Patients certainly value their doctors’ skills and diagnostic practices. But patients, particularly those suffering from the trauma of physical and sexual assault, most value awareness, support and compassion.

Studies suggest that very few medical practices have escaped this national health care epidemic. Patients may be unwilling to talk about partner violence, but many are suffering in silence.

This abbreviated guide will help you to recognize some of the signs of abuse and enable you to find the right words.

Free copies of “A Guide to Working with Survivors of Sexual Assault” are available to physicians, social workers, nurses and students. Call 412.431.5665 for more information.

how do i ask?…

Intimate partner violence and sexual violence screening can be done by asking 3 simple questions:

1. Within the past year – or since you have been pregnant – have you been hit, slapped, kicked or otherwise physically hurt by someone?
2. Are you in a relationship with a person who threatens or physically hurts you?
3. Has anyone forced you to have sexual activities that made you feel uncomfortable?

If you get a positive result to any of these questions, you should:

• do immediate safety planning,
• give the patient referral information to appropriate agencies,
• suggest that the patient call the agency from the office and
• schedule a follow-up appointment.

If she says yes, refer to “yes” section below for suggestions on responding to the disclosure.

i know the answer was no, but i’m concerned…

Survivors often feel isolated and vulnerable. Admitting abuse can be very painful. In all likelihood, they’ve received little support. You can assist your patients by stating your concern and discussing abuse.

Victims of sexual and physical violence report that validating statements and compassion from physicians are among the most desirable interventions. (Hamberger, 1998)

If you suspect violence because of persistent injuries and symptoms….

• Continue to do routine screening despite answers of “no” and
• Let the patient know you are concerned by making the following statements…

“I’m really concerned about your injuries. Is anyone in your life hurting you or making you feel afraid?”

“It’s okay to not want to talk about it. If you ever change your mind, or if violence ever happens in your life, I want you to know that this is a safe place to talk about it.”

If your patient has frequent somatic complaints/substance abuse issues/eating disorders, consider asking…

“I’m concerned about the difficult time you are having. Sometimes when I have talked to patients with similar symptoms, they have had abuse experiences at some point in their lives. It can be a really difficult connection to make. Is that true for you?”

when the answer is yes…

 If your patient directly discloses sexual violence or a history of abuse, you have a unique opportunity to validate that experience and to provide information and referral if that is what your patient is seeking.

Your next step will depend on the context of your patient’s immediate needs. The following statements are intended to give you some ideas on how to handle the moment when she/he discloses violence. The key is to use language that is comfortable for you. Here are some suggestions:

• “I’m so sorry that this happened to you. I want you to know that this isn’t your fault.”
• “It takes a lot of courage to talk about that. I’m really glad you felt safe enough to talk about it here.”
• “I want you to know that what is happening to you is illegal. You don’t deserve to be abused. Would you like to talk about steps that might help to keep you safe?”
• “I know that when abuse occurs in people’s lives, it can affect them in many different ways and for long periods of time. Are you able to recognize any ways that the abuse has affected you?”
• “Do you feel safe in your home right now? Is there a weapon in the home? If it is OK with you, I would like to ask you some questions to assess your risk?”
• “Would you like to talk to someone at Pittsburgh Action Against Rape or Women’s Center and Shelter (or any other shelter in their area)? They have helped a lot of people who have gone through similar experiences.”
  

Other treatment considerations after disclosure of sexual violence:

• Document your patient’s disclosure and your interventions.
• If your patient discloses a recent sexual assault and has not reported it to the police or hasn’t been to the emergency room for a forensic exam, you should discuss this with your patient. Keep in mind that this must be her/his choice.
• Schedule an appointment for follow-up.

Offer to let your patient call Pittsburgh Action Against Rape from your office. One of our advocates will be able to discuss options with her/him. Also, let her/him know that our advocates are available to accompany her/him to the emergency room or police station.

For additional information, log onto www.acog.org.