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SCREENING SERIES

Detecting Domestic Violence: To Screen or Not to Screen?

Sonia G. Laumbach, MD


Various medical professional organizations have recommended that screening for domestic violence (DV) be incorporated into routine medical practice.1-4 However, significant barriers have inhibited adoption of these recommendations. Physicians practicing in today's fast-paced environment find it more and more difficult to administer all recommended health screenings to their patients. The use of reliable, time-saving, and cost-effective screening tools makes this a more attainable goal. A number of DV screening tools have been developed, but few have been validated. This paper reviews four reliable, efficient screening tools. General approaches to screening and intervention will also be discussed.


IMPACT

Each year in the United States, nearly 5 million domestic physical or sexual assaults occur to nearly 1.5 million women over 18 years of age.5 The true incidence of DV is probably much greater than official estimates because DV often goes unreported. Both men and women can be victims of DV, but women are more likely than men to experience it. Yearly prevalence rates of DV ranging from 2% to 23% have been cited in the literature.1,6,7 One in four white women and nearly one in three black women will experience DV in their lifetime.5 In 2002, more than 3,000 women were homicide victims; of these, 32% were killed by their husbands or boyfriends.8

Women who experience DV, also referred to as intimate partner violence, report poorer health status overall and use health care services more frequently.1,6,7,9 They seek medical care not only for serious injuries, but for a variety of other somatic and psychological complaints. They have more frequent gynecologic, gastrointestinal, chronic pain, and psychiatric complaints.6,7,9 Other common complaints include frequent sexually transmitted diseases (STDs), unwanted pregnancies, pelvic pain, digestive problems, back pain, and depressed mood.6,7,9 Abused women have higher rates of comorbid psychiatric disorders, including mood, eating, and substance abuse disorders.7,10

Domestic violence often escalates during pregnancy.1-3 Women who are pregnant have a documented rate of abuse during pregnancy of 4% to 20%.1,2,7,11 Abuse during pregnancy puts both mother and baby at risk for complications. Several studies have identified an association between abuse during pregnancy and low birth weight.11,12 Women abused before and during pregnancy are also at higher risk for abuse after pregnancy,3 and child abuse occurs in 33% to 77% of families with DV.1

In 2003, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control published a report that estimated direct and indirect costs of DV at $5.8 billion per year in the United States.5 Medical and mental health care services accounted for nearly $4.1 billion. Annually, 8 million days of lost productivity were attributed to DV. These figures are probably underestimates, because health care and other costs due to DV are often not recognized or not reported. These figures also do not take into account the cost of health care services sought for other somatic complaints associated with DV, but not directly related to abuse.


SCREENING CONTROVERSY

Domestic violence is widely recognized to be a public health issue of epidemic proportions. Various medical professional institutions have promoted guidelines for screening, yet studies show that fewer then 15% of physicians actually screen for DV.3,13,14 A number of studies have attempted to identify physician and patient barriers to screening for DV. Insufficient time, lack of education, discomfort, and a lack of known effective interventions have been cited as primary barriers for physicians.14-16 When physicians do attempt to screen for DV, patients often fail to disclose abuse due to fear, shame, and lack of trust.14,15,17 Combined patient and physician barriers make DV screening complex and challenging.

Despite widespread screening recommendations, a lack of consensus on the value of universal screening may lead to additional physician uncertainty about screening for DV. Two recent evidence-based reviews conclude that there are insufficient data to justify implementing universal screening for DV.18,19 Primary reasons for this conclusion included lack of adequate research data regarding the benefits and risks of both DV screening and DV interventions. The US Preventive Services Task Force has also concluded that there is insufficient evidence to support universal use of DV screening tools.20 However, all of the sources agree that screening may still be appropriate in adult patients due to the high DV prevalence rates, low cost of screening, and the potential benefit for individual patients.18-20 An additional benefit of DV screening may be that, if done appropriately, it can positively affect the patient-physician relationship.


WHEN AND HOW TO SCREEN

Domestic violence is found across all cultural, ethnic, religious, educational, and socioeconomic backgrounds.7,21 However, stereotypes still seem to influence some physicians' decisions about screening for DV.16 When a patient's history and physical examination are suspicious for abuse, screening for DV is paramount. Although clues may present from the patient's conversation or physical findings,7,21 no single symptom or finding is an absolute predictor of DV. Therefore, several organizations and experts recommend screening routinely, not just during health maintenance examinations.1,2,22 Because DV is dynamic, screening during successive patient encounters will yield different answers. An answer of "no" to a DV screening question today does not mean it will be "no" in the future.

Physician comfort and dialogue with patients are important prerequisites to effective implementation of screening. In general, it is more appropriate to screen women for abuse after a rapport has been established with the interviewer.21 Screening as part of a women's sexual history, or along with anticipatory guidance questions, would also seem appropriate. Simple and direct clinical inquiry that avoids ambiguity is best. This can be done orally or through the use of questionnaires. It is vital to ensure privacy during administration and completion of questionnaires.

The environment in which DV screening occurs is key to its success. Because women in abusive relationships live in a chaotic, violent world, it is important for the screening environment to feel private and safe.15,23,24 Normalizing statements such as "Because violence is so common in women's lives, I ask all women about possible violence in their lives"1,15,21 can help make the exchange easier for both the physician and patient. The physician needs to be aware of his/her body language and other nonverbal responses to the information shared. It is crucial to convey that the practitioner is listening and acknowledges the patient's courage in sharing this information.21 In qualitative studies, women from various cultural groups report that they seek respectful, supportive, nonjudgmental, and attentive medical providers to facilitate discussions of abuse.13,25,26


SCREENING TOOLS

Over the last two decades, a number of techniques have been suggested for facilitating DV screening. However, few of these screening tools have been validated against established diagnostic tools such as the Conflict Tactic Scales (CTS), Index of Spouse Abuse (ISA), or the Abuse Risk Inventory (ARI).27-32 Thus, the sensitivity, specificity, and predictive value of DV screening tools are often not available. The following is a presentation of four validated brief screening tools for detecting DV. Studies of DV screening tools differ greatly as to the sample sizes and demographics of populations in which the tools were tested. Only one of these tools, the Woman Abuse Screening Tool (WAST), has been studied in more than one patient population.30-32 Therefore, specific comparisons between DV screening tools are difficult at this time.

The Hurt, Insult, Threat, Scream Screen

The Hurt, Insult, Threat, Scream (HITS) screening tool was designed as a "paper-and-pencil" instrument for identifying both physical and verbal abuse.28 The four items are scored on a Likert 5-point scale (Figure 1). A score of 10 or greater is considered positive for DV. It has been validated against the CTS in a study of 160 female patients in an urban/suburban family practice setting and 99 self-identified abused women.28 The HITS scores were strongly correlated with the CTS, with sensitivity and specificity of 96% and 91%, respectively. Positive predictive and negative predictive values in the family practice setting were 87% and 97%, respectively. A verbal form of the HITS questionnaire would probably have similar accuracy.28 Of note, a woman could deny physical abuse but still screen positive for DV with this tool.24


Click to enlarge

 Figure 1. Hurt, Insult, Threaten, Scream tool28


The Partner Violence Screen

The Partner Violence Screen (PVS) tool consists of three questions that address physical violence and women's perceptions of their safety (Figure 2).29 A positive response to any of the three questions is considered positive for DV. The PVS was tested in 322 women presenting at emergency rooms in two urban hospitals. Both the CTS and ISA instruments were used for validation. Because two instruments were used for validation, ranges for sensitivity (64.5% to 71.4%), specificity (80.3% to 84.4%), positive predictive value (51.3% to 63.4%), and negative predictive value (87.6% to 88.7%) were reported.29 By including questions about past relationships, this screening test takes into account the dynamics of changing relationships. In fact, the highest prevalence of abuse in this study occurred in women who had no current partner and only a previous relationship.29


Click to enlarge

 Figure 2. Partner Violence Screen tool29


The Abuse Assessment Screen

The Abuse Assessment Screen (AAS) is the oldest short DV screening tool still used today. The AAS was developed for the detection of abuse during pregnancy. It consists of five questions, but a shortened three-question version has also been studied.27 Both the long and short AAS tools have been shown to correlate well with the CTS and the ISA. However, data regarding sensitivity, specificity, and predictive values have not been reported.27 The tool has been translated into Spanish, and it also includes body maps for documentation of injuries (Figure 3).23 It has been modified by at least by one source to be more applicable to women who are not pregnant by simply deleting the reference to pregnancy in the first part of the third question.15


