Acts, words and gestures: Recognising the signs of coercive control

Anastasia Tsirtsakis

14/09/2020 3:53:13 PM

Women’s health experts are calling for GPs to be aware of and understand the subtle signs of coercive control for women in their care.

Young woman with her head in her hands.
The frequency and severity of domestic violence is twice as high for women during pregnancy.

Lily’s* pregnancy was complicated on many fronts.
The first-time mum experienced a series of health issues along the way, all the while being subjected to coercive control by her partner.
A midwife started to grow concerned over some of the behaviours she noticed in the partner and brought it to the attention of Lily’s GP.
‘It was the GP that raised it with Lily. From there, she was able to actually speak about all the things that were unseen. That included financial abuse and quite awful emotional abuse as well at that stage – and I’m saying at that stage because what we know is that coercive control very often goes on to become physical violence later.’
That is Dr Fiona Buchanan, the lead researcher of a new study by the University of South Australia and University of Melbourne, published in the Journal of Family Violence.
Exploring women’s experiences of coercive control during pregnancy, birth and post-delivery, the study showed that obstetric health practitioners – GPs, midwives, nurses and social workers – were in a unique position to offer empathy, support and information. When they did so, they played a significant role in a woman’s decision to stay or leave an abusive relationship.
That was seen in Lily’s case, who was one of 16 study participants.
‘Lily got the support of her GP and the midwives for the rest of her pregnancy and afterwards, and that really helped her to leave when the baby was four months old,’ Dr Buchanan told newsGP.
‘It’s not an easy decision when you’re a first-time new mum, especially when your self-worth has already been undermined.’
Coercive control is a form of psychological abuse, achieved through behaviour that victimises women through acts, words and gestures designed to isolate, frighten and demean them.
In the 2017–19 NSW Domestic Violence Death Review Report, 99% of domestic violence-related homicides were characterised by coercive control.
The frequency and severity of domestic violence is twice as high for women during pregnancy.
‘Around pregnancy, time of birth, and the postpartum period it is a time when women who are suffering from a partner’s coercive control feel quite alone and quite isolated. Sometimes they’re not allowed to see friends, family,’ Dr Buchanan said.
‘Health providers are somebody that you do form a close relationship [with]. So it’s really important that relationship they have legitimate reasons for maintaining is one where they can get support.’
The study found that women felt less isolated and distressed when their health practitioners acknowledged the coercive control was happening.
‘[It was] almost as if sharing the burden helped validate their worth and affirm their feelings,’ Dr Buchanan said.
‘It’s not like your sister or your best friend and so on, who are wonderful supports and very often really help women to come through this. But somehow the GPs and other health workers have the authority that matters too, and we know that in general GPs are usually the person that the woman opens up to first.’
Dr Elizabeth Hindmarsh is a GP and Chair of the RACGP Specific Interests Abuse and Violence network. She told newsGP the study’s findings, while not surprising, are very important.
‘We’ve recognised for a very long time that pregnancy is a specific time in terms of family and domestic abuse and violence,’ she said.
‘So there has been encouragement of GPs for some time when they’re providing obstetric care or doing shared antenatal care to be inquiring of their patients about this – but always only when they are on their own.’
Dr Magdalena Simonis agrees. A GP and member of the Expert Advisory Group currently reviewing the RACGP’s Abuse and violence - Working with our patients in general practice (White Book), she told newsGP it is important GPs recognise family violence as a spectrum.
‘Studies have shown that one in 10 women, across the board, who will attend a GP will have experienced some form of violence in the past 12 months – that’s a pretty high statistic,’ Dr Simonis said.
‘[But] we’ve always interpreted it as being a woman with bruises or injuries.
‘In fact, it comes as emotional abuse, financial abuse, and now we’re discovering also that there’s this sexual and reproductive coercion where women’s choice and reproductive capacity is used as a weapon against them.
‘Until we understand it as a spectrum, we’re not going to be identifying it or looking for it.’
Study co-author, Professor Cathy Humphreys from the University of Melbourne, said there are key behaviours for health practitioners to look for as warning signals.
‘During pregnancy, instances of overbearing behaviours or alternatively a lack of interest in antenatal care may indicate that a partner is using coercive control tactics,’ she said.

Dr Magdalena Simonis says it is important GPs recognise family violence as a spectrum.
‘Signs of abuse could be limiting a woman’s contact with doctors; refusing to come to scans and appointments; and even making a scene when a visit is running late.
‘Similarly, a lack of support or self-focus by partners is also worrisome, with some women saying that their partners blamed them for having too long a labour.
‘This damaging behaviour also extends across motherhood, where partners may isolate women from family and friends, as well as criticise them on their mothering abilities.’
Dr Simonis said the conversation starts in the waiting room.
‘Do you have posters in the waiting room that support those who are experiencing family violence? That should be in waiting rooms to encourage women to think about this and also then to inform them that you are open as a GP to have this discussion,’ she said.
‘So you’re actually creating a space that says, “We understand this happens and you can talk to me if you need to”.’

But what if care is being delivered via telehealth?
With reports of family violence having risen during the pandemic, Dr Buchanan said GPs need to be particularly mindful about picking up on cues via telehealth, such as tone of voice and, if using video, body language.
‘You don’t know if the partner is present at the other end, so it’s harder to ask the questions,’ she said.
‘It’s even more important to pick up on things like silences, to find ways to subtly ask the questions, and if there’s any way of checking with the woman [to see] when she’ll be alone to call back.
‘It’s very, very tricky and very hard, but having your antenna up for what’s going on [is important].’
Provided the consultation is confidential, Dr Simonis suggests asking open-ended questions, such as: 

  • ‘What’s on your mind today?’; ‘What concerns do you have?’
  • ‘How are you feeling within yourself?’
  • ‘How able do you feel to control what goes on around your life?’, ‘How confident do you feel that you can make changes in your life in the near future?’
  • ‘Is there anything or anyone in your family that makes you feel uncomfortable, scared or unsafe?’
  • ‘Sometimes relationships can be strained; what’s the worst thing that’s ever happened in your relationship?’
  • ‘Is there anything that’s happening that’s making you feel very uncomfortable or afraid?’
‘If you know that person, you will be able to tell by their response,’ she said.
‘The good thing is that with telehealth you can actually have more of that contact than you would otherwise have face-to-face.’
Given the subtlety of coercive control, the study suggests obstetric health practitioners receive training to better understand the nuanced cues to look out for, how to respond, and safely support vulnerable women.
Dr Hindmarsh agrees.
‘Domestic violence in pregnancies causes more adverse outcomes for women and babies than preeclampsia or gestational diabetes, [and] we get a lot of training around preeclampsia and gestational diabetes,’ she said.
‘So if this is going to have more adverse outcomes than that, then we really need to be addressing it.’
* Not her real name.
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