Intimate Partner Violence


Intimate Partner Violence, Partner Violence, Partner Abuse, Spousal Abuse, Domestic Violence, Domestic Abuse, Interpersonal Violence, Battered Woman, Battered Women

  • Definitions
  1. Intimate Partner
    1. A person with whom the patient has a close personal relationship, with detailed knowledge of the other person's life
    2. Includes identity as a couple, emotional connectedness, regular contact (may be physical and/or sexual)
  2. Intimate Partner Violence
    1. Physical, sexual, emotional or economic abuse by a current or former intimate partner
  • Epidemiology
  1. Affects 10 to 12 Million people in U.S. each year
  2. Rape, physical Violence or stalking by an intimate partner (2011, U.S.)
    1. Women: 32%
    2. Men: 28%
    3. Breiding (2014) MMWR Surveil Summ 63(8): 1-18 [PubMed]
  3. Age
    1. Most common among young adults (ages 18 to 24 years old)
  4. Incidence: 20-39% of women in primary care clinics
    1. 78% of women approve of Domestic Violence Screening
    2. Only 5% of women had been asked about Domestic Violence
    3. Bradley (2002) BMJ 324:271-4 [PubMed]
  5. Rates of Violence against men is increasing
    1. Women's injuries tend to be more severe
    2. Men in the LGBT community are as likely as women to be victims of abuse
  • Types
  • Abuse
  1. Physical Abuse
    1. Any non-accidental physical injury (e.g. biting, hitting, shoving, kicking, biting, grabbing, hair pulling burning)
    2. Includes denying a partner medical care
    3. Includes forced use of Alcohol or drugs
  2. Psychological Abuse
    1. Intimidation or threatening to harm partner, family or friends, pets or property
    2. May include blackmail, suicidal threats, threats of abandonment
  3. Emotional Abuse
    1. Diminishing a partners self worth or self esteem (worthless, unloved, unwanted or flawed)
    2. Includes frequent criticism, name calling, damaging their relationships and leading to isolation
  4. Sexual Abuse
    1. Coercing (or attempting to coerce) sexual contact or behavior without consent
    2. Includes marital rape, injury to sex organs, forcing sex after physical abuse, sexually demeaning behavior
  5. Economic Abuse
    1. Controlling couples finances completely so that the partner is financially dependent
    2. Limiting the partner's access to money, or forbidding school or work attendance
  • Precautions
  1. Intimate Partner Violence (IPV) frequently goes undiagnosed despite repeated medical care
    1. IPV crosses all socioeconomic, gender, race and age boundaries
  2. Victims of abuse often choose not to disclose abuse or accept help, and often return to their abuser
    1. Victims of abuse may stay with abuser to avoid poverty, Homelessness, isolation or deportment (Immigrants)
    2. Victims may be pressured by family, friends, Religion or culture to stay with their abuser
  3. One third of women murder victims are killed by their intimate partners
    1. Often murder occurs at the time the woman tries to leave the relationship
    2. Person killed may also be a friend, neighbor or first responder
    3. Safety plans (see below) are critical to keep patients and those around them safe
  • Risk Factors
  1. Age <35 years old
  2. Separated or divorced
  3. Pregnancy, peripartum or postpartum
  4. Cognitive or Physical Disability
  5. Chronic medical conditions (e.g. Asthma, autoimmune disorders, Cerebrovascular Accident)
  6. Medical assistance or no insurance
  7. Higher depression or anxiety scores
  8. Drug or Alcohol Abuse
  9. Suicide attempts
  10. Broken bones, sprains, or serious cuts
  11. Substance Abuse by a partner
  12. Ethnic Minorities
    1. Native American
    2. Mixed Race
    3. Non-Hispanic Black Women
  • Screening
  1. Background
    1. Most Battered Women require 7 episodes on average to leave a relationship, due to many barriers
      1. Victims are at high risk of serious injury or death at times they leave perpetrator
      2. Fear and shame
      3. Children are threatened
      4. Perpetrator holds onto victims money, passport, identification
    2. Vigilent and systematic screening is key
      1. May result in providing patients the intervention at the right time to spare further injury or death
    3. Violence often involves others in the same household
      1. Child Abuse
      2. Elder Abuse
      3. Animal abuse
  2. See Intimate Partner Violence Screening
  3. SAFE Screen for Intimate Partner Violence
  4. HITS Screen for Intimate Partner Violence
  5. Women Abuse Screening Tool (WAST, WAST-SF)
  6. Partner Violence Screen
  7. Example scripts
    1. Excuse others in room
      1. "I have a few quick questions I ask all patients and then I will let you back into the room"
    2. With the patient alone
      1. "I have a few brief questions I ask everyone because Violence against women is common and serious."
    3. "The injuries you have do not seem to match the story. Can you tell me how this happened?"
    4. "Has anyone hit, kicked, choked or punched you in the last year?"
    5. "Forced or coerced you to have sex?"
    6. "Threatened you with a knife or gun to scare or hurt you?"
  • Signs
  1. Presentations more suggestive of Intimate Partner Violence
    1. Multiple injury sites in variable states of healing
    2. Injuries inconsistent with stated mechanism
    3. Delayed presentation for injuries
    4. Contusions, abrasions, burns or Lacerations (especially in areas hidden by clothes)
    5. Self-abuse or self-blame for injuries
    6. Tympanic Membrane Perforation
    7. Frequent emergency department or acute clinic appointment visits for seemingly minor complaints
    8. Trauma in Pregnancy
      1. See Trauma in Pregnancy for management strategy
      2. Abuse during pregnancy was preceded by abuse outside of pregnancy in 90% of cases
    9. Frequently missed appointments
    10. Partner present for appointment and controls visit (frequently speaks for the patient)
    11. Comorbid associated conditions, especially related to mental health (see below)
  2. Most common sites of injury in Battered Women
    1. Head, face and neck (most common)
    2. Chest
    3. Abdomen
    4. Muellman (1996) Ann Emerg Med 28(5):486-92 [PubMed]
  3. Strangulation Findings (see precautions below)
    1. Subconjunctival Hemorrhage
    2. Bruising or ligature marks at the neck
    3. Bruising behind the ears
    4. Facial Petechiae
    5. Dysphonia
    6. Dysphagia
    7. Neck Pain
    8. Drooling
    9. Dizziness
    10. Headache
  4. Other Injury patterns
    1. Defensive wounds at Forearms
    2. Ligature marks or handcuff marks
    3. Linear or patterned markings from broom handle or other object
    4. Shoe sole imprints
    5. Bite or burn injuries
    6. Fist or hand imprints (linear Bruises with central clearing)
  • Associated Conditions
  1. Generalized Anxiety Disorder or Panic Attacks
  2. Major Depression
  3. Suicidality
  4. Post-Traumatic Stress Disorder
  5. Alcohol Abuse
  6. Drug Abuse
  7. Traumatic Brain Injury sequelae
    1. Personality changes
    2. Cognitive changes (e.g. memory, organization, processing)
    3. Postconcussive syndrome (e.g. Headaches)
  • Precautions
  • High risk situations for serious injury or lethality
  1. Recent escalation in Violence
  2. Available weapons
  3. Threats of serious harm or homicidality
  4. Chemical Dependency
  5. Significant fear on part of abused partner
  6. Strangulation Injury
    1. Consider CT angiography of carotid and Vertebral arteries (esp. for LOC, Dysphonia, Dysphagia)
    2. Predictor of death by Violence (10 fold increased risk)
  • Management
  • (Mnemonic: SOS-DoC Intervention)
  1. Approach
    1. Listen respectfully and demonstrate compassion
    2. Avoid condescending or judgemental language
    3. Keep questions open ended (as opposed to questions about specific experiences)
  2. Support and safety offered
    1. Talk in private offering good eye contact and emphasizing confidentiality
      1. "I'm sorry this has happened. This is not your fault. No person deserves to be abused..."
