We interviewed 27 women; 12 were black, 10 Latina, and 5 White. Fourteen were recruited by domestic violence staff, and thirteen contacted the authors in response to the informational flier. Sixteen were living in a residential program at the time of the interview. Participant ages ranged from 18–56 years; median age was 31 years. Twenty-three participants had at least one child.
A total of 185 health care encounters were described. The number of encounters per participant ranged from 3–12; median number of encounters was 7. Although it was frequently difficult to determine the professional designation (physician, nurse, therapist) of an individual provider, specialty was clear in 175 encounters. The thirty-one mental health encounters were excluded because most were visits specifically related to the IPV. Twenty-two were nurses from different treatment settings (inpatient, public health, etc.). Of the twenty-nine other encounters, there were two few (<5) of any single type and could not be easily combined into categories- such as radiology technicians, surgeons, ambulance drivers, physical therapist, child protective service worker, medical subspecialist, etc. Thirty-one were excluded because they were unrelated to abuse, and did not contribute to the analysis presented in this paper, the impact of IPV disclosure. Another three were unable to be classified by attribute, leaving a sample pool of 59 encounters (23 primary care, 17 ED, 19 OB/GYN) representing 25 participants (Figure 1).
Thirty-five (59%) of these encounters involved IPV disclosure to the clinician, 7 (12%) in discovery, and 17 (29%) in non-disclosure. Of the disclosures, 25 (71%) were beneficial. Among discoveries, 4 were beneficial (57%), while among non-disclosures, 6 (35%) were beneficial. Setting of care was associated with reported satisfaction from disclosure. In the ED, 2 (22%) disclosures were beneficial. Of OB/GYN disclosures, 9 (75%) were beneficial. In primary care, all 14 disclosures were beneficial (Figure 2). There were no harmful disclosures in any specialty, and the remaining disclosures were unhelpful. We discuss these findings further in the paragraphs below.
Consequences of Unhelpful Disclosures: Fear and Avoidance of Healthcare
The most serious negative consequences of disclosure occurred in two participants who reported feeling endangered because of the disclosure, both after treatment for acute injuries in the ED. However, neither experienced any actual increase in violence. In two OB/GYN visits, participants found disclosure experiences so problematic they ultimately left their providers. The remaining 5 unhelpful disclosure experiences resulted in dissatisfaction without cessation of the clinical relationship.
Several participants were concerned by practitioners' tendency to encourage extreme "solutions" to the violence, like telling women to file a police report immediately. While in the ED, one participant reported being told, "Just tell me the name and where he's at and we'll send the police at him right now." She recalled thinking: "But what makes them think he won't come back and kill me?" The participant did not contact the police, and returned home in fear.
A number of participants indicated the cumulative effect of unhelpful disclosure experiences was avoidance of health care encounters. One participant noted:
"I used to go without medical treatment... I'd wait until it wasn't a choice anymore. And I'd wind up having to go to the emergency room."
Another participant revealed:
"Somebody would find out something was happening in my house, like a social worker, a doctor, a nurse or whatever, I would stop going there and go somewhere else."
The lack of an emotional connection with the clinician was a prominent feature in participants' discussion of unhelpful disclosures. Describing an ED visit, one participant commented:
"He checked me, he didn't ask any questions, nothing, and they took x-rays and pulled out of there... Maybe I was hoping... that they would talk to me? I mean, they checked me out... but I didn't feel like... emotionally? Like maybe talk, some kind of comfort?"
The lack of effective communication on safety assessment, referrals, and follow-up for IPV was also a consistent problem in unhelpful disclosures. During her prenatal intake visit, for example, one participant disclosed ongoing violence, the name of her abusive partner, and his status as an undocumented foreigner. Not understanding what follow-up would occur, she became petrified that her husband would assault her for revealing his status. She subsequently switched to another prenatal care provider, where she lied about her home life. Several participants disclosed abuse but reported receiving little helpful advice from the clinician. The woman encouraged to contact the police above did not remember being offered contact information for safe houses in the area. Similarly, after treatment for acute injuries, one participant reported: "I don't recall ever getting information about a shelter... or an advocate speaking to me. Any of that."
Benefits of Disclosure: Making Changes, Improving Self-Esteem, Building Relationships
Eleven of the 25 beneficial disclosure experiences led directly to a change in the participant's circumstances, such as leaving the abusive spouse, entering a detoxification program or filing a police report. For example, one participant with newborn twins and a toddler reported that after disclosing her husband's assaults,
"I started off in a shelter in [a distant town] because I couldn't find one that would take all of us right away... My [OB] got on the phone with Social Service to try and get me all the help that I needed."
