38: Intimate Partner Violence

Intimate partner violence (IPV), is defined as any intentional, controlling behavior consisting of physical, sexual, or psychological assaults in the context of an intimate relationship. The data on IPV underscore the magnitude of the problem. In a landmark study, 28% of a random nationwide sample of couples reported violence at some point in their history; almost 4% of the women reported severe violence. If these figures are extrapolated to the general population, it is estimated that about 4 million women are subjected to violence each year in the United States (a woman is beaten or assaulted every 9 seconds in the United States), with about 500,000 women requiring medical treatment. Women visiting outpatient medical and obstetric/gynecologic clinics as well as the emergency department (ED) are often there for complaints directly attributable to IPV. Because they are frequently misdiagnosed, they may return time and time again, often with increasingly severe trauma.

Despite its magnitude in society and in medical settings, until recently IPV could be described as a “silent epidemic.” Considered a private, family problem by the government, and a social problem by the medical establishment, victims often had nowhere to turn. This ­predicament has gradually improved. Intimate partner violence is now acknowledged to be an important public health problem, and medical practitioners have a variety of diagnostic and treatment guidelines available to them. All practitioners must be knowledgeable about and comfortable with the evaluation and care of patients who are subjected to IPV.

Research conducted in a variety of medical settings has reported on the prevalence of IPV. Cross-sectional studies from outpatient primary care clinics and ED settings have found the prevalence of IPV among women to be from 6% to 28%; lifetime prevalence rates up to 50% have been reported and IPV accounts for more than half the murders of women in the United States every year. A recent systematic review reported lifetime estimates of 22–39% in the United States, with similar rates having been reported by studies conducted in obstetric/gynecologic outpatient clinics. In fact, pregnancy may double the risk of IPV. Differences in prevalence of IPV among various studies can be explained, in part, by their use of different definitions of IPV.

Most studies ask about violence exclusively in the context of heterosexual relationships. However, a similar prevalence of IPV appears to exist in LGBT (Lesbian, Gay, Bisexual, Transgender) relationships, with the same physical and emotional consequences. Primary care providers should be aware that it may be more difficult for LGBT patients to disclose that they are in an abusive relationship for social and legal reasons, and they are less likely to actively seek help compared with heterosexual victims. In addition, the commonly held bias that violence does not occur in these relationships (“women can’t hurt women”) further lowers detection rates.

Men report being physically abused by their female partners at rates just below those reported by women. The injuries inflicted by women on men, however, are generally less significant when compared with same-sex or male-on-female violence.

Many women seek medical care both for the direct and indirect consequences of IPV, but only a small percentage of them are diagnosed and treated appropriately. The following case is illustrative of the type of patient commonly seen in medical settings.

History

A thorough history is the cornerstone of the diagnosis of IPV. Because the presentation is often subtle, with few dramatic injuries, detection requires a high index of suspicion. There are many clues in the medical history, as shown by the case illustration that should prompt the physician to evaluate the patient for IPV (Table 38-1). Patients who have been assaulted often delay seeking medical attention, in contrast to accident victims who generally seek out medical attention immediately. Injuries that are attributed to a mechanism that seems illogical should always raise concern. For example, periorbital ecchymoses (“black eyes”) generally are not caused by a motor vehicle accident, a “doorknob,” or anything other than a fist.

Multiple Somatic Complaints

Some women may present with vague somatic complaints as their only symptom of IPV. Fatigue, sleep ­disturbance, headache, gastrointestinal complaints, abdominal and pelvic pain, genitourinary problems such as frequent urinary tract and genital infections, chest pain, palpitations, and dizziness are just some of the complaints with which women present. IPV should be considered as a sole or contributing cause of these problems.

Depression, Anxiety, and Other Mental Disorders

Depression, eating disorders, and anxiety disorders such as posttraumatic stress disorder (PTSD) and panic disorder are more common among victims of IPV than among the general population. If present, the medical practitioner should always screen for IPV. These mental and behavioral disturbances should be thought of as a consequence, not a cause, of the IPV. Some patients may feel hopeless and turn toward suicide as a way out. One of every 10 battered women attempts suicide. Of those, 50% try more than once.

Pregnancy

Many studies have demonstrated that women are at increased risk of physical and sexual abuse during ­pregnancy. Clues to be alert for include delay in seeking ­prenatal care, depressed or anxious mood, injuries to breasts or abdomen, frequent spontaneous abortions, and preterm labor. In addition to the physical and emotional trauma to the pregnant woman, these assaults can result in placental separation, fetal fractures, and fetal demise.

