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Summary
Intimate partner violence (IPV) is any form of physical, psychological, or sexual violence that is carried out by a current or former intimate partner who may or may not be a cohabitant. Domestic violence is a broad term for any form of violence committed by one member of a household against another, and can include IPV, older adult abuse, and child maltreatment. IPV affects nearly half of individuals in the US during their lifetime and up to 20% of pregnant individuals. Signs include multiple and/or unexplained injuries (e.g., injuries inconsistent with the medical history, in various stages of healing, or consistent with an act of defense), fearful behavior, frequent visits to the emergency department, and a partner who insists on speaking on the patient's behalf. All women of reproductive age should be screened routinely (e.g., at annual well-visits, and more frequently during pregnancy), using a validated IPV screening tool. Management includes treating physical injuries, performing a danger assessment, and facilitating contact with support services.
Management of recent sexual violence is detailed separately.
Definitions
- Intimate partner violence (IPV): any form of physical, psychological, or sexual violence that is carried out by a current or former intimate partner who may or may not be a cohabitant [2]
- Domestic violence: a broad term for any form of violence committed by one member of a household against another, and can include IPV, older adult abuse, and child maltreatment [3]
Epidemiology
- During their lifetime, in the US: [4]
Epidemiological data refers to the US, unless otherwise specified.
Risk factors
Risk factors include: [3][5][6]
- Evidence of discord in the relationship, e.g., hostility, conflict, verbal aggression
- Low socioeconomic status and/or level of education, unemployment
- History of abuse or exposure to IPV
- Substance misuse
- Mental or physical disabilities
- Mental health disorders, e.g., depression
- Younger age (ages 18–24)
- Pregnancy, especially unplanned
- Unmarried, divorced or separated relationship status
- Racial minority populations
- Sexual and gender minority populations, including:
- Transgender individuals [7]
- Same-sex couples [8]
There is a risk of escalation of violence during pregnancy and/or in the postpartum period. [9]
Red flags
The presence of any of the following should prompt consideration of IPV. [5][10][11]
-
History
- Hesitation to seek medical care
- Frequent visits to the emergency department
- Unexplained; , unusual, and/or multiple injuries
- Unexplained somatic symptoms [5][9]
- Substance misuse
- Symptoms of mental health disorders (e.g., suicidal ideation, depression, anxiety, PTSD)
-
Examination findings: Specific injury patterns can indicate IPV.
- Contusions, lacerations, and/or fractures of the head, neck, and face
- Signs of strangulation
- Signs of intentional injuries, such as injuries that are:
- In a central location (e.g., breast or chest)
- Bilateral (e.g., both arms)
- Defensive (e.g., ulnar aspect of the forearm)
- Signs of traumatic brain injury (from repeated head and neck trauma)
-
Behaviors [12]
- Fearful, avoidant, hostile behavior (e.g., avoiding eye contact)
- Partner insists on being present and speaking on the patient's behalf
Screening
Approach [5][9][11][13]
- Assess for indications for IPV screening.
- Before screening:
- Ensure the patient is in a private setting (i.e., without their partner or family member) and is clothed.
- Explain the universal nature of the screening and ask for permission.
- Provide reassurance that all information will remain confidential aside from anything required to be disclosed by law.
- Administer an IPV screening tool using a trauma-informed approach.
- Follow-up appropriately.
- Positive screen: Provide management of IPV, including facilitating IPV referral and reporting.
- Negative screen: Provide standard educational and reference materials to all individuals, e.g., a list of contact details for local and national resources.
There are several reasons why individuals may be reluctant to disclose the presence or extent of IPV, including shame, fear of stigma, financial dependence. [3][5]
Indications for IPV screening
-
The USPSTF and ACOG recommend universal screening of all women of reproductive age for IPV, e.g., at: ; [7][9][11][14]
- New patient visits
- Annual gynecological exams
- Prenatal and postpartum visits (see “IPV in pregnancy”)
- Hospital admissions [15]
- The WHO recommends targeted screening for patients with red flags for IPV. [16]
IPV screening tools [11][13][17]
- There are several validated tools that can be used to screen women for current IPV or IPV in the past year.
- Screening tools may be administered in a written or verbal format depending on patient preference. [3]
HARK screening tool [18]
- A validated four-question screening tool that assesses for different manifestations of IPV within the past year
- An affirmative response to ≥ 1 of the questions is considered a positive screen.
-
Within the past year:
- H: Has your partner humiliated or emotionally abused you?
- A: Have you been afraid of your partner?
- R: Have you ever experienced rape or been forced to have any kind of sexual activity by your partner?
