“The intentional use of physical force/power, threatened or actual, against oneself, another person, or against a group/community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”

World Health Organisation definition of abuse

Family violence

This can take many forms, namely emotional, financial, sexual or physical abuse. Those most vulnerable and at risk are children,women, elderly and disabled people. Physiotherapists work closely, often several times a day or week with patients / clients that they usually have to undress and thus have a unique opportunity to witness and/or identify abuse due to this close contact. In order to identify or suspect abuse, physiotherapists need to know the patterns, signs and symptoms of abuse. Signs and symptoms of physical abuse are usually bruises, lacerations, etc., distributed in a central pattern around the head, neck, chest and abdomen, whereas emotional/psychological abuse usually manifest as depression, mood swings, tearfulness, unusual docility or trying to please, especially in children. Where appropriate, counselling, advise and/or information about shelters, support or counselling services should be given and it should also be reported to supervisors, social workers, others in authority or a law enforcement agency. This will depend on institutional policy and legal requirements. Information and/or evidence should also be gathered and record by means of photography and/or patient records. This is particularly important once the case enters the legal system as such evidence could be critical. In South Africa it is a legal obligation to report child abuse and may also be for elder abuse once the new Aged Persons Act is promulgated.

Domestic violence is complex and often a pattern of behaviour, which can end in death of the victim(s). The victim progressively loses self-governance and self-esteem. The family unit is often isolated with few social contacts, making detection difficult. The victim tries to save the relationship by leaving several times before dissolving it- if ever or in time. Fears of retaliation abuse or violence is usually well founded.

Often it does not begin or end with one family unit- the “social heredity of family violence” is a reality, where patterns of behaviour are passed from parent to child. In this cases witness protection programmes are particularly important.

Statistics on Violence Against Women in South Africa have reported the following:

  • 25% of women in South Africa are assaulted by their boyfriend or husband every week
  • The average woman stays in an abusive relationship for 10.5 years before leaving
  • 1 in 2 South African women will be raped in her lifetime
  • 41% of all female homicide is perpetrated by the women’s partner

Based on the above mentioned statistics, it is very likely that we will all encounter an abuse victim at some stage in our careers. Here are a few guidelines as to how to communicate with someone who has experienced an abusive relationship (it is most likely that the person will be a woman):

  • Listen to her story and validate her feelings.
  • Acknowledge her courage in breaking the silence and seeking help.
  • Understand that she may feel like she is betraying her husband by talking about the abuse.
  • Never advise a woman to return home to work things out with her abuser if she has been physically battered or if her life has been threatened.
  • Don’t try to force her into making a decision she is not ready to make.
  • Don’t minimise the seriousness of the situation. This is not an uncomfortable situation you should avoid.

A few questions to ask:

  • When the two of you argue or have a very bad fight, what happens? Describe the situation to me.
  • Does he ever throw things or punch holes with his fist? Has he ever slapped or pushed you, hit you or threatened you?
  • How does he speak to you when he is angry or frustrated?
  • Does he pressure you to have sex when you don’t want to?
  • How does he react when you want to go out with friends or family?
  • Have you told anyone?

A woman is in imminent danger if:

  • The abuser has threatened her life.
  • The abuser has attempted to murder his victim in the past, or the history of abuse has included a serious near death beating/assault.
  • The abuser has weapons in the house or has recently bought a gun.
  • The abuser has killed or injured her pet.
  • The victim has sustained multiple injuries each time he battered her in the past.
  • She has threatened to leave, and he has threatened to hurt or kill himself, the children, and her if she leaves.

You should avoid saying the following (or something similar) to someone in an abusive relationship:

  • What did you do to provoke him?
  • Go home and cook your husband his favourite meal, put on your best dress, and give him a little more attention.
  • Your children need a father, so it is up to you to keep the family together

Statements of affirmation to the victim:

  • You are not alone.
  • Abuse is wrong. It is never your fault.
  • You are not responsible for his behaviour.
  • Your first responsibility is to protect yourself and your children.

Child abuse

In the preamble to the United Nations Convention on the Rights of the Child, it states that even though the Universal Declaration of Human Rights is clear in terms of defining the rights available to all human beings, “…childhood is entitled to special care and assistance”. Article 28 of the South African constitution (Chapter 2, pg. 13), special provision is made for the special rights of children, legislating for the protection of children.

It is the legal responsibility of the person witnessing signs and symptoms of child abuse to report to legal authorities, as well as supervisors. Factors influencing reports are:

  • Situational : type and severity of abuse
  • Professional : experiences, as well as attitude
  • Legal : knowledge of the law and wording of the law
  • Organisational : institution’s reporting policies, ethical and/or professional guidelines, support for reporting

A child is usually considered anyone under the age of 18 and abuse or neglect is defined as any act or failure to act which results in death, serious physical or emotional harm, sexual abuse or exploitation. Where does child labour (legislated against in South Africa) fit in?

