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Abstract

One in four American women will be physically assaulted or raped by an intimate partner during her lifetime. Such exposure has wide-ranging health effects. Abused women have an increased risk of cardiac, gastrointestinal, gynecologic, musculoskeletal, neurologic and psychological complaints. They also have a greater utilization of medical services and are more likely to access outpatient primary care and specialty care, emergency departments and mental health and substance abuse services than women without a history of partner violence. Most major US medical organizations recommend routine screening of all women for partner abuse. Offering abused women empathy and validation along with referral to local resources is encouraged. Physicians should also document the abuse in the victim's medical record.

Keywords

battered women domestic violence intimate partner violence partner abuse woman abuse

Definition

Intimate partner violence (IPV) is a pattern of coercive behaviors that may include repeated battering and injury, psychological or emotional abuse, sexual assault, progressive social isolation, economic deprivation, intimidation and stalking. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim [1]. Although both men and women may be perpetrators, women comprise the majority of IPV victims and incur the most serious IPV-related injury [2 –4]. IPV occurs in heterosexual and homosexual relationships [3].

The objectives of this article are to:

Discuss the impact that IPV has on women and their health;

Review the risk factors, natural history and symptoms associated with IPV;

Teach healthcare providers how to screen effectively for IPV;

Educate providers about caring for patients identified as victims of IPV.

Much of the data discussed in this review are derived from research based in the USA. That being said, studies performed in other countries have reported similar results [5 –7,101]. For the purposes of this article, the terms IPV and partner abuse will be used interchangeably.

Prevalence

Violence against women is primarily IPV. The National Institute of Justice estimates that 2 million women are physically assaulted or raped each year in the USA. In 76% of cases (1.5 million women), the perpetrator is a current or former husband, cohabitating partner or date [2]. Furthermore, approximately one in four American women will be physically or sexually assaulted by an intimate partner during her lifetime [2 –4].

In order to appreciate the relevance of IPV to their daily practice of medicine, healthcare providers must understand the rate at which IPV affects not only women in general, but also their particular patient populations. Fortunately, the medical literature is replete with studies examining such prevalence. McCloskey and colleagues published one of the most robust assessments of IPV occurrence across specialties in 2005 [8]. Administering the same written survey in multiple languages (English, Spanish, Chinese and Russian) across five medical specialties (obstetrics–gynecology, primary care, emergency medicine, addiction recovery and pediatrics), at eight different healthcare facilities (four community hospitals, three tertiary-care hospitals and one freestanding gynecology clinic) in a large American city and its environs, these researchers were able to demonstrate rates of lifetime and current exposure to IPV by practice setting. The results revealed that 35% of obstetrics–gynecology patients, 26% of women patients in primary-care practices, 41% of women patients presenting to emergency departments and a striking 73% of women patients in an addiction recovery program reported victimization by an intimate partner at some time in their lives. Regarding current abuse, 13% of women seeking care in obstetrics–gynecology, 9% of women primary-care patients, 17% of women patients in emergency departments and 36% of women patients in an addiction recovery program reported ongoing IPV [8].

Impact on health

In addition to acute trauma, numerous studies have demonstrated that IPV exposure has significant and wide-ranging effects on the health of women. Partner abuse has been associated with increased gynecologic, gastrointestinal, CNS [9 –14], musculoskeletal [9,10,12 –14] and cardiac complaints [9,11,12,14]. It has also been associated with an increased risk of depression [11,14 –17], anxiety [11,14], symptoms of post-traumatic stress disorder (PTSD) [17 –20], suicidality [14,17,20] and substance abuse [11,14,15,17]. Researchers have noted a dose–response relationship between the amount of symptoms reported and the number of violent episodes experienced; the number of different types of abuse (e.g., physical, sexual and psychological) and the severity of the violence [9,12,18,20,21]. In addition, when IPV continues, health-related complaints increase over time [10,15].

Given all of the above, it should come as little surprise that abused women tend to have an increased utilization of medical services. Compared with women without a history of partner violence, victims of IPV are more likely to access outpatient primary care and specialty care [11,22,23], to visit emergency departments [14,22] and to seek mental health and substance abuse services [22]. They also obtain more prescription fills from pharmacies [22]. The US CDC estimates the direct costs of IPV injury-related medical care and mental healthcare accessed as a result of IPV victimization to equal over US$4 billion annually [24]. This figure does not account for the cost of noninjury-related medical services utilized by abused women. As mentioned above, these women tend to have more comorbidities and healthcare visits than nonabused women. Thus, this figure most likely under-represents the true annual cost of IPV.

Based on Rivara and colleagues' analysis of 3333 women enrolled in a mixed-model Health Maintenance Organization, women with a history of IPV, after adjustment for age, education and major unrelated illness, incurred an extra $439 of healthcare costs each per year compared with women without such exposure [22]. When applied to the American adult female population at large, this amount could translate to approximately $12 billion of excess medical costs annually. Interestingly, in Rivara's study, although the utilization of emergency department and mental health/substance abuse services was shown to decrease once IPV ceased, the increased proportion of outpatient healthcare visits attributable to abused women did not decrease. This observation is perhaps explained by the fact that IPV victims continue to exhibit more physical and psychological symptoms than never-abused women, even after the violence against them stops [10].

