Intimate Partner Violence

Published on 10/02/2015 by admin

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93 Intimate Partner Violence

Epidemiology

The Centers for Disease Control and Prevention defines intimate partner violence (IPV) as threatened or current physical, sexual, or verbal abuse inflicted by a spouse, former spouse, or current or former boyfriend, girlfriend, or dating partner. Among women alone, IPV is estimated to result in 2 million injuries and 1300 deaths annually. Costs associated with IPV are estimated to be $5.8 million in the United States each year.1 It is estimated that 40% to 60% of homicides of women in the United States occur as a result of IPV.2

Although IPV is commonly thought to affect women and be perpetrated by men, studies suggest that women may be perpetrators of IPV as often as men, but male victims may be less likely to sustain physical injuries and seek medical care.3 Additionally, counter to these perceptions, a recent emergency department (ED)-based study performed in an urban ED found that 31% of men who had been in a relationship during the previous year had experienced some form of IPV victimization.4 In same-sex partners, IPV appears to occur at rates similar to that in heterosexual couples and with similar patterns, types of violence, and inciting factors.5

Presenting Signs and Symptoms

History

Victims of IPV often do not disclose their abuse to health providers, and studies have shown that some victims will even deny abuse when directly asked.8 Surveys of IPV victims suggest that women fail to disclose victimization when physicians do not ask about abuse, when patients perceive that the provider lacks time or interest in their disclosure, or when they have concerns about police involvement or loss of confidentiality.9 The probability of IPV disclosure may be increased if clinicians provide a reason for inquiring about abuse, create an atmosphere of concern and support, and provide informational resources about IPV regardless of patient disclosure.8

In addition to direct inquiry by a clinician, recent ED-based studies have found that patient disclosure of abuse is increased when the ED uses an automated system of IPV screening, such as a computer-based screening questionnaire.10

Physical Findings

Most commonly, IPV victims seek treatment in health care settings for complaints not directly related to their abuse or with obvious physical trauma.11 When IPV victims are seen in the ED with evidence of physical trauma, women who are victims of IPV are more likely to have trauma involving the head, face, neck, thorax, breasts, and abdomen than are women with trauma attributable to other causes.12 In addition, injuries in various stages of healing or defensive injuries may be noted.

Although any pattern or mechanism of injury may be the result of IPV, clinicians should have a low threshold for suspecting IPV when seeing women with blunt trauma to the head, neck, and face (particularly as a result of punching or slapping). Across all injuries, women who are victims of IPV are more likely to have blunt trauma injuries caused by being struck or kicked or by objects used as weapons than to have an injury caused by a knife or gun. Two other common injury patterns are strangulation and sexual assault, both of which may leave scant or no physical evidence and thus may be missed by a clinician who does not suspect abuse.7

Persistent health problems resulting from IPV include chronic headaches; chronic back pain; neurologic symptoms, including fainting and seizures; gastrointestinal complaints, including poor appetite, eating disorders, and irritable bowel syndrome; and cardiac symptoms, including recurrent chest pain and hypertension.11 IPV victimization is also significantly correlated with an increased risk for mental health problems, including depression, suicidality, and posttraumatic stress disorder.13 Long after the abuse has ended, IPV victimization has long-term consequences on health status, quality of life, and use of health care resources11 (Box 93.1).

Differential Diagnosis and Medical Decision Making

The differential diagnosis of injuries attributable to IPV include injuries related to unintentional causes, such as household injuries or motor vehicle collisions, as well as self-inflicted injuries. The cause of the injury may be distinguished by the physical patterns of injury and the history provided by patients, although no approach can entirely rule out the possibility that an injury was caused by IPV. Additionally, IPV victimization should be considered in the differential diagnosis of many patients seen in the ED with complaints unrelated to injury, including depression, abdominal pain, headaches, and chest pain, among others.

If IPV victimization is suspected, the physician should perform a thorough social history, including living situation and perceived safety at home, relationships, and access to social, familial, and financial support. Even though no diagnostic test can confirm or refute an abuse history, in some cases obtaining radiographic or photographic documentation (or both) of injuries may be useful for subsequent prosecution of the perpetrator (see the Red Flags box).

