CHAPTER 151

Intimate Partner Violence

Sara T. Stewart, MD, MPH, FAAP

Although several definitions of intimate partner violence (IPV) exist, the Centers for Disease Control and Prevention has defined it as a pattern of behavior that includes physical violence, sexual violence, stalking, and psychological aggression. It is perpetrated by an individual who is or was involved in an intimate relationship with an adult or adolescent, and the pattern of assaultive and coercive behaviors is meant to establish control over the other partner. This may include approaches such as social isolation, deprivation, and intimidation. Intimate partner violence is not only associated with negative physical and mental health outcomes for the victim but is also associated with negative mental health outcomes for children in the home. Childhood exposure to IPV is considered to have occurred when a child sees, hears, or observes the effects of verbal or physical assaults between partners. Intimate partner violence is also associated with an increased incidence of child abuse in the home.

Epidemiology

Intimate partner violence affects both sexes and occurs in all ethnic, socioeconomic, sexual orientation, and religious groups. Approximately 8.5 million women and 4 million men in the United States report experiencing physical violence, rape, or stalking from an intimate partner during their lifetime. Of adolescents who date, 12% of girls and 7% of boys have experienced physical violence in their dating relationship in the prior 12 months. In 2007, 14% of homicides nationwide were the result of IPV, and most of these victims were female. Although both men and women fall victim to IPV, women are more likely to sustain life-threatening injuries, resulting in an increasing disparity between victimization rates with increased severity of physical assault. The annual financial cost of IPV to society has been estimated at $8.3 billion, including medical and mental health costs as well as the indirect cost of lost productivity. In total, victims lose millions of days of paid work time annually.

Although no uniform profile exists of a victim or perpetrator of IPV, risk factors for victimization include a personal history of maltreatment as a child, adolescent or young adult age, disparity of status (eg, educational, professional) between partners, and high level of dependence of 1 partner on another. Batterers have also been found to frequently have a history of emotional or physical maltreatment as a child, a history of substance abuse, very low levels of self-esteem, and difficulty identifying and expressing emotion.

It is estimated that up to 15 million children in the United States are exposed to IPV in their homes annually, and these children are at risk of victimization themselves. They are almost 5 times more likely than unexposed children to sustain physical abuse and 2.5 times more likely to be victims of sexual abuse.

Clinical Presentation

Adult victims of IPV may present for medical care for themselves or may present for care of their children for issues related to the violence. Approximately one-third of victims injured in an assault by a partner seek medical care for their injuries. Although these injuries vary in severity, skin injuries are most common. Injury can occur on any part of the body; however, injury to the head, neck, and face has been particularly associated with IPV.

Many victims present to primary care physicians and emergency departments, and only a fraction are correctly identified as suffering from IPV. A recent report noted that only 28% of abused women who sought care frequently (≥7 times) were ever identified as victims of IPV. Barriers to diagnosis are patient and physician based. A patient may not disclose the abuse because of fears of social, financial, or legal repercussions; concerns for safety based on prior threats from the abuser; feeling ashamed at being a victim; and inability to trust that others can help. The patient does not appreciate that violence frequently escalates. Often the patient fears an investigation by child protective services and loss of custody of any children in the process. The patient may fabricate a story (eg, a fall) to explain the injuries, thereby discouraging the physician from further inquiry. Even in the absence of a story, the physician may avoid inquiring about the injuries, citing time constraints and lack of knowledge to effectively respond if a disclosure is made.

A parent or guardian may also seek care for any children who manifest effects of the trauma, altered stress physiology, and disrupted caregiver attachment (Box 151.1). Children exposed to IPV are more likely than their peers to be anxious, fearful, and hypervigilant and have difficulty with aggression and peer relationships. Adolescents are more likely to have school failure, substance abuse difficulties, high-risk sexual behaviors, and violent dating relationships. As they progress to adulthood, these children are at increased risk for mental health disorders and substance abuse. The Adverse Childhood Experiences Study enumerates multiple negative overall physical and mental health consequences in adults exposed to IPV as children (see Chapter 142).

Pathophysiology

The prevalent dynamic in relationships with IPV is the need by 1 partner to dominate or have power over the other. Often, this characteristic is interpreted as devotion early in a relationship, but an abuser eventually isolates the victim socially and financially. Ultimately, the violence includes a physical or sexual component as well as a psychological one. The psychological component, which typically precedes any physical violence, includes threats, humiliation, and intimidation and can be the most difficult to treat.

