Easing screens for intimate partner violence

During a routine check-up with her internist, a woman mentioned that she'd been feeling a lot of stress related to her relationship with her husband. However, she wasn't sure if her situation qualified as abusive or whether she should ask for help, since her partner was not hitting her.

“This patient was having a difficult time understanding how her husband's behaviors were concerning because she wasn't like the domestic violence victims she saw in the news who had bruises and broken bones,” said Raquel A. Buranosky, MD, MPH, FACP, an internist and medical director of the Women's Center Clinic, a shelter for women recovering from intimate partner violence (IPV), at the University of Pittsburgh Medical Center. “But when I asked her, ‘What happens if you don't do as he says?’ she told me a whole list of things that could go wrong,” such as yelling, insults, or threats of withdrawing financial support.

IPV, which encompasses physical violence, sexual and psychological aggression, and stalking by a romantic partner, is common in the United States, reported by approximately one in four women and one in 10 men annually, according to the CDC, and cases have risen since the outbreak of COVID-19. The National Domestic Violence Hotline reported a 15% increase in contacts for April 2020 compared with a year earlier, while data from several large urban U.S. police departments show sharp rises in arrests related to domestic violence following implementation of COVID-19-related stay-at-home orders, according to an April 28 report in the American Journal of Emergency Medicine.

Women experiencing IPV may have more medical, gynecologic, and stress-related symptoms than women who aren't abused, including asthma, arthritis, stroke, and cardiovascular disease, according to a review published in the Feb. 28, 2019, New England Journal of Medicine (NEJM). The acute and chronic stress caused by IPV may also increase the risk of autoimmune disorders and cancer and contribute to the use of cigarettes and other substances as coping strategies, the review said. The U.S. Preventive Services Task Force (USPSTF) now recommends routine screening for IPV in women of childbearing age (the Task Force found insufficient evidence to recommend routine screening in men and older women). ACP also cited IPV as a major health challenge facing women and supported increasing the availability of effective screening tools as well as education materials in primary care in a 2018 position paper.

“There is now a solid evidence base to confirm the short- and long-term impacts of IPV on multiple conditions, as well as research showing the benefits of health care interventions,” said IPV expert Brigid McCaw, MD, MS, MPH, FACP, clinical advisor for the California ACEs (Adverse Childhood Experiences) Aware Initiative and coauthor of the NEJM review. “This is a common and very impactful problem for which effective screening tools and interventions are available, and internists can be leaders in addressing it.”

Implementing screening

Despite the evidence for IPV screening, implementation in primary care has been slow, with rates ranging from 1.5% to 12%, according to ACP's position paper. Barriers include lack of physician comfort and/or training around the topic and reluctance by patients to bring it up on their own.

Incorporating screening into everyday practice is relatively simple, said Dr. McCaw. Tools embedded into the electronic medical record (EMR) can provide automated prompts that guide physicians through the process of initial screening, possible interventions, recommended documentation, and referrals.

“There is an early phase of IPV that primary care owns, when the patient can feel curious and safe in talking about their dysfunctional relationship and we can provide them with appropriate resources,” said Dr. Buranosky. “When someone is in a relationship that may be abusive, the most beneficial time to identify the problem is before they have become deeply dependent on the abuser.”

However, IPV often is not detected on a first visit or in answer to a routine question such as “Do you feel safe at home?”, said Melissa Dichter, MSW, PhD, associate professor of social work at Temple University in Philadelphia, whose research focuses on IPV. It often takes time for a patient to develop trust in a clinician.

“In our research, patients tell us that they are unlikely to disclose when the clinician is looking at a computer screen or seems disinterested, the questions seem routine, or they feel judged,” she said. “People feel quite vulnerable about this issue and might not have shared the information with anyone before.”

Direct eye contact, along with a caring, empathetic response, goes a long way toward making patients feel comfortable, said Dr. McCaw. It may give them courage to revisit the issue in the future or to reach out for referrals and resources after they leave.

Physicians should be alert to physical and emotional symptoms that can be triggered by IPV, such as persistent, unexplained headaches, abdominal pain, diarrhea, or fatigue, said Dr. Buranosky. “People struggle with attributing these symptoms to IPV because they're often not sure if their situations are abusive or what tips the scales into a dysfunctional relationship,” she said. “As internists, we can sometimes detect those differences and bring them to light early for the patient to consider.”

Other conditions that can signal underlying IPV include substance abuse, depression, and post-traumatic stress disorder, said Megan R. Gerber, MD, MPH, FACP, medical director of Women's Health for the VA Boston Healthcare System. Certain behaviors are red flags for abuse, such as avoiding invasive exams, having problems adhering to medication regimens, and missing appointments.

“It's quite common for abusive partners to interfere with their partner's health care by hiding medications, sabotaging birth control, or making it impossible for them to leave the house to get to appointments,” said Dr. Gerber, who is also an associate professor of medicine at Boston University School of Medicine. “When we address [these] issues, we are really addressing the patient's health.”

To encourage patients to feel comfortable bringing up concerns around IPV, it helps to normalize the topic, said Carolyn Sachs, MD, MPH, professor of emergency medicine at the University of California, Los Angeles, whose research focuses on IPV. The physician might start by saying that violence in relationships is common and that it is routine practice to ask all patients about home safety, along with other health risk factors.

“Here is an example of what I might say as part of an annual check-up: ‘Because violence is so common, I have begun asking all my patients about it routinely. In the past year, has your partner or anyone at home hit, hurt, threatened, or frightened you?’” Dr. McCaw recommended.