Substance Abuse

Although violence and substance abuse may coexist, it is inaccurate and generally not helpful to frame IPV as secondary to the substance abuse. Although the perpetrator, and at times the woman herself, often assert that the violence was a consequence of altered behavior from drugs or alcohol, in fact, the violent behavior must be addressed as a separate issue and is unlikely to end even if the substance abuse does.

Conversely, some studies have found an increased rate of substance use in victims of IPV. At times, this may take the form of increased use of pain medications or anxiolytics in an effort to cope with the assaults. It is even more imperative in this instance that physicians do not attribute the IPV to the substance use; it is precisely this mentality of “blaming the victim” that has often prevented the appropriate evaluation and treatment of IPV in all medical settings.

Recent Diagnosis of HIV

Some women report an initiation or escalation of IPV after informing their partner of their human immunodeficiency virus (HIV) seropositive status. Although every attempt should be made to notify sexual partners of HIV-positive results, practitioners should assess their patient’s risk of violence while discussing the issues surrounding notification. Discussion of IPV and review of a safety plan should always be part of posttest counseling.

Family History of IPV

Patients who report a family history of IPV, particularly those who witnessed parental violence as a child or adolescent, are at increased risk themselves even if they are not presently in an abusive relationship. Such women should, therefore, be educated and screened more carefully.

Overbearing Partner

An overbearing partner who, for example, insists on accompanying the patient into the examining room, acts overly solicitous or concerned (sometimes to the point of knocking on the examining room door to inquire about her well-being), or is hostile to the health care team may be a clue to the presence of IPV. Never probe about IPV if the perpetrator is in the examining room as this may unintentionally escalate the violence and put the patient in extreme danger.

Socioeconomic or Ethnic Status

Many health care providers mistakenly believe that IPV disproportionately affects persons from particular ethnic or socioeconomic groups; in fact, it cuts across all ethnic groups and all economic strata. Although some studies have found that women who are uninsured or on medical assistance are at increased risk of IPV, this is most likely due to selection bias in the studies. Women from lower socioeconomic status (SES) groups may be overrepresented in some statistics because those from higher SES groups have more resources available to them and the abuse is, therefore, more likely to remain hidden. Women with fewer resources are forced to take refuge in shelters or county hospital EDs, for example, whereas their middle-class counterparts may flee to a hotel or their offices and are, therefore, underrepresented by some of the surveys.

Physical Examination

The physical examination may provide the first clues of the presence of IPV. These include what appears to be inappropriate behavior, multiple injuries, central pattern of injury, and injuries at different stages of healing (Table 38-2).

Inappropriate Behavior

Behavior that appears to be inappropriate at the time of the physical examination may be a sign of IPV. Fright, inappropriate embarrassment or laughter, anxiety, ­passivity, shyness, and avoidance of eye contact may all be clues that the patient has been battered.

Multiple Injuries

Intimate partner violence victims are more likely to have multiple injuries than are ordinary accident ­victims. Women who have been subjected to IPV, for example, typically have injuries to the head, neck, abdomen, and chest, whereas accident victims often present with less widespread trauma. The common emotional reaction to an IPV assault of denial, confusion, and withdrawal may also lead to more extensive injuries.

Central Pattern of Injury

Victims of IPV often experience injuries such as bruises, lacerations, burns, bites, and more severe injuries secondary to assaults with a deadly weapon or repeated beatings that cause massive internal injuries and ­fractures. Injuries are most commonly seen in the central areas of the body—the head, neck, chest, abdomen, breasts—and occasionally upper arms from fending off blows.

Injuries at Different Stages of Healing

As with child abuse, multiple injuries at different stages of healing should always prompt an inquiry about IPV.

In summary, medical providers must be alert to the signs and symptoms of IPV. It is important to remember that most IPV victims do not present with injuries that require emergency treatment or lead to hospitalization. In fact, for many patients, even in EDs, the presenting complaint is often medical or psychological, rather than an actual physical injury. For this reason, detection of IPV will increase only if practitioners include it on the differential diagnosis and actively screen for it during the medical encounter.

