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PRIMARY CARE: Jean Ramsay, Jo Richardson, Yvonne H Carter, Leslie L Davidson, and Gene Feder Should health professionals screen women for domestic violence? Systematic review BMJ 2002; 325: 314 [Abstract] [Full text]

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Rapid Responses published:

Biopsychosocial model Revisited, Again !

Ishay Lev, Aharon Karni, Amnon Lahad   (10 August 2002)

Domestic violence screening: impact on children must not be ignored

Elspeth V Webb, Rachel B Brooks   (12 August 2002)

Asking men and women about violence in A&E

Mike Crilly, Andy Howe.   (16 August 2002)

Screening Domestic Violence: The Need for a Cultural Shift?

Jo M. Nurse   (17 August 2002)

Screening for domestic violence sows the seed

MAUREEN E DALTON, HELEN CAMERON   (17 August 2002)

Public or private matter?

Peter Davies   (19 August 2002)

The way forward

Kate Fletcher   (19 August 2002)

Confirms what I knew

Nancy G Hewer   (21 August 2002)

Screening for Domestic Violence: Let’s not throw the baby out with the bathwater!

Lucia Beck Weiss, Mary O'Brien, Candace Robertson   (28 August 2002)

Screening is absolutely essential in health care settings.

Donna Cavalluzzi, CSW   (31 August 2002)

A dissenting opinion, and a suggestion

Teresa T. Goodell   (31 August 2002)

NOT screening for Domestic Violence almost killed ME when I was living in Europe!

Jane Dimer   (2 September 2002)

It takes two to tango.

Roger KA Allen   (3 September 2002)

OBJECTION TO VIEW THAT DV SCREENING IS UNNECESSARY

KATHY L. SHORE   (4 September 2002)

Screening women for domestic violence

Kate Mulley   (6 September 2002)

the gender bias in DV research goes on

Chris Carlsten   (6 September 2002)

Bring back the ducking stool.

Roger KA Allen   (7 September 2002)

The taming of the shrew..... and the definition of violence.

Roger K.A. Allen   (7 September 2002)

Justifiable homicide and lambs' fry and bacon.

Roger KA Allen   (9 September 2002)

problematic Definitions of 'DV Screening'

Wendy B Bateman   (10 September 2002)

"Screening' for domestic violence is necessary but not sufficient

Angela J Taft, Kelsey Hegarty   (10 September 2002)

A Different Perspective on Screening Women for Domestic Violence

Robert K. Gribble   (11 September 2002)

Domestic violence: General Practitioners may have a key role

Andrew S Furber, Hilary Spencer and Rachel Loise   (17 September 2002)

Screening for Domestic Violence: Where Do We Go From Here?

Mary M Goodwin, Ileana Arias, Patricia Dietz, Linda E. Saltzman, Alison M. Spitz   (24 September 2002)

Routine Questioning – part of a whole health intervention:

Judy Watson, Monica Tuohy, Binah Taylor, Judith Rodgers, Diane Egan   (4 October 2002)

Screening for domestic violence : an ethical duty

Irène François, Grégoire Moutel, Christian Hervé   (6 November 2002)

Systematic review of screening for domestic violence: not an excuse for clinicians to ignore abuse

Gene S Feder, Katie Cosgrove, Victoria Lavis, Kate Mulley,Jo Nurse, Katrina Smith, Judy Shakespeare, Ann Taket,Judy Watson   (21 November 2002)

Re: Public or private matter?

Sarah C Whippman   (1 January 2003)

give us a break

stephen r. kettle   (3 January 2003)

