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August 2009 | Back to Table of Contents

Clinical and Health Affairs

How to Screen for Intimate Partner Violence

Susan McCormick Hadley, M.P.H.

ABSTRACT
Domestic violence affects individuals in every part of the world, regardless of age, economic status, race, religion, nationality, or educational background. In the United States, domestic violence affects as many as 3 million women each year. Physicians and other health care providers have a unique opportunity to screen their patients—both female and male—for domestic violence or abuse. This article describes signs and symptoms of domestic violence that physicians should look for when seeing patients in the medical office or hospital and offers guidelines for initiating a discussion with patients who might be victims or abusers.

Domestic violence is a genuine public health epidemic that affects women and men all over the world. It occurs within all socioeconomic groups; among people of every race, ethnic group, age, and religion; and within both heterosexual and same-sex relationships.1 A recent World Health Organization (WHO) report on physical abuse against women in 35 countries indicated that 10% to 52% of women reported physical abuse, 10% to 30% reported sexual violence, and 10% to 27% reported being abused sexually as a child and/or adult.2,3 In the United States, domestic violence is estimated to affect between 1.5 million and 3 million women annually, with one woman in four experiencing violence from a male partner at some point during her lifetime.4 The estimate is imprecise because the extent of domestic violence is virtually impossible to measure for a number of reasons including the fact that the social stigma deters victims from disclosing their abuse.5

Domestic abuse or intimate partner violence (IPV) is a pattern of psychological, economic, and sexual coercion of one partner in a relationship by the other; it is punctuated by physical assaults or credible threats of bodily harm.6 The targets of the abuse are primarily women and their children. More than 85% of cases involve women being abused by men,* with cases of men being abused by women being much less common.1,7

Because victims of IPV will need both preventive health care and treatment for injuries and symptoms, health care providers may be the first and only professionals in a position to recognize violence in a woman’s life.8 Yet, there has been debate about whether routine screening for domestic violence is effective. The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse.9 However, numerous medical organizations including the American College of Obstetrics and Gynecology, the American Academy of Family Physicians, and the American Medical Association continue to recommend inquiring routinely.

This article provides tips on how to create an environment that encourages patients to discuss what is happening to them at home, information to help physicians recognize signs of abuse, questions to ask patients, and pointers on how to assist victims who disclose abuse.

Create a Climate of Confidentiality 
Before a patient will reveal to you, her health provider, any intimate details about the domestic violence in her life, she needs to feel that she will be taken seriously, that her privacy will be protected, and that her safety and security will be assured. Thus, health care providers and clinic staff should convey to every patient that the medical office or clinic is a safe place to talk confidentially about any issue, including domestic abuse.

Posters and brochures placed in exam rooms, waiting areas, and bathrooms along with buttons worn by staff should state that IPV is a health issue and that patients should feel free to talk to their providers about any violence affecting their lives. Clinic staff should also assure patients that privacy and confidentiality are priorities and let them know if there is a designated staff person who can provide them with information about domestic violence and available community resources.

All screening should be done in private. Under NO circumstances should a woman be questioned about IPV in the presence of her partner or a nonprofessional language interpreter such as a friend or relative. Anyone accompanying a patient to the clinic should be told that the practitioner needs at least five to 10 minutes alone with the patient during the visit.

Pay Attention to Certain Populations 
In a primary care or inpatient setting, you should screen the following patients for domestic or other forms of abuse: all women and adolescent girls, men and adolescent boys who present with symptoms or signs of abuse, and all children.

Pay particular attention to women who are pregnant. Domestic violence is common during pregnancy and should be discussed during routine prenatal and postpartum visits.10 In a study of data from 2000, Gazmararian et al. found that more than 324,000 pregnant women in the United States were battered annually.11 In addition, they found that domestic violence is more common in pregnant women than gestational diabetes or preeclampsia, conditions for which pregnant women are routinely screened.

Broach the Subject Once alone with the patient, the clinician should broach the topic in a general way (Table 1). The following are suggestions for initiating the conversation:

  • We’re concerned about the health effects of domestic violence, so we ask a few questions of all our patients.
  • Because domestic abuse and violence have become so common in our culture, we’ve started to routinely assess all of our patients about these problems.
  • I don’t know if this is a problem for you, but because so many patients we see are living in or recovering from an abusive relationship, we’ve started to ask all of our patients about it routinely.
  • Domestic violence is a problem for many women. Because it affects their health and well-being, we ask all of our patients about it.

Once you introduce the subject, you should ask three direct questions:12

  • Have you been hit, slapped, kicked, punched, or otherwise hurt by someone within the past year? If yes, by whom?
  • Do you feel safe in your current relationship?
  • Is there a partner from a previous relationship who is making you feel unsafe now?

