Domestic violence is ubiquitous in our society. Few are untouched by the physical and emotional consequences of abuse — whether they were directly abused or know others who were. However, little has been done to prevent it.
We’ve recognized prevention as critical to national health. This awareness has led to everything from decreased vehicular deaths by 90% since 1925 to millions of lives saved from vaccines. But even with all these achievements, 20 people per minute are victims of physical violence by an intimate partner and more than three women are murdered by their intimate partners every day, according to the CDC. In 2014, there were 702,000 victims of child abuse, of which 1,500 died. The annual cost of domestic violence is staggering — $5.8 billion — where the direct medical and mental health services cost is an estimated $4.1 billion.
Childhood mortality from abuse is 15 times that of deaths from childhood influenza. The incidence of intimate partner violence supersedes the annual incidence of heart attacks by almost 14-fold. Evidence shows that domestic violence is not just a law enforcement concern. Exposure has extensive adverse effects on the health of its victims.
In 1998 the Adverse Childhood Experiences (ACE) Study related childhood exposure to toxic stress and adverse health outcomes in adulthood. The study examined seven categories of adverse childhood experiences including psychological abuse, physical abuse, sexual abuse, maternal violence and exposure to substance abusers in the home. The study found a graded relationship between exposure and eventual adult disease such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease. Children who experienced four or more exposures, had a 4 to 12-fold increased health risk for alcoholism, drug abuse, depression and suicide attempts when compared to children who had none of the exposures.
Since the conclusion of the ACE study, several tools have been created by the American Academy of Pediatrics — namely The Resilience Project — to identify and implement preventive measures in the practice of medicine through the Connected Kids: Safe, Strong, Secure program.
Though primary care physicians are ideally positioned to work from a preventive framework and address at-risk behaviors, other providers may encounter domestic violence first. Since victims of domestic violence may be trauma patients, emergency and surgery physicians may treat them first. It is imperative that all health care providers directly involved in patient care, reflect on these important questions:
Am I prepared to address victims of domestic violence in my clinic or hospital? What policies and procedures are already in place?
What screening tools are available?
Does my staff and I feel prepared to properly educate or even intervene for a victim of domestic violence?
Do I know where the local women’s shelter is?
What is the number or website to the National Domestic Violence Hotline?
What are the state laws concerning Child Protective Services and abuse reporting?
These questions are fundamental in addressing this problem. Thankfully, several websites and organizations can help health care providers be at the forefront of prevention and intervention:
The National Coalition Against Domestic Violence and the CDC Injury Prevention & Control: Division of Violence Prevention provide extensive resources on the topic of domestic violence.
The New England Journal of Medicine has several articles pertaining to the physician’s role concerning domestic violence and the article “Intimate-Partner Violence — What Physicians Can Do” is a helpful starting point.
The Institute of Medicine called for screening and counseling for intimate partner violence within the U.S. health care setting and outlined some system approaches to implementing tools in the electronic medical record (EMR). The Affordable Care Act requires screening and counseling for interpersonal and domestic violence without requiring a copayment, coinsurance or deductible. Physicians should contact their EMR representative, as these tools may already be available or easily added to the user interface. If not available in the current EMR, screening tools such as the Get Domestic Violence Help website and the Hurt, Insulted, Threatened with Harm and Screamed (HITS) Domestic Violence Screening Tool are readily available online.
There are many online continuing medical education (CME) courses available with a single Google search, such as the one at the University of Florida or provided by some local and state insurance agencies.
Removing victims from danger is an important step in intervention. Safe housing provides distance and time away from a perpetrator and may be pivotal in ending the abuse. The Women’s Shelters website is a national search engine of local women’s shelters by state and city. The National Violence Hotline Website and phone service [1-800-799-SAFE (7233)] are very reliable.
Collaboration is key and health care providers should call their local health and welfare office and ask for a representative to come and educate their staff on the resources available and the process involved in reporting. Request that your local law enforcement educate you on the laws and due process. This may only cost your clinic lunch and can likely be used as a CME credit.
Lastly, know who the victims are. While it’s easy to envision females of male partners and children as victims, this is only part of the picture. Remember that female to male abuse, elder abuse and abuse among the LGBT community is often overlooked and is just as prevalent.
Physicians must begin to view domestic violence as we do influenza or vehicle safety. We must prevent it at all costs. And if it is not prevented, we must aggressively treat it. This will require extensive collaboration with colleagues, public health services and law enforcement. Though the challenge is enormous, physicians ought to address this societal disease and be at the forefront of care.