Intimate Partner Violence

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Chapter 68

Intimate Partner Violence

Perspective

Background

Emergency medical specialists, by nature and by necessity, focus their problem-solving skills on the presenting health complaint or bodily symptom that motivated the patient to seek relief at that particular moment. In the case of intimate partner violence (IPV), such focus may lead to blinding tunnel vision and a missed opportunity to lift the veil of shame and empower a victim to consider options to reduce future harm and restore emotional and physical well-being. IPV is a shame-based disease not readily disclosed or discussed with the health provider, let alone anyone else. Most physicians consider partner violence in the differential diagnosis of a physically injured woman; however, patients with an acute IPV injury represent the “tip of the iceberg.” Emergency physicians probably treat many more victims of IPV without realizing it because the patients seek treatment for other problems that are complications of prior physical, sexual, or emotional abuse or for conditions that may be comorbid with IPV. The portion of the IPV iceberg lying undetected beneath the water line may be the most dangerous. The intent of this chapter is to educate emergency medicine specialists about the health problem of IPV so that they can move beyond the obvious and improve IPV identification, facilitate earlier intervention, and reduce morbidity and mortality for victims and children living in an IPV home.

Epidemiology

Definition and Types of Intimate Partner Violence

In 2002 the World Health Organization (WHO) declared that “violence is a leading, world-wide public health problem” and then added that violence is not an intrinsic part of the human condition and is preventable. Gro Harlem Brutland, the Director General of WHO, wrote, “to many people, staying out of harm’s way is a matter of locking doors and windows and avoiding dangerous places. To others, escape is not possible. The threat of violence is behind those doors—well hidden from public view.”1 The WHO report distinguishes three general categories of violence—individual, interpersonal, and collective—and then further divides interpersonal violence into familial or stranger violence. IPV is a form of interpersonal, familial violence (Fig. 68-1).

IPV has been defined by the Centers for Disease Control and Prevention (CDC) as the threat or infliction of physical or sexual violence by a current or former adolescent or adult intimate partner or spouse. This violence is often accompanied by psychological abuse.2 The physical, sexual, and psychological forms of IPV occur as a pattern of assaultive and coercive behaviors. Physical violence includes aggressive behaviors, such as pushing, hitting, slapping, punching, kicking, biting, burning, strangulation, using objects and weapons, and controlling access to physical needs, such as health care, medications, food, or shelter. Sexual abuse includes behaviors such as forced sex, coerced sex with a partner or other persons, and violence in association with sexual assault and rape, as well as prevention of or interference with the use of birth control and refusal to use condoms to prevent the transmission of sexually transmitted infections and human immunodeficiency virus (HIV). Psychological abuse includes words and behaviors meant to intimidate, degrade, humiliate, or isolate the victim from family and friends. Psychological abuse may also manifest as behaviors to arouse fear in the victim, such as violence or threats of violence against family members, stalking, attacks against pets, and destruction of property; controlling access to food, shelter, clothing, transportation, and money; and controlling employment and social or professional activities.

In the past, IPV has been referred to by a number of different terms. These include domestic violence, spouse abuse, wife abuse, battering, battered woman, and wife beating. However, the use of the term intimate partner violence is recommended, as it is a more inclusive term and applies equally to adolescents and adults, females and males, opposite- and same-sex intimate partners, married and unmarried individuals, and current and former intimate partners.2 State penal codes may use slightly different definitions of IPV from those of the CDC, especially as it pertains to the nature of the relationship between the two individuals or the forms of abuse that have transpired. The term domestic violence is generally used by the criminal justice system when referring to partner violence, whereas intimate partner violence is the preferred term of the CDC; of note, the International Classification of Diseases (ICD) includes IPV as a form of adult maltreatment.

