Intimate partner violence

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Intimate partner violence is any form of physical, emotional, or sexual violence that is carried out by an intimate partner who may or may not be a cohabitant. Domestic violence is any form of violence committed by one member of a household against another and includes intimate partner violence, older adult abuse, and child maltreatment. Intimate partner violence affects approximately one-third of the US population. 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. The use of validated screening tools may help to make the diagnosis. Management includes treating physical injuries, performing a danger assessment, and facilitating contact with support services.

• Intimate partner violence (IPV): any form of physical, emotional, or sexual violence that is carried out by one cohabitating or noncohabitating intimate partner against the other ^[3]
• Domestic violence: any form of actual or threatened physical or emotional abuse committed by one member of a household against another; frequently used as an extension of power

• Approximately one-third of adults experience IPV.
• Approximately 25% of women and 15% of men experience severe physical IPV.

Epidemiological data refers to the US, unless otherwise specified.

• Evidence of discord in the relationship, e.g., restraining orders, substance use, verbal abuse ^[2]
• Low socioeconomic status and/or level of education
• History of abuse as a child
• Mental or physical disabilities ^[4]
• Previous history of IPV

Violence may escalate during pregnancy and/or in the postpartum period. ^[6][7]

Suspect IPV if any of the following are present: ^[4][8]

• History
  • Hesitation to seek medical care
  • History of frequent visits to the emergency department
  • Multiple, unusual, and/or unexplained injuries
• Examination findings: Specific injury patterns can indicate IPV.
  • Contusions, lacerations, and/or fractures of the head, neck, and face
  • Signs of strangulation
  • Injuries that appear intentional: central location (e.g., breast or chest), bilateral (e.g., both arms), or defensive injuries (e.g., ulnar aspect of the forearm)
  • Signs of traumatic brain injury (from repeated head and neck trauma)
• Behavioral
  • Fearful, avoidant, hostile behavior (e.g., avoiding eye contact)
  • Partner insists on being present and speaking on the patient's behalf

Clinical evaluation ^[4][8][9]

Physicians who suspect IPV should speak privately with the patient, inquire further, and offer assistance.

• Obtain a detailed medical history.
• Consider using a validated screening tool; see “Screening.” ^[9][10]
• Assess the patient's safety and ask whether they have an emergency plan.
• Physical examination
  • Evaluate for red flags for intimate partner violence and associated psychological trauma (e.g., depression, substance use, suicidal ideation).
  • Assess for red flags for sexual violence, signs of strangulation, and red flags for human trafficking.

Diagnostics ^[8]

• Diagnostic testing is based on the injury and clinical suspicion.
• Laboratory studies may include pregnancy testing and STI cultures.
• Imaging may include x-rays to assess for fractures and CT head to assess for brain injury.

• The US Preventive Services Task Force (USPSTF) recommends screening all women of reproductive age for IPV.
• There is a paucity of high-quality evidence supporting screening for IPV in men, women not of reproductive age, and older individuals. ^[10]
• While there is no evidence for any appropriate screening interval, many sources still recommend routine annual screening. ^[11][12][13]
• However, screening is generally recommendable in vulnerable patients and such deserving of special protection (e.g., pregnant or disabled women) as well as in the presence of circumstances of risk (e.g., unstable household, history of abuse, substance use) or signs of violence (e.g., unexplained bruises, burns, or cuts).
• In all other patient groups, settings such as the first visit to a (new) family physician, gynecologist, or hospital admission may provide a beneficial opportunity for screening and education.
• Screening can help to address immediate threats and prevent long-term IPV-associated impacts (e.g., posttraumatic stress disorder).

IPV screening tools

• Overview
  • Screening for domestic violence and IPV should be conducted in an open, nonjudgemental, and nonstigmatizing setting.
  • Broaching the topic may be facilitated by pointing out the routine nature of the assessment and politely asking if the patient is comfortable with discussing the topic (e.g., “I routinely screen all patients for violence in their relationships, so I hope you don't mind me asking you a few questions regarding this topic?”).
  • The following screening tests should be considered positive if the patient answers “yes” to one or more questions.
• HARK screening tool: a four-question screening tool that assesses for different manifestations of IPV within the past year
  • H: Has your partner humiliated or emotionally abused you?
  • A: Are you sometimes 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 screening tool: a four-question verbal or written screening tool used to assess how often an individual has been hurt by an intimate partner ^[14]
  • H: Does your partner physically hurt you?
  • I: Does your partner insult you or talk down to you fairly often?
  • T: Does your partner threaten you with harm?
  • S: Does your partner scream or curse at you fairly often?
• STaT questions: a three-question screening tool used to identify IPV
  • S: Have you ever been in a relationship where your partner has pushed or slapped you?
  • T: Have you ever been in a relationship where your partner threatened you with violence?
  • T: Have you ever been in a relationship where your partner has thrown, broken, or punched things?
• Partner Violence Screen tool: a three-question screening tool used to assess physical abuse and safety ^[15]
  • Is there a partner from a previous relationship who is making you feel unsafe now?
  • Do you feel safe in your current relationship?
  • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
• Woman Abuse Screening Tool (WAST): an eight-question screening tool used to assess IPV
  • Has your partner ever abused you sexually?
  • Has your partner ever abused you emotionally?
  • Has your partner ever abused you physically?
  • Do you ever feel frightened by what your partner says or does?
  • Do arguments ever result in hitting, kicking, or pushing?
  • Do arguments ever result in you feeling down or bad about yourself? Often, sometimes, never?
  • Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty?
  • In general, how would you describe your relationship? A lot of tension, some tension, no tension?

General principles ^[8][16]

• Obtain informed consent for every diagnostic and management step.
• Attempt to speak to the patient in private with a chaperone.
• Maintain a low threshold for notifying hospital security about suspected IPV to ensure the safety of the patient and staff.
• Involve a multidisciplinary team early.
• Follow local protocols for preparing accurate medical documentation for potential criminal proceedings.

Treatment

• Treat acute medical, traumatic, and psychological conditions.
• Determine if the patient has any chronic conditions that require urgent management.
• Perform a danger assessment (e.g., danger assessment-5) to determine the risk of death or severe injury. ^[4]

Referral and reporting

• Facilitate contact with support services (social services, IPV support, and patient advocates).
• Provide information on resources available for IPV (e.g., domestic violence hotlines, support agencies).
• Patient consent is usually required for health care providers to report IPV.

Show empathy and ensure the patient is given immediate and ongoing support, e.g., counseling and home visits.

Disposition

• Consider admission if the patient does not feel safe returning to their home and no alternative housing is available.
• Involve social services to help obtain emergency housing and/or formulate an emergency plan (if the patient consents).
• Arrange follow-up care with a primary care provider. ^[17]

In the US, the National Domestic Violence Hotline can be contacted by calling 1-800-799-SAFE (7233) or texting “START” to 88788.