Assessment and Screening in the Healthcare Setting

In adult health care settings, universal and regular face-to-face assessment of women by trained health providers markedly increases the identification of victims of violence, as well as those who are at risk. Information gained by the interviews can assist in the treatment of the victim. Battered women have reported that the most important part of their communication with the health care provider is being listened to about abuse.

Ideally, all health care providers and counselors should be trained to assess for intimate partner violence, including physicians and all nursing personnel, dentists and all dental assistants, EMTs, public health professionals, and mental health professionals. Identification and response to victims should occur in all health care settings. The initial inquiry and response should be conducted by a health care provider who has been educated about the dynamics of domestic abuse and has been trained in how to ask about abuse, and provide information about abuse and local community resources and intervention. This person should be authorized to record this information in the patient's medical record. Again ideally, he/she should have a relationship or some trust established with the patient. Responses to victims of abuse are most effective when coordinated in a multidisciplinary manner and in collaboration with domestic violence advocates.

People who conduct interviews should be well-versed in risk factors for individuals and should understand the dynamics of violent relationships as well as cultural factors within the community. Domestic/intimate partner violence is most likely to occur in a relationship in which the male is dominant and there are strict gender roles, combined with marital conflict and instability. Often there is a desire for power and control on one side and emotional dependence and insecurity on the other, in a relationship characterized by anger and hostility.

The problem of domestic/intimate partner violence within communities is increased in the presence of poverty and poverty-related problems, especially when there are weak sanctions against domestic violence. In some communities, distrust of the police is pervasive and people are often more afraid of dealing with the police than the perpetrator. Therefore, people may need to be assured of confidentiality when they are choosing whether to call the police or not.

Ideally, all health care settings should have policies in place for dealing with domestic/intimate partner violence. Questionnaires should be readily available, as well as brochures and information about services. Staff should be trained and supervised to ensure compliance with assessment for violence.

The following section identifies a number of steps in the identification of victims and perpetrators:

inquiry, interview, questioning, validate, documenting carefully, and a special section on assessment of perpetrators.

Inquiry

Inquiry should be conducted routinely of all adolescent and adult patients, regardless of cultural background, and all parents or caregivers of children in pediatric care. According to the Family Violence Prevention Fund, assessment should be conducted according to these standards:

• Routinely, regardless of present or absence of indicators of abuse, as part of every routine health history and every new patient encounter or every additional encounter in urgent care.
• Orally as part of face-to-face health care encounter.
• Included in written or computer-based health questionnaires.
• Using direct and nonjudgmental language that is culturally/linguistically appropriate: “Have you ever been physically, sexually, or emotionally abused?”
• Questioning both current and lifetime abuse.
• Conducted in private with no friends, relatives (except children under 3), or caregivers present.
• Confidential: patients should be informed of any reporting requirements or other limits to provider/patient confidentiality.
• Assisted, if needed, by interpreters trained to ask about abuse and who do not know the patient, the patient's partner, caregivers, friends or family socially.

If there is no possibility of privacy or no interpreter available, this should be documented in patient's chart and a follow-up visit scheduled. Information about intimate partner violence and resources should be posted prominently in waiting areas, bathrooms, and treatment rooms.

When interviewing patients, there are some indications that suggest that the individuals may be at risk for being victims of domestic violence:

• Exhibit fear of their partners
• Not allowed access to family, friends, or other support networks
• Often feel guilty and may blame themselves for their partner's violence
• May complain of problems sleeping, chronic pain, GI disorders, nervousness, depression, or signs of post-traumatic stress disorder.
• More likely to have serious injuries such as injuries to head, neck, and torso.
• Can articulate what precipitated specific incidents or progression of violence.
• Report having been told by others about concern for patient's safety.

One reason that it's so important to assess all patients is that victims may present with almost any physical complaint, such as headaches, chest pains, heart palpitations, numbness and tingling, and choking sensations rather than traumatic injuries. People who complain of recurring physical complaints with negative evaluations may be victims of abuse. Chronic pelvic pain with a negative work up also suggests domestic violence. People who are abused may attempt suicide and may suffer from substance abuse. They frequently suffer from anxiety.

Once a patient discloses current abuse, there are a number of questions that should be asked about immediate safety:

• “Are you in immediate danger?”
• “Is your partner at the health facility now?”
• “Do you want to [or have to] go home with your partner?”
• “Do you have somewhere safe to go?”
• “Have there been threats or direct abuse of the children?” [if s/he has children]
• “Are you afraid that your life is in danger?”
• “Has the violence gotten worse or is it getting scarier?”
• “Has your partner used weapons, alcohol, or drugs?”
• “Has your partner ever held you or your children against your will?”
• “Does your partner ever watch you closely, follow you, or stalk you?
• “Has your partner ever threatened to kill you, him/herself or your children?”

