'I Know it was Every Week, but I Can't be Sure if it was Every Day: Domestic Violence and Women with Learning Disabilities.

BACKGROUND: Domestic violence against women is well researched in the general population, but much less so in relation to women with learning disabilities. This qualitative research study interviewed 15 women with learning disabilities who had experienced domestic violence about their experiences, the impact of the violence on them and their children, their coping strategies and help seeking behaviour.
MATERIALS AND METHODS: Semistructured in-depth interviews were conducted. Data were analysed using Inter-pretive Phenomenological Analysis. A service user advisory group helped at particular stages, notably at the formative stage and with dissemination, especially the production of accessible materials, including a DVD.
RESULTS: The violence experienced by many of the women was severe and frequent. It impacted negatively on their physical and psychological well-being. The women's awareness of refuges and others sources of help was generally low.
CONCLUSIONS: Healthcare and social care professionals have a clear remit to help women with learning disabilities to avoid and escape violent relationships.

Introduction

Since the 1970s and 1980s, domestic violence against women has been well recognized as both very common and very damaging to individuals and wider society (Dobash & Dobash 1979; Stanko 1985). There is a huge body of evidence regarding its prevalence and effects in the general population (Mullender et al. 2002; Walby & Allen 2004). Lombard & McMillan (2013: 10) give an overview of existing research and state that ‘lifetime prevalence rates tend to offer us the most reliable indicator of the extent of the problem and these suggest one in four women will experience domestic abuse in her lifetime’.

There is also a smaller body of research on domestic violence of women with physical and sensory impairments. This is mostly from countries such as Canada and the United States (for example, McNamara & Brooker 2000; Yoshida et al. 2009), but also more recently in the United Kingdom (Thiara et al. 2012). In terms of prevalence, US research suggests around 85% of women with disabilities experience domestic violence (Feuerstein 1997), with the Canadian research suggesting women with disabilities have a 40% greater likelihood of domestic violence than non‐disabled women (Brownridge 2006).

Whilst the respective fields of disability studies and violence studies are both well developed, ‘the intersection of the two fields of disability and violence has, however, received far less attention’ (Mikton & Shakespeare 2014: 3055). Thiara et al. (2011) observe that in the United Kingdom, despite the Disability Discrimination Act 1995 requiring public services to be offered on equal terms to people with disabilities, there is a still a lack of awareness and resources when it comes to support for disabled women who have experienced domestic violence. They describe disability and domestic violence services as working in ‘“siloed” ways (p. 758), that is in isolation from each other, thus exposing disabled women to further risks.

The concept of intersectionality refers to a way of looking at the interconnected nature of social categories of gender, race, class, etc. and thus at the different layers of oppression an individual might face. It is occasionally used to analyse the domestic violence experiences of disabled women; however, this is usually in relation to women with physical and sensory impairments (Thiara et al. 2011) and not those with learning disabilities. However, there are exceptions to this general rule, with the work of Chenoweth (1993, 1996) being particularly notable, as well as McCarthy (2009). The concept of intersectionality is also increasingly used to understand the domestic violence experiences of other marginalized women, such as older women (Lombard & Scott 2013), Black and minority ethnic women (Gill 2013) and lesbian women (Barnes 2010). This literature suggests that all facets of a person's identity are important and need to be taken account of. Failure to do this results in a piecemeal approach to the problem of domestic violence, which can mean that ‘many women “fall through the gaps” between policy and practice, rhetoric and understanding’ (Gill 2013: 142).

Literature review

As stated above, most of the literature on domestic violence and women with disabilities focuses on women with physical and sensory impairments. As well as establishing the above high prevalence rates, the research also makes clear that disabled women (despite their greater need) have less access to specialist and general domestic violence services (Thiara et al. 2012).

In terms of the types of domestic violence disabled women are exposed to, the literature suggests that as well as what might be termed the ‘usual’ types of domestic violence that any woman can experience (physical, sexual, financial, etc.), disabled women also experience some very specific and unique forms of abuse, such as perpetrators withholding or sabotaging needed equipment (wheelchairs, hearing aids, guide dogs, etc.); withholding assistance, for example leaving women in physically uncomfortable or embarrassing positions for a long time; making threats that leaving the relationship will result in institutionalization for the woman (Saxton et al. 2001; Hassouneh‐Phillips & Curry 2002). Ballin & Fryer (2012: 1085) conclude that ‘Abusive intimate partners exploit the challenges presented by the disability, knowing that this will seriously limit a woman's ability to take action’.

