Universal Precautions for Domestic Violence
I read with interest both the original article on screening for domestic violence(1) and the range of reponses by readers. Screening is the wrong paradigm for this condition. When screening is attempted for asymptomatic disease, neither the patient nor the physician knows if the disease or condition is present. The physician is applying a screening test or manuver to uncover occult disease. However, in the case of domestic violence, the victim is already aware of the violence and must decide, at the moment of questionning, whether she wishes to trust her physician by revealing her condition when it was not the reason for the consultation. (If the woman came to the physician for care related to the violence, this wouldn't be screening but case-finding or diagnosis.) In the United States, data made available to the National Advisory Council on Family Violence of the American Medical Association suggests that most US graduates have little training in the area. Routine trust in the expertise of physicians in this area would appear misplaced. Further, to be educated the woman is held hostage to her willingness to reveal her own history. If she reveals her history, the woman's fate may be in the hands of the provider and out of her control.
The more appropriate model for responding to domestic violence is analogous to the model adopted for preventing the spread of HIV: universal precautions. All women patients should have access to contact information for domestic violence organizations regardless of their readiness to share a history of violence. Every woman is at risk or may be at risk in the future. Every physician's office should have materials about domestic violence and telephone numbers for local agencies that provide services for domestic violence. Physicians should be ready and willing to respond to their patient's inquiries about domestic violence. They must become knowledgeble about DV through more training in medcial school and in post- graduate training. Research must be supported to answer questions about the effectiveness of directly asking women. Research into the prevention of violence shold be supported by national research agencies. In the meantime, women need to have the chance to get help without having to reveal sensitive information when they are not ready. We must practice universal precautions.
(1)Ramsay J, Richardson J, Carter Y, Davidson L, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002; 325:
Competing interests: None declared
Competing interests: No competing interests