Chapter 294: Intimate Partner Violence and Abuse

Intimate partner violence is defined as a pattern of assaultive, coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats. Such behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent individual and are aimed at establishing control by one partner over the other.¹

Intimate partner violence and abuse is the preferred alternative for previously used terms such as spousal abuse, wife battering, and domestic violence. This term more accurately reflects the fact that this type of abuse occurs not only in adult heterosexual married relationships but also in relationships between cohabiting, separated, gay and lesbian, bisexual, and transgendered individuals as well as in adolescent dating relationships.^2,3

Intimate partner violence and abuse occurs in every racial, ethnic, cultural, geographic, and religious group, and it affects individuals of all socioeconomic and educational backgrounds worldwide. Men are affected, but the overwhelming burden of victimization from intimate partner violence is borne by women.^2,4,5 Risk factors for intimate partner violence and abuse include female sex, age between 18 and 24 years, low income level of the household, and relationship status of separated rather than divorced or married.² Sexual and/or physical abuse during childhood and adolescence is a frequent predictor of future victimization.^2,6 Presence of weapons in the home and threats of murder are associated with increased risk of homicide.

Effects extend to family members, friends, coworkers, other witnesses, and the community at large.² Children who grow up in violent homes may be physically or emotionally abused or neglected, and witnessing violence can have short- and long-term adverse health consequences.⁷ In families in which either child maltreatment or spousal abuse is identified, it is likely that both forms of abuse exist. Children may be incidentally injured or killed when they try to intervene in a struggle.⁷ Children exposed to violence in the home may develop behavioral difficulties, including depression, abusive behaviors, and drug abuse. Frequent exposure to violence in the home may teach children that violence is a normal way of life. Perpetrators of violence, in particular severe violence, may be at risk for suicide, committing murder, or being murdered by a family member.^7,8

Ask about a history of intimate partner violence or abuse during healthcare encounters. Failure to recognize and intervene in situations of intimate partner violence may have serious consequences for the survivor and family. Such consequences may include continued violence, physical and psychological health problems, and injury or even death.^2,9,10

Intimate partner violence is most often cyclical in nature. The cycle begins with a period of tension building, which may include arguing, blaming, or controlling behaviors or jealousy. The next phase is escalation and may include verbal threats, physical and sexual abuse, or assault. Weapons may be used at this point. Subsequently, there is a "honeymoon" phase in which the perpetrator may apologize or make excuses for inappropriate behavior. Over time, the abusive behavior tends to increase in severity, and the intervals between abusive episodes become shorter.

There are no "usual" features by which a person who has experienced intimate partner violence may be identified in the ED. Often it is one of a number of health-related consequences of violence or abuse that causes persons who have experienced intimate partner violence to seek medical attention (Table 294-1). Therefore, screening and assessment for elements of the history and physical examination suggestive of intimate partner violence are needed to identify victims. Signs suggestive of intimate partner violence and abuse are summarized in Table 294-2.^1,2,4,11

A defensive, hostile, or aggressive partner accompanying the patient may provide clues to the diagnosis by exhibiting controlling or abusive behavior. Overly solicitous behavior by the partner may occur. The patient may appear frightened of the partner or refuse to answer questions and instead defer all responses to the partner. In situations raising concern, and if the patient agrees, hospital police can prevent the alleged perpetrator from visiting the patient in the ED and hospital. Ask abused individuals if they have suicidal or homicidal ideation. Such ideation, particularly if accompanied by a concrete plan of action, should trigger immediate consultation with a mental health provider.

Many experts, including the American Medical Association and The Joint Commission, recommend routine screening for intimate partner violence for all adolescent and adult women who present to the ED and for mothers of children brought to the ED. National screening consensus guidelines are available online at http://www.futureswithoutviolence.org.¹³ Because of the known adverse long-term impacts of intimate personal violence on health, when time permits, consider screening for lifetime exposure.