Intimate partner violence & pregnancy

Pregnancy may be a particularly vulnerable time for women at risk for IPV. Most research demonstrates that approximately 4–8% of pregnant women are currently abused by their partners and, in some settings, the rate of current victimization exceeds 20% [8,25 –30]. Such prevalence makes IPV as common as pre-eclampsia and gestational diabetes – pregnancy-related diseases for which physicians routinely screen. Abuse may begin, cease or escalate during pregnancy [7,26,28 –30]. It is unclear why particular scenarios occur, especially why violence abates in some relationships and worsens in others. Research has shown that the following risk factors are associated with abuse during pregnancy: young age, low income, less education, delayed prenatal care [25 –27,31], lack of pregnancy intendedness [25,27] and, not surprisingly, abuse prior to pregnancy [26 –29].

Furthermore, studies have demonstrated an association between IPV and the following adverse pregnancy outcomes: vaginal bleeding [25,26], urinary tract infections [26,28,32], preterm labor [25,26,32] and substance abuse [25,26,28]. Elective terminations may also be associated with IPV [33]. Although Murphy and colleagues' meta-analysis of eight studies published in the 1990s reported a weak but significant association between low birthweight and partner abuse, research on this relationship continues to yield inconsistent results [6,7,26,32,34,35]. Such discrepancies may be reflective of differences in the IPV screening tools employed and/or the populations studied.

Clinical setting

Many misconceptions exist about abused women. To be effective, clinicians must be aware of their own biases and challenge any assumptions that may not be based on fact. To this end, it may be helpful to view IPV as a chronic illness with well-studied risk factors, a natural history and commonly associated symptoms.

Risk factors

Intimate partner violence occurs across all racial, socioeconomic, ethnic and religious segments of society [4,36]. That being said, the following risk factors have been associated with an increased likelihood of victimization by an intimate partner: female gender [2,4], young age [11,14,26,36], unmarried status [3,11,14], low income [4,14,15,26,36], coverage by medical assistance or uninsured [14] and a history of childhood maltreatment [2,15,36]. Pregnancy itself may also be a risk factor for abuse [26,28].

Natural history

In their study involving approximately 3500 women, Thompson and colleagues found that many victims of IPV experience more than one type of violence (e.g., physical, sexual or psychological), and that the longer the abuse continues, the more likely it is that multiple forms will occur [36]. In addition, most abused women repeatedly seek outside help but lack the personal or economic resources to gain independence [37,38]. Attempting to leave an abusive relationship can also be the most dangerous time for a victim [39].

Intimate partner violence is typically characterized by ongoing, repetitive acts of relatively minor physical assaults accompanied by patterns of control, intimidation and isolation. A batterer may try to control access to money, transportation, modes of communication (e.g., telephone or computer) or even healthcare [40,41]. When assessing access to medical services across multiple specialties and practice settings, McCloskey and colleagues found that nearly 20% of women experiencing IPV within the last year reported that their abuser had interfered with their healthcare, and that women reporting an interfering partner were more likely to be accompanied by that partner in the waiting room [40]. The former finding is consistent with studies of pregnant women, which have revealed an association between IPV and delayed prenatal care [25,26,31]. Identifying and addressing such a barrier to medical care could have significant public health implications. At the very least, recognition of the association should prompt clinicians to pursue inquiry about IPV more aggressively in the segment of the female patient population who do not comply with medical advice or delay medical care.

Intimidation can range from a raised eyebrow to open threats and stalking. This facet of IPV creates an unstable environment in which an abused woman may feel like she is walking on eggshells and could be assaulted for even the most benign action. Isolation can take many forms and serves multiple purposes for the batterer. Such separation from friends, family and coworkers prevents detection of the abuse, fosters dependence of the woman on her abuser and robs the victim of any potential means of escape.

Associated symptoms

As mentioned previously, IPV is associated with many health-related complaints that tend to increase as IPV continues over time. Multiple studies have shown that women exposed to partner violence are more likely to report the following symptoms: headache [9,11,13,14], dizziness [9,11], chest pain [9,11,14], palpitations [9,11], back pain [9,13], nausea and indigestion [11], stomach pain [9,11,13,14], diarrhea and constipation [9,14], menstrual/pelvic pain [9,11,13,14], dyspareunia [9,11,13], insomnia [9,14], depression [11,12,14,16], anxiety [11,14,20], PTSD and suicidal ideation [14,20]. Of course, not all patients presenting with these complaints are being abused, but a consistent constellation of these symptoms should be a red flag for healthcare providers to investigate the existence of IPV further.

Screening guidelines

Most major US medical organizations recommend routine IPV screening of all adult women [42,102 –104]. In addition, the Joint Commission on Accreditation of Healthcare Organizations – the entity that sets standards and accredits healthcare facilities in the USA – requires hospitals to have protocols in place to identify and assist victims of IPV in order to receive accreditation [105].

