The First Step Begins Within Each of Us

In 1980, fresh out of the National Health Service Corps (NHSC), I was looking for somewhere to practice as a pediatric nurse practitioner. My colleague, Jacquelyn Campbell, suggested that I could begin by volunteering at a battered women’s shelter in our community. My response was “A what?” Even though I’d just completed two years of service as a NHSC assignee and was certified as a pediatric nurse practitioner, I had never heard of an emergency battered women’s shelter. Jackie, in contrast, had conducted a study of femicide as part of her master’s thesis and had a growing awareness of the problem of violence against women. Together, we decided that as nurses we needed to do something and the one thing we had to offer was our clinical expertise. I distinctly remember calling one of the shelters in our community and telling them that two master’s-prepared nurses with extensive clinical experience wanted to volunteer. There was a long pause on the other end of the phone. “Could you take blood pressures?” the voice on the other end tentatively asked. “Yes, we could do that” I replied, and a focus that has guided my professional career began right there. Jackie and I became increasingly aware that although health care providers were interacting with abused women and their children every day, there was scant literature to guide clinical practice. This is worrisome in light of North American, population-based surveys that document that between 8% and 14% of women of all ages report physical assault in the previous year by a husband, boyfriend, or ex-partner; the lifetime prevalence of intimate partner violence (IPV) is between 25% and 30%. Estimates of the number of women presenting in health care settings with a history of IPV in the prior year varies between 4% and 23%, with middle-income, well-educated women having the lowest rates and poorer women the highest. Lifetime prevalence is estimated to be one-third of all women in any health care setting. As we became more in tune with the needs of abused women and their children, we began encouraging our students to screen for violence as part of their routine assessments. Our urging to ask about violence, which to us seemed simple and perfectly obvious, has never been simple for many of our students and colleagues. The reasons for being hesitant to ask about violence are well documented. Recently, the United States Preventive Services Task Force concluded that there was insufficient evidence to support universal screening for IPV—an assertion that was rigorously disputed. Of late, I’ve begun to hear a new excuse for why it might not be a good idea to routinely ask about violence in clinical assessments: it has been proposed that screening for violence might cause harm to the patient. In this issue of the Journal of Midwifery & Women’s Health, compelling research is presented that addresses these and other concerns that have direct relevance to clinical practice. It is also worth noting that, unlike previous continuing education issues of the Journal of Midwifery & Women’s Health, all of the articles are research reports, which is further evidence of the ongoing attention being given to this pervasive problem. Koziol-McLain et al. provide convincing evidence that IPV screening is nonthreatening and safe. In fact, the abused women in their study themselves recognize that being asked about IPV is an essential step in addressing a problem that disproportionately affects women and their children. Yet professionals continue to struggle with how to ask about violence and trauma. Renker expertly analyzes computer-assisted self-interviews as a promising approach to IPV screening. The need to consider violence and trauma is not limited to women’s health practice settings. Ellis et al. describe how the rural abused mothers in their study sought health care more often than the nonabused women for their infants. The authors suggest that hypervigilance in abused women may explain their greater use of pediatric care. However, they also suggest that these abused, rural women may seek our help as a safety net to supplement scant available services. Likewise, Chan et al. document the pervasiveness of physical assault, sexual coercion, and suicidal ideation among university students in 21 countries. In the median country in their study, 30% of the students had physically assaulted a dating partner in the previous 12 months alone! Data amassed over the past 20 years, including articles in this issue, demonstrate the immense physical and psychological health consequences that result from IPV. Studies in this issue and elsewhere note that abused women have poor health status, poor quality of life, and high use of health services, and these findings persist long after the IPV has ended. Woods et al. explicate the complex relationship between IPV and women’s physical health symptoms and provide compelling evidence that may help us to understand why these sequelae persist. Likewise, Seng et al. document the mental health and behavioral risk sequelae that affect abuse survivors in prenatal care, and Fried et al. offer