An Update on Domestic Violence

September 6, 2007

purple-ribbon.jpgCommentary by Sean Cavanaugh MD, Associate Editor, Clinical Correlations

Most doctors are aware that Domestic Violence, or Intimate Partner Violence (IPV), is a serious health care issue, but the statistics are still startling to most of us. Some surveys have reported that IPV affects up to 30% of women and up to 7.5% of men. These numbers are highly variable and depend on the type of survey being conducted and the population being surveyed. Actual report-statistics of IPV are widely acknowledged as seriously underestimating the prevalence of the issue. There seems to be a higher prevalence of IPV in couples of lower socio-economic status, but it is a public health issue that extends across all demographics and in significant enough numbers to require screening at clinical visits. The rates of IPV seem roughly comparable in homosexual and heterosexual relationships – with the qualification that the incidence of male victims may be higher in gay male relationships than in heterosexual relationships. The USPTF has stated that there is insufficient data to recommend screening in primary care settings, largely because the data is so variable and clear evidence of decreasing morbidity and mortality is lacking. This position has been criticized for possibly perpetuating the tautological problem of under-reporting and insufficient evidence, and almost all state health agencies recommend screening. Screening has been shown to increase disclosure and facilitate referral, and surveys indicate that most patients want their provider to inquire about IPV. Surveys have demonstrated that most physicians believe it is an important public health concern and warrants screening – but recent surveys have published that only 7% of women reported that they were asked about IPV at their clinical visits (JGIM). The question, then, is why are the rates of screening so low?

It is assumed that providers are often unaware of the extent of the problem or, more commonly, do not have the time to open what is recognized to be an important and time-consuming part of the interview. There is also evidence that providers are both not confident in their own ability to obtain information and not aware of what to do with the information that they might obtain. What is confidential and what must be reported? What interventions can be made?

There are standardized screening tools that can be used – but the most important thing for providers to remember is to ask. Routinely. Screenings should occur in private and with an effective translator. Primary care offices should have mechanisms in place to conduct these screenings (whether they are done by nurses or social workers or physicians) and information on resources ready to hand to their patients. If you have concerns about IPV but are unable to conduct a screening, it is recommended to note as much in the medical record. Because medical documentation can be used in court or even required to obtain appropriate social services, the medical record should be prepared carefully and should include at least the following:

- an assessment of patient safety and children safety (including presence or use of weapons)
- a medical history that includes a history of trauma
- an evaluation of mental health, including anxiety, depression and suicidality
- a physical examination with particular attention paid to descriptions of injuries

You do not necessarily need to report IPV – information disclosed by a patient is regarded as confidential UNLESS certain facts become known:

The following should be reported by calling the local police:
- injury from discharge of a firearm:
- potentially life threatening injury inflicted by a knife or other sharp object

The following should be reported in writing to the NY State Office of Fire Prevention and Control (518-474-6746) within 72 hours of visit:
- all 2nd and 3rd degree burns to 5% or more of the body
- all respiratory tract burns due to inhalation of super-heated air
- all life-threatening burns

The following should be reported to New York State central Registry of Child Abuse and Maltreatment (800-635-1522):
- abuse of a child by a parent or guardian

Screening is manageable and very likely to be effective. It also will enhance your relationship with your patients. As with any other interviewing skill, it gets easier the more it is practiced. Even if all that you accomplish is listening to your patient, you have likely taken the first and most important step in the process. For excellent resources on both how to conduct a history and physical as well as local resources, see the February 2007 City Health Information Vol. 26 (2) 7-14 published by the New York City Department of Health and Mental Hygiene and the NY State website:

http://www.opdv.state.ny.us/health_humsvc/health/index.html

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