- K: Has your partner kicked, hit, slapped, or otherwise physically hurt you?
HITS score [19][20]
- A validated four-question verbal or written screening tool used to assess how often an individual has been hurt by an intimate partner
- The E-HITS screening tool has a fifth question that assesses sexual violence.
| HITS score [19][20] | ||||||
|---|---|---|---|---|---|---|
| How often does your partner… | Never | Rarely | Sometimes | Fairly often | Frequently | |
| H | ...hurt you physically? | 1 | 2 | 3 | 4 | 5 |
| I | ...insult you or talk down to you? | 1 | 2 | 3 | 4 | 5 |
| T | ...threaten you with physical harm? | 1 | 2 | 3 | 4 | 5 |
| S | …scream or curse at you? | 1 | 2 | 3 | 4 | 5 |
| Interpretation Score ≤ 10: negative screen Score > 10: positive screen | ||||||
STaT questions [21]
- A validated three-question screening tool used to identify a history of IPV (high sensitivity; moderate specificity)
- An affirmative response to ≥ 1 of the questions warrants further evaluation for IPV.
-
Have you ever been in a relationship where your partner has:
- S: pushed or slapped you?
- T: threatened you with violence?
- T: thrown, broken, or punched things?
Woman Abuse Screening Tool (WAST) [22][23]
-
WAST-Short
- Consists of two questions:
- Do you and your partner work out arguments with: great difficulty, some difficulty, or no difficulty?
- In general, would you say your relationship has: a lot of tension, some tension, or no tension?
- Scoring: A response of either “great difficulty” to the first question or “a lot of tension” to the second question is considered a positive screen.
- Positive screen: Explore further with the additional WAST questions.
- Consists of two questions:
- Additional WAST questions (answer options: often, sometimes, or never)
- Do arguments ever result in you feeling put down or bad about yourself?
- Do arguments ever result in kicking, hitting, or pushing?
- Do you ever feel frightened by what your partner says or does?
- Has your partner ever abused you physically?
- Has your partner ever abused you emotionally?
- Has your partner ever abused you sexually?
Screening for sexual and reproductive coercion [14]
The ACOG recommends using questions such as the following to assess for sexual or reproductive coercion.
- Has your partner refused to wear condoms or forced you to do something sexual against your will?
- Has your partner ever tried to interfere with your birth control, or get you pregnant when you did not want to be pregnant?
- Is your partner supportive of your decisions around pregnancy?
- Pregnant individuals: Are you concerned that your partner will hurt you if you do not comply with their wishes around pregnancy?
Management
General principles [3][5][10][13]
- Evaluate the patient in a private setting.
- Clearly explain the confidentiality policy.
-
Use an empathetic, trauma-informed approach.
- Validate the patient's experiences; avoid blaming.
- Ask open-ended questions.
- Obtain informed consent for every diagnostic and management step.
- Allow the patient to undress to the extent they are comfortable with.
- Maintain a low threshold for notifying hospital security about suspected IPV to ensure the safety of the patient and staff.
- Consider early involvement of a multidisciplinary team.
- Consider legal requirements and follow local protocols for:
- Preparation of accurate medical documentation for potential criminal proceedings
- Sexual health forensic examination
- IPV referral and reporting
Be aware when documenting IPV that patient-accessible parts of the electronic health record may also be read by abusive partners. [3]
Evaluation [3][5][13]
Evaluation may be prompted by positive screening for IPV and/or the presence of signs or symptoms of IPV.
Clinical evaluation
-
Obtain a detailed history and perform a thorough examination. Identify and/or further evaluate:
- Red flags for IPV, including associated psychological trauma and signs of strangulation
- Red flags for sexual violence
- Red flags for human trafficking [24]
-
Assess the immediate safety of the patient and any children; this may include use of an IPV danger assessment tool such as the danger assessment-5 (DA-5). [25]
- The DA-5 consists of the following five questions:
- Has the severity or frequency of physical violence increased in the past year?
- Has your partner ever tried to choke or strangle you?
- Is your partner violently and constantly jealous of you?
- Has your partner used or threatened to use a weapon against you?
- Do you believe your partner is capable of killing you?
- A positive DA-5 screen is an affirmative response to ≥ 2 questions.
- Further management for patients with a positive DA-5 screen
- Inform the patient that they are at increased risk of lethal or severe injury by their partner.
- Refer or connect the patient to a support service of their choice: See “IPV referral and reporting” for details.
- The DA-5 consists of the following five questions:
Patients who have experienced strangulation are at increased risk of becoming a victim of homicide. [25]
Diagnostic studies
- Diagnostic testing is based on the injury and clinical suspicion.
