INTRODUCTION
Intimate partner violence (IPV), is defined as any intentional, controlling behavior consisting of physical, sexual, or psychological assaults in the context of an intimate relationship. The data on IPV underscore the magnitude of the problem. In a landmark study, 28% of a random nationwide sample of couples reported violence at some point in their history; almost 4% of the women reported severe violence. If these figures are extrapolated to the general population, it is estimated that about 4 million women are subjected to violence each year in the United States (a woman is beaten or assaulted every 9 seconds in the United States), with about 500,000 women requiring medical treatment. Women visiting outpatient medical and obstetric/gynecologic clinics as well as the emergency department (ED) are often there for complaints directly attributable to IPV. Because they are frequently misdiagnosed, they may return time and time again, often with increasingly severe trauma.
Despite its magnitude in society and in medical settings, until recently IPV could be described as a “silent epidemic.” Considered a private, family problem by the government, and a social problem by the medical establishment, victims often had nowhere to turn. This predicament has gradually improved. Intimate partner violence is now acknowledged to be an important public health problem, and medical practitioners have a variety of diagnostic and treatment guidelines available to them. All practitioners must be knowledgeable about and comfortable with the evaluation and care of patients who are subjected to IPV.
EPIDEMIOLOGY
Research conducted in a variety of medical settings has reported on the prevalence of IPV. Cross-sectional studies from outpatient primary care clinics and ED settings have found the prevalence of IPV among women to be from 6% to 28%; lifetime prevalence rates up to 50% have been reported and IPV accounts for more than half the murders of women in the United States every year. A recent systematic review reported lifetime estimates of 22–39% in the United States, with similar rates having been reported by studies conducted in obstetric/gynecologic outpatient clinics. In fact, pregnancy may double the risk of IPV. Differences in prevalence of IPV among various studies can be explained, in part, by their use of different definitions of IPV.
Most studies ask about violence exclusively in the context of heterosexual relationships. However, a similar prevalence of IPV appears to exist in LGBT (Lesbian, Gay, Bisexual, Transgender) relationships, with the same physical and emotional consequences. Primary care providers should be aware that it may be more difficult for LGBT patients to disclose that they are in an abusive relationship for social and legal reasons, and they are less likely to actively seek help compared with heterosexual victims. In addition, the commonly held bias that violence does not occur in these relationships (“women can’t hurt women”) further lowers detection rates.
Men report being physically abused by their female partners at rates just below those reported by women. The injuries inflicted by women on men, however, are generally less significant when compared with same-sex or male-on-female violence.
DIAGNOSIS
Many women seek medical care both for the direct and indirect consequences of IPV, but only a small percentage of them are diagnosed and treated appropriately. The following case is illustrative of the type of patient commonly seen in medical settings.
CASE ILLUSTRATION 1
A 40-year-old nurse presents to the ED with a chief complaint of a headache. She reports having been in a motor vehicle accident 3 days earlier and striking her head on the dashboard. She says that her friends encouraged her to come in, and she is accompanied to the ED (but not the office) by her partner. On physical examination, she appears tense and sad, with bilateral, periorbital ecchymoses.
A thorough history is the cornerstone of the diagnosis of IPV. Because the presentation is often subtle, with few dramatic injuries, detection requires a high index of suspicion. There are many clues in the medical history, as shown by the case illustration that should prompt the physician to evaluate the patient for IPV (Table 38-1). Patients who have been assaulted often delay seeking medical attention, in contrast to accident victims who generally seek out medical attention immediately. Injuries that are attributed to a mechanism that seems illogical should always raise concern. For example, periorbital ecchymoses (“black eyes”) generally are not caused by a motor vehicle accident, a “doorknob,” or anything other than a fist.
Some women may present with vague somatic complaints as their only symptom of IPV. Fatigue, sleep disturbance, headache, gastrointestinal complaints, abdominal and pelvic pain, genitourinary problems such as frequent urinary tract and genital infections, chest pain, palpitations, and dizziness are just some of the complaints with which women present. IPV should be considered as a sole or contributing cause of these problems.
Depression, eating disorders, and anxiety disorders such as posttraumatic stress disorder (PTSD) and panic disorder are more common among victims of IPV than among the general population. If present, the medical practitioner should always screen for IPV. These mental and behavioral disturbances should be thought of as a consequence, not a cause, of the IPV. Some patients may feel hopeless and turn toward suicide as a way out. One of every 10 battered women attempts suicide. Of those, 50% try more than once.
Many studies have demonstrated that women are at increased risk of physical and sexual abuse during pregnancy. Clues to be alert for include delay in seeking prenatal care, depressed or anxious mood, injuries to breasts or abdomen, frequent spontaneous abortions, and preterm labor. In addition to the physical and emotional trauma to the pregnant woman, these assaults can result in placental separation, fetal fractures, and fetal demise.
Although violence and substance abuse may coexist, it is inaccurate and generally not helpful to frame IPV as secondary to the substance abuse. Although the perpetrator, and at times the woman herself, often assert that the violence was a consequence of altered behavior from drugs or alcohol, in fact, the violent behavior must be addressed as a separate issue and is unlikely to end even if the substance abuse does.
Conversely, some studies have found an increased rate of substance use in victims of IPV. At times, this may take the form of increased use of pain medications or anxiolytics in an effort to cope with the assaults. It is even more imperative in this instance that physicians do not attribute the IPV to the substance use; it is precisely this mentality of “blaming the victim” that has often prevented the appropriate evaluation and treatment of IPV in all medical settings.
Some women report an initiation or escalation of IPV after informing their partner of their human immunodeficiency virus (HIV) seropositive status. Although every attempt should be made to notify sexual partners of HIV-positive results, practitioners should assess their patient’s risk of violence while discussing the issues surrounding notification. Discussion of IPV and review of a safety plan should always be part of posttest counseling.
Patients who report a family history of IPV, particularly those who witnessed parental violence as a child or adolescent, are at increased risk themselves even if they are not presently in an abusive relationship. Such women should, therefore, be educated and screened more carefully.
An overbearing partner who, for example, insists on accompanying the patient into the examining room, acts overly solicitous or concerned (sometimes to the point of knocking on the examining room door to inquire about her well-being), or is hostile to the health care team may be a clue to the presence of IPV. Never probe about IPV if the perpetrator is in the examining room as this may unintentionally escalate the violence and put the patient in extreme danger.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
