Analyses revealed that the three different groups of respondents had similar concerns, with some variation according to their group’s particular perspective. The GPs considered time and cost/benefit issues and discussed the awkwardness of confronting a woman with such a personal question. The survivors of IPV demonstrated great confidence in their GPs while simultaneously worrying about breaches in confidentiality. The women with no experience of violence demanded more knowledge on the subject and thought that questions regarding violence should be put into context in a consultation. The next sections present the attitudes, perspectives, and opinions expressed by each respondent group regarding the barriers to implementing routine inquiries. In the following, all of the names are pseudonyms.
GPs - views and perspectives
The main issue for the GPs was the awkwardness of discussing IPV with women. Although they did not overly emphasise the time issue, it was of some significance as most GPs have between 5 to 15 minutes per patient to cover the issues that need to be addressed during the consultation. When GPs considered the time issue, they were more concerned that IPV screening/routine inquiry would be too large a burden on the consultation and that this screening was not related to their competencies. None of the GPs who were interviewed had much experience with IPV. Additionally, in their opinion, IPV did not occur much in their practices:
“I think you should find the right formulations. You should have learned about it so it seems natural if you are to ask about it routinely. Because, in the majority of the consultations that we have here with women, it will not be relevant … I have always been fortunate enough to work in places where that kind of problem did not occur” (GP, 6 years in private practice).
Cost and benefit issues were raised both for and against screening. The GPs interviewed shared the view that the economic costs were too high compared to how many women they believed were affected by IPV. Some perceived a flexible form of routine inquiry as an extra pressure given that it relies more on their interpersonal skills. This sample of GPs thus did not deem it reasonable to introduce routine inquiry in private practice. They insisted that they should not ask every woman during consultations. The GPs had a high degree of confidence in their own abilities to detect abused women.
When the GPs were interviewed about IPV, all of them stated that they considered this to be a serious issue. All responded that they ask about bruises that do not match individuals’ explanations, just not in a direct manner. During this type of situation, age and experience played a role, as all of the GPs mentioned that asking became less difficult with age and experience. However, age and experience did not influence the GPs’ perceptions of their ability to detect IPV, as they all reported that they felt very comfortable inquiring about IPV on suspicion and did not hesitate to respond that they recognised the signs of IPV. Their statements that they asked patients when they recognised signs of IPV are difficult to reconcile with the self-reported number of times they asked (see Table
3), given that 35% of Danish women are exposed to violence or sexual assaults in their lifetime. It is important to note that all of the GPs spoke almost exclusively about the physical signs of IPV.
Table 3
Approaching IPV in private practice
Female GP | 6 | Less than 5/less than once a year |
Male GP 1 | 15 | approx. 20/approx. 1.3 times a year |
Male GP 2 | 28 | approx. 100 /approx. 3.6 times a year |
One GP critiqued the judicial system and the response system when women disclose abuse, arguing that the response should cover the ‘bigger picture’ to provide more coherence. The GP criticised the judicial system for being slow with regard to divorce, separating the woman from her perpetrator, and providing her with financial freedom.
Survivors of IPV – views and perspectives
A number of the survivors of IPV initially stated that they did not want their GPs to ask them about IPV unless they came to the clinic with bruises caused by IPV or looked sad.
“In some ways, I would find it offensive if a GP asked me about that. Of course, if a patient comes to the clinic and starts crying, then he can ask. But if I came with bruises and I had not been exposed to IPV and he kept asking, then I guess I would shut off and say, “What do you mean by that?” But, on the other hand, if a woman came in with internal bleeding due to being punched, then I think he should 100% ask and interfere because that’s not something you can get in some other way, in my opinion at least” (Aisha, no children).
This statement indicates that the GPs should guess when a bruise, bleed or mental condition is due to IPV occurring at home. In general, the survivors of IPV trusted that their GP could see what was going on, as the women expected the doctors to know whether they were sad or struggling at home with serious issues.
During the course of the interviews, this attitude became less dominant and the respondents focused more on accepting the inquiry provided it was not presented in an impersonal manner: “I don’t just want to be an X on a piece of paper”. Thus, the GPs’ empathy, knowledge, and willingness to address the issue were important factors during consultations regarding violence. In addition, the coherence of the response system, (responses from police, the judicial system, the help provided by the refuges, and the support from the municipality and social workers), was regarded as insufficient and full of gaps by all of the participants. The participants mention poor communication between police and refuge and GP and refuge, poor security at the refuges, where the women are urged to take care of their daily life as normal, paying bills and such, risking bumping into their perpetrator.
