IPV SCREENING AND ASSESSMENT
The clinician’s role The healthcare encounter can be invaluable for those in abusive relationships. Although survivors of IPV access medical services more frequently than non-abused individuals, most do not volunteer a history of abuse even to their primary care clinicians. Sensitive inquiry about IPV during an annual physical examination, scheduled visit, or non-acute appointment, may reveal previously undisclosed abuse or can shed light on the underlying cause of an established chronic medical problem. In addition, research has shown that most patients both welcome and appreciate inquiry about violence and abuse in the course of the medical visit when questions are asked in a manner that is sensitive, respectful, and confidential. 19 Abused individuals are more likely to disclose a history of abuse to their healthcare provider if the provider is perceived to be knowledgeable, nonjudgmental, respectful, and supportive. Patients prefer that their Clinician barriers to effective, compassionate care Some healthcare providers find it challenging to address IPV, as well as other forms of violence and abuse. Survivors present frequently for medical care, and/or may come across as difficult patients. Many survivors believe that healthcare providers do not know about or understand the dynamics of violence and abuse, may not take the situation seriously, may not believe them, or may even blame the survivor for the abuse. As a result, survivors may exhibit a variety of problematic responses to the stress of ongoing or prior abuse (e.g., hypervigilance from PTSD, substance abuse), many of which make them “less than ideal” patients in a busy medical practice. Patient barriers to disclosure Patients may hesitate to disclose current or past abuse to a healthcare provider for a variety of reasons: 21 1. Fear of: ○ The healthcare provider confronting the perpetrator. ○ Retribution if the perpetrator learns of the disclosure. ○ A breech in confidentiality if medical records are accessed by the perpetrator, child protective services, employers, police, or immigration authorities. 2. Shame and humiliation that abuse is taking place, or took place in the past, or not wanting to be perceived as a “victim.” 3. Belief that they deserved the abuse. 4. Protective feelings for the partner. 5. Inability to fully comprehend the situation. 6. Assumptions that: ○ The doctor and staff are not knowledgeable or do not care about IPV because IPV may not be viewed as a medical issue. ○ The doctor is too busy to spend time talking about IPV. ○ The doctor can't help with this problem or that it is inappropriate to discuss it.
clinicians take the initiative to inquire, as a matter of standard practice, about violence and abuse during the course of clinical encounters. The gender of the physician is not an important factor in the willingness of most patients to disclose or discuss abuse. The physician may need to ask on multiple occasions and over time, as a patient may need to feel they have a safe relationship to disclose their status. The physician can then help the patient develop a safety plan to prime the patient’s next leave attempt. It’s important to reiterate that a patient who remains in a dangerous or potentially dangerous relationship should not be labeled as a treatment failure or non- compliant. As noted earlier, choosing not to leave usually reflects the limited resources available to the survivor, or the patient’s reasonable assessment of available options and safety needs. When interviewed about their beliefs about partner abuse, and about their personal experiences of victimization, many primary care providers expressed fear of “opening Pandora’s Box” by broaching the topic of IPV with patients. 20 Associated with this metaphor were five strong themes identified as distinct challenges. The first was “too close for comfort,” relating to the finding that 14% of male physician respondents and 31% of female physician respondents in the study disclosed a previous personal experience of abuse. Other themes were fear of offending, powerlessness, loss of control, and “tyranny of the time schedule.” ○ Same-sex abuse is not recognized, screened for, or treated. 7. Language, culture, and religion: ○ Language barriers when communicating with providers, and fear of losing confidentiality with the use of an interpreter. ○ Religious customs pushing survivors to stay silent about abuse. ○ Reluctance to “air dirty laundry” and cast a bad light on their community. 8. Immigration status being contingent on their current relationship, especially if they’re trafficked foreign nationals. 9. Sexual orientation and gender identity leading to fear of being “outed” or shamed. Additionally, perpetrators can control a patient’s ability to access healthcare. They may accompany the patient to healthcare visits and even dominate the encounter and speak for the patient. Perpetrators can also affect a patient’s ability to adhere to medical instructions. They may confiscate or discard medications or medical devices as a way to control the patient.
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Book Code: CT24CME
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