Silent signs, critical role: why physiotherapists need training on domestic violence – Editorial

Among non-human primates, particularly chimpanzees, our closest relative, male harassment and physical intimidation of females occur, especially on the part of low-ranking males who seek to coerce reluctant females into mating despite the fact that those females risk being punished with aggression by higher-ranking males [1]. Evolutionary determinism such as this might be either scorned or endorsed, but notably human males’ violence against women is hardly a new phenomenon.

Domestic violence (DV) remains a pervasive and insidious societal issue impacting millions across the European Union (EU). It transcends gender, socio-economic background, and age, leaving a trail of physical, emotional, and psychological scars. While support services exist, a critical gap remains in healthcare settings, particularly within physiotherapy. Here, the lack of comprehensive education on DV recognition and referral protocols hinders the ability to identify and support victims and survivors, often marooning them in a cycle of abuse.

The gravity of the problem cannot be understated. Interviews with a random sample of 42,000 women conducted across the EU in 2014 revealed that 1 in 3 women had experienced physical and/or sexual violence at least once since she was 15 [2]. This equates to a staggering 65 million women 15 years and older who have endured some form of DV in today’s EU [3,4]. However, the true figure is likely much higher, with underreporting a significant issue, especially in countries especially in regions where deeply rooted customs create obstacles to change (see, e.g. Kljajić [5].). And while the survey is a decade old, troubling statistics are emerging that the problem could be worsening, rather than abating [6,7]. Furthermore, because the impact of DV extends beyond the immediate victim, affecting children, families, and society as a whole, the fiscal cost of contending with DV stands at €366 billion per year [8].

The EU has taken commendable steps to address DV. The Council of Europe Convention on Preventing and Combating Violence Against Women and Domestic Violence (the ‘Istanbul Convention’ [9]) establishes a comprehensive framework for preventing and combating violence against women and girls. It outlines measures to improve support services, strengthen legal protection, and raise awareness. As of January 2024, the Convention has been signed by all EU member states (and ratified by 22) as well as the EU itself [10]. In February 2024, a political agreement was reached between the European Parliament and the Council of Europe on the European Commission’s 2022 proposal for a Directive on combating violence against women and domestic violence, which would criminalise physical violence, as well as psychological, economic and sexual violence against women across the EU, both offline and online [11]. The subsequent Directive of May 2024 focuses on the definition of relevant criminal offences and penalties, the protection of victims and access to justice, victim support, enhanced data collection, prevention, coordination and cooperation, and notes how observing DV can be devastating to children. As is the usual course of action ensuing from EC Directives, there will be a transposition into national laws: ‘Member States shall bring into force the laws, regulations and administrative provisions necessary to comply with this Directive by 14 June 2027’ [12].

However, a crucial gap exists in translating these legislative measures into tangible action within healthcare settings. To bridge this, healthcare professionals – including physiotherapists – must receive training to align with the Istanbul Convention’s Article 15, which calls for ‘relevant professionals’ to be trained to identify, document, and report domestic violence. Notably, physiotherapists, due to the nature of their profession, often find themselves in a position of trust with patients. In some cases, they may be the first healthcare professional a victim or survivor encounters, presenting a unique opportunity for intervention and support.

It is also important to note that complications arising from domestic violence cases can also hinder the work of physiotherapists. Victims of abuse may have more difficulty in adhering to rehabilitation regimens, may be exposed to re-injury by the abuser, or may have additional difficulties in re-entering work. Despite this, physiotherapy education often lacks adequate training on DV. Current curricula may include basic modules on safeguarding vulnerable adults, but these rarely delve into the complexities and nuances of DV. Consequently, physiotherapists may struggle to recognise red flags in patient presentations, missing opportunities to intervene and offer appropriate referrals.

Red flags of domestic violence

• Unexplained Injuries: Repeated injuries, particularly in atypical locations, or injuries with inconsistent explanations can be indicators of abuse.

• Delayed Care-Seeking: Victims or survivors may delay seeking treatment or provide vague explanations for their pain or limitations.

• Fearful or Deferential Demeanour: Patients may exhibit anxiety, nervousness around a partner who accompanies them, or a reluctance to discuss their personal lives.

• Financial Dependence: Financial limitations or difficulty accessing their own resources could suggest control tactics employed by the abuser.

• Mental Health Concerns: Symptoms of depression, anxiety, or post-traumatic stress disorder (PTSD) can be associated with DV.

The role of the physiotherapist

Like other healthcare professionals, physiotherapists already have a great many responsibilities in carrying out their work. The intention should not be to add many new requirements on top of already overworked professionals. Instead, a balance should be sought by which the physiotherapist can help victims within the frames of their normal work (e.g. having pamphlets on domestic violence available in washrooms or waiting rooms, asking about possible abuse in non-judgemental ways, assessing for safety or using a trauma-informed approach. This should start with the incorporation of comprehensive DV training into entry-level and continuing education programs, so physiotherapists can become better equipped to identify and support victims and survivors. This training should encompass several key areas:

• Understanding DV: Physiotherapists should gain a thorough understanding of the nature of DV, including its different forms (physical, emotional, sexual, financial, and coercive control).

• Recognising Red Flags: Education should equip physiotherapists to recognise potential signs of abuse presented by patients, both physical and behavioural.

• Communication Skills: Developing a patient-centred approach, utilising open-ended questions, and creating a safe space for disclosure are crucial communication skills.

• Referral Protocols: Training should cover existing referral pathways, including local DV support services, police, and other relevant resources.

• Self-Care: Education should not solely focus on patients, but also equip physiotherapists with self-care strategies to manage the emotional impact of encountering DV cases.

Pursuing more inclusive approaches

It is also important to acknowledge that DV impacts individuals of all genders and sexual orientations. Here, older training materials and referral protocols, if they exist, might not be sufficiently inclusive. Education needs to address the specific needs of female, male, and non-binary victims and survivors, as well as the special needs of elderly persons and minors. Knowing appropriate referral pathways that encompass specialist services catering to vulnerable groups is a cornerstone of a comprehensive approach to tackling domestic violence in all its forms.

Summary

DV is a complex issue demanding a multi-pronged approach. While the EU's legislative framework provides a foundation, tangible action within healthcare settings is critical. Physiotherapists, due to their position of trust, have the potential to be a vital first contact point for victims and survivors. By integrating comprehensive and inclusive DV education into their training, they can play a crucial role in breaking the cycle of abuse and empowering individuals to reach safety. This educational shift is not merely an option, but a necessity to ensure a future where physiotherapy becomes a safe haven for all those in need, regardless of their gender or the violence they have endured.

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