Director of Public Health Annual Report 2021: Domestic violence and abuse

Experiencing and witnessing domestic abuse can have devastating impacts on victims, and their children, friends and wider family. There are also wider societal impacts. Tools such as the DASH risk checklist help trained health and social care professionals to identify the risk of harm victims may be facing.

Harm as a result of domestic abuse can have lifelong impacts on physical, mental and sexual health. The more severe the abuse, the greater the impact. In the worst cases, domestic abuse can result in homicide, including suicide as a result of domestic abuse.

One in five domestic abuse victims at high risk of serious harm or murder reported attending an accident and emergency department because of their injuries in the year before getting help. Abuse can also result on long term health problems.

A study interviewing women and girls over 15 years old found that those who had experienced physical or sexual violence by a partner were more likely to report overall poor health, chronic pain, memory loss, and problems walking and carrying out daily activities.

Sexual violence can lead to infections, chronic pelvic pain, sexually transmitted infections, unintended and unwanted pregnancies, and abortions.

Alcohol and drugs can be used by the victim as a way of coping or self-medicating, putting victims at risk of further ill health. Their effects may also leave victims less capable of negotiating resolution and at risk of further violence.

Domestic abuse and mental ill health are commonly associated. A recent study found that half of women presenting to their GP with domestic abuse had already had some form of diagnosed mental illness. Victims experience anxiety, depression, low self-esteem, inability to trust others, flashbacks, eating and sleeping disorders, and emotional detachment. Considering or attempting suicide has been reported in 16% of victims, and self-harming in 13% of victims. An estimated one in three women who attempt suicide in the UK have experienced domestic abuse.

Domestic abuse affects all areas of life, as well as poor health.

Domestic abuse is a leading driver of homelessness. Latest national figures from 2020 show that domestic abuse was the second most common reason given for losing a home (14.5% of cases).

The homeless charity Crisis estimates that almost one in five of homeless women (18%) are homeless due to domestic abuse. Domestic abuse accounts for at least one in ten people who require local authority support for homelessness in England, Wales and Scotland. Actual need may be higher; the survey showed that one in three respondents left their home because of the abuse or leaving a relationship.

A recent survey of female survivors of domestic abuse found that one in three respondents said their access to money during the relationship was controlled by the perpetrator. One in four respondents said that their partner did not let them have money for essentials during the relationship. A similar number reported that they used savings or children’s money for essentials. Many (43.1%) reported being in debt because of the abuse, and over a quarter regularly lost sleep through worrying about debt.

The consequences of domestic abuse can increase the risk of poverty. One study found that women in poverty were more likely to have faced extensive violence and abuse (14%), compared to women not in poverty (6%).

Over half (56.1%) of respondents who had left an abusive relationship felt that the abuse had impacted their ability to work. Just under half of all respondents felt the abuse had negatively impacted their long-term employment prospects/earnings.

In the words of UNICEF, some of the biggest victims of domestic abuse are the smallest. Domestic abuse has a negative impact on the mental, emotional and psychological health of children. Children can suffer social and educational developmental problems, and in some cases grow to accept abuse as normal behaviour. An estimated one in five children are exposed to domestic abuse in the UK, with 130,000 children living in homes where there is a high risk of serious harm or murder due to domestic abuse.

In Buckinghamshire for the financial year 2020 to 2021 there were over 2,400 referrals for a social care assessment to children’s social care where domestic violence was the primary concern. This represents a 31% increase on the previous year. This accounts for 23% of all children’s social care referrals. Almost 700 children and young people where domestic violence was a concern were given children in need plans, child protection plans or became looked after. Children starting a social care service from 2020 to 2021 – where domestic violence was the primary concern – accounted for 23% of all children’s social care services received. 105 children who had domestic abuse mentioned as a factor in their assessment became looked after by the local authority from 2020 to 2021. This represents half of all children who became looked after in that year. These figures will underestimate domestic abuse suffered and witnessed by children in Buckinghamshire as not all cases will be referred to social care. Of the 116 children accommodated in Women’s Aid Buckinghamshire refuges from 2019 to 2020, over half (66%) had directly witnessed domestic abuse, and 17 of the families were subject to a Child Protection Plan.

The full extent of harm will differ for each child depending on their circumstances and age. Around two in three (62%) children living with domestic abuse are thought to be directly harmed by the perpetrator; harm is also caused by witnessing abuse. Wider effects such as having to move home and school to escape abuse can further harm children by increasing instability in their lives. A survey of women in English refuges showed that about two in three residents had children with them.

Growing up with domestic abuse is likely to be a traumatic and stressful negative experience, and the impacts will vary between children. Children may demonstrate outward behaviours such as aggression, anti-social behaviour and risk taking; others may have difficulty expressing their emotions. Children may also feel depressed, anxious, angry, guilty, confused, and helpless.

