Chapter 60 Petra Norris Woman abuse, wife assault, domestic violence, relationship terrorism, and intimate partner violence (IPV) are all terms that have been used to describe the violence that occurs between two people in an intimate relationship. Although domestic violence includes IPV, it also refers to violence against other family members; therefore, for the purpose of this chapter, the term IPV will be defined as the intentional use of tactics to gain and maintain power and control over the thoughts, beliefs, and conduct [1] of an intimate partner. The term partner may be defined as a current or former girlfriend, boyfriend, spouse, or common-law spouse. Tactics used to gain control in IPV create fear, isolation, and the entrapment of one partner. The majority of non-fatal intimate partner victimizations occur at home [2]. The EMT or EMS physician is in the unique position to attend to the patient in the home and observe the environment in which the violence took place, as well as the behaviors of the victim and abuser along with their interactions with each other. Being aware of these behaviors will allow the EMS provider to identify situations in which abuse may not yet have escalated to physical violence, thereby allowing early intervention. Violence against women is well documented by the World Health Organization (WHO). IPV occurs in all countries, regardless of social, economic, religious, or cultural status [3]. Although it is recognized that violence occurs against men in both opposite and same-sex relationships, the prevalence of women as victims is overwhelmingly greater than men. Therefore, this chapter will focus on male violence against female partners. About one in four women and one in seven men have experienced severe physical violence [4]. Women are three times more likely to report that they have been beaten, choked, sexually assaulted, or threatened with a gun or knife [5] and therefore more likely to require medical attention. Domestic violence is a leading cause of injury to American women between the ages of 15 and 44 and is estimated to be responsible for 20–25% of emergency department (ED) visits by women [6]. One in five homicides involves killing of an intimate partner [7]. Part of identifying IPV is awareness of the high-risk groups. Although it already has been established that women are a risk group, there are subgroups that are at even higher risk. Women who are separated or divorced report higher rates than women of other marital status [2]. Aboriginal women are three times more likely to experience spousal violence than non-aboriginal [7]. Visible minorities report a rate of IPV of 5% [8]. Women with disabilities are 1.5–10 times as likely to be abused as non-disabled women, depending on whether they live in the community or in institutions [9]. At least 4–8% of pregnant women report suffering abuse during pregnancy [10], and 39.2% of same-sex cohabiting women, and 23.1% of men, reported being raped, physically assaulted, and/or stalked by a marital or cohabiting partner at some time in their lifetime [11]. Abuse often begins in a close, mutual relationship, which over time becomes exclusive, allowing the abuser to isolate the victim. Violence can appear gradually or suddenly, but generally there is a period of “testing [12].” This may begin with verbal abuse and then progress to sexual and physical abuse (Box 60.1). Shoving and pushing can escalate to punching, kicking, and assault with blunt and penetrating weapons. Many abusive relationships undergo a cycle of violence, which occurs in three stages (Figure 60.1) [12]. In phase one, tension builds and the woman increases her efforts to please the abuser in hopes of avoiding violence. The woman may intentionally trigger the abuse at a time when she feels the violence is inevitable to decrease the stress she feels about the impending violence, or to be in control as to where and when the violence will occur. In phase two, violence erupts and may increase in frequency and severity over time. Phase three represents a “honeymoon” phase in which the abuser apologizes for the abuse, may purchase gifts, blames the victim, and offers rationalizations (e.g. “If you only didn’t… I wouldn’t….”). This phase may become shorter over time. Figure 60.1 Cycle of violence. The cycle of violence can also occur generationally because it is passed through the family. Children witnessing abuse learn that it is tolerated or even appropriate behavior and a way of gaining power and control, and therefore may repeat the behavior in their own relationships. Studies report that about one in four women seeking care in the ED for any reason is a victim of violence (one in three treated for trauma), and 37% of female patients who are treated in the ED for violent injury have been injured by intimate partners [13]. Health care providers are being encouraged to universally screen for violence in the ED and primary health care settings. This means that all women over the age of 12 are asked about abuse, not only those in whom injuries appear suspicious. The National Violence Against Women survey revealed that 125,000 (17.5%) female victims of assault used ambulance services [14]. Because EMS personnel are often the first responders to situations that involve violence, it is critical to be able to identify, ask about, and respond appropriately to the unique situations that involve IPV. If violence can be identified early then there is an opportunity to intervene, thereby improving the health and lives of women and children and stopping the cycle of abuse. Many women living with abuse experience more than just physical injuries such as fractures and soft tissue injuries; they may present with psychiatric and medical conditions such as those listed in Box 60.2 [1]. Between 2001 and 2005 the US Department of Justice statistics reported that fewer than one-fifth of victims reporting an injury sought treatment following the injury. Approximately 8% of female and 10% of male victims were treated at the scene of the injury or in the home. Females who experienced an injury were slightly more likely than their male counterparts to seek treatment at a hospital [2]. EMS might be called to a scene at which the patient is experiencing any of the aforementioned conditions. Through noticing the environment, patient injuries, and/or interactions between the patient and her partner at the scene, the EMS provider may be able to identify IPV. If EMS is activated through a 9-1-1 call for IPV, it is important to have law enforcement secure the scene before EMS access. If EMS personnel arrive at the scene of a non-disclosed IPV situation and feel that they are at risk, law enforcement should be called. Once the scene is secure, the providers can proceed with assessing safety in the immediate area where the patient is located to provide medical assistance. Patients should be assessed in the appropriate sequence with the primary survey, ABCs, and life-saving interventions undertaken, followed by a secondary survey and further history. While on the scene, EMS providers should keep the following in mind. Be aware of your jurisdiction’s legal requirements with respect to reporting to law enforcement. Some states require EMTs responding to an injury sustained during a crime to report to police; others will allow or mandate the patient to decide the best action to take. Requirements may be different for physicians. On the initial interaction with the patient, EMS personnel may find there was a delay in seeking help and/or that this patient may have experienced repeated calls and visits to the ED for injuries. The physical assessment may reveal injuries such as abrasions, bruises, burns, dislocations, lacerations, bites, fractures, abrasions, or marks on the neck consistent with strangulation, petechial hemorrhage in the eyes, a combination of old and new injuries, and/or patterned injuries to the head, face, neck, throat, chest, breasts, back, abdomen, or genitals. Injuries that suggest a defensive posture, such as those found on the hands or ulnar aspect of the arms, are suspicious. Patients may also experience mouth and dental trauma. It may also be found that the patient’s or partner’s description of accident is inconsistent with the observed injury. If this is the case, EMS should document both what is reported and objective observations.
Intimate partner violence
Introduction
Scope of the problem
High-risk groups
Understanding intimate partner violence
Cycle of violence
Intimate partner violence as a health care issue
Health effects of abuse
Emergency medical services provider safety
Assessment and examination
Physical assessment
Behavioral assessment
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