However, in 2004, the US Preventive Service Task Force (USPSTF) issued recommendations that were discordant with the above-stated mandates. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling and preventive medications. Its recommendations are considered the gold standard for clinical preventive services in the USA [106]. The USPSTF concluded that insufficient evidence existed to recommend for or against IPV screening in the primary-care setting [43]. As might have been expected, this statement prompted a strong response from the healthcare and advocacy communities [44,102,107]. Although an indepth discussion of their rebuttals is beyond the scope of this article, the various constituencies argued that the standards by which the USPSTF had assessed IPV screening were inappropriate. Specifically, it was argued that the USPSTF's decision to evaluate routine IPV inquiry as a screening test rather than as a behavioral assessment and counseling service (such as that carried out on depression screening) had placed too stringent a requirement for evidence linking IPV screening to reduced morbidity and/or mortality [102,107].

Since repeated inquiry may increase the detection of abuse [31,45], guidelines typically encourage periodic screening beyond that performed at new patient visits (e.g., at annual exams). In light of these many recommendations for ongoing screening, are physicians asking all women patients about partner abuse? The data are discouraging. Research suggests that only 10% of primary-care women's health providers screen for IPV routinely. When assessed separately, obstetricians–gynecologists perform better with screening rates closer to 20% [46 –48]. From a societal standpoint, physicians' failure to screen routinely for IPV screening could have tremendous impact on the adult female population at large. Indeed, in their survey of 5000 adult women with access to regular healthcare, Klapp and colleagues found that only 7% reported ever receiving IPV screening by a healthcare professional [49].

When physicians do screen for IPV, do they do it effectively? To help answer this question, Rhodes and colleagues audiotaped patient encounters at two emergency departments, an urban academic facility and a suburban community hospital. Approximately 300 discussions of IPV were transcribed and analyzed for content [50]. The authors found many instances in which physicians' discomfort with the topic of IPV was evidenced by long pauses or quick changes of subject after patients disclosed being abused. Such a lack of facility with discussing partner violence is particularly concerning because abused women report that providers' confidence and ease with this subject is integral to the victims' willingness to talk openly about their abusive circumstances [41,51].

Enquiring about intimate partner violence

Screening for IPV should be done in a safe, private setting. Certainly, no other adult known to the patient should be present and children ideally should be excused from the room prior to initiating inquiry about partner abuse. Clinicians should be cognizant that language interpreters may come from the patient's community and, therefore, could pose a potential threat to open communication.

Healthcare providers should begin IPV screening with a general statement about the prevalence of violence against women followed by an open-ended question directed toward the patient. An example of this approach would be, “Because violence against women is so common in our society, I ask all my women patients about violence in their lives. Do you feel safe in your current relationship?” If the patient denies abuse, the provider should follow-up with direct inquiries about specific types of abuse. For example, the question, “Does your partner ever hit, kick, punch, threaten or try to control you?” should be asked and then followed by, “Does your partner ever force you to have sex?” Asking directly about specific forms of abuse is not only acceptable to women patients [52], but has been shown to be a more effective approach to IPV screening [33,53 –55]. In addition, different screening modalities, for example computer-based or written questionnaires, may be substituted for face-to-face inquiry without diminishing detection of IPV [56].

If a physician suspects abuse even though a patient does not disclose it, he/she should leave the door open for future discussions by directly informing the patient of his/her concerns in a gentle and nonjudgmental manner. Such a statement might be, “I am concerned that there may be something going on at home and would like to check in with you in a few months” or, “I am concerned that your pattern of injury does not fit the scenario you described and would like to see you again soon.” At subsequent visits, the physician should address IPV as part of the patient's ongoing problem list and also be aware that the patient – out of shame, denial, fear of repercussions (physical and financial) or concerns about confidentiality – might continue to withhold information about her abusive situation [41,51,53]. If the physician does not suspect abuse (and the patient does not disclose), screening for IPV should still occur periodically, for example at annual check-ups, in accordance with recommended guidelines [42,102].

Intervention

In order to be effective, IPV interventions should be tailored to the victim's readiness to change her abusive relationship [57 –59]. While all abused women (suspected or confirmed) should receive affirmation that partner abuse is wrong, an assessment for immediate or escalating danger and information about available resources, a physician encountering a patient who does not recognize her situation as abusive should spend more time trying to raise the patient's awareness of the violence and its impact rather than offering detailed referrals to outside resources.

Safety assessment

When a patient reveals that she is being abused, the physician should validate her experience by telling her that she is not alone, that no one deserves to be beaten and that she is a survivor. Qualitative research demonstrates that such brief statements of empathy and validation can be powerful interventions in themselves [41,51]. The physician should then perform a quick safety assessment. He/she should establish the severity of the patient's situation by asking if the batterer has a weapon, if the abuser has ever threatened to kill the patient and if the patient feels if she is in any immediate danger. The first two scenarios have been shown to be risk factors for femicide [39].

