Michael A. Rodríguez, Elizabeth McLoughlin, Gregory Nah, Jacquelyn C. Campbell. Mandatory Reporting of Domestic Violence Injuries to the PoliceWhat Do Emergency Department Patients Think?. JAMA. 2001;286(5):580–583. doi:10.1001/jama.286.5.580
Author Affiliations: Department of Family and Community Medicine, University of California, San Francisco (Dr Rodríguez); Trauma Foundation (Dr McLoughlin and Mr Nah), and The Johns Hopkins University School of Nursing (Dr Campbell) Baltimore, Md.
Context Laws requiring mandatory reporting of domestic violence to police exist
in 4 states. Controversy exists about the risks and benefits of such laws.
Objective To examine attitudes of female emergency department patients toward
mandatory reporting of domestic violence injuries to police and how these
attitudes may differ by abuse status.
Design, Setting, and Participants Cross-sectional survey conducted in 1996 of 1218 women patients (72.8%
response rate) in 12 emergency departments in California (a state with a mandatory
reporting law) and Pennsylvania (without such a law).
Main Outcome Measures Opposition to mandatory reporting to police and the characteristics
associated with this belief.
Results Twelve percent of respondents (n = 140) reported physical or sexual
abuse within the past year by a current or former partner. Of abused women,
55.7% supported mandatory reporting and 44.3% opposed mandatory reporting
(7.9% preferred that physicians never report abuse to police and 36.4% preferred
physicians report only with patient consent). Among nonabused women, 70.7%
(n = 728) supported mandatory reporting and 29.3% opposed mandatory reporting.
Patients currently seeing/living with partners (odds ratio [OR], 1.5; 95%
confidence interval [CI], 1.1-2.0), non-English speakers (OR, 2.1; 95% CI,
1.4-3.0), and those who had experienced physical or sexual abuse within the
last year (OR, 2.2; 95% CI, 1.6-2.9) had higher odds of opposing mandatory
reporting of domestic violence injuries. There were no differences in attitudes
by location (California vs Pennsylvania).
Conclusions The efficacy of mandatory reporting of domestic violence to police should
be further assessed, and policymakers should consider options that include
consent of patients before wider implementation.
Most states require clinicians to report to police injuries due to violence,
criminal acts, or deadly weapons.1 From 1991
to 1994, California, Colorado, Rhode Island, and Kentucky passed various forms
of mandatory reporting laws requiring health care professionals to report
intimate partner violence (IPV) to the police. Since 1994, California has
required clinicians to report to police suspected IPV-related injuries, even
if this is contrary to patient wishes. Noncomplying clinicians face penalties
of fines up to $1000 and/or jail sentences of up to 6 months in California.
The law does not specify how police should respond, local jurisdictions vary
in response, and the degree of enforcement is unknown.
Mandatory reporting is controversial among clinicians, patients, and
domestic violence prevention advocates. Supporters of the policy argue that
it will facilitate the prosecution of batterers, encourage health care clinicians
to identify domestic violence, and improve data collection.2,3
Opponents believe it may increase violence by the perpetrators, diminish patients'
autonomy, and compromise patient-clinician confidentiality.4,5
Mandatory reporting laws are not affected by the new Federal Medical Privacy
Protections for Victims of Domestic Violence because they fall under the provision
relating to disclosures required by law.6 The
National Resource Council has recommended a moratorium on such laws until
more research is conducted on the advantages and disadvantages of mandatory
reporting policies for domestic violence.7
While patients frequently look to police for help during acute episodes
of violence, clinician reporting to police may raise fears of increased violence,
loss of control, and family separation, all of which may lead some abused
patients to avoid seeking help from health care clinicians.2
Two recent studies have found that some women may be supportive of mandatory
reporting policies.8,9 However,
another study reports that a majority of abused patients are opposed to mandatory
reporting of IPV to police.4 A Colorado study
found that 9% of female patient respondents were less likely to seek medical
care as a result of mandatory reporting.10
Limitations of these studies include low response rates, small sample sizes,
or samples primarily from states where specific domestic violence mandatory
reporting laws do not exist. An evaluation of an emergency department intervention
to improve the health system response to abused patients permitted us to survey
a large random sample of female patients in California and Pennsylvania about
mandatory reporting. Unlike California, Pennsylvania does not have a specific
law that mandates clinicians to report IPV to police.