Click to enlarge

 Figure 3. Abuse Assessment Screen23


The Woman Abuse Screening Tool

The WAST consists of eight questions addressing emotional, physical, and sexual abuse.30-32 It has been validated against the ARI. The first two questions of the tool have been shown in a small population (n = 24) to have a sensitivity and specificity of 91.7% and 100%, respectively.30 It has been tested in a larger population31 and in Spanish-speaking patients,32 and maintained its validity. When used in the Spanish-speaking population, it was found to have a lower sensitivity in primary care patients then in self-identified shelter patients.32 This underscores the importance of studying this and other tools in diverse populations.


Click to enlarge

 Figure 4. Woman Abuse Screening Tool30



ESTABLISHING A PROTOCOL

Administering any of these tools takes no more than a few minutes. Listening, assessing, and providing interventions as necessary will take additional time. The practitioner should consider in advance how disclosure will be handled. Busy practitioners can employ an approach such as, "I'm glad you felt comfortable talking to me about what has been happening to you. Your safety is very important to me. Although I can't fully address all your concerns right now, there is someone whom we can call who has a lot of experience with this. I hope you can stay and talk with this person today."15

Utilization of community resources is essential. The National Domestic Violence Hotline [1-800-799-SAFE, or 1-800-787-3224 (TTY)] can provide information on local resources. Allowing abused patients to use private office telephones to speak to DV crisis counselors or law enforcement is especially important if the woman is in immediate danger. Giving a patient a handout with a written telephone number for her to call at a later time may put her at risk, so it is important to always ask first if it is safe to give her that information.

To assess the patient's safety, she should be questioned about recent threats, escalating physical violence, and firearms in the home.15,23 Asking about abuse to children in the household is also essential. Also, it is not uncommon for victims to express both suicidal and homicidal ideations.15 These are "red flags" to practitioners. Some states require reporting for DV, so it is important to understand any such mandates. Patients should be informed of any legal reporting requirements prior to screening.15

Of course, it is the woman's choice about whether to leave an abusive relationship, but the physician should encourage her to develop a "safety plan" regardless, for contingencies. It is important to explore her particular support systems, such as family, friends, and coworkers. She should be advised to prepare a bag with copies of important documents and essential belongings (personal clothing, children's clothing, a preferred toy) that she can easily grab if she needs to flee.7,15,33 Finally, the discussion must be documented using the patient's words wherever possible, and referral provided to appropriate services. Regardless of any fears for the patient, she should not be "told" what to do. She must decide what is best for her. It may take multiple cycles of abuse before she decides to leave her abuser. The role of the physician in intervention is to provide the necessary information and resources to allow the patient to make an educated decision.23


TO SCREEN OR NOT TO SCREEN?

The objective of screening is to aid in the identification of a significant problem for which an effective intervention is available. The tools discussed here are good starting points, but more comparative studies in different populations are needed. These interventions have not been proved effective in either preventing or treating abuse.18,19 Nonetheless, although solid intervention studies with objective outcomes measurements are lacking in the field of DV, some evidence suggests that interventions can be effective.19 For example, 2-year follow-up has shown that assistance provided by a DV advocate to women who were in an abusive relationship and spent at least one night in a women's shelter was associated with experiencing less violence over time, a perception of a better quality of life and social support, and less difficulty in obtaining community resources.19,34


CONCLUSION

Domestic violence is a multifaceted problem with high prevalence and substantial costs to society. Using these time-saving screening tools can facilitate discussion of abuse. However, it is important to note that a positive screen with any of these tools demands further evaluation. On recognition of ongoing DV, assessment of safety and referral to appropriate resources are essential. A team approach in which practitioners, office staff, mental health professionals, law enforcement, and advocacy groups work together is needed to effectively intervene in this complex and challenging problem.

Sonia G. Laumbach, MD, is clinical instructor and health policy fellow, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Department of Family Medicine, New Brunswick, NJ.

References

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  3. American Academy of Family Physicians. Policy and Advocacy Statement: Violence(position paper). New Orleans, La: AAFP; 2003.
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