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Dr. Jennifer Caudle:
The CDC released a report on the prevalence of sexual violence and intimate partner violence that stated that about 36 percent of women in the United States are raped or sexually assaulted by an intimate partner during some point in their life. About six percent experience this in any given year. The costs are burdensome to the healthcare system, and it's estimated at 2.3 to seven billion dollars in the first year after the assault. So what can physicians do, and how can we address this public health issue?

I am your host, family practitioner, Dr. Jennifer Caudle, and joining me today is Dr. Jane Liebshutz. She's an Associate Professor of Medicine in Community Health Science and the Director of the General Internal Medicine, Family Medicine, and Pediatrics Academic Fellowship at Boston Medical Center.

Dr. Liebschutz, welcome to ReachMD.

Dr. Jane Liebshutz:
Thank you.

Dr. Jennifer Caudle:
So I'd like to start out by having you share with us where your passion lies and what your passion is for intimate partner violence.

Dr. Jane Liebshutz:
I have many patients over the years who have been adversely affected by violence in their relationship, and it impacts their health, and they also become quite isolated because of the violence, and as as a physician, I have the opportunity to really connect with the patients, help them see what's going on, help them find ways out of the violence, and then maintain those intimate long relationships with them in a patient-doctor mode, and it's very, very rewarding to see how people can turn their lives around over time.

Dr. Jennifer Caudle:
You know, can you talk to us a little bit about the rates of intimate partner violence? Maybe how they differ in women compared to men and maybe any other gender differences when we're talking about intimate partner violence.

Dr. Jane Liebshutz:
What's very interesting is that numerous studies, when they ask both men and women the same questions about intimate partner violence, find that actually men and women both have high levels of experiencing violence. However, the experience is quite different. Men tend to have less serious injury and have more resources to leave or end relationships than women, but probably a third of all adult women have had violence in their adult lives. One of the main differences between men and women in the way they experience it is that women tend to have much higher proportions of physical and sexual violence that goes along with the relationship and the intimate partner violence. Whereas men have more psychological violence and less physical violence.

Dr. Jennifer Caudle:
We know that this is a substantial public health problem. You mentioned just now even that women experience more of the physical and sexual side effects, etcetera. Can you tell us, are there any other sort of health sequela that may present for a patient who's involved with intimate partner violence? You know, things we might see down the line, other health effects that might occur?

Dr. Jane Liebshutz:
Well, the most common health effects are psychological with depression, anxiety, and post-traumatic stress disorder being right up at the top. In addition, there's a strong relationship with substance use disorders or substance problems, such as drinking too much, smoking cigarettes, being addicted to cigarettes, use of drugs, and what's interesting is that we know that some of these issues, particularly the substance disorders, put people at higher risk for experiencing it, whether it's the environment and the other people who are using drugs or whether it's lowering defenses and not being able to defend or make judgment around safety issues, and then lastly, there are a number of physical health sequeli.

So, first, there would be injuries, mostly minor injuries in the scheme of things, but a small percentage have very serious injuries such as fractures, or internal hemorrhaging, or traumatic brain injury. Another physical side effect, which is probably more common, which is chronic somatic illness. So what do I mean by that? I mean, chronic aches and pains, and it could be fibromyalgia. It could be chronic pain disorders. It could be disabling arthritis or other kinds of physical or musculoskeletal problems.

Dr. Jennifer Caudle:
You really have broken down some of the potential sequela into four groups. The psychological, substance abuse, mental health, physical injuries, and then chronic somatic illness. So, with those ideas and the issue of intimate partner violence in general, let's transition a little bit to talking about physicians and our role, why the physician can be so important in helping patients with intimate violence. Can you talk about the role of the physician and how we can kind of insert ourselves to help our patients?

Dr. Jane Liebshutz:
I guess I would start by saying that, first and foremost, it's not a medical problem. It's a social problem. However, physicians have a social role in our society and in the lives of patients that make us ideal candidates to help women and men who've been experiencing violence. So I don't mean to say it's not a medical problem in that there are no medical sequeli, but the underlying problem is in outside of the doctor's office. The underlying problem is in the home. So what we can do is we can develop relationships with our patients. We can empower them. We can refer them to treatment and resources where they can help get themselves out of these relationships.

Dr. Jennifer Caudle:
You know, along those lines, are there guidelines for screening, and what's the role of screening for intimate partner violence in the office setting?

Dr. Jane Liebshutz:
So, screening is a really interesting word. We think of screening when we think of screening for high blood pressure. We think of screening when we think of screening for cancer. So that when we think of screening, we think people who are asymptomatic, and they have a disease that they don't know about, and we're going to find it, and we're going to treat it and prevent some other bad outcome. In the intimate partner violence world, these are not asymptomatic. They may be asymptomatic to us as the physician, but they, in fact, are people who know and experience the negative effects of intimate partner violence in their lives.

So, really, I like to think about it as detection and identification. We use the word screening because we want to look at all of our patients who have these problems, but in reality, it's just that the doctors don't know what's going on, the patients do, and this differs from things like high blood pressure, diabetes, where, often, the patients don't know and neither do the doctors, and that's why we do the screening.

Dr. Jennifer Caudle:
That's a really good point. Well, you know, let's say that I'm a family practitioner. I see patients all the time, just as you do, and our colleagues as well. Is there a role then for a routine physical exam for someone who may not exhibit symptoms? Is there a role for even physicians asking the question as part of our routine questioning?