Prevalence

There are numerous population-based and health care–based studies that report prevalence rates of IPV victimization. Because of the different types of IPV (i.e., physical, sexual, psychological and emotional), the pattern of the violence (i.e., first episode, ongoing, intermittent, previous experience), and the population being surveyed, the reported IPV victimization prevalence rates vary widely. The prevalence of IPV victimization is often expressed as either a 1-year prevalence (the proportion of the population experiencing IPV in the previous year) or as a lifetime prevalence (the proportion of the population that have ever experienced IPV). To fully understand the meaning of reported IPV prevalence rates or to be able to compare IPV prevalence rates between studies, one should look at the population being studied, the types of abuse being measured, and the period of time being studied. The variation in research methodology among studies makes IPV surveillance challenging. In an attempt to improve IPV surveillance, the CDC published recommended uniform definitions and data elements for IPV research.2

The National Crime Victimization Survey (NCVS) and the National Intimate Partner and Sexual Violence Survey (NISVS) are two large population-based surveys. In the NCVS in 2010, a randomized telephone survey of 41,000 households and approximately 73,300 males and females 12 years and older, 22% of violent crime against women was IPV compared with 5% against men,3 and about 80% of IPV victims were women.4 In the NISVS in 2010, a random telephone survey of 7421 men and 9086 women 18 years and older, 35.6% of women and 28.5% of men reported having been physically or sexually assaulted and/or stalked by an intimate partner during their lifetime; 5.9% of women and 5.0% of men reported having been physically or sexually assaulted and/or stalked by an intimate partner within the previous year.5 According to one survey, women in same-sex relationships reported lower rates of IPV (11%) than women in opposite-sex relationships (20%). On the other hand, men in same-sex relationships reported increased rates of IPV (23%) compared with men with female partners (8%).6 According to Behavioral Risk Factor Surveillance System (BRFSS) data from 2005, 23.6% of women reported a lifetime history of IPV and 11.5% of men reported IPV.7 The rates are about the same in rural and urban populations.8 Domestic violence also occurs in older women.9 The National Women’s Health Initiative reported that 11% of women aged 50 to 79 years disclosed that they had experienced physical or psychological abuse over the previous year.10

The prevalence rates of IPV among emergency department (ED) patients are greater than those in population-based studies. Although numerous IPV prevalence studies have been conducted in the ED, they are difficult to compare owing to differing methodologies. The majority of ED-based studies have examined IPV prevalence rates among women. In general, ED-based studies report the incidence of acute abuse, 1-year, and lifetime prevalence rates. Based on several ED-based surveys, 1 to 7% of all adolescent and adult females who came to the ED for any reason did so as a result of an acute episode of physical abuse.11 Moreover, 14 to 22% of all female patients in the ED disclosed that they had experienced IPV in the previous year.12,13 From the Michigan Intimate Partner Violence Surveillance System, all female assault victims were identified based on International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and E codes. Of 3111 assault victims, 2926 were victims of physical or sexual violence, and 38.8% (95% confidence interval [CI], 37.1-40.6) of these cases were attributed to IPV.14 The lifetime prevalence of IPV among female ED patients may be as high as 54%.15 Few studies have investigated the prevalence rate of IPV among male ED patients, and those that did failed to differentiate whether the relationship was homosexual or heterosexual IPV, did not specify whether injuries were sustained in the course of partner retaliation, defense, or retribution, and did not differentiate the force used and nature of injuries sustained.16 The chief concern in comparing male and female victimization is that the dynamics and consequences of the abuse may be very different.

Homicide is one of the top five leading causes of death for females aged 1 to 34 years.17 According to the National Violent Death Reporting System report on 2007 data, 64.4% of intimate partner–related homicides involved female victims, whereas 13.7% of non–intimate partner–related homicides involved female victims. The highest percentage of victims and suspects (26.1 and 23.5%, respectively) were persons aged 35 to 44 years, 37.8% of whom were married at the time of death.18 Women are killed by current or former intimate partners almost nine times more often than by strangers.19 IPV fatalities do not usually occur as a freak event in an otherwise happy family. IPV is a precursor to the homicide in 65 to 75% of cases.20 Of even greater concern for health professionals is that almost half of IPV homicide victims saw a health care provider (HCP) within the year before their death.21,22 The incidence of homicide attributed to IPV has continuously decreased since the mid-1970s, a phenomenon that is attributed to societal shifts to more openly address family violence and to improvements in criminal justice, social service, and health system responses to both victims and perpetrators.