To comprehend fully the nature of the abusive relationship and assess if the violence is escalating, a physician who has identified a case of IPV should inquire about the first episode of abuse, the most recent episode of abuse and the most severe episode. The physician should also ask about the specific types of abuse and whether the patient has ever sought medical treatment. Lastly, it is important to ask the patient if she has ever attempted suicide. Such an assessment can take place in a matter of minutes.

Referrals

As in the case of any newly diagnosed medical condition, a healthcare provider who has identified IPV should provide his/her patient with information about available resources. Especially for the patient who is evaluating her relationship and considering changing her situation, resources should include telephone numbers or websites of hotlines, shelters, local support groups and legal aid services. In the USA, a nationwide domestic violence hotline exists with trained operators who can offer aid and direct callers to local resources. Furthermore, each state has a domestic violence coalition where abused women may call to inquire about services in their area. Providers may also obtain useful informational materials, such as posters and pamphlets, from these statewide coalitions. Such materials can be displayed in the waiting and patient-exam rooms and may serve not only as resources, but also as cues that the clinical environment is a safe place to discuss IPV [41].

When providing resource information, clinicians should make certain that their patients are able to use them. Many materials are available in languages other than English and for patients with low literacy. Healthcare providers are encouraged to reach out to their local shelters and to police and court-based domestic violence units, if available, for such resources. One brief telephone call could save valuable time during multiple patient encounters. In addition, physicians should be aware that take-home materials regarding IPV could pose a threat if discovered by an abuser and, therefore, they should discuss this possibility with their patients. If there is concern about discovery, then information taken out of the doctor's office must look innocuous. Simply writing down an unidentified telephone number on a small piece of paper may be all that is necessary.

Safety planning

After IPV has been disclosed, the patient's experience validated, her safety assessed and referrals made, the physician should schedule a follow-up appointment to discuss safety planning. At that encounter, he/she should review a ‘quick-escape’ plan in the event that the patient ever needs to flee immediately or decides to leave her abusive situation permanently. Specifically, the physician should encourage the patient to identify places she could go if she were in imminent danger (e.g., friends, family and shelter) and to make copies of important personal and family documents, such as driver's license, passports, pay stub, birth certificates and immunization records. If the patient has a social security number, bank account or credit cards, she should make note of those numbers. The physician should suggest that the patient put these documents and numbers in a plastic bag along with a change of clothes for her and her family and, if possible, an extra set of car keys. This bag may be hidden outside the home, for example, at a friend's house or at work, to be used in the event she ever decides to escape. Once an abused woman leaves her violent home, transitioning to a new life, especially if she has young children, could be much easier if she has access to these important items.

Cultural sensitivity is important during every patient encounter. While there should be no cultural norm that ethically or legally permits violence against women, there are women who unfortunately reside in communities where options for escaping such violence are severely limited. The physician should take this into consideration when discussing safety planning.

Documentation

The medical record is a means of chronicling disease and communicating diagnoses and interventions among providers. It is also a legal document that could someday aid a patient in prosecuting her abuser in a court of law. To that end, it is of utmost importance that physicians document their suspicions of IPV and their discussions with abused women. In the event of injury, physicians should clearly document all physical findings, using a body map and photographs if possible. When physical evidence of abuse is not present, physicians should state in the patient's own words a description of the abuse. In all cases, physicians must take special care to document the identity of the abuser (e.g., husband or boyfriend) as recounted by the patient. Lastly, if a physician suspects abuse but the patient does not disclose, he/she should note this suspicion in the medical record.

In the USA, counseling for IPV is a clinical activity that may be coded on charge sheets for insurance-billing purposes. Prior to billing for this activity, a physician should discuss with his/her patient whether the abuser has access to insurance statements. These documents might reveal that the victim has disclosed her abuse and could potentially put her at risk.

Mandatory reporting

In the USA, most states do not require healthcare providers to report instances of IPV to law enforcement unless injury has been inflicted by a gun or knife [108]. If physicians are uncertain of their local reporting requirements, they may contact their local domestic violence coalition for clarification.

Physicians' reactions

Medical doctors are acculturated to fix a problem with medication or surgical intervention. Therefore, it is not surprising that many physicians report feeling frustrated, powerless and helpless when working with IPV victims whose situations defy such a quick-fix [47,48,60]. Similar to many other chronic illnesses (e.g., obesity), IPV requires physicians to work in concert with patients year after year, strategizing, encouraging and congratulating them on even the smallest steps forward. Since the time frame for change will most probably be prolonged, the goal should be to provide nonjudgmental support for these patients to make informed, healthy choices. Although it may be challenging, healthcare providers must try to appreciate an abused woman's timetable and her particular situation. If and when to leave an abuser is her decision alone.

Conclusion

Intimate partner violence affects one out of four women and has a tremendous impact on the health and wellbeing of female patients. Healthcare providers are uniquely positioned to lessen this impact, at the very least by alleviating the isolation that is often integral to victimization. Fortunately, over the last several decades, physicians as a community have progressed from viewing partner abuse as a private matter to a health-related concern that merits discussion in the medical literature, classroom and clinic.