During the interviews, all of the women with experience of IPV agreed that they would not mind questions about IPV if the GPs asked in an empathic, sensitive, and non-judgemental manner. Most of the women who had IPV experience (6 of 8) were very firm in their responses to whether the GPs should ask about IPV. They wanted to be asked because they wanted help and they did not feel that they were able to ask for help themselves:
“I want him to ask me how I am doing, because you can’t say it yourself without him asking about how things are going at home. Because you don’t know how to say it at all. I would have told him if he had asked. It would have saved me from 12 years” (Amina, no children).
This quote suggests that when no one listens or asks about the violence occurring in women’s lives, the women need to “pull it together” day after day. Therefore, they are most likely discouraged from leaving the relationships when no one addresses the issue of violence.
“Certainly the GP should ask. It depends a little on the context… If my GP had asked me directly, I would have gotten help earlier from Mothers’ Help and maybe it would not have escalated so much… The longer you are dragged through this, being exposed to violence… It’s such an extreme experience that, from health and societal perspectives, the sooner that people receive help, the better” (Charlotte, one child).
This quote suggests that GPs should act on their suspicions; however, it can be difficult for GPs to act when they experience immense time pressures. The abused women often stated that GPs provide patients with the impression that they are very busy. The women felt that this created an unsupportive environment where patients were not likely to confide in their GPs. They also stated that a generic form of questioning was not acceptable, as most of the women emphasised a personal approach. Thus, abused women preferred a more flexible routine inquiry to a formalised screening procedure. Routine inquiry provides the GPs with the opportunity to customise the questions to specific situations. The survivors of IPV emphasised the importance of medical doctors being trained in the aetiology of violence, its prevalence, and inquiry techniques.
There were a number of contradictions evident in the views of the survivors of IPV. On one hand, they believed in the GPs’ ability to perceive the abuse that they were hiding. On the other hand, they discussed how dangerous it could be if the GPs did not fully understand the implications of harmful advice and breaches of confidentiality for women living in violent relationships.
“The GPs should be careful about how they counsel their patients, for instance, the idea of just leaving him, that’s not so easy. If it was easy, you would have done it a long time ago” (Aisha, no children).
Although they knew that GPs were bound by confidentiality, the women were concerned about the confidentiality issue.
“My big brother got some information from my GP. It is about honour. It can be very dangerous to discuss this in some cultures. So, the doctor thinks, well, it is her own brother, he will probably help her. I have experienced that once and that’s a drawback” (Amina, no children).
Although confidentiality issues were discussed, the abused women thought that General Practice was the right forum. Based on the women’s concerns, providing further education and a proper referral system may eliminate a number of issues, allowing routine inquiry to be a positive experience.
Women with no experience of violence – views and perspectives
When discussing routine inquiry with the women with no experience of violence, these women believed that the GPs recognised the signs of abuse and asked the patients about it. The majority of the women who participated in this study (4 of 5) stated that it was acceptable to ask questions about violence during clinical visits when presented in a non-judgemental and empathic way. Their statements reflected that knowledge about the subject was important. The greater their knowledge on the subject, the more the women accepted routine inquiry.
“It gives me an impression of the doctor as being more holistic, if you ask about that kind of thing, like the doctor is more sensitive. I think it could have a positive effect, given that it’s a topic to be addressed with your own GP, because in time these kinds of things will become less taboo. Because it’s something that you are asked about by your GP, ergo it’s something we talk about. In Denmark, we also talk about if we are exposed to violence” (Rikke, no children).
All of the women who had not been exposed to violence emphasised the importance of providing information in some kind of form prior to any questioning so that the context was natural. During the group interview, there was significant discussion about how to ask about abuse appropriately and in what context it should be asked about. The women agreed that inquiry was a good idea if the context was appropriate and the GP was empathic.
One woman was reluctant to accept being asked routinely about violence. This suggests that there are women who may feel caught off guard and insulted if they are not appropriately informed about IPV prior to an inquiry. Although only a small percentage of women opposed being questioned about IPV, it is important to consider their objections in any future interventions.