Issue:
Health care providers reported an increase in intimate partner violence (IPV) during the COVID-19 pandemic. IPV survivors seek medical care in many health care settings, but survivors often don’t readily share their abuse experiences with providers unless specifically asked and if they are ready to accept help.
According to the World Health Organization, “Intimate partner violence refers to behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours.”1 The Centers for Disease Control and Prevention (CDC) expands their definition of abuse to include stalking and provides uniform definitions.2
Domestic violence as a term is broader than IPV and includes violence across the lifespan, such as child abuse, adolescent dating violence, IPV, and elder abuse at the hands of current or former partners or family members.
As an international problem, many refugees seeking medical care have experienced or are experiencing IPV as well. No matter the country, or target population, it is abundantly clear that violence is a public health problem. According to the CDC, approximately 1 in 10 men and 1 in 4 women experience: contact sexual violence, physical violence, and/or stalking during their lifetime.2 Emotional abuse is estimated to occur during one’s lifetime with staggering prevalence: over 43 million women and 38 million men.2
Requirements and national recommendations regarding IPV
In 2004, The Joint Commission issued Standard PC 01.02.09 that requires organizations to use written criteria to identify those patients who may be victims of physical assault, sexual assault, sexual molestation, domestic abuse, or elder or child abuse and neglect. Furthermore, the Joint Commission requires providers to report cases of possible abuse and neglect to external agencies, in accordance with laws and regulations.
Because women in their childbearing years are prone to IPV, in 2014, the United States Preventive Services Task Force updated its recommendations for providers to screen women of childbearing years and provide referrals as warranted.3 Bright Futures – a national health promotion and prevention initiative led by the American Academy of Pediatrics – recommends providers discuss IPV at a woman’s prenatal, newborn, 1-month, 9-month, and 4-year child visits, and discuss dating violence at middle and late adolescence visits. They also recommend screening both mothers and adolescents when signs or symptoms become present and/or a new partner is revealed.4
IPV screening in clinical practice using telehealth
However, the recent rise in the use of telehealth, including telephone calls, with patients may be an opportunity to rethink the way health care providers address IPV during telehealth visits. While there are disadvantages associated with telehealth, one advantage is that it may provide the opportunity for survivors to receive evidence-based safety information and psychotherapy via Zoom or telephone calls. Also, the ability to connect via telehealth may reduce IPV-associated barriers like isolation as well as lack of transportation which leads to delayed medical care. However, it is important for providers to continue to conduct essential screening, education and referrals during telehealth visits after ensuring the patient is in a safe space to talk.
Safety actions to consider:
Given the intersection between child abuse and neglect, adolescent dating violence, and adult IPV, it is important to consider policies and practices to screen, assess, and refer for domestic violence across the lifespan of your patients to break the intergenerational cycle of violence. Health care settings, including hospitals and clinics, can use the following actions to help better address violence and protect patients:
- Partner with your local domestic violence provider to engage in potential on-site training or training resources as well as potential advocacy.
- Provide training to all employees who interact with patients, not just for licensed health care providers. Front desk staff, patient care technicians, and even transportation personnel within hospital settings have patient contact. All employees should be trained on the basics for how to identify IPV and next steps. Staff should be comfortable making referrals to appropriate providers within the health care settings. Training should include helping providers understand the prevalence of IPV, varying types of abuse, and how to intervene safely.
- Create an interdisciplinary medical-law partnership which allows health care professionals to make immediate referrals where patients can receive integrated care from a team comprised of advocates, attorneys, and specialty-trained medical and mental health providers.
- Consider ensuring patients receive evidence-based mental health care when they disclose IPV. An important aspect of care involves assessing immediate safety as well as future provider communications, including who can access the patient’s electronic medical record.
- Explore different professional organization’s recommendations for your various providers to see what protocols exist for the type of patients your organization cares for. Your employees may be more familiar and comfortable with information from their own discipline organizations which detail how IPV screening, assessment and referral is part of their specific discipline and often within their ethical duty.
- Examine whether your screening questions are specific enough and your providers are asking the questions as indicated in your written policies.
- For non-English speaking patients, providers should rely on interpreters and not on family members or escorts when evaluating a patient.
- Consider privacy when discussing IPV. It is suggested that providers ask a patient whether they have headphones which can lend privacy to not just the inquiry for IPV but the entire health care visit. Some providers have been issuing headsets to patients during the pandemic.
A recent Journal of the American Medical Association article provides the following suggested questions and advisements for IPV screening in clinical practice settings.5
How to approach a person experiencing IPV who may or may not be alone:
- “Is now a safe time to talk?”
- “Are you alone?”
How to approach a person experiencing IPV when someone else is present:
- The clinician should state “HIPAA laws require that I conduct the telehealth visit with no one else present.”
- Once the other person has left the room, questions should be framed in yes/no response format to include the following: “I’d like to ask some questions that I ask everyone right now.”
- Follow-up with “Are you feeling stressed?” or “Do you feel safe at home?”
- Alternate ways to approach the subject include the following statements. It is the patient’s choice whether or not and when to take action.
- “I care, and I am concerned about your safety and the safety of your child/children. I can help connect you with counseling and support, legal resources, and shelter. Everything is free and confidential. Would you be interested?”
Resources:
- World Health Organization. Violence Against Women fact sheet.
- Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. Atlanta, Georgia: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
- U.S. Preventive Services Task Force. Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening. Oct. 23, 2018.
- Bright Futures website.
- Simon MA. Responding to Intimate Partner Violence During Telehealth Clinical Encounters. Journal of the American Medical Association. 2021;325(22):2307-2308. doi: 10.1001/jama.2021.1071
Other resources:
Futures Without Violence National Health Resource Center on Domestic Violence have experts who can provide technical assistance and offer on-line toolkits. Their resources include step-by-step checklists for how to keep patients safe. Some trainings and webinars offer continuing medical education credits.
Futures Without Violence. Prevent, Assess, and Respond: A Domestic Violence and Human Trafficking Toolkit for Health Centers & Domestic Violence Programs. 2017
Note: This is not an all-inclusive list.
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Contributor: Catherine Cerulli, JD, PhD, Professor of Psychiatry at the University of Rochester Medical Center (URMC) and Director of the Laboratory of Interpersonal Violence and Victimization. In 2016 Dr. Cerulli cofounded an innovative medical-law program that integrates health, legal, and advocacy services for victims of intimate partner violence where they can obtain court orders of protection right on-site (https://www.urmc.rochester.edu/mental-health-wellness/adult-services/outpatient/heal.aspx). Dr. Cerulli also directs the Susan B. Anthony Center, which focuses on translating science regarding social determinants of health into practices that changes lives.