JOURNAL OF WOMEN’S HEALTH
Volume 18, Number 2, 2009
© Mary Ann Liebert, Inc.
Report from the CDC
The Controversy on Screening for Intimate
Partner Violence: A Question of Semantics?
Joanne Klevens, M.D., Ph.D. and Linda E. Saltzman, Ph.D.
In this paper, we review the basis of the U.S. Preventive Services Task Force’s recommendations related to rou-
tine screening for intimate partner violence (IPV), focus on two of the arguments of those who have rejected
these recommendations, and based on these, suggest that this controversy has occurred, in part, as a result of
different interpretations of the meaning of “screening.” We differentiate screening from situations in which ask-
ing about IPV is essential for differential diagnosis, that is, exploring exposure to IPV when there are signs and
symptoms that might result from this exposure. Finally, we describe the randomized, controlled trial CDC is
conducting to contribute to the evidence the U.S. Preventive Services Task Force requries to make its recom-
U.S. Preventive Services Task Force (USPSTF) concluded,1as
have others,2,3that there was insufficient evidence to rec-
ommend for or against routine screening of women for IPV.
This recommendation sparked a flurry of reactions from
medical associations,4advocates,5and even an Annals of In-
ternal Medicine Editorial6rejecting the USPSTF’s conclusion
and recommending that screening be continued. Since the
USPSTF’s report was published, the debate has continued,7,8
which is why it might be useful to clarify some of the issues
involved. In this paper, we review the basis of the USPSTF’s
recommendations, focus on two of the arguments of those
who have rejected the recommendation on screening for IPV,
and based on these, suggest that this controversy has oc-
curred, in part, as a result of different interpretations of the
meaning of “screening.”
The USPSTF was convened by the Department of Health
and Human Services in 1984 to evaluate the scientific basis
of various preventive services and develop recommenda-
tions concerning their appropriate use in clinical settings.
The creation and approach of the USPSTF came in response
to increasing dissatisfaction with the efficiency and effec-
tiveness of the prevailing practice of the annual checkup, in
which a battery of tests and a complete physical examina-
tion were performed.9To formulate its recommendations,
N 2004, BASED ON A CAREFUL REVIEW of the evidence on the
impact of screening for intimate partner violence (IPV), the
the USPSTF conducts a systematic literature review and crit-
ical appraisal of studies identified in accordance with pre-
determined, standardized (across problem types) method-
ological criteria. Recommendations are based on explicit
rules of evidence applied equally to all interventions stud-
ied. Since its creation, the Task Force has reviewed the clin-
ical evidence, practice standards, and implementation issues
for more than 200 interventions. Its recommendations sum-
marize the Task Force members’ best judgment, based solely
on the scientific evidence of the utility of the selected clini-
cal preventive services. The purpose of this information is to
help clinicians with limited time or managed care providers
with limited resources to choose appropriate preventive in-
terventions for their patients.
The USPSTF judges the effectiveness of screening interven-
tions based on the availability of an accurate test that is able
to detect the target condition earlier than without screening
and the impact of screening and treating persons with early
disease on health outcomes.10Being able to accurately detect
a condition in its early stages is of little value, however, if there
is no efficacious treatment. Even if efficacious treatment is
available, the Task Force requires evidence that early detection
offers added health benefits over conventional diagnosis and
treatment for screening to be judged beneficial.
In judging the utility of an intervention, the Task Force
also considers its potential adverse effects. Many kinds of
Centers for Disease Control and Prevention, Atlanta, Georgia.
testing have potential adverse effects that include direct
physical or psychological harm from the test itself, and the
consequences of labeling and of diagnostic errors. Tests also
have economic costs, including opportunity costs. For ex-
ample, resources devoted to a screening program of uncer-
tain effectiveness may consume time, personnel, or money
that might be better invested in other more effective health-
The USPSTF’s methods and criteria,11which are similar to
those used in other countries,12,13have been systematically
applied to many other interventions in the clinical setting for
a variety of health problems. Some of these health problems
share similarities to IPV, such as screening for suicide risk
or alcohol misuse, in that detection depends on the patient’s
willingness to disclose.
There were various criticisms aimed at the methods used
by the Task Force to evaluate this intervention. Some argued
that the Task Force should have evaluated this intervention
as a behavioral assessment rather than as a screening inter-
vention.5They also criticized the report’s exclusion of re-
search publications, that evaluated screening among symp-
tomatic patients (e.g., patients with trauma). These criticisms
suggest that those who were making these criticisms were
not using the same definition of screening as the Task Force.
The USPSTF defines screening as a “preventive service in
which a special test or standardized examination procedure
is used to identify patients requiring special intervention.”11
Screening is carried out on asymptomatic persons, that is, in-
dividuals who lack any signs or symptoms of the target con-
dition. Tests involving symptomatic patients are not consid-
ered screening tests but diagnostic tests. Thus, asking a
woman about IPV when she comes to the emergency de-
partment because of an injury would be part of the effort to
make a diagnosis, not screening. It follows that studies eval-
uating the use of these tests among symptomatic patients
would have to be excluded from the Task Force’s review.
Clinicians devote a great deal of their time to diagnosing
diseases. Diagnosis is based, for the most part, on history
taking and physical examination. Physicians commonly con-
sider various diagnoses (differential diagnoses) before reach-
ing a definitive one for which they will then decide on a
course of treatment. Physicians are expected to make their
best effort in coming to a correct diagnosis regardless of the
availability of effective treatments. The Task Force’s recom-
mendation applies only to the use of IPV screening tools
among asymptomatic patients, not when there are symptoms
that could be related to IPV.
IPV has been associated with numerous clinical condi-
tions, including migraine and headaches, back pain, arthri-
tis, appetite loss, stomach ulcers, spastic colon, frequent
indigestion, diarrhea, constipation, digestive problems, ab-
dominal pain, chronic pelvic pain, sexually transmitted dis-
eases, vaginal bleeding, vaginal infections, pelvic pain,
painful intercourse, urinary tract infections,14,15depression,
substance abuse, suicidality, posttraumatic stress disorder
(PTSD),16and, of course, injuries. Given the prevalence of
IPV and the increasing evidence suggesting a causal mech-
anism for IPV in these illnesses or conditions,17–19its pres-
ence should be routinely explored and considered as a dif-
ferential diagnosis in these conditions.
On the other hand, as previously explained, expecting
healthcare providers with limited time and resources to ask
women about IPV in the absence of any signs or symptoms
(i.e., screening) requires that we have evidence that early
treatment (during the asymptomatic period) produces bet-
ter health outcomes than waiting for the appearance of
symptoms and a diagnosis. There are reasons to suspect that
it may not. Most IPV disappears on its own.20,21Moreover,
although there are interventions that appear promising,
these often require that the diagnosed patient actively seek
to use available services. Possibly, women who have not ex-
perienced any signs or symptoms as a result of exposure to
IPV may not be ready or willing to use these services.
In addition, because women being screened are relatively
healthy, it is important to make sure they are not being need-
lessly harmed by this intervention. Qualitative studies have
suggested that asking women about IPV may reinforce their
feelings of being stigmatized and increase their anxiety.22
Women also report feeling disappointed in their healthcare
providers’ behavior, often finding the provider uninterested,
uncaring, or uncomfortable.23,24As the Task Force noted, the
potential harms of screening for IPV need to be documented
in more rigorous studies. There have been many examples
of well-intentioned or intuitively appropriate interventions
leading to harm (e.g., banning relatives from the delivery
room, not realizing the importance of social support25;
bedrest for low back pain, which can delay recovery26).
Clinicians might want to consider other factors, in addi-
tion to the scientific evidence, before deciding to routinely
screen their own patients. Perhaps a case might be made for
screening in order to provide information to patients so they
can make informed choices as to their best options. Clini-
cians might provide their patients with information on the
potential benefits and harms of screening so that patients can
decide for themselves whether or not they want to be
An additional criticism of the methods used by the Task
Force was its limited focus on morbidity, disability, and mor-
tality as outcomes.5However, if healthcare providers with
limited time and resources are asked to deliver an interven-
tion, we need to have evidence that the intervention im-
proves the outcomes healthcare providers are trained to fo-
cus on. To address the need for evidence of the impact of
screening on women’s health and potential harms of screen-
ing, the CDC is currently conducting a large three-arm ran-
domized, controlled trial. This trial will compare the impact
of computerized screening and referral to advocacy services
with the provision of information on IPV services to all pa-
tients and to a “no screen no referral” control group. Out-
comes will be assessed at a 1-year follow-up and include dis-
ability, healthcare utilization, mental health, and exposure to
IPV. Harms from exposure to screening will also be assessed.
The results of this trial, which are anticipated to be available
by 2012, should inform future reviews and recommendations
from the Task Force. In the interim, the Task Force’s state-
ment, based on the scientific evidence using the criteria they
apply to all the screening interventions they review, says
nothing about exploring IPV as a differential diagnosis in pa-
tients with signs or symptoms that are associated with IPV.
This is part of every physician’s responsibility to reach a cor-
rect diagnosis and appropriately treat and manage their pa-
The debate surrounding screening for IPV will likely con-
tinue based on other arguments. With these clarifications
KLEVENS AND SALTZMAN ET AL.144
about the meaning of screening and the evidence required Download full-text
in order to ask that healthcare providers implement this in-
tervention, we hope that those on different sides of the de-
bate will have a better understanding of each other’s per-
spectives. In addition, we believe that the research being
undertaken by CDC has the potential to further clarify
whether or not screening could feasibly be taken on by
healthcare providers. Regardless of the outcome of the
screening debate, we assert that healthcare providers should
continue to or begin to inquire about exposure to IPV in pa-
tients who have signs or symptoms associated with IPV.
This paper is dedicated to the memory of co-author, Linda
E. Saltzman, who passed away suddenly while this paper
was in progress.
The findings and conclusions in this report are those of
the authors and do not necessarily represent the official po-
sition of the Centers for Disease Control and Prevention/the
Agency for Toxic Substances and Disease Registry.
No competing financial interests exist.
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Address reprint requests to:
Joanne Klevens, M.D., Ph.D.
Centers for Disease Control and Prevention
4770 Buford Highway, Mailstop F-64
Atlanta, GA 30341
DEBATE ON SCREENING FOR IPV145