Case 25

Domestic violence against the elderly in Germany


  1. To illustrate that domestic violence can be overlooked due to a lack of knowledge
  2. To show as best case example a succesful intervention of a GP
  3. To demonstrate that it is not always clear – domestic violence case or not?

Narrative cases:

  1. Domestic violence not recognized due to lack of knowledge

During a home visit as a general health practitioner, I saw a family at an isolated rural location (edge of Wuppertal in Germany). A lady of around 80-years of age presented in a weak state [1] with various pains in different places caused by several falls. The patient herself was silent and her home, clothing and family seemed rather neglected. [2]

After writing an admission note for the hospital, I had the vague feeling that something was being withheld from me.  I had asked the family to call an ambulance but should have waited for the ambulance to arrive. I realized this much later when I learnt more about violence against elderly people within the family. [3]

2. Successful intervention of the GP

An 85-year-old woman was said by her family to be unable to pass urine and suffering from severe abdominal pains. This history was given in an excited and wordy account. The patient was very restless, anxious and her bladder clearly full. While writing down the results of my examination, I hear the patient ask her family: “Can I now go to the toilet?” and hear a hissing whispering: “No”!

I wrote a hospital admission note and called the ambulance myself. [4] I had the suspicion that the family had forced the patient not to go to the toilet. I think they did not know how to care for the grandmother and feigned illness in a very clumsy way to bring help from outside. [5] Soon after the visit, I informed my colleague on duty at the hospital about my suspicion. [6] After admission, the patient had been able to pass urine without any problems. Social/familiar background problems could be solved at the hospital by a special care service for needy and lonely patients. [7]

3. Unclear situation- case of domestic violence or not?

A patient on my list  for over 10 years [8], aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house [9]. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and disturbed. The patient insisted that she was kindly nursed by him [10] and a niece with a nurse living nearby looked after her [11].

Until now I have not known what to think about the situation [12]

Learning points

[1] The WHO state there are several risk factors concerning elderly abuse such as illnesses and shared living situations. In addition,  strong dependence on caregivers can make such abuse more likely.

[2] Elderly  abuse can have many different forms and involves more than physical components. The neglect of an elderly person, whether intentional or not, is also considered as abuse. At times, it is difficult to determine whether it is already abuse or still unkemptness.

[3] Here the main problem is described; the general lack of knowledge regarding this topic. The physician did not even think about it! Not only are there few studies on this topic but there are also no reports on this issue worldwide. The topic itself is also regarded as taboo (should stay within the family) and no-one wants to talk about it, which makes recognition even more difficult.

[4] In comparison to the first story, the physician recognized the abuse and decided to intervene. She stayed and made sure that the patient went to hospital.

[5] In this example, the family is clearly overburden with the care of the old lady. They wanted to get help from outside but didn´t know how to do this. The physician was sensitive to the issue but as the awareness is not very high many cases can go undetected. The WHO started preventative programmes for people who are caring for their older relatives. These provided assistance and teaching on how to deal with the situation.

[6] Here we see the positive impact of an intact chain of information between physicians. The physician at the hospital is informed about the suspicion and can further intervene.

[7] This is a best practice example. In most hospitals such a special service is not available. It will assist families that want to get help.

[8] The physician knows the patient for a very long time and the family situation as well. If a relationship like this exists, a physician can recognize changes faster and usually some kind of trust exists between doctor and patient.

[9] Another risk factor is social isolation. It goes together with dependency as the abused person might have only the abuser as their sole contact person.

[10] The physician suspects abuse but does not get a sufficiently detailed answer. Here a standardized sample of questions might help which can be answered with yes or no. Questions like this do already exist such as the H-S/East (Hwalek-Sengstock Elder Abuse) screening test. Recently the WHO has tried to develop a more simple approach using 12 easy to understand questions, EASI – The Elder Abuse Suspicion Index. These questions can be found on the internet (see below). It might also help to question the patient in private. There are many reasons why potential victims do not want to talk about abuse including feeling afraid to be alone or feeling  ashamed.

