Domestic violence and the definition of screening

We are currently completing a review of the evidence for screening for domestic violence, which the United Kingdom National Screening Committee commissioned us to undertake. We note the Committee's proposal to change the definition of screening which it originally adopted, and the commentary written by Wald (Wald N. The definition of screening. J Med Screen 2001;8:1.). Domestic violence is a problem that does not easily fit into a medical model. Many of the most extreme consequences are treated by the health sector (injury, psychological distress, etc), but the likely solutions to the problem largely lie with the women experiencing domestic violence with assistance from outside the health sector. Nevertheless, as far as screening for domestic violence is concerned, the Committee's earlier definition focusing on a disorder rather than a disease is preferable, although neither is entirely appropriate. We agree with Wald that a person's perception of risk is not of relevance in coming to a decision on whether he or she should be the focus of a screening program. The important point about screening for domestic violence is that women may not have sought medical attention (or may have done so but have been ignored) and this aspect is absent from the new definition. Also, women experiencing domestic violence are only too aware of the risks posed by an abusive partner. The reviews we have conducted so far suggest that screening for domestic violence using either definition) is not currently justified. However, it is an issue with major health impact which health services need to con- sider, and screening should not be ruled out on the basis of a women's knowledge of risk. The same arguments would also apply to some existing screening programs--for example, breast screening--where a woman may know that she is at high risk perhaps from her family history but has failed for various reasons to seek medical attention for a breast lump. Similarly, those screened for hypertension may know the risks, but still benefit from screening. Again, the earlier definition of screening better encompasses the purpose of screening. We strongly advise the committee not to adopt the new definition.