Intimate Partner Violence and Abuse

Background

Intimate partner violence (IPV) consists of acts or threats of physical, psychological, or sexual violence between intimate (or formerly intimate) partners. Physical violence includes any behavior with the potential to cause death, disability, injury, or other harm: pushing, hitting, slapping, punching, kicking, biting, burning, strangulation, and aggressive use of objects or weapons. Exact legal definitions of criminal IPV acts vary by country and even within countries by local and state laws. Each state in the United States (US) maintains separate penal codes for IPV crimes, with differing legal definitions of IPV. Definitions and crimes also differ under federal law, military law, and tribal law, among others. Psychological or emotional violence also fulfills the medical and sociologic definitions of IPV: words and behaviors meant to intimidate, degrade, humiliate, or isolate the victim from family and friends; threats; controlling access to clothing, transportation, money, and other basic needs; and limiting professional and social activities. Sexual violence involves threats or physical force to attempt or complete sexual contact and includes any physical contact with a sexual organ with a person unable to consent. Sexual violence within a current or former dating or intimate relationship most often fulfills criteria for a separate crime, in addition to IPV. Reproductive coercion, a relatively recently described subset of sexual IPV, involves prevention of (or interference with) the use of birth control and refusal to use condoms to prevent the transmission of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV).

The Centers for Disease Control (CDC) periodically performs a National Intimate Partner and Sexual Violence Survey (NISVS) which assesses sexual violence, stalking, and intimate partner violence victimization among adults in the United States. According to the 2015 NISVS, 36.4% of US women experience physical violence, rape, or stalking during their lives. One in three of those reporting IPV experienced multiple forms of IPV.

Emergency department (ED) patients suffering from injuries due to IPV may present with a clear history of the IPV but may also fail to disclose the true nature of the injuries due to shame or fear of retaliation. Thus, national estimates of IPV injuries among ED patients likely underestimate the true prevalence. In ED studies, observed IPV prevalence among women ranges from 12% to 19%. Though the majority of injured IPV patients are females injured by a male partner, men may also be victims; IPV is at least as common in same-sex relationships as in heterosexual relationships. ^, Eleven percent of US men self-report IPV during their lifetime, including contact sexual violence, physical violence, or stalking by an intimate partner.

The high prevalence of IPV reported by men may be partly understood by the frequently bidirectional nature of partner conflict and violence. In a simplified model, IPV falls into two distinct forms: intimate terrorism and situational couple violence. Intimate terrorism is defined as “the attempt to dominate one’s partner and to exert general control over the relationship,” whereas situational couple violence is “violence that is not connected to a general pattern of control.” Situational couple violence is usually less physically severe and more likely to be engaged in by either member of the couple. Intimate terrorism characteristically involves more severe injury, occurs more frequently, and is perpetrated more often by men against women. The type of IPV is unlikely to change the role of the ED clinician, which remains identification, treatment, documentation, and referral ( Box 192.1 ). Overall, women continue to be the primary targets of violence, and to experience high rates of health sequelae. Therefore, health care responses to IPV, as well as community resources for survivors, are largely directed toward women. This may translate to decreased community resources available for male victims who also deserve our compassionate and complete care. Although this chapter often assumes the more common female victim and male perpetrator, principles herein apply to all IPV victims, irrespective of gender identity.

IPV affects many aspects of health and is associated with risky health behaviors, such as cigarette smoking, heavy alcohol and drug use, and physical inactivity, as well as mental illness (e.g., depression, anxiety, posttraumatic stress disorder [PTSD], suicidality). ^{, , ,} IPV patients often have poor maintenance of chronic medical conditions, such as asthma, diabetes, and chronic pain syndromes. Pregnant IPV victims tend to seek prenatal care late and are at risk for termination of pregnancy, placental abruption, preterm delivery, and low infant birth weight. ^{, ,}

The majority of all assaults on women worldwide and in the US are by intimate partners. Approximately half of all female homicides with a known perpetrator are committed by a former or current partner. Partner violence is a precursor in 75% of IPV homicide cases, and many IPV homicide victims see a health care provider within the year before their death. ED visits provide an opportunity to identify IPV and those at high risk for future severe injury or death.

The morbidity and mortality associated with IPV translates to an economic burden of 3.6 trillion US dollars over the lifetime of those suffering. Both victims and perpetrators generate some of these costs with lost productivity and criminal justice activities, however, more than half of the estimated costs have been attributed to medical care. Encouragingly, survivor health care use has been observed to return to normal rates several years after the cessation of IPV, suggesting that interventions against IPV may have a positive overall effect on health.

Causes and Natural History of Intimate Partner Violence

Clinicians may find it difficult to comprehend why humans choose to physically, sexually, or psychologically hurt someone whom they purport to love. Potential answers to this paradox involve multiple societal, community, relationship, and individual factors. Individual-level risk factors for both perpetration and victimization include childhood exposure to IPV or other abuse, presence of a physical or mental disability, and use of alcohol or drugs. Though prevalent in all socioeconomic groups, IPV occurs at increased rates among those with lower income, job or housing instability, and male unemployment. Housing instability also increases the risk of sequelae, such as PTSD, depression, and increased ED use in IPV victims. Lack of social support for women, and delinquent peer associations for men, have been associated with victimization and perpetration, respectively.