Domestic violence against women with learning disabilities

Whilst there is research on certain forms of abuse against women with learning disabilities, in particular sexual abuse, these studies tend to look at abuse from a variety of different perpetrators. McCarthy 2014a). Studies looking specifically at domestic violence from an intimate partner are rare. However, there are a few. Walter‐Brice et al. (2012) conducted a small qualitative study in the United Kingdom, interviewing five women with learning disabilities and found that the women experienced multiple forms of abuse from their partners, much of it severe, including the use of weapons; that the abuse, harassment and threats continued after the end of the relationship; that responses from Police and Social Services were minimal and the women were left unprotected (although children were removed from their mothers). Similarly, Pestka & Wendt (2014) also conducted a small qualitative study interviewing five women with learning disabilities in Australia. They found the women in their study had all experienced rejection in their childhoods and sought a sense of belonging in adult intimate relationships, even if they were abusive, and that the women's low social status increased their vulnerability. They conclude that women with learning disabilities ‘settle with or accept abuse in their lives to gain social value that has often been missing throughout their life course’ (p. 12). Findings from both these studies strongly resonate with our findings below.

Mikton & Shakespeare (2014: 3056) state that ‘among the evidence gaps, the exact nature of violence against persons with disability requires more detailed mapping’ and it is this which the research project reported here sought to do.

Methods

In this study, we used the UK Home Office definition of domestic violence which was current at the start of the research in 2012: ‘Any violence between current or former partners in an intimate relationship, wherever and whenever the violence occurs. The violence may include physical, sexual, emotional or financial abuse’.1

This was a mixed methods study, involving interviews with 15 women with learning disabilities who have experienced domestic violence and an online survey of 717 professionals (police, domestic violence workers, adult safeguarding specialists, advocates, etc.). Survey findings are reported elsewhere (McCarthy M., Hunt, S. and Milne‐Skillman, K.).

Qualitative data collection

Semistructured interviews with women with learning disabilities were chosen as the most appropriate method for data collection because inquiry into sensitive and personal topics requires a one‐to‐one method, which allows for in‐depth, wide‐ranging discussion (McCarthy 1999). The interview schedule was designed by the research team and included the following topics: the women's understanding and experience of domestic violence; the impact on themselves and their children (if any); their coping strategies; whether and how they sought help to leave the relationship; and life after the abusive relationship.2

The nature of the topic meant that the interviews were often distressing for the women, but none of them wanted to stop, or shorten, the interviews. No time limit was imposed on the length of interview and most lasted between 1 and 2 h, with some lasting considerably longer. Many of the interviewees commented on the fact that it was the first time they had been able to speak at length about what had happened to them, that they found the interviews helpful, they wanted to talk and wanted people to hear their accounts. In experiencing what might be loosely termed as some therapeutic benefits from a research interview, they are far from unique (Hutchinson et al. 1994; Murray 2003). Stefánsdóttir & Traustadóttir have described how the qualitative research process can help women with learning disabilities to ‘face their past and to move on’ (2015: 374). Some of the women had keyworkers or other supporters with them during the interview, although most were interviewed alone.

Whilst the participants may have experienced the interviews positively, the researchers found themselves having to listen to distressing, disturbing and harrowing tales of, in some cases, extreme abuse. This takes an obvious emotional toll and it something that needs to be managed by debriefing, supervision and constant dialogue (Ellsberg & Heise 2002). In anticipation of this, researchers were recruited to this study who had experience and knowledge of both the learning disability and domestic violence fields.

Service user involvement

This research project worked with an advisory group of women with learning disabilities. They helped at various stages of the research, for example, at the formative stage by helping us to shape the research questions and towards the end, by helping to disseminate findings. They played a crucial role in helping to make an educational video for women with learning disabilities.3

Ethical approval

Ethical approval for the study was given by the Social Care Research Ethics Committee (SCREC) (Ref. 12/IEC08/0028). It received Research Governance approvals from all the participating Local and Health Authorities and unconditional approval from the Association of Directors of Adult Social Services (ADASS) (Ref. RG12‐016).

