It should come as no surprise that domestic violence is an enormous public health issue. 22% to 39% of women are estimated to experience intimate partner violence at some point in their lives. IPV affects 1.3 to 5.3 million women each year, generating $2 to $7 billion of health care costs annually in the form of treating injuries, infections, unintended pregnancy, neurological disorders, PTSD, and substance abuse – among other effects. IPV is especially devastating for pregnant women – 325,000 of whom are battered by their partners yearly before having a baby – and the children they carry. Given these numbers, it seems like domestic violence is not only a public health issue, but one of the biggest public health issues. So why aren’t hospitals and doctors doing more about it?
The Problems of Identification
One of the biggest challenges to helping victims of domestic violence is figuring out who to help. For any number of reasons, a victim may fail to report intimate partner violence to law enforcement – fear of retaliation, fear of losing economic security if her abuser goes to jail, a distrust of the system after past failures to gain the help of the law. She may avoid victims’ services because she doesn’t see herself as the kind of person who would become a “victim,” or because her abuser has convinced her that the repeated violence is her own fault. In last week’s blog post on domestic violence in the workplace, I pointed out the obvious reasons why a victim would rarely want to disclose IPV to an employer in a state that doesn’t prohibit discrimination against victims. And even when it comes to ‘informal’ methods of disclosing the violence, victims are frequently isolated and cut-off from friends and family they may previously have chosen to confide in. This perfect storm of factors makes domestic violence a dangerously underreported phenomenon.
Fortunately, there is one place where it is consistently possible to safely access, identify, and assist IPV victims. While IPV victims are frequently cut-off and isolated from their communities in other ways, they still interact with the health care system. Roughly three-quarters of reproductive-aged women in the US received reproductive health care in 2005, and pregnant women frequently seek prenatal or pediatric care even if they do not typically seek health care for themselves. In fact, 10-30% of abused women still interact with community clinics or pediatric services, a significantly higher percentage than those accessing shelters or counseling services. The health care system is clearly an invaluable mechanism for reaching out to victims who may not get help in any other way.
And not only are IPV victims still part of the health care system; they are also more comfortable disclosing domestic abuse to a health care provider. One study found that 95% of women would want to speak to a health care provider about IPV, compared to 90% wanting to speak with a mother and 89% wanting to speak with a counselor. While some IPV victims may still be unwilling to disclose current or past abuse to anyone, medical professionals included, others may still be more likely to disclose to doctors than to any other source.
The solution is for medical service providers to implement universal screening of their patients, or at least of those female patients at the ages most at-risk for intimate partner violence. “Screening” can sound scary, like a blood test or a TSA scan at the airport, but in actuality it’s very simple. A medical professional just needs to ask the patient a few questions, questions like “Has your partner ever hit, slapped, or physically hurt you in the past year?” or “Has your partner forced you to have sex when you didn’t want to?” They can even treat it like a conversation about intimate partner violence in the abstract, asking the patient her general thoughts about abuse and seeing if she discloses anything. And if they’re worried about opening a “Pandora’s box” by asking the victim about important details in her life (seriously, this is a concern some doctors have), they don’t even have to conduct the screening in person. Both victims and doctors prefer automated screening over a computer or with an audio track, seeing it as more private and less personal. For anyone still concerned about whether screening works, the U.S. Preventive Services Task Force just updated its inconclusive 2004 review of IPV screening with a new report, which concludes that several screening instruments are accurate at identifying IPV and have minimal adverse effects.
How Health Service Providers Fail Victims
It seems self-evident that doctors and other medical professionals not only have the incentive to address this major public health concern, but also are in a uniquely capable position to help victims. But unfortunately, too few doctors actually screen their patients for intimate partner violence, and victims consequently fall through the cracks. Only about 10% of primary-care physicians routinely screen for IPV during new-patient visits, while only about 9% screen on a periodic basis. Even though victims are even more likely to go to a medical professional when pregnant, physicians providing prenatal care only routinely screen about 11% of patients. Even when doctors do successfully screen for and identify domestic violence, they inadequately manage these cases 60%-90% of the time, resulting in further lack of faith in the system from victims who disclose and then receive insufficient support.
Why are medical providers so reluctant to screen for IPV? Some may have certain, somewhat legitimate concerns about victim safety or an inability to help victims adequately when they do disclose – all of which could be addressed by partnering with a local victims’ service provider to help victims get the help they need as soon as they disclose. Others may have concern about the time that the screening would take up and how it may detract from other important medical services (though that doesn’t explain why doctors screen for domestic violence less frequently than less-common diseases like diabetes in pregnancy or preeclampsia). Health care providers with questions about how screening will affect the health or well-being of their patients should try to resolve these problems by referring to demonstrably successful programs like the Planned Parenthood of NYC model.
But, unfortunately, it seems that many health care providers don’t provide screening simply because they don’t think it matters. This study from the University of Washington’s Department of Medicine found some truly unsettling results: 50% of clinicians and 70% of nurses and assistants surveyed believed that IPV was rare (affecting 1% of the population) or very rare (affecting 0.1% of the population) at their practice site. Only 12% of clinicians and 1% of nurses and assistants believed that it affected more than 10% of the population at their practice site. This points to an astounding lack of knowledge about IPV among medical professionals, which undoubtedly contributes to an overall reluctance to screen patients for a problem which affects ‘so few’ members of society. But that’s not all – 15% of the professionals surveyed went so far as to say that they had patients whose personalities caused them to be abused, and 25% said that victims’ ‘passive-dependent personalities’ led to their abuse. Doctors, it would seem, are not immune to the outdated and misogynistic attitudes about domestic violence which stop victims from getting help from so many other sources.
Medical professionals are frequently the best line of defense against domestic violence – but as long as they continue to believe that it is not a serious problem which warrants a serious response, this incredible resource in the fight against violence is underutilized. This is not to say that no medical professionals currently screen for IPV. As mentioned before, there are certainly effective screening programs out there. But it is clear that more need to be educated about the huge public health harm that IPV creates, and about the ways in which they – and they alone – can stop it.