[11] Once again the importance of a network is seen. The physician could contact this nurse and talk with her about the situation in the patient´s home. In addition, the physician could visit the patient to check the situation for herself.

[12] As already described in [2] it can be rather difficult without screening tools to determine abuse. This underlines the importance of raising awareness and proper training for physicians

Further Information

According to the WHO elder abuse is a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. It can have many different forms such as physical, psychological or emotional, sexual and financial.

The importance of this topic has long been underestimated but it has gained growing attention. Still elder abuse is believed to be underreported by up to 80% with a prevalence ranging from 1% to 35% according to various questionnaires. There exists a remarkably lack of studies concerning it. The biggest study regarding this topic was in 2002 the Missing voices: views of older persons on older abuse study conducted by the WHO. It was conducted in eight different countries: Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden.

This study demonstrated the necessity of addressing this topic. The WHO has started to develop screening tools to make it easier to raise physicians’ awareness and help to detect more cases. Different methods and questionnaires previously used such as the H-S/East but were regarded as taking too much time to ask, were difficult to understand and non specific. Taking these issues into account, EASI the Elder Abuse Suspicion Index was drawn up which consists of only six questions of which five are answered by the patient and the last one by the doctor.


The WHO identified five fields of risk factors:

  1. Individual: illnesses (mental disorders, alcohol abuse), gender (in countries where woman have a lower society status than men, they are more likely to experience elder abuse)
  2. Relationship: shared living situation, dependence, financial dependence of the caregiver on the elderly person, history of poor relationships within the family, overburden of the caregiver
  3. Community: social isolation of the elderly person
  4. Socio-cultural: financial problems, general depiction of old people as weak and helpless, erosion of bonds between the generations, migration of young couples
  5. Institutional: low standards, poorly trained and overworked staff, economic reasons (the economic situation of a home for the elderly is more important than the well-being of its residents)


As with any type of abuse, elder abuse can cause not only physical injuries but may lead to long-lasting psychological problems such as anxiety and depression.

After raising awareness, the WHO proposes various measures to tackle this form of abuse such as a general screening for abuse and better caregiver support and training. They are demanding mandatory reporting on each case, building  safe houses and shelters for victims and the foundation of self-help groups.

All these measures show great similarity to the measures against domestic violence.


Purpose: Screening device for service providers interested in identifying people at high risk of needing protective services.

Instructions: Read the questions and write in the answers. A response of noto items 1, 6, 12, and 14; a response of someone elseto item 4; and a response of yesto all others is scored in the abuseddirection.


  1. Do you have anyone who spends time with you, taking you shopping or to the doctor?
  2. Are you helping to support someone?
  3. Are you sad or lonely often?
  4. Who makes decisions about your lifelike how you should live or where you should live?
  5. Do you feel uncomfortable with anyone in your family?
  6. Can you take your own medication and get around by yourself?
  7. Do you feel that nobody wants you around?
  8. Does anyone in your family drink a lot?
  9. Does someone in your family make you stay in bed or tell you youre sick when you know youre not?
  10. Has anyone forced you to do things you didnt want to do?
  11. Has anyone taken things that belong to you without your O.K.?
  12. Do you trust most of the people in your family?
  13. Does anyone tell you that you give them too much trouble?
  14. Do you have enough privacy at home?
  15. Has anyone close to you tried to hurt you or harm you recently?

EASI Questions

Instruction: Q.1-Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

  1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
  2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?
  3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
  4. Has anyone tried to force you to sign papers or to use your money against your will?
  5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
  6. Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?



  1. WHO. A global response to elder abuse and neglect. 2008. ISBN: 978924156381 (25.09.2015)
  2. WHO. Discussing screening for elder abuse at primary health care level. 2008. ISBN: 978 92 4 159453 0. (25.09.2015
  3. WHO. Missing voices: views of olfrt persons on elder abuse. 2002. (25.09.2015)
  4. Fact sheet on elder abuse. Dec. 2014. (26.09.2015)
  5. The elder abuse suspicion index. 2015 (28.09.2015)
  6. (28.09.2015)
  7. (28.09.2015)

Case 21

Case study from Kenya on FGM and cultural practices which violate girls’ rights


To show how cultural practices violate the rights of girls.

