Screening for Domestic Violence May Not Help

It may seem like a no-brainer to some: wouldn’t asking every woman who comes into a doctor’s office about intimate partner violence help women who do suffer from this problem? The answer, according to one recent study, may be an unpopular ‘no.’

Both the study’s authors and other experts are quick to point out its limitations, but a study published in the Journal of the American Medical Association found that women who were screened for intimate partner violence did not fare much better than women who were not screened in terms of improved quality of life or rate of violence recurrence.

“You shouldn’t screen for something unless you have an effective intervention to which you can refer people once identified,” said the study’s lead author, Harriet MacMillan of McMaster University in Hamilton, Ontario. “Understandably, there is a sense of urgency about wanting to reduce partner violence. It’s a horrendous problem — it’s common, it’s serious, but there has been more emphasis on the screening part without the accompanying emphasis on the intervention. In other words, what do you do once you identify it?”

More than 6,500 women were included in the study, randomly assigned to a screening or a non-screening group. Because of ethical considerations, the “non-screened” women completed the same survey, called the Woman Abuse Screening Tool, but did so after seeing their doctor rather than before. The real intent of the study, then, was to see what a physician who is informed of a woman’s problems with violence can do to help.

Importantly, a substantial number of women whose screening tests showed they might be victims of violence in both groups – more than 40 percent – did not complete the entire study, which lasted 18 months following the initial assessment. Women who did not finish the study may have been more likely to have improved quality of life or a reduction in violence, making the results difficult to interpret.

Although initial analyses showed some women benefited from screening, when the researchers made calculations that accounted for those women who did not complete the study, those differences disappeared. Also, just as many of the women who were screened experienced a recurrence of violence compared to those who were not screened.

“Just going along and doing something without knowing whether it works or not is unacceptable,” said Thomas Cole, a researcher at the University of North Carolina, Chapel Hill. “You may be doing harm, and even more likely, you may not be helping.” He added that some of the potential harm of screening could come from retaliation from an abusive partner. Cole was not involved in the research, but co-wrote an accompanying editorial for JAMA suggesting some of the areas that research into interventions should target.

Some organizations dedicated to prevention and treatment for domestic violence worry that the study produced a message that since screening doesn’t work, physicians should stop asking women about intimate partner violence.

“Domestic violence is still a major health issue,” said Lisa James, the director of health for the Family Violence Prevention Fund, or FVPF. “I would hope that you wouldn’t stop asking and identifying women and helping them while you wait for the science to catch up.” The FVPF recommends screening, but the U.S. Preventive Services Task Force, which gathers evidence on screening for many different health problems, does not.

MacMillan stressed that her group’s intention was to shine a light on gaps in health care rather than to convince physicians to ignore the problem. “We think that clinicians need to be alert and responsive,” says MacMillan, “and they need to have training in how to respond when a woman does disclose.”