Screening for Domestic Violence in Health Care Settings. Reasons for Screening in Health Care Settings

08/01/2013

Domestic violence is prevalent among women

According to the 2010 National Intimate Partner and Sexual Violence Survey (NISVS), 1 more than one in three women have experienced physical violence at the hands of an intimate partner, including a range of behaviors from slapping, pushing or shoving to severe acts such as being beaten, burned, or choked. An estimated 3.6 percent of women reported experiencing these behaviors in the 12 months prior to taking the survey. Roughly one in four women (24.3%) have experienced severe physical violence, which includes having been slammed against something, having been hit with something hard, or having been beaten (Black et al., 2011). Additionally, nearly one in ten women in the United States (9.4%) have been raped by an intimate partner in her lifetime (Black et al., 2011).

DEFINITIONS

For the purposes of this brief:

Health Care Settings: Any location where health issues are addressed, including but not limited to emergency departments, patient treatment centers, and the offices of primary care clinicians and other health care practitioners.

Clinicians: Includes doctors, nurses, nurse practitioners, physician assistants, counselors, and other health care practitioners in a variety of health care settings.

Screening/Counseling: Screening may consist of a few short, open-ended questions asked by a clinician to the patient. It can also be facilitated by the use of forms or other assessment tools. Counseling may include provision of basic information, including on how a patient’s health concerns may relate to violence, and referrals for additional assistance when patients disclose abuse.

Universal Screening: In this brief, universal screening is defined as a clinician screening every female patient through age 64 for domestic violence, as opposed to only screening certain patients because of risk factors or warning signs.

Domestic violence (DV) / Intimate partner violence (IPV) “physical violence, sexual violence, threats of physical or sexual violence, and psychological/ emotional violence. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy” (CDC, 2010).

Interpersonal violence is an overarching term that refers to “the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” This type of violence includes family and intimate partner violence as well as violence between two unrelated individuals (World Health Organization, 2013).

Roughly one in four women (24.3%) have experienced severe  physical violence by an intimate partner in her lifetime.

Intimate partner violence is associated with poor health outcomes

Intimate partner violence is associated with life-threatening injuries as well as other physical and mental health problems of both an immediate and long-term nature. In its most severe form, physical IPV can result in death or major injuries. According to the CDC’s National Violent Death Reporting System, in 2003, 20 percent of homicides were directly associated with intimate partner conflict. For victims aged 40 to 44 years old, intimate partner violence was the most common form of violence resulting in death (Centers for Disease Control, 2006).

Physical violence can also result in less severe injuries, including bruises, black eyes, cuts, scratches, or swelling (Salber and Taliaferro, 2006). These types of physical injuries are commonly associated with abuse and may trigger clinicians to ask their patients about IPV (Salber and Taliaferro, 2006). Sexual abuse can result in injuries or infections, such as vaginal and anal tearing, bladder or vaginal infections, and sexually transmitted infections. These types of injuries may also cause a clinician to ask about abuse (Campbell and Lewandowski, 1997; Letourneau et al., 1999).

IPV is also associated with a number of long-term health impacts that may be more difficult for a health care provider to identify as resulting from abuse. Sustained exposure to violence is linked with central nervous system problems, including back pain, headaches, and seizures, as well as gastrointestinal problems (Coker, Smith, et al., 2000; Dillon et al., 2013). Sexual abuse is associated with higher risk of contracting sexually transmitted diseases, such as HIV/AIDS, either through forced unprotected sex or through the increased likelihood of risky sexual behavior (Hess et al., 2012; Mittal et al., 2012; Stockman et al., 2012).

The severe and prolonged stress caused by IPV can be detrimental to mental health as well. IPV is a major risk factor for depression, deliberate self-harm, and suicide (Jaquier et al., 2012; Pico-Alfonso et al., 2006; Van Dulmen et al., 2012). One study found that women who had experienced domestic violence were over twice as likely to suffer from depression than women who had never experienced abuse (Dienemann, et al., 2000). IPV is also correlated with alcohol and drug abuse. One study found that survivors of IPV were over nine times more likely to be dependent on alcohol than women who had not experienced abuse, and eight times more likely to have used illicit drugs in the past 12 months (Lipsky et al., 2005).

IPV is associated with more subtle physical and mental health problems in addition to serious physical injuries.

Research indicates that the relationship between IPV and alcohol and drug abuse by the victim is complicated. Abuse may be more likely to occur when the victim is under the influence of alcohol or drugs (El-Bassel et al., 2005). However, survivors often “self-medicate” to cope with abuse, suggesting that identifying abuse as a root cause for alcohol and drug abuse may be useful in providing treatment (Campbell, 2002; El-Bassel et al., 2003; La Flair et al., 2012).

In addition to the direct linkage between IPV and physical and mental health problems, IPV can affect health outcomes in indirect ways. For example, the National Intimate Partner and Sexual Violence Survey reports that nearly 30 percent of women who have experienced any kind of violence, including physical violence, stalking, and/or rape, reported at least one major detrimental impact related to these experiences, such as being fearful or missing at least one day of work (Black et al., 2011; Kovac et al., 2003). The debilitative impact of abuse can potentially inhibit a woman’s ability to attend medical appointments, adhere to medical treatment plans, or overcome other adverse behaviors such as smoking, substance abuse, or overeating (Salber and Taliaferro, 2006).

The debilitative impact of IPV can potentially inhibit ability to attend medical appointments, adhere to medical treatment plans, or overcome other adverse behaviors.