Narrative Case:

The UN convention on the rights of children define this group as those aged under 18 years. One ethnic grouping in Kenya honours the rites of passage for adolescent boys by unfortunately violating the rights of girls.

Mwandi is fifteen years old. She has known since she started her menses at the age of 12 years that she was destined for something special. Her mother kept a close eye on her and did not allow her to spend nights away from home at her friend’s houses like other girls. Early one morning her mother woke her up and after she had bathed, dressed her up nicely and took her to a strange hut in the nearby village where she was told to lie on a bed and keep her legs open[1].  Before she could scream, she felt a sharp excruciating pain down below after which she felt the sting of some herbal preparations [2]. She was told to keep her legs together. That was the beginning of the end of her childhood. Two weeks later when it had all healed up her mother gave her some special fragrant herbs to bathe with and told her she had to be good as she was going to bring honour to their family.

Later she learnt that ‘warrior’ boys are confined in a camp for various rites. Tradition and culture means girl children are circumcised and given to ‘warriors’ as sexual companions.There was no protection offered against sexually transmitted infections when she developed sores and was later told at the clinic that she was HIV positive [3]. Treatment consisted of herbs that her mother procured from a medicine man [4].

If girls get pregnant, because these relationships are outside marriage, the mother of the girl has to find a way of aborting the foetus. This is done by crushing the head of the foetus against the girl’s pelvis.  Mwandi was brought to the clinic by an aunt who visited the village and noticed the severe pain and extreme bleeding (menorrhagia) she was having [5,6].


Learning Points:

[1] Perpetrators are primary caregivers, parents, teachers and close relatives in Kenya and many other countries where culture and tradition are the predominant reason for a large number of practices that are harmful and violent, especially to girls.

[2] Female genital mutilation is believed to help control sexual urge in young girls and keep them chaste. The same tradition and culture is however throwing these virgin girls at young men to whom they are not married.

[3] There is no sex education of either young men or the young women to protect them against sexually transmitted infections (STIs) or pregnancies.

[4] There is a lack of healthcare available for those who get STIs.

[5] Women doctors must be aware of these practices and use every available opportunity to educate their patients on the dangers of these practices and the continued violations of the rights of children especially girls.

[6] Women doctors need to work with community opinion leaders to offer education on the effects and outcomes of these harmful practices.



  1. Mohamed  FJ. Does Kenya have the courage to lead on women’s rights in Africa? The Guardian April 21 2014. Available at : [Accessed 28th August 2015]
  2. Munyao WL.  Gender Issues Affecting the Girl Child in Kenya International Journal of Humanities and Social Science 2013; 3(4): 125-9. Available at: [Accessed 28th August 2015]
  1. Queens University Belfast. Children’ rights resources. Available at [Accessed 28th August 2015]
  1.  Armstrong S. In Kenya, a Victory for Girls and Rights. The New York Times June 4 2013. Available at:  [Accessed 28th August 2015]



Case 15

Domestic violence and impact on children


  1.  Safeguarding children, and considering the impact on them, is a very important component of dealing with domestic violence


DVPP       Domestic Violence Perpetrator Programme
ISS            independent Support Service

Narrative case

Tom and Sarah separated a year ago because of Tom’s violence and abuse, which culminated in an incident where he was violent in front of their children Jack (9) and Sam (7). Tom had not seen the children since. He was desperate to resume contact and applied for an order to do so through the family court. The court instructed him to attend a Domestic Violence Perpetrator Programme (DVPP) for risk assessment and to complete the group work programme. The programme was required to provide an initial assessment and then report on Tom’s progress half way through and at the end of the programme.

During the programme, Tom started a new relationship with Julie. He gave her contact details to the DVPP workers as required. The ISS then contacted Julie, who said she did not need any support and that Tom had not been violent to her. She said that Tom had admitted his past violence towards Sarah and she was pleased to know he was attending the DVPP. If Tom was ever violent or abusive, she knew she could call the ISS. Just knowing this – and knowing that Tom knew it – made her feel safer.