The patient survey was part of an emergency department IPV intervention
study and involved 12 emergency departments, randomly drawn from all midsized
hospitals (20 000-40 000 patient visits annually) within 160 km
of San Francisco, Calif, and Pittsburgh, Pa.11
In contrast to previous published analyses of 3 waves of data collection for
11 of these 12 emergency departments,12 this
study used only the third wave of patient surveys from all 12 emergency departments.
Response rates had improved for that wave and the questions on mandatory reporting
had been revised to allow for better assessment of patient preferences. We
attempted to survey 1672 patients during 1996 using the Patient Satisfaction
and Safety Survey, an anonymous self-administered questionnaire. The questionnaire
contained 20 items designed to (1) verify eligibility for participation; (2)
identify patients currently in abusive relationships; (3) assess satisfaction
with care; and (4) determine attitudes about mandatory reporting of domestic
violence to police. To assess abuse status and identify those patients with
histories of physical or sexual partner violence in the previous year we used
the Abuse Assessment Screen.13 To assess patients'
attitudes toward the mandatory reporting law, respondents were asked the question:
"Do you think that the emergency department staff in hospitals should be required
to call the police when they think that a husband, boyfriend, or partner (ex-husband,
ex-boyfriend, ex-partner) has hurt or abused an adult patient?" Respondents
were given 3 options: (1) yes, every time; (2) every time unless the patient
objects; or (3) never.
Data were collected from any eligible woman patient by female nurses
during 8-hour and 12-hour evening shifts between Friday and Tuesday to obtain
representation from weekday and weekend shifts. We excluded patients too ill
to respond to questions and those never left alone by accompanying persons.
The institutional review boards at the coordinating institutions in Pennsylvania
and California approved the study. Signed consent forms were waived by the
institutional review boards and oral consent was obtained. The patients were
informed that the questionnaire was anonymous and voluntary, had no impact
on the care they would receive, and would not be seen by the clinicians treating
them that day.
We analyzed the data using univariate and logistic regression analysis.
For cross-tabulation, mandatory reporting attitudinal responses were dichotomized
into "report always" (support) vs "report never" or "only with patient consent"
(oppose). Predictor variables included age, race, primary language spoken
at home, total family income per month, relationship status, and partner violence
in the past year. Statistical significance was determined by Pearson χ2 statistical test with a 2-tailed P value
of less than .05. We generated adjusted odds ratios (ORs) and 95% confidence
intervals (CIs) for factors independently associated with opposition to mandatory
reporting. All statistical analyses were conducted using SAS version 8 software
(SAS Institute Inc, Cary, NC).
A total of 1218 eligible emergency department patients responded to
the Patient Satisfaction and Safety Survey (response rate, 72.8%). Overall,
the response rates for respondents who answered the question on mandatory
reporting and completed information on each characteristic ranged from 67.3%
to 70.2%. There were no significant state-specific differences in response
to the survey attitudinal questions, including support for or opposition to
mandatory reporting laws.11 Overall, 12.0%
of respondents (n = 140) reported being physically abused or forced to have
sexual activities in the previous year.
Among the abused respondents, 44.3% (n = 62) opposed mandatory reporting
of domestic violence to police (36.4% [n = 51] supported reporting but only
with patient consent; 7.9% [n = 11] thought that physicians should never report
to police), while 55.7% (n = 78) supported mandatory reporting. Of nonabused
respondents 70.7% (n = 728) reported higher levels of support for the policy,
while 29.3% (n = 301) opposed the law (25.7% [n = 264] favored reporting with
consent; 3.6% [n = 37] preferred physicians never to report, P<.001).
