National Guide

Chapter 4 | Child and family safety

Family abuse and violence







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Family abuse and violence

Child and family safety | Family abuse and violence

Dr Elizabeth Hindmarsh, Dr Melanie Dorrington 

Key messages

  • The prevention of family abuse and violence (FAV) for Aboriginal and Torres Strait Islander peoples and communities begins with recognising that FAV is a complex issue involving many interconnected factors, such as systemic racism, institutional barriers, gender and power inequality, discrimination and the ongoing impacts of colonisation.1,2
  • FAV is a serious issue that impacts the health and wellbeing of individuals and communities. Effective prevention requires an Aboriginal and Torres Strait Islander-led approach, with culturally appropriate involvement of health services and practitioners. Aboriginal and Torres Strait Islander approaches to FAV are more holistic, with a desire for a whole-of-community and collective healing approach.3–5 Central to preventing FAV is supporting the family as a whole and recognising that trauma and loss contribute to FAV. Culture is protective and involving Elders in healing where appropriate can support meaningful community solutions.6–8
  • Respectful therapeutic relationships, building rapport and a culturally safe approach to healthcare (asking the patient what feels like safety for them) are crucial to supporting the prevention of FAV. There is a need and expectation that health professionals will offer safety from racist attitudes and institutional control.7
  • Recognising and responding to FAV requires that all staff have been trained in how to ask about and manage FAV. This is preferably done as whole-of-service/practice training and viewed as core skills to be developed as a basic requirement for new staff and ongoing professional development for all staff.9
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Primary healthcare practice Implement service-level systems and protocols to train and support staff in identifying and responding to FAV (see Implementation tips) Opportunistically and as part of staff professional development Good practice point Policy brief10
National guideline11		 The best available evidence supports whole-of-practice training in the prevention and identification of FAV, safety of patients and staff and the care and support of staff dealing with FAV
Primary healthcare practice  Support and access training in providing culturally safe and trauma informed care  During induction of new staff and as part of ongoing staff professional development Good practice point Policy brief10
Aboriginal and Torres Strait Islander-specific framework4		 Cultural safety is always paramount and the delivery of care that is trauma informed is best practice in dealing with patients involved in FAV
Primary healthcare practice  Offer support services to staff experiencing stress from working with victims/survivors and perpetrators of FAV Opportunistically and as needed Good practice point National guideline11 People working with those experiencing abuse and violence can experience stress, burnout and vicarious trauma
Primary healthcare practice  Promote training in assessing perpetrators and clear referral pathways for behaviour change programs, including pathways for non-Indigenous perpetrators During induction of new staff and as part of ongoing staff professional development Good practice point National outcome standards12 Identifying and changing perpetrator behaviour is critical to reducing FAV
Clinicians and health services with links to secondary schools Advocate for implementation of school-based education programs to promote the development of healthy personal relationships, and an understanding of FAV As part of school curricula when health services are linked to schools Good practice point Aboriginal and Torres Strait Islander-specific studies13,14
Framework and narrative review15,16		 Respectful relationship education in schools is a key strategy in the primary prevention of FAV

 
Type of preventive activity - Screening (Enquiry)
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Adults and adolescents where risk factors or concerns are identified Ask sensitively about the possibility of experiencing FAV Opportunistically/when risk factors or concerns are identified Conditional International guideline17
Aboriginal and Torres Strait Islander-specific studies3,13		 Awareness of the presentations where FAV may be the underlying issue (eg depression)

Culturally safe and respectful inquiry about FAV can support disclosure and enable informed care

There is a risk of harm if the enquiry is not done appropriately/sensitively
Pregnant people Assess for the risk of FAV as part of a comprehensive pregnancy care assessment (refer to Chapter 5: Preconception and pregnancy care, Pregnancy care)

Ask about FAV with general questions about relationships and specific questions (eg ACTS [Afraid, Controlled, Threatened, Slapped] tool (refer to Figure 1)		 At least once in early pregnancy and checking again at 20 weeks onwards Strong International guideline18
National guideline11		 There is evidence for the benefit of screening women in pregnancy to support early engagement in support and services

