Utah researchers say nearly half of patients withhold serious issues like domestic violence or sexual assault from doctors

Jordan Allred, Deseret News

Advocates working to help people feel comfortable to find the resources they need

SALT LAKE CITY — Nearly half of those facing domestic violence, recovering from sexual assault or experiencing depression don’t tell their doctors about those issues that can be life-threatening, according to new research.

“These are really sensitive issues and things that are very difficult to discuss with your best friend, much less your primary care provider,” said Angela Fagerlin, first author of the study published recently in JAMA Network Open.

But telling one’s doctor can be the first step in receiving essential help.

“We think it’s really important because many of these four issues can have at least a temporary, if not sometimes a significantly long term, impact on people’s both mental and physical health,” Fagerlin said.

“For providers to really provide the best physical care for their patients, they need to know whether these things are impacting their mental or physical health.”

Fagerlin serves as chairwoman of the University of Utah Department of Population Health Sciences and is an investigator with the V.A. Salt Lake City Health System’s Informatics Decision-Enhancement and Analytic Sciences Center for Innovation.

U. researchers worked with researchers from Middlesex Community College, University of Michigan and University of Iowa to analyze responses from 4,500 people who participated in two national surveys in 2015.

They found that between 40% and 47.5% of survey participants chose not to tell their primary care providers that they had experienced at least one of the issues. More than 70% of those said it was because they were embarrassed, researchers said.

Other reasons for not disclosing the threats included fear of judgement or being lectured, and concern that they would be required to do something they didn’t want to do if they told their provider.

Dr. Kathy Franchek-Roa, assistant professor in the U. Department of Pediatrics and staff member at Primary Children’s Medical Center, said she believes a problem might be that providers and physicians often “haven’t been trauma-informed.”

The U. is trying to create a trauma-informed system and use “a universal approach to everybody as if they have been traumatized, because we know more than half of adults in this state have had a significant adverse childhood experience.”

Though not everyone has been traumatized, she said it’s important to approach everyone with sensitivity as if they have. Over the years, according to Francheck, oftentimes when people have disclosed the issues to health providers “they got a really negative response” that included victim blaming. That’s due to a lack of education and understanding, Franchek-Roa said.

Fagerlin wanted to emphasize that the researchers aren’t suggesting that “patients are doing something wrong,” or that patients are responsible to share the information. Instead, the research was meant to help figure out why people don’t disclose certain issues and to help doctors learn how to make them feel more comfortable.

It’s a problem that the Utah Domestic Violence Coalition has been fighting for the last few years.

Jenn Oxborrow, coalition executive director, said the study’s findings are “pretty consistent with what we’ve known for a long time about reporting and how people work with their medical professionals, and how we really have a lot of work to do there to improve the way that we screen and engage in a trauma-informed way.”

The coalition represents a team of community-based programs statewide that provide services to survivors.

“One of the things that we hear consistently from our programs across the state, and from over 40,000 crisis calls that we take per year, is that people are really scared to talk about this. They’re afraid of victim shame. They’re afraid of getting in trouble. They’re afraid of implications in their parental rights,” Oxborrow explained.

“And so I think that’s one of the big reasons that we see these barriers with medical professionals, too. People are afraid to talk to their doctors sometimes because they’re afraid that their doctor will have to report something. And that can be a very scary thing. It can be a very dangerous thing, too, for a survivor.”

Dr. Audrey Jiricko, an obstetrician and gynecologist at Intermountain Healthcare, says that when she started practicing, she didn’t see a lot of patients who disclosed those threats.

“The first 10 years I was in practice, I did not screen for traumatic stressors like sexual assault and domestic violence. And so I didn’t really see it because it wasn’t on my mind and I wasn’t asking routinely about it,” she recalled.

But Jiricko said that once some survivors opened up to her and told her about their experiences, as well as information they’d like to receive in health care, she realized: “I really need to be routinely asking people about sexual violence and intimate partner violence, or domestic violence.”

Since she started screening patients routinely, “Now I see (those issues) every day in my practice. But it’s definitely been a process of figuring out how to effectively screen.”

According to Jiricko, patients often have real concerns about where the information will go, confidentiality and judgement, as well as not being believed. Doctors are required to report to police when someone tells them children are witnessing domestic violence, if they come in for treatment to an injury caused by someone else, or if they’ve been threatened with a lethal weapon.

She said it’s helpful to let patients know that before she even asks them screening questions. “Just so they know where they stand, because I think a lot of patients are scared. ‘What is going to happen? Is someone going to call the police? Because sometimes that’s not very helpful. That might put me at more risk, or in more danger from a partner.’”

Patients also want to know that there’s real help available.

“It doesn’t really help to disclose something and then there’s nothing really definable that’s going to actually improve their quality of life. And I feel like if patients know there’s something that can really improve their quality of life, they’re much more likely to disclose.”

Jiricko says she always asks a “framing question.” First, she’ll let patients know the statistics about sexual assault — that 1 in 3 women in Utah are sexually assaulted in their life — and asks if it’s ever been a problem for them.

“And I find that that has really opened a lot of people up because they’re surprised, ‘Wow, it’s that common.’”

It’s important for patients to tell their doctors about those issues because traumatic stress can cause a number of different health problems, including higher rates of depression, anxiety and suicidality, Jiricko said. It can also cause higher rates of gastrointestinal problems, chronic pain, headaches, and even heart and lung conditions.

“So we’re trying to do a better job as a health care community to screen for these things and help people understand that it really does affect their physical and mental health, and that learning more about it and getting counseling really can help patients.”

The Utah Domestic Violence Coalition has been working “extensively” with law enforcement agencies, paramedics and doctors to standardize the way they assess risk and help patients open up about serious threats to their well-being.

That work can save lives, Oxborrow said.

Last year, at least a third of Utah’s 78 homicide victims were killed by someone who was either related, dating or previously acquainted to them, according to statistics kept by the Deseret News.

“We don’t have a lot of murders overall, but an exceptional number of the homicides that are perpetrated in Utah are perpetrated by a current or former intimate partner. Typically a man with a gun against a woman, and if it’s someone that has had a history of an ongoing set of risk factors that if we can recognize, we can start to intervene and get someone some help sooner,” Oxborrow said.

Research has shown that if domestic violence is screened earlier, domestic violence homicides can be prevented, according to Oxborrow. Additionally, when someone at a high risk of abuse meets with a professional victim advocate, their risk of re-assault decreases by 65%, she said.

Improving communication between different entities and standardizing risk assessment across the state can help ensure that victims don’t have to repeatedly answer questions and tell their stories to receive help.

Fagerlin said she would like to see the research lead to new studies that test different interventions to help improve patients’ disclosure of sensitive information to their providers. She also hopes the health community can find better solutions to make patients feel more confident to disclose the information.

Help for those facing domestic violence can be found by calling the Utah Domestic Violence Hotline at 1-800-897-LINK.

Those who have experienced sexual abuse or assault can get assistance from Utah’s statewide 24-hour Rape and Sexual Assault Crisis Line at 888-421-1100.

The Utah Department of Health offers suicide prevention help at utahsuicideprevention.org/suicide-prevention-basics. The national crisis hotline is 1-800-784-2433.

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