Biopsychosocial model Revisited, Again ! 10 August 2002
Ishay Lev, MD Family Medicine Intern Family Medicine Department, Hadassah, Jerusalem, Israel, Aharon Karni, Amnon Lahad Send response to journal: Re: Biopsychosocial model Revisited, Again !	The review by Ramsay et al. has brought into the light the poor state of the social care of patients by Doctors and the Medical foundation. Doctors reported to screen Women for Domestic Violence in only a small fraction of cases while Women expressed their approval of such inquireis. Furthermore, there was no strong data to support any change in the state of domestic violence due to Medical intervention. The Biopsychosocial model of GP and family Medicine had not sank apparently in to the awareness of the international health services. This model repreasants not only the realistic way to look at an illness but also as an efficient and a cost benefit way of practicing Medicine. While working under the constraints of a 15 min visit doctors may become more of a technicians. Doctors may be reluctant to bring up non immediate or any new content into the meeting - this is evident even more in big cities when the line of waiting patients is always long. In the last few years it became evident that if doctors would just say to the patient for example that it is not healthy to smoke there will be an immediate effect on the intention of patients to stop smoking. What if we raise the attention of patients to issues of quality of life such as violence, marital discordance, inappropriate jobs, inappropriate degree of leisure - is it possible that we will raise the patients health, decrease the cost of care, while not stepping out of our appointed tasks ?
Domestic violence screening: impact on children must not be ignored 12 August 2002
Elspeth V Webb, Senior Lecturer in Child Health University of Wales College of Medicine, Cardiff CF14 4XN, Rachel B Brooks Send response to journal: Re: Domestic violence screening: impact on children must not be ignored	Editor, Both the systematic review by Ramsey et al, exploring the evidence base for domestic violence screening, and the reviewed research, all omitted the risks and benefits of domestic violence screening to children (1). Children living with domestic violence face significant harm. This includes: foetal effects, resulting in death, injury, or low birth weight (2); child abuse (3); the emotional and developmental sequelae of mothers’ emotional unavailability and witnessing violence (4); and compromised access to services (5). Any debate on this issue is incomplete if the risks and benefits to women only are considered, ignoring those faced by their children. Indeed, the harm to children resulting from domestic violence is so grave that we believe it is unethical to leave the plight of affected children out of any risk/benefit analysis of screening and associated interventions. Yours sincerely Elspeth VJ Webb Senior Lecturer Rachel B Brooks Clinical Lecturer Department of Child Health, UWCM, Cardiff CF14 4XN References 1. Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314-318 ( 10 August ) 2. Mezey GC, Bewley S. Domestic violence and pregnancy. BMJ 1997;314:1295 3. O’Hara M. Domestic violence and child abuse-making the links. London: National Children’s Bureau 1995. (Highlight No 139) 4. Grych JH, Jouriles EN, Swank PR, McDonald R, Norwood WD. Patterns of Adjustment among children of battered women. Journal of Consulting and Clinical Psychology 2000;68: 84-94 5. Webb E. Shankleman J. Evans MR. Brooks R. The health of children in refuges for women victims of domestic violence: Cross sectional descriptive survey. BMJ. 2001;323:210-213
Asking men and women about violence in A&E 16 August 2002
Mike Crilly, Senior lecturer clinical epidemiology University of Aberdeen, Andy Howe. Send response to journal: Re: Asking men and women about violence in A&E	EDITOR- We agree with Ramsay and colleagues that domestic violence is an important problem with major health consequences for women.[1] But the wider issue of violence in society (not just domestic violence) also deserves consideration. Particularly since violent assault is most commonly directed against men.[2] Police data provides an incomplete picture of violent assault in a community [3] and public health action to reduce the levels of violence in society will require the use of health service data to identify priorities and monitor change.[4] The routine questioning of patients attending accident and emergency departments (A&E) is one option for assessing the levels of violence in a local community. We have recently reported on the acceptability of the routine questioning of patients (both men and women) attending A&E in England.[5] In our questionnaire survey of a representative sample of 281 adults, 67% (95%CI 60% to 74%) supported routine questioning about violent assault, with similar levels of support from both men (66%; 95%CI 59% to 73%) and women (68%; 95%CI 59% to 76%). The proportion of respondents supporting routine questioning increased with age (52% of 16-24 year olds; 65% of 25-44 year olds; 85% of those over 45 years of age). Overall 89% (95%CI 85% to 93%) felt that health care staff should actively encourage victims of violence to inform the police. Indeed 74% (68% to 80%) felt that health professionals should routinely inform the police – as is the case in some American states. Patients attending A&E support a far more active approach from health care professionals in identifying victims of violence than is currently the case in the UK. But we agree with Ramsay that further evidence is required to assess the effectiveness of both population-based and individual-based interventions intended to reduce violence. References 1. Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314-8. 2. Howe A, Crilly M. Violence in the community: a health service view from a UK Accident and Emergency Department. Public Health 2002;116(1):15-21. 3. Howe A, Crilly M. The identification and characteristics of victims of violence identified by emergency physicians, triage nurses and the police. Injury Prev 2002: in press. 4. Shepherd J, Sivarajasingam V, Rivara F. Using injury data for violence prevention. BMJ 2000;321:1481-1482. 5. Howe A, Crilly M, Fairhurst R. Acceptability of asking patients about violence in accident and emergency. Emerg Med J 2002;19:138-140.
Screening Domestic Violence: The Need for a Cultural Shift? 17 August 2002
Jo M. Nurse, SpR in Public Health/ Honary Visiting Research Fellow Health Policy Unit, London School of Hygiene and Tropical Medicine, London, WC1E 7HT Send response to journal: Re: Screening Domestic Violence: The Need for a Cultural Shift?	Editor- The Systematic Review of Ramsay et al(1) makes a valuable contribution to the debate around whether or not to screen for domestic violence. This debate also needs to consider some of the wider cultural issues influencing the acceptability of the existence of domestic violence within society. The taboo nature of recognising, acknowledging and bringing into the open issues surrounding domestic violence has led to resistance by the health profession in dealing with what is increasingly becoming understood as an important influence on the health of women(2-5). However, domestic violence is not unique, the recent history of the denial of the existence of child sexual abuse has undergone a major societal and cultural shift in the last 20-30 years, resulting in a heightening of awareness and recognition by health professionals and society at large. A similar cultural shift is starting to take place in attitudes towards domestic violence, for example, with its inclusion within Local Authority Community Safety Plans. Although there are clear research needs in determining the effectiveness of interventions for the prevention of domestic violence, part of the resistance towards ‘screening’ of domestic violence appears to be related to negative attitudes held by health professionals. To address this, I agree with the authors that more work needs to be done in assessing the training needs of health professionals in relation to domestic violence. Furthermore, the approach to dealing with domestic violence within the health sector may benefit from actively creating an environment whereby health professionals are seen not to support the use of violence as a means to deal with interpersonal conflict in any setting. A stronger emphasis needs to be placed upon becoming a part of the cultural shift upon non-tolerance of violence within relationships in a similar way that health professionals have been able to contribute to the prevention of child abuse. References: 1. Ramsay J, Richardson J, Carter Y H, Davidson LL and Feder G (2002) ‘Should health professionals screen women for domestic violence? Systematic Review’ BMJ; 325: 314-8. 2. World Health Organisation ‘Violence against women: A health priority issue’ FRH/WHD/97.8 Geneva, 1997. 3. Alison M et al (2000) ‘Violence and reproductive health’ Maternal and Child Health Journal, Vol. 4, No. 2; pp. 77-78. 4. British Medical Association (1998) ‘Domestic violence: A health care issue’. 5. Home Office (1999) ‘Domestic violence: Findings from a new British Crime Survey self-completion questionnaire’ Home Office Research Studies.
Screening for domestic violence sows the seed 17 August 2002
MAUREEN E DALTON, cons. obs.& Gynae SUNDERLAND ROYAL HOSPITAL, KAYLL ROAD, SUNDERLAND SR4 7TP, HELEN CAMERON Send response to journal: Re: Screening for domestic violence sows the seed	EDITOR - Ramsey et al based their conclusions on the premise that asking a woman about domestic violence (DV) is a screening test. Whilst the term ‘screening’ is used it will always fail as a conventional screening test. We do indeed know that approximately one quarter of women in the UK have been victims of DV, yet the majority will deny it when asked. Even if they are willing to discuss their experience of violence, rarely are they prepared to leave the abusive relationship. Asking about DV is an exercise in ‘sowing the seed’. Questions need to be asked in a supportive and non-judgemental way so that the message that a woman perceives is that the doctor is aware that each and every patient could be a victim and that the doctor (and by inference the rest of the health profession and society in general) appreciate that violence against women is unacceptable in any community. Having undertaken the ‘sowing the seed’ exercise to continue the analogy the ‘seed’ can be ‘watered’ by further questioning during contact with other members of the health team. This process will help some women towards disclosure of their personal experience, thus allowing them to benefit from the local interventional support programmes. We wish to question the authors assertion that ‘rate of referral to outside agencies are not a convincing proxy’ for the effectiveness of screening programmes, there must be excellent opportunities for referral patterns to be included in a research agenda. If health professionals fail to ‘screen’ for DV then in effect we are condoning the practice. Doctors need to take a lead in screening for DV and become skilled in applying appropriate management strategies so that the impact of DV on health can be minimised. Without the health professional input, we believe that campaigns to change societal attitudes to DV will flounder. As Bewley et al pointed out in 1997, robust research data are lacking in the British Isles. Surely the best way forward is not to abandon newly established DV screening programmes but to secure national research funding to examine the benefits and costs of asking women about their experience of violence and to explore different models of intervention for the victim.
