Good afternoon. It is a great honor to be the president of the American Gynecological Society and to have served on the council for the past 8 years. It is indeed my pleasure to give my presidential address to you.
Contemplating this address, I considered a variety of different topics and found myself in the position of considering 3 or 4 topics to present. As I often do when I need valuable input into decision making, I turned to Lynn (my wife) for her advice. She said, “It’s simple: choose the topic that you feel most strongly about.”
That advice helped tremendously. Although I was strongly considering topics that have been an important part of my academic career, such as preterm labor and the pharmacologic management thereof, as well as prenatal diagnosis, and more recently issues related to leadership, or the recent cultural change within the American Gynecological and Obstetrical Society, I immediately knew that my presentation would relate to intimate partner violence (IPV) and its unacceptable consequences on women.
IPV was largely ignored in our society prior to the 1970s. At that time the women’s liberation movement focused attention on the many forms of violence, and specific names were introduced (eg, date rape, sexual harassment, and others). Although progress has been made in the understanding and recognition about IPV in the past 30 or more years, significant sociocultural barriers continue for abused women to seek or receive help. These include the patriarchal and sexist attitudes and practices that exist in American society today, particularly gender role socialization and a normative acceptability of violence perpetrated against women.
Violence persists in our society and is a dominant consideration in our television shows and advertisements, children’s games, sporting events, literature, and music. Indeed, the United States has been classified as a rape-prone culture. In 1991, Surgeon General Everett Koop declared violence to be a public health epidemic. Since that time, an increase in funding in primary and secondary prevention as well as research efforts to study the diverse implication of this vexing problem followed.
IPV has been defined in many different manners by various groups and in studies in the literature. It is defined as actual or threatened physical, sexual, psychological, or stalking violence by current or former intimate partners (whether of the same sex or opposite sex) by the Centers for Disease Control and Prevention (CDC).
Another definition is that outlined by the American Medical Association in their treatment guidelines on domestic violence. In those guidelines, IPV is defined as a “pattern of coercive behaviors that may include repeated battering and injury, psychological or emotional abuse, sexual assault, progressive societal isolation, economic deprivation, intimidation, and stalking.
These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim.” As can be noted from each of these definitions, men too can be the victims of IPV.
Because of considerations that will be developed more completely in the following text, it is difficult to determine the exact background prevalence of IPV. In nearly all studies, it is evident that although IPV affects both sexes, irrespective of which index of severity we consider, women are disproportionately affected and suffer more severe consequences than men.
To date, the study by Breiding et al provided us with the best estimates of the prevalence and risk factors of IPV within the United States. In that study, noninstitutionalized adults aged older than 18 years who were participating in a random digit dialed (RDD) telephone survey developed by the CDC to provide telephone survey (behavioral risk factor surveillance system [BRFSS]) also completed an IPV module.
To determine the prevalence of physical violence, respondents were asked: “(1) Has an intimate partner ever threatened you with physical violence? This includes threatening to hit, slap, push, kick, or hurt you in any way; (2) has an intimate partner ever attempted physical violence against you? This includes times when they tried to hit, slap, push, kick, or otherwise hurt you, but they were not able to; or (3) has an intimate partner ever hit, slapped, pushed, kicked, or hurt you in any way?”
In this study, 19.2% of women reported threatened physical violence over their lifetime, 14.5% reported attempted physical violence, and 20.2% reported completed physical violence. The respective percentages for men were 8.7%, 10.3%, and 10.7%.
To determine the prevalence of sexual IPV, the respondents were asked: “Have you ever experienced any unwanted sex by a current or former intimate partner? Unwanted sex was defined with the following statement: “Unwanted sex includes things like putting anything into your vagina (a female), anus, or mouth or making you do things to them after you said or showed that you did not want to. It includes times when you were unable to consent (for example, you were drunk or asleep or you thought you would be hurt or punished if you refused).”
Prior to the administration of the questions, an intimate partner was defined as “any current or former spouse, boyfriend, or girlfriend; someone you dated would also be considered an intimate partner.” The frequency of unwanted sex for women was 10.2% as compared with 1.5% for men. The lifetime prevalence rates for women for physical and sexual abuse was 26.4% compared with 15.9% for men, whereas the lifetime prevalence for completed physical and/or sexual violence for women was 23.6% compared with 11.5% for men.