The impacts can be long term. Studies suggest that exposure to domestic abuse in early life may increase the risk of:

• Alcohol use. Children witnessing violence are more likely to misuse alcohol later in life.
• Becoming a victim or perpetrator of domestic abuse, although this association is complex. For example, normalising experiences of abuse will make it difficult for children to establish and maintain healthy relationships. This may increase their risk of domestic abuse in the future.
• Antisocial and risk-taking behaviour, early pregnancy and homelessness. Experiencing any or a combination of these in adolescence increases vulnerability to sexual exploitation and criminal behaviour.

A Home Office report estimated the annual economic and social costs of domestic abuse, including domestic homicides, to be over £66 billion in England and Wales (year ending March 2017). The largest costs as a consequence of domestic abuse were the physical and emotional harms (£47,287 million). The largest costs in response to domestic abuse were police costs (£1,2357 million). The average total cost per victim was an estimated £34,010, made up of lower-costing crimes such as indecent exposure, to the highest-cost crime of domestic homicide.

Using Home Office costs with our local estimate of 21,000 victims, we estimate that the potential annual cost of the consequences of domestic abuse in Buckinghamshire is £687 million. This is physical and emotional harm costs of £510 million, lost output costs of £152 million (time off work and reduced productivity), and health service costs of £25 million.

Using Home Office costs with our local estimate of about 4,000 victims known to the police from 2020 to 2021, we estimate that the potential annual cost of responding to domestic abuse in Buckinghamshire only for those we know about is £3.5 million, of which police costs account for £2.5 million. However the health impact and costs would still accrue whether the victim reported the crime or not, so the local health costs will be an underestimate.

A domestic homicide review must be carried out by local authorities in England and Wales following the death of an individual aged 16 or over, which has, or appears to have resulted from violence, abuse or neglect, and inflicted by a someone personally connected to the victim.

Each review provides a detailed account of events leading up to the homicide, the context, and what we can learn from the event. The most recent data from the Home Office (December 2016) show that over 400 reviews have been completed since domestic homicide reviews started in 2011. As of July 2020, 39 have taken place in the Thames Valley region, and 15 in Buckinghamshire.

Published homicide data for England and Wales (from the Home Office report and another recent report), show that no two cases are similar. However, there are certain key themes which have been identified. Data for England and Wales are used given the limited data available for local cases.

• Women are more likely to be victims than men. About eight in ten victims are female.
• Men are more likely to be perpetrators than women. About nine in ten perpetrators are male.
• Data on ethnicity of victims is often missing from review information.
• Substance misuse can be a prominent feature in the lives of both victims and perpetrators.
• Victims and perpetrators are commonly known to services prior to the homicide. For example, just under half of cases were known to the police to be in an abusive relationship.
• Perpetrators of homicides follow a pattern of behaviour, including having previous controlling behaviour, and reacting violently to loss of control of the victim or relationship.

Given that domestic homicide reviews aim to identify learning, service improvements and better prevention of domestic abuse and homicide, an anonymised and accessible national database of reports would help local authorities learn from other areas to help prevent these tragedies from happening.

Between 2009 and 2018, a woman was killed every four days by her partner or ex-partner in the UK.

Most victims of intimate partner homicides are women. A review of 372 intimate partner homicides of female victims, and patterns of behaviour in national domestic homicide review information identified eight stages that may predict homicide. Controlling behaviour by the perpetrator was the best predictor of homicide, rather than a history of violence. This review has led to learning about how these homicides can be predicted, and therefore prevented.

All perpetrators who reached the last stage and committed homicide moved through each of the eight stages. However, many cases saw progression to stage five or six, followed by either regaining control and returning to stage three, or moving to another relationship.

1. Pre-relationship history. In almost all cases the perpetrator has a history of coercive control, stalking or domestic abuse.
2. Early relationship. The relationship moves at speed, such as moving in together and declaring love early on.
3. Relationship. There are controlling patterns in every case study, such as limiting the victim’s movements, what she wears, or who she sees. The relationship may be dominated by coercive control, stalking, or domestic abuse. This stage ranged from 3 weeks to 50 years in the case studies.
4. Trigger/s. Risk rises due to possible loss of control by the perpetrator over the victim or the relationship. Usually this loss of control comes from separation initiated by the victim.
5. Escalation. The perpetrator tries to gain back control back. More frequent and severe controlling behaviours are seen, such as crying, violence, stalking, or suicide/murder threats.
6. Change in thinking. With the loss of control comes a decision by the perpetrator about how they deal with this loss. This may be to form a new relationship, to mend the current relationship, or to decide to kill someone.
7. Planning. The perpetrator plans the homicide. This could include buying weapons, digging a grave, researching methods online, planning and organising finances, or stalking to gather intelligence.
8. Homicide. Case studies showed violent homicides where the level of violence used appears to have no direct relation to that within the relationship

Over 125 domestic abuse organisations and professionals have been calling for a national response to perpetrators for some time, including a national perpetrator strategy. A positive step towards this came in the HM Treasury Budget 2021, which included funding across England and Wales for perpetrator behaviour change programmes that work with offenders to reduce the risk of abuse occurring.