Public or private matter? 19 August 2002
Peter Davies, GP Mixenden Stones Surgery,Halifax.HX2 8RQ Send response to journal: Re: Public or private matter?	Sir, I read this article and responses with interest.I cannot see asking about domestic violence as a screening test as there is no agreement on effective subsequent intervention, even if there if there is a statement confirming domestic violence. The difficulty in these cases is the conflict between the doctor's duty of confidentiality to the patient and the doctor's common law responsibility to report a crime that has been committed. At present the duty of confidentiality is ranked far higher than the doctor's duty to society. If we as a society are to tackle domestic violence it needs to move from being treated by doctors, the police and legal service as a personal matter and instead be treated as seriously as any other crime. In particular the police and prosecuting authorities need to stop asking victims whether they want the prosecution to go ahead. If the crime has been committed the prosecution should go ahead anyway as a domestic crime strikes as much at society as it does at the immediate victim. Perhaps it is time to look at whether the doctor's duty of confidentiality is really in the patient's (and the community's) interest in cases such as these. I should add that I do not necessarily know the answer to these questions and that I find these areas where law and medicine mix difficult territory to navigate. A clearer map would be useful.
The way forward 19 August 2002
Kate Fletcher, Designated Nurse Child Protetction Alderley Building, Macclesfield Hospital, Victoria Road, Macclesfield. SK10 3BL Send response to journal: Re: The way forward	EDITOR - The article by Ramsay et al on screening women for domestic violence in healthcare settings concludes that such screening cannot be justified. The findings replicate research I undertook last year with health visitors in Eastern Cheshire PCT. I too found a general reluctance to screen for domestic violence, despite the recommendation that this should be an integral part of any health needs assessment . Many health visitors were concerned that screening would raise client expectations, which we would then be unable to fulfil. Most women refuse to consent to referral to the police, the refuge, social services or the domestic violence outreach team, and therefore remained unsupported. Health visitors thus felt extremely anxious about the well-being of the family, without being able to lessen the risk. (Clearly, where children were considered to be at risk of significant harm , child protection procedures were initiated and consent to referral, although desirable, would not be required.) The solution was to ask Cheshire police, in the spirit of “Working Together” , to train all the Trust’s health visitors to discuss safety planning with women experiencing domestic violence . The planning has three stages: the women plan to maximise their safety while staying in the household, secondly they plan to leave safely, and thirdly they plan to remain safe whilst establishing independence in a new setting. Previously these women would only have received this help after referral to an external agency. This has proved successful. Eastern Cheshire health visitors now feel confident to broach the subject of domestic violence, and can provide assistance to those women who need it. The training is about to be extended to all community nurses, to enable them too to protect other vulnerable adults not in receipt of health visiting services. It is true, as Ramsay et al assert, that there has been a problem with health professionals screening for domestic violence, but there is a solution. I urge health professionals to contact their police family protection units to explore local possibilities for maximising the safety of vulnerable adults and children in their areas. Kate Fletcher Designated Nurse Child Protection Eastern Cheshire Primary Care Trust kate.fletcher@echeshire-tr.nwest.nhs.uk Alderley Building, Macclesfield Hospital, Victoria Road, Macclesfield Cheshire SK10 3BL
Confirms what I knew 21 August 2002
Nancy G Hewer, faculty, perinatal specialty British Columbia Institute of Technology, 3700 Willingdon Avenue, Brunaby, B.C. Canada, V5G 3H2 Send response to journal: Re: Confirms what I knew	I was thrilled to read this article as it confirms what I have known and have been telling health care providers for the past few years. Violence against women is a health care issue, but screening is not the answer. We need to be educated in how women's health can be impacted by violence and incorporate this knowledge into our practice. Just as we know that someone experiencing a heart attack can have chest pain, we know that women living in abusive relationships can have depression, anxiety, headaches, abdominal pain....the list is endless. This is the first step, making the link between unexplained health concerns and the possibility of abuse. Rather than asking a screening question, we can say, "over the years I have cared for many women who live with abusive partners and their health can suffer because of that. Living with constant fear and stress can cause headaches, anxiety, etc." I have seen first hand in clinical practice how women's safety has been compromised by having "Domestic Violence" written in her chart. Screening does nothing to support women who do not feel safe to disclose nor is there any evidence that it improves women's safety and health. Increasing identification numbers is not a successful outcome in my opinion. As far a planting the seed? Again, I have heard numerous stories from women who avoid going to specific agencies because they know that screening takes place there. Women know the risks of telling well meaning but unprepared professionals. I agree wholeheartedly that women's groups need to be involved in deciding how the health care system can best respond. Thankyou for stirring up this long overdue debate! Nancy Hewer RN BScN
Screening for Domestic Violence: Let’s not throw the baby out with the bathwater! 28 August 2002
Lucia Beck Weiss, Assistant Instructor 19129, Mary O'Brien, Candace Robertson Send response to journal: Re: Screening for Domestic Violence: Let’s not throw the baby out with the bathwater!	This letter is written in response to the Ramsay et al., (2002) article addressing the issue of health care providers screening women for domestic violence. It is very clear that domestic violence is a major public health problem that affects a significant number of women, and yet Ramsey et al assert that insufficient evidence exists to show the effectiveness of interventions, and that DV screening by healthcare professionals is not justified. These conclusions are troubling in the face of such a pronounced public health priority. Physicians are charged with the responsibility of providing the type of medical care that will best benefit their patients. Physicians commonly screen patients for various illnesses such as heart disease, renal failure, and pulmonary disease, and often refer them for specialty care. In fact, the screening and referral model has been the long-standing standard of care in medical practice. Additionally, it is clear that the role of the physician in assessing health risks is crucial. We assert that the screening of domestic violence as a health risk is not any different from other risks that are routinely assessed.1 Physicians ask about sexual practices that may increase the risk of contracting HIV/AIDS. They also ask about smoking, alcohol consumption, and the use of illicit drugs. Patients who are screened may be advised about condom use or referred to cessation programs, Alcoholics Anonymous, or drug rehabilitation programs. These services and programs typically do not provide follow-up reports to the referring physician. Similarly, domestic violence - like the risky behaviors discussed above - involves behaviors that are not easily modified. However, the complexity of these behaviors does not negate the need for screening given the attributed health consequences. Physicians may be more reluctant to screen for DV than they are for other health risks due to their lack of training, unfamiliarity with available resources, discomfort in asking the questions, and follow-up potential. In addition, physicians may fear that asking questions about DV may open up a "Pandora's box" of issues the patient may be facing, for which the physician may not feel prepared to effectively address.2-3 However, these limitations should not suggest that screening be avoided; rather they dictate that medical students as well as physicians should be trained in proper DV assessment protocols and guidelines.4-8 Most importantly, health care professionals need to become familiar with the resources and services available in the community so that the burden of expertise does not fall on their shoulders. It is necessary to recognize that the primary intervention for DV in the health care setting involves screening patients and referring them to the appropriate resources. It is imperative that women are asked questions regarding their history and experience with intimate partner violence and that they are empowered to take action. While the expertise in counseling victims of abuse may lie outside of the medical arena, it is important to recognize the potential of physicians in addressing this major public health problem. We recognize that more work needs to be done in order to effectively measure “quality of life and mental health outcomes” as a result of domestic violence interventions. However, to dismiss and not recognize the benefits of increased referral to outside agencies as a positive outcome resulting from screening, undermines the efforts of countless health professionals and medical educators who have long recognized the crucial role of the physician as activating the "chain of survival." Lucia Beck Weiss, M.S. Assistant Instructor Drexel University, College of Medicine Mary O’Brien, Ph.D. Associate Professor Drexel University, School of Public Health Candace Robertson, MPH Research Associate Drexel University, College of Medicine, Philadelphia, PA 1.Gerbert B, Gansky S, Tang J, McPhee S, Carlton R, Herzig K, Danley D, Caspers N. Domestic Violence Compared to Other Health Risks: A Survey of Physicians' Beliefs and Behaviors. American Journal of Preventive Medicine. 