The research project sought, but was not granted, ethical approval to include participants who were still in violent relationships. The SCREC felt that the risks to participants did not outweigh the benefits; thus, the research could only include those who had left violent relationships. This draws attention to one of the main ethical issues in researching domestic violence, namely the physical safety of participants. Whilst it is, of course, necessary for ethics committees to ensure that all researchers minimize risk to participants, some prominent commentators in the field of domestic violence research are now arguing that some ethics committees may be going too far; conceptualizing all research on violence and abuse as ‘sensitive’ and all victims/survivors as ‘vulnerable’ leads to greater ethical scrutiny of these projects compared to others, and makes ethical approval harder to get (Downes et al. 2014). They argue that this can prevent some research from taking place, leading to a lack of evidence and thus to increased risks to those who experience violence. Downes et al. (2014) also argue that some ethics committees lack an understanding of the ways in which victims/survivors competently manage risk themselves. They also claim that ethics committees sometimes lack an understanding of the dynamics of violent relationships and insist on certain protocols which could increase risks to participants, such as written Participant Information Sheets and signed consent forms, either of which, if found by a perpetrator, could endanger a woman. A similar situation arose in the research project reported here, where, in the response to the lead researcher saying she would advise women with learning disabilities not to tell a violent (ex‐) partner that she was taking part in the research, the ethics committee stated that it was unethical to encourage secrecy in relationships.

Such concerns, alongside the fact that different ethics committees adopt different ethical standards and that those granting or withholding ethical approval may have less specialist knowledge and experience than those wishing to conduct the research, mean that some reforms may need to take place if confidence in the ethical approval system is to persist. The goal should surely be for researchers to embrace a genuine wish to have committees help them to conduct ethically rigorous research, rather than seeing ‘getting through ethics’ as an administrative hoop to be jumped through, as it often is (McCormack et al. 2012).

Data analysis

All interviews were recorded and transcribed. Data were analysed using thematic analysis, and we employed some of the principles and practices of Interpretative Phenomenological Analysis (IPA) to guide the data analysis. The rationale for using this approach is that IPA is well suited to a relatively small sample size, as it allows for in‐depth exploration of interview data and is deemed particularly suitable for under‐researched topics of inquiry (Padgett 2008).

This aim of this method of analysis ‘is to explore in detail how participants are making sense of their personal and social world’ (Smith & Osborn 2007: 54). However, it goes beyond that in that the findings from IPA research are highly nuanced. They seek to offer a detailed understanding of both the themes which have emerged across interviews and individuals’ own accounts and in this way build up a picture of the general as well as the particular experience of individuals. Analysing data, using an IPA approach, involves not only ‘giving voice’ to participants’ experiences, important though that is, but also engaging in a ‘more overtly interpretative analysis, which positions the initial “description” in relation to a wider social, cultural and perhaps even theoretical context’ (Larkin et al. 2006: 104).

Initial coding was done by two researchers independently, with a high level of agreement. Data were read and re‐read several times, then codes were identified from the data content, using inductive techniques rather than predetermined categories. Emerging codes were then clustered into subthemes, and finally into overarching themes. Themes were identified and given prominence not only because they recurred consistently across participants, but also because of persuasiveness and extensiveness, that is the strength of feeling and meaning participants conveyed when giving their accounts.

Participants

We recruited a purposive sample of women with mild learning disabilities who had experienced domestic violence. No formal assessments of learning disabilities were conducted, but all participants were recruited from professional contacts in a variety of learning disability organizations in London and the South East.

Eligibility criteria were as follows:

Women with learning disabilities who were willing and able to speak about their experiences.

Aged over 18.

Who were no longer in the violent relationship.

Domestic violence had to have occurred no more than 5 years previously.

Women in same sex relationships were eligible to participate in the research, but none were referred to it (Table 1).

Table 1

Participant characteristics

Participant	Age	Ethnicity	Relationship status at time of domestic violence	Had children
1	46	White British	Had been married	No
2	23	White British	Never married	Yes
3	28	White British	Never married	No
4	30	White British	Never married	No
5	67	White British	Never married	Yes
6	49	White British	Had been married	No
7	23	Bangladeshi	Had been married	Yes
8	31	White British	Never married	No
9	25	White British	Never married	No
10	39	White British	Had been married	Yes
11	27	Indian	Never married	No
12	36	White British	Never married	Yes
13	20	White British	Never married	No
14	41	White British	Had been married	Yes
15	33	Bangladeshi	Had been married	Yes

Findings

There were six main themes emerging from the data:

Severity of the abuse.

Psychological impact.

Women's resistance strategies.

Perpetrator issues.

Seeking help.

Life after the abuse.

