within multiple layers of legislative and policy frameworks across health, ageing and law at Commonwealth and state level”.
As our vulnerabilities increase with age, there may be a corresponding lack in agency. Elderly people may feel they are no longer relevant. They may feel ignored, overlooked, even invisible. HCPs need to be alert to this. They need to consider the possibility, like child maltreatment, that aged members of the community can be at risk of harm. Threat can come from friends and family members, even people tasked with the role of caring for elderly people. I’ll finish this section with a quote from my former neighbour who is in her nineties and said, when we visited her shortly before COVID-19 shut out visitors from all the nursing homes and aged-care facilities: ‘she’s being nice to me today because you’re here’.
According to the Global Slavery Index, there were 15,000 victims of modern slavery in Australia in 2016. Additionally, the states that:
“Cases of forced labour exploitation in Australia predominantly occur in industries considered at risk, including agriculture, construction, domestic work, meat processing, cleaning, hospitality, and food services. Historically, those identified as victims of labour exploitation were working as domestic workers, however there has been an increase in referrals relating to hospitality, agriculture and construction.”
Modern slavery refers to any kind of…
- Trafficking in persons (human trafficking/people smuggling)
- Forced labour
- Debt bondage
- Forced marriage
- Organ harvesting
- Sale of or sexual exploitation of children
- o The list above should not be read as absolute and can include other examples of exploitation
Paramedics attend to workplace safety incidences where they may encounter victims of modern slavery. Victims of slavery may be unlikely to complain as they believe they will jeopardise their safety and the safety of others held in captivity. Victims of modern slavery may not have legal entitlement to remain in Australia. This dilemma poses several issues. Without scrutiny modern slavery practices will persist. Views on immigration may impact interventions to free individuals from modern slavery. However, paramedics are well placed to respond to victims of modern slavery based on health service delivery in the community. Further information from the Australian Department of Home Affairs Modern Slavery Act 2018 (Cth) can be found here.
9.4 Roles for Paramedics
There is no formalised role for paramedics responding to people experiencing adversity. States and territories in Australia legislate differently on reporting child maltreatment. The legislation can be found in the required reading for this week available on QUT Readings. Irrespective of the what laws mandate HCPs to report, I believe it is everyone’s professional responsibility to benefit patients and their lives. This may mean lobbying for change and establishing a commitment to patients that we can lend a supportive hand to reduce all forms of violence in the community.
Here are my suggestions to you when you encounter patients at risk of harm, abuse and and/or adversity (please email your additional suggestions to add to this list to firstname.lastname@example.org):
- Be willing to accept that people can be victims of abuse
- Challenge you prejudices and your biases
- Ask patients
- Acknowledge doubts, concerns, fears, barriers before asking a patient about their exposure to abuse
- Contact services for support in relation to doubts, concerns, fears, barriers.
- Ask for help
- Offer help
- Believe people
- Document observations
- Report and refer
Remember, not all patients are seen in the ED. This should encourage front-line HCPs to be willing to recognise and address this limitation. I’ve left many patients at home and I have been let with the feeling that I wish I could have done more. I felt limited by a combination of issues. It was either a lack of formal policy, a fear I was going to make it worse, not understanding fully the role of other services or just something as simple as uncertainty to know what to do or what I was permitted to do. Sometimes people choose not doing something over doing something on the basis they believe the consequences of commission may be worse than the consequences of omission. You have a voice, use it. We must move away from standing by, recording events on our phones and recognise these issues will not go away unless health services utilise a public health response to abuse and violence.
9.5 Case Studies
Case Study 1
This case study is taken from Bartlett Stephen, Protective Jurisdiction in Townsend, Ruth, Applied paramedic law, ethics and professionalism: Australia and New Zealand (Elsevier Australia, 2nd edition. ed, 2020) pp 178-180
“You are a newly recruited qualified paramedic who has achieved all of your graduate competencies. It is your first shift as an unsupervised qualified paramedic, and you are working with another paramedic who is coming to the end of their graduate-entry program. It is 22:35 on a busy Friday night. You have both overheard on the radio, dispatch encouraging crews to clear from the hospital as quickly as possible due to the number of emergency calls still waiting response.
You are dispatched under emergency conditions to a somewhat isolated property. The call is to a 31-year-old, insulin-dependent, hypoglycaemic female; she is breathing, but her level of consciousness is still being established by the call-taker. You arrive on scene within 7 minutes of the call being made. There is a short delay in gaining entry to the property, as there are four cars on the property blocking your access. A deep, loud voice shouts, ‘The back! Come around to the back way.’ You make your way to the back of the property. You are careful not to scrape the response kit you are carrying against any of the cars, which are parked tightly on the driveway.