It's important to remove the stigma around IPV in order to open the door to disclosure, said Martina J. Jelley, MD, MSPH, FACP, professor and vice chair for research in the department of internal medicine at the University of Oklahoma School of Community Medicine in Tulsa, who investigates the adult health effects of violence and abuse. For example, the physician might say, “A lot of times when people struggle with controlling an illness or condition it's because there's something really stressful going on in their lives. Knowing what's going on in your life will help me take better care of your health,” Dr. Jelley said.

Restrictions on in-person visits due to COVID-19 have created additional barriers to disclosure, she noted. It's difficult to ensure privacy during telehealth visits, when the abuser or other family members could be nearby and patients feel uneasy about discussing possible abuse.

With this in mind, remember to ask whether or not the patient is alone at the beginning of a visit, she said. Ask “yes” or “no” questions in case the patient doesn't feel safe offering details and suggest that the patient wear earphones so your questions can't be overheard.

Don't be surprised if patients log in from somewhere like a car or public park because they don't have privacy at home. This can be a red flag for IPV, said Dr. Gerber. During the call, be alert to other cues that someone might be in danger or afraid of being overheard, such as looking startled, glancing frequently to the side, or abruptly changing the subject.

Although the USPSTF recommends screening women of childbearing age, recent research suggests that older women might also benefit from routine screening. Women ages 45 years and older may be even more reluctant or unlikely to disclose abuse than younger women because they grew up in an era that predated widespread media attention to and social recognition of IPV, according to a study led by Dr. Dichter that was published June 8 by the Journal of General Internal Medicine.

In addition, middle-aged women often are not used to thinking about IPV as an issue to address with their physician, the study found. Their physician may never have asked about IPV in the past, and older women may be less prepared to respond to screening questions compared with younger patients.

Although the USPSTF found insufficient evidence to screen men for IPV, that could be due in part to men's discomfort around the subject, said Dr. Jelley. “Men may be even less likely to reveal IPV due to the stigma or perception that men shouldn't be victims,” she said. “But there is data showing that the IPV rate is similar in same-sex and opposite-sex relationships.”

Men and older women, in particular, need reassurance that IPV is an appropriate and necessary issue to raise during a routine checkup, said Dr. Gerber.

“Long before there were strong recommendations for IPV screening, those of us doing this kind of work would often hear women say, ‘I'm really glad you asked me this because I wasn't going to tell you, or I was deeply ashamed,’” she said. “Just asking the question opens the door to disclosure and gives patients the safety and understanding that this issue really does belong in an exam room.”

Managing the visit

In a frequently referenced 1992 study, primary care physicians cited discomfort about disclosure and fear of losing control of the visit as major barriers to effectively treating IPV patients. The study, published in the June 17, 1992, JAMA, found that physicians considered exploring IPV to be analogous to “opening Pandora's box.”

Although the study was published almost 30 years ago, that sentiment still lingers in the minds of many physicians, said Dr. Dichter. Clinicians often fear a revelation of IPV will open the floodgates to a long, tearful disclosure that may be difficult to manage. However, she said, such scenarios tend to be the exception rather than the rule.

“Even when done with genuine empathy, these conversations may take only a few minutes,” she said. “When patients do disclose, they may be tearful, but they know that the visit has a timeframe. The provider can direct her to resources and schedule a follow-up appointment or connect her with a social worker or counselor.”

Physicians should practice eliciting an empathetic response, devoid of judgment, pressure, or blame, said Dr. Gerber. “The patients often feel responsible for or ashamed by these situations,” she said. “Letting them know they are not to blame can cause so much relief, because you're putting your finger on a burden they've been carrying around with them for quite a while.”

Even if a visit takes a little longer than usual, a disclosure can save time in the long run, Dr. Gerber added. “Finding out about IPV can make care easier because you may be getting to the root of what's really bothering the patient,” she said. “Identifying IPV may move the patient toward a healthier place because it addresses the elephant in the room, something that has been preventing the patient from being safe and healthy.”

Once IPV has been disclosed, it's best practice to document exactly what patients say regarding violent incidences or threats; details of any injuries; their home situation; and any medical conditions thought to be related to the trauma, said Dr. Gerber. Documentation is useful for continuity of care and may be helpful in custody cases or related legal actions.

However, it's important to balance those considerations with privacy concerns, especially when making notes in the electronic record, she added. Inform patients of your legal responsibilities, when appropriate, and ask patients directly what they feel comfortable having documented in their chart.

“These patients already feel like their sense of agency is compromised, and they may be fearful that an abuser has access to their medical records,” she said. “Documenting is a good practice, but if the patient feels unsafe, in most states, the physician is not required to record the details.”

It's best to check your state's specific laws around reporting, said Dr. Sachs. In California, for example, clinicians are required to fill out a written police report for any suspicious injury caused by another person, including sexual assaults. State statutes on reporting of partner (as a subset of domestic) violence vary widely—for example, all states require reporting child abuse or assaults with a deadly weapon but may not specifically mention IPV.

If you are in a mandatory reporting state, make sure to inform the patient about your legal responsibility, said Dr. Sachs. It's often reassuring for patients in California to hear that they are not required to talk to law enforcement directly unless they want to and that the clinician can wait until after patients leave the office to file a report.

Remember, physicians should seek to identify the problem, not necessarily fix it, said Dr. Buranosky. “Patients don't expect us to save them or know exactly what to do,” she said. “They do expect us to give them resources. Our job is to identify the problem, refer, and support, which is what internists are truly good at.”

The important thing is to let patients know that you care about their situation and have resources to help them, Dr. Sachs agreed. As with any chronic condition, such as asthma or diabetes, the goal is to help patients manage it and stay as healthy as possible, not necessarily to offer a cure.

“We have to think of IPV as part of the chronic disease model; it's not our goal to completely eliminate IPV and make sure every woman leaves every abusive relationship,” she said. “Screening and making resources available are the first steps and open the door to letting patients know they can get help.”