Valenti J. Domestic Violence. JAMA. 1998;280(5):470C. doi:10.1001/jama.280.5.470
Prepared by Ashish Bajaj, Department of Resident Physician Services,
American Medical Association.
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.