Addressing Intimate Partner Violence in Primary Care Practice

Leigh Kimberg, MD

Disclosures
In This Article

How to Screen

Most cases of intimate partner violence go undetected in healthcare settings in which there is no routine screening program. There are numerous studies documenting the increased detection of intimate partner violence through verbal or even written screening of patients in various settings.[8,12,14,15,18,21,59,87,88,89] Obviously, there is no gold standard test for intimate partner violence. Screening tools that have been used include the Conflict Tactics Scale (CTS),[90] the Abuse Assessment Screen (AAS),[91,92] the Index of Spouse Abuse (ISA),[93,94] and the Partner Violence Screen (PVS).[87] Different tools screen for different aspects of abuse. (For example, the CTS does not include questions about sexual violence). The use of any one of these tools applied to all women presenting to a particular healthcare setting by researchers or practitioners can dramatically increase detection of intimate partner violence.

It is absolutely essential to understand what the limits to confidentiality are for adolescents and adults before screening for intimate partner violence. In all states, providers are required to report an instance of child abuse when a minor is victimized, but each state has different definitions and laws governing child abuse reporting.[95,96] The response of child protective services can vary from one locale to another and on a case-by-case basis. Adolescents may or may not be eligible for confidential health services related to mental health and reproductive health in different states. Because many adolescents who are victimized by an intimate partner have also been victimized by a family member[13] and/or do not want their family to know about an intimate relationship, it is important that one understand and explain the limits of confidentiality for adolescents before screening.

For adult patients, it is also important to know whether healthcare providers are required to make a mandatory healthcare report to police or another agency before screening. Screening a patient for intimate partner violence without discussing limits of confidentiality is unethical if a provider will be obligated to break confidentiality and force the patient to accept the involvement of a non-health-related agency (the police). In many states, providers are required to make mandatory health reports[97] to a law enforcement agency without patient consent. Whether mandatory reporting increases or decreases safety is a matter of heated debate.[98] There is little data to guide this debate. As with any intervention, mandatory reporting may have "benefits" in some cases and cause "iatrogenic harm" in other cases. In cases in which the patient is not at immediate risk of losing life or limb, this author and many others, including the AMA's ethics council,[99] believe it is unethical to violate provider-patient confidentiality and force an intervention on an adult patient without patient consent.

Screening is best done in a private, confidential, face-to-face encounter with a trusted provider who has had training in both intimate partner violence and cultural competency. One cannot assume that it is safe to ask someone about intimate partner violence in front of anyone else except a preverbal child. How to screen women in pediatrics practices when there is insufficient staffing or time to remove children from the room is an active area of investigation.[84]

As discussed previously, there is no gold standard for measuring the incidence or prevalence of abuse. Some tools, while having research utility, are too cumbersome to be useful in a busy primary care practice. The 5-question Abuse Assessment Screen (AAS) developed by McFarlane and Parker[91] has been evaluated in relation to the longer CTS and the ISA-P [physical] and ISA-NP [nonphysical].[92] The AAS is used to screen for physical and sexual abuse by anyone over the past year.

There are insufficient data on the validity of tools for identifying potential victims of homicide in the healthcare setting. But as intimate partner violence is a significant risk factor for homicide, screening for intimate partner violence will at least identify many patients at some increased risk of being killed. A "Danger Assessment Scale" has been developed to assist victims of intimate partner violence in elucidating factors that have been found to be associated with homicides by an intimate partner or ex-partner, but has not been studied prospectively.[100,101]

The significant finding that women and girls respond positively to very direct questions about abuse in the healthcare setting cannot be underestimated. In the experience of this author[72] and other experts,[30] patients will only very infrequently reveal abuse if asked indirect questions. As discussed previously, it does not make sense to assume that someone who is being threatened and abused will feel safe revealing abuse if not given direct messages that a provider (or practice) is ready to hear a positive response and be supportive of her. In practical clinical practice, then, one must ask direct questions about abuse using behavioral terms rather than words like "abuse" or "rape." Many victims and survivors will presume these terms do not apply to them if the perpetrator is an intimate partner. Direct questions about forced and unwanted sexual activity are necessary, as forced sexual activity is so common in abusive relationships but so distressing to victims/survivors that they most often do not volunteer unsolicited information about this. The American College of Obstetricians and Gynecologists has suggested a series of questions to use in screening adolescents for rape and sexual assault.[102] Indirect questions can be used judiciously, as time permits, to build trust and understanding, introduce discussions of relationship dynamics, and gather other enlightening information.

Sample direct and indirect questions as well as framing questions that can be used to put both the interviewer and the patient at ease are highlighted below.

Direct Questions.

  • Does your partner ever hit you, hurt you, or threaten you in any way?