The annual economic cost to society in the United States is estimated at more than $8 billion dollars for direct medical and mental health services as well as lost productivity.23 Studies have found that female patients with documented IPV have higher health care system utilization and costs than those without IPV.24,25 Furthermore, higher health care system utilization and costs were seen in children whose mothers had experienced IPV, even if the abuse had ceased before the children’s birth.26

Risks for Victimization

A few individual factors have been identified that appear to place persons at risk for IPV victimization: female gender, younger age,27 exposure to violence in family of origin,28,29 presence of a physical or mental disability,30 and use of alcohol. Abbott found that among women patients who abused alcohol, 71% also experienced IPV.15 Alcohol use plays a role in both victimization and perpetration of violence, probably because of its disinhibitory effects. In Caetano’s study, 30 to 40% of men and 27 to 34% of women arrested for IPV perpetration were drinking at the time of the event.31 If men were drinking at the time of the physical assault, their female partners were at 3.6 (95% CI 2.2-5.9) times greater risk of sustaining a serious physical injury.32

Other factors appear to contribute to the risk for IPV because either they contribute to relationship stress or they heighten victim vulnerabilities. IPV appears to occur at increased rates in relationships with lower socioeconomic status in which the abuser is unemployed or at a lower level of academic achievement.3234 Homeless women, in general, have higher cumulative rates of violence over the life span than women with stable housing,35 and fleeing IPV homes has been noted to be one of the causes of homelessness in women. Immigrant women are another vulnerable population, as they may be reluctant to disclose IPV, fearing deportation of themselves and/or their spouse. Immigrant women may be further isolated from services owing to language barriers, lack of social support, or lack of economic independence.36 In one study of 1861 New York femicides, the strongest predictors of intimate partner femicide victimization were foreign country of birth and young age.37

Two presentations should provoke consideration of IPV as an underlying or comorbid condition. One presentation is the woman with injuries to the head, face, or neck.38 Muelleman and other researchers found maxillofacial injuries to be the most common injury type among battered women.39,40 Another presentation that prompts consideration of IPV is the female patient who has attempted suicide. Abbott found that among female patients with a lifetime history of a suicide attempt, 81% also had a history of IPV.15 More than 90% of women hospitalized after a suicide attempt report current severe IPV.41,42 Women seen at one ED in England as a consequence of IPV assault (N = 294) were compared with a matched control (N = 558) to determine risk of future self-harm. IPV victims had a relative risk of 3.6 (95% CI, 2.1-6.5) of returning to the ED because of future episodes of self-harm.43

Risks for Perpetration

Most of the research on persons who abuse their intimate partner is done on men who have committed violence of sufficient severity to have been arrested. Although batterers are a heterogeneous group, there are three typologies commonly described: (1) the borderline or dysphoric individual, (2) the antisocial or generally violent individual, and (3) the “family only, no psychopathology” batterer.44 The men in the borderline or dysphoric group are often described as both charming and moody with “Dr. Jekyll–Mr. Hyde” personality changes from one extreme (complacent) to another (rageful). High rates of alcohol and drug use appear in this group, as well as increased contacts with police for violent or disorderly conduct offenses, and increased concerns about rejection or abandonment. The antisocial or generally violent batterer is described as “self-centered, self-absorbed, and lacking in empathy.”44 Intimate partners are viewed as objects or possessions that serve the perpetrator’s needs. Although he may appear confident and exciting, he also manipulates and imposes his values on others. Antisocial batterers usually commit both physical and sexual violence that is more severe than with the other two types, as well as committing more violence outside the family. The third typology is composed of men described as the “guy next door,” not violent outside the home but usually with evidence of passive dependency or obsessive-compulsive personality style. They are rigid, rule bound, and conventional. Any deviation from “the rules” can cause internalized resentments that occasionally erupt in aggressive outbursts of hostility and violence.44 Other factors associated with IPV perpetration include younger age, lower socioeconomic status, exposure to violence in the family of origin,45 alcohol abuse, history of traumatic brain injury (TBI) (anger flares and poorer impulse control), and highly or abnormally spouse-specific dependency.46,47

Risks to Children Living in Intimate Partner Violence Homes

Children who live in IPV homes often witness the violence and suffer physically and emotionally,48,49 and the health impact can be acute or can lead to long-term health risks. The risk of exposure begins in the prenatal period. Pregnant women who are abused are more likely to smoke, consume alcohol, and use illicit drugs than nonabused pregnant women.50,51 Pregnant women who experience IPV physical abuse experience miscarriage,52 premature rupture of membranes, preterm labor,53 and placental abruption at higher rates than pregnant women who have abdominal trauma from other causes.5456