In the USA, many models of IPV curricula exist [61] and, according to a 2003 survey, the vast majority of medical students receive some IPV training [62]. Furthermore, an understanding of IPV and knowledge about screening and intervention is now one of the competencies expected of medical students completing their mandatory third-year obstetrics and gynecology clerkships [109]. Many residency programs (e.g., those in obstetrics and gynecology, internal medicine, family medicine and psychiatry) are also required to include curricula on partner abuse in order to receive accreditation by the Accreditation Council for Graduate Medical Education (ACGME) [110]. Such instruction is critical because studies have consistently identified lack of education as a barrier to provider screening and intervention [46 –48]. As might be expected, recent training on IPV has been found to be more effective than that experienced remotely [46,47].

In accordance with expert guidelines, physicians should screen all women for partner abuse and provide support and information about available resources for those patients identified as victims of violence. In daily practice, it may be helpful to recall the following mnemonic, RADAR, developed by the Massachusetts Medical Society:

Remember to ask routinely about intimate partner violence

Ask directly about intimate partner violence

Document information about ‘partner violence’ or ‘suspected partner violence’ in the patient's chart

Assess safety

Review options and refer as appropriate [63]

Future perspective

Unfortunately, most medical school graduates still report feeling unsure about their ability to talk with patients about partner abuse [62]. In the future, IPV curricula will be developed, studied and disseminated so that effective training may be implemented easily across the medical education continuum. Medical students in their preclinical years will be taught first in the classroom about the health effects and protean presentation of IPV, and then at the bedside as they rotate through their various clinical experiences. This range of opportunities to learn and observe appropriate approaches to partner violence will reinforce a culture of screening and intervention in clinical practice. Screening for IPV will become as routine as asking about tobacco use. Inquiry about partner abuse will be part of every female patient's initial history and physical examination regardless of the clinical setting. Physicians will feel knowledgeable enough about IPV in order to screen with ease and to intervene with empathy and confidence.

Based on the success of model programs [64,65], institutions will adopt systems-based improvements to promote effective, long-term management of IPV victims. Specifically, screening for partner abuse will be standardized throughout organizations. Healthcare providers, social workers, case managers and community-based advocates will collaborate on intervention and follow-up. Finally, IPV identification, management and outcomes will be monitored for systems compliance and program effectiveness.

As enhanced clinical awareness of IPV leads to improved identification and referral, researchers will have greater opportunity to assess:

How adverse health conditions and IPV interact on both a physiologic and psychologic basis (i.e., whether violence causes or results from these comorbid conditions);

Why patterns of IPV sometimes change in pregnancy and what the possibilities are for violence prevention in patients who are childbearing.

In addition, studies will reveal which interventions are most helpful for patients who are currently being abused and which are most effective in preventing recurrent abuse for those women who have a history of violent relationships. Lastly, research will identify primary-prevention strategies that best promote healthy parenting and partnering in order to end the cycle of violence before it ever begins.

Executive summary

Definition

The majority of IPV victims are heterosexual women.

Prevalence

One in four American women will be physically assaulted or raped by an intimate partner during her lifetime.

A total of 35% of obstetrics-gynecology patients, 26% of women patients in primary-care practices and 41 % of women patients presenting to emergency departments report victimization by an intimate partner at some time in their lives.

Impact on health

IPV is associated with increased gynecologic, gastrointestinal, CNS, musculoskeletal and cardiac complaints. It is also associated with an increased risk of depression, anxiety, symptoms of post-traumatic stress disorder, suicidality and substance abuse.

Compared with women without a history of partner abuse, victims of IPV are more likely to access outpatient primary care and specialty care, to visit emergency departments and to seek mental health and substance abuse services.

Direct costs of IPV are estimated to equal over US$4 billion annually.

Intimate partner violence & pregnancy

Overall, 4-8% of pregnant women are currently abused.

Abuse may begin, cease or escalate during pregnancy.

Risk factors

IPV occurs in all racial, socioeconomic, ethnic and religious groups.

Risk factors for victimization by an intimate partner are female gender, young age, unmarried status, low income, lack of coverage by medical assistance or uninsured and a history of childhood maltreatment. Pregnancy itself may also be a risk factor for abuse.

Natural history

Many victims of IPV experience more than one type of violence (e.g., physical, sexual and psychological). The longer the abuse continues, the more likely it is that multiple forms will occur.

Most abused women repeatedly seek outside help but lack the personal or economic resources to gain independence.

IPV is often accompanied by patterns of control, intimidation and isolation.

Associated symptoms

Symptoms associated with partner abuse include headache, dizziness, chest pain, palpitations, back pain, nausea and indigestion, stomach pain, diarrhea and constipation, menstrual/pelvic pain, dyspareunia, insomnia, depression, anxiety, post-traumatic stress disorder and suicidal ideation.

Screening guidelines

Routine screening of all adult women for IPV is recommended by many major medical organizations and should at least be carried out at new patient visits and periodic exams.

Enquiring about intimate partner violence

Ask in a safe, private setting. No other person known to the patient should be present.

Begin with a general statement about the prevalence of violence against women and follow with an open-ended question about the patient's current relationship. Then inquire directly about specific types of abuse.

