Silent Epidemic
Vol. 19 No 4 | Summer 2017
Feature
The case against routine screening for DFV
Dr Deborah Walsh
BSW, MSW, PhD, GCHEd


This article is 4 years old and may no longer reflect current clinical practice.

International estimates by the World Health Organization1 indicate that approximately one-in-three women have experienced violence, with much of the violence perpetrated by an intimate male partner in a domestic setting. While there may be one-in-three women who are victimised, that does not mean there are one-in-three men who are violent. The majority of men are not violent, but those who are often have multiple partners.

When the health impact is measured, it has been found to cause a global disease burden of 30 per cent for women. In addition, as many as 38 per cent of homicides of women worldwide are committed by a male intimate partner2 and approximately one woman per week is murdered by a domestic partner in Australia,3 demonstrating the potential catastrophic consequences for women victims. Considering the gravity of domestic and family violence (DFV) an attempt to intervene early in these situations was introduced by various health services, and routine screening for DFV was born. This article will argue that help seeking is complex behaviour and while routine screening may detect DFV in healthcare populations, disclosure does not equal help seeking nor does it mean women’s safety and health outcomes will improve. Therefore, I will be arguing the case against screening.

In the 1980s and 90s, as prevalence data emerged about DFV, recommendations in favour of routinely screening women for domestic violence, particularly in antenatal care, became commonplace.4 5 6  In the US the Preventive Services Taskforce recommended screening and counselling in all healthcare settings for women of childbearing age.7 As a result, many nursing and health researchers went on to produce volumes of research data on standardising different screening tools.8 9 10  Many argued to acknowledge awareness of DFV affecting women was important and healthcare would be seen to be doing something to break the cycle of violence and improve women’s safety. 11 12 As screening became popular, there were some who were cautious about its implementation in Australia. As an example, Taft cautioned against the use of screening tools as she felt these were problematic strategies attempting to address complex psychosocial issues such as DFV.13

There were advocates who argued that routine screening was an effective and efficient way to acknowledge the gravity of violence and reassure patients that it was not acceptable behaviour.14 15 While I believe the motives behind screening are well meaning, I will argue here they are based on two false assumptions: one, that disclosure equals help seeking and with support the woman will leave her partner thus reducing exposure to violence and, two, as a result of leaving there will be improvements in the woman’s safety.

Disclosure does not equal help seeking

Several studies have explored the results of DFV screening programs and have consistently found that screening increases disclosures of violence.16 17 18  However, it appears that there is little evidence to show a corresponding increase in help seeking once identified.19 20 21  Irwin and Waugh, reporting on a screening program in NSW, found that of the 11 per cent who screened positive for DFV only 30 per cent agreed to some sort of assistance.22

When exploring the barriers to help seeking, Fugate et al found that women felt the violence they were experiencing was not serious enough, they didn’t think any help would be useful, it was nobody’s business, they feared reprisal, they were embarrassed or they feared being judged or criticised. In addition, women felt that if they disclosed there would be an expectation that they would have to leave the partner and end the relationship and so they felt they needed to protect the partner to preserve the relationship.23

In my own practice of some 20 years working in the field of DFV, women frequently stated that they loved the partner and didn’t want to leave, but they wanted the violence and abuse to stop. I have found that help seeking is a complex process that takes time and will occur when women have exhausted all their own resources to end the abuse and fix the relationship. Or, alternatively, if the physical violence is escalating or is severe, then women will leave, particularly if they fear for the children. Fugate et al24 and Meyer25 found that if a woman’s tolerance threshold has not been reached or they were not prepared to end the relationship, then women will not seek help. So, while DFV screening may increase the numbers of women who identify violence, it does not mean they will actively help seek. So why screen?

