IPV is defined as a pattern of coercive behaviors that one partner in a relationship uses to exert control over the other. In the older literature, it was also referred to as spousal abuse or battering. The term IPV is preferred because it also encompasses the many psychological and non-physical types of intimidation and control involved in these relationships.1 Domestic violence, which also encompasses child abuse and elder abuse, has also been used as a synonym for IPV in the medical literature.
It is only in the past 25-30 years that IPV has emerged from the "privacy" of the home or marriage and assumed the mantle of a public health problem. In 1979, Stark and Flitcraft published a landmark article accusing medical and social service providers of perpetuating IPV by treating only the physical injuries, assigning some of the blame to the victim, and attempting to maintain the "family unit" at all costs.2 In 1980, Appleton published the results of a questionnaire in the Annals of Emergency Medicine.3 In comparing the findings of 620 women who presented to his ED for any problem to 30 "acutely battered women," he found that 35% of the women there for other reasons had at one time been "struck with intent to harm." When he looked at the number of women there for acute battery, they represented 1.9% of trauma visits for women. These authors were among the first to suggest that there were many more women suffering from violent relationships than physicians were identifying, and that this was a huge epidemic that was not being addressed.
One of the problems in reviewing the field of IPV research is that many different disciplines and professions approach the issues from varying perspectives and use many different techniques, definitions, and methods. Sociologists survey large numbers of people to develop theories to explain the violence. Criminologists study crime statistics provided by the Federal Bureau of Investigation or the Bureau of Justice Statistics. While both types of surveys may be generalized to the population as a whole, reported crime statistics and large surveys that use telephone numbers (which ignore those without phones, the homeless, or those who speak other languages) are notorious for underestimating the actual incidence of crimes.4 In contrast, psychologists and other therapists study small, clinical samples, and report outcome data that may not necessarily be true for the population as a whole. Surveys of ED populations or physician practices in different parts of the country, or the world, may not hold true for other areas. Because of the relapsing, remitting nature of IPV, the most difficult area to assess is whether any particular intervention has the outcome of reducing IPV at all. As this section discusses, hard evidence is almost uniformly lacking.
In 2004, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation statement concerning family and intimate partner violence based on a systematic review of the literature.5 It found that factors associated with IPV include young age, low income status, pregnancy, mental health problems, alcohol or substance use by victims or perpetrators, separated or divorced status, and history of childhood sexual and/or physical abuse. The USPSTF also concluded that patients in whom abuse is suspected should receive proper documentation of the incident and physical findings (e.g., photographs, body maps); treatment for physical injuries; arrangements for skilled counseling by a mental health professional; and the telephone numbers of local crisis centers, shelters, and protective service agencies. However, evidence was lacking for most of the major outcomes evaluated for this recommendation statement. It found no existing studies that determine the accuracy of screening tools for identifying IPV in the general population, limited evidence as to whether interventions reduce harm to women, no direct evidence that screening for IPV leads to decreased disability or premature death, and no studies that have directly addressed the potential harms of screening and interventions for IPV. Clearly, despite the emphasis on family violence as a whole over the past couple of decades, much further research is needed in order to develop recommendations based on consistent, high-quality evidence.
In 1992 the Surgeon General, Antonia Novello, wrote a "callto- arms" editorial for an issue of the Journal of the American Medical Association devoted to family violence. The editorial cited domestic violence as an "extensive, pervading, and entrenched problem" in the United States and called for physicians to take a leading role in the identification and treatment of its victims. She promised that the Public Health Service would take a leading role in developing guidelines to assist communities in implementing programs aimed at preventing violence and that it would also conduct research to evaluate specific interventions.6 In 1994 Congress passed the first Violence Against Women Act, which provided funding to state and local governments as well as to advocacy groups.
Many professional and regulatory groups have implemented guidelines and educational programs for their members, as described below.
There is an abundance of data concerning IPV. Whether the low end or the high end of the scale is more accurate, IPV is a problem of great magnitude. IPV touches every race, class, and culture in the United States. Victims are more likely to be young, between the ages of 18 and 30, poor, and urban. While men are frequently the victims of violence, it is rarely at the hands of their domestic partner. The victims of IPV are overwhelmingly female. (Because most victims are women and most batterers are men, this article uses female pronouns for victims and male pronouns for abusers— although it is important to recognize that men can be victims and women can be perpetrators.)
Much of the current data on IPV in the general population has come from National Family Violence Surveys (1979 and 1989), Bureau of Justice Crime Victimization Surveys (1993-1998), the Federal Bureau of Investigation's uniform reporting program (yearly), and a study by the Centers of Disease Control and Prevention (CDC) in collaboration with the National Institute of Justice Survey (1995-1996). They all used statistically validated methods for sampling and analyzing their data. Yet even the most well-constructed survey may result in underestimation of the problem. For instance, the use of telephone numbers to generate a sample excludes transients, the homeless, those withou telephones,and those who do not speak English.12 Questioning allMuch of the current data on IPV in the general population has come from National Family Violence Surveys (1979 and 1989), Bureau of Justice Crime Victimization Surveys (1993-1998), the Federal Bureau of Investigation's uniform reporting program (yearly), and a study by the Centers of Disease Control and Prevention (CDC) in collaboration with the National Institute of Justice Survey (1995-1996). They all used statistically validated methods for sampling and analyzing their data. Yet even the most well-constructed survey may result in underestimation of the problem. For instance, the use of telephone numbers to generate a sample excludes transients, the homeless, those without telephones, members of a household could expose the woman, if she is a victim, to potential danger. This, in turn, could affect the woman's willingness to disclose IPV.13
Bureau of Justice National Crime Victimization Surveys sampled almost 300,000 households, and all the individuals over age 12 in those homes, between 1993 and 1998. They recorded about 1 million violent crimes per year committed against persons by their current or former intimate partners. In 1998, 85% of these acts were against women, and IPV represented 22% of crimes against women, whereas it represented only 3% of the crimes against men.14 In 1998, three-quarters of the 1830 victims murdered by their intimate partners were women. In non-lethal attacks, 50% of women were injured, vs. 32% of male victims. Women between the ages of 20 and 24 suffered the most IPV, at a rate of 21 per 1000 women—eight times the rate of men of the same age. Women in households of lower socioeconomic class suffered more abuse, as did women living in urban areas. Women who had never married or who were divorced or separated had higher rates of IPV.14
In 1995 and 1996, the CDC, in collaboration with the National Institute of Justice, surveyed 8000 women and 8005 men. They interviewed individuals and made every attempt to preserve the confidentiality as well as the safety of their respondents. Stalking was included as a form of aggression. Twenty-two percent of women and 7.4% of men reported having experienced some form of IPV in their lifetime. They reported a 1.3% female vs. a 0.9% male annual incidence. Sixty-four percent of the women who were raped, physically assaulted, and/or stalked since the age of 18 were victimized by a current or former partner, compared to 16% of men.13
In 1996, two New York epidemiologists undertook a review of the literature on incidence and prevalence. They included all publications between the mid-1970s and 1995. Based on their analysis, 2%-4% of women suffer severe IPV annually; but the prevalence of total violence was 8%-12% in the previous year. Overall, they concluded that 9% of women suffer severe IPV, and 30% of women experienced some IPV in their lifetimes. Because of variation in how IPV was defined in each study, they felt that there was considerable underreporting and that the actual figures could well be significantly higher.15
The prevalence of IPV during pregnancy is between 3.9% and 8.3%, with data coming from surveys at shelters as well as prenatal clinics, most from 15-30 years ago. While authors such as McFarlane reported that violence increased during or as the result of pregnancy,16 current authors feel that this apparent increase may have more to do with the age of the woman (women in their 20s being at increased risk of IPV in general), socioeconomic class, or marital status as much as with the pregnancy itself.17
Many of the existing studies of pregnancy-related complications of IPV do not successfully distinguish between the effects of young age, late entry into prenatal care, missed compliance, substance abuse, and IPV, which may cause or be related to all of the other problems. It is hard to assess exactly which factors resulted in lowbirth-weight.17
Three studies in the 1990s in New York City, Chicago, and rural North Carolina found murder to be a significant etiology in maternal mortality, causing death more frequently than any single medical complication.17
The Bureau of Justice survey found that blacks of both sexes suffered higher rates of IPV than their white counterparts.14 However, the rates for Hispanics were similar to those of whites.14 A survey conducted by Hampton and Gelles from data obtained from the Second National Family Violence survey (1989) using a statistically derived representative sample of black couples found a higher incidence of violence at all income levels when compared to white populations.18 In contrast, the CDC survey found no difference in the incidence of IPV between white and black women, although it found that Hispanic women were less likely to report sexual assault than the other two groups.13
Both the CDC and the Second National Family Violence surveys had relatively small numbers of families compared to the Bureau of Justice survey. It is possible that the small sample size contributed to the different results.