In others, changes resulted after a clinician worked with a participant over a period of time. One participant described the effect of the close relationship she developed with her midwife:
"She was real supportive through my pregnancy, and told me 'everything will be okay,' and I'll be a good mother. And I am a good mother. 'Cause it made me realize a lot of things... that I was thinkin', and I had my whole life to live, but now I could do better with myself, as well as with my daughter... I'm workin' on gettin' housin', takin' care of my schoolin', just bein' responsible."
Instead of an immediate end to the abuse, these patient-clinician encounters resulted in a shift in the participant's self-esteem, perception of the violent relationship, or awareness of alternatives, eventually empowering her to seek help for the abuse on her own. For example, clinicians' assurances that relationship violence was unacceptable resonated with several participants. One participant reported her primary care doctor's sympathetic insistence that the batterer's behavior was wrong set the stage for her to take action:
"She was like, 'No... no one who loves you will put their hands on you.' You know, it's not right. 'That's not real love.'...After [he broke] the wrist, I said, 'No more.'"
After being treated in the ED for IPV-related injuries, another participant left with information on local safe houses that she later consulted when she was ready to leave her abuser.
Some of the beneficial disclosure experiences resulted in a more positive attitude toward health care in general, as in 5 instances where participants reported feeling a greater closeness with their clinicians despite no other change in their circumstances. Whether or not disclosure led to change, analysis revealed three common characteristics of provider behavior in beneficial disclosures: 1) explicit acknowledgement of the content of the disclosure (all cases), 2) demonstration of a caring attitude after disclosure (most cases) and 3) specific referral to other resources (some cases). For example, one participant said an ED clinician explicitly acknowledged her abuse and demonstrated concern:
"He said, well, 'I hear you're in a battered women's shelter. What's the deal? I take a special interest in domestic violence and what happens,' and he sat and talked to me. I felt comfortable in talking to him because he was showing this special interest in what was going on with me."
Also of note, in all but two beneficial disclosures the participant reported familiarity with the clinician. In primary care, these relationships involved getting to know the clinician through a variety of contacts both related and unrelated to the IPV. In OB/GYN, these relationships generally formed during prenatal care, or in the peri-partum period when the participant had daily contact with hospital clinicians. Such familiarity can also occur in the ED setting, as in one case where the participant accepted advice from a nurse who had treated her a few weeks earlier for IPV-related injuries. When the participant returned to the ED with more injuries, the nurse recognized her:
"And I started crying, and she's like, 'Two weeks ago you was here, now you're back here again today and it's for the same thing. Your face isn't all bruised up like it was two weeks ago, but you're hurtin'. What's goin' on?' I broke down and told her...She was like, 'Well, you don't need to be in a relationship like that."'
The participant acted on referrals and left her abusive partner as a result of this encounter.
Potential Benefits and Problems without Disclosure
The common thread to benefits and problems without verbal disclosure by the participant included explicit clinician acknowledgement of potential abuse (or lack thereof). In particular, participants reported being upset by health care providers who they felt should have recognized IPV but did not acknowledge it. This, in turn, led to avoidance of healthcare. One participant reported that healthcare personnel failed to bring up IPV even after her husband yelled at her in the ED during two separate visits. She interpreted this lack of acknowledgement as an indication that clinicians did not care to get more involved. Another participant was particularly disappointed that her primary care clinician did not address the abuse with her, given that she had received counseling about it from his nursing staff: "He never gave me any type of indication...he didn't talk to me about it. That's why I left him...because he wasn't really direct with me."
Several participants reported benefit when the clinician spoke openly with the participant about IPV but did not insist upon disclosure. Furthermore, clinicians in these encounters used verbal and non-verbal cues to convey concern, and offered options for intervention while not forcing the participant to take action. The aftermath of acute injury was a particularly vulnerable time, as survivors were emotionally and physically exhausted as well as fearful of more injury.
"They asked me, 'How did it happen?' 'What happened to you?' 'Who did that?' I was in so much pain that I really didn't want to talk about it."
A critical component of beneficial non-disclosure experiences was consideration of the patient's safety, as in this ED visit:
"She realized that I had other bruises on me. I thought he might hear her and I was like, 'No. Let's just drop the conversation. Let's just get me stitched up.' My husband came in so there was no more talk about it. When I left, she called me apart, and she [said]: 'you could call here in an emergency and we could get you some help."'
Another example included ED staff suggestion that a participant treated for acute injuries continue care in PC: "and they gave me a choice, 'would you rather go to your doctor and tell them what happened?"' As a result of that referral, she revealed the abuse to her primary care clinician.