Addressing Intimate Partner Violence in Primary Care Practice

Leigh Kimberg, MD

Disclosures
In This Article

Primary Care as an Opportunity

Primary care practice presents a confidential, safe, and powerful opportunity to confront intimate partner violence. In many primary care settings, a patient may develop a long-term, trusting relationship with a provider and/or a practice. Accessing primary care practice is generally not associated with the potential risks and stigma that accessing "battered women's" services may present. To go to a primary provider for help, a fearful or traumatized person does not have to identify with the label of "battered woman" or "abused" woman or man. For various cultural groups in the United States, going to a healthcare provider is a socially condoned way of seeking help. The focus of primary care on health and well-being presents an ideal opportunity for discussing violence and abuse as an important health concern in a nonjudgmental way. In addition, the provider may feel confident that she/he is addressing an issue often considered "private" or "taboo" in a socially acceptable way.

Many studies,[57,58,59,60,61,62,63,64] however, have shown that providers do not adequately screen for intimate partner violence. Ironically, providers cite personal (provider) discomfort with delving into the topic of intimate partner violence as a major barrier against screening.[64,65,66,67,68] Providers have suggested that patients would be too uncomfortable with screening,[64] whereas patients report that they want to be screened. In 4 different studies[61,62,63,69] of survivors of abuse, 70% to 81% of the patients studied reported that they would like their healthcare providers to ask them privately about intimate partner violence. The American Medical Association (AMA) commissioned a survey of Americans' attitudes about intimate partner violence and found that over 85% of those surveyed believe that physician screening for intimate partner violence is a good idea.[70]

Do screening and the interventions that follow from screening improve patient outcomes? Despite persuasive anecdotal evidence of benefit,[30,71,72] there is little empiric data on health outcomes. The astounding lack of empiric studies of interventions to reduce the complications of intimate partner violence and prevent intimate partner violence is highlighted in an Institute of Medicine review describing existing evidence in this field.[73] Since publication of this review, few other published reports have been released. A small nonrandomized cohort study population of pregnant and postpartum abused women who were offered brief safety planning interventions by trained nurses has been described.[74,75,76] The pregnant abused women given safety and empowerment counseling by nurses adopted more safety behaviors than postpartum abused women given a resource card without counseling.[75] The noncounseled comparison group, though, utilized more community resources, and there was evidence that resource use may have related primarily to severity of abuse.[76] After adjusting for the initial differences in levels of abuse (present in this nonrandomized study), there was less violence in the counseled group.[74]

If one screens a patient for and discovers intimate partner violence, her problems and reaction to those problems often simply make more sense. A patient may be so deeply traumatized that she does not make a connection between the abuse she is suffering and the problem she complains of. Case examples of the interaction between intimate partner violence, health, and healthcare can be remarkably instructive. Let us take a case example (adapted from my practice) to illustrate the different scenarios that could unfold in the work-up of a patient with poorly controlled asthma without and with screening for intimate partner violence.

A 35-year-old woman with poorly controlled asthma presents repeatedly to her primary provider and the emergency room with asthma exacerbations without bringing an inhaler. She reports that she uses her steroid and albuterol inhalers as directed but seems most concerned about "insomnia." Without screening for intimate partner violence, one might wonder whether she really is using inhalers and might focus on teaching proper inhaler technique, re-explaining the necessity of peak-flow monitoring, and the importance of calling sooner or increasing the steroid inhaler dose for changes in peak flow. After frequent emergency room visits by this patient, one might refer her to a pulmonologist, initiate further work-up for exacerbating factors or even other lung diseases, and do pulmonary function testing -- all without any significant improvement in the patient's health. One might feel quite mystified and even exasperated by this patient's continued focus on insomnia and lack of sleep as her most pressing problem.

How would this case unfold in a practice in which patients are routinely screened for intimate partner violence? The provider would discover that whenever the patient tries to leave the house to go the pharmacy or regular healthcare appointments, the boyfriend hides her car keys and wallet. (He receives advance notification of all her appointments by the routine appointment reminder calls the primary provider's office staff makes to their home.) The boyfriend often hides her inhalers, making her feel like she is losing her mind. The patient also describes that he will often light up a cigarette, blow smoke in her face, and berate her for hours at a time as she is forced to sit in a chair. She feels progressively more short of breath as she gets more anxious. If she tries to move or ask for her inhalers he hits her in the chest or stomach. (She has never sought care while bruised because she feels so ashamed about this abuse.) Finally, for the past 3 months, on certain nights when she falls asleep she is awakened as he smothers her with a pillow to the point of near suffocation. She is now too scared to fall asleep, but says she is also too afraid to call the police or leave, as her boyfriend has threatened to kill her if she leaves.

By screening for intimate partner violence on the first visit and taking a brief history of the methods of abuse and control the patient's boyfriend uses, the provider would be immediately aware of the reasons the patient's asthma is poorly controlled. Her concern about "insomnia" would be instantly understandable.

Clearly, the absence of this history completely alters the assistance, interventions, and recommendations made to this patient. In both cases, the patient might be changed to a more potent steroid inhaler and long-acting beta agonist inhaler, but for such different reasons. Obviously, a much more cogent plan would be possible after screening for intimate partner violence. The provider might plan with the patient to set up a confidential appointment schedule for times that her boyfriend is not at home, brainstorm with the patient about whether she could safely hide extra inhalers in her apartment and at a friend's apartment, arrange for her to see a counselor (if one were available) before each provider appointment for both additional safety planning and supportive counseling, and provide her with information about how to call the police and local crisis hotlines and shelter services. Most importantly, the provider would provide this highly traumatized patient with repeated messages of support to enhance her self-esteem and help her gain enough confidence to take steps to increase safety.

As 5% to 25% of women presenting to primary care settings are currently in abusive relationships and 25% to 66% of women presenting to primary care have been victims of intimate partner violence in the past, this type of completely hidden misunderstanding occurs with regularity in primary care settings in which screening for intimate partner violence is not done. So, while there is inadequate data on the health outcomes related to intimate partner violence screening and intervention, the converse option of "not screening" is not acceptable.

This author recommends that all women and adolescent girls in primary care (internal medicine, family practice, obstetrics/gynecology, and pediatrics) be screened for past and present intimate partner violence. This recommendation is consistent with the recommendations of the AMA,[77] the American College of Obstetricians and Gynecologists,[78] the US Preventive Services Task Force,[79] the American Nursing Association,[80] and the Family Violence Prevention Fund.[81] The American Academy of Pediatrics states that "the abuse of women is a pediatric issue"[82] and recommends that pediatricians screen for "exposure to violence in the home (domestic violence or child abuse)."[83] In pediatric practice, some logistic barriers to screening the female parent/guardian of a patient remain to be elucidated by investigation and expert experience.[84]

Because of the epidemic proportions and severe adverse effects of intimate partner violence, there is growing interest in addressing screening for perpetration of violence. Experts hope that preventive counseling by a healthcare provider and other interventions might prompt changes in behavior, especially in less severe or early cases of perpetration. Excellent advice on how to screen for and intervene with perpetration of intimate partner violence[85,86] has been published, but there are no experimental trials of screening programs or tools.

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