If a patient discloses abuse, follow up with these questions:

  • If a patient discloses abuse, follow up with these questions:
  • Where will you go after you leave my office?
  • Is there a friend, neighbor, or family member you can call?
  • Do you need immediate shelter?

In addition, convey these messages:

  • You do not deserve to be abused. You are not responsible for the abuse. You did not cause it.
  • You cannot fix it. What happened to you is a crime; it’s against the law. There is help available.

It is important to understand that the victim is not likely to bring up domestic abuse or disclose it the first time you ask. The victim needs to perceive you as being safe and nonjudgmental; she needs to learn to trust you before she will disclose private information, and that may take time. On the other hand, most victims are relieved to be asked about the abuse and may open up if you ask simple, direct questions in a nonjudgmental way.

If a patient does not disclose domestic abuse or violence, you might reassure her that if anything ever does happens to her or to someone she knows, your office or the hospital are safe places where she can talk confidentially about her situation. If you have concerns about her safety, you could express them using “I” messages such as these:

  • I am really concerned for your safety.
  • I’d like to give you a toll-free number for the National Domestic Violence Hotline.

Let her know that someone is at the other end of the hotline 24 hours a day, seven days a week to talk about anything related to IPV. (The hotline is also available to health care providers as a resource.) In addition, tell her you’d like to schedule a follow-up appointment so that you can see how she is doing.

DO NOT give her written information that the abuser may find when she returns home; you may be endangering the victim if her partner suspects or discovers she has talked with you about the abuse. Consider writing a contact number on a small piece of paper that she can insert in her shoe, where she can access it later.

Note the Partner’s Behavior 
The word “hover” describes a common and recognizable behavior displayed by domestic abusers when they are around their partner. The abuser may appear controlling, want to explain why the patient is there, and try to answer the questions you might have. Notice whether the patient defers to the partner or if she seems hesitant to speak up in front of him or to disagree with him. It is a serious red flag when the abuser won’t leave the partner with you, as he may be concerned about what she might disclose.

Generally, abusers hold traditional views of gender roles and parenting and often blame their partners for the abuse. In addition, the patient may actually deny or minimize any abuse or violence if the partner is present or nearby. This reinforces the importance of interviewing the victim alone, as it is simply not possible to obtain an accurate view of the home situation with the partner present.

Assess for Physical Findings and Mental Health Symptoms No single sign or symptom will confirm the presence of interpersonal violence. Instead, you should look for a pattern of injuries and symptoms. Watch for a combination of indicators and be alert for clues that require further exploration.13,14

Consider the possibility of domestic assault when a patient’s explanation of how an injury occurred does not seem plausible or match the story given or when there has been a delay in seeking medical care. It is often useful to have the patient change into a gown, as it may give you a chance to see if she has other, less-visible injuries. Be suspicious of the following:

  • Contusions, abrasions, lacerations, fractures or sprains, and multiple injuries in various stages of healing;
  • Injuries at multiple sites;
  • Repeated or chronic injuries;
  • Injuries to the face, head, neck, chest, breasts, or abdomen;
  • Missing clumps of hair at the back of the head;
  • Choke marks on the neck;
  • Bruises on the chest, breasts, abdomen, and genitals;
  • A fractured mandible, nasal fractures, or perforated tympanic membrane;
  • Burns or whip-like bruises;
  • Grab marks on the upper arms or contusions on lower arms that may have been caused by warding off blows;
  • Unexplained injuries or types of injuries that are incompatible with the patient’s explanation of how they occurred; and
  • Swollen knuckles possibly from fingers being twisted.

In addition to injuries, you should consider the possibility of domestic abuse in patients who have a number of other vague and nonspecific complaints including chronic or diffuse pain, sleep and appetite disturbances, fatigue, sexual dysfunction, chronic headaches, abdominal and gastrointestinal complaints, palpitations, dizziness, paresthesias, dyspnea, atypical chest pain, and gynecologic problems such as frequent vaginal and urinary tract infections, dyspareunia, and pelvic pain.

Note that signs of abuse in pregnant women include injuries to the breasts, abdomen, and genital area; unexplained pain; substance abuse; poor nutrition; depression; late or sporadic access to prenatal care; “spontaneous” abortions; miscarriages; and premature labor. Also note that the following indicators have been identified as being more prevalent among women who report domestic violence: unintended pregnancy, unhappiness about being pregnant, young maternal age, single marital status, higher parity, late entry into prenatal care and missed appointments, and substance use and abuse.

Be aware that the stress of living with domestic violence may exacerbate comorbid psychiatric or mental health disorders. Symptoms might include suicide attempts, anxiety, difficulty concentrating, panic attacks, and insomnia. Also be aware that chronic illnesses such as asthma, seizure disorders, diabetes, arthritis, hypertension, and heart disease may be exacerbated by abuse or poorly controlled in patients who are being abused. Because of the abusive partner’s control over the victim, she may have limited access to routine and/or emergency medical care and thus not be able to obtain medications or comply properly with medical treatment.

