Inside "Pandora's box" - Abused women's experiences with clinicians and health services

OBJECTIVE: To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting. DESIGN: Focus group data conducted and analyzed with qualitative methodology. SETTING: Three community-based mental health centers and one women's shelter. PARTICIPANTS: Twenty-one women in group therapy for domestic violence. MAIN RESULTS: Eighteen (86%) of the 21 women had seen their "regular doctor" in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse. CONCLUSIONS: Many abused women experience worsening health and seek medical care: most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences.