Intimate Partner Violence

Definition

Intimate partner violence is defined as any behavior that is within an intimate relationship or ex-relationship and that causes physical, psychological, or sexual harm. Such behaviors can include physical aggression, such as hitting, kicking, and beating; psychological violence, such as intimidation or constant humiliation; various controlling behaviors, such as isolation from family and friends, monitoring movements, financial control, and restricting access to services; and sexual violence, including forced intercourse and other sexual coercion. Intimate partner violence is a gendered problem. Lifetime prevalence of isolated violent acts within relationships is comparable for men and women, but repeated coercive, sexual, or severe physical violence is perpetrated largely against women by men. Intimate partner violence is also experienced at high rates by sexual minorities, and transgender individuals ( Chapter 214 ) appear to be at higher risk compared with cisgender individuals. Although intimate partner violence is present in all demographic groups, its prevalence is greater in lower socioeconomic groups globally.

Historically, the stereotype was a male batterer who used severe, repeated, and unilateral violence against a nonviolent female victim, but bilateral violence is common, even though the overwhelming burden of morbidity and mortality related to intimate partner violence is experienced by women. Bilateral violence, sometimes referred to as common couple violence , is considered less severe than the pattern of abuse known as battering or intimate terrorism —a severe and escalating form of intimate partner violence characterized by threats, terrorization, multiple forms of abuse, and controlling behavior. Current data indicate that women rarely subject men to battering.

Intimate partner violence is a risk factor for a wide range of medical and psychiatric conditions that require a clinical and public health response. Intimate partner violence is a violation of human rights and a preventable public health problem that must be addressed through social and educational policies.

Epidemiology

The prevalence of intimate partner violence against women varies internationally, but worldwide about 25% of ever-married or partnered women report having been subjected to physical and/or sexual violence at least once in their lifetime from a current or former husband or male intimate partner. In the U.S., about 35% of women and 25% of men reported having been raped, subjected to physical violence, or being stalked by an intimate partner. The likelihood of intimate partner violence is higher among women with non-White racial/ethnic identities. Indigenous women also are at higher risk, in part owing to colonization, structural violence, racism, and discrimination. Globally, about one in seven homicides is committed by an intimate partner, with the rate six times higher for female homicide victims compared with male homicide victims.

Pathobiology

The ecologic model attempts to integrate evidence on individual (genetic and life course), family, community, and societal factors. Most research has focused on factors associated with increased risk for women who experience violence from men ( Table 223-1 ), but it is difficult to determine causality because data are obtained overwhelmingly from cross-sectional studies.

Social learning theory suggests that intimate partner violence is a learned behavior. Male perpetrators and female victims are more likely to report histories of exposure to violence in childhood, but most individuals exposed to violence in childhood do not go on to commit violence as adults, and not all who commit abuse have violent upbringings. Furthermore, the link between poor parenting generally, including neglect, and subsequent intimate partner violence in adulthood suggests that the effect is not simply one of modeling abusive behavior. Exposure to rejecting or neglectful parenting is associated with adverse effects on intrapersonal (e.g., poor self-worth) and interpersonal development, which are associated with intimate partner violence.

A feminist perspective understands intimate partner violence against women as a form of coercive control rooted in society’s patriarchal structure and reflecting the persistent inequality in economic and social relationships between men and women. Lending support to this perspective is the finding that intimate partner violence appears to be less common in more democratic and less economically polarized societies. Although intimate partner violence occurs more often in contexts in which there is support for male authority in the family and in which women have less access to economic security, it is not clear why some individuals are more likely to be violent under such conditions than others.

Evidence is conflicting regarding an association between intimate partner violence and psychopathology. Abusive males may have deficits in one or more coping mechanisms, anger control, and communication skills, but intimate partner violence also can result from dysfunctional interactional patterns between partners. Because types of intimate partner violence are not the same for all couples, there are likely multiple causes for its occurrence.