Once at the back door, you are greeted by a male whose demeanour appears unnaturally relaxed and polite given the potentially grave circumstances of the call. He leads you from the porch, through the kitchen, down a short, poorly lit hallway and into an unkempt and rather compact bedroom at the front of the house. Your crewmate follows a short distance behind. In there you find a female. She is alert and, without offering a greeting, says, ‘It’s 3.2 … I’m getting better. I’m beginning to feel better.’
To the right of the patient’s bed there is a young child sitting on the floor, playing what appears to be a box-building, character-slaying video game. He wears thick glasses, and his face is scarcely an arm’s length from the television screen, which is propped on top of two cardboard boxes. Your arrival does nothing to distract him from his game. You turn your attention to your female patient and commence your assessment and standard cares.
All the while, the male who greeted you stands in the door jamb between the hallway and the bedroom. The size of the bedroom and the male in the doorway prevents your colleague from getting into the bedroom and helping you treat your patient. The man leans to the left against the door jamb, his left arm propped above his head, and the thumb of his right hand runs through the belt loop of his jeans. There are fresh abrasions on the knuckles of his right hand. His presence can be felt despite his silence. During your assessment you glance around at various items in the bedroom.
Answers to your questions on how the patient came to be hypoglycaemic are vague and guarded. The patient claims to have been feeling ‘under the weather’ for the past 3 days. Her temperature and other vital signs are normal. Following intervention, the patient’s blood glucose level returns a reading of 4.6 mmol/L. Feeling happy that her health is steadily improving, your crewmate asks you to make your excuses and leave the patient for a short time.
You both walk out the way you came in, and without saying anything your crewmate points to a door to a larder in the kitchen. The door is caved in and is broken in several places. There appears to be fresh blood smeared on the broken remnants of the door. Various jars, which you hadn’t noticed on the way in, lie in pieces on the ground. You exchange glances with your colleague before returning to the patient. You tell her that you would like her to be checked up at hospital; the reason for her hypoglycaemic episode needs to be explored fully. The male protests, while at the same time attempting to gain your favour. The patient consents to transport to hospital. The man’s disapproval fades.
The patient asks to walk out to the ambulance. As you move past the first car, she whispers, ‘I don’t want him to come.’ ‘Who? Your child? Or your partner?’ you reply. ‘Him’ is all she says. When you ask, ‘Is your child safe?’, she asks whether her son can come in the ambulance, too. You agree, and your colleague goes to collects him as well as some night things for them both. You are concerned that some disturbance could break out at this point. None does.
A short time later, with everyone in the ambulance and the trip to hospital commenced, your patient begins to sob. ‘I only did it to escape! I only did it to escape! I’ve tried to break free; I’ve tried to leave but it keeps coming back to this. I had no other option but to do it!’”
Case Study 2
It is 8am on the first day of the Bendigo summer school holidays. 11-year-old Alex has called an ambulance for his mother. He tells the ambulance call-taker his mother is choking, and she has stopped breathing. A paramedic crew, critical care paramedic (CCP) and doctor are dispatched. The crew arrive first, within minutes. They are met at the door by Alex’s mother. She is coughing, her voice is raspy, and she is rubbing her neck. She greets the crew. Standing in the doorway with his mother is Alex. The crew ask the boy if he called the ambulance for his mother. Alex nods. “Yes,” he says. Alex’s mother tells the paramedic crew she is fine. She just has a sore throat and is feeling a bit light-headed. The crew stand the CCP and the doctor down, stating that the patient’s presentation is no longer life threatening. The crew ask to come inside and examine the patient. Alex’s mother agrees.
In the 20 minutes that follows the paramedics discover:
- Before Alex became his mother was in trouble, Alex and his 9-year-old sister, Bailey were outside playing on the trampoline.
- While they played, Alex’s mum was in the house sharing breakfast with Alex’s and Bailey’s father.
- Outside, Alex heard a bang followed by an ugly noise. He told the crew that the sound was like a grunt but not like a grunt he had heard before.
- Alex and his sister went upstairs to see if their mum and dad were okay.
- Alex found his mum standing over the sink, coughing and retching. She was finding it hard to catch her breath.
- She didn’t respond when Alex spoke to her and that made him nervous, and Alex’s dad looked like he had left to go to work so he couldn’t help Alex.
- Alex had grown up watching Operation Ouch! and he was able to recognise that something was seriously wrong with his mum. He knew what calling for an ambulance involved.
- The paramedic crew recorded Alex’s mum’s vital signs as being within normal limits, pulse and blood pressure elevated slightly. She is fit and well with no significant medical history. She is 11 weeks pregnant.
- She tells the crew she was talking to her husband and eating at the same time, and that caused some food to go down the wrong way.
- Asked about the whereabouts of her husband, Alex’s mum says he had to leave for work as he had an important meeting with a client.
