e6-08: Intimate Partner Violence Issues for Women

Intimate partner violence (IPV) is a pattern of abusive behavior by a person who is in some type of intimate relationship with the victim. The abuse can be physical, sexual, or emotional and can include economic deprivation. Although anyone can be a victim of IPV, women are much more likely than men to be victims. Regardless of the type of abuse, the goal of the abuser is to gain control over the victim. IPV is common but is often not diagnosed, in part because individuals try to hide the abuse.

The prevalence estimate of IPV varies depending on the setting. Rates are higher when measured in emergency departments than when measured in the general population. In a randomized controlled trial of IPV screening in emergency departments, the prevalence over 12 months ranged from 4% to 18%.

Risk factors for abuse include being young (under age 35 years); being pregnant; being single, divorced, or separated; alcohol or drug abuse in the victim or the partner; smoking; and being poor.

Since patients often do not volunteer that they have been abused, clinicians must be alert to clues that suggest abuse, including an explanation of the injuries that does not fit with what is being seen; frequent visits to the emergency department; and somatic complaints such as chronic headache, abdominal pain, and fatigue. The patient may be vague about some of her symptoms and may avoid eye contact. If the abusing partner is present, he or she may answer all the questions or may decline to leave the room. It is critical that the patient has the opportunity to speak with the clinician alone. The patient's description of the events should be carefully detailed in case there are any subsequent legal issues.

Physical examination often reveals injuries in the central area of the body. There may be injuries on the forearms as well if the patient tried to defend herself. As with any situation of expected abuse, bruises that are in various stages of healing may be an important clue. All physical examination findings should be well documented.

In addition to the physical consequences, abuse can have psychological consequences. Posttraumatic stress disorder, depression, anxiety, and alcohol or other substance abuse can develop in victims. Somatization is also common among victims.

Several instruments have been developed to screen for IPV. These include the HITS (Hurt, Insult, Threaten, Screamed at) tool, the Women Abuse Screening Tool (WAST), the Partner Violence Screen (PVS), the Abuse Assessment Screen (AAS), and the Women's Experience with Battering (WEB) scale. A systematic review of these screening tools showed that most tools only had been evaluated in a relatively small number of studies and the sensitivities and specificities varied widely within and between the tools.

Many studies have addressed how the questions about IPV are asked. Inclusion of one question in the context of the medical history, "Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?" has been shown to increase identification of IPV. The SAFE questions are also useful. Stress/Safety: Do you feel safe in your relationship? Afraid/Abused: Have you ever been in a relationship where you were threatened, hurt, or afraid? Friend/Family: Are your friends aware you have been hurt? Emergency Plan: Do you have a safe place to go and the resources you need in an emergency? In one randomized trial, women preferred written questionnaires over face-to-face interviewing. The USPSTF recommends that clinicians screen women of childbearing age for IPV, including domestic violence and provide or refer women who screen positive to intervention services.

Interventions for IPV can include encouraging the woman to leave the abusive situation, ensuring that she has a safe place to go, and counseling so that she can adequately assess her risk of danger and create a plan for safety. There is no evidence that treatment of the abuser changes abuser behavior.

• Victims should be referred to social services so that they can provide information on local resources. A national domestic violence hotline (1-800-799-SAFE) can provide information on local resources.

• In general, mandatory reporting of IPV or suspicion of it in adult women who are competent is not required in most states. However, mandatory reporting by clinicians is required in several states. Clinicians should be familiar with their state guidelines.