“Ask me,” begs Paula Spencer, the protagonist of Roddy’s Doyle’s The Woman Who Walked into Doors. While waiting for the doctor to put her arm back into its socket, she lies and tells the nurse she fell down the stairs. Again. The nurse doesn’t ask about her missing patches of hair, her broken teeth or the burn on her hand. Paula silently wills the nurse, “Look at the burn. Ask me about it. Ask.”
Though the account is fictional, it’s not far from the truth. The 2010 National Intimate Partner and Sexual Violence Survey reported more than one in four women has experienced severe physical violence inflicted by an intimate partner, including being slammed against something, hit with a hard object or beaten. Studies show that many of these women would disclose abuse to health care providers if they were asked—but few are. And even when abused women are asked, they aren’t necessarily connected with services that give them the help they need.
In an effort to close the gap between health care and domestic violence prevention, the Affordable Care Act (ACA) includes domestic violence screening and brief counseling as services that must be fully covered under health insurance plans. Medical providers are not required to screen patients for domestic violence, but now they have a financial incentive to do so.
“It’s a great opportunity for early intervention,” says Lisa James, director of health at Futures Without Violence. While doctors usually aren’t experts in domestic violence, care providers (doctors, nurses and physician assistants, for instance) could still play a key role in helping women who are too scared to ask for help.
“So many people won’t walk through our doors because they’re afraid,” says Jesse Torrey, associate director of RISE, an agency that serves victims of domestic violence and sexual assault in San Luis Obispo County. “But they will go to the doctor to get a check-up.”
Domestic violence survivors face not only acute injuries in the immediate aftermath of abuse; their long-term health is also poorer than average. “It’s not just broken bones. Domestic violence is associated with a whole host of chronic health conditions,” says James.
Research shows that women who experience domestic violence are more likely to suffer from heart disease, asthma, headaches, gastrointestinal problems and substance abuse. The U.S. Department of Health and Human Services lists interpersonal violence as a major risk factor for depression, self-harm and suicide. Numerous studies have linked domestic abuse to a higher rate of unplanned pregnancies, STD transmission (including HIV) and premature delivery.
Evidence suggests that medical providers can help. A 2014 review published in the American Journal of Preventative Medicine reported that primary care-based screening and intervention for domestic violence resulted in a number of patient benefits, including reduced violence, an increase in safety-promoting behaviors, enhanced use of community resources, and health improvements such as decreased symptoms of depression and fewer unplanned pregnancies.
When asked about her health care experiences, one domestic violence survivor in San Luis Obispo County put it this way: “I wish there was someone who would have asked me about domestic violence when I went in for my birth control as I was in a bad place and would have done anything to have someone offer a helping hand.”
Screening for domestic violence seems like a simple step medical providers can take to help their patients, but problems including short office visits, lack of training in how to respond to domestic violence and no system for offering effective follow-up and referrals means that too many patients leave the doctor’s office with no help in escaping their dangerous situations at home.
Shelters and clinics work together
A collaboration in San Luis Obispo County is testing a new approach to treating victims of domestic violence in the doctor’s office. Health care providers are trained to identify victims of intimate partner violence and connect them with the appropriate community resources and, in turn, domestic violence advocates are trained to identify health needs of victims and connect them with medical providers.
“It’s bringing domestic violence prevention advocates together with health care providers so they see they don’t need to do this alone,” says James.
RISE is part of the San Luis Obispo County partnership, in collaboration with The Women’s Shelter Program of San Luis Obispo County, The Center for Health and Prevention (part of the Community Action Partnership of San Luis Obispo County) and Community Health Centers of the Central Coast. The work is funded by a grant from the Blue Shield of California Foundation, which has also provided funds to 18 similar collaborations across the state.*
RISE began the process with a provider survey they administered to medical professionals at The Center for Health and Prevention and Community Health Centers of the Central Coast, and a survivor survey they administered to survivors at their facilities and online. They received responses from more than 400 survivors.
Only 33 percent of survivors reported they had sought medical treatment for injuries resulting from abuse—and even fewer Spanish-speaking survivors (3 percent) sought treatment. The most common reasons for not seeking treatment were embarrassment and fear of the abuser finding out.
The majority of medical providers rated their knowledge of domestic violence as high, but their comfort with having a conversation about the topic as low. Torrey relays a common feeling among providers: “You’ve got 15 minutes, and maybe you don’t want to know—because then what do you do?”
Of survivors who sought treatment for injuries resulting from abuse, 43 percent were not asked about domestic violence. For those that were asked, the most frequent outcome from disclosing abuse was “none”—no follow up, no counseling, no referral.
Some responses made the discomfort of care providers clear. “The health care worker suspected that I was being abused,” one survivor wrote, “but since I didn’t want to talk about it he left it alone, but made joking comments about my visits to emergency room to get stitched up.”
Another wrote, “I was scoffed at when they learned I was a 911 dispatcher. I should’ve known what to do.”
Others reported that their medical interaction was a doorway to healing. One survivor reflected, “I went to the hospital and they were incredibly supportive and helped me not go back and gave me so many resources to help me move on and rebuild my life.”
RISE and The Women’s Shelter Program used results from the survey to develop training for medical providers.
“It was a very powerful training,” says Kayla Wilburn, clinic director of the Center for Health and Prevention. “It had a powerful emotional component because those quotes were from people in our community.”
New approach a challenge for smaller clinics
Some of the solutions were surprisingly simple. Providers were given five questions printed on dry-erase sheets, so the slate could be wiped clean after each patient, and business-sized cards with instructions for how to access slocares.org, a website with local resources for survivors and medical providers. Medical providers and violence prevention advocates role-played different scenarios of disclosure, to help providers work through the fear of saying the wrong thing to their traumatized patients.
As a federally funded family planning clinic, providers at The Center were already required to screen their patients for domestic violence. But the new tools allowed each provider a consistent approach to screening, says Wilburn.
Providers also learned how to address health issues in a trauma-informed way, including awareness that an abusive partner may interfere with a patient’s health plan. James explains, “In trying to control her, he might take her asthma puffer away, or he might interfere with her birth control. That is very common. … So it’s important to create a health care plan she can manage within the context of her relationship.”
Service providers learned the importance of screening victims for health problems as well as signs of sexual and reproductive coercion.
“Asking health questions on intake happens regularly for sexual assault survivors, but often for intimate partner violence it gets left alone,” says Torrey, adding that RISE is now in the process of updating their intake forms.
Though the partnership has had initial success, some challenges remain. As a smaller organization specifically focused on reproductive health care, The Center was able to readily embrace the model. However, for Community Health Centers—a large network of countywide clinics—adding the screening to the new requirements that took effect under the Affordable Care Act has been difficult.
For domestic violence agencies, funding remains a challenge. With increased identification and the potential for more referrals, demand on domestic violence organizations will likely increase. And while medical providers are reimbursed for domestic violence screening and counseling under the ACA, domestic violence providers are not.
“We’re already having to turn away victims in many communities because there aren’t enough service providers,” says James. “The health care system is really accelerating its response, so we need to make sure domestic violence providers aren’t under the water with no additional resources to respond to increased capacity.”
One of the biggest challenges for health care providers is concern about mandated reporting in California. According to state law, they are required to make a police report if they provide medical treatment to a patient who suffers from a physical injury inflicted by abuse.
“We want to make sure we’re meeting our obligation to patients and to the law, and those things don’t seem to mesh all the time,” says Wilburn. “We tell patients our services are confidential, but if they disclose that they’re being harmed, we have to violate that confidentiality and call law enforcement.”
Mandated reporting is a topic of ongoing conversation between Torrey and Wilburn, who says this strengthened relationship has been the most valuable component of the partnership.
“My staff know who to call if they need guidance,” she says. “And RISE and the Women’s Shelter know they can send patients here and it’s going to be a safe place for their clients.”
*These collaborations are funded by the Blue Shield of California Foundation, which is also a funder of the California Health Report.