Intervention

If a patient reveals that she is being abused, validate her experience by telling her that she is not alone, that no one deserves to be beaten and that she is a survivor. Also perform a quick safety assessment by asking if the batterer has a weapon, if the abuser has ever threatened to kill the patient and if the patient feels if she is in any immediate danger.

Provide abused patients with information on hotlines, shelters and legal aid services, and also strategize about a quick escape plan. State domestic violence coalitions and the nationwide domestic violence hotlines are invaluable resources.

Documentation

The medical record is a legal document that might aid a patient in prosecuting her abuser. Document suspicions of IPV and discussions with abused women. State in the patient's own words a description of the abuse and document the identity of the abuser.

Conclusion

IPV has a tremendous impact on the health and wellbeing of female patients.

Screening for IPV should be as routine as asking about tobacco use. Inquiry about partner abuse should be part of every female patient's initial history and physical examination regardless of the clinical setting.

RADAR: remember to ask routinely about intimate partner violence; ask directly about intimate partner violence; document information about ‘partner violence’ or ‘suspected partner violence’ in the patient's chart; assess safety; and review options and refer as appropriate.

Footnotes

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

References

Flitcraft

Hadley

Hendricks-Matthews

McLeer

Warshaw

: American Medical Association Diagnostic and Treatment Guidelines on Domestic Violence. AMA, Chicago, IL, USA (1992).

Tjaden

Thoennes

: Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. National Institute of Justice and Centers for Disease Control and Prevention, Washington DC, USA (2000).

Tjaden

Thoennes

: Extent, nature and consequences of intimate partner violence: findings from the National Violence Against Women Survey. National Institute of Justice and Centers for Disease Control and Prevention, Washington DC, USA (2000).

Centers for Disease Control and Prevention: Adverse health conditions and health risk behaviors associated with intimate partner violence – United States 2005. MMWR 57(5), 113–117 (2008).

Council of Europe: Group of specialists for combating violence against women: final report of activities. Council of Europe, Strasbourg, France (2000).

Yang

M-S

S-Y

Chou

F-H

Chang

S-J

Y-C

: Physical abuse during pregnancy and risk of low-birthweight infants among aborigines in Taiwan. Public Health 120, 557–562 (2006).

Valladares

Ellsberg

Pena

Hogberg

Persson

: Physical partner abuse during pregnancy: a risk factor for low birth weight in Nicaragua. Obstet. Gynecol. 100, 700–705 (2002).

McCloskey

Lichter

Ganz

: Intimate partner violence and patient screening across medical specialties. Acad. Emerg. Med. 12, 712–722 (2005).

Eberhard-Gran

Schei

Eskild

: Somatic symptoms and diseases are more common in women exposed to violence. J. Gen. Intern. Med. 22, 1668–1673 (2007).

10.

Gerber

Wittenberg

Ganz

Williams

McCloskely

: Intimate partner violence exposure and change in women's physical symptoms over time. J. Gen. Intern. Med. 23, 64–69 (2008).

11.

Kovac

Klapow

Kroenke

Spitzer

Williams

JBW

: Differing symptoms of abused versus nonabused women in obstetric–gynecology settings. Am. J. Obstet. Gynecol. 188, 707–713 (2003).

12.

Nicolaidis

Curry

McFarland

Gerrity

: Violence, mental health, and physical symptoms in an academic internal medicine practice. J. Gen. Intern. Med. 19, 819–827 (2004).

13.

Campbell

Jones

Dienemann

: Intimate partner violence and physical health consequences. Arch. Intern. Med. 162, 1157–1163 (2002).

14.

McCauley

Kern

Kolodner

: The ‘battering syndrome’: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann. Intern. Med. 123, 737–746 (1995).

15.

Bonomi

Thompson

Anderson

: Intimate partner violence and women's physical, mental, and social functioning. Am. J. Prev. Med. 30, 458–466 (2006).

16.

Coker

Davis

Arias

: Physical and mental health effects of intimate partner violence for men and women. Am. J. Prev. Med. 23, 260–267 (2002).

17.

Golding

: Intimate partner violence as a risk factor for mental disorders: a meta-analysis. J. Fam. Viol. 14, 99–142 (1999).

18.

Dutton

Kaltman

Goodman

Weinfurt

Vankos

: Patterns of intimate partner violence: correlates and outcomes. Violence Vict. 20, 483–497 (2005).

19.

Lipsky

Field

Caetano

Larkin

: Posttraumatic stress disorder symptomatology and comorbid depressive symptoms among abused women referred from emergency department care. Violence Vict. 20, 645–659 (2005).

20.

Houry

Kemball

Rhodes

Kaslow

: Intimate partner violence and mental health symptoms in African–American female ED patients. Am. J. Emerg. Med. 24, 444–450 (2006).

21.

McCauley

Kern

Kolodner

Derogatis

Bass

: Relation of low-severity violence to women's health. J. Gen. Intern. Med. 13, 687–691 (1998).

22.

Rivara

Anderson

Fishman

: Healthcare utilization and costs for women with a history of intimate partner violence. Am. J. Prev. Med. 32, 89–96 (2007).

