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The Scope of the Clinical Problem
Although the reported incidence of domestic violence varies, the literature indicates that violence issues are a common problem in women’s health, as common (or more so) than other lifestyle and health problems that are a part of routine health screening. Despite this, domestic violence remains an area of silence between most patients and their physicians. A study of female patients in a Veterans’ Administration ambulatory setting found 40% of women had experienced emotional or physical abuse by a partner and 7% were currently in abusive relationships, yet only 12% report being asked about violence by their physicians.1 The majority of these women reported a willingness to talk about partner violence with their physician and an expectation that the physician would be an advocate.
Domestic violence is not confined to urban or low-income settings. Studies of women seen at family practice clinics in rural and medium-sized communities in the Midwest find a 34-39% lifetime rate of physical abuse, with 8-23% reporting abuse within the past year.2,3 Although domestic violence may be more common in young women of low educational background, a relatively high rate (25%) of violence with the current partner has been found in an older population of women in a rural area.4 Other identified risk factors are partner violence in the family of origin and substance abuse by the partner.5 Domestic violence is a common finding in women treated for depression.6
Pregnancy health is affected by domestic violence. A study of women in public prenatal clinics found a 17% incidence of physical or sexual abuse during pregnancy; abused women were twice as likely as nonabused women to enter prenatal care in the third trimester.7 Physical abuse during pregnancy has also been associated with poor outcomes such as preterm birth and placental abruption.
Acute injuries from domestic violence constitute from 15-35% of all emergency room visits by women. Up to 50% of all homicides in women are committed by a current or former partner. Many of these women have been seen in an emergency room setting within a year or two prior to the homicide.8
Physician Awareness and Behavior
Domestic violence education has become a requirement in undergraduate and graduate, medical education (postgraduate in some states), but domestic violence screening is not a routine part of practice for most physicians providing primary care to women. The U.S. Preventive Services Task Force did not recommend universal screening on the basis of clear evidence of benefit.9 A large study in California suggested that physicians routinely screen injured patients for intimate partner abuse, but that most do not screen during routine checkups, prenatal care, or new patient visits.10 This study found no difference in screening by gender of physician or recent training in partner violence. A physician survey about factors affecting screening rates cited lack of physician education in screening (34%) as a deterrent. Other factors that may affect the behavior of physicians include a belief that domestic violence is not an issue in one’s patients (46%), a lack of time to deal with abuse (39.2%), and frustration at not being able to help victims (34.2%). Physicians may mistakenly believe that domestic violence does not occur in patients of higher socioeconomic status, but a study of medical school students and faculty found that 17% of female faculty and students and 3% of male faculty and students have experienced partner violence during their adult life.11
Short-term physician behavior may be altered by education. An educational intervention for internal medicine residents resulted in significant increases of patients being asked about domestic violence.12 Whether such an intervention will be effective in establishing a change in practice patterns is not clear. At the current time, there is no evidence that mandatory CME affects physician awareness and response to domestic violence. In one study of mandatory CME, the only positive predictor for likelihood of screening was the presence of a female physician in the practice.13
What do Patients Want?
The literature indicates that abused and nonabused women believe health care providers should screen for abuse. Less than 50% of victims have been screened by medical providers for partner violence.14 Patients who have been abused believe that clinicians should ask more specific questions than women who have not experienced abuse.
Structured screening methods may improve the detection rate of domestic violence. A study of pregnant women screened using a five-question Abuse Assessment Screen found significantly improved rates in detection of domestic violence as compared to standard interview at prenatal intake visits.15
A number of brief screening tools have been developed and validated in primary care settings. The HITS questionnaire is a four-item questionnaire that asks how frequently the patient was physically Hurt, Insulted, Threatened with harm, and Screamed at by the partner.16 Other brief screening tools include the single question "Have you been hit, slapped, kicked, or hurt during this pregnancy?"17 The WAST (Women Abuse Screening Tool) uses an initial shortened form that asks two questions about how much tension is present in the relationship and how much difficulty is experienced in resolving conflict with the partner. Positive responses to these questions are followed by administration of the other six questions in this screening instrument.18
Structure of a Screening and Treatment Plan
Universal screening for domestic violence may be adopted, although no outcome data are available on the effect of screening. If a strategy of selective screening is used, multiple clinical problems, including depression, unexplained symptoms, injuries, delayed prenatal care, and other psychosocial red flags should prompt more thorough inquiry. A screening tool is likely to be helpful, used in the same way that the CAGE instrument has been used in screening for alcoholism. Clinicians and office personnel should develop routine signals for separating patients and their partners briefly to facilitate screening. The first step in dealing with partner violence is to create a safe environment where patients may tell their story.
A study of physicians working with abuse victims identified these key components of care: giving validating messages that identify abuse as abuse; acknowledging that abuse is not justified; labeling abuse as wrong; listening in a nonjudgmental way to the woman’s story; and documenting the history and physical signs of abuse.19 Patients benefit from referral to community resources; it is unlikely that an individual physician has as much to offer as a team approach. A small business card with important contact numbers should be provided to patients (and may be displayed discreetly in the women’s bathroom). In settings where the physician treats both the woman and her partner, ethical and strategic considerations may make it advisable for the physician to refer the partner to another clinician.
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