Disclosing Domestic Violence: Role of Privacy and Modesty
Screening for medical and psycho-social problems should be a primary function in physician history-taking beyond asking about the symptoms for which the patient has come for consultation and treatment. Screening is a pro-active way of discovering conditions in the patient’s life which may lead to disorder and symptoms in the future. Screening often involves asking patients about whether they smoke, drink alcohol or take illicit drugs. Hopefully, with the feedback from the physician, the patients will understand the reason for screening and will be forthcoming in their answers. However, screening may involve issues which are felt by some patients to be “too personal” to disclose to anyone. Screening about sexual history and practices, as an example, is being discussed on another thread.
An important screening topic which physicians should inquire is history of domestic violence. This also is complicated by the patient’s concern about the privacy issues and consequences of providing the physician with such information if their abusive spouse finds that the patient “talked.”
An interesting article about this subject is present in Postgraduate Medicine Online
titled “Screening for domestic violence
Identifying, assisting, and empowering adult victims of abuse” by
Katherine J. Little, MD in the August 2000 issue.
Barriers to disclosure are noted both on the part of the patient and that of the physician. Excerpts from the article:
Patients also face barriers to disclosing violent relationships. The perpetrator may have threatened to beat the victim more severely if she discloses information, or he might have implied that their children would be taken away. If the victim reported abuse in the past, she may have been blamed for the situation or the abuse may have escalated. Perpetrators may not allow victims who disclose information to participate in appropriate medical follow-up care. In some cases, a victim's cultural background may have taught her that she must accept her situation and that she should not question or discuss the subservient role into which she has been forced by the perpetrator.
...
Physicians face many barriers when trying to provide the kind of patient care that they themselves would expect to receive. Lack of time--to establish rapport with a patient, to hear in detail about all of her problems, and to ask a multitude of questions for further diagnostic elucidation--is a commonly cited reason for not routinely screening for domestic violence in primary care practice. Physicians do not want to open a Pandora's box of complicated social and psychological issues that could not possibly be evaluated in an allotted 30 minutes or less. Also, for some physicians, such a discussion may trigger memories of their own violent relationships; in such cases, the well-recognized survival technique of distancing oneself from a patient's pain may be ineffective.
I wonder if my visitors might discuss here how they would consider their being screened for domestic violence by their physician, perhaps as part of a routine history and physical. Would it be easier to disclose information about abuse if the questions were asked not face-to-face but in the form of a written or computer driven questionnaire? Is there a kind of modesty involved in this screening, modesty not to reveal ones private marital life? ..Maurice.
posted by Maurice Bernstein, M.D. @ 8:54:00 PM
11 comments
11 Comments:
I am the author of a bestselling memoir on emotional and physical abuse and speak often -- next month at a medical school -- about how to recognize and intervene when someone is being abused. Any insights from the medical community that would make me a more effective speaker would be much appreciated. Please weigh in!
Janine Latus
But Janine,what is your opinion as to which mode of communication to physicians regarding history of abuse would be more acceptable by patients: face to face, written or by a computer application? Also, beyond insights from the medical community, I think that views of the lay public would be very helpful to anyone investigating and speaking on the subject. ..Maurice.
In acknowledging domestic violence, the patient might expect (or fear) that the doctor will now offer advice for her terrible ordeal, if indeed the abuse is ongoing. How will the doctor use this information, other than perhaps as an aid to properly identify and treat any body damage resulting from this abuse.
And your suggestion of a written or computer driven questionnaire would be the way to go, in my opinion. That format might also be more comfortable in revealing the patient's sexual history discussed a couple of threads ago.
State and local laws describe the responsibilities of healthcare workers regarding reporting evidence of domestic violence. For example, as a physician in the Los Angeles, CA area we must follow the law as decribed in this summary from UCLA Womenshealth:
SUMMARY OF REPORTING REQUIREMENTS
See complete text of law in Penal Code Section 11160et. Seq.
Any health practitioner* employed in a health facility; clinic; physician?s office; local or state public health department; or public health department operated clinic or facility is required to make a report if s/he provides medical services for a physical condition to a patient whom s/he knows or reasonably suspects is:
• suffering from any wound or other physical injury inflicted by his or her own act or inflicted by another where the injury by means of a firearm and/or
• suffering from any wound or other physical injury, that is the result of assaultive or abusive conduct.
