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.
CASE ILLUSTRATION 1
A 40-year-old nurse presents to the ED with a chief complaint of a headache. She reports having been in a motor vehicle accident 3 days earlier and striking her head on the dashboard. She says that her friends encouraged her to come in, and she is accompanied to the ED (but not the office) by her partner. On physical examination, she appears tense and sad, with bilateral, periorbital ecchymoses.
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.
Table 38-1.When to screen for IPV. ||Download (.pdf) Table 38-1. When to screen for IPV.
|• Delay in seeking care |
|• Illogical explanation of injury |
|• Multiple somatic complaints |
|• Depression, anxiety, and other mental disorders |
|• Pregnancy |
|• Substance use |
|• Recent diagnosis of HIV |
|• Family history of IPV |
|• Overbearing partner |
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.
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.
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.
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.
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.
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.
CASE ILLUSTRATION 2
A 28-year-old postdoctoral fellow presents to her primary care practitioner (PCP) complaining of new-onset insomnia and headache. On physical examination, the PCP discovers bruising on her chest and back and inquires about IPV. The patient breaks down and reports that her partner, a professor at the university, has been emotionally and physically abusing her for years and that only one friend was aware of this history. When the abuse escalated, the patient would seek refuge in her laboratory, sometimes conducting experiments all night.
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).
Table 38-2.Physical examination clues to the presence of IPV. ||Download (.pdf) Table 38-2. Physical examination clues to the presence of IPV.
|• Inappropriate behavior |
|• Multiple injuries |
|• Central pattern of injury |
|• Injuries at different stages of healing |
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.
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.
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:
Doctor: “We all fight at home. What happens when you or your partner fight or disagree?”
Doctor: “Because abuse and violence are so common in women’s lives, I’ve begun to ask about it routinely. At any time, has a partner hit or otherwise hurt or threatened you?” (See Table 38–3 for suggested screening questions.)
If the answers are vague or evasive, more direct questions must be asked to determine if abuse is taking place. If this is done in a supportive, nonjudgmental manner, most patients will feel comfortable and respond honestly.
Table 38-3.Screening questions. ||Download (.pdf) Table 38-3. Screening questions.
|• We all fight at home sometimes. What happens when you or your partner fight or disagree? |
|• Do you feel safe in your home and in your relationship? |
|• Do you ever feel afraid of your partner? |
|• Because abuse and violence are so common in women’s lives, I’ve begun to ask about it routinely. At any time, has a partner hit or otherwise hurt or threatened you? |
|• Does your partner ever force you to engage in sex that makes you feel uncomfortable? |
|• Does your partner threaten, hit, or abuse your children? |