Respondents who reported any experience of physical violence or unwanted sex by an intimate partner were also asked the following: In the past 12 months, have you experienced any physical violence or had unwanted sex with an intimate partner? Respondents who reported physical or sexual IPV within the past 12 months were asked: In the past 12 months, have you had any physical injuries, such as bruises, cuts, scrapes, black eyes, vaginal or anal tears, or broken bones as a result of this physical violence or unwanted sex? Within the past 12 months, the prevalence of completed physical and/or sexual violence was 1.4% in women compared with 0.7% in men.
As might be expected, rates of abuse varied based on race/ethnicity, age, income, and education. Although sobering, these data likely underestimate the true prevalence of IPV. Because of the limited number of questions that could be asked in such a survey, questions regarding emotional abuse were eliminated. Thus, the data did not include emotional abuse.
In addition, not all respondents who completed the BRFSS core completed the subsequent IPV module. These patients tended to be female and of ethnic/racial minority, to have a lower income, to be less educated, and were older than those who completed the entire survey. Each of these characteristics, with the exception of advanced age, was shown in the data to be associated with a higher prevalence of IPV, again suggesting the data underestimate the true prevalence of IPV.
Another reason that these data underestimate the prevalence of IPV is associated with the methodology of the study, which used an RDD telephone study. Therefore, it is difficult to survey those not living in a stable household residence (for instance, those in prisons, nursing homes, military bases, college dorms, shelters, homeless and transience populations, or those without a land-line telephone).
To determine the prevalence of IPV based on specific patient populations, McCloskey et al used written surveys to assess prevalence rates across 5 medical specialties at 8 different health care facilities in a large American city and its environs. Rates of lifetime IPV victimization ranged from 26% among women in primary care to 73% among women in addiction recovery programs. Thirty-five percent of obstetrics and gynecology patients reported IPV by a partner. Regarding current abuse, 13% of women seeking care in obstetrics and gynecology, 9% of women primary care patients, 17% of women patients in emergency departments, and 36% of women patients in an additional recovery program reported ongoing IPV.
Although the rates of IPV in the United States are alarming, the worldwide rates are of even greater concern. Women aged 15-49 years of age completed standardized population-based household surveys in 15 sites in 10 countries worldwide. Those who had ever had a male partner were asked in private about their experiences of physically and sexually violent and emotionally abusive acts. The reported lifetime prevalence of physical or sexual partner violence or both varied from 15% to 71%, but 2 sites had a prevalence of less than 25%, 7 between 25% and 50%, and 6 between 50% and 75%. Between 4% and 54% of respondents reported physical or sexual partner violence, or both, in the past year. Men who were more controlling were more likely to be violent toward their partners.
The consequences of IPV are staggering and can be considered within the categories of immediate and longer term. Each year in the United States, it is estimated that 4.5 million women are assaulted by their intimate partners. Forty-one percent of those assaults cause observable injuries, and 519,031 of the assaults (28.1% of those injured) require medical care. The types of injuries that women suffer at the hands of their intimate partners range from minor injuries (such as scratches, bruises, and welts) to death.
IPV resulted in 1544 deaths in 2004. Of these deaths, 75% occurred in females. Between 1976 and 1996, 30% of femicides in the United States were at the hands of intimate partners. Other common injuries that result from IPV include broken bones, broken teeth, burns, bullet wounds, lacerations, knife wounds, and sore muscles. Approximately 67% of women who visit emergency rooms after IPV have symptoms of a head injury; 30% of IPV victims have suffered a loss of consciousness at least once.
It has been estimated that approximately 68% of victims of domestic violence are strangulated at least once; the average is 5.3 times per victim. Strangulation is undoubtedly so common because it is particularly terrifying to the victim. If the woman survives the index episode of IPV, she is at increased risk for a variety of longer-term life-altering consequences.
IPV may directly or indirectly influence a range of mental health conditions and other longer-term health consequences. Because physical assaults are highly likely to produce anxiety and fear of pain, injury, and even death, posttraumatic stress disorder has been frequently assessed in battered women. Kesler et al established a mean prevalence of posttraumatic stress disorder of 63.8% in women who survived physical violence, and Kemp et al noted that the odds ratio for violence and this disorder was 2.87. A mean prevalence of depression in surviving physically abused women of 47.6% was noted in a metaanalysis in 1999. Moreover, the works of several authors appear to establish a temporal length between battering and depression, thus strengthening the causal connection between physical IPV and depression.
