Guest post: The elephant in the doctor’s office: Intimate Partner Violence (IPV)

Intimate Partner Violence (IPV) is the elephant in the office and doctors need to be ready to detect it.

By Dr. Daniela Martinez Valenzuela

According to the NIPSVS, 43.6 million U.S. women experienced violence and/or stalking by an intimate partner during their lifetime, and 24.3% experienced severe physical violence. It’s not surprising, given the vast inequity issues in our healthcare system, that these numbers raise significantly if we talk about Hispanic women. Economic insecurity, immigration status, language barriers, food and housing insecurity as well as poor access to health services, puts Hispanic women in a more vulnerable position and lowers their chances to overcome IPV.

The American Medical Association and the American College of Obstetrics and Gynecology, recommend that clinicians screen all female patients for DV, and I agree it´s necessary, given that ¼ of our female patients may be impacted, and we can help them. Domestic violence has been cited in the Journal of Surgical Research as the leading cause of injury and death for women younger than 45 years of age. When they don´t end in death, cases often result in unwanted pregnancies or injuries, requiring medical treatment where doctors can play a major role if they inquire properly about signs of abuse.

Doctors are encouraged to act against domestic violence (DV). The U.S. Preventive Services Task Force enforces screening while the American Medical Association urges investigation and reporting signs of abuse. However, are doctors trained to detect and manage DV as they are for other prevalent conditions? I don’t think so.

Women can break the silence easily with doctors because talking about intimate things during a consultation is normal as they expect healthcare professionals to be active listeners, open minded, respectful about confidentiality, and willing to help. The problem is most doctors don’t know how to approach patients about IPV. Carmen Alvarez found that screening rates are low and vary, ranging from 2% to 50%. In Barriers to screening for Domestic Violence, Lorrie Elliot and her team described that even 80% of the doctors have been trained about DV, only 27% feel confident in their abilities to recognize victims. Also, they don´t feel equipped to respond appropriately if they are told about abuse.

The truth is, it is not hard to incorporate screening for DV on a regular basis. The first step is educating yourself about the topic. You might want to check the NYC Medical Providers’ Guide To Managing Domestic Violence Patients and then adopt some new practices like the following:

Before appointments:

Partner with support agencies like domestic violence hotlines and advocates, lawyers, social workers or therapists to make sure you can offer reliable referral resources.

Enhance the clinical environment for privacy and remember that not every survivor will show up with a black eye or wearing a turtleneck to cover bruises; sometimes missing appointments is a red flag.

During consultation:

Use a screening tool. John Wenzel, et al, found that routine screening with a few questions increases detection and empowers patients to ask for help. You can use one of the validated questionnaires the USPSTF found to be the most accurate (HARK, HITS, E-HITS, PVS or WAST).

Identify vague or psychosomatic symptoms; ask about depression, anxiety, substance abuse, self-harm, or emergency room visits; detect injuries that might be concealed or minimized (mostly in abdomen and breast) or unwanted pregnancy.

Be intuitive to spot reactions and detect if a patient´s heart rate accelerates while they try to explain something, if they refuse to make eye contact, or if there is unwillingness to discuss findings.

Remember that some women have experienced IPV in the past and may experience PTSD. You need to be careful not to underestimate the effects of the physical examination, and ask for permission for everything you do step by step to avoid retraumatizing the patient.

If you suspect a patient needs help, you can use the CUES method. Prioritize confidentiality so they feel safe to speak and offer accurate information and support. Validate the patient’s experience and provide an opportunity to legitimately seek help (whether that means breaking the cycle or psychologically overcoming a past experience). If needed, you can shift the conversation to focus on how IPV may impact her health but always try to connect them with the agencies you researched before.

Also, never use a patient´s partner as an interpreter. And, let women whose citizenship status might be unclear know that laws in the US guarantee protection regardless of immigration status and offer to connect them with free or low-cost resources.

As you can see, it is possible to incorporate good practices to identify an under-recognized and under-addressed condition like IPV in your consultation and offer appropriate help. Incorporating a few modifications in your practice may change or save someone’s life.

Daniela Martinez Valenzuela (dmartinez@cdtspartners.com) is a Mexican doctor with a Master Degree in Public Health, who has worked as an advocate for healthcare quality improvement, value based medicine and women’s health. She is currently obtaining a Master of Science in Health Care Transformation at The University of Texas at Austin.