Introduction and Defining Intimate Partner Violence

The issues of substance use disorder, interpersonal violence and pregnancy are often intertwined and cannot be treated in isolation. Intimate partner violence (IPV), also called domestic violence (DV), is defined as: Behavior that results in emotional, physical, sexual, or psychological harm to a current or former partner or spouse (including common-law spouse), dating partner, or boy/girlfriend. IPV occurs in all races, ethnicities, sexual identity and orientation, and social and economic levels of society. IPV is neither a spontaneous act of anger nor a one-time occurrence [1, 2]. Intimate partner violence impacts an estimated one in four women, and one in eight men across the lifespan, resulting in numerous mental, physical, and reproductive health consequences (Figure 6.1).

Figure 6.1 Lifetime prevalence of IPV of Women in the United States

Source: National Intimate Partner and Sexual Violence Survey, 2010

Substance use disorder has been found to co-occur in 40–60 percent of IPV incidents across various studies. A review of the characteristics of 2,729 women enrolled in treatment programs designed to integrate trauma-informed services with services for co-occurring substance use and mental health disorders found that approximately 75 percent of these women experienced multiple and repeated abuses, including sexual abuse, physical abuse, and emotional abuse and neglect. The average age of initial sexual and physical abuse was 13 years of age, while the age of onset for emotional and physical neglect was nine years of age [3]. Such a pervasive history of trauma has significant implications for health service delivery practices on several levels. Pregnant women with substance use disorder are more likely to be in a current or recent intimate partner violence (IPV) relationship than pregnant women without such a disorder [4]. An interwoven and strong relationship between substance use disorder and perpetration of IPV has been found in numerous primary care healthcare settings, including prenatal clinics, family practice settings, rural and urban healthcare clinics, substance use disorder treatment centers and psychiatric settings [2]. The ripple effects of IPV extend well beyond health care, affecting interpersonal, familial, community, educational, occupational, and societal functioning. IPV strains all the legal, medical, cultural and societal resources [5, 6]. This chapter first reviews the inter-relationship between IPV, substance use disorder and pregnancy. Next discussed is the context that keeps victims and perpetrators of violence within the abusive relationship followed by a summary of ways to identify, assess and respond to a woman with IPV, substance use disorder, and pregnancy.

Who is At Risk for IPV?

Primary health care professionals may overlook IPV due to a number of factors including, age, lack of awareness, misconceptions, lack of education, time constraints, risk liability, as well as other factors. Rarely are senior age patients, male or female, evaluated for IPV. IPV is a risk for all age populations [6]. It is important to know the risk factors for IPV so that those who are suffering can be identified and helped. Below are some known risk factors for IPV:

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  Verbal abuse is the single variable most likely to predict IPV [1].

  
  
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  Prior history of IPV victimization is often seen in perpetrators.

  
  
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  Racial and ethnic minorities experience higher rates of IPV than whites [7].

  
  
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  The rates of IPV do not significantly differ in urban or rural locations.

  
  
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  Same gender relationships may also be at higher risk for IPV than opposite gender relationships. In same gender relationships, frequently an inaccurate assumption is that there is equal control or strength in the partners and/or when there is evidence of violence, it was not deliberate. However, data for rates amongst lesbian, gay, bisexual, transgender (LGBT) persons are difficult to assess with very limited reporting and study biases to date [2, 5].

  
  
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  Women compared to men, regardless of sexual orientation, have a higher incidence of IPV. Intimate partners can be of same or opposite gender [8].

  
  
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  Spousal abuse has been identified as a predictor of developing a substance use disorder [1, 2].

  
  
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  One of the strongest correlated risk factors for future aggression by both males and females is a history of previous partner aggression [9].

  
  
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  In some relationships, the issue of mutual aggression may also be occurring.

In a study of pregnant patients in North Carolina, victims of IPV were significantly more likely to use multiple substances before and during pregnancy than those who had no experience of IPV. This study also found that on days of heavy drug and/or alcohol use, physical violence was 11 times more likely among IPV batterers and victims [10].

The Interconnection between IPV and Other Life Stressors

Distinct connections between IPV and several issues cannot be overlooked. Figure 6.2 shows examples of the co-occurring issues that are associated with IPV. Of note, past history of childhood sexual abuse (CSA) increases the likelihood of sexual victimization as an adult [8, 11]. That said, many people who experience such situations never become perpetrators or victims of IPV. Similarly, resolution of these issues may not stop or reduce IPV [12–14].

People experiencing and surviving IPV often turn to alcohol, drugs or other substances/behaviors to cope with abuse; substance use disorders/addiction can, in turn, decrease inhibitions and increase risk of further violence. IPV affects the whole family unit; children in the home where IPV occurs and extended family suffer serious adverse effects in childhood and adulthood, creating additional burden on the healthcare system [15]. Verbal and physical abuse has profound effects on self-esteem and can affect mental and physical health outcomes as a result.

