Advisability of screening for violence debated.

Fearing disbelief, blame, or retribution, many victims of forced sex tell no one about their experiences--unless they are asked. (1) Routine screening for physical and sexual abuse by intimate partners is recommended by several professional associations in the United States and the United Kingdom, (2) and a growing number of organizations in developing countries are training providers to ask all clients (3) or all clients with certain symptoms (4) about such abuse. Some experts question, however, whether such screening is advisable or even ethical in most resource-poor settings.

Proponents of screening say that failing to inquire about sexual coercion or other forms of violence compromises quality of care and misses opportunities to save women from potentially life-threatening situations. Others insist that screening should not take place unless the necessary support, policies, procedures, and referral networks are in place to ensure clients' safety.

At the heart of the debate is the question of what is an effective intervention: Is providing emotional support to women who have disclosed sexual coercion or other forms of violence beneficial in itself, or is screening effective only when it prevents further abuse?

The evidence to date suggests that screening efforts can improve detection of sexual coercion and other abuse. (5) In most surveys among women who have experienced violence, the majority of women support screening, and many express relief and gratitude for the chance to talk about their abuse, often for the first time. (6) But whether disclosure has a positive effect on women's health and safety is still in question. (7)

Researchers at the State University of New York in Albany, New York, USA, and Johns Hopkins University in Baltimore, Maryland, USA, are conducting a randomized controlled trial to assess whether screening and intervention for partner violence among women receiving primary care services reduces their exposure to future violence. The trial, which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), will also measure the impact of provider intervention on the women's quality of life and mental and physical health. Results are expected in 2005. Additional studies are needed to determine when and how to screen for violence in different settings, particularly in developing countries. (8)

In the meantime, based on the experience of family planning associations in the Dominican Republic, Peru, and Venezuela, the International Planned Parenthood Federation's Western Hemisphere Region office recommends that health facilities establish routine screening only when they can ensure clients' privacy, safety, and confidentiality. Managers should also help ensure that providers have positive attitudes toward victims of violence and can offer clients who disclose violence some assistance on-site or through referrals.

Even when screening policies and protocols are not in place, some clients will seek care for the effects of abuse or disclose their experiences to a provider. Therefore, providers need to be prepared to respond sensitively to victims of violence and to care for women in crisis. (9)

References

(1) Garcia-Moreno C. Sexual violence. IPPF Med Bull 2003;37(6):1-2; Jejeebhoy S, Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from Developing Countries. New Delhi, India: Population Council, 2003.

(2) Garcia-Moreno C. Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet 2002;359(9316):1509-14.

(3) Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR members associations in Latin America. Non-consensual Sexual Experiences of Young People in Developing Countries: A Consultative Meeting, New Delhi, India, September 22-25, 2003.

(4) Schraiber LB, d'Oliveira AF. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynaecol Obstet 2002;78(Suppl 1):21-25.

(5) Bott; Velzeboer M, Ellsberg M, Clavel Arcas C, et al. Violence Against Women: The Health Sector Responds. Washington, DC: Pan American Health Organization, 2003; Waalen J, Goodwin MM, Spitz AM, et al. Screening for intimate partner violence by health care providers: a review of barriers and interventions. Am J Prev Med 2000;19(4):230-37.

(6) Bott S, Guedes A, Claramunt MC, et al. Improving the Health Sector Response to Gender-based Violence: A Resource Manual for Health Care Professionals in Developing Countries. New York, NY: International Planned Parenthood Federation, Western Hemisphere Region, 2004; Parsons L, Goodwin MM, Petersen R. Violence against women and reproductive health: toward defining a role for reproductive health care services. Matern Child Health J 2000; 4(2):135-40.

(7) Nelson HD, Nygren P, McInerney Y, et al. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(5):387-96; Family Violence Prevention Fund Research Committee. Review of the U.S. Preventive Services Task Force draft recommendation and rationale statement on screening for family violence. San Francisco, CA: Family Violence Prevention Fund, 2003. Available at: http://endabuse.org/programs/ healthcare/files/FullResponse.pdf; Ramsay J, Richardson J, Carter YH, et al. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325(7359):314-18.

(8) Garcia-Moreno, 2002.

(9) Bott, Guedes, Claramunt.