Suicidality, including both ideation and attempts, seems well established as linked to IPV with a weighted mean odds ratio of 3.55, although the prevalence of approximately 18% is lower than that of posttraumatic stress disorder or depression. Sexual violence has also been associated with an increased incidence of depression. Coker et al noted that sexual IPV alone is even more strongly associated with depression than physical violence alone.
IPV has also been associated with risky behaviors. Women who have suffered IPV are more likely to smoke than nonabused women and to be current smokers. Women who experienced recent or lifetime IPV are more likely to report problem drinking or drinking every day. In the study by McCauley et al, a mean prevalence rate of approximately 9% for drug abuse/dependence was noted among women experiencing IPV, which is less than that associated with alcohol problems.
IPV also influences sexual risk-taking behaviors. Among women attending a public sexually transmitted infection clinic, those who had experienced IPV in the last 12 months were more likely to report alcohol or other drug use before last sexual intercourse and having a nonmonogamous sex partner. In women studied who had domestic violence protective orders, nearly 98% engaged in at least 1 risky sexual behavior with the partner against whom they had the protective order.
There are numerous longer-term consequences to physical health in survivors of IPV. Not unexpectedly, IPV has been noted to be associated with sexually transmitted infections (STIs). Three studies have reported that sexual IPV was more strongly associated with a history of an STI than was physical or psychological abuse. Also, Tubman et al found that increasing numbers of abuse experiences were associated with ever having had an STI for men and women.
It is difficult to determine the temporal sequence of associating IPV and STI because most studies were cross-sectional. However, 5 studies did address both lifetime and current STI status to better time frame exposure-outcome sequencing. From these studies IPV was more strongly associated with having a history of an STI than with current STI.
IPV has consistently been associated with a variety of adverse gynecological outcomes including an increased risk of chronic pelvic or abdominal pain as well as painful menses and dysmenorrhea. Lack of sexual pleasure or sexual dysfunction has likewise been associated with IPV as has the risk of having an abnormal Papanicolaou test or cervical dysplasia. Campbell et al noted that sexual abuse was more strongly associated with painful intercourse than was physical abuse.
IPV has also been associated with menstrual irregularity, including excess of bleeding and/or endometriosis. Two studies found an association between IPV and hysterectomies. Women experiencing IPV find contraception more difficult to navigate because of partner interference.
With the exception of the largest study, IPV has consistently been associated with heart disease. Additionally, IPV has been correlated with ever having a stroke or symptoms consistent with a stroke. Tiwari et al noted that lifetime IPV strongly correlated with poorer current quality of life, suggesting the persistent effect of IPV in cases long after women have left an abusive relationship.
The studies addressing the association of chronic disease and IPV have found that IPV was associated with an increase in the number of symptoms and generic physical symptoms. Likewise, IPV has consistently been associated with gastrointestinal disorders, including inflammatory bowel syndrome, chronic fatigue syndrome, and arthritis. Loxton et al noted that IPV was associated with an increased risk of cervical cancer, and we have noted the association between IPV and a later stage of diagnosis of women’s cancers, including cervical, endometrial, ovarian, and breast.
For obstetrician-gynecologists perhaps the best-known adverse consequences of IPV are those associated with pregnancy. Unfortunately, pregnancy puts a woman at increased risk of IPV. Researchers reported that pregnancy increased the risk of experiencing violence by a factor of 2.11. Approximately 4-8% of women are physically abused at least once during pregnancy; the woman’s abdomen is a frequent target for punching and kicking by the assailant in an attempt to damage the fetus.
IPV has been shown to be significantly associated with unintended pregnancies, and women seeking abortions show elevated rates of IPV compared with the general population. Studies have shown that physical abuse during pregnancy delays prenatal care by an average of 6.5 weeks and can also result in an increased risk of miscarriage. Furthermore, most published studies that address IPV as the primary exposure noted a significant association with perinatal death and a significant increase in low birthweight infants.
Hospitalization during pregnancy was correlated with IPV in the majority of studies, and postpartum depressive symptoms have been associated with IPV in the majority of studies. Sadly, pregnant women abused by their partner are more likely to be murdered than nonpregnant abused women.
