Scanning for Signs of Domestic Abuse

(Inside Science) -- A new study reviewing the medical images and other records of more than 100 victims of intimate partner violence who were treated at Brigham and Women's Hospital in Boston in 2016 suggests that in addition to routine screening provided by other hospital staff, radiologists may be able to identify people who suffer this sort of physical, sexual or psychological abuse -- also known as domestic violence.

Emergency room doctors already play an important role in the hospital by looking for certain signs of victims of intimate partner violence. They screen patients when they suspect abuse, and when they find it they link people to support programs, social workers and shelter spaces.

The study was presented late last year at the Radiological Society of North America meeting in Chicago, and it suggests that the radiologists who order and interpret X-ray, CT and MRI scans may be an untapped resource in identifying victims of domestic violence because these scans may reveal subtle but telltale signs of abuse.

"If we see injuries at different points in time, and if it’s a recurring pattern, that can be suggestive of intimate partner violence," said Elizabeth George, a radiology resident at Brigham and Women’s Hospital and a clinical fellow at Harvard Medical School. She presented the study in Chicago. "Radiologists may be able to put these pieces together, which is one of the key findings of our study."

Preventable injuries with profound consequences

The U.S. Centers for Disease Control and Prevention considers intimate partner violence a serious public health problem, affecting millions of Americans each year. The World Health Organization calls it one of the most common forms of violence against women worldwide, affecting countless victims from every country, culture, religion and socio-economic class.

The U.S. Preventive Task Force, a volunteer professional body that dispenses advice on best practices related to preventable illness, recommends that primary care physicians and ER doctors provide question-based screening for intimate partner violence to all women of child bearing age, though uptake of this practice varies from state to state.

Historically, radiologists have long played the role of raising red flags when they spot signs of child abuse, or "non-accidental trauma" in minors who come to hospitals for treatment. One of the motivations for the new study, George said, is to see if radiologists could raise the same sorts of flags for adults.

"There are very specific findings that are seen in kids with non-accident trauma and the radiologist is the person who’s often involved in making that diagnosis," said George. "We are far from that point in intimate partner violence."

Even in states like Massachusetts, which has implemented screening for women of childbearing age, correctly identifying those victims is sometimes made difficult because of their own reluctance to come forward. Many have lives that are complicated by social issues like homelessness. Some suffer from psychiatric disorders and substance abuse. They may be financially dependent on their assailants, or they may be otherwise unwilling to identify them because of misplaced allegiance.

"Intimate partner violence is very common but often underreported and under-recognized as a health care problem," George said.

What the study found

She and her colleagues looked back at the medical records of 87 people who came to the Brigham and Women's Hospital emergency department between January to October of 2016 and were referred to their intimate partner violence support program. They also looked at 35 additional people who were victims of sexual assault and were also screened and also linked to interventions. Most of the people in the study were women.

They reviewed the medical records as well as five years' worth of radiological scans for each person, going back into the records to ask if a radiologist might have been able to objectively recognize telltale clinical signs of domestic violence. They found plenty of evidence to support that -- common patterns of soft tissue bruises or fractures to the extremities that indicate defensive wounds, lots of cuts and other non-specific injuries and pregnancy complications, including fetal deaths.

(George cautioned the study could not definitively determine if those pregnancy complications were directly related to the domestic violence or not -- though violence is known to lead to adverse outcomes in pregnancy).

The study shows radiologists could offer the same checks for adult victims of violence as they do for children, said Max Wintermark, who is the chief of neuroradiology at Stanford University in Palo Alto, California.

"It’s not that you can diagnose non-accident type trauma in children, but we can raise a flag, bring up that possibility, and that allows our clinical colleague to investigate further," Wintermark said. "It allows the clinician, again, to ask additional questions, to take a few extra steps that they would not otherwise have taken if that possibility had not been brought up."

Wintermark was not involved in the research but serves on the RSNA public information committee, which selected George's presentation for promotion to the press.

What is needed now, George said, is more data on the mechanisms that cause certain kinds of fractures and on types of trauma that would be involved in intimate partner violence. Radiologists also need to be trained to recognize those signs and to be able to distinguish them from injuries resulting from accidents.

"If somebody twisted your arm, are you going to see something different from when you actually fell down and fractured your arm?" George asked. "Those kinds of things need to be sorted out before we can make a definite recommendation."