Intimate partner violence (IPV): a pattern of assaultive and/or coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, intimidation, and reproductive coercion
Domestic violence (DV): an older and very similar term referring to assaultive and/or coercive behavior within a shared household; IPV and DV strongly overlap
Population-specific violence: includes different forms of population-specific violence affecting particularly vulnerable patients, such as child abuse, adolescent abuse, elder abuse, and patterns of behavior affecting vulnerable or marginalized populations
Affects individuals of all ages, races, and educational and economic backgrounds
Occurs in both heterosexual and homosexual relationships; however, the most common presentation is a heterosexual relationship with a female victim
Can be thought of as part of a larger disempowerment syndrome and is seen more often in women affected by low socioeconomic status, sexually transmitted infections, and unintended pregnancy
Long-standing abusive relationships tend to develop a cycle in which a violent episode is followed by a period of reconciliation and apology. A tension-building phase soon begins and culminates in a repeat violent attack and the cycle begins anew.
Escape from the relationship may be difficult because of fear, shame, powerlessness, and social isolation. Over time, the degree of violence may escalate.
The majority (85%) of individuals affected by IPV are women.
In primary care practices, nearly 25% of women endorse current or previous IPV.
Approximately 25% of women in the United States will be abused by a current or former partner sometime during their lifetime.
IPV is the single most common cause of injury to women in the United States; more than 30% of all women’s emergency room visits can be attributed to IPV.
Fifty-four percent of IPV is reported to police; only 24% of sexual assaults are reported.
One third of female homicides in the United States are IPV-related.
Women are more likely to be injured, raped, or killed by a current or former male partner than by all other types of assailants combined.
According to the Centers for Disease Control and Prevention (CDC), 4% to 8% of pregnant women report abuse during pregnancy.
One in six abused women reports her partner was first abusive in pregnancy.
Abuse often escalates during the course of the pregnancy and postpartum.
IPV can result in poor pregnancy outcomes, such as miscarriage, preterm labor, low birth weight, and fetal injury or death.
Women with an unintended pregnancy have a threefold higher risk of abuse than those women whose pregnancy was planned.
Pregnant women have a threefold higher risk of being victims of attempted or completed homicide, and IPV-related homicide is the number one cause of death in pregnancy.
Defined as “explicit male behavior to promote pregnancy unwanted by the woman and can include ‘birth control sabotage’ and/or ‘pregnancy coercion,’ such as telling a woman not to use contraception and threatening to leave her if she doesn’t get pregnant.”
More broadly, clinicians will encounter a spectrum of coercive behaviors that aim to influence women’s reproductive choices.
Strongly correlated with the following demographics:
Ethnic and/or racial minority
Low educational achievement
Lack of employment
Low socioeconomic status
History of sexually transmitted infection (STI)
History of unwanted pregnancy
Increasing age difference between the individual and her partner
Current unwanted pregnancy
Reproductive coercion represents another form of controlling behavior within a relationship displaying power differentials. Of women experiencing IPV, nearly half will also endorse reproductive coercion upon direct questioning from a clinician.
Regular screening for IPV is the most important thing clinicians can do and routine surveillance has been recommended by the U.S. Department of Health and Human
Services, the Institute of Medicine, and the American College of Obstetricians and Gynecologists (ACOG).
Routine IPV screening significantly increases detection. In a study of trauma victims, the institution of a screening protocol increased detection from 5.6% to 30%.
The opinion published by ACOG supports specifically asking women about their abuse history and recommends screening at the following patient encounters:
New patient visits
Annual visits
Problem visits where unintended pregnancy or STI is diagnosed
First prenatal visit
Once during each trimester in pregnancy
Postpartum visit
Guidelines for screening
Setting is very important. A patient must feel that she is in a safe and comfortable environment. Ideally, screening should be done without a partner, children, or other relatives present. Be aware that the aggressor often accompanies the woman to the appointment and wants to remain in the room to monitor what is said.
Ensure patient confidentiality.
Begin with an objective statement that demonstrates that your screening is universal and necessary to provide comprehensive health care. This type of introduction increases the detection rate and helps the patient feel that she has not been singled out.
Never ask what the patient did wrong or why she remains with her partner. Avoid judgment or value-laden terms, such as “abused” and “battered.”
Choose quick screening questions that feel comfortable and make screening routine. Several useful questionnaires have been developed to address abuse:
Family Violence Prevention Fund questions (Table 33-1)
The Structured Analysis Family Evaluation questions (Table 33-2)
The three-question Abuse Assessment Screen (Table 33-3)
Be patient. Patients will often fail to disclose on first questioning, but they will almost never reveal IPV if not asked. If the provider suspects abuse and the patient initially denies it, the provider should readdress the issue during a subsequent visit.
Leave the conversation open and make sure patients are aware that they can discuss any issues at future visits. This supportive environment where information is available regarding options or resources could prompt patients to seek help in the future.
Women affected by IPV will often have numerous office or emergency room visits for injury. There may be an inconsistent explanation for the injuries or a delay in seeking treatment. The injuries classically involve multiple sites, such as three or more body parts; affect the head, back, breast, and abdomen (whereas accidental injuries are more likely to be peripheral); and are in various stages of healing.
Patients who are abused tend to report somatic complaints, such as fatigue, headache, and abdominal pain. They are also more likely to suffer from eating disorders, gastrointestinal complaints, psychiatric disorders, and substance abuse.
TABLE 33-1 Screening Questions from the Family Violence Prevention Fund
Sample Intimate Partner Violence Screening Questions
While providing privacy, screen for intimate partner violence during new patient visits, annual examinations, initial prenatal visits, each trimester of pregnancy, and the postpartum checkup.
Framing Statement
“We’ve started talking to all of our patients about safe and healthy relationships because it can have such a large impact on your health.”a
Confidentiality
“Before we get started, I want you to know that everything here is confidential, meaning that I won’t talk to anyone else about what is said unless you tell me that … (insert the laws in your state about what is necessary to disclose).”a
Sample Questions
“Has your current partner ever threatened you or made you feel afraid?” (Threatened to hurt you or your children if you did or did not do something, controlled who you talked to or where you went, or gone into rages)b
“Has your partner ever hit, choked, or physically hurt you?” (“Hurt” includes being hit, slapped, kicked, bitten, pushed, or shoved.)b
For women of reproductive age:
“Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?”a
“Does your partner support your decision about when or if you want to become pregnant?”a
“Has your partner ever tampered with your birth control or tried to get you pregnant when you didn’t want to be?”a
For women with disabilities:
“Has your partner prevented you from using a wheelchair, cane, respirator, or other assistive device?”c
“Has your partner refused to help you with an important personal need such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink or threatened not to help you with these personal needs?”c
a Modified and reprinted from Family Violence Prevention Fund. Reproductive health and partner violence guidelines: an integrated response to intimate partner violence and reproductive coercion. San Francisco, CA: Family Violence Prevention Fund, 2010. http://www.futureswith outviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf. Accessed October 12, 2011, with permission.
b Modified and reprinted from Family Violence Prevention Fund. National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. San Francisco, CA: Family Violence Prevention Fund, 2004. http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf. Accessed October 12, 2011, with permission.
c Modified and reprinted from Center for Research on Women with Disabilities. Development of the abuse assessment screen-disability (AAS-D). In Violence against Women with Physical Disabilities: Final Report Submitted to the Centers for Disease Control and Prevention. Houston, TX: Baylor College of Medicine, 2002:II-1-II-16. http://www.bcm.edu/crowd/index.cfm?pmid=2137. Accessed October 18, 2011, with permission.
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