The DVPP’s half way report was largely positive. Tom had remained non-violent and had not attempted to contact Sarah or the children, despite desperately wanting to. However, he needed to work more on his empathy for Sarah and workers thought that he still underestimated the likely effect upon the children of witnessing violence. In the court proceedings Tom admitted he had been violent and abusive to Sarah and took responsibility for it. Sarah had also been in regular contact with the ISS and was pleased with how Tom appeared to be changing. However, she was still worried about the impacts of contact on the children and wasn’t sure she could trust him. Tom was granted supervised contact at this point.

Tom continued to engage with the programme and appeared profoundly affected by the sessions relating to children and the impact of his behaviour towards Sarah. In the week before his first supervised session he discussed with the group how he would handle the situation – particularly how he might deal with his children’s anger towards him or answer difficult questions about his past violence. The next week he reported how useful this had been as Jack had directly challenged him, asking ‘Why did you hit Mum?’. If he had not been prepared he would not have known what to do. He said he would probably have tried to avoid the question or would have played down how serious it was. Instead, he was able to fully admit what he did, explain it was wrong, say how much he regretted it and give the children a heartfelt apology.

By the time of the final court hearing Tom and Sarah had not seen each other for almost 2 years. Sarah approached Tom through her lawyer and asked to speak with him. He was able to tell her what he had learned on the programme, saying that he was totally responsible for the violence, that she was not to blame and that he deeply regretted the harm he had caused to her and the children. Sarah felt safe enough to tell him how angry, afraid and hurt she had been. She felt more confident that Tom was in the right place to be a decent father – and also knew who to contact with any future concerns. At the final hearing Tom was granted unsupervised contact which has been reliable, safe and positive to date.

Learning points

  1. Perpetrators are often not aware of the impact of domestic violence on their children. Children who have witnessed violence are more likely to become perpetrators themselves in their future relationships.
  2. Providing new partners  and ex- partners of perpetrators with support gives them reassurance and confidence that they and their children will be safe.
  3. The relationship between fathers and their children is often underestimated when couples separate. Wherever possible this relationship must be maintained as long as suitable safeguards are in place.


Acknowledgments: This case has been adapted from cases from the UK charity Respect, with their kind permission.

Case 12

Children are at serious risk in households where there is domestic violence


  1. To show how children who live in households where there is domestic violence are seriously at risk and need child protection.
  2. To illustrate how parents can manipulate health care professionals and deliberately set out to deceive them
  3. To demonstrate the need for all agencies involved with children to share information and to ensure it is formally documented.

Narrative Case

This case is about Daniel a 4 year old boy and his 27-year-old-mother Ms. Luscak, who has had four different partners and did not seem able to detect abusive relationships or learn from past experiences [1]. This was made worse by her alcohol misuse [2] and occasional violence towards her partners. Originally from Poland she spoke little English [3].

Daniel had 2 siblings, a 7 year old sister Anna by her first partner, and a 1 year old brother Adam by her fourth partner, Mr. A.  On 27 different occasions, the police were called to domestic violence incidents often complicated by both parents being drunk [4]. On 2 occasions Daniel’s mum took overdoses with the intention of committing suicide [5]. She suffered a number of serious incidents with partners including attempted strangulation, being threatened with a knife, suffering a hand fracture and rape allegations. When asked to press charges she withdrew her statements [6]. On numerous occasions the children were judged not to be at risk and left with the parents with sometimes children’s social care not being informed [7]. The family moved house on a number of occasions due to inability to pay the rent [8].

When pregnant with Adam, Mr. A urged Ms. Luscak to have a termination. She missed 4 antenatal appointments. At one stage she was hospitalised and Mr. A took the drip out of her arm and she self discharged. Ms. L phoned the midwife and told her there was  domestic violence, despite previously denying this fact to healthcare professionals [9].