The Morbidity and Lethality of IPV

Every healthcare professional must take seriously the great harm that IPV inflicts on those individuals experiencing it. Clinical outcomes in those individuals experiencing IPV are wide ranging and can include, but are not limited to, fractures, head trauma, chronic gynecological conditions, somatic disorders, co-occurring neurological and/or psychiatric disorders (e.g., PTSD), and suicide. Further, IPV can have a negative impact on the immune system [8], and may negatively affect medication adherence and lead to exacerbation of disease effects including those of substance use disorder. Further, the below bullets highlight critical harms of IPV.

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  Survivors of IPV are twice as likely to attempt suicide multiple times and causes of murder/suicide are most likely to occur in the context of IPV [11, 16].

  
  
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  Over 50 percent of intimate partner violence survivors are strangled at some point in the course of the relationship – often repeatedly, over years and the overwhelming majority of strangulation perpetrators are men.

  
  
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  The victims strangled to the point of losing consciousness are at high risk of dying within the first 24–48 hours after the incident from cerebral vascular accident, aspiration, blunt force trauma and/or thromboembolism. Such incidents cause traumatic brain injury (TBI).

  
  
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  The vast majority of IPV victims showing signs of TBI never receive a formal diagnosis [11]. The act of strangulation is the penultimate abuse by a perpetrator prior to a homicide. Yet, today only 38 states prosecute strangulation as a felony. For many survivors, IPV leads to post traumatic stress disorder (PTSD) [17, 18].

The interwoven and connected effects of these conditions have significant impact on health care. These syndemics, the presence of two diseases that interact and exacerbate the negative health effects of one or both of the diseases, are the consequential interactions of substance abuse/addiction, trauma including violence and other conditions [19, 20].

The Context Bonding Perpetrators and Victims of Violence within the Abusive Relationship: Trauma Bonded

People in violent relationships frequently remain in the relationship for numerous reasons. Figure 6.3 lists examples of the diverse array of reasons why victims stay with perpetrators. Bonding is a biological and emotional process that makes people more important to each other over time. Bonding is not something that can be lost, unlike love, trust, attraction. Bonding is cumulative. Experiencing, together, extreme situations and extreme feelings tends to bond people in a unique way. Trauma bonding is the misuse of fear, excitement, sexual feelings, and sexual physiology to entangle another person [21–23]. Trauma bonding occurs when the target (victim) feels emotionally and physically dependent on the abusive person (perpetrator) who rewards the target to make them believe the perpetrator is all-powerful. Trauma bonding is used to gain control over the victim (target) and can include control over all aspects of life. Alcohol and drug misuse can complicate motivation to leave an abusive or violent partner, if he/she is providing the drug or alcohol or sharing with the victim. Compounding these challenges is the fear that leaving will not make the survivor any safer. Termination of a relationship can explode into violence [7, 13].

Pregnancy is also a very significant complicating factor in IPV; an unwanted pregnancy can lead to escalation of the violence and abuse. An unexpected pregnancy can also lead to forced starvation, eating disorders, physical impairments, self-harm (cutting), alcohol and/or substance use disorder, and other chronic medical issues. Miscarriages and abortions can be forced and/or induced by the perpetrator. Perpetrators may restrict and/or monitor all aspects of a victim’s life. Abusers frequently also control the financial resources, transportation, nutrition, clothing, bathing, sleeping, activities inside or outside the domicile, as well as access to medical care, severely limiting the victim’s ability or willingness to leave. The strongest predictor of whether a victim will permanently separate or stay in the relationship is what, if any, access to adequate financial resources are available to the victim, independent of the perpetrator [17].

Screening and Assessing for IPV Risk

Evidence suggests that if IPV is identified, brief clinical interventions focused on providing universal education about healthy relationships, routine inquiry about violence exposure, and brief counseling may be promising strategies for increasing awareness about violence, reducing isolation survivors feel, and, in some populations, reducing violence victimization. Addressing IPV is complicated because of social, ethnic, cultural, and religious stigma. No one wants to discuss this issue. Yet, understanding IPV and the syndemics that accompany it has significant implications for effective risk reduction and improving health outcomes, especially in women of childbearing age. The task of screening, treating or referring of IPV survivors can seem staggering. Healthcare professionals and law enforcement professionals who are trained in this issue are then better able to assist with this public health issue. The US Preventative Services Task Force (USPSTF) issued a recommendation in 2013 for primary care clinicians to screen women of childbearing age for IPV and refer any patient to intervention services that has a positive screen [24]. The statement only mentions women of childbearing age. It is imperative to remember women of any age and in any relationship can be at risk. Screening and assessing history of IPV, childhood sexual abuse and PTSD offers an opportunity to implement interventions early and has the potential to improve outcomes. There is no evidence that screening has caused harm to a patient.