2002;23(2):82-90. 2.McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside "Pandora's Box": Abused Women's Experiences with Clinicians and Health Services. Journal of General Internal Medicine. 1998;13(8):549-55. 3.Sugg NK, Inui T. Primary Care Physicians' Response to Domestic Violence. Opening Pandora's Box. JAMA. 1992;267(23):3157-60. 4.Kassebaum D, Anderson MB, Proceedings of the AAMC’s Consensus Conference on the Education of Medical Students about Family Violence and Abuse, Academic Medicine 1995; 70(11):961-1001. 5.Alpert, E. Violence in intimate relationships and the practicing internist: new disease or new agenda? Annals of Internal Medicine. 1995; 123 (10):774-781. 6.Varjavand N, Cohen D, Novack D. An Assessment of Residents' Abilities to Detect and Manage Domestic Violence. Journal of General Internal Medicine. 2002; 17:465-468. 7.Haase C, Short P, Chapman D, Dersch S. Domestic Violence Education in Medical School. Academic Emergency Medicine. 1999; 6(8):855-857. 8.McCaw B, Berman W, Syme S, Hunkeler E. Beyond Screening for Domestic Violence: A Systems Model Approach in a Managed Care Setting. American Journal of Preventive Medicine. 2001; 21(3):170-176.
Screening is absolutely essential in health care settings. 31 August 2002
Donna Cavalluzzi, CSW, Domestic Violence Coordinator Elmhurst Hps[ota; Cemter 11373 Send response to journal: Re: Screening is absolutely essential in health care settings.	The only way to intervention is identification. Due to the screening methods here we identify up to 60 patients a month who are or have experienced domestic violence. All of the women get counseled with safety planning, children are assessed for risk of abuse, and long-term counseling is offered. Our staff are trained in domestic violence. Women are educated about domestic violence, the legal and court systems, and what they can do to protect and help themselves with the backup of trained and sensitive personnel. Granted, screening will not help if the only interest is quantitative. So many women have been helped and freed from abusive relationships. It is our business as part of a community to help each other. Otherwise, the rate of domestic violence would be higher than it already is and we will only perpetuate the myth that "it's a family problem." Thank you.
A dissenting opinion, and a suggestion 31 August 2002
Teresa T. Goodell, Clinical Nurse Specialist Providence St.Vincent Medical Center, Portland, Oregon, USA 97225 Send response to journal: Re: A dissenting opinion, and a suggestion	I wholeheartedly disagree with Ramsay et al's conclusion that "most health professionals surveyed do not agree with screening of women [for domestic violence] in healthcare settings." The authors reviewed two studies of health care provider attitudes toward screening for domestic violence. In one of the studies, slightly over half of the sample of emergency department nurses agreed with routine screening. In the other, one-third of physicians agreed with screening. The reviewers' conclusions are at variance with these studies' findings, and no explanation for this discrepancy is offered, not even the obvious one: that two studies with disparate samples do not comprise adequate evidence on which to base a conclusion. Additionally, there is very little cost or risk in screening for domestic violence. Ramsay et al note that there is scant research on the possibly harmful effects of screening (although patients commonly support the idea), yet the authors fail to note that this lack of research should deter anyone from supporting their recommmendations against screening. Why cease a practice that costs little and poses little risk, especially one that has proven effective in identifying women at risk? The authors cite a lack of evidence for effective domestic violence interventions in support of their conclusion that "implementation of [domestic violence] screening programmes in healthcare settings cannot be justified." The dearth of controlled studies does not support the cessation of screening programs, but instead emphasizes the dismal state of research into this acute public health problem. With approximately 1/8 of the population suffering from some form of domestic violence, the lack of controlled trials of interventions for domestic violence is shameful. Finally, most interventions are aimed at the victim of domestic violence, not its root. (Ramsay et al mention counselling, advocacy and referral for victims.) But interventions aimed at the perpetrator (including legal action) and the cirumstances that sustain domestic violence may be the ultimate treatment for this health problem. Referral, advocacy and counselling merely treat the victim's physical & psychological wounds. If domestic violence were a pathophysiological process that afflicted one-eighth of the population, scientists, research centers and funding agencies would be clamoring to root out its cause and eliminate it. Reference: Ramsay et al, Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314 (10 August.)
NOT screening for Domestic Violence almost killed ME when I was living in Europe! 2 September 2002
Jane Dimer, Maternity-Child Clinical Service Chief for Group Health Cooperative Hospitals Seattle Washington USA 98112 Send response to journal: Re: NOT screening for Domestic Violence almost killed ME when I was living in Europe!	Screening for DV is not a part of health care in Germany either. 'Domestic Violence' does not really even translate into many languages and I found no appropriate words available in the German language either. While I was pregnant and living in Central Europe and working as a teaching faculty at the largest perinatal center in Berlin, I was severely beaten by my German-citizen spouse during both of my pregnancies. The economy was bad and my husband's family business was bankrupt but that was, in retrospect, no excuse for the violence directed at me. I was working full-time and was the family breadwinner. If I would have been reminded by my physician/boss/colleagues that 'there is no excuse for domestic violence' and if there was support from the legal and police authorities, my children could have been spared the last near-death experience before we escaped back to the USA!
It takes two to tango. 3 September 2002
Roger KA Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia Send response to journal: Re: It takes two to tango.	Dear Editor, In this enlightened age of equality of the sexes and affirmative action, I am amazed at the lack of recognition of the domestic violence by women towards men. Although often less physical than male violence, it may be just as pernicious, protracted and wearing on the recipient. The mental and physical health of the man may suffer terribly and will not usually manifest as obviously as for male violence. I have also seen knifings, blows by heavy objects and gun shots from women. Domestic violence by women putting men down day and night, unrealistic expectations, etc are still violent, abusive acts. The man often is just as trapped and helpless in society as a woman. Do all acts of domestic violence occur in a vacuum with a saintly spouse/partner and a crazy male? Why has he become violent? Often the role model imprinted on sons by mothers have much to do with this too. They treat boys differently. My daughter age 3 has an orange juice container with a smiling cute baby dinosaur on it while my five year old son has a boy's one with a Pokemon boy committing some act of violence with a gun or something. They come in six packs.Societal attitudes are at fault and include excessive materialism and the changing status of the father. Come off the grass. Get scientific and balanced in all this stuff. It takes two to tango. Start screening men too! Cheesed off male, Roger ALLEN
OBJECTION TO VIEW THAT DV SCREENING IS UNNECESSARY 4 September 2002
KATHY L. SHORE DEPT. OF HEALTH, OLYMPIA WA 98504-7852 Send response to journal: Re: OBJECTION TO VIEW THAT DV SCREENING IS UNNECESSARY	COMMENTS: I am a survivor of domestic violence. I have firsthand, real life experience on what it feels like to be a victim, to deal with the struggles of leaving a violent marriage and the challenge of trying to rebuild a life afterwards. While I can respect the viewpoints of "health professionals" I do not consider them to be "experts" on what it means to be a victim of domestic violence. If you haven't walked in someone else's shoes, you do not know. There is a big difference between clinical expertise and personal experience. Just like being the doctor who treats cancer is a totally different perspective than being a cancer patient. I also don't consider them able to determine whether "intervention" is "effective" or not. How would they know? Do they keep tabs on every single patient they see to determine whether they have left their abusive spouses or not? I highly doubt it. Domestic violence is a CRIME. Let's treat it as such! I believe it is extremely important to not only screen - and to ask the questions - but to report DV whenever a physician has strong reason to believe it is happening. A physician's screening, intake and notes could conceivably HELP the woman in court should she ever have to press charges against the abuser. You never know when some simple thing you might say can "plant a seed," so to speak, in the mind of a victim. Even if she does not disclose much about the abuse at the time of the appointment - even if she does not leave an abuser immeidately after the doctor appointment - it does not mean that she will not think about what has been said - or that she will not leave him eventually. A trusted health professional can do much to educate, to provide resources, and to steer victims in the direction of advocates and other social services in the community. I believe it is their RESPONSIBILITY to do so! On the average, victims try to leave their abusive spouses seven times before they