Intimate partner violence (IPV) is defined as an intimate partner's assaultive, coercive behaviors that may include

inflicted physical injury

Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes scratching; pushing; biting; punching; use of a weapon; and use of restraints or one's body, size, or strength against another person.1

psychological abuse,

sexual assault,

progressive social isolation,

stalking,

deprivation including economic,

intimidation,

and threats.

 

 

Evaluation

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 do not fit with what is being seen; frequent visits to the emergency department; and somatic complaint 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 have 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 very 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.

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.

Many studies have addressed how the questions about IPV are asked. 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.

 

These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent individual and are aimed at establishing control by one partner over the other.

Intimate partner violence and abuse more accurately reflects the fact that this type of abuse occurs not only in adult heterosexual married relationships but also in relationships between cohabiting, separated, gay and lesbian, bisexual, and transgendered individuals as well as in adolescent dating relationships.

Intimate partner violence and abuse occurs in every racial, ethnic, cultural, geographic, and religious group, and it affects individuals of all socioeconomic and educational backgrounds worldwide. Although men are affected, the overwhelming burden of victimization from intimate partner violence is borne by women.

Effects extend beyond the abused individual. Others affected include family members, friends, coworkers, other witnesses, and the community at large.Children who grow up in violent homes may be physically or emotionally abused or neglected, and witnessing violence can have short- and long-term adverse health consequences.6

Children exposed to violence in the home may develop significant behavioral difficulties, including depression, abusive behaviors, and drug abuse. Frequent exposure to violence in the home may teach children that violence is a normal way of life. This increases the risk of continued violence in the next generation, in that they may abuse others or be abused themselves. Perpetrators of violence, in particular severe violence, may be at risk for suicide, committing murder, or being murdered by a family member.9

Victims of intimate partner violence and abuse present to health care agencies twice as often as they report violence to police.10,11 Health care providers should ask about a history of intimate partner violence or abuse during health care encounters. Failure to recognize and intervene in situations of intimate partner violence may have serious consequences for the survivor and family. Such consequences may include continued violence, physical and psychological health problems, and injury or even death.12–16

Abused individuals want providers to be nonjudgmental, sensitive, and direct. They also want to be assured of confidentiality. They want the provider to have an understanding of the complexity of intimate partner violence and the difficulty of achieving a “quick fix.” Women value the reassurance that their experiences with intimate partner violence and abuse are unacceptable and undeserved (it is not their fault). They also value a nonpressured encounter and a provider who respects their decisions and works with them to determine an appropriate course of action.

The responsibilities of the ED team include the following:

  1. 1. Identification of intimate partner violence

    2. Validation of the abused individual’s experience

    3. Assessment of immediate risk and safety planning

    4. Referral to intimate partner violence experts

    5. Documentation in the medical record

 

 

  • Abuse – physical, emotional or sexual
  • Neglect – The vulnerable person does not have necessary food, shelter, clothing, health care or supervision due to neglect by a caregiver, or because the vulnerable adult cannot meet their own needs.
  • Financial exploitation – the vulnerable adult’s money, assets or property are not used for their benefit or are stolen or kept from them.

 

 

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.

A vulnerable adult can be any person over age 18 who:

•Has a physical, mental or emotional disability that makes it difficult for the person to care for themselves or to protect themselves from maltreatment

• Is in a hospital, nursing home, transitional care unit, assisted living, housing with services, board and care, foster care or other licensed care

• Receives services such as home care, day services, personal care attendant/PCA, employment training, treatment for mental illness, etc.

the elderly, immigrants, and members of racial or cultural minorities.

 

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 patients try to hide the abuse.

In a randomized controlled trial (?)of IPV screening in emergency departments, the prevalence over 12 months ranged from 4% to 18%.

  • An estimated 4.9 million IPV rapes and physical assaults occur each year among U.S. women (age 18 years and older) and 2.9 million assaults occur among U.S. men. Most of these assaults include pushing, grabbing, shoving, slapping, and hitting and do not result in major injury.3 
  • Physical violence by an intimate partner can result in direct injury including death (1181 women and 329 men in 2005; Bureau of Justice, 2007), adverse psychological, and social consequences, and impaired endocrine and immune systems through chronic stress and other mechanisms.4
  • In the family practice setting, the lifetime prevalence of abuse of women was 38.8%, with current abuse reported by 2% to 48% of women.1
  • A national survey estimated that 503,485 women and 185,496 men are stalked by intimate partners each year.4
  • Clinicians identify only a small number of victims (1.5% to 8.5%).1Only approximately 20% of IPV rapes or sexual assaults, 25% of physical assaults, and 50% of stalking directed toward women are reported; fewer events against men are reported.4
  • Between 4% and 8% of women are battered during pregnancy.5
  • According to the National Violence Against Women Survey, more than 200,000 women age 18 years and older were raped by intimate partners in the 12 months preceding the survey.6

 

Interventions 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. There is a national domestic violence hotline (1-800-799-SAFE) that 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 California, Colorado, Kentucky, Mississippi, Ohio, and Rhode Island.