Domestic violence: Don't forget to ask

Violence against women, most often in the form of intimate partner violence, is all too common in the United States. Among the intimate partners women are likely to become victims of are current or former boyfriends, girlfriends, or spouses. The violence may take the form of homicide, rape, sexual assault, robbery, aggravated assault, or simple assault. And the statistics are quite grim: In the average American woman's lifetime, she faces a one in four chance of being victimized by an intimate partner, while the prevalence of any kind of violence involving women is as high as 50%.^1,2

This perpetration of violence crosses racial, ethnic, religious, educational, age, and socioeconomic lines and causes immense health and social problems for our patients. As obstetrician/gynecologists, we're in a unique position to identify women in abusive situations, to treat the medical consequences of violence, and to work to end the self-perpetuating cycle of abuse. Yet far too many physicians shy away from addressing this issue. The reasons are varied and can include:
1. denial that the problem exists in your patient population,
2. not knowing how to identify abuse victims, and
3. the fear that any attempt to intervene won't make a significant difference.

Our purpose here is to show clinicians that they can make a difference. We will quantify the extent of the problem, explain its specific health consequences, and present effective ways to screen and assist affected patients.

Pregnancy is a particularly vulnerable time for women, and by some estimates, as many as 20% of women experience violence during gestation.³ While all women are at risk for intimate partner violence, women between 16 and 24 years have the highest per capita risk (19.6 per 1,000 women). In fact, homicide is the second leading cause of death in this age group and the sixth cause of death in women aged 25 to 44; pregnancy-associated deaths reflect these dismal statistics.⁴ In several studies from the 1980s through late 1990s, the rate of pregnancy-associated violent deaths ranged from 13% to 26%.^5-8

A study focusing on the prevalence of physical and sexual violence in pregnant and nonpregnant women presenting for urgent obstetric or gynecologic care found 46% of women reported a history of past abuse and 10% noted current abuse.⁹ And although most women come into contact with the health-care system at some point in their lives, partner violence remains a barrier to health-care access. For example, one study found that one of every 20 patients reported their partner prevented her from seeking or interfered with health care.¹⁰ Further, 17% of women with physical abuse in the previous year reported that a partner interfered with their health care, compared to 2% of women without abuse. Risk factors for partner interference included having less than a high school education, being born outside the United States, and visiting the clinic with a man attending.¹⁰

Few studies have examined the prevalence of violence against women with gynecologic malignancies or associations of violence with cancer, although a recent study of women with breast, cervical, endometrial, or ovarian cancer found that the prevalence of a history of violence was 48.5%.¹¹ In those women with a history of violence, half had suffered abuse in childhood, three-quarters suffered abuse as an adult, and half had suffered sexual violence. For gynecologic oncologists, this high prevalence has multiple repercussions. Women with a history of violence more often have advanced cancers and may lack the social support to be compliant with cancer treatment. Women with gynecologic malignancies tend to be older and may also be at risk for elder abuse.

One 1998 study reported by the National Center for Elder Abuse estimated that approximately 450,000 older individuals in domestic settings are neglected or abused each year in the US.¹² This may manifest in malnutrition, inability to obtain prescription drugs, or as failure to thrive.