ARCHIVED: Appendix I: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Inquiry about interpersonal violence

Appendix I: The Evidence Debate Pertaining to Inquiry about Interpersonal Violence

While the empirical evidence is clear about the high prevalence of childhood sexual abuse and links between childhood adversity and adult health problems, it is less clear about whether health care practitioners should routinely assess for current and past abuse/violence (usually including intimate partner (or domestic) violence and childhood abuse). Three recent systematic reviews from the United States,¹¹⁵ Britain,¹²³ and Canada¹⁷⁹ concluded that there is insufficient evidence to recommend routine screening for family and/or intimate partner violence. In contrast, the Intimate Partner Violence Working Group of the Society of Obstetricians and Gynaecologists of Canada (SOGC)¹⁵³ and the Registered Nurses of Ontario¹²⁸ both issued clinical practice guidelines endorsing routine assessment for intimate partner violence/woman abuse as standard practice. Furthermore, existing practice guidelines and recommendations for management of a number of conditions also call for an assessment of abuse history (e.g.,^{6,7, 8,12).}

This debate is pertinent to any discussion of making inquiries about a history of child sexual abuse. Exposure to childhood violence or abuse increases an individual's risk for intimate partner violence in adulthood (e.g.,¹⁷). Because the two co-occur with some frequency, childhood abuse/ violence and intimate partner violence may not be categorically discrete entities. This means that if an individual discloses intimate partner violence, there is also the possibility of past childhood abuse/violence.

Considerable expert opinion (including^57,153,181) disagrees with the findings of the systematic reviews cited above. Much of this disagreement centres around the distinction between inquiring about violence and screening (which by definition must meet strict requirements related to lack of symptoms, specificity, sensitivity, positive predictive value, negative predictive value, etc.). Those who oppose universal screening point to the "absence of any high quality evidence of the benefit and a similar lack of evidence that screening does not harm."^181p.163 Those who support routinely inquiring about violence point out that such inquiry does not equate to screening but rather, represents "asking questions about domestic violence during a health care contact."^181p.163 The SOGC reiterates this in its consensus statement on intimate partner violence screening:

Asking women about violence is not a screening intervention [emphasis added]: victims are not asymptomatic; disclosure is not a test result, it is a voluntary act, and the presence or absence of violence is not under the victims' control; and most interventions required to protect and support survivors are societal, not medical.153p.366

Because the three systematic reviews looked only at those studies that met the criteria for "screening," they considered only a small portion of the existing intimate partner violence research. For example, of the 806 abstracts that related to screening for intimate partner violence, only 14 met the inclusion criteria that Nelson and colleagues115 used; similarly, only two of the 667 abstracts on intimate partner violence intervention studies were considered.57 This led the Family Violence Prevention Fund's Research Committee to conclude:

As a consequence of this overly narrow approach to what the most relevant research questions are, an important body of studies related to IPV [intimate partner violence] was not considered. The outcomes most closely focused on are harm, death, and disability. In contrast, most researchers in the field would expect that measurable benefits (desirable outcomes) would include improved health and safety of the patient and their children, enhanced protective factors, and decreased frequency and severity of physical and/or emotional abuse.^57p.2

We believe that the research on which this Handbook is based further supports the argument that routinely inquiring about a history of past abuse is not harmful to individuals and, if done in a sensitive and informed manner, is likely to lead to improved health for all patients.