are often finally successful in doing so. The fact that they have such a hard time doing so usually relates to simple economics, fear of being killed if they do leave, and a legal system that discriminates and does not adequately protect them. They may have children in tow and no place to go. If they tried leaving before, chances are, their partner "punished" them for trying to leave and beat them worse. Domestic violence shelters are turning women away due to lack of resources. Although things are improving, they aren't improving fast enough. It takes an enormous amount of courage to face these kinds of challenges. If every person in the community were committed to ending violence - and if the police departments, health professionals, and politicians together created a coordinated systems delivery to deal with this problem head on, I believe domestic violence could be greatly reduced. But as long as professionals think they should "get off the hook" women are going to die. DV screening may not eradicate the problem, nor is it the only tool to determine where violence is occurring, but it could potentially do much to help. Let's not turn a blind eye when someone is in trouble. I am a living example of people who cared. There were friends, advocates, neighbors who made my problems "their" business. They did everything in their power to help me. They confronted me about the danger I was in. They listened to me and validated me. They helped me move. They held my hand in court. They gave me food, money, whatever they had when I was desperate, and they assured me that the domestic violence was not my fault. I owe my life and the safety of my family to those people who "stuck their neck out." Don't ever say that that isn't "effective." You don't know until you have been there. Professionals need to imagine that the desperate woman on the other side of the table could be their sister, their daughter, their best friend, someone they love.
Screening women for domestic violence 6 September 2002
Kate Mulley, Policy Manager Victim Support Send response to journal: Re: Screening women for domestic violence	As policy manager at Victim Support, the national charity for people affected by crime, I found Ramsey at al’s article ‘Should health professionals screen women for domestic violence’ interesting if somewhat disheartening. Ramsey et al’s study argues that while the screening of women by health professionals increases the identification of domestic violence, as well as referral to outside agencies: “the implementation of screening programmes in healthcare settings is not justified by the current evidence.” The primary reason given is the lack of evidence for the effectiveness of interventions. The study does not regard rates of referral to outside agencies as a convincing proxy. Yet, as the paper acknowledges, domestic violence is a complex issue and, as such, it requires complex solutions with outcomes that are unlikely to be readily measured and assessed. The authors have approached the subject from a medical perspective, so understandably they are looking for direct health impacts. Arguably, however, they are looking in the wrong place. The social impact of health interventions in domestic violence is not necessarily to be defined by a narrow medical outcome, it needs to be looked at from a wider perspective. Agencies working with victims of domestic violence aim to provide options, enabling women to make informed choices. Positive outcomes will vary depending on the needs and circumstances of the individual concerned. One of the reasons why health professions appear not be in favour of screening may be because they feel ill equipped to use this information. Yet with under half of all crime reported to the police, crime victims are more likely to contact health workers than any other professional. While the paper recognises domestic violence as a major healthcare issue, it appears to dismiss the importance of increased referral to other sources of support as a legitimate outcome in its own right. It ends with a list of questions for future research, including how can we promote better multi-agency working? I would suggest that one way is for health professionals to recognise their responsibility as gatekeepers. They are likely to meet those individuals whom nobody else sees and in so doing they have a unique opportunity to provide access to help. The importance of this role should not be underestimated.
the gender bias in DV research goes on 6 September 2002
Chris Carlsten, resident, internal medicine university of washington, seattle wa usa Send response to journal: Re: the gender bias in DV research goes on	I can only repeat (cut and paste) what I said to the BMJ recently (the exact same point applies; I continue to find the authors 'choice to focus on men-versus-women DV exclusively' [this is a paraphrase of their response to my letter, below] to be highly irresponsible. There are very severe repercussions of such a choice, which perpetuates literature bias and consequent unbalanced sociologic, media-related and mass cultural perception of this important issue. The victims are thereby all of us who seek a balanced, equitable presentation of this issue) The following is from BMJ 2002;325:44 ( 6 July ) Literature is biased as studies rarely look at female-to-male violence Several papers in the BMJ have looked at domestic violence. 1 2 3 Although this problem has been well documented, in the movement to expose it properly there is a gender bias that, ironically, betrays the underlying concern with gender equality. The language of domestic violence reporting often makes a bold assumption by speaking exclusively of violence by men against women. The title of Richardson et al's paper is misleading.2 It implies that they are reporting a cross sectional study, but what the authors actually looked at was 50% of the populationnamely, women. The title of Jewkes's editorial is gender neutral, yet the subtitle shows the exclusion, lamenting that women are not consistently asked about the possibility of domestic violence. This is not necessarily more misleading than the early studies of coronary artery disease, which were presumed to be inclusive though in fact studied only men. The justification for this slant in the domestic violence literature has been that female victims vastly outnumber male victims. Many data, however, suggest otherwise. Cascardi et al found that 86% of marital aggression was reported as reciprocal between husbands and wives.4 Schafer et al reported lower and upper bounds on intimate partner violence of 5.21% and 13.61% for male-to-female partner violence and 6.22% and 18.21% for female-to-male partner violence.5 Interestingly, female-to-male violence was reported to be higher than male-to-female. These data force a recognition that female-to-male violence must be included in any discussion. Bradley et al note that "there is generally no universally agreed method of defining and measuring domestic violence."1 A simple first step would be for the authors to recognise that, regardless of the precise percentages, this is a bi-directional, bi-gender issue. The authors lament that women are inconsistently asked about domestic violence, but they ignore the even greater lack of inquiry into men's potential victim status. This reporting bias may partly explain the disparity in the limited literature that attempts to include data on bi- directional violence. None of the three articles in the BMJ even allude to female-to-male domestic violence. This reflects a literature bias that will undoubtedly influence future work. Such bias ignores many thousands of male victims and alienates those who demand a more balanced presentation. Let's keep working to get better data, but let's recognise the bi- gender nature of this societal ill. That way, all of us can become involved in research, advocacy, and teaching and be part of the solution. In other words, "it is now time for the medical establishment to embrace the issue of gender."3 Chris Carlsten, resident in internal medicine. Department of Medicine, Box 356421, University of Washington, Seattle, WA 98195, USA --------------------------------------------------------------------- ----------- 1. Bradley F, Smith M, Long J, O'Dowd T. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002; 324: 271-274[Abstract/Full Text]. (2 February.) 2. Richardson J, Coid J, Petruckevitch A, Wai SC, Moorey S, Feder G. Identifying domestic violence: cross-sectional study in primary care. BMJ 2002; 324: 274-277[Abstract/Full Text]. (2 February.) 3. Jewkes R. Preventing domestic violence. BMJ 2002; 324: 253-254[Full Text]. (2 February.) 4. Cascardi M, Langhinrichsen J, Vivian D. Marital aggression. Impact, injury, and health correlates for husbands and wives. Arch Intern Med 1992; 152: 1178-1184[Medline]. 5. Schafer J, Caetano R, Clark CL. Rates of intimate partner violence in the United States. Am J Public Health 1998; 88: 1702-1704[Abstract].
Bring back the ducking stool. 7 September 2002
Roger KA Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia Send response to journal: Re: Bring back the ducking stool.	