Asking About Violence
A clinician guide to asking about sexual assault history and screening for intimate partner violence, with a pathway for what to do with the answer.
Prepare
Privacy, explanation, documentation
Ask
Sexual assault history (ACOG)
Screen
Partner violence: HARK (USPSTF)
Respond
Safety, referral, trauma-informed care
What this tool does
It walks you through two different kinds of screening that are often confused. The first asks about a lifetime history of sexual assault, which ACOG recommends for all women. The second asks about current or recent abuse by a partner, which the USPSTF recommends for women of reproductive age, including during pregnancy and postpartum (grade B), using a brief validated questionnaire.
For the partner violence screen, this tool uses the four HARK questions, published open access under a Creative Commons Attribution license, and reports the diagnostic accuracy the original study found.
How the HARK result is calculated
Each "yes" scores one point (0 to 4). The tool displays the likelihood ratio and post-test probability for each score exactly as reported by Sohal et al. (2007); it does not recalculate or adjust them. A score of 1 or more was the optimal cut-off in that study.
Before you begin
This tool stores nothing and sends nothing; answers disappear when the page closes or when you press Clear all answers. It is designed for use by a clinician, in private, with the patient alone. It does not replace clinical judgment, local protocols, or legal reporting obligations.- Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract. 2007;8:49. doi: 10.1186/1471-2296-8-49.
Diagnostic accuracy studyHARK questions and scoringSource of the four HARK questions, the cut-off, and every accuracy figure shown in Step 3 (n=232 women, UK general practice).
- US Preventive Services Task Force. Screening for intimate partner violence and caregiver abuse of older or vulnerable adults: US Preventive Services Task Force recommendation statement. JAMA. 2025 Jun 24. doi: 10.1001/jama.2025.9009.
Guideline, grade BRecommends IPV screening of women of reproductive age, including pregnant and postpartum women, with a brief questionnaire; names HARK among the instruments.
- American College of Obstetricians and Gynecologists. Sexual assault. ACOG Committee Opinion No. 777. Obstet Gynecol. 2019 Apr;133(4):e296-e302. doi: 10.1097/AOG.0000000000003178.
Guideline, expert consensusRecommends screening all women for a history of sexual assault with direct, nonjudgmental questions, validation and referral (Step 2).
- American College of Obstetricians and Gynecologists. Caring for patients who have experienced trauma. ACOG Committee Opinion No. 825. Obstet Gynecol. 2021 Apr;137(4):e94-e99. doi: 10.1097/AOG.0000000000004326.
Guideline, expert consensusAsks obstetrician-gynecologists to implement a trauma-informed approach universally, avoiding stigmatization (Step 4).
- Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey: 2023/2024 sexual violence data brief [Internet]. Atlanta (GA): CDC; 2025 [cited 2026 Oct 10]. Available from: https://www.cdc.gov/nisvs/media/pdfs/sexualviolence-brief.pdf
National surveyPrevalence: 45.1% of US women report lifetime contact sexual violence, including 21.0% completed or attempted rape.
- Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med. 1998;30(7):508-12.
Alternative instrumentNot reproduced here; copyrighted by the developer and used with permission.
- Brown JB, Lent B, Sas G. Application of the Woman Abuse Screening Tool (WAST) and WAST-Short in the family practice setting. J Fam Pract. 2000;49(10):896-903.
Alternative instrumentNot reproduced here; the developers grant permission on request.
Step 1. Prepare
How you ask matters as much as what you ask.
- See her alone. No partner, family member, or friend in the room. If an interpreter is needed, use a professional interpreter, not a family member. In the HARK study, women accompanied by another adult were not approached, to reduce the chance that an abusive partner would learn about the questions.Sohal et al. 2007 [1]
- Explain why you ask. Tell her you ask every patient, so she knows she has not been singled out, and that these experiences can affect health.
- Explain where her answer goes. Before she answers, tell her what will be written in the record, who may be able to read it (patients increasingly read their own notes through online portals, and others may have access to her portal), and the limits of confidentiality in your setting.
- Make declining safe. Tell her she does not have to answer, and that her care will be the same either way.
- Know your next step before you ask. Have referral resources and your local reporting requirements ready. Asking without a pathway to care is incomplete.USPSTF 2025 [2]: screening is linked to evaluation and, where appropriate, multicomponent interventions with ongoing support.
What to look for
Whether you can truly ensure privacy today. If she is accompanied and cannot be seen alone, do not ask in front of the companion. Find another moment.Step 2. Ask about sexual assault history
ACOG recommends screening all women for a history of sexual assault, with direct questions asked without judgment.
