Violence within homes between people who care for each other is confusing and terrifying for both those involved and their health professionals. Violence manifests in numerous ways in healthcare such as trauma or an undifferentiated patient, psychosomatic illness, substance abuse or dependency and/or mental health challenges. Different forms of violence exist such as intimate partner violence, gender-based violence, domestic violence, child abuse, neglect, elder abuse, sexual violence, self-directed violence and collective violence that may be included in domestic violence or standalone forms of violence.¹ Apart from the statutory obligations of health practitioners, they are also pivotal in managing incidents of domestic violence. Practitioners must create awareness, screen for and identify abuse, assess and document incidents and provide emotional support.² In addition, they must develop safety plans, offer medical treatment and referrals, ensure continuous support and follow-up and encourage victim-survivors to report abuse.²

It is often difficult to figure out the cause or consequence of this complex interplay between power and vulnerability. A systematic review indicated that women who experienced violence as a child (either violence in the family of origin or adult victim-survivor of child abuse) are often more vulnerable, economically dependent and have a lack of social support and thus, are more likely to experience violence in the household.^3,4 Emotional dependency in men is a risk for violence.^3,4 Women with disabilities are more likely to be abused than women without disabilities.⁵ Numerous research articles link alcohol use to emotional dysregulation and impaired judgement, which often leads to domestic violence.⁶ There may also be a greater risk for women using marijuana to perpetrate violence if they have a history of perpetrating violence before marriage.⁷ Mshweshwe⁸ postulated that domestic violence is a ‘consequence of the complex interplay of patriarchy, culture, and the negative masculine construct’. Not only does violence cause trauma and even death, it also affects the quality of life of families, and has a wide range of physical and mental sequelae.⁹

Women exposed to domestic violence are more likely to present with sleep challenges, headaches, gastrointestinal disorders or depression.¹⁰ A study in the United States identified intimate partner problems in 26% (n = 1327) of suicide cases and 43% of these individuals experienced relational problems before attempting suicide.¹¹ For both men and women, mental health issues such as depression and anxiety are statistically associated with domestic violence.^1,9 Physical and mental conditions are not the only sequelae of domestic violence. Sexual and reproductive health, low birthweight babies and increased risk for human immunodeficiency virus (HIV) are also noted consequences of domestic violence resulting in poorer health outcomes for women with chronic conditions.^12,13 Primary care services can play a crucial role in identifying and managing patients experiencing domestic violence appropriately. The current statutory obligation under the new Domestic Violence Amendment Act trumps recommendations in national guidelines and policies as they predate the amendment act. Despite this, the South African National guideline concerning the empowerment of victim-survivors of violence encourages all services to recognise and respond to vulnerable individuals affected by violence and abuse.¹⁴ The Health Professions Council of South Africa is clear that domestic violence is not a private matter and health professionals must screen, assess, manage and refer appropriately.¹⁵ The South African Maternal Perinatal and Neonatal Health Policy (2021),¹⁶ and various legislations mandate that healthcare professionals manage domestic violence.^17,18,19

Health professionals often are focussed on the visible presentation of domestic violence and have limited knowledge and understanding about the scope and complexity of what legislation defines as domestic violence. For the purpose of this continuous medical education article, we want to suggest an approach to identify and manage domestic violence as defined by law in South Africa.^19,20

There is often confusion between the terms domestic, gender-based and intimate partner violence (IPV).²¹ Figure 1 illustrates how these three concepts may overlap within a household. Domestic violence is violent or aggressive behaviour within the home, typically involving the violent abuse of a spouse or partner but can involve other members of the household. In the past, child abuse and elder abuse were covered under its own legislation. The amended Domestic Violence Act of 2021 explicitly includes child and elderly abuse and thus, complements existing legislation for these two groups.¹⁹ Therefore, domestic violence in this article includes violence against children, the elderly and vulnerable members of a household.^19,20

To screen for and manage domestic violence, it is important to know the relevant basic legal definitions. A complainant is:

A respondent is ‘any person who is or has been in a domestic relationship with a complainant and who has committed or allegedly committed an act of domestic violence against the complainant’ (Box 1).^19,20

The law defines a ‘close relationship’ as a degree of trust that exists between two persons who have a level of dependence on, and commitment to, the other person.^19,20 They also have frequent contact and there is a degree of intimacy between them. It is no secret that South Africa has some of the highest levels of gender-based violence in the world and therefore the socio-political emphasis is on protection and empowerment of women. However, men and persons from sexually diverse or minority groups are also victims of domestic violence.^22,23,24,25 The prevalence of IPV between same-sex couples is just as high as in heterosexual couples.²⁶ The Centres of Disease Control in the United States reported that 47.3% (n = 59 million) women and 44.2% (n = 52.1 million) men were exposed to domestic and sexual violence over their lifetime.²⁷ In a South African study of 3048 men and women in sexual minority groups, nearly 70.5% reported to police witnessing physical violence against people in same-sex relationships.²⁵ This does not include verbal abuse, bullying and sexual violence or abuse not reported to law enforcement.²⁵ According to the second quarter of 2023 crime statistics in South Africa, the police recorded 10 516 rapes, 1514 cases of attempted murder, 881 women murdered and 14 401 assaults against female victim-survivors in July, August and September.²⁸

Domestic violence is a criminal offence and there can be no reason for the justification of abuse. It is important to show empathy and demonstrate a non-judgemental attitude to all victim-survivors of abuse.

Several tools exist to assist practitioners in identifying and documenting domestic violence namely, HITS (Hurt, Insult, Threaten and Screen), Woman Abuse Screening Tool (WAST), Partner Violence Screen (PVS) and Abuse Assessment Scale (AAS).^29,30,31,32 Saimen et al.³³ found that the WAST two-question tool³⁴ developed for family practice had a sensitivity of 45.2% and specificity of 98% in the South African context. Overall, these tools use various psychometric parameters to assess risk, but there is no one tool that has been found to be superior to the others.³⁰ Furthermore, the focus of these questionnaires, with the exception of the AAS tool, is mainly on physical and verbal abuse. Considering the several types of domestic violence specified in the South African legislation (see Box 2), it can be missed if only these tools are used.

Domestic violence can be a generational curse compromising biopsychosocial wellbeing. To break the perceived culture of violence, healthcare workers play a pivotal role in screening, management and the mandatory reporting of domestic violence, especially when children or the elderly are involved in such households.