Severity of the abuse

Many women reported very serious assaults and, in some cases, potentially life‐threatening injuries, for example a head injury from being pushed downstairs, being strangled and being stabbed. The use of weapons including knives, bottles and heavy objects were also reported.

He would normally like push me against the wall, grabbed my neck, I couldn't breathe… like last time, he's got like a scarf and tried to put that around my neck…the worst thing was the strangling

I felt really scared of him. I thought 1 day I'm gonna end up in a coffin.

As well as being serious, the violence was often frequent and often happened over long periods of time, in some cases, for many years.

I know it was every week, but I can't be sure if it was every day

How often did the abuse happen? To put it bluntly, everyday

It was 12 years of abuse

Another defining feature of the women's experience was that the end of relationship was not always the end of abuse. As is frequently reported in the general domestic violence literature (Fleury et al. 2000), violence, abuse and harassment often did not end when the relationship did. As some of the women in our study could describe, it often got worse:

It got worse towards the end, because after we split it got even worser. He would say he would kill me, he would say if I can't have you, no one else can.

He would phone and text me and say “I will find where you live. I'll burn your house on fire with your kids in it”

Leaving don't make no difference…they still come back for you

Domestic violence commencing or escalating during pregnancy is well established in the literature as a common phenomenon (Mezey & Bewley 1997), and it was found to be common within our sample. In fact, all of the women who had been pregnant whilst with an abusive partner reported experiencing physical assault whilst pregnant. Two women reported miscarriages which they attributed to violent assaults:

When I was pregnant he thumped me, kicked me. I lost one of the babies – and there was two, I didn't even realise I had twins. I went to hospital, I was bleeding

Sexual violence was common amongst our sample and in some of the more extreme cases, happened in front of children or when children present in the home

He raped me in front of my daughters…he threatened to cut me with a knife in my private area, he said that in front of my 7 year old.

The sexual violence was generally harder for the women to talk about than physical or other forms of abuse. It was usually not mentioned in the early stages of the interviews, but was revealed later, presumably after a level of rapport and trust had been established.

Financial abuse was also reported by many of our sample. As outlined below, many of the perpetrators had drug/alcohol problems and almost all were unemployed. The men used the women's money, both their regular income as well as savings, as a matter of course, using force where necessary and leaving the women with debts to be repaid long after the relationship had ended.

He wanted my money always, for the drugs, he's left me in a lot of debt which is what I'm still struggling with now

He would ask me for money and if I said no, he'd twist my arm. He took a lot, all the money I had been saving up

Verbal abuse was an everyday occurrence, with the women being continually insulted:

He called me a bitch, a bastard and a liar

He called me a fat bitch, ugly and a slag

Psychological and emotional abuse of women by their partners can take many and varied forms (WHO 2012). One of ways it manifested itself for the women in our study (and this was found also to be the case in Hague et al.'s 2011 study) was the perpetrators using the woman's disability itself to taunt her with:

Because I had learning disabilities and needed support, he used to drive that in my face.

He used to take the piss out of me because of my learning disability. He used to show me up in front of his mates if I couldn't work something out. He'd say “you're useless, you can't do nothing”.

Women who had additional mental health problems experienced similar treatment. For example, a woman with depression and suicidal thoughts describes how her partner would goad her:

He gave me a wire and told me to strangle myself, he wanted me to suicide myself, he wanted me to die.

Coercive control (see Stark 2007) is an all‐encompassing form of domestic violence that featured strongly in our sample. All but one of our participants experienced having their freedoms curtailed through unreasonable and non‐negotiable demands, threats and intimidation:

When I got up first thing I had to do everything he wanted. If I didn't he would hurt me straightaway. I had to bring him breakfast in bed. If I didn't, I'd get a clap round the head…I had to just leave the baby to cry…to sort him out first

He said not to talk to boys, he told me “don't wear sexy clothes”. If I did, he would hit me. He wouldn't let me see my friends.

I wanted do different things, take my son out on days out…he made me stop them, he….everything was always about him

A common form of coercive control was to deliberately isolate the woman from her friends and family. The women reported that the perpetrators did this in two main ways: either intimidating the women into stopping going to see their family and friends or using various tactics to ensure the family and friends stopped seeing the women:

he was nasty to them outside [neighbours]I lost all my friendships with the neighbours…he made it so I didn't have anyone to talk to and things like that

my oldest, kindest friends, he accused them of stealing, so they wouldn't come here again.