Aside from the aforementioned health considerations, IPV is costly beyond the tears and agony associated with adverse health consequences. The economic consequences are dramatic. Approximately one-sixth (about 742,000) of the victims of IPV each year lose time from paid work as a result of the assaults.
There is also a loss of daily earnings as well as a cost to replace the woman’s work at home. Women who experience IPV have more annual health care visits and higher annual health care costs. Estimates of the annual costs of IPV range from $2.3 billion to $7.0 billion for direct health care costs; the indirect costs of lost productivity are approximately $1.8 billion. Even if the violence stops and the woman survives, health care costs for women who experience IPV remain elevated.
At this point, I hope that the reader will agree that IPV occurs at a high frequency and is associated with unacceptable and significant immediate and longer-term mental and physical health consequences. It is perhaps logical to ask questions such as, can we screen/query women to identify current or past IPV so we can intervene in an effort to affect more favorable outcomes and what guidelines exist and, if so, what guidelines exist to help shape our clinical practices?
Currently, there is no unanimity in the recommendations for screening for IPV. In 1992, the American Medical Association recommended that all adult women entering the primary care setting be screened, regardless of the reason for presentation. Conversely, the US Preventive Services Task Force in 2004 concluded “there is insufficient evidence to recommend routine screening for family violence to include abuse of women, children, or the elderly.”
Whereas there are divergent opinions about routine screening for IPV, there is no divergence in the need to ask a patient about IPV if she presents with signs or symptoms that may be associated with IPV. Given the protean manifestations and associations of IPV, this means, from a practical standpoint, that a significant number of women patients would be appropriate candidates for screening. Given the recommendations of the American College of Obstetricians and Gynecologists, I believe it is incumbent on obstetricians and gynecologists to routinely screen all women in their practices regardless of signs or symptoms.
Many of those who advocate for routine screening believe that the Preventive Service Task Force makes incorrect assumptions about the endpoints of screening in determining its value. Moreover, they believe that there is a therapeutic value associated with screening, in and of itself. It should also be noted that in Canada, the United Kingdom, and many other countries, routine screening for IPV is encouraged.
Given the unique role that we play in women’s lives as their women’s health care specialists, it may be of interest to ask, “What education and training do obstetrician-gynecologists receive in relation to intimate partner violence?” During postgraduate education obstetrician-gynecologists are provided direction for their educational efforts by the American Board of Obstetricians and Gynecologists as well as the Council on Residency Education of Obstetrics and Gynecology.
For the office practice section of the written examination specifically related to prevention/primary care, domestic violence and sexual assault is listed in the blueprint as a major area for emphasis on the examination. Moreover, in instructions for case preparation for the oral examination, 2 of the office practice categories are “sexual assault” and “spousal abuse.”
The learning objectives are also outlined in the Educational Objectives, Core Curriculum in Obstetrics and Gynecology , ninth edition. In the unit entitled Primary and Preventive Ambulatory Health Care in the section, Periodic Health Assessment, in which objectives are listed to “perform routine screening for selected diseases,” for women 13-64 years old, it outlined that residents should learn to “evaluate psychosocial well-being, including issues regarding abuse.” In unit 5 in the section on pediatric and adolescent gynecology (birth to menarche), it is stated that residents in training should “describe gynecologic problems experienced by pediatric patients such as … sexual abuse” and further “to perform a forensic examination (including appropriate laboratory tests) to evaluate sexual abuse.”
In the special gynecologic conditions section of unit 2 in the section Crisis Intervention, it is stated that “the obstetrician-gynecologist should be able to identify an abused woman, provide immediate medical evaluation and treatment for her, and, if indicated, assist with referrals for legal assistance and psychological counseling.
Specific objectives include: (1) discuss the principal types of violence against women of all ages (incest, rape, physical abuse, and psychological abuse); (2) elicit a pertinent history from a possible victim of physical, psychological or sexual abuse; (3) perform focused mental status examination and physical examination to detect findings of physical, psychological, or sexual abuse; (4) describe the appropriate legal safeguards that must be observed in evaluating a victim of abuse, such as maintaining the proper chain of evidence in handling laboratory specimens and reporting the crime to the appropriate authorities; (5) perform or order selected laboratory tests to evaluate a victim of abuse; (6) provide immediate treatment for victims of abuse, including prophylaxis for STIs and postcoital contraception; and (7) provide appropriate follow-up care and referrals for victims of abuse.
The American College of Obstetricians and Gynecologists has provided robust practice guidelines related to screening for IPV for practicing obstetricians–gynecologists. For instance, in committee opinion number 343 (psychosocial risk factors: prenatal screening and intervention), the following recommendation is given: Psychosocial screening of all women seeking pregnancy evaluation or prenatal care should be performed, regardless of social status, educational level, race, and ethnicity. Furthermore, it is better to perform psychosocial screening at least once each trimester to increase the likelihood of identifying important issues and reducing poor birth outcomes. There is evidence that women who are screened for psychosocial issues once each trimester are half as likely as women who are not screened to have a low birthweight or preterm baby.
Additionally, in the patient care section of the Guidelines for Women’s Health Care, it is stated that “clinician responsibilities in addressing IPV and domestic violence include the following: implement universal screening, acknowledge the trauma, assess immediate safety, help establish a safety plan, review options, offer educational materials, offer a list of community and local resources, provide referrals, document interactions, provide ongoing support at subsequent visits.”
It thus appears that our professional organizations have clearly outlined learning objectives and practice requirements for IPV. A natural question at this juncture may be “how do we as obstetrician-gynecologists perform in screening for and the secondary prevention of intimate partner violence?” Secondary prevention is defined herein as “activities aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms.”
We will review the performance of screening for IPV within the context of pregnant and nonpregnant patients, various health care settings, and by specialty. While reviewing screening performance for IPV, it should be kept in mind that the published studies are typically questionnaire based surveys and do not represent actual chart reviews. Most of the data has been obtained from primary care physicians, and overall, the results can be categorized as “less than reassuring.”
Rodriguez et al queried family physicians, internists, and obstetrician and gynecologists as to their screening practices. The frequency of routine screening for new patients, periodic visits, and patients receiving prenatal care were 10%, 9%, and 11%, respectively. Overall, 79% of the physicians routinely screened women for IPV in the setting of injury. The frequency of screening by health maintenance organization physicians was 1%, by obstetricians and gynecologists, 17%; and by physicians who worked in public clinics, 36%.
Similar results were published by Chamberlain and Perham-Hester when evaluating screening practices of family physicians, internists, obstetricians and gynecologists, and general practitioners. Fully 86% screen “often or always” if a woman presented with an injury, whereas screening was performed “often or always” at initial visits and annual examinations in 6.2% and 7.5% of patients, respectively.
In a subsequent “presentation,” Chamberlain and Perham-Hester indicated that the screening frequency was similar among specialties (however, the study was likely underpowered to have found a difference should it have existed) and indicated that screening occurred at 17% of initial prenatal visits and 5% during return prenatal visits. These authors raised the important question as to the possibility of screening being over reported on the basis of a social desirability bias. To date, the largest study was reported by Elliott et al in a national systematic sampling of 2400 obstetricians and gynecologists, emergency room physicians, internists, and family medicine physicians. It was noted that 6% of physicians screened all women and obstetricians and gynecologists screened 20% of their patients.
Finally, Sitterding et al through the Virginia Department of Health Center for Injury and Violence Protection surveyed 516 practicing family physicians and obstetricians and gynecologists. Overall, family physicians reported 9.7% of women screened, whereas obstetricians and gynecologists reported screening 25.3% of their patients.
As noted in the studies cited earlier, screening for IPV is not a frequent event in most physicians’ offices. Whereas obstetrician-gynecologists appear to perform screening at rates greater than other specialties, screening is still not prevalent. It is likely therefore, that barriers that result in the relatively low rates of screening for intimate partner violence exist.
In the Table , I have outlined some of the possible barriers for IPV screening for physicians. The role of some of these barriers has been addressed in several studies. Rodriguez, et al categorized major barriers to physician identification of intimate partner abuse and referral of patients into 3 categories: (1) patient-related barriers, (2) mutual barriers, and (3) provider-related barriers. Eighty-two percent of physicians believe that the patient’s fear of retaliation was a barrier, 78% “lack of disclosure,” 55% “fear of police involvement,” and 52% “lack of follow-up.” When components of “mutual barriers” were evaluated, “cultural difference,” “lack of privacy,” and “language differences” were felt to be barriers by 56%, 48%, and 39% of physicians, respectively.