If the violence has escalated, the perpetrator has used weapons, there is stalking or threats to kill the victim, then further assessment for suicide/homicide should be done. After the initial questions, the health provider should continue to question to ascertain the pattern and history of current abuse, questioning how long the violence has gone on and whether the patient has been hospitalized because of abuse. The patient should be asked about the most serious recent events and about other abuse:

• “Has your partner forced you to have sex, hurt you sexually, or forced you into sexual acts that made you feel uncomfortable?”
• “Have other family members, children, or pets been hurt by your partner?”
• “Does your partner control your activities, money, or children?”

If a patient reports a history of previous abuse, it's important to ascertain whether the patient is still with the perpetrator and whether or not s/he feels any present danger. If patients deny abuse, that response should be treated with respect, but the patient should be told that the health provider is available should the situation change. If the patient says "no" but appears to be at considerable risk, the health provider should discuss specific risk factors and offer information and resources.

It's very important to listen non-judgmentally and offer reassurance.

• “I am concerned for your safety [and the safety of your children].
• “You are not alone and help is available.”
• “You don't deserve the abuse and it is not your fault.”
• “Stopping the abuse is the responsibility of your partner, not you.”

Provide information:

• “Domestic violence is common and happens in all kinds of relationships.”
• “Violence tends to continue and often becomes more frequent and severe.”
• “Abuse can impact your health in many ways.”
• “You are not to blame, but exposure to violence in the home can emotionally and physically hurt your children or other dependent loved ones.”

At this point, it's good to offer the patient a brochure or information about safety planning, and then go over it with him/her. The health provider should discuss keeping information private and safe from the abuser and offer the patient immediate and private access to an advocate in person or via phone. If the patient wants to press charges of abuse, the health provider should provide support and offer to place the call to the police. Throughout this process, the patient's autonomy should be reinforced so that the patient is making decisions about his/her own safety and not being coerced.

Because a criminal proceeding may follow identification of abuse, it is of the utmost importance that documentation be complete and clear. All evidence of trauma should be described in detail and pictures of injuries taken as they may be needed as evidence at a later time. The health provider should document all relevant history:

• Chief complaint or history of present illness
• Details of the abuse and its relationship to the presenting problem
• Any concurrent medical problems that may be related to the abuse
• Summary of past and current abuse, including patient's statement of what happened.
• Patient's appearance and demeanor.
• Any objects or weapons used in the assault (closed or open fist, knife, cigarette, iron)
• Account of any threat
• Names or descriptions of any witnesses.

The results of the physical exam should also be documented, as is customary. The health provider should also document if a patient does not disclose victimization by stating that the assessment was conducted but the patient did not disclose abuse. If the health care provider suspects abuse based on physical evidence, that should be documented as well:

• “Physical findings are not congruent with history or description.”
• “Patient presents with indications of abuse.”

There are many factors that contribute to the risk that someone will become a perpetrator of violence toward an intimate partner. It is important to remember, however, that risk factors are not causes. Some men, for example, who grow up in violent homes, become violent; others do not. Research has indicated that these are risk factors:

• Young age
• Low self-esteem
• Low income
• Low academic achievement
• Aggressive delinquent behavior as a youth
• Alcohol use
• Drug use
• Witnessing or experiencing violence as a child
• Lack of social networks and social isolation
• Unemployment

While much energy has been expended on identifying the victims of domestic violence, much less research has been done related to assessing for perpetrators. Almost always, when it is evident that an act of violence has taken place, priority is given to keeping the victim safe. Perpetrators may be identified only after they have been charged with abuse and referred for intervention. However, healthcare providers do provide care to people who are at risk for becoming perpetrators. Any type of counseling or intervention program (substance abuse, anger management, psychological counseling) should include discussions about abuse. In primary care or emergency departments, healthcare providers can stress the damage that anger and stress can cause. Some questions that might be used to assess for perpetration of domestic/intimate violence are the following:

• “Do you ever feel that your anger is out of control?”
• “Do you ever feel like hitting someone?”
• “Have you ever acted on your anger and struck someone?”

It's very important to remember that perpetrators of violence often do not exhibit violent tendencies in public, and some may be well-liked and very pleasant to others. On the other hand, some perpetrators are very volatile, and the health care worker must always assess whether it's safe to broach the subject of violence. If someone is already belligerent and angry, that individual may not be receptive to any questioning. There are some types of responses and injuries that are clues that people being interviewed may be perpetrators:

• Notably jealous of friends, family, coworkers, and others
• Scornful of their partner's perspective
• Claim authority in various ways (profession, education, etc.)
• Minimize or explain their behavior, make excuses, become defensive
• Vague about violent incidents, “can't remember”
• Often have offensive wounds (scratches or bite marks) caused by victim

The CDC provides "Measuring Intimate Partner Violence Victimization and Perpetration: A Compendium of Assessment Tools". The purpose of the Compendium is to provides researchers and prevention specialists with a compilation of tools designed to measure victimization from and perpetration of IPV.

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