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Disclosing violence to primary care or obestetrics/gynecology physicians most beneficial

July 07, 2008

(Boston, MA)-Researchers from Boston University School of Medicine (BUSM) and Boston Medical Center (BMC) found that patients who disclose intimate partner violence (IPV) to their clinicians of any type did not experience serious harm. However, those who disclosed IPV in a primary care or obstetrics/gynecology setting received the most benefit. The findings, which appear in the Biomedical Central Public Health Journal, also conclude that disclosures made in an emergency department setting were more problematic from the patient's point of view.

Researchers studied 27 IPV survivors recruited through community support programs in Massachusetts. The participants were given in-depth interviews to ascertain types of medical encounters relating to abuse, with encounters described as either single interactions or continued contact over a period of time.

Participants described disclosure of IPV to medical personnel. They also reported episodes in which they were asked about or treated for an IPV related problem in which they did not disclose. The researchers determined the medical specialty in which the encounters occurred, and limited their focus to emergency department, obstetrical/gynecological care, and primary care. The researchers also labeled whether harms occurred as a result of any disclosure as well as the perceived helpfulness (beneficial or not).

Of the 59 visits studied; 23 were in a primary care setting, 17 in the emergency department and 19 in obstetrics/gynecology. Participants reported disclosure IPV to a clinician in more than half of the encounters, and actively did not disclose in 30 percent, while sensing the clinician's knowledge without their own disclosure in 10 percent. No situations of any type resulted in serious harms. The vast majority of disclosures were deemed beneficial, whereas only a third of the non-disclosure were considered beneficial. However, in the emergency department setting, only one quarter of the disclosures were considered beneficial, compared to three quarters in obstetrics/gynecology and 100 percent in a primary care setting.

According to the research, consequences from unhelpful disclosures resulted in fear and avoidance of health care. "The most serious negative consequences of disclosure occurred when participants reported feeling endangered because of disclosure after treatment for acute injuries in the emergency department," said lead author Jane Liebschutz, MD, MPH, FACP, physician in the section of General Internal Medicine at BMC, associate professor of medicine and social and behavioral sciences at BUSM. Liebschutz added. "Participants felt that ineffective communication on safety assessment referrals and follow-up for IPV, as well as the lack of emotional connection with clinicians, were key factors in determining unhelpful disclosures."

Many participants who had a beneficial disclosure experienced a change in their circumstances such as, leaving an abusive spouse, entering a detoxification program or filing a police report. These changes occurred after a clinician worked with an individual over a period of time. Instead of immediate end to the abuse, these patient-clinician encounters resulted in a shift in the participant's self-esteem, perception of the violent relationship, or awareness of alternatives, eventually empowering the victim to seek help for the abuse independently.

"Treatment for acute injury relating to IPV should be viewed by clinicians as an opportunity to educate and empower patients, and providing options for the patient when they are ready," said Liebschutz. "Clinicians may be empowered if they feel they have a task in helping the patient, rather than just uncovering a painful problem."

Boston University