Intimate Partner Violence
Ann L. Coker
Corrine M. Williams
James E. Ferguson II
Intimate partner violence (IPV) is a pattern of coercive behaviors that may include repeated sexual and physical violence, psychological abuse, reproductive coercion, and stalking and often results in progressive social isolation, deprivation, and intimidation of the victim. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim and are used to establish power and control over the victim.1,2 IPV can occur among heterosexual or same-sex couples and does not require sexual intimacy to be present, either currently or in the past, to occur. IPV is estimated to result in 2 million injuries to women and nearly 600,000 injuries to men on an annual basis.3 The assumption that all IPV is initiated by men and directed toward women in heterosexual relationships is not correct, although women are far more likely to experience IPV than men.4
IPV cuts across gender, racial, ethnic, and socioeconomic boundaries, although certain groups are at greater risk for either suffering from or perpetrating IPV.5 Accurate prevalence figures for IPV are difficult to get because of underreporting and differences in IPV definitions and data collection methods. Lifetime estimates for IPV involving women in the United States range from 22 to 39%.3,6 The prevalence of IPV involving male victims is not well known, although a 2010 national survey found that about one in four men had experienced rape, physical violence, and/or stalking by an intimate partner at least once in their lifetime.2
Most IPV physical assaults are relatively minor and consist of pushing, grabbing, shoving, slapping, and hitting.7 However, IPV resulted in an estimated 2340 deaths in 2007, with 70% occurring in women and 30% in men.3 Murder by a partner is among the five most common causes of death for women ages 15 to 34 years.8 In many cases, there are historical indicators of escalating levels of violence. In one study, 44% of women murdered by their intimate partner had been to an emergency department within 2 years of the homicide, and 93% had at least one injury visit.9
According to the World Health Organization, two patterns of violence between couples have been described.4 “Battering” involves severe and escalating violence with concurrent terrorization and increasingly controlling behavior by the abuser. “Common couple violence” is a more moderate form of IPV in which violence occurs occasionally and is usually triggered by frustration and/or anger. IPV is often categorized into four main types: physical violence, sexual violence, psychological/emotional violence, and stalking.10 Experiencing one type of IPV-related abuse may increase the risk of other types of abuse. In one study, 68% of physically abused women were also sexually abused.11
Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to, such things as scratching, shoving, biting, choking, shaking, and slapping punch. It may be inflicted by some part of another person’s body, a weapon, or the use of restraints. Although many think of IPV as being predominately physical in its manifestations, physical violence occurs less frequently than other forms of IPV and is usually preceded by other forms of control.12
Sexual violence is divided into three categories: (1) use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; (2) attempted or completed sex act involving a person who is unable to understand the nature of the act, to decline participation, or to communicate unwillingness to engage in the sexual act, for example, because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and (3) abusive sexual contact, including unwanted touching or fondling.
Psychological/emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological/emotional abuse can include, but is not limited to, such things as humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing or saying something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, denying the victim access to money or other basic resources, and threats of physical or sexual violence.
Stalking generally refers to “harassing or threatening behavior that an individual engages in repeatedly, such as following a person, appearing at a person’s home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person’s property.”5 It is estimated that more than 1 million women and 371,000 men are stalked by intimate partners every year in the United States.7
As previously mentioned, both men and women can be victims of IPV, but this chapter will focus on femaledirected IPV only.
IMPACT OF INTIMATE PARTNER VIOLENCE
The frequency of partner violence poses a serious public health challenge not only because of its prevalence but also because of the long-term impact of violence on women’s short-term and longer term physical and psychological health. In general, the severity of abuse correlates with the impact on the woman’s physical and mental health, multiple episodes and types of abuse overtime are cumulative in their impact, and the effects of abuse persist long after the abuse has stopped.13 It is important to note as well that the more severe the abuse, the stronger its relationship to negative health behaviors among victims, for example, high-risk sexual behavior, substance abuse, or unhealthy diet-related behaviors such as overeating or bulimia.14,15
IPV may result in acute physical injury but it also commonly leads to “functional” physical issues such as chronic pain syndromes, gastrointestinal problems, headaches or musculoskeletal pain.13
Gynecologic Outcomes
IPV has been associated with an increased risk of chronic pelvic or abdominal pain.16, 17, 18, 19, 20 IPV, ongoing or in the past, has also been associated with increased risk for dyspareunia and this association is stronger when the abuse is/was sexual in nature.16,17,21,22 Dysmenorrhea, menorrhagia, irregular bleeding, and endometriosis have all been found to be increased in victims of IPV in some studies as well.18, 19, 20, 21, 22, 23, 24 Studies have also shown an increased risk for abnormal cervical cytology in victims of IPV, but this may be related, in part, to the increase in high-risk sexual behavior(s) that has been seen in some victims of IPV as a psychological response to the violence.18,25,26 There does not appear to be an association between IPV and fibroids.16 Some studies suggest an increased risk of sexual dysfunction and IPV.19,27,28
Adverse Pregnancy Outcomes