Feder et al describe that a key element in justifying screening programs is that there will be an effective intervention available.26 Despite the claims that early intervention will eliminate violence and improve women’s lives,27 there is no evidence of any effective interventions that will improve women’s health and increase women’s safety once screening has detected DFV. Two systematic reviews have concluded that there is insufficient evidence to support DFV screening programs either in health services generally or in specific clinical settings28 29 as they found no robust evidence that DFV screening reduces violence or improves health outcomes for victimised women.

In addition to the research findings above, my (yet untested) concern is that routinely asking women about violence that relies on questions about physical assault, sexual violence and fear has the potential to reinforce the notion that DFV is about black eyes and broken bones, negating other damaging forms of coercive controlling behaviours. Women victims already minimise and deny their experiences of violence and, in my view, screening for DFV has the potential to reinforce their silence or the feeling that the violence is not that bad. It is my view that there are far more compelling arguments against screening than there are for screening because when we do detect violence the only option we can offer the victim is support services to help her to leave and that is a problem as the next section will show – leaving DFV does not mean an increase in safety.

Leaving DFV does not equal safety

It is a common myth that DFV ends when the victim leaves the relationship, but even a cursory glance at domestic violence service websites highlights the danger involved when leaving a violent partner. Numerous studies have found that violence escalates if the woman leaves the relationship, with separation being a risk factor in the domestic homicide of women.30 31 32  McKenzie et al33 note that: Contrary to common perceptions, non-physical forms of violence can be ‘red flag’ indicators of high risk. These include controlling behaviour, obsessive jealousy, stalking, and sexual assault, as well as threats to kill the victim, children or pets, trying to choke the victim, and abuse during pregnancy… Separation is a relationship factor that is consistently found to be associated with higher risk of lethal violence.

The key factor for the increase in risk at separation and during the first 12 months post-separation is the violent partner has lost control of their partner and the violent response may be severe, life threatening or fatal.34  In my experience running behaviour change intervention programs, men report that they first try to be nice and promise to change or to go to counselling and if that doesn’t work the violence escalates. If that fails to get the partner back they frequently resort to punishing her for leaving in any way possible. Research undertaken with men who kill found that they describe experiences of losing control, suspicions of infidelity, involuntary separation, jealousy and rage.35 36 37

Women who separate from violent partners and share biological children find that ongoing victimisation frequently occurs at child handover, exposing the children to ongoing abuse and violence.38 39 40 While for some women the experience of abuse post-separation may decrease over time, for others the violence never ends, even after the violent man re-partners.

In summary, routine screening in health settings is based on two assumptions that have been challenged. One, that screening will identify victims who will then help seek and, two, that support to leave the violence will improve health outcomes and reduce violence.

With the current responses to DFV in Australia, staying with the partner or separating are the only options for women. The decision to separate frequently comes at the end of a long process. Women will have exhausted all other options, have reached their tolerance threshold and are prepared to end the relationship before they engage in help seeking. Professionals who respond to cues, ask about what is happening at home, are prepared to listen and believe without judgment are in fact providing a valuable intervention. Respecting her timing in terms of disclosure and listening to the experience will help her to come to terms with the fact her partner may not change no matter what she does or does not do. To have up-to-date community resources available is critical to ensure that when women are ready to seek help, links to those resources can be made.

References

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  2. World Health Organization. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. 2013. Geneva, Switzerland.
  3. Bryant W, Cussen T. Homicide in Australia: 2010–11 to 2011–12: National Homicide Monitoring report. Monitoring report series no 23. 2015. Canberra: Australian Institute of Criminology.
  4. Bates L, Redman S, Brown W, Hancock L. Domestic violence experienced by women attending an accident and emergency department. Aust J Public Health. 1995;19(3)293-9.
  5. Helton A. Battering during pregnancy. Am J Nurs. 1986;86(8):910-3.
  6. Roberts GL, O’Toole BK, Raphael, B. Prevalence Study of Domestic Violence Victims in an Emergency Department. Ann Emerg Med. 1996;27(6):741-53.
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  17. NSW Health. Policy and procedures for identifying and responding to domestic violence. 2003. NSW Health Department.
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