Archives

Medicine’s reckoning with genocide and crimes against humanity

Gene Feder, Professor of Primary Healthcare and VISION Director, has written an opinion piece with colleagues stating that accountability for human rights must guide every collaboration in medicine and science.

In their BMJ publication, Medicine’s reckoning with genocide and crimes against humanity, the authors build the case that in the nearly eight decades after the Genocide Convention in 1948, prevention has advanced in principle but faltered in practice. Many states remain indifferent, but medicine must not. Beginning with genocide, medical and academic leaders have a duty to implement reforms to safeguard the line between valuable collaboration and toxic complicity, break institutional silence, and declare medicine’s commitment to the right to existence and life for all peoples, in all states.

For further information: Please contact Gene at gene.feder@bristol.ac.uk

To cite: Minhas R, Shellah D, Maynard N, Goodwin-Gill G, Chalmers I, Feder G et al. Medicine’s reckoning with genocide and crimes against humanity BMJ 2025; 391 :r2277 doi:10.1136/bmj.r2277

Photograph from Adobe Photo Stock subscription

Impact of consecutive COVID-19 lockdowns on GP referrals of women experiencing domestic abuse in England and Wales

To curb COVID-19, three periods of severe physical distancing measures (‘lockdowns’) were imposed by the Government throughout 2020 and 2021 in England and Wales: between 23 March and 1 June 2020 (68 days), 5 November 2020 and 2 December 2020 (27 days) and between 6 January and 8 March 2021 (61 days). These lockdowns resulted in societal changes, including full or part-time school and workplace closures, and reduced community mixing.

The pandemic also necessitated a change in clinical consultations in primary care, with a shift from predominantly face-to-face to mostly remote consultations (telephone, digital and video), complicating the provision of care and support, including safeguarding. The lockdowns made it harder for people to disclose domestic violence and abuse (DVA) to health professionals, as online consultations can form barriers to support.

Long and enforced lockdowns can make it harder to disclose DVA and can have a detrimental impact on DVA victim-survivors and their families. Previous studies suggest that the COVID-19 pandemic and its lockdowns have led to an increase in DVA incidence. Refuge, the organisation running the 24-hour national DVA helpline in England, reported that calls surged by 60% during 2020 compared with the previous year. There is, however, scarce evidence on the impact of consecutive lockdowns over a period of almost 2 years on referrals from primary care to DVA support services in England.

The research team, led by Dr Jasmina Panovska-Griffiths and others including VISION researchers Professor Gene Feder and Dr Estela Capelas Barbosa, evaluated the impact of the three successive national lockdowns on the referrals from general practice (GP) to the Identification and Referral to Improve Safety DVA services. Their study, Interrupted time series and non-linear regression analyses to evaluate the impact of the three consecutive COVID-19 national lockdowns on the general practice referrals of women experiencing domestic violence and abuse in England and Wales, is the first to evaluate the continual impact of the COVID-19 pandemic and the three consecutive national lockdowns in 2020 and 2021 on DVA referrals. The researchers also explored the relationship between stringency of lockdowns and number of DVA referrals.

Anonymised data on daily referrals, interrupted-time series and non-linear regression quantified the impact of the three national lockdowns over 2020 and 2021 comparing analogous periods in the 2 years before and after, reporting incidence rate ratios, 95% Confidence Intervals and p values. Time spent at home and workplace visits over the lockdown periods were quantified as proxies for the stringency of the different lockdowns.

The first national lockdown in early 2020 led to a reduced number of referrals to DVA services. Over the second and the third lockdown, there was a possible increase in the number of referrals. The first national lockdown was more stringent (58% decline in workplace visits; 22% increase in time spent at home) than the second (34% decline in workplace visits; 14% increase in time spent at home) or the third (18% decline in workplace visits; 18% increase in time spent at home).