23.

Wisner

Gilmer

Saltzman

Zink

: Intimate partner violence against women: Do victims cost health plans more? J. Fam. Pract. 48, 439–443 (1999).

24.

Centers for Disease Control and Prevention: costs of intimate partner violence against women in the United States. CDC, Atlanta, GA, USA (2003).

25.

Rodrigues

Rocha

Barros

: Physical abuse during pregnancy and preterm delivery Am. J. Obstet. Gynecol. 198, 171.e1–171.e6 (2008).

26.

Silverman

Decker

Reed

Raj

: Intimate partner violence victimization prior to and during pregnancy among women residing in 26 US states: associations with maternal and neonatal health. Am. J. Obstet. Gynecol. 195, 140–148 (2006).

27.

Goodwin

Gazmarian

Johnson

Gilbert

, Saltzman LE; for the PRAMS Working Group: Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996–1997. Matern. Child Health J. 4, 85–92 (2000).

28.

Parker

McFarlane

Soeken

: Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet. Gynecol. 84, 323–328 (1994).

29.

Helton

McFarlane

Anderson

: Battered and pregnant: a prevalence study. Am. J. Public Health 77, 1337–1339 (1987).

30.

Gazmararian

Lazorick

Spitz

Ballard

Saltzman

Marks

: Prevalence of violence against pregnant women. JAMA 275, 1915–1920 (1996).

31.

McFarlane

Parker

Soeken

Bullock

: Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 267, 3176–3178 (1992).

32.

Cokkinides

Coker

Sanderson

Addy

Bethea

: Physical violence during pregnancy: maternal complications and birth outcomes. Obstet. Gynecol. 93, 661–666 (1999).

33.

Glander

Moore

Michielutte

Parsons

: The prevalence of domestic violence among women seeking abortion. Obstet. Gynecol. 91, 1002–1006 (1998).

34.

Murphy

Schei

Myhr

Du Mont

: Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. CMAJ 164, 1567–1572 (2001).

35.

Yost

Bloom

McIntire

Leveno

: A prospective observational study of domestic violence during pregnancy. Obstet. Gynecol. 106, 61–65 (2005).

36.

Thompson

Bonomi

Anderson

: Intimate partner violence: prevalence, types, and chronicity in adult women. Am. J. Prev. Med. 30, 447–457 (2006).

37.

Brookoff

O'Brien

Cook

Thompson

Williams

: Characteristics of participants in domestic violence: assessment at the scene of domestic assault. JAMA 277, 1369–1373 (1997).

38.

Sabina

Tindale

: Abuse characteristics and coping resources as predictors of problem-focused coping strategies among battered women. Violence Against Women 14, 437–456 (2008).

39.

Campbell

Webster

Koziol-McLain

: Risk factors for femicide in abusive relationships: results from a multisite case control study. Am. J. Public Health 93, 1089–1097 (2003).

40.

McCloskey

Williams

Lichter

Gerber

Ganz

Sege

: Abused women disclose partner interference with health care: an unrecognized form of battering. J. Gen. Intern. Med. 22, 1067–1072 (2007).

41.

McCauley

Yurk

Jenckes

Ford

: Inside “pandora's box”: abused women's experiences with clinicians and health services. J. Gen. Intern. Med. 13, 549–555 (1998).

42.

American College of Obstetrics and Gynecology: special issues in women's health: intimate partner violence and domestic violence. ACOG, Washington, DC, USA (2005).

43.

US Preventive Services Task Force: Screening for family and intimate partner violence: recommendation statement. Ann. Intern. Med. 140, 382–386 (2004).

44.

Lachs

: Screening for family violence: what's an evidence-based doctor to do? Ann. Intern. Med. 140, 399–400 (2004).

45.

Bullock

Bloom

Davis

Kilburn

Curry

: Abuse disclosure in privately and medicaid-funded pregnant women. J. Midwifery Womens Health 51, 361–369 (2006).

46.

Elliott

Nerney

Jones

Friedmann

: Barriers to screening for domestic violence. J. Gen. Intern. Med. 17, 112–116 (2002).

47.

Rodriguez

Bauer

McLoughlin

Grumbach

: Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 282, 468–474 (1999).

48.

Parsons

Zaccaro

Wells

Stovall

: Methods and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am. J. Obstet. Gynecol. 173, 381–387 (1995).

49.

Klapp

Tang

Wells

Starks

Rodriguez

: Screening for domestic violence among adult women in the United States. J. Gen. Intern. Med. 22, 579–584 (2007).

50.

Rhodes

Frankel

Levinthal

Prenoveau

Bailey

Levinson

: “You're not a victim of domestic violence, are you?” Provider-patient communication about domestic violence. Ann. Intern. Med. 147, 620–627 (2007).

51.

Feder

Hutson

Ramsay

Taket

: Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch. Intern. Med. 166, 22–37 (2006).

52.

Friedman

Samet

Roberts

Hudlin

Hans

: Inquiry about victimization experiences: a survey of patient preferences and physician practices. Arch. Intern. Med. 152, 1186–1190 (1992).

