Screening for Intimate Partner Violence in the Primary Care Setting: A Critical Review

Intimate partner violence* has widespread public health ramifications in the United States among all ethnic and socioeconomic groups. It is defined as actual or threatened physical or sexual violence, or psychological/ emotional abuse by a spouse, ex-spouse, boyfriend/ girlfriend, ex-boyfriend/ex-girlfriend, or date [1]. Both men and women experience intimate partner violence, but women are the victims in 85% of the cases [2]. Lifetime prevalence among U.S. women ranges from 25% to 54%, with 1.5% to 15% of women reporting having been victimized within the previous 12 months [3‐6]. Further studies have shown that women who have experienced violence have more general health and mental health problems [7‐12]. Survivors of violence are more likely to report worse health status, greater disability, and higher levels of depressive symptoms and are more likely to have a diagnosis of anxiety or depression than women without a history of violence [7]. Furthermore, abuse has been associated with increased health care utilization [8,11] and higher annual health care costs [12]. Primary care physicians can offer validation, evaluate for psychological and medical sequelae, and offer mental health and domestic violence referrals to survivors of abuse. However, they can only offer such help if intimate partner violence is identified. Identification of a history of abuse is most effective when direct questioning is used, either in routine screening of all patients or questioning when there is suspicion of abuse. Studies show that routine screening in primary care practice greatly increases identification of intimate partner violence [13,14]. However, most primary care physicians do not routinely screen their patients for abuse [15,16]. A survey of primary care attending physicians found that only 10% reported routinely screening for intimate partner violence during new patient visits and 9% at periodic checkups [16]. A nationwide survey found that less than one third of women with a history of domestic violence report having discussed their trauma history with their doctor [7]. The purpose of this article is to review practical methods for routine screening of intimate partner violence in the primary care setting. We define routine screening as inquiry about intimate partner violence in all patients, regardless of the physician’s level of suspicion that the patient may be a survivor of abuse. We include a discussion of the importance of screening, screening tools, appropriate ways to manage disclosures of abuse, and common barriers to screening. Although the intent of this article is to discuss routine screening, many of the concepts reviewed also may be helpful in case identification when abuse is suspected. Importance of Screening The main benefit of screening for intimate partner violence is that it allows the health care provider to identify the patient as a survivor of abuse. The provider is then able to bear witness to the patient’s experience of suffering, offer empathy to the patient, document the history, and offer referrals to mental health and community resources. Furthermore, the physician can screen for comorbid psychiatric conditions, which may be treatable with medications or other interventions. These types of clinical interventions will be described later in this review. Patients endorse the practice of physician screening for intimate partner violence. A survey of female patients at an ambulatory VA clinic revealed that 77% of women with a history of abuse and 70% of women without a history of abuse believed that physicians should do routine screening