Increased freedom of movement alongside easier access to GP services during the two latter, less stringent, lockdowns compared with the first, stringent, lockdown could have contributed to the different trends in referrals. The research team determined that ensuring access to primary care and adequate and continuing provision of specialist support for people experiencing DVA is important during national emergencies. Further research, coproduced with DVA survivors and DVA agencies, is necessary to establish and evaluate the most appropriate support during both potential future national lockdowns and other systemic closures (eg, school holidays).

Recommendation

More stringent systemic closures will lead to a reduced number of referrals to a specialist DVA programme, while more relaxed system closures may result in increased referrals. This highlights the importance of ensuring adequate access to support, such as primary care, where people can safely disclose DVA and be referred to service providers during system closures, regardless of the stringency.

For further information: Please contact Jasmina at jasmina.panovska-griffiths@queens.ox.ac.uk

To cite: Panovska-Griffiths J, Szilassy E, Downes L, Dixon S, Dowrick A, Griffiths C, Feder G, Capelas Barbosa E. Interrupted time series and non-linear regression analyses to evaluate the impact of the three consecutive COVID-19 national lockdowns on the general practice referrals of women experiencing domestic violence and abuse in England and Wales. BMJ Public Health. 2025;3:e002408. https://doi.org/10.1136/bmjph-2024-002408

Photograph from Adobe Photo Stock subscription

Neighbourhood characteristics and violence rates: Investigating associations over time

Violence is a critical issue in the UK, both in terms of its impact on individuals and communities and its prominence in public and media discourse. Violence has many negative effects for victims, ranging from emotional and/or physical impacts to isolation and withdrawal from social life. Victims of violence suffer the effects for longer periods of time compared to victims of other crime types and the societal economic cost of violence is also considerable with the total cost of violence in London alone in 2018–19 was £3 billion.

Few studies have examined violence at the neighbourhood level, and even fewer have investigated how changes in neighbourhood characteristics relate to changes in violence over time. The recent study, Increases in disadvantage and instability are associated with rising violence, led by Ferhat Tura (Bournemouth University) with Oluwole Adeniyi (Nottingham Trent University) and VISION researchers Ruth Weir (City St George’s University of London) and Niels Blom (University of Manchester) investigates the association between changes in neighbourhood characteristics and changes in violence rates in England and Wales between 2011 and 2021.

They argue that rising levels of social disadvantage—particularly in relation to unemployment, poor health, lone-parent households, residential mobility, and social housing—are associated with increased neighbourhood-level violence.

The research team highlights that increased ethnic heterogeneity when it coincides with growing deprivation (e.g. poor health and no qualification) is associated with rising violence risk. There is a need to address structural inequalities through investment in housing, health, education and community stability. Policy responses should extend beyond criminal justice to promote long-term violence reduction and community well-being.

Recommendation

Social policies should focus on long-term investment in deprived neighbourhoods, including affordable and stable housing to reduce residential turnover and improve long-term outcomes for residents.

For further information: Please contact Ferhat at ftura@bournemouth.ac.uk

To cite: Ferhat Tura, Ruth Weir, Niels Blom, Oluwole Adeniyi, Increases In Disadvantage and Instability Are Associated With Rising Violence, The British Journal of Criminology, 2025;, azaf080, https://doi.org/10.1093/bjc/azaf080

Photograph from Adobe Photo Stock subscription

Assisted dying bill: Safeguards against domestic abuse and coercion must be strengthened

One in four women and one in seven men in England and Wales have experienced domestic abuse. Coercive and controlling behaviours are core to domestic abuse. They result in loss of autonomy and independence and are intended to isolate and reduce self-worth. Such behaviours are common but hard for health professionals to detect.

If passed, the Terminally Ill Adults (End of Life) Bill will allow people who are terminally ill and expected to die within six months to request assistance to end their lives. VISION researchers Gene Feder, Elizabeth (Lizzie) Cook and Sally McManus have written an opinion published in The BMJ that calls for safeguards in the bill need to be strengthened to prevent coercion in the context of domestic abuse.

