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Brief Report |

Mandatory Reporting of Domestic Violence Injuries to the Police:  What Do Emergency Department Patients Think? FREE

Michael A. Rodríguez, MD, MPH; Elizabeth McLoughlin, ScD; Gregory Nah, MS; Jacquelyn C. Campbell, PhD, RN, FAAN
[+] Author Affiliations

Author Affiliations: Department of Family and Community Medicine, University of California, San Francisco (Dr Rodríguez); Trauma Foundation (Dr McLoughlin and Mr Nah), and The Johns Hopkins University School of Nursing (Dr Campbell) Baltimore, Md.


JAMA. 2001;286(5):580-583. doi:10.1001/jama.286.5.580.
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Published online

Context Laws requiring mandatory reporting of domestic violence to police exist in 4 states. Controversy exists about the risks and benefits of such laws.

Objective To examine attitudes of female emergency department patients toward mandatory reporting of domestic violence injuries to police and how these attitudes may differ by abuse status.

Design, Setting, and Participants Cross-sectional survey conducted in 1996 of 1218 women patients (72.8% response rate) in 12 emergency departments in California (a state with a mandatory reporting law) and Pennsylvania (without such a law).

Main Outcome Measures Opposition to mandatory reporting to police and the characteristics associated with this belief.

Results Twelve percent of respondents (n = 140) reported physical or sexual abuse within the past year by a current or former partner. Of abused women, 55.7% supported mandatory reporting and 44.3% opposed mandatory reporting (7.9% preferred that physicians never report abuse to police and 36.4% preferred physicians report only with patient consent). Among nonabused women, 70.7% (n = 728) supported mandatory reporting and 29.3% opposed mandatory reporting. Patients currently seeing/living with partners (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.0), non-English speakers (OR, 2.1; 95% CI, 1.4-3.0), and those who had experienced physical or sexual abuse within the last year (OR, 2.2; 95% CI, 1.6-2.9) had higher odds of opposing mandatory reporting of domestic violence injuries. There were no differences in attitudes by location (California vs Pennsylvania).

Conclusions The efficacy of mandatory reporting of domestic violence to police should be further assessed, and policymakers should consider options that include consent of patients before wider implementation.

Most states require clinicians to report to police injuries due to violence, criminal acts, or deadly weapons.1 From 1991 to 1994, California, Colorado, Rhode Island, and Kentucky passed various forms of mandatory reporting laws requiring health care professionals to report intimate partner violence (IPV) to the police. Since 1994, California has required clinicians to report to police suspected IPV-related injuries, even if this is contrary to patient wishes. Noncomplying clinicians face penalties of fines up to $1000 and/or jail sentences of up to 6 months in California. The law does not specify how police should respond, local jurisdictions vary in response, and the degree of enforcement is unknown.

Mandatory reporting is controversial among clinicians, patients, and domestic violence prevention advocates. Supporters of the policy argue that it will facilitate the prosecution of batterers, encourage health care clinicians to identify domestic violence, and improve data collection.2,3 Opponents believe it may increase violence by the perpetrators, diminish patients' autonomy, and compromise patient-clinician confidentiality.4,5 Mandatory reporting laws are not affected by the new Federal Medical Privacy Protections for Victims of Domestic Violence because they fall under the provision relating to disclosures required by law.6 The National Resource Council has recommended a moratorium on such laws until more research is conducted on the advantages and disadvantages of mandatory reporting policies for domestic violence.7

While patients frequently look to police for help during acute episodes of violence, clinician reporting to police may raise fears of increased violence, loss of control, and family separation, all of which may lead some abused patients to avoid seeking help from health care clinicians.2 Two recent studies have found that some women may be supportive of mandatory reporting policies.8,9 However, another study reports that a majority of abused patients are opposed to mandatory reporting of IPV to police.4 A Colorado study found that 9% of female patient respondents were less likely to seek medical care as a result of mandatory reporting.10 Limitations of these studies include low response rates, small sample sizes, or samples primarily from states where specific domestic violence mandatory reporting laws do not exist. An evaluation of an emergency department intervention to improve the health system response to abused patients permitted us to survey a large random sample of female patients in California and Pennsylvania about mandatory reporting. Unlike California, Pennsylvania does not have a specific law that mandates clinicians to report IPV to police.

