Domestic violence used to be the problem no one talked about. But in the past few years, the issue has clearly emerged from the shadows. This summer the Obama administration appointed longtime advocate Lynn Rosenthal to the newly created post of White House adviser on violence against women. Around the same time, singer Chris Brown pleaded guilty to a felony after being charged with assaulting his then-girlfriend, Rihanna; the case drew so much negative publicity for Brown that he had to embark on an intensive campaign to revive his image and his career. In an appearance earlier this month on Larry King Live, Brown even added victim to his résumé when he discussed growing up in a violent household himself.
All this attention creates a unique opportunity to find new ways to help the 1.5 million women who are raped or assaulted annually by a spouse or intimate partner, according to the Centers for Disease Control and Prevention. But what's the next step? Some advocates have argued that health-care providers should routinely screen all women who appear in emergency rooms and other medical settings for signs of abuse. But that's a controversial effort. A study published last month in The Journal of the American Medical Association indicated that screening may not be the most effective approach. Lead researcher Harriet MacMillan, a psychiatrist and pediatrician at McMaster University in Canada, and her colleagues studied 6,743 women ages 18 to 64 who had gone to ERs, family-practice offices, obstetrics and gynecology clinics, and other health-care locations. About half completed a domestic-violence screening questionnaire; information about women who reported abuse was passed on to their physicians. Eighteen months later, there was no significant difference in levels of violence between the women who had been screened and those who had not, MacMillan said.
The push for screening is really the second stage of a major shift in the fight against abuse. The landmark 1994 Violence Against Women Act made it clear that partner violence is a criminal act. After the passage of the act, "there was a big surge in funding and interest by the criminal-justice community," says Lisa James, director of health at the Family Violence Prevention Fund, a nonprofit advocacy group. "The first step was just getting this recognized as criminal behavior. But now we'd like more attention paid to this as a major public-health issue; more attention to the long-term health-care consequences of domestic violence."
And everyone agrees that doctors and nurses can play a critical role. "Women are much more likely to come to a health setting than a criminal-justice setting," James says. "By the time the police are involved, it's usually at a crisis level. It's late in the game." Health-care providers might be able to intervene earlier, before the pattern of violence becomes overwhelming.
But MacMillan's research raises questions about whether routine screening of all women is the most effective approach, although some advocates say the study can't be definitive because there was no follow-up to prevent ongoing violence. "We are still not at the point where we have major training or research funded or a model program on the ground," says James. Health-care providers, in particular, have very little training in recognizing signs of abuse beyond the obvious physical injuries, James says: "There is some minor teaching of this issue in medical and nursing school, but it's spotty and it's nowhere near where it needs to be."
MacMillan agrees that health-care providers are unprepared to spot more subtle signs of abuse. Broken bones or bruises aren't the only symptoms. She thinks more clinicians "have to be aware of the mental-health problems associated with domestic violence"—for example, depression, posttraumatic stress disorder, and substance abuse.
In an editorial accompanying MacMillan's study, Kathryn Moracco and Thomas Cole of the University of North Carolina at Chapel Hill point to research showing that women in shelters for victims of violence who get consistent counseling with specially trained advocates are less likely to suffer repeated occurrences of physical abuse.
Another possibility is using home visits for high-risk new mothers as an opportunity to look for signs of abuse. Home-visit programs generally target low-income mothers who need help with parenting skills or referral to community support services. Moracco and Cole say that although these visits are not specifically designed to look for partner violence, one review found that half did indeed assess women for signs of abuse and that the prevalence of violence in those programs ranged from 14 to 52 percent. Given those numbers, Moracco and Cole urge research into ways to integrate home-visit programs into other efforts to help abuse victims.
Although there's a widespread belief among the public that violence increases during pregnancy, MacMillan says it's not clear that's true. She says incorporating abuse prevention into these programs might work for another reason: "Women are most open to intervention when they realize the effects on their child."
Women in substance-abuse treatment programs could also benefit from screening, Moracco and Cole say, because addiction may increase a woman's vulnerability to violence and make it harder for her to get out of an abusive relationship.
While all these approaches seem logical, they still need to be studied, MacMillan says: "In the long run, it will be to everyone's benefit if we find what's effective."