Some perpetrators even tried to isolate the women from their own children, particularly where the children had been taken into care and the women were desperate to maintain contact through access visits or phone calls. The perpetrators would prevent these visits and calls. Social Services Departments who were unaware of the dynamics of the violent relationship, would then infer that the women were not interested in maintaining contact with their children, with all the implications that entails. The callousness of some of the perpetrators was evident and shocking, for example:

He wouldn't even let me see my children…once I'd lost my kids [in care], he said “get rid of their photos, your kids are not coming back”

Psychological impact

As a consequence of the above, it is not surprising that the abuse the women experienced had a significant psychological impact, both on the women themselves and on their children. Many women described feeling humiliated by what was happening and how their self‐esteem became very low:

I felt hatred, towards myself

I was putting myself down, I couldn't even look in the mirror.

Some spoke of developing mental health problems, and for a few, these included self‐harm and suicidal thoughts:

I was very very low, I was on anti‐depressants and they got highered and highered

I wasn't getting any help…I took an overdose, a small one,

I tend to want to take my life…and I have got a very bad habit of trying to do that.

The women were distressed about the impact on their children. In particular, they focussed on the effect on children of witnessing their mothers being upset, humiliated or physically hurt:

There was screaming matches and he used to make my son [aged 9] believe it was my fault…but my son never liked to see me upset, so he always used to be on my side

He was dragging me and hitting me and my daughter [aged 4] was slapping him, saying “Let mummy go”. He turned around and said to her “Shut up, before you get the same”

He used to call me names in front of the children and I think it's something they do pick up on, kids, they don't understand what the names actually mean, but they pick up on it. I thought it would grow off them, but it doesn't, it stays with them.

Some women were also aware of the social and psychological implications for children of multiple moves to escape from a violent ex‐partner. One woman with two young children said ‘I moved 10 times and that's not right for kids, is it?’ Another, who had experienced very extreme and sadistic abuse from her partner, described how she struggled to bond with her eldest child, because the child physically resembled the perpetrator and said the child was receiving therapy for emotional and behavioural problems.

The psychological effects of domestic violence on the women in this study echo those found by Taggart et al. (2008, 2009) in their studies looking at risk factors for psychological distress in women with learning disabilities. They highlighted abuse as a key risk factor. Similarly, the above findings echo those by Conder et al. (2015) who found that the mental health of women with learning disabilities was adversely affected by the experience of abuse.

Women's resistance strategies

Despite the severity of the abuse outlined above and the disadvantageous position of the women in relation to the men who abused them, it would be wrong to assume that the women were simply passive victims. Resistance to domestic violence can take many forms, although the literature often focuses on physical resistance to a one‐off, violent, usually sexual, assault (Cermele 2010). In this study, the women's resistance strategies included verbally resisting/standing up to perpetrators, sometimes hitting back, rejecting apologies, using contraception secretly and reporting animal abuse to the authorities.

Many women in our study made multiple attempts to leave and of course, the ultimate resistance is to permanently leave the violent relationship, which all our sample did eventually.

Perpetrator issues

We did not speak with any of the perpetrators in this study, so any information we have comes from the women with learning disabilities, although much of it was corroborated by the professionals who referred them to the research project or by keyworkers who supported women during the interviews.

From this information, it was clear that mostly, the violent partners did not have learning disabilities themselves but did tend to have mental health problems, sometimes also alongside drug and alcohol dependency (a minority had serious physical health problems too). They tended to be jealous and manipulative, make threats of self‐harm/suicide/murder (including murder of children). They had a history of abusing previous partners and would sometimes boast of this to the woman with learning disabilities. Animal cruelty featured in several accounts of the perpetrators (the link between perpetrating animal abuse and domestic violence is well established in the literature (Febres et al. 2014) and the women stated that the men often had criminal records and were known to Police already.

Seeking help

An important general point to make here is that a lot of professionals were aware of the abuse the women were experiencing, especially healthcare workers. However, because the knowledge was gained in indirect ways and because the women with learning disabilities did not specifically ask for help in escaping from the relationship, little or nothing was done. This seems to be a common phenomenon with the general population (SafeLives 2015) and with women with physical and sensory impairments (Hague et al. 2011).