53.

Rodriguez

Sheldon

Bauer

Perez-Stable

: The factors associated with disclosure of intimate partner abuse to clinicians. J. Fam. Pract. 50, 338–344 (2001).

54.

Reichenheim

Moraes

: Comparison between the abuse assessment screen and the revised conflict tactics scales for measuring physical violence during pregnancy. J. Epidemiol. Community Health 58, 523–527 (2004).

55.

Norton

Peipert

Zierler

Lima

Hume

: Battering in pregnancy: an assessment of two screening methods. Obstet. Gynecol. 85, 321–325 (1995).

56.

MacMillan

Wathen

Jamieson

: Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA 296, 530–536 (2006).

57.

Zink

Elder

Jacobson

Klostermann

: Medical management of intimate partner violence considering the stages of change: precontemplation and contemplation. Ann. Fam. Med. 2, 231–239 (2004).

58.

Burke

Gielen

McDonnell

O'Campo

Maman

: The process of ending abuse in intimate relationships: a qualitative exploration of the transtheoretical model. Violence Against Women 7, 1144–1163 (2001).

59.

Frasier

Slatt

Kowlowitz

Glowa

: Using the stages of change model to counsel victims of intimate partner violence. Patient Educ. Couns. 43, 211–217 (2001).

60.

Sugg

Inui

: Primary care physicians' response to domestic violence: opening Pandora's box. JAMA 267, 3157–3160 (1992).

61.

Hamberger

: Preparing the next generation of physicians: medical school and residency-based intimate partner violence curriculum and evaluation. Trauma Violence Abuse 8, 214–225 (2007).

62.

Frank

Elon

Saltzman

Houry

McMahon

Doyle

: Clinical and personal intimate partner violence training experiences of US medical students. J. Womens Health 15, 1071–1079 (2006).

63.

Massachusetts Medical Society Committee on Violence: Partner violence: how to recognize and treat victims of abuse. Mass Medical Society, Waltham, MA, USA (2004).

64.

McCaw

Bauer

Berman

Mooney

Holmberg

Hunkeler

: Women referred for on-site domestic violence services in a managed care organization. Women Health 35, 23–40 (2002).

65.

Short

Hadley

Bates

: Assessing the success of the womankind program: an integrated model of 24-hour health care response to domestic violence. Women Health 35, 101–119 (2002).

66.

Finney

: Domestic violence, sexual assault, and stalking: findings from the 2004/05 British Crime Survey. Home Office Online Report, London, UK (2006). http://rds.homeoffice.gov.uk/rds/pdfs06/rdsolr1206.pdf

67.

American Medical Association: Report 7 of the Council on Scientific Affairs: Diagnosis and Management of Family Violence. AMA Online Report, Chicago, IL, USA (2005). www.ama-assn.org/ama/pub/category/print/15248.html

68.

American Academy of Family Physicians (AAFP): Policy on Family and Intimate Partner Violence and Abuse. AAFP, Leawood, KS, USA (2004). www.aafp.org/online/en/home/policy/policies/f/familyandintimatepartner-violenceandabuse.html

69.

American College of Emergency Physicians (ACEP): Policy on Domestic Family Violence. ACEP, Irving, TX, USA (2007). www.acep.org/practres.aspx?id=29184

70.

Family Violence Prevention Fund: JCAHO additional standards for victims of abuse. Standard PC.3.10. FVPF, San Francisco, CA, USA (2008). http://endabuse.org/programs/printable/display.php3?DocID=266

71.

Agency for Healthcare Research and Quality (AHRQ): About USPSTF: The New US Preventive Services Task Force. AHRQ, Rockville, MD, USA (2007). www.ahrq.gov/clinic/uspstfab.htm

72.

Chamberlain

: The USPSTF recommendation on intimate partner violence: what we can learn from it and what can we do about it. FVPF, San Francisco, CA, USA (2005). http://endabuse.org/health/ejournal/archive/1-1/Chamberlain.pdf

73.

Family Violence Prevention Fund: State codes on intimate partner violence victimization reporting requirements for health care providers. FVPF, San Francisco, CA, USA (2002). www.endabuse.org/health/mandatoryreporting/tables1.pdf

74.

Association of Professors of Gynecology and Obstetrics: Women's Health Care Competencies for Medical Students. APGO, Crofton, MD, USA (2004). http://wheocomp.apgo.org/area-of-competency.cfm?compid=5

75.

Accreditation Council for Graduate Medical Education: Residency Review Committees – Program Requirements. ACGME, Chicago, IL, USA (2008). www.acgme.org/acWebsite/navPages/nav_comRRC.asp

Intimate Partner Violence: A Clinical Review of Screening and Intervention

Abstract

Keywords

Definition

Prevalence

Impact on health

Intimate partner violence & pregnancy

Clinical setting

Risk factors

Natural history

Associated symptoms

Screening guidelines

Enquiring about intimate partner violence

Intervention

Safety assessment

Referrals

Safety planning

Documentation

Mandatory reporting

Physicians' reactions

Conclusion

Future perspective

Footnotes

References