- Laboratory studies may include pregnancy testing and STI screening. [14]
- Imaging may include:
- X-rays to assess for fractures
- CTA head and neck and/or CT neck or spine for patients with blunt neck trauma resulting from strangulation [26]
- CT head for traumatic brain injury
- See also “Blunt trauma.”
Initial medical management
- Treat acute conditions.
- This includes medical, traumatic, and psychological conditions.
- See “Management of sexual violence” if relevant.
- Refer to specialists as appropriate, e.g.:
- Orthopedics for fractures
- Plastics for lacerations
IPV referral and reporting [3][5][13]
Referral
Connect patients to support resources; consider the level of immediate danger, local protocols, and patient preference when determining appropriate resources and methods of referral.
-
Resources
- National Domestic Violence Hotline
- Community resources (e.g., a local domestic violence agency)
- Social worker (e.g., to arrange home visits and/or counseling; , to obtain emergency housing)
- IPV legal advocate [10]
- Patient advocate
-
Methods
- Warm handoff, i.e., introducing the patient in person or joining the phone call
- Offering a private phone for the patient to use. [9]
- Providing contact details for local and/or national resources, e.g.:
- As a printed list
- By programming important numbers into the patient's phone under a code name
Referring individuals who have experienced IPV to ongoing support services can decrease abuse and adverse consequences of IPV (e.g., PTSD, depression. anxiety, substance abuse, and suicidal behavior). [11]
In the US, the National Domestic Violence Hotline can be contacted by calling 1-800-799-SAFE (7233) or texting “START” to 88788.
Reporting
Determine and follow local reporting requirements. Generally, the following guidelines apply.
- Law enforcement: Report if required by law or if patient requests it. [27]
- Child protective services: Report if children are involved. [13]
- Adult protective services: Report if the patient is an at-risk adult.
Patient consent is not required to report IPV in some states and in certain situations (e.g., if children are involved).
Subsequent management [3][9][13]
- Determine if the individual wishes to leave their partner immediately.
- If so: Consider admission if they feel unsafe returning home and no alternative housing is available.
- If not: Nonjudgmentally support their choice and emphasize that help is always available.
- Recommend creating a safety plan for leaving, including:
- Making copies of important personal documents
- Ensuring they have easy access to money and other essentials if they need to leave their home quickly
- Identifying a safe place to go
- Establishing a code word or phrase with trusted friends or family to communicate if they are in imminent danger
- Offer the following:
- New prescriptions for their regular medications [9]
- Discrete contraception options
- Determine the patient's preferred (i.e., safest) form of future medical communication.
- Arrange follow-up care with a primary care provider to: [28]
- Identify and manage acute and long-term conditions associated with IPV
- Ensure ongoing assessment of the patient's risk of immediate harm (e.g., with the DA-5 at each visit)
- For pregnant patients, additional considerations are detailed in “Management of perinatal IPV.”
Individuals experiencing IPV may choose not to leave or report their partner for various reasons, including financial concerns, concern about the well-being of their children, and fear of further harm. [13]
Advise all individuals experiencing IPV to develop a safety plan for leaving. [13]
Special patient groups
Perinatal IPV [3]
- Up to 20% of pregnant individuals experience IPV. [3][9][27]
- Homicide by a current or former intimate partner is one of the most common causes of maternal mortality.
Risk factors for perinatal IPV
- See “Risk factors for IPV.”
- Pregnancy itself increases the risk of IPV, especially unplanned pregnancy.
Red flags for perinatal IPV
- See “Red flags for IPV.”
- In addition, the following features are red flags in pregnancy:
- Perinatal anxiety or depression
- Substance misuse during pregnancy
- Missed or deferred perinatal visits
- Avoidance of, anxiety, and/or dissociation during pelvic examinations
- Obstetric complications of IPV
Screening for perinatal IPV [9]
-
Screening for IPV is recommended for all patients:
- At the initial prenatal visit
- At least once every trimester
- During the postpartum visit
- Any IPV screening tool can be used.
Explain to pregnant individuals that IPV screening is part of routine prenatal care. [3][9]
Management of perinatal IPV
The general principles of management are the same as for nonpregnant individuals; see “Management of IPV.” In addition:
- Consider that patients may have experienced reproductive coercion. [14]
- Determine if the patient wants to continue the pregnancy, and refer for induced abortion if requested.
- Consider more frequent visits for prenatal care, using shared decision-making.
- Consider increased fetal monitoring, e.g.:
- Nonstress test at ≥ 32 weeks' gestation
- Third trimester growth scan
- Provide perinatal-specific trauma-informed care.