Long-term health risks associated with child exposure to adult IPV have been elucidated through the Adverse Childhood Experiences (ACE) Study based on data collected from 17,337 adult health maintenance organization members. Each person was assessed for exposure to adverse childhood experiences (verbal, physical, or sexual child abuse as well as family dysfunction caused by an incarcerated, mentally ill, or substance-abusing family member; IPV; or absence of a parent because of death or divorce or separation). Adverse childhood experiences have been linked to a range of adverse outcomes in adulthood, including substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality.5759 Adverse childhood experience exposure has also been linked to risk of perpetration and victimization of adolescent dating partner violence.60,61 Trauma-related adverse childhood experiences have demonstrated a “dose-response” relationship to 18 selected health outcomes.57

Children in IPV homes are at increased risk for direct physical abuse by the IPV abuser and less often by the IPV victim.6264 Some state child welfare data have demonstrated that IPV appears to be associated with the most severe and fatal cases of child abuse.65 Children of IPV mothers have been found to be twice as likely to be re-reported to Child Protective Services than children of non-IPV mothers.66

Of great interest is the neurobiologic impact of exposure to violence at a young age. Chronic stress can cause the emotional, more primitive parts of the developing infant or toddler brain to become overly active or reactive to the environment and may affect myelination and synaptogenesis, thus resulting in problems with learning, memory, and behavior.67 Infants exposed to severe IPV in the home environment have demonstrated severe post-traumatic symptoms, as have their mothers.68

Because various forms of violence and abuse are inter-related, when an adult victim is identified, an assessment of the well-being of the children is also indicated. Alternatively, when child neglect or abuse is suspected, there is a good chance that IPV is also occurring and should be considered in the child or parental interview. Intervention programs should be prepared to address the health and safety needs of both child and adult victims that may co-occur in one family. Clinicians should interview older children alone and younger children in the presence of a guardian. If in the course of interviewing a pediatric patient IPV is disclosed, the child’s medical records can be sealed by court order to prevent access by an abusive guardian parent if the physician can document sufficient concern for the health and safety of the child.

Special Considerations for Adolescents in Abusive Relationships

In a nationally representative sample of 7500 adolescents, 12% reported an experience of physical violence in an opposite sex relationship in the previous 18 months. If the question included sexual, physical, or psychological abuse, the rate rose to 32%.69 Miller and colleagues found that 40% of adolescents who sought care at adolescent health clinics disclosed IPV—32% with disclosed physical abuse and 21% sexual abuse.70 In a 2009 survey conducted by the CDC, 9.8% of male and female high school students reported an episode of dating violence (being hit, slapped, or physically hurt) in the preceding year.71 Higher rates are found in rural populations and when youth from lower socioeconomic groups were surveyed.72,73 Surveys show that boys and girls both report acts of physical aggression; however, girls report experiencing more serious acts, such as strangulation or use of a weapon in the physical assault or rape.74,75 Girls are more likely to be worried or scared of relationship violence, and boys minimize the psychological impact of the aggression; however, this may be more of an enculturated response than a true reflection of boys’ level of anxiety.76 Complicating understanding regarding prevalence of relationship violence in teens is the fact that in some states it is reported as child abuse and in others as IPV. Pregnant teens seem to be a high-risk population for prior exposure to violence. In one study of 724 pregnant adolescents, 12% had been assaulted by the man who had impregnated them, and of those who had experienced relationship violence, 40% also reported having experienced violence by a family member or other relative.77,78

Adolescents are more likely to endorse stereotyped gender roles (dominant or aggressive males and submissive or supportive females) and are more likely to interpret jealousy, violence, or controlling behaviors as signs of love or devotion.79 Adolescents are also less likely to disclose abuse to parents, from whom they are trying to individuate and separate, and less likely to disclose abuse to peers for fear of being considered odd or rejected by the peer group.80 Homosexual teens have the additional anxiety of being “outed” should they disclose the abuse.81

Health professionals should routinely spend time alone with adolescents in the course of the history taking or physical examination to explore health issues such as reproductive and relationship health and prior exposures to violence, threats of violence, or bullying. The health professional should be familiar with the rights of minors regarding confidentiality, as well as state laws regarding mandatory reporting of relationship violence and sexual assault. Many states have enacted legal exemptions that allow minors as young as 12 years to seek a domestic violence protective order.