This is a lifetime history question, separate from partner violence screening. No validated scored instrument is used here; ACOG describes an approach: ask directly, without judgment, validate the patient, and offer referral.
Suggested wording
Written for this tool to reflect ACOG's approach. It is not a validated instrument and not ACOG's own text.
Be especially attentive when she reports
- Chronic pelvic pain
- Painful periods
- Sexual difficulties
Many women with a history of sexual assault do not volunteer it but may present with these symptoms. None of them establishes a history of assault.
Clinical tip
"Prefers not to answer" is a complete answer. It is not evidence that violence did or did not occur, and it is not a failed screen.Step 3. Screen for partner violence: HARK
Four questions about the past year. One point for each "yes."
Diagnostic accuracy studyUSPSTF-named instrumentQuestion wording reproduced from Sohal et al. 2007 [1] (CC BY 2.0). Read each question as written.
| HARK score | Likelihood ratio (95% CI) | Post-test odds* | Post-test probability* |
|---|---|---|---|
| 0 | 0.2 (0.1 to 0.4) | 0.1 | 9% |
| 1 | 9.01 (3.7 to 21.9) | 2.67 | 73% |
| 2 | 14.6 (4.3 to 49.4) | 4.3 | 81% |
| 3 or 4 | Undefined (no false positives) | Undefined | All 14 women scoring 3 or 4 had IPV on the reference scale |
*At the study's prevalence of past-year IPV, 23% (95% CI 17% to 28%), measured with the 30-item Composite Abuse Scale. Post-test odds are as published; probability = odds ÷ (1 + odds). In a population with lower prevalence, the same score carries a lower probability. The "14 women" figure is 6% of 232 as reported in Table 3, rounded.
| Cut-off score 1 or more | Value (95% CI) |
|---|---|
| Sensitivity | 81% (69% to 90%) |
| Specificity | 95% (91% to 98%) |
| Positive predictive value | 83% (70% to 91%) |
| Negative predictive value | 94% (90% to 97%) |
| Likelihood ratio, positive | 16 (8 to 31) |
Limits of the evidence
One cross-sectional study: 232 women in 12 London general practices, response rate 54%, questions self-administered with a researcher present, English speakers only, women accompanied by another adult excluded. Performance in US obstetric settings, in pregnancy, or when asked aloud by a clinician was not tested in this study. Translation of the questions would require separate validation.Other USPSTF-named instruments
HITS (Hurt, Insult, Threaten, Scream) scores how often a partner does each of four things; it has no sexual violence item. It is copyrighted by its developer, who should be contacted for permission [6]. WAST (Woman Abuse Screening Tool) has eight items, with a two-item short form; its developers grant permission on request [7]. Neither is reproduced here.
Step 4. Respond
What she told you, and what to do next.
If she disclosed anything
- Acknowledge and validate. Thank her for telling you. Tell her it is not her fault, and that you believe her.Validation and referral: ACOG CO 777 [3]
- Assess immediate safety. Ask whether she is safe to go home today, and whether she has a safe place if she needs one.
- Ask what she wants. She decides what happens next, including whether to talk now, later, or not at all.
- Offer referral, not just a phone number. For partner violence, the USPSTF found evidence for multicomponent interventions with ongoing support; brief interventions alone were not found effective.USPSTF 2025 [2]
- If an assault was recent, follow your institution's protocol for acute care and forensic examination, which vary by jurisdiction, and involve a trained examiner where available.ACOG CO 777 [3]
- Know your reporting obligations. Requirements differ by state and by the patient's age. Check your institution's guidance before documenting or reporting.
- Document with care. Record what she wants recorded, in her words where possible, remembering who may read the note.
Resources to offer
Numbers checked October 2026. Consider whether a printed card is safe for her to take home; some women prefer to memorize a number.
For every patient, whatever she answered
ACOG asks obstetrician-gynecologists to apply a trauma-informed approach universally, across every level of practice, with attention to avoiding stigmatization [4]. Disclosure is not a prerequisite.
- Explain each part of an intimate examination before you begin, and why it is needed.
- Ask for consent, and keep talking during the examination.
- Offer choices about positioning, pace, a support person, and pauses.
- Tell her she can ask you to stop. When she does, stop, and do not chart it as "refused" or "uncooperative."
- Extend the same approach to every member of the team who examines or touches her.
Before printing, consider where the paper will go. This summary contains her answers.