An introduction to the curriculum

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Family violence, and particularly intimate partner violence against women, is a public health epidemic in the United States. Between 2 million and 4 million women are physically or sexually abused by their intimate partners each year in the United States. Many of these women use a variety of medical and health care services at rates significantly higher than women who are not abused. For example, compared to non-abused women, women in abusive relationships have been found to make twice as many Emergency Department visits, have more hospital admissions for both trauma and non-trauma related problems, and more substance abuse and psychiatric hospitalizations. Typical psychiatric problems suffered by partner violence victims include depression, anxiety, and post-traumatic stress disorder. Victims also present with problems related to substance abuse and sexual dysfunction. In a study of a managed care system, battered women consumed about $1,700.00 more in health care services than non-abused women, including more emergency and psychiatric services, and referrals for subspecialty care. Indeed, within primary care settings, estimated prevalence of abused women is between 14% and 25%. In emergency departments, prevalence of battered women ranges between 10% and 59%, with approximately 2% battered within the past 24 hours. Obstetrical settings can expect a prevalence of abuse victims of 6% to 23%. Intimate partner violence not only occurs among heterosexual couples, but in the gay and lesbian communities, as well. In addition, partner violence is not limited to married couples. Prevalence rates of intimate partner violence among gays and lesbians, as well as heterosexual dating and cohabiting couples are comparable to those observed for adult, married heterosexual couples. Hence, physicians in a wide variety of medical specialties are ideally positioned to identify and partner violence victims.

Unfortunately, the rate at which physicians actually ask about and identify partner violence victims is abysmally low. Identification rates in primary care clinics have been shown to be between 1% and 4%. In emergency departments, identification rates are estimated to be about 10%. This means that the vast majority of battered women seeking health care services are not being identified and provided with support and appropriate referral information. Without such support and information, those women will continue to remain invisible and not receive the care they need to begin the healing process and ensure their safety.

Several barriers have been identified to explain why physicians are not more active in screening to identify and help partner violence victims. These include lack of knowledge about domestic violence, a belief that domestic violence is a rare phenomenon, lack of skill to screen and help identified victims, personal discomfort with the topic, and fear of losing control of the doctor-patient relationship in the event that a patient does acknowledge victimization and experiences a subsequent crisis. A major system-related barrier frequently cited is lack of time to both ask about violence and provide adequate help if a patient screens positive. A common complaint of medical students exposed to such training on a repeated basis is that training experiences do not vary between specialties, leaving them feeling as though they have "heard it all before."

The purpose of this project is to address the barriers noted above and provide learners with knowledge of domestic violence and its complex dynamics as well as skill at screening and helping partner violence victims within the context of the subspecialty practice. A primary goal of this compendium of partner violence training curricula has been to craft and present screening and intervention from the unique perspective of each of the specialties represented. As such, Modules 1 and 3 present screening and intervention within a psychiatric intervention context. Module 2 covers screening and intervention with gay male patients. Modules 4 and 6 provide curricula related to screening and intervention in primary care settings. Module 5 facilitates training screening and intervention skills for family violence across the lifespan, including child physical abuse, partner abuse and elder abuse. Modules 7 and 8 cover screening and intervention in pediatric settings, including emergency departments (Module 7) and outpatient adolescent medicine clinics (Module 8). Module 9 emphasizes assessment and intervention with abused patients in obstetrical settings. Modules 10 and 11 focus training on screening and intervention in emergency settings with both physical (Module 10) and sexual (Module 11) assault. Module 12 provides guidelines for training students to identify and help victims of elder abuse.

We wish to thank each of the module contributors for their excellent efforts to clarify goals, objectives, and methods and materials for training medical students to identify and help family violence victims. Each module is accompanied by the authors' names. Finally, this project was made possible by a grant from the Violence Against Women Act, administered by the Wisconsin Office of Justice Assistance.