A.F., a 32-year-old woman, presents for a health maintenance visit. It has been more than a year since she was last seen. She has no significant medical history and has never used tobacco, alcohol, or any other substances. She works as a senior project manager for a large company and lives alone. She is not currently in a formal relationship, but she dates and has casual “hookups.”
Case Study Questions
1. According to the U.S. Preventive Services Task Force (USPSTF) recommendation on screening for intimate partner violence (IPV), how should you proceed with this patient?
A. Ask about IPV only if she reports symptoms suggestive of physical, sexual, or psychological aggression.
B. Screen for IPV because she is a woman of reproductive age.
C. Do not screen for IPV because she is not in a formal relationship.
D. Do not screen for IPV because the harms outweigh the benefits.
E. Do not screen for IPV because she has no risk factors.
2. According to the USPSTF recommendation, which of the following screening instruments accurately detect IPV in the past year among adult women?
A. Humiliation, Afraid, Rape, Kick (HARK).
B. Hurt, Insult, Threaten, Scream (HITS).
C. Extended–Hurt, Insult, Threaten, Scream (E-HITS).
D. Partner Violence Screen (PVS).
E. Woman Abuse Screening Tool (WAST).
3. A.F. screens positive for IPV. According to the USPSTF, which of the following services should you provide or refer her to?
A. Brief support services.
B. Information about referral options.
C. Ongoing support services that focus on counseling and home visits and that address multiple risk factors (not just IPV).
D. Psychiatric services.
E. No services.
1. The correct answer is B. The USPSTF recommends that clinicians screen for IPV in women of reproductive age and provide or refer women who screen positive to ongoing support services (B recommendation).1 IPV refers to physical violence, sexual violence, psychological aggression (including coercive tactics, such as limiting access to financial resources), or stalking by a romantic or sex partner, including spouses, boyfriends, girlfriends, dates, and casual “hookups.” The recommendation for screening applies to women of reproductive age because the evidence of intervention benefit is predominantly seen in studies of pregnant or postpartum women. IPV is experienced by approximately 36% of all U.S. women in their lifetime. Despite the prevalence, IPV often is undetected. Although all women of reproductive age are at potential risk of IPV and should be screened, several risk factors increase risk of IPV, such as exposure to violence as a child, young age, unemployment, substance abuse, marital difficulties, and economic hardships; however, the USPSTF did not identify any risk assessment tools that predict greater likelihood of IPV in populations with these risk factors. In addition to the immediate effects of IPV (e.g., injury, death), other health consequences—many with long-term effects—can occur, including development of mental health conditions such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior; sexually transmitted infections; unintended pregnancy; and chronic pain and other disabilities.
2. The correct answers are A, B, C, D, and E. Several screening instruments can be used to screen women for IPV. The HARK, HITS, E-HITS, PVS, and WAST instruments accurately detect IPV in the past year among adult women. Sensitivity ranged from 64% to 87% and specificity from 80% to 95%.2 HARK includes four questions that assess emotional and physical IPV in the past year. HITS includes four items that assess the frequency of IPV, and E-HITS includes an additional question to assess the frequency of sexual violence. PVS includes three items that assess physical abuse and safety. WAST includes eight items that assess physical and emotional IPV. Most studies included only women who could be separated from their partners during screening, during the intervention, or both so that screening and the intervention could be delivered in private.
3. The correct answer is C. The USPSTF concludes with moderate certainty that providing or referring women of reproductive age who screen positive for IPV to ongoing support services has a moderate net benefit. Effective interventions included ongoing support services that focused on counseling and home visits, addressed multiple risk factors (not just IPV), or included parenting support for new mothers. Brief interventions and providing information about referral options were generally ineffective. Examples of effective counseling include cognitive behavior therapy aimed at reducing behavioral risks, including depression, IPV (emphasizing safety behaviors), smoking, and tobacco exposure; and cognitive behavior therapy aimed at risks specific to the individual. Examples of effective home visits include tailored IPV-related information based on the individual's expressed needs and level of danger at each visit (e.g., information addressing the cycle of violence, risk factors for homicide, choices available to the woman, safety planning, and other IPV resources in the community). The average duration of services ranged from 31 weeks to three years; the total average number of sessions ranged from four to 14.