Broaching topics patients may not want to talk about

Ethics Forum. April 5, 2004.

Scenario: How can you encourage a patient to discuss domestic violence?

Internist Dr. Warren, who has had both Mr. and Mrs. Doane as patients for three years, suspects that Mrs. Doane is being physically abused and has tried to get her to talk about her home life. He has offered her pamphlets with hotline numbers and information about health and legal resources for domestic violence. Mrs. Doane has never admitted she is being abused and refuses to answer Dr. Warren's direct questions. She leaves the pamphlets in the exam room.

Reply:

Increasingly, health care professionals are expected to regularly and competently screen patients for violence in intimate relationships. Studies have found that women in abusive relationships use more health care services and will often access the health care system multiple times before the abuse is detected. Consequently, health care professionals are in a unique position to regularly encounter women who are survivors of violence.

The case of Dr. Warren and the Doane family highlights the fact that many intimate partner violence survivors do not readily disclose abuse, even when faced with a direct inquiry. Physicians with expertise in treating domestic violence admit difficulty in identifying the presence of abuse in all cases.

Research has found that women might choose not to disclose abuse because of shame, guilt or fear of perpetrator retaliation. Both survivors and their physicians have identified patient distrust of the health care professional as another barrier to abuse disclosure.