Dear Editor, I have noticed that nearly all the respondents to this section have been women (as well as a few men in touch with their Jungian female persona). As one of the latter, the sensitive rare variety of Homo domesticus feminatus, and as a sleep physician (Homo hypnos)who listens to both sexes all day talking about their sleep or lack thereof, I would like to expand my previous "two bob's worth" to this rubrique (an old Oz term of my generation meaning 20 cents worth or 2 shillings' worth to be more 'Imperial'). I also have read the above personal accounts to Rapid Responses by women who had misguidedly fallen in love with physically abusive Homo violens non-sapiens (why had they been such poor judges of these DNA doners?). I shall not indulge the readers with an account of my previous private life on the Internet, but suffice to say that domestic violence does not have to be just physical. Incessant verbal abuse is violent and unacceptible in the work place and in the street. Why not at home?? If the SAS tortured a prisoner without even touching him (or her, heaven forbid), would that not be violent, abusive behaviour? There are countless disturbed women out there with poor domestic role models from their childhood, all sorts of personality disorders including borderlines, usually sexually abused as children by everyone from nuns to fathers, 'dépressives' as the French call them, etc etc. To use an Australianism; female fruit-cakes. My wife sees them all day. Need I go on? Women can 'do the dirty' on men and they usually end up with the house and the kids regardless.A famous Australian personality recently said,' All my three wives were housekeepers.....they all kept the house!' Until we redefine domestic violence in a broader and more scientific sense, this discussion will remain a sexually biassed male-bashing diatribe. I fully appreciate the awfulness of any form of domestic violence and the effect on all parties involved, including grandparents, the silent sufferers. Boys and men are becoming increasingly marginalised both in education here by the feminisation of the system by the androphobis do-gooder political Amazons, and of the court system, especially the Family Court, which is loaded against the ex-male-beloved and ex-father. Most primary school teachers are now female and the good male role model is in short supply. Men won't become school teachers or Boy Scout Masters for fear of paedophilic accusations. In Australia, after five years of spousal separation, about 60% of men have no further contact with their children despite their desires to the contrary in many cases. Women frequently use their children as domestic missiles or nail bombs directed at the father; yet another form of subtle but equally destructive domestic violence. As an aside, I stay home one day each week to look after our preschool daughter and then pick up the other children after school while my wife goes to work as a psychiatrist once a week. If only such work flexibility were available to most parents and especially fathers, I think domestic satisfaction would improve and violence by both parties would decline. This problem has been around for a long time. I saw a photo of the mummy (not his mother) of a pharoah on the weekend in a book I was reading on the Egyptians. He had died of two large axe blows to his upper face and frontal lobes, supposedly inflicted by the Hixxos.I suspect that his wife really did it when he said he was going away for the weekend to fight them. May I suggest we bring back the scold and the ducking stool to cool off the debate. Yours sincerely, Still cheesed off male and genuine good bloke, Roger Allen Potential conflict of interest: This has not been passed by the 'Board of Control', 'She who must be obeyed'also affectionately named, 'the Fat Controller' while on the bathroom scales.
The taming of the shrew..... and the definition of violence. 7 September 2002
Roger K.A. Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia Send response to journal: Re: The taming of the shrew..... and the definition of violence.	Dear Editor, while not suggesting we bring back the scold and the ducking stool, I am heartened to read for the first time a balanced approach to domestic violence and one giving support to my opinion. As the majority of the respondents to this topic have been women (how I detest the term, "male" and "female", for they are people not sexes), their bias from personal experiences already revealed by some adds little. Were they above reproach? How many men who have been recipients of years of domestic violence have written to this section? It is not the nature of a man to seek refuge in others apart from in the bottle of in the anonymous company of the pub? About one quarter of women and an unknown number of boys have been sexually abused in this country before they are adults (a). As a result, psychiatric illness often manifests in some form or other in later adult life (eg borderline personality disorders, sexual problems, depression, anxiety, lack of trust, inability to develop intimate relationships, abuse of children verbally if not physically, eating disorders etc etc.) It should be clear to see that a significant proportion of woman have serious psychosocial problems that manifest in marriage and such male-female relationships. It is also common, by the way, for socially "powerful" male doctor to be attracted to the initially intimate, very attractive borderline woman. I could write a book on it. Therefore our profession is not above all this either i.e. DV…. but who identifies it. Quis custodies custodiet? …Who guards the guards? Our definition of violence in the home seems curiously limited to "physical"...not a mention of "verbal" and "psychological". The withdrawal of intimacy and passive aggressive behaviour is also "violating" in my opinion. Men (and their children) become depressed, withdrawn, and desperate and may develop serious psychosomatic as well as psychiatric disorders, and substance abuse and in turn become physically abusive. The lack of peer support structures aided and abetted by the taciturn male ethos is a lethal combination. In conclusion, there are a lot of long-suffering men out there who daily suffer in abusive relationships, where the violence to their psyche may be just and destructive and a bashing, knifing or a gun shot. Unless this sexually stereotyped approach to domestic violence matures, the prevention and identification of DV will remain "stuck" just like the term "nurse". I do not believe that a personal testimony is needed to validate this opinion. But why do so many women marry violent men and so many men marry verbally abusive and disturbed women? I have not outlined mental illness in men but we all know that the misssing junk on the Y chromosome has left the male in a weakened state. O what fools these mortals be... Yours sincerely, Roger Allen
Justifiable homicide and lambs' fry and bacon. 9 September 2002
Roger KA Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia Send response to journal: Re: Justifiable homicide and lambs' fry and bacon.	Dear Editor, In my rush to gulp down my lambs fry and bacon, and go to work, I have committed another violent act towards my lingua franca (not French),viz, "homocide" instead of "homicide". This is partially Freudian and also because of my use of the word "Homo" in my thesis and should not be seen by American or female critics as latent or repressed homosexuality. The word "homo" means "same" (Latin adj) and should not be confused with "homo" (Latin, noun for "man"). Unfortunately our lingua mater has no word yet for "killing women". Hence my use of the word "homicide". With sincere apologies, Roger K A ALLEN P.S. I prefer living dangerously and with verbal spontaneity without the "safe sex" of "Spell Check" and other literary prophylactics. I suppose "lambs" could be followed by an apostophe or is it "lambsfry" a compound Anglosaxon or German noun.
problematic Definitions of 'DV Screening' 10 September 2002
Wendy B Bateman, Doctoral Student The University of Manchester, Oxford Road, Greater Manchester, England. Send response to journal: Re: problematic Definitions of 'DV Screening'	Dear Editor, As a doctoral student in criminology & social policy, plus an ex nurse - might I highlight a common problem with multi agency definitions, which invariably, reflect our way of thought. 'Screening' to social scientists is not only to produce vast amounts of quantifiable data, but used as a method of identification. Therefore, it does not resemble the ethos of health care specialists who screen with the intention of 'curing all ills' or as with an A&E department who 'treat them & street them'. Therefore, to try and encompase lengthy questionnaires in the expectation of making the patient better is unobtainable in reality outside of quantitative analysis. For example, in the City of Salford, Public Health Officer/Domestic Violence Coordinator & research academic staff are raising domestic abuse awareness throughout health, education, legal professions & social agencies. Bringing together the broader concepts of 'family dynamics' as a city wide programme in the hope of each agency being enabled to provide appropriate information or instigate and effective referal. However, creating a coordinated multi agency response has its limitations. Primarily, the limitations have been identified as agency 'definition' & agency 'expectation'. Resulting in inapropriate barriers to an effective response. Previous Research conducted in order to obtain attitudes towards mandatory domestic abuse screening/questioning in a health care setting was identifed as an acceptable practice by male or female patients attending their general practitioner, midwife, health visitor & A& E dept etc. For example, pre hospital care professionals (paramedics) and an A&E department triage nurse could ask two brief initial identification questions, a third response would be a clinical opinion, encompassed under the rubric of social or safety. Tick boxes to record patient response: confirms, denies, past, present & yes or no to clinical opinion. The first question could be phrased: 1)Has anyone ever made you feel unsafe within a personal relationship 2) Has anyone ever hurt you in a personal relationship 3)(clinical opinion) is injury consistent with mechanism. This process could result in the provision of appropriate information being given to the patient. I.E. 'Credit card' sized data, encompassing local helpline numbers - CAB, Victim Support, Housing, Benefits, Police DVO, DV male & female contacts etc. Or if the patient wishes to discuss or disclose information then staff should also know how to document patient disclosures in order to support a legal case that may take years to appear before the courts. The latter intervention should be conducted by, perhaps a DV advocate within the department or a nurse trained in DV issues, in order to create an appropriate safe environment. Therefore, health care professionals should not feel the need to 'cure' the patient, but learn to accept the cycle of violence & limitations of their intervention. Thus, empowering the patient to make an informed choice when he/she is ready & finds it safe to do so. Furthermore, considering domestic violence is an important public health problem with muliple health effects including serious injury, long standing health problems; psychological difficulties etc. and problems for children as well as the vulnerable parent. Cost implecations should also be considered. Domestic abuse is extremely costly in health resources considering facts such as - frequent presentations for medical services either in an A&E dept or at their GPs surgery with non related symptoms. Finally, UK health policy has developed over the past few years to raise the profile of domestic violence, to advocate education and training for health care professionals and to encourage the development of local policies. Unfortunately, too little has been accomplished and not enough has been evaluated. There is an urgent need for implementing training and education initiatives to enable professionals to identfy and support victims of domestic abuse, and for a substantive research programme to evaluate health service interventiions to reduce the impact of domestic violence. The lack of comprehensive evidence on how the health service could effectively reduce the impact of domestic violence should not be an excuse for lack of action on what we know is a major cause of difficulty in the lives of men, women & children.