It is vital that this is done in a respectful and culturally safe way, to minimise the fear pregnant Aboriginal and Torres Strait Islander people may have of their child being removed
All children Stay alert for signs and indicators of FAV such as particular types of physical injury (non-accidental injury), emotional distress or behavioural problems (refer to Chapter 4: Child and family safety: Child maltreatment: Supporting families to optimise child health and wellbeing) If there are concerns, as clinically indicated Good practice point International resource19
National resource20		 This is one way that FAV can present
Women aged over 16 years attending with mental health issues and women aged over 16 years with drug and alcohol issues Ask about potentially experiencing FAV When being assessed for their mental health and/or drug and alcohol issues Good practice point Aboriginal and Torres Strait Islander-specific studies13,15 There is an association between mental health presentations, drug and alcohol issues and FAV

 
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Adults and teenagers  Screen for the use of alcohol, other drugs, gambling and for financial or other stressors Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific study13
Aboriginal and Torres Strait Islander-specific framework4		 This is to help identify potential perpetrators of abuse and violence
There is an association between mental health presentations, drug and alcohol issues and FAV
Known victims/survivors of FAV  Ask about economic abuse, coercion and sexual abuse As clinically indicated/when assessing   Good practice point National guidelines11 These are some of the FAV issues that are often not recognised and not addressed 
Adults and teenagers, especially known victims/survivors of FAV Assess for social and emotional wellbeing (refer to Chapter 20: Mental health)

Refer to local social support services (see Resources)		  Opportunistically  Good practice point National guideline11 People who are victims of FAV have a much higher chance of having mental health and emotional issues
 
 
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Pregnant women, especially known victims/survivors of FAV Promote regular health professional contact via nurse, Aboriginal health worker or practitioner-initiated home visits Assess regularly in the antenatal period and continue until the child is aged two years (using specially trained staff and addressing safety issues) Good practice point Policy brief10 Engagement in healthcare provides an opportunity for support and services that can reduce the incidence and harms of FAV
Men who use violence Engage men who use violence in behaviour change programs and other healing programs where available (see Useful resources)
 		 Opportunistically Good practice point National outcome standards12 Identifying and changing perpetrator behaviour is critical to reducing FAV
Victims and people who use abusive behaviours where there is high household use of alcohol and other drugs Assess for alcohol and other drug-related harm and work to limit use (refer to Chapter 2: Healthy living and health risks, Alcohol and Chapter 7: The health of young people) Opportunistically and as part of an annual health assessment  Good practice point National guideline11
Aboriginal and Torres Strait Islander-specific framework4		 There is an association between mental health presentations, drug and alcohol issues and FAV
 
ANote, the Environmental recommendations have been presented first for FAV because the need for appropriate training is fundamental to being able to provide safe, appropriate and effective healthcare.
BNote, the World Health Organization (WHO) recommends enquiry rather than screening as the safest approach to FAV.
  • Establishing rapport with individuals and their families is paramount. Establish a safe space for the individual to slowly learn to trust you. Reassure the client that their needs will be prioritised and that you intend on taking an approach that values their priorities. It is acceptable to let Aboriginal and Torres Strait Islander people know you have limited knowledge about their cultures but are willing to learn.
  • It is important to ensure that all practice team members are sensitive to the issue of FAV. This means that everyone working in the practice feels confident in their knowledge about how they can support patients and each other when FAV is identified.
  • Consider staff training:
    • to understand the connection between colonisation and ongoing trauma and FAV, as well as the impact of other factors, such as housing, poverty and financial stress, racism and unemployment
    • to know how to enquire about FAV and what to do when cases are identified
    • about providing trauma- and violence-informed healthcare
    • to know how to support each other when working with people who experience FAV and people who use abusive and violent behaviours; be aware of culturally appropriate services in your area:
  • support services for people experiencing FAV
  • behaviour change and other services for people who use abusive and harmful behaviours.
  • Consult with and involve the community in making decisions about the types of programs and ways of implementing effective services.

Clinical guidelines

Resources for patients and families

Wherever possible, access locally developed and appropriate resources, including in local language(s).