Etiology

Intimate Partner Violence Social Ecology Model

There are multiple theoretic explanations for the cause of IPV; these can best be organized with the Social Ecology Model, which nests individual, family, community, and cultural factors.82

The “individual” layer includes the biologic, ontogenic, or experiential makeup of a person, such as childhood exposure to IPV as well as certain personality psychopathologies.44,82 A small number of studies have shown a relationship between mild traumatic brain injuries and increased anger and aggression, poor impulse control, and decreasing marital satisfaction.44

The second nested layer is the “family” or the relationship itself, with its own style of communication, decision-making, and conflict resolution, also referred to as the “microsystem.” Male dominance and male control of financial decision-making in a family have been predictors of societies that have high rates of violence against women.82 Not surprisingly, couples with high levels of conflict also have a greater risk of physical violence, and this risk increases when there is an asymmetrical power structure within the relationship.82

The third nested layer is “community” or “exosystem” and refers to the neighborhood, institutions, local services, and social structures that surround the family. Although IPV occurs across all socioeconomic strata, it appears to be more common in families with low income and in unemployed men. It is likely that income level is not the critical variable, but rather the stress of poverty, crowding, or hopelessness that actually contributes to increased violence. Lack of social support for women and delinquent peer associations for men have both been associated with victimization and perpetration, respectively.82

Finally, the individual, family, and community all function within a society or culture with rules, laws, taboos, attitudes, and biases—also referred to as the “macrosystem.” The predominant cultural theory regarding the cause of IPV is Feminist Theory, which states that violence against women results from gender inequity, both ideologic (belief, norms, values) and structural (access to and positions within social institutions).83 The more unequal women are to men, the more likely men are to be violent to women.84,85

Forms of Intimate Partner Violence

Some IPV researchers have suggested that there may be two distinct forms of IPV: intimate terrorism and situational couple violence.86,87 The two forms are differentiated based on the use of power to control. Intimate terrorism is defined as “the attempt to dominate one’s partner and to exert general control over the relationship,” whereas situational couple violence is “violence that is not connected to a general pattern of control.”88 Situational couple violence is usually less injurious or severe, and more likely to be engaged in by either member of the couple. Intimate terrorism is characterized as more injurious, more frequent, and almost exclusively perpetrated by men against women.

In one study a five-item index to measure controlling behavior was created: (1) partner tries to limit your contact with family or friends,89 (2) partner insists on knowing who you are with and where you are at all times, (3) partner becomes jealous and does not want you to talk to other people, (4) partner prevents you from knowing about or having access to family income even if you ask, and (5) partner controls most or all of your daily activities (α = .72). The study found that controlling behaviors are present in 69% of physically violent relationships but present in only 11% of non–physically abusive controls.

Clinical Assessment

Medical History

Patients who are currently experiencing or have previously experienced IPV may visit the ED for a wide range of health care issues. IPV patients may seek care after an acute physical or sexual assault or for the chronic sequelae related to a previous injury. They may seek treatment of an acute medical condition or care for a chronic illness exacerbated by IPV. In addition, IPV patients may require mental health care and may have conditions related to alcohol and substance abuse. IPV patients’ presentations may be obvious, such as a geometrically patterned physical injury, or subtle, such as headaches resulting from repetitive blunt head trauma. Therefore it is important that the HCP be aware of the broad possibility of IPV presentations as well as the comorbid conditions that are associated with IPV (Fig. 68-2).

When HCPs are eliciting a history from a patient with injuries, they should attempt to determine the mechanism of injury. If the patient attributes the injuries to interpersonal violence, the identity of the other person, as well as that person’s relationship to the patient, should be ascertained and documented. Not only is noting the nature of the relationship important for accuracy of diagnostic coding, but the intervention for a victim who lives with the assailant will be very different from the intervention for a victim of a stranger assault. If the injury is a result of IPV, the patient may be reluctant to divulge the information. Additional historical clues that an injury may be a result of IPV are a vague or changing history, a history that is inconsistent with the injuries, a statement by the patient that he or she is “accident prone,” and a past history of injuries.90