"Screening' for domestic violence is necessary but not sufficient 10 September 2002
Angela J Taft, Research Fellow Centre for the Study of Mothers' and Children's Health, La Trobe University, Carlton, Victoria 3053, Kelsey Hegarty Send response to journal: Re: "Screening' for domestic violence is necessary but not sufficient	Dear Editor Webster and Creedy argue that screening has “improved diagnosis and the provision of health services and information to women who experience domestic violence”.[1] The Queensland domestic violence initiative found a very high acceptability of screening, although of the 6.5% of women disclosing abuse, only 10% accepted help. A recent case-control study [2] of acceptability of screening to women demonstrated complex differences in attitudes depending on the question and only 54% of abused and 48% of non- abused women supporting routine screening. Further, there have been no studies to date discriminating between those who disclose current and those who disclose past abuse. Acceptability about being asked a particular question is not the same as saying one is accepting of or confident about the follow up response. There is some evidence that brief interventions in the antenatal setting can increase abused women’s safety seeking behaviour which is important in light of the new finding that women abused in pregnancy are three times more likely to become an attempted or completed femicide victim.[3] However, Davidson and colleagues recently conducted a systematic review of the evidence for which domestic violence interventions work in health systems, in the context of possible screening policies.[4] They concluded there have been no systematic evaluations and therefore there are serious limitations about what could be achieved in the current UK health care setting. They noted the challenges of staff time and workload, lack of sustainable or any staff training, lack of privacy for women and the problems when partners are present. Their recommendations included further evaluation and improved provision for confidentiality, privacy, time, links to child protection and weekend provision of support for victims who disclose, prior to any major policy shifts. We agree. Routine inquiry in health care settings is a critical goal, but currently there have been no studies of the longer-term outcomes for women of routine inquiry and disclosure to health providers, with some evidence of negative outcomes for women disclosing to general practitioners. In addition, limited evaluation of health provider training indicates that significant problems remain including negative health provider attitudes.[5] So that we do no harm, prior to routine inquiry or 'screening' being implemented there needs to be a sensitive, safe and effective health system in place. The imperative is with the health system to provide and rigorously evaluate (FROM VICTIM/SURVIVOR LONG TERM PERSPECTIVES) sustainable training and then implement routine inquiry, not before. Angela Taft, Research Fellow, Centre for the Study of Mothers’ and Children’s Health, La Trobe University, 251 Faraday Street, Carlton, Victoria 3053, Australia. Email: a.taft@latrobe.edu.au Kelsey Hegarty, Senior Lecturer, Department of General Practice, University of Melbourne, Australia 1. Webster J, Creedy DK. Screening can be made acceptable to women (letter). BMJ 2002. 325(7354): 44. 2. Gielen AC, O'Campo PJ, Campbell JC, et al. Women's Opinions About Domestic Violence Screening and Mandatory Reporting. Am J Prev Med 2000. 19(4): 279-285. 3. McFarlane J, Campbell JC, Sharps P, Watson K. Abuse During Pregnancy and Femicide: Urgent Implications for Women's Health. Obstet Gynecol 2002. 100(1): 27-36. 4. Davidson L, King V, Garcia J, Marchant S. Reducing Domestic Violence...What Works? Health Services. 2000; Home Office: London. 5. Taft A. Violence in pregnancy and after childbirth. 2002; Issues Paper No.6. Australian Domestic and Family Violence Clearinghouse: University of New South Wales. Sydney. http://www.austdvclearinghouse.unsw.edu.au/PDF%20files/Issuespaper6.pdf
A Different Perspective on Screening Women for Domestic Violence 11 September 2002
Robert K. Gribble, Medical Director - Quality Improvement Marshfield Clinic; 1000 N. Oak Ave.; Marshfield, WI 54449; USA Send response to journal: Re: A Different Perspective on Screening Women for Domestic Violence	I would like to propose a different perspective on two of the UK National Screen Committee's criteria for a screening programme as it relates to domestic violence screening. These two criteria, acceptability of the screening program to health professionals and an effective treatment or intervention for the problem, were used to justify the conclusion that domestic violence screening for women in a healthcare setting, "cannot be justified." The fact that most physicians and half of emergency department nurses were not in favor of screening may be more reflective of the need for provider education than a reason to abandon screening. Providers may feel screening is not appropriate if they do not know how to correctly and expeditiously screen patients or how to refer patients who ask for help as a result of screening. Certainly a great deal of effort has gone into educating providers in this area and one wonders if the statement about physician acceptance, which is based on a single, 10-year old study of 33 physicians, would be true today. Regarding the value of interventions for women who are identified by screening as a victim or domestic violence, the authors correctly conclude that there is insufficient evidence to demonstrate effective interventions. However, the level of evidence is also insufficient to conclude that interventions are ineffective. In other words, the research to date has left us with the dilemma of knowing that screening can identify victims of domestic violence but not whether that identification results in better outcomes. We can all hope that future research will resolve this dilemma but in the meantime, we have to choose: Do we err on the side of screening and risk discovering at some future date that this effort was wasted or even harmful? Or do we err on the side of not screening and then discover that our patients were harmed by that choice. My opinion is that the professionals in our domestic violence agencies are sufficiently experienced and skilled that we should give them the benefit of the doubt and take action to identify and refer these women through routine domestic violence screening. One might invoke the "first do no harm" rule to justify the conclusion that unless we know for certain that an action will not harm the patient, we should defer that action. I would propose that one could make the same argument about inaction and its potential to "harm" the patient. It is unfortunate that there are so many areas like this in medicine where there is insufficient evidence to know which is the correct thing to do - but healthcare professionals need to make those hard choices and not arbitrarily default to the "no action" option.
Domestic violence: General Practitioners may have a key role 17 September 2002
Andrew S Furber, Specialist Registrar in Public Health Eastern Wakefield Primary Care Trust, Castleford, WF10 5LT, Hilary Spencer and Rachel Loise Send response to journal: Re: Domestic violence: General Practitioners may have a key role	Ramsay et al conclude that screening women for domestic violence in health care settings is not justified (1). These findings are not surprising as screening as an approach to resolving domestic violence is flawed in both theoretical and practical terms; it does not meet accepted criteria for screening (2,3) nor is such a simplistic biomedical approach suitable for a complex social problem. However doing nothing in health care settings is also not an option. Support and Survival has been working in the Wakefield area since 1995 and is developing innovative ways of addressing this issue, latterly through General Practitioners (GPs) and other health professionals (4). Most women attending health care facilities, as Ramsey et al have shown, find enquiry into possible domestic violence acceptable. This understates the experience of Support and Survival. Enquiry by GPs and other health professionals into domestic violence has brought immense relief to women suffering from its effects, and has helped GPs to understand previously unexplained presentations. The particular nature of the doctor patient relationship may well be a key issue for primary care teams wishing to intervene effectively for their patients. Developing skills in addressing domestic violence should certainly be on the curriculum for all GP Registrars. More research is certainly required. Much of the work funded by the British government’s Home Office whilst making a valuable contribution, has been small scale and short term. We need to know the value of a range of interventions; the current evidence base is inadequate. Longer term outcomes are crucial for those who have suffered domestic violence and future research needs to address this area. Consideration also needs to be given to the wider impact on the health, well being and social inclusion not only of survivors of domestic violence, but also their children and other family members. Women from ethnic minorities and other marginalised groups face even greater difficulties in seeking help, and yet little research has identified these women as a priority. The lack of evidence identified by Ramsay et al should be a wake up call to address these issues as a matter of urgency. Yours faithfully, Andrew S Furber Specialist Registrar in Public Health Medicine Eastern Wakefield Primary Care Trust andrew.furber@ewpct.nhs.uk Hiliary Spencer Primary Care Link Worker Eastern Wakefield Primary Care Trust Rachel Loise Project Coordinator Support and Survival Health Initiative, Wakefield References 1. Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314-318 (10 August) 2. Wilson JMG, Jungner G. Principles and practice of screening for disease. WHO Public Health Paper 34. Geneva: World Health Organisation, 1968. 3. UK National Screening Committee. The criteria for appraising the viability, effectiveness and appropriateness of a screening programme. London: UK National Screening Committee. Available from http://www.nsc.nhs.uk/pdfs/criteria.pdf Accessed 6/9/02. 4. Harris V, Loise R, Spencer H, Cox H. Domestic abuse screening pilot in primary care 2000-2002 Final Report. Wakefield, UK: Support and Survival, 2002. Unpublished report.
