Patients in your exam room may be experiencing one of a number of forms of abuse—domestic violence, human trafficking or other violence—and identifying those being abused can sometimes be tough.
An article published in the AMA Journal of Ethics® outlined the challenges and identified ways for physicians to better spot and help trafficking victims. The authors noted research showing that 88% of victims had contact with a health professional while being trafficked, but none were identified or offered help in getting out of their situation during the medical encounter.
Family physician Anita Ravi, MD, MPH, MSHP, discovered that she has had to rethink the way she approaches patients to best help those facing abuse or violence. Dr. Ravi is co-founder and CEO of the PurpLE (Purpose: Listen & Engage) Health Foundation, a nonprofit organization that advances health equity for survivors of Gender-based violence, including those who have experienced human trafficking and domestic violence, through an interconnected model of direct services, research and education.
Dr. Ravi said her clinical and research experience, including a study that involved interviewing sex-trafficking survivors about their interactions with the health care system, has taught her that patients experiencing violence or abuse can be of any gender, age, documentation status or background and they may be encountering a range of medical issues. It may be a patient who has rarely encountered the health care system because their abuser denies them access to care, or the person seeking care was not in a position to leave the trafficking or abusive environment in order to seek medical care.
It is important to recognize that patients may choose not to disclose abuse for a variety of reasons, even when screened. Patients have told her there were times when they avoided essential health care or have left a medical setting in the middle of a visit because they felt they were being judged. The absence of abuse disclosure is not the same as the absence of abuse, and as such, provision of trauma-informed care by physicians remains an effective tool in helping the patient in cases of clinical suspicion without patient confirmation.
Dr. Ravi offered as an example a patient who comes in for frequent sexually transmitted disease testing because they are being forced to have unprotected sex, but is not comfortable disclosing this to a physician because they fear being stigmatized or misunderstood about their complex reasons for remaining in an abusive relationship.
“The goal here is to be able to provide the care sought, in a consistently sensitive, and caring way, so survivors know they are always welcome to return,” Dr. Ravi said. “Because, while a patient may not open up to what is really going on during a first or even second visit, those initial interactions still lay the necessary groundwork in signaling to survivors that the physician’s office or an emergency department is a safe and appropriate place to address abuse.”
In addition to providing trauma-informed care, Dr. Ravi said physicians can play an important role in connecting people with critical resources such as housing, legal and social services that further address survivors’ social determinants of health.
“Ultimately, trauma-informed acute and longitudinal health care is an essential part of a collaborative, multidisciplinary ecosystem of services to support survivors of abuse in their journey towards safety and long-term wellness,” she said.
The AMA Code of Medical Ethics offers physicians guidance on their obligation to take appropriate action to help patients avert harms that violence and abuse cause.
What physicians can do individually
What physicians can do individually
In Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse,” the Code explains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient’s health or ability to adhere to medical recommendations. Physicians, in light of their obligation to promote the well-being of patients, have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse.
The Code says that to protect patients’ well-being, physicians individually should become familiar with:
- How to detect violence or abuse, including cultural variations in response to abuse.
- Community and health resources available to abused or vulnerable persons.
- Public health measures that are effective in preventing violence and abuse.
- Legal requirements for reporting violence or abuse.
Physicians also should:
- Consider abuse as a possible factor in the presentation of medical complaints.
- Routinely inquire about physical, sexual and psychological abuse as part of the medical history.
- Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.
- Offer treatment for the immediate symptoms and sequelae of violence and abuse and provide ongoing care for patients to address long-term consequences that may arise from being exposed to violence and abuse.
- Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources.
- Report suspected violence and abuse in keeping with applicable requirements.
What to consider before reporting
What to consider before reporting
Before reporting suspected violence or abuse, the Code says physicians should:
- Inform patients about requirements to report.
- Obtain the patient’s informed consent when reporting is not required by law. Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision.
Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.
Learn more about AMA policy supporting survivors of LGBTQ+ intimate partner violence.
