Intimate partner violence (IPV) is a global epidemic and human rights issue. It has marked harmful effects on the safety, health, and overall well-being of those victimized, their families, and communities. The term intimate partner violence describes physical violence, sexual violence, threats of physical or sexual violence, and psychological abuse by a current or former intimate partner. IPV may occur throughout the lifespan, from adolescence to old age. While IPV is related to child abuse as children who are exposed to parental or guardian IPV are often also the victims of direct maltreatment (Table 35-1) and may become both victims and perpetrators in adulthood, discussion of child abuse and elder abuse are beyond the scope of this chapter.

For many victims, the health-care setting is the only safe point of contact outside of the abusive relationship and presents an ideal opportunity to identify and address IPV. Health-care providers who effectively screen for and address IPV can be the difference between life and death for victims of IPV and their families. This chapter describes IPV and provides an overview of how to address IPV in the health-care settings serving vulnerable populations.

The overall burden of IPV on girls and women is of epidemic proportions. An estimated 30% of women worldwide have experienced physical and/or sexual violence perpetrated by their intimate partner.¹ In the United States, more than one in three women (35.6%) have experienced physical violence, rape, and/or stalking by an intimate partner in their lifetimes, and 18.3% of all women have been raped in their lifetimes. Ninety percent of all rapes are committed by an intimate partner or an acquaintance.² Globally, more than 38% of all female homicides (and 6.3% of male homicides) are committed by an intimate partner.³ In the United States in 2008, around 45% of female and 5% of male homicides were committed by an intimate partner.⁴

In medical settings, the prevalence of IPV is higher, likely due to the physical and mental health sequelae of IPV that prompt IPV victims to seek care. A study of adult patients seeking primary care at an urban public hospital revealed that 15% of women reported abuse within the last year, and 51% reported abuse in their lifetime.⁵ In the United States, IPV costs a staggering $8.3 billion annually due to $5.8 billion in medical costs for injuries and health sequelae and $2.5 billion in lost productivity.⁶

Most victims of IPV are women and women are far more likely than men to be injured when victimized by an intimate partner. Nevertheless, there is increasing recognition of IPV with male victims.^2,7 Lesbian and gay people have rates of IPV victimization equal to or higher than heterosexual people,⁸ but rates for people who identify as bisexual are significantly higher.² The prevalence of IPV among transgender people is not well studied but likely to be higher than in gender-conforming people.⁹

In adolescents and adults, IPV victimization results in poor mental and physical health, and sometimes life-long disability. IPV is also associated with a higher prevalence of chronic diseases including arthritis, asthma, stroke, heart attack, heart disease, hyperlipidemia, chronic pain, and high-risk behaviors such as tobacco use, heavy alcohol use, and high-risk sexual behaviors.¹⁰ In addition, IPV victimization correlates with mental health problems including posttraumatic stress disorder, anxiety, depression, suicidality, eating disorders, and substance use.¹¹ Globally, suicide rates are significantly elevated in women victims of IPV.¹²

As demonstrated by the histories of Jasmine and Amina, victims of IPV often have little control over their own sexual and reproductive health. Their partners are often non-monogamous, refuse to use condoms, sabotage birth control methods, and coerce them into unwanted pregnancies or abortions.^13,14 Such reproductive coercion often results in an increased prevalence of unwanted pregnancy, abortion, HIV, other sexually transmitted infections (STIs), and gynecological problems.¹¹ In parts of the world with high HIV prevalence, IPV has emerged as an important risk factor for HIV transmission.¹⁵ In addition, IPV is associated with poor birth outcomes such as fetal low birth weight, preterm births, and miscarriages.¹⁶ Furthermore, young women forced into early and abusive marriages are at extremely high risk of adverse maternal outcomes such as preeclampsia. Male IPV victims who have sex with men are also at increased risk for forced unprotected anal intercourse, as well as higher rates of depression, HIV, and substance abuse.¹⁷

It is estimated that almost 9 million children are exposed to parental or guardian IPV each year in the United States alone.¹⁸ Children may witness physical, sexual, and emotional violence; be caught in the “crossfire” of violent acts; or suffer direct child abuse. More than 50% of children who are exposed to IPV are also directly abused.¹⁹ Children exposed to IPV have multiple mental health, physical health, and behavioral problems including posttraumatic stress disorder, depression, anxiety, chronic somatic complaints, learning problems, increased aggression, fearfulness, and developmental problems.^20,21 Adverse childhood experiences, such as being abused or witnessing parental violence, are increasingly being recognized as key determinants of health that have an impact on biological processes and brain development. Adverse childhood experiences often result in risky adult behaviors (e.g., smoking cigarettes, using drugs, having a higher number of sexual partners) and adulthood chronic diseases²² (see Chapter 36.)