The responsibilities of the ED team include identification of intimate partner violence; validation of the abused individual's experience; assessment of immediate risk and safety planning; referral to experts for care; and documentation in the medical record.¹²

Screening should be conducted by providers educated about the dynamics of intimate partner violence. Provide a safe and private environment for the interview. Take into account cultural differences and expectations. If translators are required, use individuals who have no connection to the patient and, if possible, who have education in the dynamics of abuse. Document screening results, safety assessment, and any interventions, including referrals and required reporting. Screening guidelines for adolescent and adult patients are summarized in Table 294-3.¹³ Sample verbal screening questions are listed in Table 294-4.

Abused individuals want providers to be nonjudgmental, sensitive, and direct. They also want to be assured of confidentiality. They want the provider to have an understanding of the complexity of intimate partner violence and the difficulty of achieving a "quick fix." Women value the reassurance that their experiences with intimate partner violence and abuse are unaccepTable and undeserved (it is not their fault). They also value a nonpressured encounter and a provider who respects their decisions and works with them to determine an appropriate course of action.¹⁴

Ensuring the safety of the abused individual and children is the foremost goal. "Placing the patient in a shelter" or "having the attacker arrested" may not be congruent with the individual's goals. Ultimately, the abused individual must make the determination of whether it is safe to return home. By providing information about intimate violence, risks, and options, the physician can help the patient decide what is best for themselves and their family members. The patient's decision making may be very complex, because depression, lack of self-esteem, lack of support, social isolation, financial dependence on the perpetrator, and fear make it difficult to leave the relationship.

Patients must be told that violence, abuse, and intimidation are not a part of normal, healthy relationships. For some, this may be the first time they have heard such information. The abused individual's reports and experiences should be acknowledged and believed. Let the patient know that you take the situation seriously and that you are concerned about the health and safety of her (or him) and the children. Emphasize that he or she has done nothing to warrant violence and abuse. It is the perpetrator whose behavior is unacceptable. Clarify that ED personnel can help patients contact trained social workers or intimate violence advocates, who can then help develop logistical plans either for safety or for ending the relationship. Respect the abused individual's wishes about the future of the relationship. Screening and validation may be the stimulus needed by the patient to begin planning for change.

Indicators of a high-risk and potentially lethal situation include escalation in the frequency or severity of violence; the threat or actual use of weapons, in particular firearms; obsession with the abused individuals; hostage taking; stalking; and homicide or suicide threats or attempts and evidence of violent behavior outside the home. Another risk factor for serious injury or death is substance abuse by the perpetrator, which can increase violent behaviors.^2,11

The most dangerous periods for abused individuals are during the time of abuse disclosure and during attempts to leave the relationship. Some patients feel safer remaining in the violent relationship than leaving without adequate planning for a safe departure.¹³

Refer survivors to intimate violence experts, such as hospital social workers or community-based advocates, who can help the victim assess the situation, understand options, plan for safety, and arrange safe shelter. Community advocates are typically on call or available by telephone. If the patient can be safely discharged from the ED and personal contact with an advocate cannot be made before discharge, give the patient up-to-date information about available services in the community. Intimate personal violence advocates should not be asked to call the patient directly unless the patient agrees, because calls to the home could jeopardize the patient's safety.

Resources for healthcare providers to assist in preparing their practices for optimal response to victims of intimate personal violence are available from a number of organizations (Table 294-5).

If lethality risk is high, consult with experts before ED discharge. Hospital admission of the abused individual or children is an option in high-risk situations in which there is no other way to ensure safety. Use of a 24-hour safe room, a location established by some hospitals and communities to provide a safe place for the patient to stay while arrangements for safe disposition of the patient and family members are made, is another option. Use of an alias name on admission and screening of incoming phone calls may also be of benefit.

ED RECORD DOCUMENTATION

Documentation in the ED should be clear and legible. Voluntary descriptions of intimate personal violence should be quoted and described in the patient's own words. Do not use the word alleged because it implies that the person recording the incident does not believe the complaint. A complaint of "sexual assault" is no more alleged than is a complaint of "ear pain" or a "sore throat."