The cycle of violence between intimate partners is chronic and cyclic in nature, with 3 phases. The first phase is the tension- building phase, in which the abuser uses verbal, emotional, and physical threats. The next phase is the violent episode, which includes some combination of physical, sexual, emotional, and psychological assault. The final phase is the honeymoon phase, in which the abuser apologizes and assures the victim that it will not happen again, and re-bonding occurs. These phases escalate over time as the violence becomes more frequent and more severe and the honeymoon phase shortens. At least 50% of women who suffer sexual IPV report multiple rapes, and two-thirds of men and women with physical violence report multiple episodes of assault as well. The violence can also continue after the relationship has ended, and this most commonly manifests as stalking of the victim by the abuser. The violence also becomes intergenerational, because children exposed to IPV are at increased risk for victimization and perpetration of violence in their future intimate relationships.

Particular circumstances exist in which IPV victims are at even higher risk of harm. Threats from the perpetrator to harm or kill the victim or another person, the use of drugs or alcohol at the time of the violent episode, and the use of a weapon are all associated with an increased risk of injury. Approximately 4% to 8% of women report having experienced IPV during a pregnancy. It has been hypothe-sized that this is a time of increased stress as well as a time when a woman’s attention may be diverted from her partner, thus placing her at increased risk for harm. Victims are also at increased risk of injury or death at the time they report the abuse or attempt to leave the relationship. In comparison with the systems in place for children, no protective service agencies with mandates to protect these adult victims exist, and as a result, disclosure of IPV may not occur unless the victim feels that she, he, or they has a plan for escape.

Differential Diagnosis

Adult or adolescent victims of IPV often present with vague symptoms, and women who have been abused are 3 times more likely than women who have not been abused to present with gynecologic complaints, such as recurrent sexually transmitted infections, vaginal bleeding, or chronic pelvic pain. These victims may also present with nonspecific symptoms of sleeping difficulties, appetite changes, weight loss, chronic pain, or syncope. They are 3 times more likely to experience depression and 4 times more likely to experience posttraumatic stress disorder (PTSD) than non-abused women and may present to their physician with symptoms of anxiety or after a suicide attempt. Other symptoms reflect conditions associated with stress, such as irritable bowel syndrome, headaches, or temporomandibular joint disorder. The pregnant victim may present with vaginal bleeding, preterm labor, placental abruption, or fetal distress. The most common adverse birth outcome attributed to IPV during pregnancy is low birth weight of the neonate.

Mental health manifestations of childhood exposure to IPV may vary depending on the developmental stage of the child; however, these children may present with developmental delay, low self-esteem, symptoms of PTSD and hypervigilance, poor academic performance or truancy, or antisocial behavior. Exposed children also have significantly more internalizing disorders (eg, depression, anxiety, somatization) and externalizing disorders (eg, attention-deficit/hyperactivity disorder, aggression) than nonexposed children.

Children in the home may also sustain direct physical trauma as the result of being held in a parent’s arms during an episode of violence or in an effort to intervene and protect a parent during a violent episode. The children may also be direct targets of the violence and present with head, skin, skeletal, or abdominal findings caused by physical abuse (see Chapter 144).

Evaluation

History

Many victims of IPV do not freely offer information about the violence occurring in their relationships, even if they present with overt injuries. Screening for IPV in medical settings is cited as the optimal approach and is an area of continued research. Several different screening tools have been used clinically, but no standard screening tool has yet been established. Proposed approaches in the primary care or emergency department environment have included universal screening of all women and targeted screening of women with high-risk signs and risk factors. Although each approach has its proponents, a 2013 US Preventive Services Task Force statement recommended that physicians screen all women of childbearing age. Universal screening may detect increased numbers of cases of IPV and “open the door” to effective intervention, but it remains unknown whether improved social, physical, or mental health outcomes have been achieved with this approach. Critics of universal screening argue that forcing the issue before a woman is psychologically and logistically ready to leave the situation may put her at increased risk of harm and decreased likelihood of success. However, a 2015 Cochrane Review found no evidence of harm resulting from IPV screening. The universal screening approach has not typically addressed the population of male victims of IPV.

Alternatively, targeted screening is performed in some medical settings on patients who present with risk factors for IPV (Box 151.2). Studies have shown that self-administered, written screening tools are more sensitive and are preferred by victims over verbal questioning.

Because IPV has been shown to have a direct effect on the health and well-being of children in the home, the pediatric medical setting is a potential site for IPV screening to occur. Targeted screening practices may focus on families of children with anxiety, depression, or somatization or in situations in which child abuse is suspected. Surveys of mothers generally support IPV screening in the pediatric office setting, and women who have been abused are more likely to seek medical care for their children than for themselves. Sensitivity to whether children should witness discussions of positive screening questions is necessary, because older children may react to or repeat portions of an overheard conversation, ultimately placing the victim, their mother, at increased risk of harm.

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