Assaultive or abusive conduct is defined to include 24 criminal offenses, among which are murder, manslaughter, torture, battery, sexual battery, incest, assault with a deadly weapon, rape, spousal rape, and abuse of spouse or cohabitant.
*Health practitioner is defined to include practitioners such as a physician, surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropracter, licenced nurse, dental hygienist, optometrist, MFCC, MFCC trainee or registered intern, emergency medical technician I or II, paramedic, public health employee who treats minors, coroner, person who performs autopsies, and a religious practitioner who diagnoses, examines or treats children. (This is not a complete definition; see Penal Code 11165.8)
The health practitioner is required to make a report by telephone immediately or as soon as practically possible and send a written report to a local law enforcement agency within two working days.
CONFIDENTIALITY
Health care facilities must keep reporting forms confidential. Family, friends and other third parties should not have access without patient consent.
LIABILITY
Civil and criminal immunity is provided health practitioners who make required or authorized reports pursuant to these provisions.
PENALTY
Violation of this law is a misdemeanor.
Of course, since apparently there are no conclusive studies to prove that such required reporting is so beneficial that it trumps the adult victim's privacy and autonomy and the other risks of reporting,there are two opposing points of view on whether it is ethical to have such laws. To read the arguments for each view from Western Journal of Medicine, October 2000 issue titled "Should Physicians Be Required to Report Domestic Violence to the Police?" click on PRO and CON links.
With regard to how the information to the physician should be communicated, the face to face approach, of course, enables more immediate questions and feedback by the physician to the patient than the other less direct communications. ..Maurice.
How does mandatory reporting reconcile itself with HIPAA confidentiality requirements. People are less likely to want to discuss things if there are too many loopholes.
Maurice,
It is hard enough to utter the words or indicate with the eyes or hands or helpless shrug. To write it down? Perhaps only if the questions were oblique and impossible to jigger, ala the MMPI. Culturally it is unlikely to be effective to ask, "are you experiencing violence in your home?" You're not going to say 'yes' to that until you're ready to reach out and begin the process of escape. Face to face, I think. And gently.
Janine
HIPAA permits disclosure of protected information when ordered by health and safety laws including those laws applying to abuse, neglect or domestic violence. As long as patients are aware of the limitations of HIPAA as often disclosed in Privacy Postings within institutions and doctor's offices, then it is up to the patient to decide what they wish to disclose. Fortunately our medical profession has not gotten into the illegal and unethical practices our dear government has allegedly used to obtain information from unwilling subjects. (I just had to put in this political/ethical statement!) ..Maurice.
As a psychologist, I find that patients disclose these things when they are ready to deal with them. It is our job to help the patient as best we can based on where they are in the process of disclosure vs nondisclosure. Education of BOTH genders is important. I have dealt with both male and female abusers and victims. On occasion (but not often enough) a person comes to us wanting to stop being abusive. Most perpetrators know its wrong. I'm glad my state does not require me to report this unless its against specific populations who are vulnerable.
I've actually been asked about this a few years ago when I was participating in a martial art that involved being hit with rattan swords. I frequently left practice with large welts because I still wasn't good enough at blocking. Upon seeing the bruises, I did have at least two doctors ask if I was being abused, which led in my case to some interesting discussions about what I'd been doing and how to explain it. I'm not sure how I would have responded if I'd actually been abused, but they definitely were intent on following up on the bruising.
Effective January 1, 1995, psychotherapists (psychologists, MFTs, LCSWs) are NEVER required to report domestic violence (and thus, MUST NOT breach confidentiality by making a report), regardless of where they are employed. Only MD's are required to report instances of domestic violence reported by patients receiving medical services for physical conditions. For one year only, 1/1/94 through 12/31/94, psychotherapists who were employed by physicians or health facilities licensed pursuant to Section 1250 of the H&S Code, or by clinics as specified in Section 1204 or 1204.3 of the H&S Code were required ONLY while working in those settings to report domestic violence.
Anonymous from yesterday 10-13-07, is the H&S Code in your comment a state code, such as for California? Would the rationale for the code be that physical consequences of abuse cannot be verified clinically by anyone other than a physician? And that anything other than physical evidence is heresay? ..Maurice.
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