The Battering Syndrome: Prevalence and Clinical Characteristics of Domestic Violence in Primary Care Internal Medicine Practices

It is estimated that 2 to 4 million U.S. women are physically abused each year and that domestic violence may occur in as many as one of every four U.S. families [1]. In one study involving primarily low-income patients presenting to three primary care internal medicine practices, approximately 14% of women had recently experienced domestic violence, and 28% had experienced domestic violence at some time in their lives [2]. Studies indicate that U.S. women are more likely to be assaulted, raped, or killed by a current or former male partner than by all other types of assailants combined [3]. Some experts have suggested that domestic violence leads to a battering syndrome, in which physical assault is followed by an increase in general medical symptoms and emotional problems [4]. Violence against women, both domestic and nondomestic, is associated with increased use of health care [5-7] and, in one study, was the most powerful predictor of physician visits and outpatient costs [5]. See the related articles on pp 774-81, 782-94, 800-2 and 804-5. Little research has been done on the clinical characteristics of physically and sexually abused women who present to primary care practices [6]. Most information comes from studies done in specialized medical settings [7-17]; other information is obtained from studies of women living in shelters [18], student populations [19], or general population samples [20, 21]. In these studies, abuse was associated with depression, anxiety, and other psychological disorders [6-812, 15-20]; drug and alcohol abuse [7, 8, 15-17]; sexual dysfunction [8, 15, 17, 21]; functional gastrointestinal disorders [6, 10, 14, 17]; headaches [6, 9]; chronic pain [10, 11, 13, 15, 16]; and multiple somatic symptoms [10, 12, 16-19]. Despite the seriousness of domestic violence, women rarely volunteer a history of abuse when they see their physicians [22]. In addition, although some authors have suggested that physicians should question all female patients about physical and sexual abuse [23], few primary care physicians do so [22]. Although some women would probably disclose a history of current abuse if a physician directly inquired about it, other patients may be hesitant to disclose such information because of fear or shame. A physician may also be overwhelmed when a woman presents with multiple physical and psychological problems and may defer inquiry to address the immediate symptoms. If certain somatic and emotional problems are more common in patients experiencing current domestic violence who present to internal medicine practices, the presence of these symptoms might raise physician suspicion and lead to an initial inquiry. If the association between these symptoms and abuse is strong enough, physicians might inquire again about abuse on subsequent patient visits, even if the woman had initially denied the abuse. Our primary objectives were to 1) determine the prevalence of domestic violence among female patients presenting to four community-based, primary care, adult medicine practices that serve patients of diverse socioeconomic background and 2) identify demographic and clinical differences between currently abused patients and patients not currently being abused. A secondary purpose was to use this information to develop a clinical model that succinctly explains our data. Methods Participants and Survey Administration Between February and July 1993, we surveyed adult female patients for 1 to 2 months in each of four community-based, primary care internal medicine practices in the Baltimore area. All practices were affiliated with The Johns Hopkins Bayview Medical Center, a private university teaching hospital. These practices serve approximately 23 000 adult patients. Office nurses determined patients' eligibility for participation. A patient was considered ineligible if she was blind or could not read because she had forgotten her glasses, was illiterate, did not speak English, was mentally retarded or demented, was too acutely ill to participate, or was accompanied by a male or female companion who refused to leave the examining room. To ensure that patients were surveyed only once, each patient indicated on a cover sheet whether she had already completed a survey. If so, her response was excluded. If an adult female patient was eligible to participate, an office nurse explained the purpose of the study, reassured the patient that all responses would be kept anonymous, and asked for participation. To maximize patient privacy, recruitment was done in the examining rooms, and patients completed the survey while awaiting the physician. To preserve the anonymity of participants, no names or coding numbers appeared on the survey. Patients placed surveys in a box after completion so that their responses would not be read by medical personnel or family or friends who may have