Do you screen for domestic violence? Call goes out for universal screening

Reproductive-age women at highest risk for domestic violence

Can you identify the victim of domestic violence? Consider these cases: A young woman, despite receiving contraceptive counseling and pills at her last visit, returns with a positive pregnancy test. A mother in her early 30s has a persistent vaginal infection but doesn’t follow her treatment regimen. A pregnant 18-year-old seeks a first-trimester abortion.

All of the women described above could easily be abuse victims, but because many signs of violence are relatively subtle, providers may fail to detect them unless they screen every patient.

There is room for improvement when it comes to implementing universal screening into daily practice. Close to half of 397 pregnant and nonpregnant women seen at an urgent care OB/GYN unit reported that they had been victims of either physical or sexual abuse, but only 18% of them could remember having been asked about abuse by a provider.1

"It’s like Pap smear screening: There are no outward signs of pre- cancer or cancer of the cervix, but we routinely screen to detect it," says Jeffrey Peipert, MD, MPH, associate professor of OB/GYN at Brown University and director of clinical research in the OB/GYN department of Women and Infants Hospital in Providence, RI. "The same thing holds true for violence: You want to routinely screen so you can detect as many cases as possible."

Abuse can take many forms, such as slapping, punching, and hitting; criticism, threats, and humiliation; forced isolation or control of money; or forced sexual activities. While the majority of abuse victims are women in a heterosexual relationship, victims can be men or same-sex partners.

The highest rates of intimate violence are recorded in women ages 16 to 24, according to national statistics.2 This age group constitutes a sizable segment of the family planning population. A study of women seeking elective pregnancy termination found that almost 40% reported a history of abuse.3

Violent men typically seek control over their partner’s behavior and sexuality. In a U.S. focus group study, women reported that their violent partners often dictated contraceptive choice.4

Some men do not want their partners to use birth control because they believe they will then have sex outside the relationship, says Ronald Chez, MD, professor of OB/GYN and community and family health at the University of South Florida in Tampa. Women may not even to able to negotiate condom use for STD protection if the man considers it a threat to his sense of control or masculinity.

Screen routinely

"I think clinicians need to first routinely screen women for abuse, such as physical violence and other aspects of control, such as contraceptive decision making, so that they know which women are facing this issue," explains Jacquelyn Campbell, PhD, RN, FAAN, asso -ciate dean of doctoral education programs and research in the school of nurs ing at Johns Hop kins University in Baltimore. "The screen for abuse needs to include asking specifically about forced sex, since this form of abuse is not always accompanied by [other] physical violence."

If women indicate they have been abused, the first intervention concerns their ongoing safety, notes Campbell, referring to domestic violence programs, providing information about their legal options, and planning for their safety. Further interventions can focus on sexual coercion. This measure can include discussion of which contraceptive methods are least intrusive, what actions the patient can take unilaterally, and what it means when a woman cannot control her own sexuality, she says.

While a national survey of OB/GYNs show that the majority of providers screen when they suspect abuse, there is room for improvement when it comes to universal screening.5

"Our survey indicated that when physicians have reason to screen, they do a wonderful job," notes Deborah Horan, manager of special issues at the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, which conducted the national poll. "But if someone does not present with symptoms, and she is in an abusive relationship, she may not be screened and may not have an opportunity to be offered assistance."

ACOG is leading the charge toward incorporating abuse screening into clinical practice. It has developed a number of provider resources to educate both medical residents and practicing physicians, says Horan.

The American College of Nurse-Midwives in Washington, DC also has taken an activist stance in promoting universal screening. Abuse often begins or escalates during pregnancy, so nurse-midwives must be vigilant in screening for violence, says Pat Paluzzi, CNM, MPH, associate medical director of Planned Parenthood of Maryland in Baltimore. Paluzzi served as director of the college’s domestic violence project, which addressed policy, education, and materials development, as well as advocacy/activism among nurse-midwives.

If domestic violence is so prevalent, why aren’t more providers putting universal screening into practice? Chez and Peipert agree that a concern about time constraints may make clinicians hesitant to raise such a sensitive subject. The process, however, need not be time-consuming.

First, be sure to be alone in the room with the patient. Then preface your question with the following statement: "Because it is so common, I’ve started asking all patients about the presence of violence and abuse in their home. I routinely ask these questions of all of my patients because I’m concerned about their safety and well-being."

Use HITS to screen patients

Chez points to a short domestic violence screening tool, HITS, as one way to assess abuse. Providers who use the HITS acronym ask patients how often their partners:

• physically hurt them;

insult or talk down to them;

threaten them with physical harm;

scream or curse at them.

This practice has proven effective in identifying abuse.6 (See abuse assessment offered by American College of Nurse-Midwives, p. 14, for more questions.)

All women should be screened for domestic violence at the outset of the examination, says Paluzzi. If disclosure is not forthcoming, contraceptive counseling can offer an ideal time to explore the issue again. Ask about how a partner feels about different methods of contraception. If the woman is currently using a method, but she seems be a poor contraceptor, treat it as a "red flag" for potential abuse, she says.

Like wise, a woman who continues to present with a recurrent infection may be a victim of ongoing violence.

How can you help women become comfortable in sharing information on abuse?

• Send out the signal that your office is a "safe space." Put up posters, not only in waiting rooms but in bathroom stalls and exam rooms as well. Chez places ACOG printed material in several strategic areas so patients know that it is OK to talk about abuse. (See resources, p. 15.)

• Make sure your office staff are informed about domestic violence, Paluzzi recommends. Hold inservice training so everyone understands the importance of confidentiality and privacy issues.

• Have fingertip information on community resources. Because domestic violence laws vary from state to state, providers need to understand the legalities of documenting and reporting abuse. In many cases, reporting is not a substitute for thorough documentation of the abuse in the medical records.

Watch out for reports of aches

Women in abusive situations often present with chronic, multisymptom complaints, such as headaches or backaches. By identifying the source of the problems, providers can eliminate the series of repeat visits and lab work and move forward in referring women to community resources.

"I am not skilled at counseling, but I am skilled at giving patients permission to seek alternatives," Chez explains. "Knowing the community resources in my locale allows me to provide information about them to the patient after giving her permission to the right to safety and the right to seek viable alternatives for a crime which is not her fault."

References

1. McGrath ME, Hogan JW, Peipert JF. A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynecol 1998; 91:511-514.

2. American College of Obstetricians and Gynecologists. Interpersonal Violence Against Women Throughout The Life Span. Washington, DC: American College of Obstetricians and Gynecologists; 1998.

3. Glander SS, Moore ML, Michielutte R, et al. The prevalence of domestic violence among women seeking abortion. Obstet Gynecol 1998; 91:1,002-1,006.

4. Campbell JC, Pugh LC, Campbell D, et al. The influence of abuse on pregnancy intention. Womens Health Issues 1995; 5:214-223.

5. Horan DL, Chapin J, Klein L, et al. Domestic violence screening practices of obstetrician-gynecologists. Obstet Gynecol 1998; 92:785-789.

6. Sherin KM, Sinacore JM, Li XQ, et al. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med 1998; 30:508-12.