to the editor: This well-written article provides excellentinformation about intimate partner violence (IPV) andthe role of family physicians in identifying, assessing, andintervening in cases of IPV. The authors present the gapsin evidence and the varying recommendations by professionalorganizations to support routine IPV screening,including the 2004 U.S. Preventive Services Task Force(USPSTF) review that found insufficient evidence to supportroutine IPV screening.1
Many organizations, including the USPSTF, focuson a narrow definition of “benefit” through analysis ofquantitative outcomes (e.g., mortality), and minimizethe validity of qualitative outcomes. IPV screening isdifferent from using Papanicolaou smears to screenfor cervical cancer or using mammography to screenfor breast cancer. Although the benefit of cervical andbreast cancer screening can be judged by disease-specificmortality 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 generatesself-reflection, which is the first step toward recoveryand behavior change. This insight can occur at anypoint along the continuum of the battering relationship.For a patient entrenched within the relationship, thismay include the patient’s recognition of the cycle ofviolence or the perpetrator’s violent tactics, leading toheightened responsiveness by the survivor toward theabuser. For those moving toward leaving the relationship,this could include requesting help and inquiringabout or contacting community resources.
The authors mention that the USPSTF used especiallyrestrictive exclusion criteria for the studies related toIPV and neglected to support other IPV research that isdescriptive and that has merit in ways other than numericoutcomes. The Family Violence Prevention Fund summarizesthe weakness of the methodology used:
Screening for IPV should be viewed within the contextof a behavioral health assessment rather than a medicalevaluation for identifying asymptomatic patients.IPV is a long-term, recurrent, and usually escalatingproblem that is multidimensional in its medical, psychological,and emotional presentation. IPV is unlikely tobe addressed appropriately unless the physician asks thepatient 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 ofself-efficacy, and recognition of the stages of changemodel. The potential of IPV screening for identifyingearly abuse, risk reduction, public health benefits, andsecondary and tertiary prevention must be evaluatedwithin the context of behavioral health and wellnessassessment and counseling. Physicians should broadentheir perspective and consider these factors when consideringwhether to routinely screen for IPV.
in reply:We appreciate the comments from Drs. Kureshiand Bullock critiquing the USPSTF clinical screeningguidelines for IPV,1 an issue that has strong overlap withsociobehavioral domains. Criticisms of the USPSTF recommendationsinclude: the omission of 750 studies onscreening and 650 studies on intervention—including those that evaluated pregnant women and patients presentingwith trauma2—from its review by treating IPVscreening as a medical rather than a behavioral healthassessment; and giving too much weight to possibleharms when no evidence supports this concern.
An important supplement to the USPSTF guidelineswas recently published by the Institute of Medicine(IOM). The U.S. Department of Health and HumanServices commissioned the IOM to review health servicesthat should be considered in the development ofcomprehensive guidelines for preventive services forwomen. The IOM’s review of the USPSTF recommendationsand the body of evidence that has emerged sincethe guidelines were issued resulted in the recommendationthat screening and counseling for interpersonal anddomestic violence be considered a preventive service forwomen. This would involve eliciting information aboutcurrent and past violence and abuse in a culturally sensitiveand supportive manner to address current healthconcerns, prevent future health problems, and providefor the patient’s safety.3 The USPSTF is in the process ofupdating its 2004 recommendation.4
We agree that IPV is best conceptualized and evaluatedas part of a behavioral health assessment, rather thanas a medical screening test in the traditional sense, inwhich the level of evidence considered is limited to randomizedcontrolled trials. Although more sophisticatedstudy designs are emerging to assess the benefits andharms of IPV screening, it remains clear that exposureto violence, including IPV, has multiple adverse consequences,including increased risk of medical and psychiatricillness and increased health care use. We know thatpatients are accepting of IPV screening when conductedappropriately,5 and that screening does not appear tocause harm.6 Brief interventions in health care settingscan lead to increased safety planning and to women consultingcommunity resources, such as shelters.
Screening for IPV is an important example of whatcan be lost if family physicians limit their actions tothe few conditions that can be evaluated by a flawlessrandomized controlled trial. When the evidence is lacking,we recommend doing what we already should bedoing for all of our patients: guiding your actions andrecommendations as best you can to promote the safetyand empowerment of your patients. Information aboutIPV screening and training materials can be found onthe Academy on Violence and Abuse Web site at http://www.avahealth.org/ and the Futures Without ViolenceWeb site at http://www.futureswithoutviolence.org/.