Health-Care Professional’s Role

Routine screening of all women who contact the health care system is advocated by many institutions and professional organizations including the American College of Obstetricians and Gynecologists. Other organizations advocate more focused screening. The support for routine screening is more the result of consensus than grounded in strong research. If a more focused approach is chosen, the index of suspicion must be at the highest level and the practitioner should remain constantly vigilant for the more subtle signs of abuse. Available literature suggests that the majority of women support routine screening in a primary care setting.(8) In addition to this studies have shown that women who have been victims of abuse would have disclosed had they been asked in a supportive manner.(9,10)

Abuse during pregnancy has been demonstrated to be a significant problem with a higher incidence than other complications that are routinely screened for.(12,13) Its presence has been linked to significant pregnancy complications including miscarriage, placental abruption, premature labor and delivery, low birth weight and fetal loss.(14,15,16) Studies indicate that the prevalence of women experiencing violence in pregnancy is between 0.9% and 20.1%.(12) It is as yet unclear from research as to whether pregnant women are at greater risk for the initiation of violence, or if in a violent situation whether the severity or frequency of violence escalates or decreases in pregnancy.(17) What is clear is that the regularity of visits may make it easier for both the physician and woman to broach the topic, and given the fact that there is a pregnancy at stake make it more important that the problem be recognized. Given these factors, pregnancy may be a time when routine screening would be important.

Remember that there are barriers to disclosure on both the client/patient’s and the health professional’s part.

Have a high index of suspicion in your practice

Frequently the clinical presentations are not overt. However, studies have suggested that 30% of injured women presenting to emergency rooms were injured during domestic altercations, whereas 22.7% of women seeking health care from family physicians reported assault by their partner in the preceding year.(5,6)

Suspect abuse when:

• History of recurrent trauma or “accidents”
• The explanation of injuries does not fit the physical evidence
• Delay in seeking medical assistance
• Injuries to multiple sites that may be in multiple stages of healing
• Symmetrical and bilateral injuries
• Injuries to head, neck torso, breasts , abdomen or genitals
• Fingerprint or strangulation bruises.
• Injuries when pregnant
• Chronic illness that is refractory to treatment
• STI’s without a history of multiple partners
• Frequent pregnancies when unwanted by woman
• Sexual dysfunction or disinterest
• Sexually addictive behaviour.
• Frequently miss appointments
• Poor eye contact, flat affect or hypervigilant
• Seldom goes anywhere without partner: partner speaks for the patient
• Family history of abuse
• Runaway children

Create an office environment which facilitates disclosure

1. Talk to your staff about domestic violence and how to respond if they suspect that a patient is being abused. 
2. Display posters, brochures, small information cards and lists of community resources can all help to tell women that you consider violence to be an important health issue. 
3. Ensure that the woman finds herself in a situation where she can disclose if she chooses or can pick up information safely. 
4. Put portable information in the women’s bathroom. 
5. Leave business cards out in case the woman is afraid to take any information that may cause her partner to become suspicious.

Take advantage of opportunities to incorporate questions about domestic violence into your routine

• During annual check-ups
• During emergency room visits
• During prenatal or obstetrical visits
• During family planning visits
• During well child exams, sport and camp physicals
• During assessment for admission into home care programs or long term care facilities
• During admission or discharge from hospital

Screening Tools

Ways of asking about abuse are obviously dependant upon communication styles. There are tools available for practitioners to use as a foundation. Whether direct or indirect questioning is employed will depend upon the physician’s clinical judgment and how the interview progresses. A tool that has shown good reliability in the primary care setting is the WAST (Woman Abuse Screening Tool). It begins with indirect questions that will uncover the problem in the majority of cases and then moves onto more direct questions.

Women’s Beliefs and feelings that act as Barriers to Disclosure

• Tendency to minimize the abuse (denial)
• Cultural/ethnic/religious beliefs
• Fear of reprisal
• Shame
• Belief that the abuse is deserved
• Love for the perpetrator
• Belief that he will change
• Financial dependence
• Concern about children
• Previous negative experience with disclosure

Health-Care Professional’s beliefs that act as barriers to detecting abuse

• That abuse is not a medical or health issue
• That women provoke the violence and could leave the situation if they want
• That abuse is rare, and is a private matter when it occurs
• That intervention is too time consuming
• Physicians are unable to do anything
• Women will not comply with medical advice

Self care issues:

• Fear of being overwhelmed
• Reluctance to identify with the “victim”
• Helplessness and inadequacy if can’t fix the situation
• Anger at client for not responding to caregiver’s need to cure.
• Lack of knowledge and skills