Assisted dying requires a careful consideration of the risks posed by domestic abuse and coercion. The current bill does not fully tackle specific safeguarding concerns for patients experiencing domestic abuse which can include economic, emotional, physical, and other forms of abuse from a partner or other family member. To safeguard against domestic abuse and associated coercion, Gene, Lizzie and Sally propose a set of principles that should be part of the UK bill.

  1. For doctors responding to any request for assisted dying, training must be extensive, specialist, in person, and backed up by referral pathways.  Independent domestic abuse advocates, with expertise in recognising coercive control, could contribute to assessment of assisted dying requests. 
  2. Commitments to confidentiality and data security must not obscure assisted dying decisions and the contexts in which they occur. The bill must ensure transparency.
  3. The bill must establish accountability. Transparent data about each stage of the approval process would also enable monitoring and regular scrutiny of the processes and outcomes of assisted dying legislation.
  4. Lawmakers must resist expansion. Dementia and mental health conditions are now being considered for eligibility. These are conditions prevalent in survivors of domestic abuse. The UK bill should include clauses that limit any expansion of scope to other conditions and situations.

To read the opinion piece: Safeguards against domestic abuse and coercion in the assisted dying bill must be strengthened

To cite: BMJ 2025;390:r1914

For further information, please contact Gene at gene.feder@bristol.ac.uk

Arms industry as a commercial determinant of health

Experts are urging the medical profession to confront the global arms industry as the UK and other NATO nations dramatically increase defence spending to counter growing global aggressions, one under-recognised aspect of security debates is the role of the arms industry. And as London prepares to host the world’s largest arms fair, Defence and Security Equipment International, health professionals must do more to resist the arms industry’s influence on government agendas and its damaging effects on human and planetary health.

Looking critically across this landscape, the BMJ has produced a new series examining the role of the arms trade in health and calling for more scrutiny of its health-harming activities and its unhealthy relationship with governments.

In the series, two VISION researchers, Professor Mark Bellis of Liverpool John Moores University and Professor Gene Feder from University of Bristol, with colleagues, lay out the direct and wider harms of arms and show how weapons manufacturers use commercial strategies to subvert public health agendas and shape discourse around security and violence.

They argue that, like the tobacco, alcohol, and fossil fuel industries, the arms industry should be seen as a commercial determinant of health, where corporate practices matter as much as products when considering how industries can harm health.

These practices include marketing, lobbying, funding of think tanks and universities, and forging close relationships with governments, which the industry uses to shape public policy and regulatory environments in its favour while deflecting responsibility for its contribution to perpetuating conflict, injuries, and death.

Mark, Gene and colleagues’ analyses suggest that examining these industry dynamics can help uncover both direct and systemic health harms and inform how health considerations should feature alongside defence and profit.

They acknowledge that this is a conceptual shift but say “it is also a call to action for health professionals including researchers, policy makers, and civil society to advocate for a reorientation away from design, distribution, and deployment for profit and towards global priorities of health, human rights, and peace.”

To access the entire BMJ Series : Arms industry as a commercial determinant of health | The BMJ

To access the analyses by Mark, Gene and their colleagues:

For further information, please contact Mark at m.a.bellis@ljmu.ac.uk

Illustration from University of Bristol

What is tech abuse and how can we tackle it?

Drs Leonie Tanczer and Madeleine Janickyj of the University College London (UCL) Gender and Tech Research Lab and the VISION research consortium, developed a policy briefing, What is tech abuse and how can we tackle it?, with their colleagues at the Gender and Tech Research Lab and the UCL Policy Impact Unit.

Technology-facilitated abuse (tech abuse) refers to the deliberate (mis)use or repurposing of digital systems to coerce, harass, or abuse others. While it is most commonly associated with domestic abuse and stalking, it also occurs in professional and institutional contexts, as well as from strangers.

