Seeking safety in the doctor-patient relationship

The doctor-patient relationship has traditionally been a safe space for women experiencing abuse in terms of disclosing their situations and seeking help. That’s because of the sanctity and the privacy of the clinical setting. During the coronavirus pandemic, this has been disrupted. The introduction of telehealth has been remarkable in so many ways, but remote caregiving has thrown some kinks into that natural safe zone for women to discuss violence with their trusted healthcare provider.

Doctor telehealth consulting by Fizkes

The pandemic has brought profound isolation to women who are experiencing abuse and has caused tremendous economic disruption for women in general. The data around women’s disengagement from the workforce has been startling. For women who are experiencing abuse, that has many implications. Women who are experiencing abuse have limited alternative housing options because of the pandemic, which creates a breeding ground for worsening violence.

From a clinical perspective, with these kinks in telehealth also comes great creativity. I have read with tremendous awe and gratitude about how clinicians are addressing and helping their patients who experience abuse in this brave new world of telehealth, where someone’s abuser could be sitting in the next room or in the same room during a remote visit.

Asking women patients about intimate partner violence

About one third of women report experiencing physical violence, sexual violence or stalking by an intimate partner in their lifetime. That’s data from the US, but the numbers worldwide are not better; in some countries, they’re much worse. What we’re dealing with is something that is very, very common. Because of this, in the US, most major medical organisations recommend routine inquiry of women by their healthcare providers for intimate partner violence, particularly for women of reproductive age.

Individual practitioners are therefore encouraged to ask, and there are evidence-based approaches to asking that have been shown to be more effective. Behaviourally specific inquiry is the best approach. That means avoiding vague questions, like ‘Are you being abused?’ and instead asking, ‘Does your partner hit, kick or choke you? Does your partner force you to do something sexually that you don’t want to do?’ Those types of questions have been shown to be more effective.

It's vital to ask these questions privately, with no one else in the room. Privacy is incredibly important. First, you would never want to ask a woman who is potentially being abused about the violence in her life if there was someone else in the room who could potentially be the abuser or tell the abuser. Second, you’re probably not going to get a positive answer where one exists if you’re not asking in a private, safe space. Another thing to keep in mind, and there’s been qualitative literature on this, is that women in general – not just women experiencing abuse – do not mind being asked. So asking directly in a private setting is not only okay, but it’s recommended.

The responsibility of healthcare providers

Should healthcare providers be responsible for recognising signs of abuse? Absolutely. This is why most major medical organisations recommend that physicians and clinical practitioners ask their women patients routinely about violence. It’s because of the incredible prevalence. If another type of disease or process impacted a third of a population, there would be no question. This is not a social justice issue; this is a medical concern.

Doctor looking through the window blinds with a mask by Fizkes

However, requiring physicians or providers to do something is a different story. In the US, we have accreditation and certification to make sure providers and physicians have baseline knowledge and know how to treat their patients within a particular specialty. But we don’t have requirements per se for individual practitioners.

Providing practitioners with appropriate training

I devoted the first 10 years of my academic medical career to developing medical education curricula for medical students, residents and faculty around how to ask and how to respond in an effective way to women experiencing abuse. There are trainings or medical education curricula on this topic to varying degrees at medical schools in the US. Could it be better? Absolutely, and the same goes for graduate medical training. Things have gotten better since the early 1990s, when the American Medical Association first came out with its guidelines stating that this was the responsibility of physicians, but we could continue to move along that trajectory.

Training is about helping medical students, residents and faculty both understand the prevalence of intimate partner violence and that it’s okay to ask questions that are sensitive. I work in women’s health, and there are a lot of sensitive topics in women’s health, such as taking good sexual history or taking an addiction history. But we learn to do that. The way we learn is both through didactics that we receive from our professors and through practice and role playing. There’s no substitute for doing it. The qualitative literature – and my own experience over the past 40 years working with women who experience abuse – shows that asking the question in a safe, private way is validating. There’s no wrong way to do that.

How to respond to women experiencing violence

The first, second and third responses are to acknowledge the abuse and to validate your patient’s experience as a survivor. Even if someone is currently in a situation that’s abusive versus a past situation, they’re still a survivor. Showing empathy and validating your patient’s experience is the most critical intervention. After that, there are several important steps to take

Number one is to establish the severity of the abuse. That can be done very quickly by asking a couple of questions. Does the abuser have a gun? If the abuser has a weapon, that has been shown in peer-reviewed literature to increase the risk of femicide. Has the abuser threatened to kill the patient? And does the patient feel she’s in immediate danger? Because that’s a really important barometer.

Once the validation and empathy has been shown, and once the severity of the situation has been assessed, the next step is about holistically assessing the abuse. That can be done by asking about the first time and the last time the abuse occurred, and what the patient considers the most significant episode of abuse. Again, it’s about unpacking this term of abuse. Is this something physical: hitting, kicking, choking, pushing, shoving? Is this sexual? What kinds of sexual abuse, what kinds of emotional abuse, if any, are happening? Are there threats of violence, humiliation or other similar activities?

The importance of safety planning

Last but not least, and this often needs to go into a second visit, is safety planning. Safety planning is relatively easy. It takes place in the quiet of an office space. It’s allowing the woman who’s experiencing abuse the opportunity to think about what she would do if she ever wanted to leave, or if she could leave quickly. That means thinking about where she could go to keep herself and her kids safe; some examples that have come up in my practice are the local grocery store, the library, a friend’s house. It’s important to provide the space for the woman to think about that and identify safe venues.

by Insta_photo

Another element of safety planning is encouraging the patient to make copies of all of her important documents, and her kids’ important documents, if she has kids. That includes birth certificates, passports, driver’s licences, Social Security numbers, credit card numbers. It’s taking all those documents, or copies of those documents, and putting them someplace safe. We live in a digital world, so that could make things somewhat easier, but a lot of people want paper copies. It’s important to hide them someplace outside the home where the woman could get them if she ever needed to leave quickly: in an office, at a friend’s house, wherever she identifies.

Finally, and this can be hard, is getting together a bag of clothes, extra medications, some stuffed animals for her kids – putting all of those items in a plastic bag and hiding them somewhere outside the home in case she ever needed them. Based on all my years of working with women experiencing abuse, having access to those documents and some of those personal belongings when they leave, when they escape, can really make a world of difference.

Discover more about

intimate partner violence

Clark, L. E., Allen, R.H., Goyal, V., Raker, C.A., Gottlieb, A. S. (2014). Reproductive coercion and co-occurring intimate partner violence in obstetrics-gynecology patients. American Journal of Obstetrics & Gynecology, 19(4), 371–390.

Gottlieb, A. S. (2012). Domestic violence: a clinical guide for women’s health care providers. The Obstetrician & Gynaecologist, 14, 197–202.

Gottlieb, A. S. (2018). Intimate partner violence: a clinical review of screening and intervention. Women’s Health, 4, 529–539.

Why we need new approaches to intimate partner violence