Clinical Manifestations

Patients seldom present with a complaint of intimate partner violence. Injuries are the most obvious manifestation, and a clinician should have increased suspicion for intimate partner violence if a patient has multiple injuries, if the presenting history of injuries is not consistent with the physical examination, and if a delay has occurred before seeking medical care for injuries. Patients exposed to physical violence may present with injuries that vary from minor abrasions to life-threatening trauma. Although there can be overlap between injuries resulting from intimate partner violence and injuries from other causes, the former typically involve trauma to the head, face, and neck, whereas the latter are more typically injuries of the extremities. Multiple facial injuries are suggestive of intimate partner violence rather than other causes, and injuries that are more specific for intimate partner violence include zygomatic complex fractures, orbital blow-out fractures, and perforated tympanic membrane. Although facial injuries are the most common injuries associated with intimate partner violence, they have low specificity. Musculoskeletal injuries, which are the second most common type of injuries, include sprains, fractures, and dislocations. Blunt force trauma to the forearms should raise suspicion of intimate partner violence because it can occur when trying to block being struck.

Victims of intimate partner violence often experience multiple mechanisms of injury; being struck by a hand is the most common, followed by use of a household object. Injuries from weapons such as knives and guns are far less common (<1%) but are associated with higher risk of mortality. Attempted strangulation occurs frequently. Other injuries that raise suspicion of intimate partner violence include fractures of the spine or trunk, bites, hair pulling, and open wounds. Patients who are exposed to sexual abuse may show signs of trauma to the genital area, but sexual assault is associated with signs of injury in less than one third of cases.

Most victims of intimate partner violence present to health care settings with overlapping physical and mental health problems rather than signs of obvious trauma. A patient who presents with vague signs and symptoms or chronic somatic complaints, including pain, suggests the possibility of intimate partner violence. Other behaviors that suggest intimate partner violence include delay in seeking medical care, multiple cancellations of medical appointments, or a partner insisting on being present throughout the consultation.

Other physical conditions that should raise suspicion of intimate partner violence include chronic gynecologic or gastrointestinal symptoms, such as chronic pelvic pain or irritable bowel syndrome. Intimate partner violence is associated with an increased risk for sexually transmitted infections, including HIV/AIDS, as well as sexual reproductive dysfunction.

Regardless of sex or gender, victims of intimate partner violence experience an increased risk of poor health as well as chronic physical and emotional health problems and injuries. Exposure to any type of intimate partner violence, whether physical or psychological, can be associated with a wide range of emotional and behavioral symptoms; depression and post-traumatic stress disorder (PTSD) are the two most commonly associated emotional conditions, but anxiety disorders and substance use disorders are also associated with intimate partner violence ( Chapter 362 ). Women who reported intimate partner violence at least once in their lives also reported three to four times more emotional distress, suicidal thoughts, and suicide attempts than nonabused women. The relationships appear to be bidirectional, with depressive symptoms, substance use, and depression as both risk factors and outcomes of intimate partner violence. ^, Women who have experienced intimate partner violence have increased rates of chronic physical conditions, particularly gynecologic, gastrointestinal, and nervous system disorders; cancer; cardiovascular disease; type 2 diabetes; and all-cause mortality, but a cause-and-effect relationship between intimate partner violence and these medical conditions is not established.

Intimate partner violence may begin, increase, or decrease during pregnancy, and it is more likely if the pregnancy was unplanned or unwanted. Abuse directed to the abdomen may lead to poor pregnancy outcomes and perinatal death. Intimate partner violence is associated with negative effects on parenting, including lack of effective parenting skills, increased aggression, and diminished communication. Additionally, a child’s exposure to intimate partner violence is significantly associated with the child’s internalizing and externalizing problems, including trauma symptoms, developmental delay, educational problems, and long-term mental health conditions. These sequelae are consistent with a cycle of abuse, with child abuse leading to increased violence against women and additional child maltreatment, which in turn increases the risk of adult violence.