Practice recommendations
- Physicians should routinely screen women for domestic violence (C). Although the US Domestic Task Force considers the evidence for or against specific instruments insufficient, the recommendation to include questions about physical abuse may be made on other grounds, such as the high prevalence of undetected abuse among women patients, the potential value of this information in helping such patients, and the low cost and low risk of screening.
- Offer abused patients information about community resources and advocates (B). Advocacy and connections with community agencies have proven helpful (in a randomized controlled trial) in improving quality of life and preventing violence-related injuries.
Screening is effective in detecting domestic violence, and increases the rate of referrals to community resources, resulting in improved quality of life and fewer violence-related injuries.
Screening can be accomplished with a questionnaire filled out by the patient or a directed interview conducted by you or a staff member.
Newer screening tools are briefer and easier to use than before. A self-administered questionnaire can even become part of the routine intake at annual health examinations.
These advances may be a remedy for a finding of one study—only 10% of primary care physicians routinely screen for domestic violence.1 Although 92% of women surveyed who were physically abused by their partners did not discuss these incidents with their physicians,2 studies show they would like their health care providers to ask about abuse.3-5
How screening makes a difference
Domestic violence is a chronic life-threatening condition that is treatable. If abuse is left untreated, the severity and frequency of abuse can worsen, leading to serious adverse effects to health and potentially life-threatening consequences.6,7 However, if we identify victims by screening and offer information including safety plans and referrals to advocacy services, the prognosis is improved in terms of reported quality of life and fewer violence-related injuries (LOE: 1b).8,9
Although the effectiveness of screening on every aspect of the recovery process has not been validated by randomized controlled trials, the current literature certainly suggests likely benefit in certain stages. Qualitative evidence from abuse victims supports the assumption that screening for abuse enables patients to recognize a problem, even if they are not ready for help at that point.10
Prevalence of domestic violence
A study by the Centers for Disease Control and Prevention of 1,691,600 women found that 30% had experienced domestic violence during their lifetimes.11 The prevalence of domestic violence is difficult to measure due to different definitions of abuse and factors that preclude accurate reporting by victims, such as safety and social stigma.
One anonymous survey in a family practice setting found that 23% of women had been physically assaulted by their partners in the past year,12 and another anonymous survey of 1952 female patients attending 4 different community-based primary care practices found that 1 of every 5 had experienced violence in their adult lives.13
Domestic violence is also a financial burden to victims and to society: domestic violence victims have 2.5 times greater outpatient costs than do nonvictims.14
Why screen all women?
Particular history and physical findings are associated with increased likelihood of domestic violence (Table 1).15-20 Neither victims nor batterers fit a distinct personality or profile, however, and abuse affects women of all ages, ethnicities, and socioeconomic classes. Predicting which women will be affected is difficult,21,22 which suggests that universal screening is more appropriate than targeting specific groups (LOE: 5).
The US Preventive Services Task Force (USPTF) gave a strength of recommendation of C for domestic violence screening because evidence to recommend for or against use of specific screening instruments is insufficient.23 Two recent systematic reviews concluded that evidence is lacking for the effectiveness of interventions for women experiencing abuse, and the potential harms of identifying and treating abused women are not well evaluated.24,25 However, the USPTF noted that asking questions about physical abuse is justifiable on other grounds, such as the high prevalence of undetected abuse among women patients, the potential value of this information in helping such patients, and the low cost and low risk from screening.
The American Academy of Family Physicians,26 the American College of Physicians,27 the American Medical Association,28 and the American College of Obstetricians and Gynecologists29,30 all recommend screening for domestic violence. Screening does increase the detection of domestic violence.25 The screening can be a questionnaire filled out by the patient or a directed interview conducted by a staff member or physician. Two recent studies found that questionnaires are better than interviews at detecting domestic violence (LOE: 2b).31,32