accompanied them to the office. Because the survey was anonymous, the Institutional Review Board of the Johns Hopkins Bayview Medical Center did not require informed consent from the participants. During the study period, 3203 female patients presented to the offices. Of these, 283 (8.8%) were ineligible, and 528 (16.5%) were not approached because the nurses failed to recruit them. Of the 2392 remaining patients, 1952 (81.6% of those approached, 66.9% of those eligible, 60.9% of those presenting) completed the questionnaire; 398 (16.6% of those approached, 13.6% of those eligible, 12.4% of those presenting) refused to complete the questionnaire; and 42 (1.8% of those approached) did not answer any of the questions about violence. We derived prevalence statistics from the total sample of 1952 patients. For the analysis of clinical and demographic differences between patients who were currently experiencing domestic violence and patients who were not, we included 1826 patient responses (93.5%). We did not include the remaining 126 patients for the following reasons: Twenty-six (1.3%) had experienced violence from a stranger within the last year; 23 (1.2%) did not identify the abuser and it was therefore unknown whether the abuse had been domestic; and 77 (3.8%) did not meet strict criteria for current abuse because they answered no to the question Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? but in subsequent questions indicated that they had been physically threatened, pushed, or grabbed in the last year. These patients, who reported some form of actual or threatened abuse within the last year but did not meet our definition for current domestic violence, had characteristics that differed from those of patients who were currently experiencing domestic violence and those of patients who were not. Such patients were therefore excluded from this analysis. Survey Instrument The survey instrument, called The Women's Health Questionnaire, was developed by a team consisting of a psychologist-researcher, a biostatistician, and seven primary care internists, one of whom is a health services researcher and three of whom had previously developed an educational program on domestic abuse. The self-administered survey included approximately 85 questions and could be completed in 5 to 7 minutes. The two questions that defined the presence or absence of current domestic violence (see below) were taken from the three-question Abuse Assessment Screen developed by McFarlane and colleagues [24]. The third question, about abuse since the onset of pregnancy, was dropped because it was irrelevant to most of our respondents. The Abuse Assessment Screen has been shown to discriminate between abused and nonabused women better than two longer instruments whose reliability and validity have been measuredthe Conflicts Tactics Scale [25] and the Index of Spouse Abuse [26]. Our survey also included questions on the frequency and severity of current abuse and on whether the respondent had ever been physically or sexually abused as a child or adult. We used the CAGE questions to assess current and past alcohol abuse. Previous research has indicated that a score of 2 or more on the questions has a sensitivity of 74% to 76% and a specificity of 91% to 94% for the diagnosis of alcohol dependence or abuse (area under the receiver-operator characteristic curve, 0.89) [27, 28]. We used a 22-item symptom inventory, the Symptom Checklist-22 (SCL-22) (Table 1), to measure anxiety, depression, somatization, and interpersonal sensitivity (low self-esteem). The 22 items were taken directly from the 58-item Hopkins Symptom Checklist, which has proven reliability and validity for measuring these variables [29]. Items were chosen on the basis of the size of their factor-analysis loadings on the relevant dimension. Internal consistency measures, or Cronbach measures, for the SCL-22 were the following: 0.79 for anxiety, 0.86 for depression, 0.75 for somatization, 0.82 for interpersonal sensitivity, and 0.92 for the total inventory. Table 1. Items Included in the Symptom Checklist-22* The questionnaire also contained questions on demographic characteristics, physical symptoms, psychiatric history, use of street drugs, use of current medication, and medical history. The final questionnaire was ranked as being at a seventh-grade reading level according to the Flesch Readability Statistics (available in Microsoft Word, version 2.0). Before final revisions were made, a pilot survey was administered to 130 patients seen at an obstetrics and gynecology practice. Definition A patient was considered to be a current victim of domestic violence [currently abused] if 1) she answered yes to either of the following questions: Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? or Within the last year, has anyone forced you to have sexual activities? and 2) she identified the abuser as a husband, ex-husband, boyfriend, or relative. Patients were defined as not currently abused if they