Domestic violence affects a third of women worldwide, according to the World Health Organization. In many cases nobody knows of the suffering, and victims aren't able to get help in time.
That's why in many countries, including the U.S., there's been a push to make screening for domestic violence a routine part of doctor visits. Last year, the influential U.S. Preventive Services Task Force recommended that clinicians ask all women of childbearing age whether they're being abused.
These days, after your doctor asks you whether you're allergic to any medication, or whether you smoke, she might also ask whether you feel safe with your partner.
But an analysis published Monday in BMJ, formerly the British Medical Journal, suggests such generalized screenings may not be helping much. A review of 11 studies involving 13,027 women in wealthy countries found that screening questions did help doctors identify more than twice as many patients who were suffering from abuse. But routine screenings didn't necessarily help those women get the follow-up support they needed, researchers found.
"The emphasis on how to identify victims distracts attention from the real issues," says Dr. Gene Feder, a professor of primary care medicine at the University of Bristol, and one of the researchers behind the review. Instead, the medical community should be focusing on providing known victims with proper support, Feder tells Shots.
"We don't think screening is necessarily harmful," Feder says. "We just can't give doctors a compelling reason for doing it."
To be effective, doctors and nurses need to be trained how to ask the right questions, and to connect those who've been abused with the right resources, Feder says. Instead of indiscriminately spending a little time screening everyone, clinicians would do better to spend more time with the patients who they think might be in trouble, he says.
That's pretty much in line with the WHO's recommendation that clinicians only ask in certain contexts — the group doesn't recommend universal screening.
Great Britain once had a policy to screen every pregnant woman for domestic abuse as a part of prenatal care, Feder says. "But it was being asked in a very mechanistic, impersonal way," he says, and that doesn't help anyone.
Still, the notion of completely doing away with screenings is controversial among health care workers and fairly complicated, says Nancy Glass, a nurse practitioner and associate director of the Johns Hopkins Center for Global Health.
"We've been having this conversation for several years now," says Glass. She's a proponent of routine screenings. Even skilled doctors can miss subtle signs of abuse, she says, and there's not one symptom that all abused women have in common. So, she says, asking more women more often is better than not asking at all.
"Women in abusive relationships have a lot of reasons not to report," Glass says. Women are often afraid that their partner will retaliate, or they simply don't feel comfortable talking about it.
But if a physician asks respectfully, in a private setting — and with the assurance of confidentiality — women are more likely to open up, Glass says.
"That doesn't mean that, that day they're going to go out to shelter or call a hotline," Glass says. But she thinks such conversations between patient and doctor are a step in the right direction.
Glass and Feder both agree that doctors need training to ask the right questions. They also agree that the way doctors ask makes all the difference.
"It's not ... rolling down a list of questions," Glass says. The American College of Obstetricians and Gynecologists has a guideline, and so does the Centers for Disease Control and Prevention. But asking the right way takes practice.
Dr. Owen Montgomery, who chairs the department of obstetrics and gynecology at Drexel University's College of Medicine in Philadelphia, says he's found in dealing with his own patients that screenings are helpful. "I can tell you, 100 percent of the time, when I ask a woman if she's safe, even if the answer is no, she is grateful," he says.
Until the research unequivocally shows that screening doesn't help at all, Montgomery says, it makes sense to continue the practice. "Every woman who delivers in our hospital is screened for post-partum depression and domestic violence," he says. "To not acknowledge the importance of domestic violence doesn't sit right with me."