Many IPV patients seek care for chronic conditions that are a result of previous injuries or are comorbid medical conditions of the abuse. From results of a survey of 3568 English-speaking women that used BRFSS and Women’s Experience with Battering (WEB) questions, the health status of abused and nonabused women were compared. Abused women were consistently and significantly at increased risk of psychosocial disorders (substance abuse, depression, anxiety, tobacco use), musculoskeletal disorders (degenerative joint disease, low back pain, joint trauma, cervical pain, acute sprains), reproductive complaints (menstrual disorders, vulvovaginitis, sexually transmitted infections), and others (confusion, headaches, urinary tract infections, abdominal pain, chest pain, respiratory infections, reflux disease, and lacerations).7,91 Other common medical presentations of IPV patients include cardiorespiratory illnesses (palpitations, chest pain, asthma exacerbations, shortness of breath), gastrointestinal disorders (functional bowel disease), and general constitutional complaints (weakness, fatigue, dizziness, chronic pain). Additional analyses of the 2005-2007 BRFSS data revealed that same-sex and opposite-sex IPV victims experienced similar poor health outcomes.92,93 When IPV victims experienced both physical and sexual IPV, they had even lower health outcome scores and more depression than those with physical abuse only.94

If the patient exhibits comorbid conditions common to IPV, the HCP should consider the possibility of IPV. Likewise, in the reverse, if the patient has experienced IPV, he or she should be questioned about the presence of any comorbid conditions that may warrant intervention (see Fig. 68-2). Other findings in the medical history that may be suggestive of IPV include a delay in seeking medical care or noncompliance with medications and/or medical appointments, which may be a result of the abuser controlling the patient’s access to care. Frequent visits to the ED and alcohol and substance abuse are also highly associated with IPV.

Physical Examination

IPV patients may come to the ED with acute injuries, or injuries may be an incidental finding discovered during the physical examination for medical complaints. When examining an injured patient, the HCP should look for clues that the injury may be intentional in nature, such as a central location (e.g., trunk, breasts), bilateral injuries (both arms or both legs), defensive injuries (e.g., ecchymoses on the back of the hand because of protecting the face), and patterned injuries (having the markings of an object such as the sole of a shoe or a burn with the imprint of an iron). Common locations for IPV injuries are the head, face, mouth, and neck. Types of injuries may include facial contusions, lacerations, fractures, traumatic alopecia, concussion, skull fractures, intracranial hemorrhages, and strangulation. Extremity injuries with “grab” marks (fingertip contusions) to the upper arms are suggestive of IPV. In one study, 2% of women with acute fractures related their injury to IPV, and one third of injured women revealed IPV exposure at some previous time.95

HCPs should assess injuries for location, size, swelling, tenderness, coloration, evidence of healing, and the presence of a pattern. In noting the color of each ecchymosis, the HCP should be careful not to make a determination as to the age of each one, as this may vary depending on the force used, the vascularity of the tissue injured, the age and health status of the victim, and the use of medications or alcohol, which can alter coagulation profiles.

Mental Health Assessment

The HCP should assess any patient known or suspected to have been exposed to IPV for associated mental health conditions. IPV victims frequently experience depression, suicidal ideation, homicidal ideation, post-traumatic stress disorder (PTSD), insomnia, eating disorders, and alcohol and substance abuse. In a meta-analysis of mental health disorders among women who had experienced IPV, the weighted mean prevalence was 50% for depression, 61% for PTSD, and 20% for suicidality: higher prevalence rates were seen in women with more severe abuse or who were in shelters or court programs.96 These rates are all significantly higher than those in individuals who have not experienced IPV. IPV patients should also be questioned about alcohol and substance abuse, a common coping mechanism or form of pain control for IPV patients.

Other Intimate Partner Violence Injuries

Strangulation, mild TBI, and intimate partner sexual abuse are three forms of injury that occur frequently in IPV and have been under-recognized by HCPs.