  • Has your partner ever forced you to have sex when you didn't want to?

  • Are you ever frightened of your partner?

  • Has anyone ever hit you, hurt you, or threatened you in the past?

Indirect Questions.

  • What happens when you and your partner disagree? How do you settle disagreements?

  • How do you feel your partner/family members treat you?

  • Tell me more about your home environment.

  • Do you feel safe at home?

Framing Questions.

  • I ask all my patients about violence in their relationships; does your partner ever hit you, hurt you, or threaten you?

  • I want to make sure that each of my patients is safe in her/his relationships. Does anyone you know ever hit you, hurt you, or threaten you?

  • Feeling that a person close to you does not respect you or treat you well can be so difficult. How do your partner/family members treat you?

Some practices use a written questionnaire to screen patients for intimate partner violence. Even written screening may increase detection over usual detection rates.

[103]

There are 2 nonrandomized studies,

[88,104]

though, that suggest that written screening alone probably underestimates the prevalence of intimate partner violence.There are obviously other problems, such as privacy for completion of forms and illiteracy (another highly underdiagnosed problem), that limit the utility of screening only with written forms.

Who Asks? Different practices, depending on staffing patterns, patient populations served, and the model of care (private solo practice, group practice, public clinic, managed care plan), may develop different models of screening. In some settings, the primary provider may have responsibility of screening. In others, a nurse, social worker, or mental healthcare provider may do intimate partner violence screening. As long as patients are screened in a private, confidential, compassionate, and culturally competent manner, and the patient's responses are shared with the primary healthcare providers caring for the patient to ensure coordination of care, there is no evidence to support any particular type of provider doing screening rather than another. My experience as a primary provider responsible for and doing universal screening is that the experience of screening itself is a highly therapeutic intervention that deepens my relationships with my patients.[72]

The Injured Patient. In the author's experience in training providers and staff about intimate partner violence, providers commonly express frustration that "patients won't admit to abuse." Providers describe that, when faced with a patient who is injured and who the provider presumes is a victim of abuse, the provider asks the patient, "What happened?" The provider reports, "The patient won't tell the truth. I know her description does not make sense, but what can I do if she won't admit abuse? I don't feel comfortable contradicting her." By understanding the victim's/survivor's point of view as an isolated, threatened, and vulnerable person who, in all likelihood, has experienced little positive support (even in the healthcare setting), the provider can realize that she/he needs to make possible an opportunity for a discussion about abuse. This occurs by stating one's concern and allowing for the possibility of abuse in history taking. One might say, "I see you have a bruise on your chest. I am very worried that someone might have hit you there. Did anyone hit you?" Because injuries in a woman patient have such a high probability of being from intimate partner violence or other interpersonal violence, this type of questioning is quite useful.

Saving Time. Among the barriers cited by providers as reasons for not implementing universal screening are time and productivity concerns.[65,67,105] These concerns loom large in an era in medicine in which providers are seeking to "do more in less time." Brief tools have been developed for screening.[87,92] For practical purposes in clinical work, the "tool" length used to "open Pandora's box" is less relevant, though, than the time it takes to evaluate and assist a patient with the "content of Pandora's box." In primary care, the tool used to screen for intimate partner violence ideally becomes a respectful and empowering conversation.

If a patient answers negatively to the screening questions and is one whom the provider believes is not a victim of intimate partner violence, screening is rapid. Positive answers to screening may take longer. One is obligated to assess the situation further if the patient feels that she can discuss the abuse further. Just as with other healthcare emergencies, assessing a patient who is currently experiencing severe abuse takes additional time. There are no data to look at how varied approaches to screening affect time management and productivity.

Yet, creative solutions exist to save time while enhancing screening rates. First, if the provider recognizes and accepts that intimate partner violence can so dramatically affect health, well-being, and the ability to access healthcare effectively, providers may understand that screening for intimate partner violence early in a patient's care may ultimately save time and inappropriate referrals for cryptic chronic conditions. Providers, then, may elevate screening for intimate partner violence to a higher priority than many other aspects of traditional history taking and save time by substituting questions about such a highly prevalent and morbid condition for discussion of other, less pressing and less common concerns.

Second, as providers work in multidisciplinary teams, different aspects of screening, assessment, and intervention may be shared by a multidisciplinary team both to expand support for the victim/survivor and to save time for each team member. Providers may create expanded notions of "team" to include community counseling services and hotlines. Not infrequently, as I am seeing patients and realize I do not have sufficient time to speak to a victim/survivor, I will call a local hotline (with the patient's permission) during a visit, explain to the hotline advocate that my patient has revealed a history of intimate partner violence, and request that the advocate do safety and supportive counseling with this patient while I see other patients. Calling a hotline from a clinic may also increase the likelihood of the patient calling again in the future.

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