Make it your business

DOMESTIC violence has recently been described by a senior Scottish police officer as "a badge of shame for Scotland". Over the last Christmas and New Year period 9,812 incidents were reported to the police, nearly 2,000 more than the previous year. While this, to an extent, reflects efforts being made to encourage victims to report violence it is still an alarmingly high number. Every 10 minutes the police in Scotland deal with an incident of domestic abuse but it takes around 35 previous incidents of abuse before the victim feels able to make that call to the police or support services. In 2008-9 alone 11 murders resulted from domestic abuse.

Domestic abuse is essentially about one individual exerting control over another and this may take the form of verbal, physical, emotional or sexual abuse. Many victims find it difficult to leave an abuser for a variety of reasons, including issues associated with their family and finances. While the majority of victims of domestic abuse are female, it can affect anyone regardless of their gender, sexual orientation, age, disability, ethnic background or social class and this is an important point to remember.

The elephant in the room

Have you ever sat in your surgery after a patient has left and asked yourself how she really got that broken upper incisor or that black eye? Did she give you a story that didn’t quite ring true? Were you too embarrassed to ask more questions? Did you think it was none of your business? Well, you are not alone. Domestic violence is something notoriously hard to deal with and raising the issue is something that many dental professionals find extremely difficult. This often means that a victim may leave the surgery without being asked about abuse.

So how is domestic violence relevant to dentistry? Most victims of domestic violence suffer injuries to the head or neck; in fact facial trauma in women is more likely to be due to domestic violence than any other cause. Dentists often form long-term relationships with their patients and their families so are in an ideal position to notice changes in someone’s appearance or behaviour and signpost victims towards appropriate help.

However, there are barriers. A study from the USA in 2001 found that although 47 per cent of dentists suspected that a patient had been a victim of domestic abuse, 87 per cent never screened patients for domestic abuse. Unfortunately this often means that the ‘golden’ moment where help could be offered is lost. Very real barriers do exist and they include lack of training and time but also fear of offending the patent, embarrassment and a lack of awareness of what to do to help. Research shows that as many as 85 per cent of women visiting their dentist with signs of abuse were not asked about it, and the same study showed that 70 per cent of patients who sought help wished the dentist had asked them about it. Sometimes just asking is enough to encourage the victim to seek help.

Remember AVDR

Medics against Violence, a Scottish charity, was founded in 2008 by three individuals with dental qualifications who felt we should do more to help prevent the violent injuries we see in our day-to-day practice. To this end we researched what, if any, programmes for domestic violence were available for dentists. We came across AVDR (Ask Validate Document Refer) developed by Dr Barbara Gerbert and her coworkers at the University of California, San Francisco, School of Dentistry. This programme had been designed, evaluated and found to be effective, so with Dr Gerbert’s permission we adapted it for use in Scotland. The first cohort of dentists in Scotland received training in the use of AVDR in November 2010.

So how does it work? The programme is very simple and doesn’t require any additional skills; nor does it require the dentists to get involved with trying to deal with the abuse or the abuser. There are four steps:

1: ASK The most important and first step is to ask the patient about possible abuse. Asking in a nonjudgemental, caring way will often encourage a victim to disclose. Always ask in private and reassure the patient that everything they tell you is confidential. Even if a patient denies any abuse at this stage don’t be discouraged as the fact that you as a trusted healthcare professional have raised the issue may encourage them to seek help once they have left the surgery. Routine screening for domestic abuse has already been introduced in key medical settings including maternity services, mental health and emergency medicine across Scotland so you may decide to include this in your routine medical history for all patients.

2: VALIDATE Telling your patient that abuse is wrong and totally undeserved is the next step. Many victims believe that the abuse is somehow their fault and these validating messages can provide them with the confidence to do something about it. It also lets them know that you care about their safety; even if they chose not to disclose the abuse to you it is still important to let them know that you feel abuse is wrong.

3: DOCUMENT It is very important to document the signs and symptoms of any injuries as well as any disclosures that the patient makes about abuse carefully in your notes. Use the patient’s own words if they tell you about the abuse and be as accurate as possible. Diagrams, photographs and radiographs (for example, if required for management of broken teeth) can also be very helpful if a case goes to court.

4: REFER Finally you can refer a patient or signpost them towards help. There are many organisations experienced in dealing with domestic abuse that are best placed to provide detailed advice and help to victims. Dealing with the details of the abuse, the abuser and providing a holistic solution is not the dentist’s role so referring patients on to specialist services by having phone numbers of help lines available in the practice is the best way to support your patient.

When the police become involved

Sometimes your support may encourage a victim to report the abuse to the police. If this happens, the police will respond immediately and the abuser will be detained in police custody until the matter can be investigated. If you have seen the patient following an injury you may be asked for a statement, your notes will be taken as evidence and you may be required to attend when the case comes up in court. If your statement and notes are clear and factual it may be possible for the defence and prosecution to agree your evidence without you being present in court, so good clear note taking is of the utmost importance.

For more information on the Domestic Violence Initiative visit www.medicsagainstviolence.co.uk. We provide free training in the use of AVDR to large groups and will soon have a number of teaching materials available via our website which can be used in practice settings.

You can also phone an MDDUS dento-legal adviser for guidance in dealing with specific cases.

Dr Christine Goodall is a senior lecturer and honorary consultant in oral surgery at Glasgow University’s Dental School and co-founder of Medics against Violence