Finally, human beings are not uniform and reflect different cultures with their own laws, attitudes, norms, and biases, including degrees of societal tolerance toward violence. Historically and worldwide, increased violence against women can be seen in societies with greater gender inequity. All aspects of our community, including law enforcement agencies, schools, the media, social services, and medical professionals play a role in changing dangerous attitudes that ignore IPV and helping those who are already affected find refuge. The literature overwhelmingly supports the concept that IPV victims want help from their doctors, and that they frequently seek help in the medical setting. Though medical resources alone cannot solve the societal problems that lead to IPV, through a collaborative community response and the four principles of identification, documentation, treatment, and referral, emergency clinicians can give their patients a chance to live without the excess burden of IPV.

Identification

Optimal medical intervention for IPV requires systematic screening for identification, and multidisciplinary care for treatment and referral. In addition to providing acute medical care, emergency clinicians need resources to secure that patients with positive IPV screens have access to primary care physicians and IPV community agencies for what is often a long-term, recurring problem, requiring long-term physical and mental health care, counseling and advocacy, legal aid, and long-term strategies for financial and social independence. Due to the human suffering and potential efficacy of treatment, the US Preventive Services Taskforce (USPSTF) recommends routine screening for IPV in women of childbearing age, even in the absence of overt injuries.

Emergency clinicians may perceive barriers to identification, treatment, documentation, and referral of patients suffering from IPV. For the last few decades, medical schools have included some education on the identification and treatment of victimized patients, but many current emergency clinicians lack comprehensive training. In busy clinical settings such as the ED, the high volume of patients and acuity of disease may preclude private screening and more in-depth discussions of partner abuse. Given the complex psychosocial issues that may accompany IPV, emergency clinicians may also fear opening a Pandora’s box, uncovering additional interventional needs that may be impossible to effectively address during an ED visit.

Furthermore, ED providers may harbor their own prejudices and misunderstandings that can interfere with identifying and treating IPV victims. Despite obstacles, the majority of EDs endorse screening patients for IPV, and most EDs provide universal screening during triage nurse evaluations. Though nurses most often verbally query patients and record the screening information in the patient’s chart, paper or computer self-administered private surveys may provide improved disclosure rates.

Screening

Asking all patients about partner violence (past or present) is called IPV screening. The USPSTF recommends routine screening of asymptomatic women of childbearing age for IPV in the health care setting, with referral to intervention services. Directed screening for IPV involves questioning patients presenting with illnesses and conditions associated with IPV (e.g., chronic pain, multiple ED visits, STIs, unintended pregnancy, mental health issues such as depression, anxiety, PTSD, and suicide, alcohol and drug presentations).

Although studies have shown an increase in identification, proving a decrease in violence and increase in quality of life for ED screening has remained a challenge. The USPSTF screening recommendation does not name a specific medical site, but given that IPV survivors use the ED at high rates, the ED provides a safe place for intervention. When surveyed in the ED, 26% of women in a past-year relationship screened positive for IPV; at 1 week and 3 months follow-up, there was no report of increased violence or harm as a result of screening.

Despite the organizational recommendations and institutional protocols to screen for IPV, practical implementations of screening cast doubt on the efficacy of the protocols. Challenges to ED protocol implementation include time constraints, privacy issues, and continued provider discomfort or indifference. Documentation of screening is often included in the triage section of the medical record and tasked to the triage nurse in a hectic and sometimes public area. This approach puts privacy and security at risk, because IPV survivors may be accompanied by their abusive partner. Additionally, other companions with the patient may not be aware of the situation and patients will rarely disclose without privacy.

Some well-studied IPV screening tools—the Partner Violence Screen (PVS) and Modified Abuse Assessment Screen (AAS)—are presented in Box 192.2 . Studies that investigate the incidence and prevalence of IPV most often use a second longer survey, the Conflict Tactics Scale (CTS), as a gold standard to determine sensitivity and specificity of the tool. However, the CTS was developed for purposes of research rather than detecting IPV in the acute medical setting and may not be the most applicable gold standard for ED use. Emergency clinicians should ask about specific actions and avoid using the terms “victim” and “abuse,” as patients may not yet see the actions as abuse or themselves as victims. Paper and electronic screening, an underutilized method, are at least as effective as face-to-face screening and more likely to be universally applied with less bias introduced by interprovider variability. Patients should be informed about state-specific reporting requirements that may accompany disclosure of IPV. Triage screening should be followed up privately, after all visitors have been asked to step out of the room. Initial framing statements can normalize and destigmatize IPV and may improve victims’ disclosure to providers ( Box 192.2 ). Patients are more likely to disclose abuse if the provider asks at least one additional related question.