C l i n i c a l  G u i d e l i n e s

 
Screening for
 Intimate Partner Violence

Note: Before you begin screening your patients, make sure that you are prepared to intervene if your patient discloses abuse.

Think with your health care team about defining roles, responsibilities and procedures. A well-thought out protocol and a supply of forms and practitioner resources will support you in integrating effective screening into your office flow and tight schedule. (see also: Effective Health Care Response to IPV and Tools and Forms to download)

Screening should be done:

• routinely
• in private (screening in presence of partner/family member is ineffective or dangerous)
• confidentially (address limits of confidentiality if any)
• for all adult and adolescent female patients; for male patients if indicators  are present (see below)
• by health care practitioners trained to detect IPV and offer appropriate interventions

Screening Questions

1. Frame:

“Because so many people are impacted by violence, I have begun to ask all my patients about it.”

OR: “I am concerned that your symptoms may have been caused by someone hurting you.”

AND: “If you talk to me about violence it is confidential. I will not share this information unless you are telling me about child abuse, or about [fill in other limitations if applicable].”

2. Ask directly:

• “Has anyone/your partner/your husband/your boyfriend ever hurt you physically?”
• “Has he/she hit you? grabbed you? prevented you from leaving the room or house?”
• “Does he/she ever put you down, call you names, make you feel bad about yourself?”
• “Has he/she threatened to hurt you, or to hurt someone close to you?”
• “Does he/she try to control what you do, who you see?”
• “Has he/she ever forced you to have sex? Or hurt you during sex? “
• “You said he/she acts out sometimes when he/she is drunk. What exactly does he/she do to you then?” “You said you fight like all couples. Does it ever get physical? Do you ever feel afraid?”

If a patient discloses abuse:

Give validating messages (See Interventions) and then proceed to assessment, documentation and referrals

If a patient screens negative:

Open doors to future disclosure or self-referrals

You could say something like: “I would like you to know that if this ever happens to you, this [clinic] is a safe place to talk about it. Also, if you ever want to pick up some more information, for yourself or for someone else, we keep brochures and safety cards in the [restrooms]. They have numbers that people can call confidentially 24 hours/day and also other resources.”

Possible Indicators of Intimate Partner Violence in your patients:

• Injuries
  • frequent
  • unexplained or history inconsistent
  • delayed treatment
  • multiple stages of healing
  • defensive posture
  • pattern (e.g. finger imprints)
  • “bathing suit” pattern
  • genital area
• Depression, anxiety, PTSD, suicidal ideation
• Chronic pain without etiology
• GI complaints: ulcers, irritable bowel disease, vague epigastric pain
• High number of STIs, vaginal/urinary tract infection, pregnancies, abortions, miscarriages
• Frequent visits
• Non-compliance with treatment protocols, cancelled visits

Screening in Private

“I remember the first time I went to the ER was when he broke my arm and he of course brought me and the doctor says “what happened” and I said “I broke it in the tub”. And he looks at me from the x-rays and says “that’s not consistent, is there something else going on here?”. I looked at him and Bill and I said “No, that’s really what happened,  I can’t tell you anything else” and he just looked at me and we didn’t go any further.   I was thankful that he didn’t really force the issue.  I couldn’t say [in front of Bill that] he hit me or pushed me and this is what happened.” “That’s the hard part - I think if the doctor or nurse suspects any kind of  abuse they need to be careful when they ask the questions - if that woman is there and the batterer is with her she’s not going to disclose.  So I think they need to find a window of opportunity to talk to her for a minute- but they would have to know she may still not disclose because it may not be safe and there is trust issues.” Julie, Survivor of Domestic Violence, Excerpt from the video “Voices of Survivors”, VT Curriculum on Intimate Partner Violence for Health Care Providers.

Protocols must allow for private screening. Screening for IPV in front of partners or family members will force most victims to lie. This will likely increase their sense of isolation and hopelessness. It may also result in retaliatory violence if the abusive partner did not like the way the victim responded to the question.

If your facility simply does not allow for routine private screening you could do indicator- based screening: whenever a patient presents with typical signs and symptoms, you arrange for private screening. This could be done by taking patients to a different room “for a urine sample”. Your health care team can invent other procedures or code words to use in order to separate an at-risk patient from their partner and ensure a few minutes in private.

It’s Not Working?

Sometimes clinicians report that they have been screening for domestic violence for years but that they feel unsatisfied with their screening outcomes. The following article explains in detail the most effective screening strategies for intimate partner violence – in the words of physicians who have tried.

“A Qualitative Analysis of How Physicians with Expertise in Domestic Violence Approach the Identification of Victims” Barbara Gerbert, PhD; Nona Caspers, MFA; Amy Bronstone, PhD; James Moe, PhD; and Priscilla Abercrombie, RN, NP, PhD Annals of Internal Medicine 19 October 1999, Volume 131, Issue 8 , Pages 578-584

Important insights from the study:

• Most abused patients will not disclose, for safety and other reasons.
• Disclosure is facilitated by building trust in the clinician-patient relationship over time.
• Clinicians may get frustrated unless they revise their definition of success:  compassionate screening and offering resources and information is in itself a helpful intervention, even if patients choose not to disclose.

Find a summary at http://ebmh.bmjjournals.com/cgi/reprint/3/2/63

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