Screening for Domestic Violence: Where Do We Go From Here? 24 September 2002
Mary M Goodwin, Epidemiologist, CDC Atlanta Centers for Disease Control and Prevention, Atlanta, GA 30341 USA, Ileana Arias, Patricia Dietz, Linda E. Saltzman, Alison M. Spitz Send response to journal: Re: Screening for Domestic Violence: Where Do We Go From Here?	We agree with the conclusions of Ramsay and colleagues that insufficient evidence exists to justify routine screening for violence in health care settings. The finding, however, appears to contradict recommendations of numerous professional health care organizations and associations in the United States that currently urge health care professionals to screen routinely. In reality, this kind of contradiction is not uncommon in prevention and intervention research. A recently published summary of the evidence on breast cancer screening commissioned by the U.S. Preventive Services Task Force cites concerns over whether the benefits of routine mammography—a widely implemented screening tool—outweigh the potential harms, particularly for younger women. Similarly, routine screening for prostate cancer has become commonplace, despite a lack of data on efficacy of screening and, further, concerns regarding potential harm due to the detection and subsequent treatment of identified prostate cancers while the natural history of the illness and risks and benefits of available treatments remain undefined. Compared with these two widely recommended and used types of medical screening, it is evident that we are on far shakier ground in terms of an evidence base to support routine screening for violence in health care settings. Ramsay and colleagues acknowledge that their assessment of a lack of justifiable evidence is based on studies that do not include a single randomized controlled trial. Recognizing the need for such studies, the Centers for Disease Control and Prevention (CDC) recently funded a randomized controlled trial to test screening for violence and intervention in primary care settings. Outcome variables of this study include the kinds of questions we must answer in order to evaluate the effectiveness of screening: If a woman discloses to a health care provider and is offered services, does she use them? Does her risk for violence decrease? Although this project represents a step in the right direction, other researchers and funders of research must design and support additional studies, because no single trial will provide all the answers we seek. The question of screening for violence is complex and demands an interdisciplinary, community-based approach. As such, evaluation research will require complicated and expensive methodologies, and we will need numerous rigorous studies in diverse clinical settings to gather a preponderance of evidence. Meanwhile, recommendations in support of routine screening will likely remain, and screening for violence will continue. In fact, in some health care settings, screening may have gained more widespread acceptance than the Ramsay study indicates. A recent CDC survey of publicly funded family planning providers in the United States reported that among 600 clinicians (90% female and 75% nurses), 30% reported that they personally conduct verbal screening for violence every time they see a new patient and an additional 40% who did not screen for violence themselves reported that another staff person in the clinic conducts routine verbal screens with her patients (Centers for Disease Control and Prevention, unpublished data, 2002). Although screening levels of this magnitude are not likely to become widespread so long as the lack of an evidence base persists, we should take a balanced approach toward the future. On one hand, health care officials and providers who think they have adequate and appropriate screening and referral systems in place should continue their work. On the other, we must acknowledge and affirm the choices of institutions and individuals not to institute routine screening in the absence of scientific evidence. Regardless of the approach taken, health care providers must know how to respond to a disclosure of family or intimate partner violence, whether that disclosure is elicited through routine screening or spontaneously given to the provider. Even as we work to evaluate the effectiveness of screening and interventions for violence, we must continue to promote the need for health care institutions to have policies and procedures in place and for health care providers to receive adequate training. ----------------------- Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314. Humphrey LL, Hefland M, Chan BKS, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Med 2002;137:347. Neal DE, Donovan JL. Prostate cancer: to screen or not to screen? The Lancet 2000;1:17-24.
Routine Questioning – part of a whole health intervention: 4 October 2002
Judy Watson, Equalities Officer, London Borough of Camden London Borough of Camden, Equalities Unit, Town Hall, Judd Street, London WC1H 9JE, Monica Tuohy, Binah Taylor, Judith Rodgers, Diane Egan Send response to journal: Re: Routine Questioning – part of a whole health intervention:	Andrew Furber et al(1), in response to the Ramsay et al(2) article on screening of domestic violence, highlight the flaws in addressing domestic violence within a screening “biomedical” framework rather than part of a holistic multi-agency project. I would agree with him and, as Bradley et al(3)stated, “it is inappropriate to view (routine) questioning as screening”. We have been involved in developing domestic violence health interventions and routine questioning since 1997 in U.K. and have found long term multi-agency programmes as the way to sustain involvement of health professionals in this complex problem. Many responses in this debate have indicated an increased identification of domestic violence cases through routinely asking women in differing health settings. In Camden(4), we also identified more women facing both past and current domestic violence through introducing routine questioning by health professionals, following training and with referral systems in place. The Camden study identified 5.2% of women facing physical abuse by a current partner during the past 12 months in a three-month study – 28 women compared with only one identified in the prior year. Of these women 25% accepted support information or referral. Between 6 and 17% of women were identified within an A&E department, with 50% accepting information. 4% of women identified in a Well Women Clinic, with 44% accepting support information. Although in each study it was felt that there was insufficient evidence to recommend the introduction of a screening protocol at present, we did conclude that consideration should be given to incorporating a single question on current abuse within routine history taking and also on acute physical trauma, as well as mainstreamed training for health professionals and provision of interagency information in community languages and referrals. A survey of 200 women within A&E in Camden also found that 76% of women were comfortable about being asked about domestic violence and 60% thought they should always or usually be asked (38% thought they should seldom be asked and 2% never). The report concluded that even though there may be reservations in universal asking, it would seem acceptable to ask routinely within the context of the presenting complaint, e.g. injuries. The three-year Camden study, however, did not provide for the mainstreaming of this routine questioning following the pilot study and few practitioners sustained this intervention. But we did begin to work with a health advocate, from Women’s Aid, who over two, of the three years of the project, responded to 137 women referred from within the health service – 68 from hospital staff in the interventions sites; 37 self referrals, from information provided in the intervention sites; 14 primary care staff and 18 from other sources. Referrals were for refuge provision; housing; solicitor; counselling; social services and police support. Since then ,with the development of Home Office funding, Camden Safety Net, a new multi-agency project, has trained over 150 primary health care staff in DV awareness, and are planning a small pilot of routine questioning within primary care, with the direct provision of an advocate. Work within another area of London, Waltham Forest and Redbridge(5), has created a different health model – one which at the onset aimed at building in mainstreaming routine questioning and developed a whole multi- agency health project providing a range of specialist support, ranging from counselling, support groups and confidence building for the survivors, through to counselling and self-help groups for the perpetrators as well as access to legal, housing immigration and other support services. The initiation is from within the health service. Following a pilot study of introducing routine questioning, with linked training, by community midwives and health visitors, it has taken a year to ensure that all these staff continue to question and refer on to services. Now 77% of women are asked about domestic violence routinely as part of their history taking by all midwives. Support information, e.g. leaflets, posters and flyers are distributed to all patients and widely displayed within the community and hospital settings, and more recently a website has been set up. In two years of the project over 500 health professionals have been trained – the majority in general awareness, including 50 GPs, alongside the specialist routine questioning training. Staff have also been trained to become trainers and counsellors trained in domestic violence. Since March 2001, the health project as a whole has referred 110 survivors and 20 perpetrators to the support services. The majority of these referrals had no previous support from any other services and had come forward for help through the health project. Any questioning about domestic violence therefore needs to be part of a whole package – its aim is not to “treat” domestic violence but to start a cultural shift within the health service, to develop ways of working that are responsive, appropriate and address the complexity of the issue, empowering women to make choices and to take up services for longer term solutions. I welcome the continued research into the most effective methods of the health service identifying and supporting survivors but urge