Am Fam Physician. 2012 May 15;85(10) Online.
Original Article: Intimate Partner Violence
Issue Date: May 15, 2011
Available at: http://www.aafp.org/afp/2011/0515/p1165.html
to the editor: This well-written article provides excellent information about intimate partner violence (IPV) and the role of family physicians in identifying, assessing, and intervening in cases of IPV. The authors present the gaps in evidence and the varying recommendations by professional organizations to support routine IPV screening, including the 2004 U.S. Preventive Services Task Force (USPSTF) review that found insufficient evidence to support routine IPV screening.1
Many organizations, including the USPSTF, focus on a narrow definition of “benefit” through analysis of quantitative outcomes (e.g., mortality), and minimize the validity of qualitative outcomes. IPV screening is different from using Papanicolaou smears to screen for cervical cancer or using mammography to screen for breast cancer. Although the benefit of cervical and breast cancer screening can be judged by disease-specific mortality reductions, the “benefits” with IPV screening, which include psychosocial and psychodynamic effects, can be more difficult to measure.
Asking a patient about IPV is empowering and generates self-reflection, which is the first step toward recovery and behavior change. This insight can occur at any point along the continuum of the battering relationship. For a patient entrenched within the relationship, this may include the patient’s recognition of the cycle of violence or the perpetrator’s violent tactics, leading to heightened responsiveness by the survivor toward the abuser. For those moving toward leaving the relationship, this could include requesting help and inquiring about or contacting community resources.
The authors mention that the USPSTF used especially restrictive exclusion criteria for the studies related to IPV and neglected to support other IPV research that is descriptive and that has merit in ways other than numeric outcomes. The Family Violence Prevention Fund summarizes the weakness of the methodology used:
The outcomes most closely focused on are harm, death and disability. In contrast, most researchers in the field would expect that measurable benefits (desirable outcomes) would include improved health and safety of the patient and their children, enhanced protective factors and decreased frequency and severity of physical and/or emotional abuse.2
Screening for IPV should be viewed within the context of a behavioral health assessment rather than a medical evaluation for identifying asymptomatic patients. IPV is a long-term, recurrent, and usually escalating problem that is multidimensional in its medical, psychological, and emotional presentation. IPV is unlikely to be addressed appropriately unless the physician asks the patient about it during the clinical encounter.
When assessing the utility of routine abuse screening, narrow, quantitative parameters are not enough. We must consider the impact of qualitative dimensions, including reflection, behavior change, development of self-efficacy, and recognition of the stages of change model. The potential of IPV screening for identifying early abuse, risk reduction, public health benefits, and secondary and tertiary prevention must be evaluated within the context of behavioral health and wellness assessment and counseling. Physicians should broaden their perspective and consider these factors when considering whether to routinely screen for IPV.
1. U.S. Preventive Services Task Force. Screening for family and intimate partner violence: recommendation statement. Ann Fam Med. 2004;2(2):156-160.
2. Alpert E, Burgess A, Campbell J, et al. The Family Violence Prevention Fund’s Review of the US Preventative Services Task Force Draft Recommendation and Rationale Statement on Screening for Family Violence. San Francisco, Calif.: The Family Violence Prevention Fund; 2003. http://www.futureswithoutviolence.org/userfiles/file/HealthCare/FullResponse.pdf. Accessed July 23, 2011.
in reply:We appreciate the comments from Drs. Kureshi and Bullock critiquing the USPSTF clinical screening guidelines for IPV,1 an issue that has strong overlap with sociobehavioral domains. Criticisms of the USPSTF recommendations include: the omission of 750 studies on screening and 650 studies on intervention—including those that evaluated pregnant women and patients presenting with trauma2—from its review by treating IPV screening as a medical rather than a behavioral health assessment; and giving too much weight to possible harms when no evidence supports this concern.
An important supplement to the USPSTF guidelines was recently published by the Institute of Medicine (IOM). The U.S. Department of Health and Human Services commissioned the IOM to review health services that should be considered in the development of comprehensive guidelines for preventive services for women. The IOM’s review of the USPSTF recommendations and the body of evidence that has emerged since the guidelines were issued resulted in the recommendation that screening and counseling for interpersonal and domestic violence be considered a preventive service for women. This would involve eliciting information about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns, prevent future health problems, and provide for the patient’s safety.3 The USPSTF is in the process of updating its 2004 recommendation.4
We agree that IPV is best conceptualized and evaluated as part of a behavioral health assessment, rather than as a medical screening test in the traditional sense, in which the level of evidence considered is limited to randomized controlled trials. Although more sophisticated study designs are emerging to assess the benefits and harms of IPV screening, it remains clear that exposure to violence, including IPV, has multiple adverse consequences, including increased risk of medical and psychiatric illness and increased health care use. We know that patients are accepting of IPV screening when conducted appropriately,5 and that screening does not appear to cause harm.6 Brief interventions in health care settings can lead to increased safety planning and to women consulting community resources, such as shelters.
Screening for IPV is an important example of what can be lost if family physicians limit their actions to the few conditions that can be evaluated by a flawless randomized controlled trial. When the evidence is lacking, we recommend doing what we already should be doing for all of our patients: guiding your actions and recommendations as best you can to promote the safety and empowerment of your patients. Information about IPV screening and training materials can be found on the Academy on Violence and Abuse Web site at http://www.avahealth.org/ and the Futures Without Violence Web site at http://www.futureswithoutviolence.org/.
1. U.S. Preventive Services Task Force. Screening for family and intimate partner violence: recommendation statement. Ann Intern Med. 2004;140(5):382-386.
2. Soler E, Campbell J. Screening for family and intimate partner violence. Ann Intern Med. 2004;141(1):82.
3. Institute of Medicine Committee on Preventive Services for Women and Board on Population Health and Public Health Practice. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press; 2011.
4. U.S. Preventive Services Task Force. Topics in progress. http://www.uspreventiveservicestaskforce.org/uspstf/topicsprog.htm. Accessed December 13, 2011.
5. Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med. 2006;166(1):22-37.
6. MacMillan HL, Wathen CN, Jamieson E, et al.; McMaster Violence Against Women Research Group. Screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2009;302(5):493-501.
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