On the occasions when the women did report domestic violence, as opposed to indirectly letting it be known, a minority reported good experiences:

My social worker brought me to a safe place where people could look after me and take care of me

The Police were really helpful, really good

However, the majority experienced problems in seeking help, especially those who had children. Echoing the findings of Walter‐Brice et al. (2012), the women felt unsupported:

When we ask for help, there's no one to help us. They seem to take your children away instead of helping you [sobbing]

When I phoned Social Services to say that my Ex had our daughter living with him, even though the Court said he couldn't have her, they said “we can't do nothing about that now, she's not on the computer no more”.

Some women themselves interpreted the lack of help available to them as being due to financial reasons:

Because of all the fundings being cut they wasn't able to help me…I've got low support needs, they only assist people high…

I used to have an advocate, it's all been stopped

If you get counselling, they're only six sessions and that's for a normal person as well as a disability person… and that's not long enough for a disability person

We specifically asked our participants what information they had which might have helped them leave their relationship, that is about domestic violence services, women's refuges in particular. Their levels of knowledge were low, with 11 of 15 women unaware of what a women's refuge was, for example. This indicates that they had not been able to access information in a form that was easily understandable to them. This is therefore one of the things we have sought to rectify, by producing some accessible materials.

For women with physical and sensory impairments, the literature suggests that when accessible women's refuges are not available, disabled women who had experienced domestic violence would face the unacceptable practice of being ‘threatened with’ or indeed placed in, institutional forms of care as a way of getting them out of their homes (Hague et al. 2011). Whilst this was not a common finding in our study, there were a few such examples, including one woman who was placed in a care home for elderly and people with physical disability (she was neither). The staff there appeared to lack any understanding of the dynamics of domestic violence: she had not wanted to have any further contact with her abusive partner, but she was persuaded by the care home's staff to do so, because he was terminally ill in hospital and had a requested a last visit from her. When she visited him in hospital, he tried to assault her from his hospital bed.

Life after the abuse

As stated above, for many women, the end of the relationship was not the end of the abuse and some faced ongoing harassment, intimidation and, on occasions, serious assaults after they had ended the relationship. However, once the women were finally free, then most were able to explain, with some relish, the improvements in their lives:

I've got a good life now…

I'm very happy now. I'm going up and not down

I've got no worries now, I'm happy, a lot different, best thing I ever done

About half our sample had entered into a new relationship, in which they were happy and were well able to see the contrasts with the abusive relationships:

I've got a wonderful husband now…I'm so happy…It's a lot different…It feels like someone wants me…he helps me if I get stuck. He doesn't take the mickey out of my illness

I can do anything now…he's more loving, he's more caring.

The other women were choosing not to be in a relationship and saw this as a positive choice.

Discussion

Conceptualizing domestic violence

It appears from our study that a dominant model is to see domestic violence as an individual problem (instead of the widespread social problem that it is, historically and cross‐culturally). Thus, a woman who received a text from her ex‐partner threatening to kill her, was advised by Police to turn her phone off and get a new one. A young woman who had to have security on the entrance to the Labour Ward to prevent her violent partner from entering while she gave birth, was subsequently discharged from hospital to go home and live with him, with no follow‐up. Another woman was advised by her Care Manager that it was ‘her choice’ if she wanted to continue living with her violent partner, otherwise she should just leave. When domestic violence is seen in this way, then the solution is seen as largely in the hands of the woman herself, usually by leaving her home. However, this is a flawed response and one which fails to make links with other, similar, crimes against people with learning disabilities, notably so‐called mate crime (Gravell 2011; Landman 2014). Mate crime is where people with learning disabilities are befriended by those who are intent on abusing and exploiting them and its dynamics are very similar to the relationships many of the women with learning disabilities in our study found themselves in, that is, meeting someone who appears to like them, who then very quickly inveigles their way into their life and home and starts exerting power and control, through intimidation and violence. In Gravell's report (2011: 17), this process, whereby so‐called friends take over the homes and other resources of people with learning disabilities, is referred to as ‘cuckooing’ and it was certainly evident in our study, whereby many of the women found their new boyfriends moving into their homes at a very early stage of the relationships, before the women were comfortable with that. As to why, apart from a general lack of assertiveness, the women did not object to this, there were a number of different reasons why they could not assert their autonomy:

Firstly, some women felt that their own troubled backgrounds and personal histories contributed to them not being able to stand up for themselves:

If you don't see loving relationships when you're growing up, you'll get messed up, like I did.

