Domestic violence: Shattering the silence

The 73-year-old woman made repeated visits to the Olmsted Medical Center in Rochester, MN, complaining of anxiety. FP Therese Zink provided the requisite treatment each time, but she had a feeling that something else was going on. After a year of gentle probing, Zink learned that the woman's husband had pulled a gun on her early in their 50-year marriage, and he'd been terrorizing her ever since.

Among the many things that your patients may be reluctant to tell you, the fact that they're in an abusive relationship is high on the list. It's important to learn to break through this reticence because intimate partner abuse is as hazardous to patients' health-and as common-as many clinical problems that you typically inquire about.

What to watch for and what to ask

L. Kevin Hamberger, professor of family and community medicine at the Medical College of Wisconsin in Milwaukee, recommends asking all patients about intimate partner abuse. Doctors should do this during patients' annual checkups, he says, and when they present with what Hamberger calls "red flag" conditions that can result from physical abuse, and from the hostile language and controlling behaviors that characterize verbal and emotional abuse. These include depression, anxiety, and any type of chronic pain: headaches, pelvic pain, back pain, and IBS. Keep watch, too, for injuries-bruising, for example-that don't fit the patient's explanation. And ask about the patient's home situation when chronic health problems, such as asthma, don't improve or worsen. People in coercive relationships have difficulty following recommended treatment regimens, or may even be prevented from doing so.

Smoking and alcoholism also can be red flags. There's a high correlation between intimate partner violence and addictive behavior. Indeed, Harvard researchers recently reported that a woman who smokes and drinks to excess has nearly a one in three likelihood of having been abused by an intimate partner within the past year.

Don't limit your screening for domestic abuse to a checkoff box on a health history form, says Debbie Lee, managing director of the Family Violence Prevention Fund (FVPF), a nonprofit advocacy group based in San Francisco. Question the patient face to face. Begin the discussion by indicating that because verbal and physical abuse are common in intimate relationships, and because patients are often too afraid or too uncomfortable to raise the subject themselves, you're asking all your patients about it. Among the screening questions suggested by the FVPF and other experts: