93 Intimate Partner Violence
Key Points• The estimated prevalence of intimate partner violence victimization in women accessing emergency departments is as high as 36% in some populations.
• Interpersonal violence occurs across all populations regardless of social, economic, religious, cultural, or sexual orientation factors.
• More than 40% of women murdered by an intimate partner had visited an emergency department within 2 years of the homicide, and more than 90% had at least one visit for an injury.
• The emergency department serves a critical role to screen for, identify, and provide help to victims of 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
Pathophysiology
The etiologic factors and mechanisms mediating IPV are both complex and the subject of ongoing dispute by researchers in the field. Known factors associated with increased risk for IPV include poverty, societal and individual views of gender relationships, relationship conflict, alcohol use, and societal views about the use of violence in conflict.6 The sequelae of IPV range from mental health issues and minor injuries to multisystem trauma and death.7
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).