Screening for IPV

Many experts and national groups such as the US Preventive Services Task Force and the Joint Commission on Accreditation of Healthcare Organizations advocate screening for IPV in health care settings, along with improved provider education. Since the potential benefits of screening appear to outweigh the potential harms, and since research has demonstrated that most abused and nonabused patients favor routine screening by their health care practitioners, questions about IPV should be incorporated into the routine history and physical examination for all female patients. Some practitioners also screen men, particularly men in intimate relationships with other men. The optimal method of screening, whether by including questions about abuse on the electronic medical record (EMR) or intake medical history questionnaire, or verbally as a part of the social or past medical history, or both, is a subject of ongoing research. The HITS screening instrument is widely used and consists of four questions (“Have you been hit, insulted, threatened, or screamed at?) on a 5-point Likert scale from “never” to “frequently”; it is available in several languages and has been validated for use with men and women. Some patients may feel more comfortable revealing IPV by screening with the following questions that seek to normalize the problem:

When IPV is detected, five basic tasks must be accomplished (Table 38–4). First, validate the problem by making a clear statement to the patient that violent behavior is unacceptable and illegal, and that nobody has the right to abuse her. The physician’s acknowledgment of the IPV as a real issue may be the first step in helping to free her from the abuse. Under all circumstances, avoid language that could be interpreted as blaming the victim for the violence.

Because the majority of women are not ready to leave the relationship when the IPV is detected, a main task for the primary care provider is to build the relationship with the patient. Statements that express empathy can be an effective way to accomplish this task, for example: “I really respect the way you have been dealing with this” and “we can work on this problem together.” Research has shown that even brief ­discussions with physicians are therapeutic and health outcomes are improved when the conversation is conducted in a concerned way. It is important to help the patient set short-term goals (e.g., to obtain the skills required for a particular job) so that she is not distressed when it takes time to realize her long-term goal of ending the abuse and/or the relationship. Above all, avoid recapitulating the power and control dynamics that so often characterize the patient’s abusive relationship. Never insist that she leave the relationship and always allow her the autonomy to make her own decisions.

Second, it is essential to assess the patient’s safety. Is it safe for her to go home? Other options (such as friends, shelters, and so on) should be explored and an emergency escape plan reviewed if she chooses to return home. For women not returning home, advise them to inform one or two coworkers about the situation as the perpetrator may attempt to find her at work. It is important to ask if there are children who are potentially at risk. Risk factors for escalating violence such as an increase in the frequency and severity of assaults, an escalation in threats, and the availability of a firearm should be carefully assessed.

Third, it is imperative that practitioners document clearly and completely when they uncover IPV. The medical record should include a complete description of the assault with quotes, if possible, from the patient’s own account. Include relevant details in the past ­medical history and social history. Be sure to document clearly; successful prosecution should never be compromised by sloppy recordkeeping. Injuries should be described and visually documented, either with a body chart or with photographs, if the patient consents (include the patient’s face in at least one photograph). If the police are called, always include the name of and any actions taken by the investigating police officer.

Fourth, the patient must be provided with information and appropriate referral. Health care providers should be familiar with the social and legal services available for battered women in their area. Information about shelters should be offered even if the woman intends to return home (though it is important to understand that discovery of such information by the perpetrator may lead to an escalation of the abuse). All patients should be assessed for the presence of psychiatric or substance abuse problems that would benefit from treatment or referral. Practitioners should have a basic understanding of legal options, such as restraining orders, so that they can help advise women who wish to take immediate action to ensure their safety.

Finally, understand the IPV reporting requirements, if any, in your state. For example, in California, health practitioners are required to report to the police all incidents of IPV that result in an injury. The usual doctor–patient privileged communication is explicitly preempted by this law. Providers should work with their ED, hospital, or clinics to be sure that information about reporting requirements as well as other patient education literature is freely available and in multiple languages.

What to Avoid

There are four pitfalls to avoid when caring for victims of IPV:

1. Do not insist that the patient terminate the relationship, even if you believe that this is the most appropriate action. Only she can make that decision. Trying to control her behavior, albeit subtly, recapitulates the same negative dynamic that is taking place in the abusive relationship.

2. Recommend couple counseling only when the perpetrator acknowledges the problem, wants to change his or her behavior, and both partners want to preserve the relationship.

3. Do not use the word alleged in the medical record. It implies that you do not believe the patient’s story, and you may inadvertently impede her ability to bring her case to court.

