Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.
To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.
Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.
"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.
A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).
Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.
"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.
When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.
Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.
Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.
She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.