It is a widespread problem: in the UK, 1.4 million women experienced domestic abuse in 2023-24. In abusive intimate relationships, tech abuse can extend and intensify existing patterns of coercive control, leading to greater levels of harm. Abusers may, for example, send persistent, obscene, or threatening digital communications or track a partner’s movements via GPS or app surveillance. They may also restrict access to accounts, services, or finances.

Despite a shared understanding of tech abuse across sectors and stakeholders, a consensus remains lacking on its precise definition and scope. This definitional ambiguity hinders efforts to measure its prevalence and impact, ultimately limiting how effective prevention and intervention strategies can be.

Recommendations

Tackling tech abuse requires a whole systems approach and better measurement. Other recommendations include:

  • Enforce safety-by-design principles and mandatory abusability testing for technology products to proactively address potential misuse
  • Deepen understanding of perpetrator behaviour and motivations to inform prevention and intervention strategies
  • Leverage innovative methods, such as machine learning, to better understand and respond to tech abuse
  • Improve coordinated responses from police, frontline domestic abuse services, tech companies, and government/international bodies, backed by sufficient and sustainable funding
  • Future-proof policies and regulations, clarify responsibility, and determine accountability across different stakeholders
  • Stop the normalisation of Tech Abuse to support more victims/survivors to seek help, including through honest conversations around digital consent

To download: What is Tech Abuse and how can we tackle it?

To cite: Janickyj, M., Koukopoulos, N., Polamarasetty, A., Reed, J., & Tanczer, L. M. (2025). Policy Brief: What is Tech Abuse and how can we tackle it? Gender and Tech Research Lab, University College London.

For further information, please contact Maddy at m.janickyj@ucl.ac.uk

Illustration from Adobe Stock subscription

Impact of verbal abuse as a child just as harmful as physical abuse

Globally, one in six children are estimated to suffer physical abuse within domestic and family relationships. As well as immediate health risks associated with the physical trauma of abuse, physical abuse can have lifelong impacts on mental and physical health and well-being. Thus, even as adults, individuals who have been physically abused as children show higher levels of anxiety and depression as well as more problematic alcohol and drug use.

As a source of toxic stress, verbal abuse, like physical abuse, may affect the neurobiological development of children, leading to immediate and long-term impacts on health and well-being. Like physical abuse, verbal abuse has also been linked with poor mental and physical health outcomes during childhood and across the life course. Increasingly, empirical evidence supports verbal abuse causing damage to child development.

For the study, Comparative relationships between physical and verbal abuse of children, life course mental well-being and trends in exposure: a multi-study secondary analysis of cross-sectional surveys in England and Wales, VISION researcher Professor Mark Bellis and his team, combined data from multiple studies measuring child abuse across England and Wales. They tested the associations with poorer mental well-being across the life course with experiencing physical abuse or verbal abuse as a child individually as well as the impact associated with combined exposure to both abuse types.

Their research showed that exposure to childhood physical or verbal abuse has similar associations with lower mental wellbeing during adulthood. In fact, results identified around a 50% increase in likelihood of low mental wellbeing related to exposure to either form of abuse. With regard to verbal abuse, children who experienced ridicule, threats or humiliation from a parent / guardian have a 64% higher chance of poor mental health as an adult. The researchers also discovered that whilst physical abuse reduces over time, verbal abuse increases.

Verbal abuse may not immediately manifest in ways that catch the attention of bystanders, clinicians, or others in supporting services with a responsibility for safeguarding children. However, as suggested here, some impacts may be no less harmful or protracted. The potential impact of verbal abuse should be better considered in policy, and parenting and child protection interventions. The potential role of childhood verbal abuse in escalating levels of poor mental health among younger age groups needs greater consideration.

Recommendation

Interventions to reduce child abuse, including physical chastisement, should consider both physical and verbal abuse and their individual and combined consequences to life course health.