Strangulation

Intentional strangulation occurs as a result of the perpetrator applying compression using a body part (one or two hands, forearm, or knee) or a ligature (a necklace or piece of clothing worn by the IPV victim). In asking patients if their partner attempted to strangle them, the lay term “choked” may be more appropriate to use because people often associate strangulation with a rope or object, whereas the word “choking” is associated with neck compression by the hands. Patients may complain of a hoarse voice, pain or difficulty swallowing, neck pain, difficulty breathing, loss of consciousness, incontinence, or confusion, or they may have no symptoms. On examination they may have a hoarse or muffled voice, difficulty swallowing, neck tenderness, respiratory difficulties, stridor, laryngeal fracture, facial petechiae, subconjunctival hemorrhages, ecchymoses or ligature marks on the neck, or altered mental status. They may also have normal examination findings that do not show any specific signs of strangulation.97,98

Mild Traumatic Brain Injury

According to one study, 71% of women experiencing IPV have incurred TBI from a physical assault, and 51% incurred multiple episodes of TBI from repetitive assaults.99 Women appear to be at greater risk for postconcussive syndrome than men.100 IPV patients may also sustain TBI from “shaken adult syndrome,” resulting in diffuse axonal injury. Like shaken babies, these patients may have retinal hemorrhages, subdural hematomas, and ecchymoses of the upper arms and chest.101 IPV patients frequently report difficulty concentrating, memory problems, headaches, depression and anxiety, and confusion, as well as problems with judgment, problem-solving, and decision-making. In these cases, TBI can be missed, and patients may be labeled as having borderline personalities, post-traumatic stress, or depression. The sequelae of TBI, which is frequently undiagnosed and under-recognized, include neurocognitive deficits and long-term disability. It has been postulated that perhaps TBI interferes more with a patient’s ability to make safer choices than has been previously recognized. The IPV patient with mild TBI should be referred for a comprehensive neurocognitive assessment.102

Intimate Partner Sexual Abuse

Approximately 8 to 14% of women are sexually abused during their lifetimes by an intimate partner.34 Whereas societal biases result in intimate partner sexual abuse being considered less severe and the victim being disbelieved or blamed more often than in stranger sexual assault, the sequelae of intimate partner sexual abuse are at least as serious as those of stranger sexual assault. In addition, victims of intimate partner sexual abuse have been found to be more likely to sustain more serious nongenital injuries than victims of stranger assault.103 When questioning IPV patients about intimate partner sexual abuse and rape, the HCP should ask whether they have ever been forced by their partner to do sexual activities they did not want to do, rather than asking if they have been raped or sexually assaulted. Many IPV patients do not consider that they have been raped or sexually assaulted if their partner, husband, or boyfriend was the perpetrator. Many IPV patients also do not recognize that sexual activity under coercion or threat is a form of sexual assault. In one study, 19% of women reported pregnancy coercion (coercion to become pregnant) and 15% reported birth control sabotage (partner interference with birth control), both of which were associated with unintended pregnancy.104

Diagnostic Strategies

The ability of a clinician to identify and diagnose IPV in the ED largely relies on the interaction between the clinician and patient, and the rapport the patient has with the clinician. In addition, because IPV is a shame-based health care problem, the more comfortable the environment and the clinician-patient interaction, the more likely the clinician will be able to have a conversation about IPV with a patient.

Milieu Considerations

Privacy and safety are issues for all patients, but they are particularly critical for IPV patients when the consequences of a breach of either could result in further injury or death. Specific provider behaviors that foster disclosure by IPV patients have been identified and are reviewed in the following sections. In addition, there are institutional barriers, professional and personal HCP barriers, and patient barriers that should be addressed and minimized to support the disclosure of IPV.

Provide Privacy

One key behavior that promotes privacy is having a patient-only interview policy for at least part, if not all, of the interview, as patients who have experienced IPV may choose not to disclose their abusive relationship in the presence of their family, children, or friends, owing to shame and embarrassment. Research has shown that women experiencing IPV prefer to talk to their physicians alone about the abuse.105 If a partner is reluctant or refusing to leave, the HCP may need to be creative in finding an opportunity to talk to the patient alone, such as when a patient is in the radiology department. In addition, if an interpreter is needed, only trained and authorized hospital employees or a nationally based telephone interpreter service should be used. A hospital employee should not be used as an interpreter if the employee knows the patient. If a patient is asked to complete a written or computer-based questionnaire before being assessed by the HCP, he or she should be provided with a private, safe location in which to do this. Before questioning a patient about activities that must be reported to law enforcement, such as IPV-related injuries in some states, the HCP should inform the patient about the limits of confidentiality (see the later section on ethical considerations).

Provider Behaviors That Foster Disclosure

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