Background

  • Intimate partner violence (IPV) is physical, sexual, or psychological harm perpetrated by a current or former intimate partner (such as spouse, cohabitating partner, or dating relationship)   
  • Types of IPV include:
    • Physical violence
    • Sexual coercion
    • Psychological abuse
    • Controlling behaviors, including:
      • Threats
      • Intimidation
      • Stalking
      • Forced social isolation

  • Women are more likely to experience increased frequency and severity of intimate partner violence than men, and often with a male perpetrator, but IPV affects women and men in all types of relationships, regardless of race, sexual orientation, or economic status

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  • About 1.5 million women and 834,700 men report rape and/or physical assault by an intimate partner annually in the United States
  • Likely risk factors include:
    • Victim-related factors, such as:
      • Preexisting mental health and/or substance abuse problems
      • History of traumatic events (childhood sexual abuse, prior IPV, war-related trauma)
    • Perpetrator-related risk factors
      • Exposure to parental violence
      • History of physical abuse
      • Substance abuse problems
      • Exposure to political violence
  • 1 in 5 women killed by an intimate partner are reported to receive emergency care in the previous year for injuries inflicted by the same partner

History

  • Consider starting with a generalized statement when asking about IPV, such as “many people experience problems at home or in their relationships that can affect their health, so I have started to ask all my patients about any issues at home.”
  • Ask victim about:
    • Type of assault, including any weapons that were used
    • When the assault took place
    • Risk of pregnancy (if victim is a woman)
    • Risk for HIV infection and other sexually transmitted infections
    • Mental health status

  • Routine inquiry of all women in health-care settings is not recommended and should be reserved for those with conditions that can be caused or complicated by IPV, such as:
    • Depression, anxiety, posttraumatic stress disorder [PTSD]
    • Suicidal or self-harming behavior 
    • Alcohol or other substance abuse 
    • Unexplained chronic gastrointestinal symptoms or unexplained chronic pain
    • Unexplained reproductive symptoms, including pelvic pain, sexual dysfunction 
    • Adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delayed pregnancy care, or adverse birth outcomes 
    • Repeated vaginal bleeding and sexually transmitted infections 
    • Traumatic injury, especially if repeated and with unclear explanations 
    • Problems with headaches, cognitive problems, and/or hearing loss 
    • Repeated health consultations with no clear diagnosis 
    • Intrusive partner or spouse during consultations 

  • Screening questions should address current or history of violence, and/or aggressive behavior by the partner, such as:
    • Have you been hit, kicked, punched, or otherwise hurt by an intimate partner within the past year, and if so, by whom?
    • Do you feel safe in your current relationship?
    • Is someone from a previous relationship making you feel unsafe now?
    • Is anyone forcing you to do something sexual that you do not want to do?
    • Is anyone in the community following or harassing you?
    • Have you ever been in a relationship where you were frightened or hurt by your partner?
    • Did anyone ever physically hurt you, force you to do something sexual, or hurt you psychologically (such as telling you that you were worthless or unwanted) when you were a child?

Physical

  • Perform complete physical exam (including genitalia) to assess for injuries in patients with suspected IPV 
    • Obtain informed consent prior to ensure patient understands the purpose of the exam
    • Ensure patient feels comfortable; explain each step of the exam
    • Sensitivity is required, particularly when examining victims of sexual assault 
  • Specific signs of violence may include 
    • Multiple injury sites 
    • Contusions, abrasions, or minor lacerations to
      • Head/neck and facial area (most common) 
      • Torso 
      • Abdominal area 
      • Genital area 
      • Anal area 
    • Burns 
    • Fractures/sprains 
    • Injury during pregnancy 