Record past and current abuse, with details of date, time, location, witnesses, and specific injury. Describe the patient's health complaints, injuries, appearance, and demeanor. Annotated body maps and photographs can supplement written notes.

Obtain relevant forensic evidence, and follow the appropriate chain of custody of evidence. If sexual assault has occurred, document ED testing and treatment.

Record safety assessment and disposition. A safety assessment form or referral notes from an expert are helpful adjuncts. Discussion of a safety plan with the patient is an important discharge function and also requires documentation.

LEGAL CONSIDERATIONS

Most states in the United States have laws that require healthcare providers to report injuries resulting from firearms, knives, or other weapons. Twenty-three states have reporting requirements for injuries resulting from crimes (intimate personal violence is a crime in all 50 states); seven states have statutes that specifically require health providers to report injuries resulting from intimate personal violence. The specifics of the reporting requirements vary from state to state, and the adequacy of response by the police to reporting varies by jurisdiction.¹⁵ Inadequate or inappropriate response to the reports (e.g., informing the perpetrator of the report without providing for the safety of the abused individual) can increase the risk of harm to abused individuals. ED personnel should be aware of reporting requirements and police response in their area. Patients must be informed if there is an obligation to make a police report and should also be told about possible ramifications.

ED PREPARATION FOR OPTIMAL RESPONSE

The Joint Commission requires, and the Institute of Medicine recommends, that staff receive initial and ongoing training about intimate partner violence and abuse. This should include education related to cultural competency, victim perspective, and consequences of violence, as well as how to assess, intervene in, support, and document care. Employees should also be informed of their options for assistance if they or someone they know is in an abusive relationship.

A routine screening protocol should be implemented that addresses training of ED personnel, confidential interviewing, and appropriate interventions, including validation and referral.

Multicultural and multilingual information about interpersonal violence and effects on abused individuals and family members should be made available to the public and employees. This may consist of posters and/or brochures in areas of the hospital such as public areas, examination rooms, and restrooms. Community resources that provide services to victims should be a part of the shared information.

Implement a continuous quality improvement program that assesses adherence to recommended screening and intervention strategies.

Form professional relationships with hospital- and/or community-based experts to ensure appropriate referral practices.

PREGNANCY

Prevalence during pregnancy ranges from 6% to 22%.^5,11 Women who report intimate partner violence and abuse during pregnancy are at increased risk of postnatal abuse. Approximately half of female murder victims are killed by a current or previous intimate.^2,11 Women assaulted during pregnancy are three times more likely to be admitted to the hospital than nonpregnant women.¹¹

GLOBAL ISSUES

Globally, death from interpersonal violence is ranked as the 20th most common cause of death.¹⁶ The World Health Organization's Violence Against Women Survey demonstrates that intimate partner violence and abuse not only are substantial health problems due to direct injury and mortality, but also contribute to other serious health problems because of an increased burden of disease. The associations between reported ill health in women and intimate partner violence and abuse are consistent within and across countries.^8,16 This effect persists even if the violence was in the past.¹⁶

In May 2014, the 67th World Health Assembly requested that the World Health Organization prepare a global plan of action to strengthen the health system to address interpersonal violence, especially against women, girls, and children (http://www.who.int/violence_injury_prevention).

Ten key strategies for violence prevention have been developed for international use¹⁷ (Table 294-6).

For resources for patients (hotlines), see Table 294-7.

The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings, revised in 2004, is available from Futures Without Violence (formerly Family Violence Prevention Fund) (http://www.futureswithoutviolence.org). Preparation of this report was funded by the Conrad N. Hilton Foundation and the U.S. Department of Health and Human Services.

Acknowledgment: The author gratefully acknowledges the contributions of Patricia R. Salber, the author of this chapter in the previous edition.