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Intimate Partner Violence

IPV has profound effects on women’s health and well-being; screening, identification, and appropriate referrals are essential.

Intimate partner violence (IPV) is characterized by a pattern of coercive behaviors (e.g., repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation, and intimidation) perpetrated by someone who is or was involved in an intimate relationship with the victim.¹ One in four U.S. women will be abused by a partner during her lifetime.²

In the clinical setting, 35% of obstetrics-gynecology patients, 26% of women patients in primary care practices, and 41% of women seen in emergency departments have reported lifetime IPV.³ Partner abuse occurs across all racial and socioeconomic sectors²; risk factors include female sex, younger age, unmarried status, low income, lack of insurance coverage, and childhood maltreatment.^2,4,5,6,7 IPV has been associated with gynecologic, gastrointestinal, neurologic, musculoskeletal, cardiac, and psychiatric complaints.^4,5,8,9 When abuse continues, these health-related complaints increase in number.⁹ Not surprising, IPV victims are more likely to seek medical care¹⁰ — and the estimated direct annual cost of this additional use is US$4 billion.¹¹

IPV DURING PREGNANCY

As many as 20% of pregnant women are abused by their partners^3,6,12 (or, in pregnant adolescents, by female nonpartners [JW Womens Health Mar 19 2001]), making IPV more common than preeclampsia and gestational diabetes. Pregnancy itself (particularly if unplanned), prior abuse, and delayed prenatal care are risk factors for IPV.^6,12 Adverse outcomes associated with IPV before or during pregnancy include urinary tract infections, vaginal bleeding, preterm labor, and substance abuse.^6,12

SCREENING FOR IPV

Most major medical organizations recommend routine screening of all adult women for IPV.^13,14 Such screening should be conducted in a safe, private setting at new patient visits and periodically thereafter (e.g., during annual exams). No adult known to the patient should be present, and older children should leave room before inquiries are initiated. Screening should begin with a general statement about the prevalence of violence against women, followed by an open-ended question directed toward the patient (e.g., "Do you feel safe in your relationship?"). If the patient denies abuse, the provider should then inquire specifically about violent behaviors such as hitting, pushing, choking, or forcing sexual intercourse. Vague terms such as "physical abuse" or "sexual abuse" should be avoided.

If a clinician suspects abuse that the patient has not disclosed, he or she should inform the patient about these concerns in a gentle, nonjudgmental manner. At subsequent visits, the clinician should address IPV as part of the patient’s ongoing problems and should be aware that the patient might continue to withhold information.¹⁵

SAFETY ASSESSMENT

When a patient reveals that she is being abused, the provider should validate her experience by telling her that she is not alone and that no one deserves to be hurt. Such brief statements of empathy and validation can be powerful interventions in themselves.¹⁵ The provider also should perform a quick safety assessment by asking whether the abuser has a weapon or has ever threatened to kill the patient and whether the patient feels that she is in any immediate danger. The provider then should ask about specific types of abuse and whether the patient has ever sought medical treatment or has ever attempted suicide.

REFERRALS

When a clinician identifies a case of IPV, he or she should provide the patient with information about available resources, including telephone numbers of hotlines, shelters, local support groups, and legal aid services. A U.S. domestic violence hotline (1-800-799-7233) is staffed nationwide by trained operators who can offer aid and can direct callers to local resources. Each state also has a domestic violence coalition that helps abused women find local services and that provides clinicians with useful public service information, such as posters and pamphlets.

SAFETY PLANNING

The clinician should help the patient to develop a "quick-escape" plan in the event that she ever needs to flee immediately or decides to leave her abusive situation permanently. Specifically, the provider should encourage the patient to identify places where she could go if she were in imminent danger (a friend’s or a relative’s home or a shelter) and to make copies of important personal and family documents (driver’s license, social security card, bank and credit card statements, birth certificates, and immunization records). The patient should put these documents in a plastic bag along with a change of clothes, and the bag should be stored outside the home.

DOCUMENTATION

In the patient’s medical record, the provider should state a description of the reported abuse and the identity of the abuser. If a clinician suspects abuse that the patient does not disclose, he or she should note this suspicion on the patient’s chart.