The axiom, “FIRST DO NO HARM” should be followed, as always, when screening. Several guidelines are suggested. The following list is suggested as components that IPV screening program should have:[24]

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  Written protocol and screening policies

  
  
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  Documentation (progress notes, chart) using body maps or photos of injuries

  
  
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  Protocols for reporting and referrals (if made)

  
  
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  Staff training and local community education

  
  
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  In-house IPV counselors/advocates

  
  
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  Availability of prevention/intervention information

  
  
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  Coordination among IPV, mental health and substance abuse providers with available support groups and services

  
  
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  Linkage with community resources

No matter how healthcare professionals execute a program for screening and support, the goal should always be the same: keep the patient safe, healthy and do no harm.

The following list provides how to screen patients for IPV:

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  Never screen in the presence of a possible perpetrator. Should the partner be in the room, request they leave, and defer screening until they have left. Request another member of staff escort the partner to another room or the waiting area. Always maintain safety for the patient. If an interpreter is necessary, language and sign services should be provided by someone unknown to the patient [17].

  
  
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  It is mandatory to maintain respectful, empathic, nonjudgmental statements and questions with the patient. Provide emotional support. Know community resources and referrals.

  
  
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  Screen in pairs. Always have another staff member in the room with the patient during the screening (optimally not same gender as perpetrator).

  
  
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  Integrate screening questions into routine intake questions, possibly in social or family section, to diminish the stress/fear of the patient (i.e., due to violence being so prevalent these days, I ask all patients if they have been hurt by someone close to them).

  
  
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  Keep the questions nonjudgmental and simple (i.e., Do you feel safe at home? How do you and your companion handle disagreements?).

  
  
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  If part of the practice includes pediatric patients, consider using some screening questions during well-child or any trauma examination. (i.e., How are things at home?).

  
  
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  How you ask matters. If the patient is reluctant to respond verbally, consider integrating a format where they can respond in writing (in intake form) or on the computer.

  
  
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  Physical signs of trauma are sentinel events and the examination should incorporate questions about violence (i.e., How did this happen? Was anyone else involved?). If there is hesitancy, stay respectful of boundaries and cease the questioning. Return to the questions at a later point in the exam. Also leave open to the patient an offer to explain in writing or discussion. Remember to always include a comprehensive physical exam including cranium when violence is suspected [25, 26].

  
  
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  Know when and how to refer in your practice community and regional support resources for violence, including hotlines, mental health centers, safe houses/shelters, trained therapists, and develop a method to transfer a patient “safely” in those cases where you assess high risk of continuation of violence.

  
  
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  Provide resources in lobby, patient exam, and waiting areas during patient appointments. Such resources should include telephone numbers and/or addresses for local food banks, suicide and violence hotlines (see Resources), law enforcement, shelters and others. Consider providing numbers in a discrete, small printout that patient can keep concealed.

  
  
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  If the patient is able to discuss the situation with you, explore resource options with the patient. Remember financial resources are the number one reason victims stay in a violent situation.

  
  
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  Know your state laws regarding mandatory reporting and become familiar with the Violence Against Women Act [27, 28]. Currently many states still define domestic violence (IPV) as a male-perpetrated violence against females. A 2002 study by the US Department of Justice found that most victims injured by an intimate partner did not seek professional medical treatment or report the injuries [29]. Many states still do not acknowledge Lesbian, Gay, Bisexual, Transgender (LGBT) relationships, lacking a system to deal with violence involving LGBT persons. As a consequence, in such states, IPV in several segments of the population is not reported due to such limitations, stigma, and discrimination. Statutes still exist, in many states, requiring a male/female relationship of offender/victim for filing a protective order [2]. A widespread lack of education and training amongst legal, medical, clergy, social services, entertainment (sports, etc.) and educational systems regarding IPV continues to exist worldwide, including in the United States [9, 30].

  
  
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  Use screening tools – There are several studies that demonstrate patients will disclose IPV on a computer screen or on paper more freely than in conversation. The USPSTF has validated six brief tools that can be used to screen patients [24–26]. Consider adding one of the tools to the patient health questionnaire (PHQ) used to screen for depression.

  
  
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  There is an IPV screening tool to use in the emergency room that aims to identify victims of IPV with a potential for traumatic brain injury (TBI), named HELPPS, although it has not been standardized as a tool, as of this date.

  
  
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  A standard protocol for IPV screening questions, gender neutral is optimal. Guidelines can also be found at: www.accesscountinuingeducation.com/ACE4000/c7/index.htm.

  
  
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  Integrate standardized screening methods to assess PTSD and other stress and anxiety disorders, such as Beck Depression Inventory, Post-traumatic Stress Checklist and the Stanford Acute Stress Questionnaire.

IPV screenings in a safe and accepting environment can increase a patient’s willingness to discuss personal or medical information. The clinical value of screening for IPV has been endorsed by the American Medical Association and other major professional organizations. The American Association of Colleges of Nursing has published guidelines [31].