- During the patient assessment, the other member of the paramedic crew examined the entrance to the house and the kitchen area. The kitchen table is clear of food. The paramedic finds a black and white framed picture of Alex’s mum, Alex and Bailey and a man of similar age to Alex’s mum to the right of the front door. In the picture, everyone’s arms are around one another. The glass in the picture frame is smashed.
- Alex’s mum says she doesn’t want to go to hospital. She thinks Alex may have overreacted, but with the best of intentions. She says she will contact her GP and let her know what has happened.
Based on the available information, please indicate if the following statements are true or false by placing a mark in the appropriate column:
|Suspected family violence is a factor in this case|
|Suspected child maltreatment is a factor in this case|
|Reporting suspected family violence to police or family violence services requires the adult victim’s consent|
|Reporting suspected child exposure to family violence to police or child protection services requires parental consent|
|A child hearing, not seeing, family violence is not an example of child exposure to family violence|
|Non-fatal strangulation by a domestic partner in the context of family violence is a sentinel event and predictor of future homicide|
|One paramedic crew member is a sole registered paramedic, the other is a dual qualified nurse and paramedic, registered with AHPRA as a nurse and a paramedic. Despite being employed as a paramedic when the events stated above take place, also being a registered nurse alters reporting responsibilities|
|Non-mandated health professionals are prohibited from reporting suspected child maltreatment encountered in the course of their work|
|Pregnancy invalidates Alex’s mum’s refusal to go to hospital|
9.6 Further reading
Available on QUT Readings
Bartlett Stephen, Protective Jurisdiction in Townsend, Ruth, Applied paramedic law, ethics and professionalism: Australia and New Zealand (Elsevier Australia, 2nd edition. ed, 2020) pp 177-204
- Sawyer, Simon et al, ‘Are Australian Paramedics Adequately Trained and Prepared for Intimate Partner Violence: A Pilot Study’ (2014) 28 Journal of Forensic and Legal Medicine 32; Sawyer, Simon et al, ‘Paramedics as a New Resource for Women Experiencing Intimate Partner Violence’ (2018) Journal of Interpersonal Violence DOI:10.1177/0886260518769363; Sawyer, Simon et al, 'Paramedic Students' Knowledge, Attitudes, and Preparedness to Manage Intimate Partner Violence Patients' (2017) 21(6) Prehospital Emergency Care 750; Sawyer, Simon et al, ‘Preventing and Reducing the Impacts of Intimate Partner Violence: Opportunities for Australian Ambulance Services. (2015) 27 Emergency Medicine Australasia 307. ↵
- Hart, Luke and Ryan, Operation Lighthouse: Reflections on our Family’s Devastating Story of Coercive Control and Domestic Homicide (CoCoAwarenes Ltd, 2018). ↵
- Heather Douglas and Robin Fitzgerald, 'Strangulation, Domestic Violence and the Legal Response' (2014) 36(2) Sydney Law Review 231. ↵
- F Clarot et al, 'Fatal and Non-fatal Bilateral Delayed Carotid Artery Dissection after Manual Strangulation' (2005) 149(2) Forensic Science International 143. ↵
- N Milligan and Milne Anderson, 'Conjugal Disharmony: A Hitherto Unrecognised Cause of Strokes' (1980) 281(6237) British Medical Journal 421. ↵
- AM Anscombe and BH Knight, 'Case Report. Delayed Death after Pressure on the Neck: Possible Causal Mechanisms and Implications for Mode of Death in Manual Strangulation Discussed' (1996) 78(3) Forensic Science International 193. ↵
- Nancy Glass et al, 'Non-fatal Strangulation is an Important Risk Factor for Homicide of Women' (2008) 35(3) The Journal of Emergency Medicine 329. ↵
- Bartlett, Stephen, 'Paramedics and Children Exposed to Domestic Violence' (PhD Thesis, Queensland University of Technology, 2019) https://eprints.qut.edu.au/133879/. ↵
- Fiolet, Renee et al, 'Indigenous Perspectives on Help-Seeking for Family Violence: Voices from an Australian Community' 0(0) 0886260519883861. ↵
- https://aifs.gov.au/sites/default/files/publication-documents/rr35-elder-abuse-nov18.pdf. ↵
- https://www.globalslaveryindex.org/2018/findings/country-studies/australia/. ↵
- Dutton, M. A., James, L., Langhorne, A., & Kelley, M. (2015). Coordinated Public Health Initiatives to Address Violence Against Women and Adolescents. 24, 80-85. ↵
- Taken from Bartlett, Stephen, Protective Jurisdiction in Townsend, Ruth and Luck, Morgan, Applied paramedic law, ethics and professionalism: Australia and New Zealand (Elsevier Australia, 2nd edition. ed, 2020). ↵