To download: Comparative relationships between physical and verbal abuse of children, life course mental well-being and trends in exposure: a multi-study secondary analysis of cross-sectional surveys in England and Wales

To cite: Bellis MA, Hughes K, Ford K, et al. Comparative relationships between physical and verbal abuse of children, life course mental well-being and trends in exposure: a multi-study secondary analysis of cross-sectional surveys in England and Wales. BMJ Open 2025;15:e098412. http://doi:10.1136/bmjopen-2024-098412

For further information, please contact Mark at m.a.bellis@ljmu.ac.uk

Illustration from Adobe Stock subscription

Violence in later life: Life course and physical and mental health trajectories

Research has demonstrated that violence is associated with worse health in older age. Most of the evidence, however, comes from cross-sectional studies. Research showing how health changes over time in people who have experienced lifetime violence is very scarce.

To address this gap, VISION researchers, led by Dr Anastasia Fadeeva with colleagues Dr Polina Obolenskaya, Dr Estela Capelas Barbosa, Professor Gene Feder and Professor Sally McManus, used seven waves of data from the English Longitudinal Study of Ageing (ELSA) collected between 2006 and 2019 (waves 3 to 9), to examine the associations between parental physical abuse in childhood and any physical or sexual violence across the life course, with the subsequent changes in depressive symptoms, the likelihood of probable depression, and long-standing limiting illness.

The team used a sample of 6171 participants aged 50 and over who answered all questions about violence exposure in wave 3 of ELSA, while information about their health was collected from wave 3 to 9.

The VISION study provides new evidence that health consequences are sustained throughout later life. Results showed that violence of different kinds predicts poorer physical and mental health in older age. Furthermore, the health disparities between victims and non-victims did not reduce over time. This was evident in both men and women.

The findings highlight the value of implementing violence prevention measures throughout the life course, not only to mitigate immediate consequences of violence and abuse but also to reduce the burden of ill health in older age. The results also underscore the need to identify modifiable risk factors such as violence in order to inform polices aiming to promote healthy ageing. More longitudinal data, including from administrative sources, are needed to further demonstrate the associations between different types of violence and health outcomes as people age.

Recommendation

Healthy aging could be improved by preventing violence across the life course. Reducing and addressing experiences of violence at a younger age could reduce the burden of – and inequalities in – poor health in later life.

To download: Violence across the life course and physical and mental health trajectories in later life: a 13-year population-based cohort study in England

To cite: Anastasia Fadeeva, Polina Obolenskaya, Estela Capelas Barbosa, Gene Feder, Sally McManus, Violence across the life course and physical and mental health trajectories in later life: a 13-year population-based cohort study in England, The Lancet Healthy Longevity, Volume 6, Issue 7, July 2025, 100738 https://doi.org/10.1093/bjc/azaf064

For further information, please contact Anastasia at anastasia.fadeeva@citystgeorges.ac.uk

Photograph from Age Without Limits image library.

Online and offline stalking victimisation in the Crime Survey for England and Wales

Stalking is a global phenomenon described as a pattern of repeated, intrusive behaviours that cause fear, alarm, and distress in the victim/survivor. Over the past two decades, offline stalking, a repeated pattern of behaviours such as physically following a person, which causes fear and distress, has been complemented through online and digital means also known as cyberstalking. Cyberstalking includes the use of the internet, email, and/or systems such as geo-location trackers to further the perpetrators’ reach and amplify the feelings of harassment experienced by a victim/survivor. 

Technology-facilitated harassment is increasingly common, but there is a lack of longitudinal analysis quantifying cyberstalking and its impact on victim/survivors. To address this empirical evidence-based gap, VISION researchers Drs Madeleine Janickyj and Leonie Tanczer at University College of London and Dr Niels Blom at University of Manchester, examined Crime Survey for England and Wales (CSEW) data from the years 2012 to 2020 to provide the first nationally representative look at cyberstalking over the last decade. Their paper, Online and Offline Stalking Victimisation in the Crime Survey for England and Wales: Its Predictors and Victim/Survivors’ Views on Criminalisation, assesses which demographic groups are most likely to experience it across two countries of the United Kingdom (UK; for example, England and Wales) and also explores how these experiences affect the perception of the victim/survivors.

