October is recognized as Domestic Violence Awareness Month in the United States. According to the National Coalition Against Domestic Violence, nearly 20 people in the United States are physically abused by an intimate partner per minute.
It is important to remember the vital role that health care practitioners can play in raising awareness about this issue and contributing to efforts to prevent it and care for patients impacted by intimate partner violence (IPV). Central to these efforts is the importance of the patient’s voice.
The American Medical Women’s Association recently held its second conference centered on educating health care providers about IPV through the voices of patients and other stakeholders – and shedding light on how to best intervene to support and protect patients.
Please consider the suggestions below on ways to improve identification and response to IPV in your health care setting.
Education and training. Intervention starts with understanding the dynamics of power and coercive control in violent relationships. Educational training sessions led by experts and advocates can provide the necessary knowledge to intervene effectively. Education can help increase a practitioner’s confidence in screening and intervention. Additionally, continuing medical education (CME) about IPV can supplement training.
Screening and assessment. Integrate simple steps into practice to screen for domestic violence with every patient. These may include use of evidence-based questionnaires and asking open-ended questions that are routinely asked. Currently, the United States Preventive Services Task Force (USPSTF) recommends screening for women of reproductive age, with mention of clinical consideration for older or vulnerable adults, women not of reproductive age, and men. One study found more than 60 percent of clinicians never asked the older adult population about abuse. The topic is currently being updated by USPSTF and more research is needed.
If written questionnaires are used, they should not be mailed to the home or presented in the waiting room where an abuser can be with the patient. Practitioners can directly ask a patient whether they feel safe or threatened by their partner, or indirectly pose questions that may reveal personal circumstances. If a person accompanying the patient could be a perpetrator, practitioners should separate the patient to ask screening questions. Questions may include how the patient feels about their personal life and relationships, and whether they have any stressors at home or work.
Consider using such tools when deciding when and how to intervene. Risk assessment helps the health care team decide whether to take immediate action or to act through long-term, consistent follow-up. Risk assessment tools, such as the Danger Assessment, help evaluate the immediate danger a patient is experiencing.
Health care professionals may be short on time, which can interfere or prevent screening and risk assessment from taking place. Involve other staff members to assist in the screening and assessment processes if time becomes a barrier.
Patient education. Use waiting room resources and restroom signs to share information about hotlines and access to support services. Suggest patients store resource information under a pseudonym, such as a doctor or a friend, which allows them to reach out for help according to their own timeline. If a patient is not ready to disclose IVP to a practitioner or their team, this will ensure that they can access some resources without doing so.
Create a safe environment. Create a non-judgmental environment where patients feel comfortable disclosing their experiences of domestic violence and train your staff accordingly. Allow for the time, space, and silence needed for your patient to be vulnerable and disclose whatever information they choose. Do not tell them they must leave their relationship, nor push them to disclose anything they don’t wish to disclose. The most important thing you can do is to listen, validate their experience, and support their decisions to act or not to act. It is imperative that intervention is survivor-led. Survivors know best what their level of danger is, and respecting this will help protect them. Do not report to law enforcement without their consent unless mandated by law.
If state law or institutional policies mandate reports to law enforcement, inform the patient about this limit to confidentiality before they reveal information that must be reported. If they choose not to disclose due to confidentiality concerns, offer confidential resources they can use. One example of a confidential resource is the National Domestic Violence Hotline 800-799-SAFE (7233).
Collaborate with the patient regarding how information about their relationship should be documented in their medical record. Consider whether their partner has access to their medical record. Also, inform the patient that the information included in the medical chart can be used in a court of law if they choose to pursue legal action in the future.
Know the next steps for resources. Many professionals can screen for IPV effectively, yet, they may not know what to do when a patient screens positive. Have a plan for when a patient screens positive for IPV. Know local resources or a social work organization they can be referred to. You can even consider contacting the organization with the patient in the office. Coordinate the safest way to communicate with the patient regarding the matter outside of appointments. Despite being well-intentioned, discussions centering on rescue attempts may feel intrusive to a patient initially; thus the focus should be on being non-judgmental and supportive. Offer the patient options and allow them to choose how they would like to move forward. Allow the process to be patient-centered.
Raise awareness throughout the year about the importance of awareness, education, and advocacy about domestic violence.
Leana Pande and Courtney Chau are medical students.