4. Do not ask what the victim did to bring on the violence.

Physician Barriers to Detection

Many studies have revealed that physicians and other health care practitioners do a poor job of detecting IPV, with detection rates rarely exceeding 10%. Several factors are responsible for this dismal record. First, many practitioners lack the appropriate knowledge and training to effectively detect and treat victims of IPV. The first step in improving their ability to do so is to disseminate information more widely about its prevalence and consequences and to include IPV in medical school, residency, and continuing medical education curricula.

Lack of institutional support is another important barrier. Despite the enormity of the problem and the increasing requirements that all health care institutions have IPV protocols in place, most hospitals and clinics have few, if any, adequately trained support staff, accessible guidelines for practitioners, or information for patients. In addition, with growing pressure to see more patients and use fewer resources, issues such as IPV may be overlooked. Many of the physicians interviewed in one study identified time constraints as the major deterrent to opening the “Pandora’s box” of IPV.

It should be noted, however, that the total annual costs related to IPV are estimated to be between $2 and $7 billion. In addition, the diagnostic and treatment strategies outlined here are not particularly time intensive. Inquiry about IPV adds less than 1 minute to the typical new patient evaluation; if widely employed, it could yield potentially enormous savings through prevention of injury and decreased health care usage.

The third barrier to detection of IPV arises from practitioner discomfort. Many practitioners feel uncomfortable addressing issues that do not fit neatly into the traditional medical model. Numerous studies have shown that many do a poor job discussing issues with their patients having to do with sex, violence, mental disorders, and substance use. Delving into the cause of a suspicious injury may make them uneasy: it is often not amenable to a straightforward solution and may raise embarrassing or uncomfortable feelings. All practitioners must reflect on the feelings that IPV raises in them to be effective in caring for these vulnerable patients.

Patient Barriers to Terminating an Abusive Relationship

Providers often have difficulty understanding why more patients do not terminate their abusive relationship. Why they remain in these relationships is complex. Some of the reasons include the following:

1. Fear. Fear for their own safety or for their children. One-third of the women are not at home when the assault takes place, so it is clear that leaving is no guarantee of safety.

2. Economic. Many battered women lack employment skills or experience and would find it very difficult to support themselves and/or their children outside of the relationship.

3. Psychological. Some may find it difficult to leave because of the “psychological dependence” the years of repetitive abuse have created. Battered women are told overtly and covertly that they are “worthless”; some eventually internalize this and come to believe that they are incapable of surviving on their own.

4. Social support—or the lack thereof. Women are often encouraged by well-meaning friends and family members to “try to work things out,” or they are advised to stay “for the children’s sake.”

5. Lack of other options. Shelters are often full, friends and family unavailable, and legal counsel not accessible.

6. Not all women want the relationship to end, just the violence.

In some cases, a patient may self-disclose violence perpetration in a health care setting. These patients may be more amenable to behavior change. However, very few studies have looked at interventions for perpetrators of violence. Few evaluation studies have been done on outcomes and recent reviews show only a small effect size for prevention of future abuse. Most interventions are ordered by the criminal justice system and, unless mandatory, have very high dropout rates. Nonetheless, women find these programs to be useful and primary care providers can contact local IPV or legal resources to find programs for perpetrators.

Most patients believe that computer-based health technologies, such as electronic health records, are effective means to improve the quality and safety of health care. In particular, patients find computer-based IPV screening methods acceptable and IPV screening done on a computer leads to substantially higher rates of IPV detection compared with a usual care. Computer-based screening methods may help to detect IPV in emergency and primary care settings. One research group was able to build a model based on symptoms that can predict the risk of future diagnoses of abuse. Next steps might be a warning system for clinicians through the EHR for such high-risk patients.

Videoconferencing-based health interventions (also called telemedicine) has been shown to help trauma and abuse victims by providing psychological services via telemedicine. Rates of symptom improvement (reductions in depressive and PTSD symptoms) are comparable to effect sizes documented for traditional cognitive behavioral therapy and appear to be a viable future option for underserved populations.

Along with the criminal justice system, physicians and other health care providers are most likely to come into contact with victims of IPV. They have a professional and ethical obligation to recognize IPV and intervene appropriately as well as to exert their influence on a broader level. This may be to lobby for more funding for shelters or to advocate for teaching about IPV at all ­levels of medical education. Screening for and treating IPV should be a routine part of the practice and training of medicine. We all have the obligation to confront the epidemic of IPV and strive to lessen its impact as one of the most important public health issues of our time.