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1.
American College of Obstetricians and Gynecologists.  Domestic Violence . Washington, DC: American College of Obstetricians and Gynecologists; August 1995. Technical Bulletin 209.
2.
Zawitz M. Highlights From 20 Years of Surveying Crime Victims: The National Crime Victimization Survey . Washington, DC: US Dept of Justice Statistics; October 1993.
3.
American Medical Association.  Diagnostic and Treatment Guidelines on Domestic Violence . Chicago, Ill: American Medical Association; 1996.
4.
Titus K. When physicians ask, women tell about domestic abuse and violence.  JAMA.1996;275:1863-1865.
Citations 0
Resident Physician Forum
August 5, 1998

Domestic Violence

Author Affiliations
 

Prepared by Ashish Bajaj, Department of Resident Physician Services, American Medical Association.

JAMA. 1998;280(5):470C. doi:10.1001/jama.280.5.470

Two years ago, the American Medical Association (AMA) and its Resident Physicians Section launched a campaign to increase physician awareness about domestic violence and to encourage physicians to discuss domestic violence with patients who showed symptoms of physical abuse. In my practice as an obstetrician/gynecologist, I am regularly reminded that physical, sexual, and psychological abuse continues to exist at epidemic levels. Residents and other physicians must recognize the prevalence of domestic violence, continue to learn to diagnose domestic violence, and be able to discuss treatment options with their patients.

More than 10 million women in the United States each year are at risk for abuse from their former and current partners.1 This violence results in lasting physical and psychological sequelae for those women and their families. One source notes that domestic violence was the cause of more than 200 deaths over a 20-year period.2 Domestic violence is one facet of the larger problem of family violence, which also includes child abuse and elder abuse. Family violence is usually an abuse of power by a physically more powerful family member. There are many psychological factors that cause family violence. The devastating results of family violence have led state and federal governments to take the following actions:

  • Legislate domestic violence and other forms of family violence as a crime.

  • Make safety for victims of domestic violence and their families a priority and train health care workers to recognize domestic violence.

  • Change Medicaid and other health care delivery systems to focus on prevention, screening, and care of abused women.

Since 1992, the Joint Hospital Commission on Accreditation of Healthcare Organizations (JCAHO) has required the emergency departments and ambulatory settings of all accredited hospitals to implement policies and procedures to identify victims and to treat or refer victims for treatment. While all hospital staff must learn to recognize domestic violence, the first and frequently most important point of contact with domestic violence victims is in the physician's office or clinic.3

Because a physician may be the first nonfamily member in whom an abused woman confides, physicians must learn to screen patients and initiate intervention. Because 20% of US women are victims of domestic violence, screening for physical, sexual, and psychological abuse should become part of the routine history. Physicians who ask patients about abuse may be surprised at its prevalence; in my former county ob/gyn clinic (serving Buffalo, NY), more than 25% of women related some form of past or present abuse. Pregnant patients have been shown to be at even higher risk and need to be a particular focus for screening.

While asking may be the first step, some physicians may find this awkward. One approach I have used is to inform my patients that I am going to ask them some questions that I ask of all my patients that I feel are important. This usually opens up an empathetic and frank dialogue. In my follow-up questions, I ask about the humiliation they may be feeling, their unwillingness to participate in the discussion, and their feelings of fear. I also ask direct questions about kicking, slapping, and hitting.4

Many organizations can provide physicians with additional details on how to discuss domestic violence with patients and other resources. These include the National Coalition of Physicians Against Family Violence (free to AMA members), join by calling (312) 464-5842; the Violence Against Women Act National Hotline at (800) 799-SAFE, TDD (800) 787-3224; the National Resource Center on Domestic Violence at (800) 537-2238; and the National Coalition Against Domestic Violence at (202) 638-6388 or (303) 839-1852.

Domestic violence is a pervasive medical problem that crosses economic, racial, and national boundaries. Healing can begin only when women know that such abuse is not their fault and that help is available. No physician can diagnose every case, but adding questions about domestic violence to the history will yield surprising results for you and your patients. Ask.

References
1.
American College of Obstetricians and Gynecologists.  Domestic Violence . Washington, DC: American College of Obstetricians and Gynecologists; August 1995. Technical Bulletin 209.
2.
Zawitz M. Highlights From 20 Years of Surveying Crime Victims: The National Crime Victimization Survey . Washington, DC: US Dept of Justice Statistics; October 1993.
3.
American Medical Association.  Diagnostic and Treatment Guidelines on Domestic Violence . Chicago, Ill: American Medical Association; 1996.
4.
Titus K. When physicians ask, women tell about domestic abuse and violence.  JAMA.1996;275:1863-1865.
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