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Domestic Violence Screening: A Preventative Health Service or No Use at All?

Posted on Aug 07, 2014 by Ailee Slater ()  | Tags: domestic violence, domestic abuse, domestic violence screening, BMJ, emotional health, mental health, doctor screening domestic violence, ACA, Affordable Care Act

Domestic abuse: it affects mental health and physical health, so: do doctor’s have a medical and ethical responsibility to ask their female patients if they are being abused? 

Some health care advocates say, yes: that during wellness check-ups, general practitioners should ask women of childbearing age if they are experiencing any abuse at home. The U.S. Preventative Services Task Force last year released recommendations that clinicians screen women for partner violence, and provide support or referrals to women who respond in the affirmative. 

Then again, other health care groups disagree. In May, the BMJ (formerly the British Medical Journal) released a study concluding that domestic violence screening might have little to no effect. In randomized trials, researchers found that screening did not lead to improved outcomes for women experiencing domestic violence. Although the study also concluded that screening by clinicians didn’t harm women, the study saw that abuse was not reduced due to clinician questionings about domestic violence. 

This BMJ study has called into question the effectiveness of domestic violence screening. Did doctors not offer appropriate support or referrals following a patient’s admission of abuse, or was that support simply not taken by the patient? Interestingly, researchers in this study did find that routine screening helped doctors identify twice as many cases of domestic violence but that identification didn’t appear to lead to reduced instances of abuse. 

Speaking with NPR health news, Dr. Gene Feder (a researcher who worked on the BMJ study) said that doctor screening can fail to protect victims because the practice emphasizes identifying rather than helping victims of domestic violence. Although screening helped doctors to find and record women who admitted abuse, follow-up services were not provided in such a way as to stop that abuse from reoccurring. 

Dr. Feder added that better training for clinicians might be the key – if doctors and nurses knew the right questions to ask and the right people to approach, domestic violence screening might have a better chance at improving domestic violence support services. For example, screening could be concentrated on women who have experienced violence in the past, or those that doctors already have a reason to think might be living in a situation of domestic abuse. By focusing resources on at-risk women, rather than engaging in universal domestic abuse screening, health care practitioners might be better able to offer useful support to women who need it. 

The U.S. Preventative Services Task Force has yet to issue a response to the BMJ study. According to their initial recommendations, universal screening of women is essential due to the benefits of early detection – if domestic violence can be identified early in a relationship, a woman has a better chance of leaving the abusive situation. Early intervention can reduce the physical and emotional harms of abuse, and moreover, evidence shows that abuse screening doesn’t cause any harm – an argument that even the BMJ study agrees with: as explained by Dr. Feder, “We don’t think screening is necessarily harmful.” 

The Task Force further found that new technology in domestic violence screening might prove useful in the future. Computerized questionnaires, for example, can make a woman feel more comfortable revealing abuse at home, and more comfortable later on talking about that abuse with a doctor. By that logic, general doctor screening of patients for domestic abuse should continue – even if it appears that the abuse is continuing, a woman may feel more comfortable approaching her doctor about the issue in the future if an initial screening has occurred. 

In the United States, the Affordable Care Act (ACA) has guaranteed a woman’s free access to domestic violence screening and counseling, as part of their yearly wellness visits to a general practitioner. According to the ACA, domestic violence screening is a preventative health service, and therefore should be available to every woman as part of her insurance plan. However, there are still no clear guidelines for doctors as to what this screening process entails – when should abuse be discussed, and what questions are appropriate to ask? It is up to each health care provider to form their own screening procedure, but if clinics are to believe the recent BMJ study, it may be preferable to do away with domestic violence screening all together. 

At the same time, some doctors say that instead of putting an end to domestic violence screening, it would be far better to concentrate on what health care interventions are offered to women who admit to abuse at home. Speaking with NPR news, Nancy Glass of the John Hopkins Center for Global Health explained that a conversation between patient and physician is an important step in the right direction, even if that interaction doesn’t immediately lead to the woman seeking help. Authors of the Affordable Care Act agree: encouraging doctors to help patients who admit abuse to seek early intervention through counseling services, covered under the ACA. 

The World Health Organization has called violence against women a major health issue, and supporters of domestic violence services are quick to point out that domestic abuse isn’t limited to women, nor is it limited to heterosexual couples. Domestic abuse is connected to health in a number of ways: abuse can lead to physical and mental trauma, affecting a victim’s general wellbeing in what is often a very significant manner. Health care researchers agree that domestic abuse is unacceptable, even if they don’t agree on whether or not doctors ought to screen for such abuse. The BMJ study is unlikely to end doctor-initiated domestic violence screening but it might just increase support for better abuse intervention – a paradigm shift that, surely, doctors, patients and researchers alike will agree is for the best.

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