Women who opposed the mandatory reporting policy tended to be young
(34.3% of 18-39 years old vs 28.3% of those >40 years old, P = .03); nonwhite (35.9% of nonwhite patients vs 29.0% of white patients, P = .02); non-English speakers at home (41.7% of non-English
speakers vs 30.3% of primary English speakers, P
= .04); and abused (44.3% of those reporting abuse in the past year vs 29.2%
of those reporting no abuse, P = .001) (Table 1). Opposition to the policy did
not differ significantly by relationship status, total family income per month,
or state (California vs Pennsylvania).
Based on regression analysis, the following factors were independently
predictive of favoring nonreporting when a patient objects: (1) physical abuse
in the last year (adjusted OR, 2.2; 95% CI, 1.6-2.9); (2) non-English spoken
at home (adjusted OR, 2.1; 95% CI, 1.4-3.0); and (3) currently seeing/living
with a partner (adjusted OR, 1.5; 95% CI, 1.1-2.0).
In this study, 44.3% of recently abused female emergency department
patients do not support mandatory reporting of domestic violence to police.
Possible reasons for such opposition include fear of retaliation by the abuser,
fear of family separation, mistrust of the legal system, and preference for
confidentiality and autonomy in the patient-clinician relationship.2 Yet, our study also demonstrated that a higher percentage
(55.7%) of recently abused female emergency department patients do support
mandatory reporting. This may be due to desires for enhanced safety and relief
from the onus of making a police report.
Many patients supported IPV reporting policies that take into consideration
patients' preferences. For example, of the 44.3% of women with recent histories
of abuse who opposed mandatory reporting, the very women who would potentially
be reported to police, the majority selected the response indicating support
for reporting to police unless the patient objects. Further research with
abused women is needed to distinguish their preferences among several options:
(1) a law requiring reporting unless the patient objects; (2) a reporting
law that requires patient consent; or (3) no reporting laws but physician
responsiveness to IPV and assistance with criminal justice interventions when
Similar to the women with recent histories of abuse, 41.7% of women
who were primarily non-English speakers were opposed to mandatory reporting.
These findings are consistent with previous qualitative research in which
abused women expressed the belief that they should control the decisions to
involve the police.2 Another study has explored
sociopolitical factors that hinder abused immigrant women from seeking help,
including social isolation, language barriers, and fear of deportation.14 Because the impact of police involvement in immigrant
women's lives may be different than for US-born women, changes in welfare
and immigration laws may interact with this policy, resulting in further disempowerment
of the female patient. Given the attitudes expressed by the respondents in
these studies, it is unclear whether mandatory reporting will help recent
IPV survivors or put them at risk for further violence. One clinical alternative
is to encourage the assessment of danger that can help women and clinicians
assess safety, yet leave the final decision as to whether to call the police
with the patient.15
Physicians' attitudes regarding mandatory reporting have varied. In
a previous survey of physicians in California, 53% to 85% responded that such
policies could prevent women from seeking medical care, provoke retaliation,
or compromise confidentiality and autonomy.5
In the same survey, 53% to 86% believed that these policies can increase recognition
and responsiveness to domestic violence, as well as improve and increase documentation
and collection of statistics.5
One limitation of our study is that we only surveyed patients seeking
care at emergency departments. Therefore, we missed IPV survivors who may
have been deterred from seeking help for reasons that include fear that they
may be reported to the police. This limitation would have the impact of underestimating
the degree of opposition among abused women to laws that mandate reporting
IPV to police.
Further research on mandatory reporting is needed to address the preferences
of those in abusive relationships. Research should also track patient and
clinician outcomes in other states that require reporting IPV to police. Lacking
answers to these concerns, our research suggests that policymakers should
consider development of IPV reporting policy options that combine respect
for patient autonomy with the greatest potential for protection from abuse.