Professional development

Safer families

Responding to perpetrators

Other resources for health professionals

 


Figure 1. The ACTS (Afraid, Controlled, Threatened, Slapped) risk identification screening tool tested in the antenatal care setting.
Reproduced from Hegarty et al, with permission.21
 

Background

This chapter focuses on opportunities for the prevention of FAV.

The Victorian Indigenous Family Violence Task Force defines FAV in the context of Aboriginal communities as ‘an issue focused around a wide range of physical, emotional, sexual, social, spiritual, cultural, psychological and economic abuses that occur within families, intimate relationships, extended families, kinship networks and communities’.22 This definition acknowledges the spiritual and cultural perpetration of violence by non-Aboriginal people against Aboriginal partners that may manifest as exclusion or isolation from Aboriginal culture and/or community.

The abuse of older people is outside the scope of this topic (see Useful resources, RACGP White Book).

Perpetrators of FAV, or people who use violence, are predominantly men, but women can be perpetrators. People who use violence come from a range of cultural backgrounds.20 The Our Watch national resource to support the prevention of violence against Aboriginal and Torres Strait Islander women states that violence against Aboriginal and Torres Strait Islander women ‘is not an Aboriginal and Torres Strait Islander problem’. Nor should Aboriginal and Torres Strait Islander people bear sole responsibility for addressing it.20,22

Prevalence

FAV occurs throughout the Australian community, and the risk of FAV increases where there is a higher prevalence of gender inequality, alcohol and drug use, gambling and poverty. These factors do not in themselves cause FAV, but can compound and cause the abuse and violence to have greater impact. Addressing these factors can prevent or reduce the impact of FAV.4

Aboriginal and Torres Strait Islander people experience FAV at higher rates due to complex and interconnected factors such as racism, discrimination, power inequalities, systemic barriers and the impacts of ongoing colonising practices.1,2 FAV has also been caused by the transgenerational trauma created through the separation and breaking up of families and kinship during the dislocation of people from Country and culture and the forced removal of children known as the Stolen Generations (see Figure 2).1,13,23 Long-term social disadvantage and the ongoing impact of past dispossession and forced child removal policies have resulted in intergenerational trauma and breakdowns of traditional parenting, culture and kinship practices.4,24 Higher unemployment and poverty rates and the overincarceration of Aboriginal and Torres Strait Islander people also contribute to higher rates of violence.13

FAV is a factor contributing to disparities in health outcomes between Aboriginal and Torres Strait Islander women and non-Indigenous women.25 Aboriginal and Torres Strait Islander women are 32-fold more likely than non-Indigenous women to be hospitalised due to family violence and 11-fold more likely to die due to assault.25 Reducing the risk and preventing family violence for Aboriginal and Torres Strait Islander women is a national priority. A complex mix of historical, cultural, social, legal and policy issues needs to be taken into account in order to achieve this.26

Aboriginal and Torres Strait Islander LGBTQIA+SB (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Sistergirl, Brotherboy) people are also deeply impacted by any acts of family violence. Studies show the complex impact of family violence on Aboriginal and Torres Strait Islander LGBTQIA+SB youth, and that they are likely to experience higher rates of FAV than non-LGBTQIA+SB people.27

Aboriginal and Torres Strait Islander men experience FAV at much higher rates than non-Indigenous Australian men.28 In addition, some Aboriginal and Torres Strait Islander men witness and/or use violent behaviours. Refer to the RACGP White Book to understand more about services for men.11

 


Figure 2. Sources of contemporary Aboriginal and Torres Strait Islander family and community violence.13

Prevention

For any services or interventions to be effective, Aboriginal and Torres Strait Islander communities and families need to be at the centre of preventive work strengthening culture, leading the development of programs that take a holistic approach, focusing on community healing and restoring family cohesion.13 These roles include shaping programs, rebuilding family and kinship ties and building cultural sensitivity into programs.13 For example, Djirra is a state-based community organisation that addresses family violence by drawing on cultural strength to increase resilience, reduce social isolation and vulnerability to family violence and foster healthy relationships.29

