Intimate Partner Violence

Intimate partner violence (IPV) is characterized by a pattern of coercive behaviors (e.g., repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation, and intimidation) perpetrated by someone who is or was involved in an intimate relationship with the victim.1 One in four U.S. women will be abused by a partner during her lifetime.2

In the clinical setting, 35% of obstetrics-gynecology patients, 26% of women patients in primary care practices, and 41% of women seen in emergency departments have reported lifetime IPV.3 Partner abuse occurs across all racial and socioeconomic sectors2; risk factors include female sex, younger age, unmarried status, low income, lack of insurance coverage, and childhood maltreatment.2^,4^,5^,6^,7 IPV has been associated with gynecologic, gastrointestinal, neurologic, musculoskeletal, cardiac, and psychiatric complaints.4^,5^,8^,9 When abuse continues, these health-related complaints increase in number.9 Not surprising, IPV victims are more likely to seek medical care10 — and the estimated direct annual cost of this additional use is US$4 billion.11

IPV During Pregnancy

As many as 20% of pregnant women are abused by their partners3^,6^,12 (or, in pregnant adolescents, by female nonpartners [JW Womens Health Mar 19 2001]), making IPV more common than preeclampsia and gestational diabetes. Pregnancy itself (particularly if unplanned), prior abuse, and delayed prenatal care are risk factors for IPV.6^,12 Adverse outcomes associated with IPV before or during pregnancy include urinary tract infections, vaginal bleeding, preterm labor, and substance abuse.6^,12

Screening for IPV

Most major medical organizations recommend routine screening of all adult women for IPV.13^,14 Such screening should be conducted in a safe, private setting at new patient visits and periodically thereafter (e.g., during annual exams). No adult known to the patient should be present, and older children should leave room before inquiries are initiated. Screening should begin with a general statement about the prevalence of violence against women, followed by an open-ended question directed toward the patient (e.g., “Do you feel safe in your relationship?”). If the patient denies abuse, the provider should then inquire specifically about violent behaviors such as hitting, pushing, choking, or forcing sexual intercourse. Vague terms such as “physical abuse” or “sexual abuse” should be avoided.

If a clinician suspects abuse that the patient has not disclosed, he or she should inform the patient about these concerns in a gentle, nonjudgmental manner. At subsequent visits, the clinician should address IPV as part of the patient’s ongoing problems and should be aware that the patient might continue to withhold information.15

Safety Assessment

When a patient reveals that she is being abused, the provider should validate her experience by telling her that she is not alone and that no one deserves to be hurt. Such brief statements of empathy and validation can be powerful interventions in themselves.15 The provider also should perform a quick safety assessment by asking whether the abuser has a weapon or has ever threatened to kill the patient and whether the patient feels that she is in any immediate danger. The provider then should ask about specific types of abuse and whether the patient has ever sought medical treatment or has ever attempted suicide.

Referrals

When a clinician identifies a case of IPV, he or she should provide the patient with information about available resources, including telephone numbers of hotlines, shelters, local support groups, and legal aid services. A U.S. domestic violence hotline (1-800-799-7233) is staffed nationwide by trained operators who can offer aid and can direct callers to local resources. Each state also has a domestic violence coalition that helps abused women find local services and that provides clinicians with useful public service information, such as posters and pamphlets.

Safety Planning

The clinician should help the patient to develop a “quick-escape” plan in the event that she ever needs to flee immediately or decides to leave her abusive situation permanently. Specifically, the provider should encourage the patient to identify places where she could go if she were in imminent danger (a friend’s or a relative’s home or a shelter) and to make copies of important personal and family documents (driver’s license, social security card, bank and credit card statements, birth certificates, and immunization records). The patient should put these documents in a plastic bag along with a change of clothes, and the bag should be stored outside the home.

Documentation

In the patient’s medical record, the provider should state a description of the reported abuse and the identity of the abuser. If a clinician suspects abuse that the patient does not disclose, he or she should note this suspicion on the patient’s chart.

Counseling for IPV is a clinical activity that can be coded on charge sheets for insurance billing purposes. Before billing for this activity, the provider should ask the patient whether her abuser has access to insurance statements; such documents might reveal that the victim has disclosed her abuse and, thereby, put her at further risk.

Mandatory Reporting

In the U.S., most states do not require healthcare providers to report IPV to law enforcement unless injury has been inflicted with a gun or a knife.16 Providers who are uncertain about their local reporting requirements should contact their local domestic violence coalitions for clarification.