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