The National plan to end violence against women and children 2022–203230 recognises that mainstream approaches will not address the specific interplay of FAV issues for Aboriginal and Torres Strait Islander peoples and communities. Studies consistently report that effective responses to violence within Aboriginal and Torres Strait Islander communities need to be underpinned by cultural connections and oriented towards healing.5,13 Stronger connections to culture and Country, among other positive cultural determinants, improve outcomes for community safety.13

The Victorian Government Nargneit Birrang – Aboriginal holistic healing framework for family violence encompasses an Aboriginal-led approach to addressing FAV.31 Principles that are consistently identified as important in programs aimed at prevention of FAV for Aboriginal and Torres Strait Islander peoples and communities:

  • support self-determination
  • strengthen community and culture
  • are culturally appropriate and respectful
  • are community focused and specific
  • are trauma-informed, including understanding the historical context of violence
  • are integrated services, preferably with Aboriginal and Torres Strait Islander leaders and workers.8

The foundation of prevention encompasses the broader wellbeing of Aboriginal and Torres Strait Islander families and communities, in the context of the ongoing impacts of colonisation. This holistic approach to community healing contrasts with a Western feminist model of responding to FAV, which more commonly reflects gendered paradigms between two people and responds to those two people for short-term support. Although these can help Aboriginal and Torres Strait Islander peoples, they are not always the most effective response.3

Ongoing and consistent funding is essential to effective prevention and services.13 The complexities of responding to FAV in Aboriginal and Torres Strait Islander families and communities can be further hindered by funding models that focus on individualised models of treatment and care for victims.24

In addition, it is noted there are limited evaluation data on the effectiveness of policies and programs targeted at preventing and reducing violence against Aboriginal and Torres Strait Islander women. Therefore, resources to implement quality evaluation, including qualitative and quantitative research, should be included in funding for services.3 

Recognising FAV

Many FAV victims/survivors have reasons for avoiding seeking help, and Aboriginal and Torres Strait Islander people have additional reasons.22,32 Fear of having their children removed from their care is a significant barrier to reporting FAV. In addition, many Aboriginal and Torres Strait Islander people have a deep mistrust of police and legal systems based on historical and contemporary systemic issues. Many Aboriginal and Torres Strait Islander people do not want their partner or family member to be incarcerated, including a fear the person may be at risk of dying in custody. There are also complexities in leaving Country, home and family, potential economic dependence on the partner/perpetrator, past experiences, a fear of not being believed and a lack of culturally appropriate support and services.13,33 When FAV is occurring, Aboriginal and Torres Strait Islander women may be reluctant to admit or discuss FAV with health professionals or to use such terms as FAV. They may be more likely to use such phrases as ‘We were arguing’, ‘My husband was acting up’, ‘He was being cheeky’, ‘It was just a little fight’ and ‘We were drinking’.13,34

Holding people who use violence to account for their abuse and violence at family and community levels is an important consideration. The discourse around FAV currently is still likely to blame survivors or hold survivors responsible. Approaches to change this need to be explored and implemented if prevention of FAV is to improve in Aboriginal and Torres Strait Islander communities.35

Screening and case finding

There is evidence that screening in pregnancy can be effective in identifying FAV, where the questions are asked and there are services available if the patient wants some intervention or support.10,36 This screening can be done in primary care settings and in antenatal clinics using an informal or a structured approach21 (see Figure 1). The aim is to screen all women in a setting where the patient is seen alone in order to provide freedom from coercion or intimidation.

Except in pregnancy, the current advice is to case find or enquire rather than screen.17,37 This will only be really successful where staff have been involved in training, preferably as a whole-of-service/practice event, in order to know how to enquire about FAV, what to do when FAV is identified, and how to support each other when working with people experiencing FAV.9 This model of training is currently being delivered to general practice, primary care groups and some Aboriginal health organisations by Safer Families through the University of Melbourne and is an example of whole-of-organisation/practice training that has been evaluated.38

The WHO has identified FAV as a significant factor in communities globally.18 The WHO is encouraging health professionals to ask and, if confirmed by the patient, to use the acronym LIVES (Listen, Inquire, Validate, Enhance safety, Support) to guide response17,18 (Figure 3).

 


Figure 3. World Health Organization (WHO) schema for first-line support in family abuse

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