Do ask, do tell about intimate partner violence

Editor's note: Dr. Sharon Horesh Bergquist is an assistant professor of medicine at Emory University School of Medicine in Atlanta, Georgia. As a practicing internal medicine physician, she encounters patients who are dealing with intimate partner violence, which can have serious health effects.

As a physician, I look to evidence-based guidelines to drive my medical decisions. Yet often there isn't a consensus - such as whether doctors should ask patients if their partner is being violent with them in any way (physically, sexually or emotionally).

The most recent recommendation issued by the United States Preventive Services Task Force in 2004 did not find sufficient evidence to support screening women for partner violence.  However, many professional organizations such as the American Congress of Obstetricians and Gynecologists, the American Medical Association and the Institute of Medicine support such screening.  

A study published on Monday in the journal Annals of Internal Medicine  comprehensively reviews the studies published since 2003 on the effectiveness of screening and interventions in reducing partner violence and its related health outcomes.

An estimated 5.3 million American women each year are the victims of partner violence, according to the report.  The prevalence certainly suggests that as physicians we have a unique opportunity, and arguably responsibility, to create a trusting environment to counter the feelings of self-blame, isolation and shame that many who are victims of partner violence experience.

However the basic tenet, "Do no harm," should apply to partner violence just as much as any other health care intervention. The Annals article points out that some women who are screened for partner violence may feel a loss of privacy, emotional distress, and concern about further abuse. Yet these adverse effects were minimal in the 14 studies that were reviewed.

Does the benefit of screening outweigh this potential harm?  In the one large randomized controlled trial reviewed, screening opened the door to a 36% increase of women who discussed abuse with their physician.  But there was no statistically significant difference between the two groups when it to came to reduced recurrence of violence, mental health and quality of life.

Still, caution should be exercised when interpreting this lack of statistical significance. Randomized controlled trials are inherently difficult to conduct on partner violence since simply being in such a study increases self-awareness that may affect behavior. Plus, true "blinding" - the gold standard of clinical trials - isn't possible in this situation, and ethical considerations require that interventions be offered to control groups of non-screened women.

When it comes to partner violence, perhaps the better question to ask ourselves is: How much convincing evidence do we need?  In the above trial, women in the screened and usual care groups both had reduced recurrence of violence and better health outcomes.

From another standpoint, the overwhelming majority of those women screened favored being asked. And I, like many physicians, feel I should do a better job asking. Yet time constraints, lack of adequate training and limited knowledge about resources often get in the way.

For health care to be effective at helping people who are victims of partner violence, we need a systematic, standardized approach to screening and well thought-out protocols on how best to intervene.

And men aren't exempt. While this new study did not look at male victims, a recent CDC study found "1 in 10 men in the U.S. have experienced rape, physical violence, and/or stalking by a partner with IPV-related impact."

In our office, we use a screening questionnaire during routine wellness visits to inquire about partner violence. Can I say that all my patients who are victims of abuse answer it truthfully? Knowing the psychological readiness it takes to break the cycle of violence, I doubt it.

I can say that for at least some (female and male patients), asking those questions opened the window to more services, more accurate diagnosis of chronic issues, and better management of their health.

There are still several steps ahead before the USPSTF issues a new final recommendation for doctors.  Check back with CNN.com/health for more on this issue.