Counseling for IPV is a clinical activity that can be coded on charge sheets for insurance billing purposes. Before billing for this activity, the provider should ask the patient whether her abuser has access to insurance statements; such documents might reveal that the victim has disclosed her abuse and, thereby, put her at further risk.

MANDATORY REPORTING

In the U.S., most states do not require healthcare providers to report IPV to law enforcement unless injury has been inflicted with a gun or a knife.¹⁶ Providers who are uncertain about their local reporting requirements should contact their local domestic violence coalitions for clarification.

Comment: IPV has profound effects on the health and well-being of women. Through routine screening, identification, and appropriate referrals, women’s healthcare providers are uniquely positioned to diminish these consequences. Because the overall timeframe for such change can be lengthy, the immediate goal is to provide nonjudgmental support so that patients can make informed choices.

— Amy S. Gottlieb, MD

Dr. Gottlieb is Assistant Professor of Medicine and Obstetrics & Gynecology (Clinical), The Warren Alpert Medical School of Brown University; Director of Primary Care Curricula and Consultation; and Internal Medicine Attending Physician, Women’s Primary Care Center, Women & Infants Hospital, Providence, RI.

Published in Journal Watch Women's Health October 2, 2008

Citation(s):

1. Flitcraft AH et al. American Medical Association diagnostic and treatment guidelines on domestic violence. AMA 1992.

2. Centers for Disease Control and Prevention (CDC). Adverse health conditions and health risk behaviors associated with intimate partner violence — United States, 2005. MMWR Morb Mortal Wkly Rep 2008 Feb 8; 57:113. [Erratum in: MMWR Morb Mortal Wkly Rep 2008 Mar 7; 57:237.]

• Medline abstract (Free)

3. McCloskey LA et al. Intimate partner violence and patient screening across medical specialties. Acad Emerg Med 2005 Aug; 12:712.

• Medline abstract (Free)

4. Kovac SH et al. Differing symptoms of abused versus nonabused women in obstetric-gynecology settings. Am J Obstet Gynecol 2003 Mar; 188:707.

• Medline abstract (Free)

5. McCauley J et al. The "battering syndrome": Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995 Nov 15; 123:737.

• Original article (Subscription may be required)
• Medline abstract (Free)

6. Silverman JG et al. Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: Associations with maternal and neonatal health. Am J Obstet Gynecol 2006 Jul; 195:140.

• Medline abstract (Free)

7. Thompson RS et al. Intimate partner violence: Prevalence, types, and chronicity in adult women. Am J Prev Med 2006 Jun; 30:447.

• Medline abstract (Free)

8. Eberhard-Gran M et al. Somatic symptoms and diseases are more common in women exposed to violence. J Gen Intern Med 2007 Dec; 22:1668.

9. Gerber MR et al. Intimate partner violence exposure and change in women’s physical symptoms over time. J Gen Intern Med 2008 Jan; 23:64.

• Medline abstract (Free)

10. Rivara FP et al. Healthcare utilization and costs for women with a history of intimate partner violence. Am J Prev Med 2007 Feb; 32:89.

• Medline abstract (Free)

11. National Center for Injury Prevention and Control. Costs of Intimate Partner Violence Against Women in the United States. Atlanta, GA: Centers for Disease Control and Prevention; 2003. (http://www.cdc.gov/ncipc/pub-res/ipv_cost/IPVBook-Final-Feb18.pdf)

12. Rodrigues T et al. Physical abuse during pregnancy and preterm delivery. Am J Obstet Gynecol 2008 Feb; 198:171.e1.

• Medline abstract (Free)

13. American Medical Association. Report 7 of the Council on Scientific Affairs (A-05): Diagnosis and management of family violence. (http://www.ama-assn.org/ama/pub/category/15248.html)

14. American College of Obstetrics and Gynecology Committee on Health Care for Underserved Women. Special Issues in Women’s Health: Intimate partner violence and domestic violence. ACOG 2005.

15. Feder GS et al. Women exposed to intimate partner violence: Expectations and experiences when they encounter health care professionals: A meta-analysis of qualitative studies. Arch Intern Med 2006 Jan 9; 166:22.

• Original article (Subscription may be required)
• Medline abstract (Free)

16. Family Violence Prevention Fund. State codes on intimate partner violence victimization reporting requirements for health care providers. (http://www.endabuse.org/health/mandatoryreporting/tables1.pdf)