Domestic violence often begins or increases during pregnancy and the postpartum period.29,30 It is estimated that 4 to 8% of women are abused at least once during pregnancy.5 IPV during or in the immediate postpartum period incurs both maternal and perinatal risks.31, 32, 33 Abused pregnant women have a three-fold higher risk of being victims of either attempted or completed homicide compared to their peers.29 The risk for postpartum depression is two- to three-fold higher in women who have experienced psychological or physical abuse during pregnancy.34 Pregnant women who experienced IPV at any time (prior to and/or during the pregnancy) are more likely to smoke or use other substances during the pregnancy.35 Perinatal death is increased with IPV,19,31,32,35, 36, 37, 38, 39 and there is a significant increase in the risk of low birth weight, NICU admissions, and low Apgar scores as well as preterm labor/delivery.31,32,35,36,38, 39, 40, 41, 42, 43, 44, 45, 46, 47
Contraceptive Challenges/Unplanned Pregnancies
IPV has been shown to be significantly associated with unintended pregnancies.48, 49, 50, 51, 52, 53 Women with an unintended pregnancy have a higher risk (up to three times higher) of physical abuse compared to those whose pregnancy was planned.29 Adolescent victims of physical or sexual dating violence are more likely to experience pregnancy than their peers.54, 55, 56, 57
In some studies, women seeking abortions show elevated rates of IPV compared to the general population.19,58, 59, 60, 61, 62 Women experiencing recent physical abuse were less likely to disclose an induced abortion to their partners, with a significant subset of abused women reporting fear of personal harm as the primary reason for nondisclosure.59 A history of physical abuse by a male partner and a history of sexual abuse or sexual violence were found to be associated with repeat abortion among Canadian women.63
Despite the literature linking IPV and both unintended pregnancies and induced abortion, little quantitative data is available on differences in contraceptive use other than decreased use of condoms among abused versus nonabused women.14,15 Young women attending a family planning clinic who were in a violent relationship were less likely to have used hormonal contraceptive at last intercourse.64 Women in New Zealand who experienced IPV were more likely to report ever having used contraception than nonabused women but were also more likely to report that a partner had refused to use or tried to stop them from using contraception.65 One study of adolescent dating violence did not find an association between contraception use at last intercourse and either current or past involvement in an abuse relationship.56 However, consistent use of contraception is less likely among abused adolescents.66
Sexual Risk Behaviors and Sexually Transmitted Infections
High-risk sexual behaviors such as early age at first intercourse; trading sex for food, drugs, or money; substance use before last intercourse; increased number of sexual partners; and engaging in unprotected intercourse have been consistently associated with IPV.53,67,68 Adolescent victims of physical or sexual dating violence were more likely to have first intercourse before the age of 15 years, to have three or more sex partners in the past 90 days, or to not have used a condom at last intercourse.54,56
Studies have consistently identified a significant association between IPV and either currently having a sexually transmitted infection (STI) or having a history of an
STI noted.16,20,23,61 In one random sample of women in a large U.S. health plan, comparing women who reported IPV in the past year and women who reported never having experienced IPV, the women with reported IPV had a risk of having or having had an STI, including HIV/AIDS was three-fold higher compared to nonabused women.69
STI noted.16,20,23,61 In one random sample of women in a large U.S. health plan, comparing women who reported IPV in the past year and women who reported never having experienced IPV, the women with reported IPV had a risk of having or having had an STI, including HIV/AIDS was three-fold higher compared to nonabused women.69
Interference With Health Care
Partner interference with health care is a relatively new area of research that may be of particular importance to physicians. In one study of 2027 women using two general questions on partner interference with health care, 17% of women abused in the past year reported that a partner interfered with their health care in contrast to 2% of nonabused women.70 Women who had interfering partners were more likely to report poorer health (OR = 1.8, 95% CI = 1.0-3.2) even after controlling for recent violence and demographic characteristics.
Cancer and Cancer Screenings
Very little research has explored the effect of either current or past IPV on cancer prevention and control, although three studies investigating IPV and invasive cervical cancer found a statistically significant association.23,26,71 Modesitt et al.72 found that almost 50% of 101 women treated for breast, cervical, endometrial, or ovarian cancer reported a history of physical or sexual violence by a partner and 25% reported childhood abuse yet current abuse was rarely reported (2%). Women with cancer who had experienced IPV were less likely to have seen a physician in the year before diagnosis and were less likely to have had a Pap test or mammography. Further, lifetime IPV was strongly associated with being diagnosed at a more advanced stage of cancer.
Women experiencing childhood sexual abuse are significantly less likely to receive Pap testing at recommended intervals and have an increased risk for cervical dysplasia.73,74 Pregnant teenagers with abnormal Pap results were more likely to report domestic violence and homelessness.75 Recent severe physical abuse was associated with cervical squamous intraepithelial lesions and recent life stressors such as physical violence, sexual violence, and/or homelessness were associated with discontinuing free follow-up care for an abnormal Pap test.76 Breitkopf et al.77 found that having a mother or partner who encouraged follow-up care for an abnormal Pap was instrumental to women receiving follow-up care, whereas avoiding conflict with a partner was a reason for not receiving follow-up care. Those least likely to get follow-up care were those with family problems or conflicts with partners.
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