The analysis, involving weighted and multinomial logistic regression, revealed considerable differences between online and offline stalking behaviours. Cyberstalking is not as widespread, but is increasing in prevalence faster than its offline counterpart.

The researchers also assessed the relationship between perpetrators and victim/survivors and found that less than 50 per cent of cyberstalking victim/survivors had an existing relationship with their stalker. Moreover, various demographic groups, such as females, the LGB community, and younger participants, are more likely to be stalked via both online and offline means. While females are more likely to view what happened to them as a crime, the latter two (LGB and younger participants) more often perceive these experiences as wrong but not necessarily a crime. Although these experiences increasingly affect participants, they do not alter their perception of the event in the same way, exposing that these online experiences are thought of differently from those offline.

Recommendation

To further the analyses of cyber-enabled and cyberstalking, some adjustments could be made to the existing stalking experiences that participants are asked about. One current question merges receiving cards, letters, or text messages, combining online and offline experiences. Separating this item into two questions would give more accurate data regarding cyberstalking.

To download: Online and Offline Stalking Victimisation in the Crime Survey for England and Wales: Its Predictors and Victim/Survivors’ Views on Criminalisation

To cite: Madeleine Janickyj, Niels Blom, Leonie Maria Tanczer, Online and Offline Stalking Victimisation in the Crime Survey for England and Wales: Its Predictors and Victim/Survivors’ Views on Criminalisation, The British Journal of Criminology, 2025;, azaf064, https://doi.org/10.1093/bjc/azaf064

For further information, please contact Maddy at m.janickyj@ucl.ac.uk

Photograph from Adobe Stock subscription

Carers’ increased risk of domestic violence and poor health outcomes

The poor health of unpaid carers is well-established, and evidence also shows they experience high levels of domestic violence. However, the links between domestic violence and carers’ poor health remains overlooked. The study, Health morbidities in carers with experience of domestic violence and abuse, led by Drs Juliana Onwumere and Emilie Wildman of King’s College London along with research team member Professor Sally McManus, VISION co-Deputy Director, and others, examined this relationship using the Adult Psychiatric Morbidity Survey (APMS), a representative sample of the adult population of England.

The results show that carers are more likely to be female, older, economically inactive, and in debt than non-carers, and that carers tend to have worse mental and physical health. One in three carers reported having had experience of domestic violence. With adjustment for confounders, carers were more likely than non-carers to be victims of physical, emotional and sexual forms of violence and abuse. People with experience of both caring responsibilities and domestic violence had particularly poor mental and physical health outcomes (compared to carers and non-carers without experience of domestic violence, as well as non-carers experiencing domestic violence).  

NICE guidelines state that carers should be offered training to help them to provide care safely, including support around managing challenging behaviour from the person being cared for. However, professionals can struggle to identify and respond to carers’ experiences of domestic violence. Facilitating routine enquiry in carers is essential, particularly given that carers often delay seeking support for their own needs carers and may not readily and independently disclose their experiences of violence to professionals.

Recommendations

Efforts to incorporate inquiry into experiences of domestic violence into carers’ needs assessments, which unpaid carers are entitled to, may help facilitate identification and referral to appropriate support services.

Carers high risk of domestic violence goes largely unrecognised in UK policy and practice. This is a sensitive and hidden topic; these findings suggest that addressing carers’ poor health requires also identifying – and addressing – their experiences of domestic violence.

To download: Health morbidities in carers with experience of domestic violence and abuse

To cite: Wildman, E.K., Dickson, H., MacManus, D. McManus, S., Kuipers, E., Onwumere, J. Health morbidities in carers with experience of domestic violence and abuse. Soc Psychiatry Psychiatr Epidemiol (2025). Https://doi.org/10.1007/s00127-025-02959-4

For further information, please contact Juliana at juliana.1.onwumere@kcl.ac.uk

For further information about APMS, contact Sally at sally.mcmanus@citystgeorges.ac.uk

Photograph from Age Without Limits