Feature: Violence and Healthcare
Interview with Esta Soler and Lisa James
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LJ: This isn’t exactly an exhaustive list: reporting – states should not mandate that women and doctors report violence to the police, insurance – victims should not be discriminated against (they have been in the past), training - healthcare providers need to learn how to recognize and help a victim, screening – meaning asking women during checkups whether they are victims of abuse, and protocols – health systems must have clear steps for doctors to follow.
The Trouble with Mandatory Reporting
HHPR: Does mandatory reporting help victims of domestic violence?LJ: No. Further endangering the victim is the problem with mandating the reporting of domestic violence to the law enforcement without the victim’s consent. There’s a very real fear of retaliation. If we were confident that the batterer would be put away and safely out of arm’s reach, that might be a different story. But in many cases, the best scenario for the patient is not to have her perpetrator either arrested or re-released.
However, when states have had mandatory reporting laws, we found that the awareness of domestic violence as a household issue increased because the healthcare providers are particularly concerned with liability and their ethical and legal obligation. So it’s been good in that way in many states.
HHPR: Who should be making the decision to report domestic violence – the victim, the doctor, or the law?
LJ: It’s critical that we leave the decision-making power in the hands of the victim. She knows what’s best for her. We have also found, anecdotally, on a large scale, that many victims of violence are hesitant to come to the healthcare setting because they know about the reporting requirement, so they’re hesitant to disclose. And more frightening is that they’re hesitant even to seek health care.
HHPR: To ensure that the victim is in control of her medical records and safety, who should be responsible for protecting the confidentiality of what goes on during the checkup – the healthcare system or the criminal justice system?
ES: What you don’t want is to turn all of the intervention and screening that’s going on in the healthcare system - albeit not as much as we want - into a law enforcement program. We want it to be a healthcare program. We’re not saying that we should create separate and unequal laws with respect to domestic violence. We do agree that you must report a serious felonious assault, but not every incidence of domestic violence is like that.
Mandatory reporting undermines the responsibility of the physician, and there’s no evidence that the criminal justice system is the best place for all situations, so why do that? It just creates an additional burden — and the efficacy of that is still very much in doubt.
The National Academy of Science’s report from a couple years ago told states that you should not do mandatory reporting until you do the research to see whether it’s the right way to go. So there’s been a real slowing down of that public policy.
We believe very strongly that the whole approach to the issue of domestic violence is not just about health intervention and screening. It is about setting a public health framework on this issue. The strategies that you use are different than if you just set a criminal justice framework. For us, the public health and the healthcare system are two of the places where we really would like to see a significant shift away from having this almost sole reliance on the institution of the justice system to deliver this service. We haven’t seen that shift, but that’s what we’re working on.
Insurance Discrimination
HHPR: How have insurance companies treated victims of domestic violence in the past?LJ: A while back, we found that a number of insurance companies were discriminating against the victims of violence and denying them insurance, basically putting them and their experience as a victim of domestic violence on par with people like hang-gliders or people who do highly dangerous activities.
HHPR: And how have states responded?
LJ: Before the Pennsylvania Coalition Against Domestic Violence (PCADV) took this issue on, a lot of the major insurance companies were denying coverage to victims of violence. It was only through the hard work of the Pennsylvania Coalition in helping states pass laws that prohibited insurance discrimination that we’ve come quite far in this area.
Twenty-two states have enacted legislation that protects victims of domestic violence. The leadership there is thanks to Nancy Durborow from the PCADV. Overall, we still need to continue to work to strengthen those discrimination laws, because as we encourage providers to screen, intervene, and document, we definitely don’t want it to then come back to the victim and harm her in some other way.
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