Reporting is mandatory on “reasonable suspicion” and most institutions have procedures to record evidence and deal with reporting. Physical abuse- be suspicious if there is emotional distress, unexplained bruises,welts, imprints of ropes, burn marks, whereas sexual abuse can be suspected if there is great emotional distress or frank verbal disclosure. An oral report should be followed by a written report(check when and/or what is required in report). Give details of the child and parent(s)/ caregiver(s) and ask for instructions on how to proceed, i.e., to whom to disclose, what to do with the child, etc.

American definitions of child abuse:

  • Physical: Physical injury, over discipline and/or physical punishment
  • Child neglect : Failure to provide for basic needs (physical, educational, emotional)
  • Physical neglect: Refusal/delay in health care, abandonment, expulsion from home, refusal to let runaway back home, inadequate supervision
  • Educational neglect: Allowing chronic truancy, failing to enrol in school or attend to special needs
  • Emotional neglect: Inattention to need for affection, refusal or failure of psychological care,spouse abuse in child’s presence, permission of substance abuse, all taking note of cultural values and/or standard of care and poverty
  • Sexual abuse: Fondling genitals, intercourse, incest, rape, sodomy, exhibitionism, commercial exploitation (prostitution and/or pornographic photography)
  • Emotional abuse: Acts and or omissions leading to serious behavioural / cognitive / mental / emotional disturbance. e.g., bizarre punishment (confinement in dark closet) but less severe, e.g., habitual scapegoating/ belittling/ rejecting, more difficult to prove

Elder abuse

Elder abuse occurs predominantly (+/- 75%) in women over 60 years old that are physically frail and in the low income group. The abusers are mainly (60%) a spouse or adult child, also other caregivers can be involved. In institutions there is some physical abuse, but more psychological and/or emotional abuse. Elder abuse receives less attention than child abuse. In the USA there are extensive child protection services, but limited adult protection services, offering even less protective service and treatment.

Elder abuse is much more difficult to detect than child abuse. Many older adults live alone, in social isolation and the abuser is often protected as the older adult fears that alternatives may be worse. It is, however, imperative to report or to do something about suspected abuse, especially if the person is frail or mentally impaired. However, there are little/or no protective services, other than institutionalisation and retaliatory abuse and violence is again a very real danger.

American definitions of elder abuse:

  • Domestic elder: Maltreatment by someone with a special relationship,e.g. spouse/ siblings/child/friend/caregiver in own/ caregivers home
  • Institutional: In a residential facility (nursing/foster/group home), board and care facility, usually by a person with legal/contractual obligation to provide care/protection (paid caregivers/staff/ professionals)
  • Physical: Physical force leading to bodily injury/ physical pain/ impairment, including inappropriate use of drugs/physical restraints/force feeding/ physical punishment
  • Sexual: Non-consensual sexual contact, including with those incapable of giving consent, touching, rape, coercion, sexual explicit photography
  • Emotional/ psychological: Inflicting anguish/pain/distress by non-/ verbal acts, verbal assault/insult/threats/intimidation/humiliation/harassment,treating a older adult like a infant / isolation from family/friends/regular activities, “silent treatment”, enforced social isolation
  • Neglect: Refusal/failure to fulfil obligations, pay for home care, provide with life’s necessities (food, water, clothing, shelter, personal hygiene, medicine, comfort, safety, etc.)
  • Financial / material exploitation: Illegal/improper of funds/property/assets/pension of an older person, forging signatures/misusing/stealing money/possessions, coercing/deceiving into signing documents, improper use of guardian
  • Abandonment: Desertion by the person responsible for care/physical custody
  • Self-neglect: Behaviour of an older person that threatens his/her own health/safety, refusal/failure to provide him/herself with life necessities, unless a competent person, understanding the consequences and does so voluntarily

Additional reading

  • Jenkin, A., & Millward, J. (2006). A moral dilemma in the emergency room: confidentiality and domestic violence. Accident and Emergency Nursing, 14(1), 38-42. doi: S0965-2302(05)00096-2
  • Olive, P. (2007). Care for emergency department patients who have experienced domestic violence: a review of the evidence base. Journal of Clinical Nursing, 16(9), 1736-48. doi: JCN1746
  • United Nations Convention on the Rights of the Child. Available at http://www.unicef.org/crc
  • Weiss, E. (2005). Domestic violence: caring for a colleague. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses, 20(4), 268-74. doi: S1089-9472(05)00144-9