Dr. Jane Liebshutz:
There is very much a role for identifying patients who may be experiencing violence, who have experienced violence in the past, through routine questioning, and that has been promoted by the U.S. Preventive Services Task Force, which does suggest for family violence screening in adults. The data is not as strong as it is for other kinds of screening, and part of that, as I mentioned, is that other kinds of screening often go with people who are asymptomatic. In this case, we're really identifying people who are experiencing or have experienced something.

And there is absolutely a role for routine screening and asking some brief questions to identify whether somebody's experiencing violence, and I would just say one more thing, which is that, oftentimes, people don't realize that the interactions and exchanges in their relationship are actually violent. They think that that's just the normal for them because most people don't have the birds eye view of what's a normal relationship. They just have their relationship as comparison.

And then the very last point is many of these relationships, many of the relationships that include intimate partner violence, 99 percent of the time, things are just normal like any other relationship, and it's that one percent of violence that really shadows the entire relationship and does put people at risk for serious problems such as injuries or worse.

And so, when you ask people, they may not recognize that they're in a violent relationship, and that's why it's important to use standardized questions and ask people, and then, if you identify behaviors, then to explore further to find out exactly the nature of what's going on.

Dr. Jennifer Caudle:
If you all are just tuning in, you're listening to ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. Jane Liebshutz about intimate partner violence. Okay. So, I wanted to continue a little bit along these lines. This is great, and I have some questions for you, Dr. Liebshutz, about the practical aspects of us dealing with intimate partner violence, but you just mentioned something very interesting, which is the idea of standardized questions. Do you have specific standardized tools that you recommend for physicians to use in their office when asking questions?

Dr. Jane Liebshutz:
There are a number of short questions. One of them I like is called the HITS screening tool for domestic violence where there's four questions, and then each question has a range of answers, and they're questions like how often does your partner physically hurt you, insult, or talk down to you, threaten you with harm, scream, or curse at you? And then the range of answers would be never, rarely, sometimes, fairly often, or frequently, and then each of those answers is scored, and then there's an overall score, and that gives a suggestion of how likely intimate partner violence is going to have occurred.

Dr. Jennifer Caudle:
I think sometimes these practical tools are very helpful in the office setting. The HITS screen is a screen that we can use. You know, let's say that, as a physician, we ask these questions to a patient. Maybe use the HITS screen or another screen. What is some recommendation you might have for the situation where a patient might be reluctant to disclose information, but as a physician, we may have a suspicion that something is going on? How can we deal with that in the office setting?

Dr. Jane Liebshutz:
One of the important pieces is that we don't need to force the patient to disclose the abuse that's going on because she or he may not be ready for that. However, we can educate patients, and we can let them know that the door is open for the future. They may be thinking about that, and then, at some point, may be willing to disclose, but we need to make a safe place for them to do that.

Dr. Jennifer Caudle:
And along these lines, are physicians mandatory reporters when it comes to intimate partner violence? Let's say we have a patient that does disclose information to us along these lines. What are some of the legal ramifications that, as physicians, we need to be aware about?

Dr. Jane Liebshutz:
As far as I know, there are no states in the U.S. that require discloser of intimate partner violence to be reported. There are a number of states that require, when an injury is noted and it's noted to be intimate partner, then that's required to be reported, and that's just I think a handful of states, and those regulations change in each state. So I can't really comment on which states have that at this point, but almost all states have a regulation about reporting gun violence and some also with stabbing injuries.

So, it really depends on the situation that the physician is seeing the patient. This is most applicable to emergency medicine physicians and not the physicians doing primary care. I would say one more think about mandated reporting. If there is a child in the home, a minor child, who is at risk or has been involved in the domestic violence, that might be considered a necessary reporting depending on the state's regulations related to this, and again, if there is concern, it is worth talking to a local expert in mandated reporting for whatever the state department of social services would be.

Dr. Jennifer Caudle:
Let's talk a little bit about resources in general. You mentioned some local resources to discuss what regulations might be in place in particular states, but what are other resource that maybe physicians can pass on to their patients or even use themselves to help intimate partner violence patients? You know, websites or other resources you have.

Dr. Jane Liebshutz:
The National Domestic Violence Hotline is very, very useful. It's any state in the U.S. People can call that, and what it does is it links you to the state and local resources. So, you know, if you're really not sure, then that's the place to start. There's also a website affiliated with the hotline, which is www.thehotline.org, and then the phone number's very easy to remember. It's 1-800-799-SAFE, S-A-F-E, and so that's really the place to start if people aren't aware of things. There's also a wonderful organization called Futures Without Violence, and again, their website is www.futureswithoutviolence.org, and that's a national organization dedicated to improving the health response to violence, and there are many resources for providers and healthcare organizations on this.

Dr. Jennifer Caudle:
You know, in our last minute or so, I just wanted to ask you if you had any additional or final thoughts on intimate partner violence that you wanted to share with our listeners?

Dr. Jane Liebshutz:
The Affordable Care Act has allowed that providers should be paid for screening for domestic violence. So this is something that they can do and actually can bill for as part of mandated routine screening for women. So I think that people should know about that.

Dr. Jennifer Caudle:
Absolutely. Well, this is great. Thank you so much. I'm with Dr. Jane Liebshutz today. She's the Associate Professor of Medicine at Community Health Science and the Director of General Internal Medicine, Family Medicine, and Pediatrics Academic Fellowship at Boston Medical Center. Many thanks to you for being with us today and discussing intimate partner violence.

Dr. Jane Liebshutz:
Thank you very much.

Dr. Jennifer Caudle:
I am your host, Dr. Jennifer Caudle, and you've been listening to ReachMD. To download this podcast and any others in this series, please visit us at ReachMD.com. Thank you for listening.