There is an emerging body of literature examining perpetration of IPV. More than 40% of men attending urban clinics in a US city reported perpetrating physical and sexual IPV in the past year.²³ Male perpetrators of IPV often have increased rates of childhood exposure to IPV and histories of child abuse.²⁴ Recognizing and addressing this cycle of violence is essential to prevent children who are exposed to violence from growing into adults who perpetrate IPV. Moreover, men who perpetrate IPV are at risk for other poor health outcomes: they have high-risk sexual behaviors and a higher risk of being HIV positive, as well as have high rates of injury, psychiatric disease, substance use, irritable bowel syndrome, and insomnia.²⁴

An “ecological model” has been developed to conceptualize individual, relationship, community, and macrosocial factors that support the development and persistence of IPV (Figure 35-1).²⁵ The Centers for Disease Control and Prevention (CDC) maintains lists of these evidence-based factors that increase or decrease the likelihood of IPV such as employment and educational status and substance use (Table 35-2). An understanding of these multilevel factors can help identify various opportunities for prevention.

Many IPV victims and perpetrators lack these factors, and many men and women with these factors do not necessarily experience IPV. Violent relationships are “passed on” from one generation to the next as witnessing IPV or being abused by parents are associated with victimization and perpetration of IPV as an adult.²⁶

SCREENING FOR INTIMATE PARTNER VIOLENCE

Multiple professional medical associations in the United States now recommend routine universal screening for IPV victimization based upon its high prevalence, myriad adverse health effects, and infrequent identification when not done routinely.^27,28,29 Routine screening for IPV is recommended by Joint Commission on Accreditation of Healthcare Organizations for all hospitalized women,³⁰ all women of childbearing age by the United States Preventive Services Taskforce,³¹ and is covered as an essential health service by all insurance companies under the Affordable Care Act.³² Additionally, the vast majority of patients state that they would like their health-care providers to ask them about IPV and that merely disclosing IPV privately to a trusted provider who responds compassionately is highly therapeutic.³³ Routine screening and identification of IPV in health-care settings is beneficial and offers a crucial opportunity to support victims and break repetitive cycles of violence.

Unfortunately, most recommendations address IPV victimization in women only, leaving out gay male patients like Trevor, transgender male patients, and gay and heterosexual male patients, including boys, who present with indicators of abuse. Yet, there are guidelines about how to screen for and address IPV victimization in women and men including LGBTQ patients.^9,28,34 We recommend adopting a universal screening approach for all girls and all women and those boys and men in high-risk populations.

In addition, people who perpetrate IPV are regularly seen in health-care settings but are rarely screened for IPV perpetration. Ultimately, in order to prevent IPV victimization, addressing perpetration is necessary. There is expert guidance on addressing IPV perpetration with men,³⁴ but scant research in this area.^24,35,36

SCREENING FOR INTIMATE PARTNER VIOLENCE: BEST PRACTICES

Reporting requirements for IPV and child abuse vary widely; therefore, clinicians need to learn about them for their specific locality, state, or country. The goal of screening is not to force disclosure of IPV but, rather, to express concern for a patient’s safety, respect for the patient’s autonomy, and offer help as needed. Through the development of compassionate, trusting relationships, the health-care team and community advocates can help reduce the patient’s isolation and increase the patient’s sense of empowerment. With proper training, various members of the health-care team can inquire about IPV. To ensure patient safety, professionally trained medical interpreters (rather than family members or friends) should be used to screen for and respond to IPV. The patient should be alone and in a private location when asked about IPV.

Detailed guidelines and validated tools for screening exist.^21,28 (See https://secure3.convio.net/fvpf/site/Ecommerce/236886779?VIEW_PRODUCT=true&product_id=1861&store_id=1241; https://secure3.convio.net/fvpf/site/Ecommerce/1501428096?VIEW_PRODUCT=true&product_id=1811&store_id=1241.)^37,38 Ideally, screening for IPV occurs within the context of a patient-centered conversation that is made relevant to the patient’s health. In general, direct questions (including questions about emotional abuse and reproductive coercion) increase identification of IPV, whereas vague questions about safety rarely elicit disclosures of IPV (Box 35-1). Introductory phrases can facilitate clinician and patient comfort with screening: “Because violence in relationships is so common, I ask all my patients about it. Has your partner ever hit, hurt or threatened you?”