Management

  • If patient denies IPV, provide education about effects of IPV (including effects on children such as increased risk of depression, anxiety, and substance abuse) and let the patient know you are available to discuss any concerns
  • If patient confirms IPV, the SOS-doc intervention may help guide clinician response:
    • S – offer Support and assess Safety (presence of weapons in house, threats to kill, forced/threatened sexual violence)
    • O – discuss Options, including legal tools, safety/emergency planning, community resources (shelters)
    • S – validate patient’s Strengths
    • Do – Document detailed observations (using direct quotes, drawings of injuries), assessment, and plans for follow up
    • C – provide Continuity by offering follow-up appointment and assessing barriers to access (transportation, partner preventing return to office)
  • Provide counseling for survivors of IPV
    • Counseling and home visits addressing multiple risk factors
    • Patient education tailored to individual needs and danger level (information on cycle of violence, risk factors for homicide, safety planning, and community resources) 
    • Services related to parenting, problem-solving skills, and emotional support 
  • Medications
    • Addition of fluoxetine to behavioral and self-help programs may reduce perpetration of intimate partner violence in patients with depression and history of alcohol-associated violence.
  • Referral to community-based treatment and advocacy programs  
    • The National Domestic Violence Hotline 
      • Phone: 800-799-SAFE (7233); TTY: 800-787-3224 
      • Website: http://www.thehotline.org/ 
    • Academy on Violence & Abuse 
      • Phone: 952-974-3270 
      • Website: http:www.avahealth.org/ 
    • Futures Without Violence (formerly Family Violence Prevention Fund) 
      • Phone 415-252-8900; TTY: 800-595-4889 
      • Website: http://www.futureswithoutviolence.org/ 
    • Institute for Safe Families 
      • Phone: 215-843-2046 
      • Website: http://www.instituteforsafefamilies.org 
    • National Coalition Against Domestic Violence 
      • Phone: 303-839-1852; TTY: 303-839-8459 
      • Website: http://www.ncadv.org 
    • National Sexual Assault Online Hotline; Rape, Abuse & Incest National network 
      • Phone: 800-656-HOPE (4673) 
      • Website: http://www.rainn.org/get-help/national-sexual-assault-online-hotline 


Complications 

  • IPV is associated with adverse mental, physical, emotional, social, and financial consequences 
  • In women with history of IPV, possible complications include:
    • Gynecologic, gastrointestinal, urinary, musculoskeletal, and neurologic symptoms 
    • Sexually transmitted infections 
    • Chronic pain 
    • Elective abortions 
    • Poor pregnancy outcomes 
  • Psychological complications of IPV may include:  
    • Posttraumatic stress disorder 
    • Depression 
    • Suicide attempts 
    • Misuse of alcohol and/or drugs 
    • Eating disorders  
  • Children exposed to household with IPV may have increased risk for negative behavioral, physical, and psychosocial outcomes that can persist into adulthood, such as:
    • Child abuse (reported in up to 50% of households with intimate partner violence) 
    • Depression/anxiety 
    • Violence towards peers 
    • Attempted suicide 
    • Drug and/or alcohol abuse 
    • Running away from home 
    • Risky sexual behaviors 
    • Increased likelihood of committing sexual assault 
    • Increased mortality and morbidity into adulthood 

Prognosis 

  • Mortality 
    • 1 in 5 women killed by an intimate partner reported to receive emergency care in the previous year for injuries inflicted by the same partner  

Kendra Church MS, PA-C, is a physician assistant at Dana-Farber Cancer Institute/Brigham & Women’s Hospital, and is also a senior clinical editor for DynaMed, an evidence-based, point-of-care database.

Sources

1. World Health Organization (WHO). Clinical and policy guidelines on responding to intimate partner violence and sexual violence against women. Accessed January 21, 2022. http://www.ncbi.nlm.nih.gov/books/NBK174250/pdf/Bookshelf_NBK174250.pdf.

2. Cronholm PF, Fogarty CT, Ambuel B, Harrison SL. Intimate partner violence. Am Fam Physician. 2011:83(10):1165-1172.

3. Sugg N. Intimate partner violence: prevalence, health consequences, and intervention. Med Clin North Am. 2015;99(3):629-649. doi:10.1016/j.mcna.2015.01.012

Topics:

Domestic Violence Psychology Substance Use Women's Health