I was vulnerable, cos I didn't have confidence in myself…cos I didn't have a great childhood

Others had clearly been railroaded into cementing the relationship too quickly (through manipulation, or through being easily led):

When I started seeing him, he moved in straightaway, because he was homeless…it was too easy, I just let people walk all over me, still do these days.

I was living in my own flat, but I suppose you could say I gave into him and let him come over at the weekend and he stayed 2–3 days, then it ended up 4, 5, then it was 7 and he was here!

I just don't know when to say no to somebody. I will give things to people that I can't afford to give

Like the idiot I am, he gets his foot in the door

Some women were indignant about the ways their homes had been taken over by the men they formed relationships with:

I always kept my place really clean and tidy, but once he come in, he brought all his stuff to my place and I had to live in the front room, sleeping on the settee, cos he'd junked up my bedroom with bags of his rubbish and it smelled

The problem with taking an individualized approach to domestic violence and expecting vulnerable people to find their own solutions to it, is that it is too simplistic. Notions of ‘choice’ can be masked by people's lack of, or poor, experiences. When people live in poverty, in poor housing and in social isolation, as many of those with mild learning disabilities do (Money, Friends and Making Ends Meet Research Group 2011), it is not surprising that some seek and maintain relationships which are damaging: ‘Given so few opportunities for relationships that bring warmth, mutual support and validation, then often any connection is better than none’ (Landman 2014: 359)

Capacity to exert and express choice is also relevant here. When controlling behaviour, intimidation and violence starts very early in a relationship or even before a ‘relationship’, as such, has begun, then the trauma a woman with learning disabilities might experience can compromise her ability to make choices and professionals need to be mindful of this. Whilst all the women in our study had mild learning disabilities and therefore did not lack mental capacity, per se, it is not well understood how trauma arising from violence and abuse affects decision‐making abilities, although this is starting to be recognized in the literature (Dixon & Robb 2015). It is also recognized in law: in 2010 a woman with learning disabilities, who had been assessed as having capacity to consent to use contraception whilst single, was subsequently assessed as not having capacity to consent to this, after she married an abusive partner. This was due to coercive pressure from her husband and his dominating influence over her (Local Authority vs A 2010 EWHC 1549 (Fam)).

The Mental Capacity Act (2005) states that people should receive support to help them make their own decisions. In this context, support could be interpreted as information about the help that could be available to women with learning disabilities if they wished to leave a violent relationship.

Implications for policy and practice

It is imperative that professionals involved in the lives of women with learning disabilities become more aware of the problem of domestic violence. Indeed, National Institute for Health and Care Excellence (NICE) guidelines (2014) state that ‘Health and social care service managers and professionals should ensure front‐line staff in all services are trained to recognize the indicators of domestic violence and abuse’(Recommendation 6, authors’ emphasis)

This research suggests the indicators or ‘red flags’ that staff need to pay attention to are as follows:

Women with learning disabilities in relationships with men

With no learning disabilities.

With mental health problems.

Drug/alcohol problems.

Who do not work.4

Who move in with the women very early into the relationship.

Similarly, staff should be alert to women with learning disabilities becoming more isolated (less contact with family, friends, professionals, her children (if in care)) after the start of a new relationship and if the women seem to have less money than before they meet their partners.

Clearly, any signs of physical injury need to ring alarm bells and staff should be aware that there is every likelihood of multiple forms of abuse will be taking place. Only one woman in our study experienced physical violence in isolation and all the others experienced multiple abuses and this is typical (WHO 2012).

The NICE guidelines (2014: 12) also state that staff in a variety of services, including those who work with vulnerable adults, should be trained to ask service users whether they have experienced domestic violence and abuse: ‘This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse…Ensure people who may be experiencing domestic violence and abuse can be seen on their own’.

Another priority is for healthcare and social care professionals to have a greater remit to work with those with a mild learning disability. Whilst this may sound unrealistic in times of austerity, considering the significance of public spending cuts on people with disability (O'Hara 2014), the context for this being made a priority is that almost 90% of local authorities in England no longer offer social care to people whose needs are ranked low or moderate (BBC 2014). Those at the most able end of the learning disability spectrum, have effectively been moved outside the social care system: and this renders them very vulnerable to abuse. They may live their lives in poor homes, in poor communities, socially marginalized and excluded. In their ground breaking report, giving a voice to such people, that is, those ‘with a learning disability who don't get help and support from formal services’ the Money, Friends and Making Ends Meet Research Group describe their situation thus: ‘We have very few friends who know things and can help us…lots of us have had bad experiences with past relationships. We are not in contact with many people who can support us to stop us getting into difficulties in the first place’ (2011: 23). This is not just an issue in the United Kingdom and Conder et al.'s recent paper from New Zealand (2015) details how women with a mild learning disability can and do become invisible to services and that this renders them vulnerable, particularly at times of crisis or transition.

