Definitions and Epidemiology of Abuse
Defining Types of Violence and Abuse
Understanding the terminology is the first step in recognizing and responding to abuse.
| Term | Definition |
|---|---|
| Domestic Violence | Abusive behavior between two people in a current or former intimate relationship. |
| Family Violence | A broader term including abuse within family relationships, kinship groups, or by carers. This term is often preferred by Aboriginal and Torres Strait Islander communities. |
| Coercive Control | A pattern of abusive behaviors over time used to create fear and deny a person's liberty and autonomy. It is the dynamic that almost always underpins family and domestic violence. |
| Gender-Based Violence | Encompasses all forms of violence, abuse, and harassment in all settings, acknowledging that violence has a disproportionate impact based on gender. |
Forms of abuse are varied and include: physical, emotional/psychological, verbal, economic/financial, social, technological, spiritual/cultural, sexual, and neglect.
Epidemiology in Australia
Family, domestic, and sexual violence (FDSV) is a major public health issue in Australia.
- 1 in 6 women and 1 in 18 men have experienced physical and/or sexual violence from a partner since age 15.
- 1 in 4 women and 1 in 7 men have experienced emotional abuse from a partner since age 15.
- Women are overwhelmingly the victims of intimate partner violence, while men are more likely to experience violence from strangers in public.
Vulnerable Populations and Intersectionality
Who is Most at Risk?
While FDSV occurs across all demographics, some groups face a significantly higher risk due to a combination of social, cultural, and systemic factors. Intersectionality means these factors often overlap, creating compounded vulnerability.
Key At-Risk Groups:
- Children and Young People: In 2022-23, over 180,000 children came into contact with child protection services. Emotional abuse and neglect are the most common primary types.
- Aboriginal and Torres Strait Islander Peoples: Are overrepresented as both victim-survivors and perpetrators. Family violence in this context must be understood as both a cause and effect of intergenerational trauma and systemic disadvantage.
- Young Women (15-34): Experience higher rates of physical and sexual intimate partner violence and sexual harassment.
- Pregnant People: Pregnancy is a time of heightened risk for the onset or escalation of partner violence.
- People with Disability: Face increased vulnerability and barriers to seeking help.
- LGBTQIA+ People: May experience identity-based abuse (e.g., threats to "out" them) in addition to other forms of violence.
- People from CALD backgrounds: May face barriers such as visa status, language difficulties, and lack of culturally appropriate services.
- Older People (Elder Abuse): Vulnerability increases with age, cognitive impairment, and social isolation.
The Paramedic Context
The Paramedic's Unique Role
Paramedics are often the first, and sometimes only, healthcare professionals to enter a person's home, placing them in a unique position to identify and respond to FDSV.
- Scene Assessment: Paramedics can provide an unadulterated view of the scene, which is crucial information for other health and justice services.
- First Point of Contact: For many victim-survivors, the paramedic may be the first person they disclose to. Your response is critical.
- Data Collection: Ambulance data (e.g., from NASS) is becoming increasingly important for understanding the prevalence and nature of FDSV in the community.
Barriers to Disclosure and Reporting
Victim-survivors face numerous barriers to disclosing abuse, and paramedics face barriers to reporting it.
| Barriers for Victim-Survivors | Barriers for Paramedics |
|---|---|
| Fear of reprisal, shame, self-blame, mistrust of authorities, fear of child removal, dependency on the perpetrator. | Uncertainty about mandatory reporting laws, confusion over confidentiality, fear of retribution, and uncertainty about their professional role in FDSV. |
Responding to Disclosure: The LIVES Model
When a person discloses abuse, the LIVES model provides a simple, supportive framework for response:
- L - Listen: Listen closely, with empathy, and without judging.
- I - Inquire: Ask about their immediate needs and concerns (physical, emotional, safety).
- V - Validate: Show them you believe them. Assure them they are not to blame.
- E - Enhance Safety: Discuss a safety plan. What can be done right now to make them safe?
- S - Support: Help connect them to information and services (e.g., 1800RESPECT, local support services).
Identifying and Responding to Child Abuse
Mandatory Reporting in NSW
In NSW, paramedics are mandatory reporters under the Children and Young Persons (Care and Protection) Act 1998. A report must be made if a paramedic has reasonable grounds to suspect that a child is at risk of significant harm.
Types of Harm to Report: Physical abuse, sexual abuse, emotional/psychological harm, neglect, and exposure to family violence.
When to Suspect Abuse: Red Flags and Clinical Tools
Identifying non-accidental injury requires a high index of suspicion. The history provided often does not match the clinical findings.
Key Historical Red Flags:
- No history or an inconsistent/changing history to explain an injury.
- Mechanism incompatible with the child's developmental capabilities (e.g., a 3-month-old who "rolled off the couch").
- Unreasonable delay in seeking medical attention.
- Any injury in a non-ambulatory infant.
The TEN-4 FACES Clinical Decision Rule: This tool helps identify bruising patterns that are highly specific for abuse.
| Component | Criteria | Action |
|---|---|---|
| TEN | Bruising to the Torso, Ear, or Neck in a child < 4 years old. | High clinical concern for abuse. Requires mandatory report and further medical evaluation. |
| 4 | ANY bruising on a child < 4-6 months old. | |
| FACES | Bruising to the Frenulum, Angle of jaw, Cheek, Eyelid, or Sclera in a child of any age. |
Fractures and Abuse: The Mitchell et al. (2020) review indicates specific fractures that warrant a routine abuse evaluation:
- Rib fractures in children < 3 years old.
- Humeral or Femoral fractures in children < 18 months old.
Identifying and Responding to Elder Abuse
What is Elder Abuse?
Elder abuse is any act within a relationship of trust that results in harm to an older person (typically >65 years, or >50 for First Nations peoples). It is often hidden and under-reported.
Most Common Types: Psychological and financial abuse are the most common forms reported, often co-occurring. Neglect is also highly prevalent.
Perpetrators: The majority of abuse is intergenerational, perpetrated by adult children, with sons more likely to be perpetrators than daughters.
Risk Factors and Recognition
Paramedics should have a high index of suspicion in the presence of key risk factors.
| Risk Factor | Description |
|---|---|
| Cognitive Impairment | Dementia or other cognitive disabilities significantly increase vulnerability. |
| Social Isolation | Lack of social networks makes the older person more vulnerable and makes abuse less likely to be discovered. |
| Dependence | When the older person is dependent on the perpetrator for care, or when the perpetrator (e.g., an adult child) is financially or emotionally dependent on the older person. |
| History of Trauma | A lifelong pattern of domestic violence can continue into older age. |
Signs of Elder Abuse: Unexplained injuries, poor hygiene, malnourishment, signs of dehydration, pressure sores (neglect), confusion about financial situations, or fear/anxiety in the presence of a carer.
Paramedic Response and Reporting
Unlike child abuse, there is generally no mandatory reporting for elder abuse in Australia (except in government-funded aged care facilities). The response should be guided by the wishes of the competent older person.
- Ensure Immediate Safety: Your first priority is the patient's immediate medical needs and safety.
- Private Conversation: If possible and safe, try to speak with the older person alone.
- Provide Support (LIVES): Use the LIVES model to listen, inquire, validate, enhance safety, and support.
- Documentation: Document your concerns and observations clearly and objectively.
- Referral: Provide information on elder abuse helplines and support services (e.g., Seniors Rights Service). In cases of immediate danger or criminal acts, police involvement is necessary.