In January 2011 Daniel had a spiral fracture to the left arm [10] reported as due to jumping off the settee with his sister the previous day. Bruises on his shoulder and lower tummy were said by his mother to be due to falling off his bike regularly. Meetings of health care professionals took place but the long history of domestic violence was not considered.[8] In September 2011, Daniel started school. There were frequent absences as for his sister Anna. On a number of occasions different members of staff noticed injuries including black bruises around the eyes, blood spots on the face, severe marks on the nose, spot bruises on the neck and forehead bruising.  They also became concerned as Daniel was getting markedly thinner and always seemed hungry, taking food from lunchboxes and rubbish bins. [11 ]His sister Anna was told by Ms L to say that Daniel had this pattern of behaviour at home, ate more food than she did and was constantly falling over. Daniel had poor English and although a cooperative boy was shy and reserved and did not talk to the teachers.

Daniel saw a Paediatrician in February 2012 who was unaware of the school’s concerns.  His mother was very convincing that Daniel had an eating disorder and fell over a lot. Tests for medical conditions were initiated.  Three weeks later Daniel died. At post-mortem he was found to have high sodium levels and over 40 injuries including an acute subdural haematoma and an older smaller one.  His mother and stepfather have been convicted of Daniel’s murder and his 2 siblings are in foster care. Daniel had been subject to the most appalling abuse including being starved at home, fed salt to make him sick if school said he had taken food, put in cold baths nearly drowning on one occasion, locked in a box room with the handle taken off the door, had a soiled mattress and urine soaked carpet. He had physical punishments given by his stepfather of situps for 1 hour, standing in the corner, squats and running on the spot which were planned in advance. He had no toys.[12] His sister Anna had tried to protect him as much as possible including physically. She confirmed that Daniel had been hit “many,many times” by the stepfather.


Learning Points

[1] Children in households with domestic violence are at serious risk and must be thought about carefully. There is a strong association between witnessing DV and severe PTSD symptoms: withdrawal, clinging, regressive behaviour, hyperactivity, aggression, difficulties in concentration (Kilpatrick et al, 1997).  Child witnesses are much more likely to grow up to be either victims (females) or perpetrators (males).

[2] This is a typical pattern in DV: alcohol and/or drug abuse leads to fighting and then reconciliation.  Often the man feels overcome with remorse after beating the woman and there are pleas for forgiveness, promises to reform, lovemaking and then further cycles. The perpetrator is often very loving and repentant following a violent outburst and this intensifies the partner’s attachment to him.

[3] Abuse of children is more prevalent in socially isolated or disadvantaged families, with alcohol and drug abuse and with domestic violence. This case has all these risk factors including the mother speaking little English.

[4] Every minute in the UK, the police receive a call from the public for assistance for domestic violence. This leads to police receiving an estimated 1,300 calls each day or over 570,000 each year.  However, only 23-35% of incidents of domestic violence are reported to the police.

[5]  Domestic violence commonly results in self-harm and attempted suicide.  Abused women are five times more likely to attempt suicide and one third of all female suicide attempts can be attributed to current or past experience of domestic violence.

[6] The low rate of conviction in cases of domestic violence can be attributed to the victim’s inability or unwillingness to give evidence (Cretney and Davis 1995).

[7] Interagency communication is vital and children’s social care should always be informed. In all the landmark cases in recent years in the UK, there has been lack of communication between agencies (Lord Laming 2003).

[8] Moving house several times is a typical pattern seen and the mother may lose all her possessions

[9] Domestic violence increases during a pregnancy and is the commonest cause of injury in pregnant women. Men often feel threatened by the prospect of having a child – economically they have little to offer and emotionally it means one more person to be cared for. This intensifies the man’s feelings of worthlessness and he defends against this by being more angry and violent. Bacchus (2004) reported 23% of women receiving care on antenatal and postnatal wards had a lifetime experience of domestic violence, and 3% had experienced violence in the current pregnancy.