Healthcare and social care professionals have a role in making women with learning disabilities aware of relevant laws and how to invoke them. For example, knowledge of the Domestic Violence Disclosure Scheme – commonly known as Clare's Law – could be very useful to women with learning disabilities entering new relationships and who are worried about their partner's behaviour. However, they are likely to need help to understand the process of applying for disclosure, as well as the rights and responsibilities attached to it.

This leads onto the need for joined up thinking and working between healthcare and social care professionals (including domestic violence services) and the Police. The Police response to domestic violence for those in the general population has been officially deemed as “not good enough” (HMIC 2014: 6) with only 8 out of 43 Police forces judged to be responding well to domestic abuse. As the police have little training in responding to women with learning disabilities who report domestic violence (see McCarthy et al. in preparation), confidence cannot be high that they would deal with these cases any better. Opportunities for learning from, and with, their colleagues in learning disability services should be taken wherever possible. This could happen during training and also through joint operations, as sometimes happened in mental health, when a nurse will accompany police officers when they respond to a call from a person with mental health needs.

However, working together across services, when adult social care, the police service and domestic violence services are all facing further cuts is a very difficult task indeed. The cuts to services which have already taken place, and further ones planned will inevitably hinder, not help, responses to women with learning disabilities who report domestic violence.

Limitations of study

As with all studies, there were a number of limitations to this one, which should be borne in mind. For example, the sample was relatively small and participants were all volunteers, which may have resulted in unknown biases. Also, within this sample, there is a lack of representation of women from Black Afro‐Caribbean backgrounds (although Asian women are included). This is despite active and repeated efforts of the research team to ensure Black and Minority Ethnic women were well represented.

Another limitation is that because we were not able to include women still in violent relationships, this meant we had a focus on historical cases. None of the women were discussing events more than five 5‐year‐old, so this hopefully did not have a large effect; nevertheless, they were relying on memory.

Finally, the participants were all women who were able to reflect on, and enter into lengthy discussions about, their experiences. Thus, the experiences of those at the more severe end of the learning disability spectrum are not included.

Conclusion

There is nothing about having a learning disability which protects women from domestic violence. This research, and that of others such as Walter‐Brice et al. (2012), suggests that the full range of mental, physical and sexual cruelty which is inflicted on other women, is also inflicted on women with learning disabilities.

In view of this, this paper has argued that healthcare and social care professionals have a clear role in trying to help women with learning disabilities to recognize domestic violence and to avoid or leave violent relationships. Specific recommendations have been made about recognizing indicators of domestic violence and being pro‐active in asking women if they need help. As well as these measures, in a more general sense, healthcare and social care professionals should seek to enhance the independence, and improve the lives, of women with mild and moderate learning disabilities in a broad sense, for example through developing their social networks (McConkey 2010) and through employment (Forrester‐Jones et al. 2004) and other meaningful interests and activities:

“As long as the most, and sometimes only, valued thing in a woman's life is her relationship with a man, this will leave her emotionally and psychologically dependent and vulnerable to exploitation and abuse” (McCarthy 2014b: 5)

In assisting women with learning disabilities with regard to domestic violence, there is a clear and strong role for advocacy, including self‐advocacy and specifically women's groups (Martin et al. 2012). In this research project, we found that some women were keen to get more involved in domestic violence work and to offer help and support to each other.

Women with learning disabilities also need accessible information, so that they become aware of the infrastructure which exists to help other women who are seeking to leave violent relationships. Only four of fifteen women in this study had heard of women's refuges at the time they were in the violent relationship. However, there would be little point in providing accessible information, if the services do not, in turn, make themselves accessible to women with learning disabilities (Hague et al. 2011). This research therefore offers a clear challenge to those in both the learning disability and domestic violence spheres to work together to help women with learning disabilities, whose experiences do not differ greatly from those of other women, but who are often less able to act on their own behalf.

Disclaimer

This paper presents independent research commissioned/funded by the NIHR School for Social Care Research. The views expressed in it are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health, NIHR or NHS.

Conflict of Interests

No conflict of interests.