The patient survey was part of an emergency department IPV intervention study and involved 12 emergency departments, randomly drawn from all midsized hospitals (20 000-40 000 patient visits annually) within 160 km of San Francisco, Calif, and Pittsburgh, Pa.11 In contrast to previous published analyses of 3 waves of data collection for 11 of these 12 emergency departments,12 this study used only the third wave of patient surveys from all 12 emergency departments. Response rates had improved for that wave and the questions on mandatory reporting had been revised to allow for better assessment of patient preferences. We attempted to survey 1672 patients during 1996 using the Patient Satisfaction and Safety Survey, an anonymous self-administered questionnaire. The questionnaire contained 20 items designed to (1) verify eligibility for participation; (2) identify patients currently in abusive relationships; (3) assess satisfaction with care; and (4) determine attitudes about mandatory reporting of domestic violence to police. To assess abuse status and identify those patients with histories of physical or sexual partner violence in the previous year we used the Abuse Assessment Screen.13 To assess patients' attitudes toward the mandatory reporting law, respondents were asked the question: "Do you think that the emergency department staff in hospitals should be required to call the police when they think that a husband, boyfriend, or partner (ex-husband, ex-boyfriend, ex-partner) has hurt or abused an adult patient?" Respondents were given 3 options: (1) yes, every time; (2) every time unless the patient objects; or (3) never.

Data were collected from any eligible woman patient by female nurses during 8-hour and 12-hour evening shifts between Friday and Tuesday to obtain representation from weekday and weekend shifts. We excluded patients too ill to respond to questions and those never left alone by accompanying persons. The institutional review boards at the coordinating institutions in Pennsylvania and California approved the study. Signed consent forms were waived by the institutional review boards and oral consent was obtained. The patients were informed that the questionnaire was anonymous and voluntary, had no impact on the care they would receive, and would not be seen by the clinicians treating them that day.

We analyzed the data using univariate and logistic regression analysis. For cross-tabulation, mandatory reporting attitudinal responses were dichotomized into "report always" (support) vs "report never" or "only with patient consent" (oppose). Predictor variables included age, race, primary language spoken at home, total family income per month, relationship status, and partner violence in the past year. Statistical significance was determined by Pearson χ2 statistical test with a 2-tailed P value of less than .05. We generated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for factors independently associated with opposition to mandatory reporting. All statistical analyses were conducted using SAS version 8 software (SAS Institute Inc, Cary, NC).

A total of 1218 eligible emergency department patients responded to the Patient Satisfaction and Safety Survey (response rate, 72.8%). Overall, the response rates for respondents who answered the question on mandatory reporting and completed information on each characteristic ranged from 67.3% to 70.2%. There were no significant state-specific differences in response to the survey attitudinal questions, including support for or opposition to mandatory reporting laws.11 Overall, 12.0% of respondents (n = 140) reported being physically abused or forced to have sexual activities in the previous year.

Among the abused respondents, 44.3% (n = 62) opposed mandatory reporting of domestic violence to police (36.4% [n = 51] supported reporting but only with patient consent; 7.9% [n = 11] thought that physicians should never report to police), while 55.7% (n = 78) supported mandatory reporting. Of nonabused respondents 70.7% (n = 728) reported higher levels of support for the policy, while 29.3% (n = 301) opposed the law (25.7% [n = 264] favored reporting with consent; 3.6% [n = 37] preferred physicians never to report, P<.001).

Women who opposed the mandatory reporting policy tended to be young (34.3% of 18-39 years old vs 28.3% of those >40 years old, P = .03); nonwhite (35.9% of nonwhite patients vs 29.0% of white patients, P = .02); non-English speakers at home (41.7% of non-English speakers vs 30.3% of primary English speakers, P = .04); and abused (44.3% of those reporting abuse in the past year vs 29.2% of those reporting no abuse, P = .001) (Table 1). Opposition to the policy did not differ significantly by relationship status, total family income per month, or state (California vs Pennsylvania).

