Domestic violence is a misunderstood topic. The context of a trusted health professional talking to a woman is one that provides an important opportunity for providing information to counter misconceptions.
I deliberately talk about this in terms of asking all women about domestic violence and not in terms of screening women for domestic violence. It is not appropriate or helpful to regard enquiry about being abused as a form of screening. Domestic violence is not a disease present in the body of the person who experiences it—rather it is a health-related risk factor.
As such, knowledge of abuse puts health professionals in a position to respond better to the needs of women affected by it. Professionals can respond by providing information on specialist services—usually provided outside the health service—that women may access if they wish. By giving information to affected women, health professionals can also help to reduce women's sense of isolation and stigmatisation. Asking about experience of domestic violence can be seen as a routine part of history taking, just as health professionals regularly and repeatedly ask patients about their smoking behaviour, alcohol use, weight, and exercise.
The prevalence of domestic violence among women is such that, even if it is not a personal issue for the woman concerned, it most likely will be for one or more of her relatives, friends, and neighbours [1
]. Since many women experiencing abuse feel alone and ashamed, and their abusers often encourage them to believe that the abuse is their fault, presenting information to counter women's negative feelings is an important preventive strategy.
Most women experiencing domestic violence report that the specialised services that exist to respond to their needs were difficult to find out about [2
]. The provision of simple information on the existence of specialised services and how to contact them is relevant to all women.
Studies have examined women's views on being asked about domestic violence. These studies have shown that once they have experienced being asked, they are usually in favour of being asked. This is true both for those who have experienced or are experiencing abuse, and those who have not [3
]. It is only a small minority of women who object to being asked, or who find the question uncomfortable. Women who have experienced abuse particularly value being asked directly.
Women experiencing violence often feel alone and ashamed
Asking about abuse should be done in a flexible fashion—the particular questions used should respond to the circumstances of the consultation. For example, it is appropriate to ask women about domestic violence as part of a health check in a Well Woman Clinic, but it would be completely inappropriate in a consultation where another adult or a child was present. By being flexible, health professionals can integrate their questioning within a variety of different encounters. Integrating questions about abuse into routine encounters provides for the maintenance of confidentiality and safety. In order to do this, health professionals require training on raising the issue and knowledge about local advice and support services.
Committees on both sides of the Atlantic have rejected the notion of screening women for domestic violence, arguing that there is insufficient evidence of the effectiveness of interventions [4
]. Part of the reason for this lack of evidence is that the systematic reviews on which these committees based their recommendations often excluded the most important types of evidence that do exist [3
]. For example, these reviews excluded studies done outside the health service setting—they excluded those based in social services, or in the voluntary or community sector. Some excluded studies show the effectiveness of specialised service provision for women experiencing abuse.
In one example of an excluded study, researchers used a randomised design to evaluate an advocacy service for women experiencing domestic violence [7
]. Women were interviewed six times over two years, and women in the intervention group reported a higher quality of life, decreased difficulty in obtaining community resources, and less violence over time than women in the control group. Other studies showing the value of specialised support services provided outside of the health system provide evidence of the potential benefits of asking about abuse [2
Systematic reviews have also excluded, or devalued, evidence from qualitative studies. For example, a study of 200 women who had used domestic violence outreach services found that about half were living in situations of domestic violence when they first contacted the service. All of these women reported that the outreach services had helped them to leave the abusive relationship—a valued outcome for them [9
Given the health impacts on women who experience domestic violence (not to mention their children) and the prevalence of the problem, routinely asking women about abuse should be seen as an important form of primary and secondary prevention for a wide range of health problems.