Treatment

Interventions for patients who are known or suspected to be victims of IPV focus on (1) treating any acute injury resulting from the violent incident, (2) ensuring the patient’s physical safety after discharge, and (3) providing referrals and resources to at-risk patients.

In the prehospital and hospital setting, priority should be placed on identifying and stabilizing physical injuries. A complete physical examination and detailed history are a priority because the patient may have prior, incompletely healed injuries that are unrelated to the trauma prompting the present visit.

History taking should focus on the mechanism of injury, as well as inquiries into the patient’s safety at home. A majority of states have laws mandating physicians to report injuries resulting from IPV; clinicians should be aware of laws pertaining to mandatory reporting in the locations where they practice. In addition to facilitating contact with law enforcement agencies, the treating clinician should ensure that the patient and any children will have a safe place to stay after discharge and should facilitate referrals to social services or local support agencies if the patient does not have a safe home setting.

If a clinician suspects that a patient may be at risk for IPV but there is no clear history of recent or current victimization, providing the patient with educational material about the warning signs of at-risk relationships and information about local support organizations and shelters may be appropriate (see the Priority Actions box).

Follow-Up, Next Steps in Care, and Patient Education

The decision to admit patients victimized by IPV should be dictated by the severity of the injuries or non–trauma-related complaints, as well as the patient’s safety at home. If the patient has minor injuries but no safe place to stay, admission may be indicated to allow time for the patient to work with social services staff to ensure safe discharge.

In addition to thorough documentation of the patient’s history of the present illness and findings on physical examination, it is essential that the treating clinician document details about the patient’s home situation, including (1) whether the patient lives with the assailant, (2) whether children are living in the home and plans for ensuring the safety of the children, (3) temporary alternative housing options available to the patient, and (4) whether the patient believes that she will be safe if discharged. In addition, given the high correlation between IPV and depression, the social history should also include inquiries into the patient’s substance use, as well as symptoms of depression or any suicidal or homicidal ideation (see the Documentation box).

References

1 Breiding MJ, Black MC, Ryan GW. Prevalence and risk factors of intimate partner violence in eighteen U.S. states/territories, 2005. Am J Prev Med. 2008;34:112–118.

2 Brock K, Stenzel A. When men murder women: an analysis of 1997 homicide data—females murdered by males in single victim/single offender incidents. Washington, D.C: Violence Policy Center; 1999.

3 Cunradi CB, Caetano R, Schafer J. Alcohol-related problems, drug use, and male intimate partner violence severity among US couples. Alcohol Clin Exp Res. 2002;26:493–500.

4 Rhodes KV, Houry D, Cerulli C, et al. Intimate partner violence and comorbid mental health conditions among urban male patients. Ann Fam Med. 2009;7:47–55.

5 McClennen JC. Domestic violence between same-gender partners. J Interpers Violence. 2005;20:149–154.

6 Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359:1423–1429.

7 Sheridan DJ, Nash KR. Acute injury patterns of intimate partner violence victims. Trauma Violence Abuse. 2007;8:281.

8 Liebschutz J, Battaglia T, Finley E, et al. Disclosing intimate partner violence to health care clinicians—what a difference the setting makes: a qualitative study. BMC Public Health. 2008;8:229.

9 Rodríguez MA, Sheldon WR, Bauer HM, et al. The factors associated with disclosure of intimate partner abuse to clinicians. J Fam Pract. 2001;50:338–344.

10 Rhodes K, Lauderdale D, He T, et al. “Between me and the computer”: increased detection of intimate partner violence using a computer questionnaire? Ann Emerg Med. 2002;40:476–484.

11 Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359:1331–1336.

12 Grisso JA, Schwarz DF, Hirschinger N, et al. Violent injuries among women in an urban area. N Engl J Med. 1999;341:1899.

13 Houry D, Kemball R, Rhodes KV, et al. Intimate partner violence and mental health symptoms in African American female ED patients. Am J Emerg Med. 2006;24:444–450.