Table Graphic Jump LocationTable. Characteristics of Respondents and Factors Associated With Opposition to and Support for Mandatory Reporting of Intimate Partner Violence to Police (N = 1218)*

Based on regression analysis, the following factors were independently predictive of favoring nonreporting when a patient objects: (1) physical abuse in the last year (adjusted OR, 2.2; 95% CI, 1.6-2.9); (2) non-English spoken at home (adjusted OR, 2.1; 95% CI, 1.4-3.0); and (3) currently seeing/living with a partner (adjusted OR, 1.5; 95% CI, 1.1-2.0).

In this study, 44.3% of recently abused female emergency department patients do not support mandatory reporting of domestic violence to police. Possible reasons for such opposition include fear of retaliation by the abuser, fear of family separation, mistrust of the legal system, and preference for confidentiality and autonomy in the patient-clinician relationship.2 Yet, our study also demonstrated that a higher percentage (55.7%) of recently abused female emergency department patients do support mandatory reporting. This may be due to desires for enhanced safety and relief from the onus of making a police report.

Many patients supported IPV reporting policies that take into consideration patients' preferences. For example, of the 44.3% of women with recent histories of abuse who opposed mandatory reporting, the very women who would potentially be reported to police, the majority selected the response indicating support for reporting to police unless the patient objects. Further research with abused women is needed to distinguish their preferences among several options: (1) a law requiring reporting unless the patient objects; (2) a reporting law that requires patient consent; or (3) no reporting laws but physician responsiveness to IPV and assistance with criminal justice interventions when desired.

Similar to the women with recent histories of abuse, 41.7% of women who were primarily non-English speakers were opposed to mandatory reporting. These findings are consistent with previous qualitative research in which abused women expressed the belief that they should control the decisions to involve the police.2 Another study has explored sociopolitical factors that hinder abused immigrant women from seeking help, including social isolation, language barriers, and fear of deportation.14 Because the impact of police involvement in immigrant women's lives may be different than for US-born women, changes in welfare and immigration laws may interact with this policy, resulting in further disempowerment of the female patient. Given the attitudes expressed by the respondents in these studies, it is unclear whether mandatory reporting will help recent IPV survivors or put them at risk for further violence. One clinical alternative is to encourage the assessment of danger that can help women and clinicians assess safety, yet leave the final decision as to whether to call the police with the patient.15

Physicians' attitudes regarding mandatory reporting have varied. In a previous survey of physicians in California, 53% to 85% responded that such policies could prevent women from seeking medical care, provoke retaliation, or compromise confidentiality and autonomy.5 In the same survey, 53% to 86% believed that these policies can increase recognition and responsiveness to domestic violence, as well as improve and increase documentation and collection of statistics.5

One limitation of our study is that we only surveyed patients seeking care at emergency departments. Therefore, we missed IPV survivors who may have been deterred from seeking help for reasons that include fear that they may be reported to the police. This limitation would have the impact of underestimating the degree of opposition among abused women to laws that mandate reporting IPV to police.

Further research on mandatory reporting is needed to address the preferences of those in abusive relationships. Research should also track patient and clinician outcomes in other states that require reporting IPV to police. Lacking answers to these concerns, our research suggests that policymakers should consider development of IPV reporting policy options that combine respect for patient autonomy with the greatest potential for protection from abuse.

Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: do they promote patient well-being?  JAMA.1995;273:1781-1787.
Rodriguez MA, Craig AM, Mooney DR.  et al.  Patient attitudes about mandatory reporting of domestic violence: implications for health care professionals.  West J Med.1998;169:337-341.
Larkin H, O'Malley N. In favor of mandatory reporting.  West J Med.1999;171:119-121.
Gielen AC, O'Campo PJ, Campbell JC.  et al.  Women's opinions about domestic violence screening and mandatory reporting.  Am J Prev Med.2000;19:279-285.
Rodriguez M, McLoughlin E, Bauer H, Paredes V, Grumbach K. Mandatory reporting of intimate partner violence to police: views of physicians in California.  Am J Public Health.1999;89:575-578.
Goldman J, Hudson RM, Hudson Z, Sawires P. Health Privacy Principles for Protecting Victims of Domestic Violence. San Francisco, Calif: Family Violence Prevention Fund; October 2000. Available at: http://fvpf.org/programs/display.php3?DocID=53. Accessed May 15, 2001.
Chalk R, King P. Violence in Families. Washington, DC: National Academy Press; 1998.
Sachs C, Koziol-McLain J, Glass N, Webster D, Campbell J. A population-based survey assessing support for mandatory domestic violence reporting by healthcare personnel.  Women Health.In press.
Coulter M, Chez R. Domestic violence victims support mandatory reporting: for others.  J Fam Violence.1997;12:349-356.
Houry D, Feldhaus K, Thorson A, Abbott J. Mandatory reporting laws do not deter patients from seeking medical care.  Ann Emerg Med.1999;34:336-341.
Campbell JC, Coben JH, McLoughlin E.  et al.  An evaluation of a system change training model to improve emergency department reponse to battered women.  Acad Emerg Med.2001;8:131-138.
Dearwater S, Boben J, Campbell J.  et al.  Prevalence of intimate partner abuse in women treated at community hospital emergency departments.  JAMA.1998;280:433-438.
Soeken K, Parker B, McFarlane J, Lominak MC. The Abuse Assessment Screen: a clinical instrument to measure frequency, severity and perpetrator of abuse against women. In: Campbell J, ed. Empowering Survivors of Abuse: Health Care for Battered Women and Their Children. Thousand Oaks, Calif: Sage Publications; 1998:195-203.
Bauer HM, Rodriguez MA, Quiroga SS, Flore-Ortiz YG. Barriers to health care for abused Latina and Asian immigrant women.  J Health Care Poor Underserved.2000;11:33-44.
Campbell J. Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers. Thousand Oaks, Calif: Sage Publications;1994.

Figures

Tables

Table Graphic Jump LocationTable. Characteristics of Respondents and Factors Associated With Opposition to and Support for Mandatory Reporting of Intimate Partner Violence to Police (N = 1218)*

References

Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: do they promote patient well-being?  JAMA.1995;273:1781-1787.
Rodriguez MA, Craig AM, Mooney DR.  et al.  Patient attitudes about mandatory reporting of domestic violence: implications for health care professionals.  West J Med.1998;169:337-341.
Larkin H, O'Malley N. In favor of mandatory reporting.  West J Med.1999;171:119-121.
Gielen AC, O'Campo PJ, Campbell JC.  et al.  Women's opinions about domestic violence screening and mandatory reporting.  Am J Prev Med.2000;19:279-285.
Rodriguez M, McLoughlin E, Bauer H, Paredes V, Grumbach K. Mandatory reporting of intimate partner violence to police: views of physicians in California.  Am J Public Health.1999;89:575-578.
Goldman J, Hudson RM, Hudson Z, Sawires P. Health Privacy Principles for Protecting Victims of Domestic Violence. San Francisco, Calif: Family Violence Prevention Fund; October 2000. Available at: http://fvpf.org/programs/display.php3?DocID=53. Accessed May 15, 2001.
Chalk R, King P. Violence in Families. Washington, DC: National Academy Press; 1998.
Sachs C, Koziol-McLain J, Glass N, Webster D, Campbell J. A population-based survey assessing support for mandatory domestic violence reporting by healthcare personnel.  Women Health.In press.
Coulter M, Chez R. Domestic violence victims support mandatory reporting: for others.  J Fam Violence.1997;12:349-356.
Houry D, Feldhaus K, Thorson A, Abbott J. Mandatory reporting laws do not deter patients from seeking medical care.  Ann Emerg Med.1999;34:336-341.
Campbell JC, Coben JH, McLoughlin E.  et al.  An evaluation of a system change training model to improve emergency department reponse to battered women.  Acad Emerg Med.2001;8:131-138.
Dearwater S, Boben J, Campbell J.  et al.  Prevalence of intimate partner abuse in women treated at community hospital emergency departments.  JAMA.1998;280:433-438.
Soeken K, Parker B, McFarlane J, Lominak MC. The Abuse Assessment Screen: a clinical instrument to measure frequency, severity and perpetrator of abuse against women. In: Campbell J, ed. Empowering Survivors of Abuse: Health Care for Battered Women and Their Children. Thousand Oaks, Calif: Sage Publications; 1998:195-203.
Bauer HM, Rodriguez MA, Quiroga SS, Flore-Ortiz YG. Barriers to health care for abused Latina and Asian immigrant women.  J Health Care Poor Underserved.2000;11:33-44.
Campbell J. Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers. Thousand Oaks, Calif: Sage Publications;1994.
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