Assess for Danger 
In addition to identifying domestic violence and abuse, health care providers need to help women assess the extent to which they are in danger. Victims who are attempting to break away from a partner are at particular risk, as leaving an abusive relationship may be the most dangerous time in that relationship. The Danger Assessment Instrument is a useful tool for helping victims identify their level of risk.15 It assesses for threatening behavior, the presence of weapons, drug and alcohol abuse, an increase in the frequency and severity of abuse, abuse of children or pets, abuse during pregnancy, and other signs of violence.

Contact Police Only with Permission 
Contacting law enforcement can put the patient in significant danger, which is why physician and other provider groups including the American College of Emergency Physicians oppose mandatory reporting of domestic violence to the criminal justice system.16 Ultimately, reporting an incident may interfere with the confidential nature of the provider-patient relationship, infringe on privacy issues, and undermine the patient’s trust in you if she believed your office was one of the few places she could turn to for assistance. For those reasons, you should only connect a patient with social service agencies and the criminal justice system if she wishes that you do so.

Leaving a relationship is a long-term process. Many victims of IPV will leave when they have the support, strength, and resources to do so. Helping a patient make informed decisions and respecting her timetable will help her move herself and her children toward safety.

Help Develop Safety and Escape Plans 
A patient may not know how to plan her escape. She may need your help as she begins to think about leaving an abusive partner. Because abusers often try to isolate their partners, thereby preventing them from getting a “reality check” by talking with others, a victim may not have anyone with whom she can stay. Let her know that resources are available. Recommendations for safely escaping an abusive relationship can be found at www.Leaving.Abuse.com. Local domestic violence shelters can provide additional help (Table 2).

Whether the patient is planning to leave the abusive partner immediately (which is less common) or in the future, her safety should be the top concern. She needs to develop a safety plan, a strategy for reducing the risks generated by her partner’s behavior. That safety plan might include such things as identifying friends who could keep a packed bag, opening a separate bank account, and having important phone numbers nearby such as those for a crisis line and safe and supportive family members or friends. You can find more information on safety planning at www.domesticviolence.org/personalized-safety-plan.

Key Points to Remember When treating and intervening with victims of IPV, remember the following points:

Time is critical. Early effective intervention by a health care provider can interrupt the cycle of violence, prevent more serious injuries and symptoms, prevent long-term mental and psychiatric symptoms, and ultimately prevent abuse to children.
You do not have to solve the victim’s problems. Resist the impulse for a quick fix, as that is very unlikely; accept the fact that many victims need time before they are ready to talk or accept help. Leave the door open. Your job is primarily to screen and identify, provide support and medical treatment, document in the medical record, propose a safety plan, and discuss resources, if the patient is ready.
Use a team approach. Some of the pressure you may feel to fix the problem can be alleviated by working with others. A team can be composed of members from the health care community and representatives from fields such as adult and child protective services, the civil and criminal justice systems, health and social services, and particularly mental health. Some teams include domestic violence advocates, substance abuse specialists, clergy, and policymakers.
You have planted a seed. The patient may not be ready to disclose abuse and/or make changes in her life, but having a conversation encourages her to begin thinking about options and resources. The patient will talk when she is ready, and caring and empathetic questioning may open the door for eventual disclosure. Even though a patient may not acknowledge that she is living in an abusive situation, she will remember that it was in your office where she was asked about possible abuse and violence. Letting her know that a health care facility, specifically your office, is a safe place to return when she is ready may be the most valuable assistance you can provide at this time. Also never underestimate the power of the smallest expressions of compassion and caring, along with sincere acts of support and concern.
The patient will likely return home. Finally, realize that the victim is not likely to leave the abuser because she has disclosed the abuse to you; it is simply not realistic to expect her to take immediate steps toward change without a carefully thought-out plan. For example, she may not yet see herself as a victim of domestic violence or she may want the abuse to end but not the relationship. As a result, it is very likely that the victim will return home, either temporarily or for an extended period. This does not mean you have failed. She will always remember not only that you asked about violence, but also how you asked. Most important, she will never again look at her home situation the same way.

In general, the most important role health care providers can play in ending abuse and protecting the health of their patients is to identify and acknowledge the abuse. That alone can empower a victim to begin to move toward safety.MM

Susan McCormick Hadley is founder and former director of WomanKind: An Integrated Model of 24-Hour Health Response to Intimate Partner Violence. She is a co-author of the AMA’s Diagnostic and Treatment Guidelines on Domestic Violence and an adjunct faculty member at the University of Minnesota Medical School.
 
REFERENCES 
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