Furthermore, abuse can have intergenerational health effects. IPV can result in unintended pregnancies either through forced unprotected sex, risky sexual behavior associated with abuse, or through reproductive coercion, which occurs when one partner interferes with the other’s method of birth control (Silverman et al., 2004). IPV that occurs during pregnancy is associated with preterm birth, low birth weight, and lower gestational age (Kovac et al., 2003; Shah and Shah, 2010). These health consequences may have negative effects on the cognitive and motor skill development of newborns (De Jesus et al., 2013; Hack and Fanaroff, 2000; Hutton et al., 1997). Moreover, children who witness domestic violence are at increased risk of experiencing emotional, physical, and sexual abuse themselves (Holt et al., 2008; Lewis-O’Connor et al., 2006; Peled et al., 1995). Witnessing IPV in childhood is one of 10 adverse childhood experiences linked to negative health outcomes across the life course, including depression, alcoholism, adolescent pregnancy, and suicide attempts (CDC, 2012). The numerous direct and indirect effects that IPV can have on short and long-term physical and mental health are frequently cited as justification for regular screening (American Medical Association, 1993; Family Violence Prevention Fund, 2004; Institute of Medicine, 2011; Salber and Taliaferro, 2006; U.S. Preventive Services Task Force, 2013).

Intimate partner violence is associated with high health care costs

In addition to the high cost of violence for society and for individuals who experience abuse, IPV is associated with high health care costs. In one study, researchers surveyed 3,333 randomly selected women ages 18 to 64 to assess their IPV history (Bonomi et al., 2009). The women, with their consent, were then linked with their health care records to determine usage of health services. The total adjusted health care costs for women who had disclosed physical abuse were 42 percent higher than for women who had never experienced abuse. Further, women who had disclosed types of abuse that were non-physical in nature had total annual health care costs 33 percent higher than those of women who had not experienced any form of abuse, suggesting that non-physical abuse can also be costly (Bonomi et al., 2009). The CDC estimated in 2003 that the costs of intimate partner rape, physical assault, and stalking exceeded $5.8 billion, with nearly $4.1 billion going directly for medical and mental health services (CDC, 2003).

Health care settings provide a unique opportunity for identification and intervention

Health care settings provide a unique opportunity for screening and intervention because of trusting relationships, confidentiality, and space away from the abuser.

Proponents of expanded screening note that screening in health care settings provides a unique opportunity to identify patterns of violence and prevent future harm (Family Violence Prevention Fund, 2004). Existing research on IPV and emergency room utilization suggests that there is potential for identification and intervention before violence escalates. For example, one study examining emergency department utilization by women who were ultimately killed by an intimate partner found that 44 percent of the women had sought help in an emergency department within the two years prior to their death (Wadman and Muelleman, 1999). Clinicians also usually see patients individually, giving patients the ability to talk to someone without the abuser present. Clinicians can also discuss abuse in the health care context, helping patients understand the implications of abuse for their health and well-being. In addition, patients may feel more comfortable disclosing abuse to a physician or health care provider with whom they have built a trusting relationship, and because of physician-patient confidentiality expectations (American Academy of Family Physicians, 2005). There are some cases where confidentiality will be limited. Some states have mandatory reporting laws, which obligate health care providers to disclose IPV to authorities. Explaining confidentiality to patients during screening requires a clear understanding of such laws.2

Major medical associations and organizations recommend routine screening

The Joint Commission on the Accreditation of Hospitals and Health Care Organizations, American Medical Association, American Congress of Obstetrician Gynecologists, American Nurses Association, and U.S. Preventive Services Task Force all recommend routine IPV screening.

There is growing consensus among major medical associations that asking women about their experiences with IPV is important for reducing its incidence and severity. Most recently, in 2013, the USPSTF released a recommendation stating that “clinicians screen women of childbearing age for intimate partner violence (IPV) such as domestic violence, and provide or refer women who screen positive to intervention services” (U.S. Preventive Services Task Force, 2013). The USPSTF is an independent group of national experts in prevention that makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. Its recommendations are widely accepted in the medical community (Agency for Healthcare Research and Quality, 2007). This recommendation was significant in that it updated a 2004 USPSTF determination which at the time found insufficient evidence to conduct universal IPV screening.

Screening and counseling for domestic violence was first institutionalized in 1992 when the Joint Commission on the Accreditation of Hospitals and Health Care Organizations (JCAHO) mandated that emergency departments develop written protocols for identifying and treating survivors of domestic violence in order to receive hospital accreditation (Joint Commission, 2009). Since then, many health associations have supported screening across health care specialties. The American Medical Association (AMA), American Congress of Obstetrician Gynecologists (ACOG), and the American Nurses Association (ANA) all recommend routine universal screening. These recommendations support screening not only in hospitals, but in a variety of health care settings, and not just when physical signs of abuse are present (ACOG, 1995; AMA, 1993; ANA, 2000).


1 The NISVS, fielded by the Centers for Disease Control and Prevention (CDC), is a nationally representative survey that collects
information about experiences with sexual violence, stalking, and intimate partner violence among non-institutionalized English and/or
Spanish speaking women and men aged 18 or older in the United States (Black et al., 2011).
2 For more information on mandatory reporting laws, see the National Health Resource Center on Domestic Violence at http://www.futureswithoutviolence.org/content/features/detail/790/.

View full report

Preview
Download

"pb_screeningDomestic.pdf" (pdf, 309.44Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®