Helping patients who are victims of abuse

Scenario: For years, primary care physicians taking a history have asked patients whether their personal safety has ever been threatened. Most anticipate a "no" answer and move on. But studies suggest more patients will be answering in the affirmative.

Reply: The Centers for Disease Control and Prevention defines intimate partner violence as physical and sexual abuse, or threat of physical or sexual abuse, and emotional-psychological abuse such as humiliating the victim, controlling what the victim can and cannot do and isolating the victim from family and friends.

IPV affects the health of all family members, contributing to such adverse health conditions as chronic pain, depression and posttraumatic stress disorder in women. Children who witness abuse between adults have behavior problems, problems in school, depression and chronic pain. And they are much more likely to be abusers and victims of abuse when they grow up.

Intimate partner violence is experienced by one in four women at some point. Men also can be victims; the CDC reports that one in 14 men has been physically abused. Given this level of prevalence, most primary care physicians are bound to get a "yes" response to the general screening question about a threat to personal safety. (While men can be victims, women are more often at risk, thus the pronoun she is used throughout.)

Research has examined the process of an IPV victim coming to terms with an abusive relationship in light of the stages of change. Early on, many victims are unaware that abuse is unacceptable; often, they saw abuse between their parents. This stage is precontemplation.

The first step we can take as physicians is to help a patient understand that abuse is not the norm in a healthy relationship and that she does not deserve to be treated in that way. Coming to terms with an abusive relationship takes time and, from the physician's point of view, can best be managed as a chronic health issue.

When the patient enters the contemplation phase, recognizing the problem and weighing the pros and cons of the various options, we can help her understand the impact of staying in an abusive household on the children and on her health. Amid the many uncertainties: Can the patient make it economically? He's a good dad; how will leaving affect the kids? Divorce is against her religion; how can she live with that? She is pregnant; she doesn't want to go through the pregnancy alone. Physicians can educate patients about options including support services from local advocacy agencies, counseling, orders of protection, or criminal charges against the perpetrator.

When a victim takes a step toward stopping the abuse by joining a support group, getting an order of protection or leaving, she is in the action stage. A person who has lived free from abuse for more than six months is in the maintenance phase. Most people cycle back and forth, often returning to the relationship six times before leaving for good. Many abused women don't want to leave, but just want the abuse to end.

Assessing whether a victim of intimate partner abuse is safe is of paramount importance. Some victims underestimate the threats of their abusers. Others, who are used to "walking among the land mines," know when they are in danger. Physicians should offer to help victims think about and assess their safety.

Based on epidemiologic evidence, the abused person is at risk for further injury if: there is suicide or homicide risk for either the victim or abuser; the abuser possesses weapons or has threatened to use weapons; drugs or alcohol are used excessively by the victim or abuser; children or pets are being abused; the severity of abuse is escalating; the victim reports fear of the abuser; the victim and perpetrator have separated recently; there has been an attempted strangulation previously; the perpetrator has been stalking the victim. These risk indicators must be asked about and their answers discussed in a nonjudgmental and supportive way.

While most states do not require physicians to report violence in the home unless the victim is a child or elderly person, positive responses to the risk assessment may dictate further intervention on the physician's part. If there is suicide or homicide risk or child abuse, we have an obligation to take action. If there are weapons, we should encourage the victim to remove them, or call the police to remove them. If the severity of the abuse is increasing or the victim is afraid, we must inquire about where the abused person can go if she needs to leave.

Who are her supports? Victims of IPV are often isolated, having been threatened not to tell anyone about the abuse or embarrassed to talk about it. If the victim does not have support, refer her to a local advocacy agency. It is helpful to dial the agency and ask the patient to speak with someone there while she is in your office. If you do not know your local agency, call the 24-hour National Domestic Violence Hotline: 800-799-7233. Translation services are available for discussion about IPV.

Safety planning may not be appropriate for all victims, especially those early in the process of coming to terms with the abuse. It can be done by the physician, a designated staff person in the office or the advocacy agency. Safety planning includes knowing where to go if one needs to leave; putting together important documents. such as bank account statements, birth certificates and insurance records; gathering health care-related items, such as medications and children's immunization records; saving extra money; and filling a bag with clothes, children's toys and other essentials.

In family or internal medicine, the same physician may care for both partners. Couples counseling endangers the victim if she reveals information about the abuse during sessions. Abusers also are expert at manipulating physicians and counselors to believe situations are better than they truly are. It is usually unsafe for the victim to discuss genuine issues of concern in the abuser's presence. Confidentiality and safety are critical when working with an abusive couple. Keep the following in mind:

• Maintain confidentiality about your discussions with the victim and the abuser. Do not share information.
• Document discussions and findings in the patient's chart. Do not document information learned from the abuser in the victim's chart or vice versa.
• Assess the victim's safety. If safety becomes a concern, seek input from domestic violence advocacy agencies.
• Discuss with each patient how to leave messages about appointments or test results. Is it OK to leave messages on a home phone? Cell phone? E-mail? You do not want to compromise the victim's safety by giving the abuser information that the victim does not want the abuser to have.
• Discuss abuse with the abuser only with the victim's permission. Before doing so, develop a safety plan with the victim. If it becomes too difficult to care for both, it may be best to refer either the victim or the abuser to a partner or another clinician.

Collaborative studies between Kaiser Permanente's Health Appraisal Clinic in San Diego, and the CDC show that children exposed to IPV are likely to engage in risky behaviors such as alcohol and drug abuse, become pregnant at an early age and are at risk for delinquency later. They have more mental- and physical-health problems. Inquiring about IPV, helping patients see the link between living with the abuse and their health, and sharing resources can help victims out of this situation, prevent abuse and halt the intergenerational cycle of abuse.

Therese Zink, MD, MPH, professor, Dept. of Family and Community Medicine, University of Minnesota. She is conducting research in family violence.

F. David Schneider, MD, MSPH, professor and chair of Family and Community Medicine, St. Louis University