[10] The possibility of abuse needs to be considered with spiral fractures and a judgment made as to whether the suggested mechanism of injury is plausible. In this case the issue was not considering other red flags i.e. the bruises on the abdomen which are unusual and for which there needs to be a clear explanation and the history of domestic violence.

[11] This eating behaviour is grossly abnormal and needed communicating to health care professional eg school nurse or general practitioner. Again there is lack of communication between different professionals.

[12] Health care professionals need to be able to “think the unthinkable” – this is a catalogue of abuse which if this was not a real case many would think was not possible

Background information

Background information on domestic violence

This is defined as abuse between persons in an intimate relationship, independent of gender, sexuality or marital status.  The term usually excludes abuse of children and the elderly.


  • One incident of domestic violence is reported to the police every minute in the UK
  • On average, 2 women a week are killed by a current or former male partner.
  • 23% of women experience DV in their relationships at some time.
  • 45% female homicide victims are murdered by their partners. (Australian Bureau of Statistics: Women’s safety survey, 1996.) Women presenting to ER (Australian study)
  • 49% had experienced DV, 40% in the last 12/12.
  • 25% had a history of childhood abuse plus adult DV (Roberts et al, 1998).


Background of risks to children of domestic violence

Unicef figures estimate that globally the number of children exposed to domestic violence is 133-275 million. This varies by country: Developed countries 4.6-11.3million,

SubSaharan Africa 34.9-38.2 million and South Asia 40.7 – 88 million. At least 750,000 children a year witness domestic violence (Department of Health UK). Estimates vary from 30%-66% children are abused either physically or sexually by the same perpetrator. Children are completely dependent on adults and all children witnessing domestic violence are being emotionally abused

Children react in various ways to living with a violent person. Age, race, sex, culture, stage of development, and individual personality affect response. Children can be affected by tension, witnessing arguments, distressing behaviour or assaults. They may get caught in the middle of an incident, sometimes trying to make the violence stop; they may be in another room but be able to hear the abuse or see their mother’s physical injuries following an incident of violence; or they may be forced to take part in verbally abusing the victim. They experience a range of emotions including that they are to blame, anger, guilt, being alone, frightened, powerless, or confused. They may have ambivalent feelings, both towards the abuser, and towards the non-abusing parent.

Effects of domestic violence on children include:

    • Anxiety and depression
    • Difficulty sleeping.
    • Nightmares or flashbacks.
    • Physical symptoms such as headaches and abdominal pain
    • Enuresis
    • Temper tantrums
    • Behave as though they are much younger
    • School problems including truanting, sometimes staying at home to protect their mother
    • Aggression
    • Withdrawal from other people due to internalizing the distress
    • Lowered sense of self-worth
    • Start to use alcohol or drugs.
    • Self-harm eg overdoses or cutting themselves.
    • Develop an eating disorder.
    • Affecting social relationships – they may feel unable to or are prevented in bringing friends to the house



  1. Bacchus L, Mezey G, Bewley S, Hawort A, (2004) Prevalence of domestic violence when midwives routinely enquire in pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 111; 441-5.
  2. Cretney A, Davis G. (1995) Punishing violence. Routledge, London  
  3. Family Rights Group:
  4. Lord Laming (2003). The Victoria Climbié Inquiry
  5. Mind ‘How to parent when you’re in crisis’.
  6. Mullender, A. and Morley, R. ‘Children living with domestic violence’ (London: Whiting and Birch).
  7. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from
  8. NSPCC Children living with domestic abuse
  10. Parentline Plus.  Support for parents under stress
  11. Radford L, Aitken R,  Miller P, Ellis J, Roberts J, Firkic A. Meeting the needs of children living with domestic violence in London Research report. 2011
  12. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from
  13. Save the Children and  Women’s Aid services.  Safe Learning – an insight into children’s experiences of domestic violence and how these may affect their learning, 2006
  14. Serious case review: Daniel Pelka
  15. The Hideout website
  17. UNICEF: behind Closed Doors the impact of domestic violence on children
  19. Women’s aid organization  – Statistics on Domestic Violence
  20. Women’s aid organization – Children and domestic violence