      2. Exceptions to confidentiality
        1. Suicidality or homicidality
        2. Mandatory reporting states (see below)
    2. Identify high risk for serious harm or lethality (see precautions above)
      1. "Are you and your children safe at home in the near future?"
  3. Options including safety planning and follow-up
    1. Discuss restraining orders, 911, shelters, resources
    2. Identify a safe point person of contact (e.g. relative, friend)
      1. Person should be ready to contact police if instructed by patient
    3. "Do you have an emergency plan in case you need to leave?"
      1. Safe place
      2. Emergency bag ("Go Bag")
        1. Extra clothes
        2. Keys
        3. Money
      3. Important papers
        1. Identification (Social security, birth certificate, driver's license)
        2. Bank accounts and insurance
        3. Phone contacts
      4. Keep an adequate amount of money separate
      5. Notify a close friend (point person)
  4. Strength of patient is validated
    1. Strength to withstand circumstances and
    2. Courage to make the needed changes for patient and their children's safety
  5. Document observations, assessment and plan
    1. Careful documentation of history, exam, potential abuse, level of safety, and overall plan
    2. Patient disclosures and safety plans should NOT be visible to abuser (e.g. online patient portal)
      1. Work with EHR staff to hide sensitive information
  6. Involve social worker
    1. Emergency shelter
    2. Child services
    3. Legal advocate
  7. Continuity offered
    1. Discuss clinic and resource follow-up and eliminate barriers for access
    2. Assist with safety planning including safe places (as above)
    3. "Know that we'll always be available to talk to you"
  8. References
    1. Ambuel (1998) J Aggress Maltreat Trauma 1(2): 55-81 [PubMed]
    2. Cronholm (2011) Am Fam Physician 83(10): 1165-72 [PubMed]
  • Management
  • Mandatory Reporting
  1. Mandatory reporting varies by state in the U.S.
    1. http://www.acf.hhs.gov/sites/default/files/fysb/state_compendium.pdf
    2. In Minnesota, the state requires reporting abuse of minors and vulnerable adults
    3. In California, health care providers are mandated to report to police injuries due to Partner Violence
  2. Example script regarding mandatory reporting
    1. "I am going to do my best to ensure your safety and involve social work, "
    2. "I am also mandated by law to report this to the police"
  • Resources
  1. Futures without Violence
    1. https://www.futureswithoutviolence.org/
  2. National Coalition Against Domestic Violence (NCADV)
    1. http://www.ncadv.org/
  3. National Domestic Violence Hotline
    1. http://www.thehotline.org
    2. Phone: 1-800-799-7233 (1-800-799-SAFE)
  4. National Sexual Assault Online Hotline
    1. http://www.rainn.org/get-help/national-sexual-assault-hotline
    2. Phone: 1-800-656-4673 (1-800-656-HOPE)
  • References
  1. Houry and Herbert in Herbert (2013) EM: Rap 13(6): 6
  2. Mayes (2021) Crit Dec Emerg Med 35(4): 25
  3. Rozzi and Smale (2022) Crit Dec Emerg Med 36(5): 22-9
  4. Swaminathan and Hope in Herbert (2019) EM:Rap 19(7): 7-8
  5. (2012) Obstet Gynecol 119(2 pt 1): 412-7 [PubMed]
  6. Ambuel (1998) J Aggress Maltreat Trauma 1(2): 55-81 [PubMed]
  7. Cronholm (2011) Am Fam Physician 83(10): 1165-72 [PubMed]
  8. Dicola (2016) Am Fam Physician 94(8): 646-51 [PubMed]
  9. McCauley J (1995) Ann Intern Med 123:737-46 [PubMed]