American Indians constitute a diverse population with many different languages, cultural traditions, and patriarchal or matriarchal societies. Data are limited, but interviews of "experts" suggest that IPV is present in at least the same proportion as the general population.19 In the CDC survey, American Indian and Alaskan native men and women reported higher incidences of violent victimization than men and women of other races.13
Published authors feel that IPV is present in the same proportion of gay and heterosexual relationships.20 Evidence on which this is based is largely anecdotal, from the few centers that serve homosexual victims or from surveys of very small numbers of people.21
Several authors have attempted to quantify the prevalence of IPV in EDs. In 1984, Goldberg et al surveyed 492 male and female patients seeking care in a general inner-city ED. They found a prevalence of IPV of 22% in males and females; however, women were 62% more likely to be victims.22 McLeer and Anwar, in a retrospective review of trauma patients, found that 5.6% of trauma cases were the result of IPV.23 A convenience sample at a large urban acute care ED in the United States showed a lifetime prevalence of 27% and an acute (defined as within the past week) prevalence of 4%.24 Abbott et al found an incidence of 11% but a lifetime prevalence of 54%.25 Between 1995 and 1997, Dearwater et al surveyed over 3400 women in 11 community EDs in California and Pennsylvania. They found an acute incidence of 2.2% for acute trauma, a 14% incidence for the past year, and a lifetime prevalence of 36.9%.26 Other investigators have published relatively similar statistics over the past 10 years.1,27
A survey of 1952 adult women at four Baltimore locations revealed that 5.5% of the women had suffered IPV in the previous year, 21% had experienced IPV sometime during their adult lives, and 32% had experienced violence either as an adult or child. The current victims of violence tended to be younger, poorer, and more likely to be single, divorced, or separated.28 A smaller survey of a Midwestern practice questioned 394 consecutive women. They found that 22% had been assaulted in the past year and a lifetime rate of 38%.29
IPV is about power and control and may take emotional, psychological, and physical forms. Table 1 contains the generally agreed upon manifestations of IPV.
A number of theories have been put forward to explain perceived patterns in IPV. Most experts currently agree to the following: a period of tension building within an abusive relationship, which may last weeks to months, during which the batterer may use threats, intimidation, and psychological and emotional abuse, in an ever-increasing pattern. The woman may try to pacify and mollify her partner until some trigger will set off the acute explosion. Depending on the severity of the event, the police may be called, the woman may require medical treatment, and some may leave; the batterer may even be imprisoned. What then follows is a "honeymoon" period in which the batterer will beg for forgiveness and promise "never to do it again." The woman may return, accept counseling, feel hopeful that the situation will improve, and attempt to stop legal proceedings. The cycle will then repeat itself with the building of tension.4
In 1996, a review of the previous 15 years of research on the effects of IPV on the victims revealed that many abused women suffered from low self-esteem, often feeling numb, passive, and confused.30 Death threats, explosive rage, and beatings were a regular part of life. They described their lives as living in a prison, constantly fearful for themselves and their children.30 Many women suffered from post traumatic stress disorder (PTSD) and depression. PTSD in battered women includes high arousal, high avoidance, intrusive memories, memory loss, and cognitive confusion.4 A significant percentage of a small sample of abused women met DSM-III criteria for PTSD.4
Abused women also use many different strategies for coping with the stress of IPV. Denial, minimizing the violence, and attempts at placating the batterer are common strategies that women employ to cope with their lives. They might express the feeling that their situation is not so bad, denying the injury. They might assume blame for the violent incident ("If only I hadn't done…"). They might ascribe the incident to a temporary situation ("He was under a lot of stress, because…").31
One of the most difficult aspects of IPV to understand for people who are not or have never been victims of IPV is why many women remain in abusive relationships. The question often arises among healthcare professionals: "If it's so bad, why doesn't she just leave?" There are many factors that affect a women's ability to leave a relationship and, conversely, her tendency to stay within an abusive situation. (See Table 2.)
Many women do leave abusive relationships. There are well-described convergences of circumstances that may push the woman into action. These catalysts to leaving were derived from small shelter-based studies or interviews of women who had sought refuge in a shelter.30,31 None has undergone validation; however, there are recurrent themes and patterns that bolster the existence of these catalysts. Some or all of the following may come into play in an individual decision:32
The process of leaving may be extremely difficult, and a woman may leave and return several times before she is successful in terminating the relationship.33 Most of the studies examining the process of leaving an abusive relationship are small in number and come from social services programs, IPV shelters, or therapists who specialize in PTSD or IPV therapy and thus often reflect their own treatment biases. One interesting study obtained subjects by advertising in a city newspaper for former victims of IPV. In a survey of 195 women who were abuse-free for one year, it took an average of eight years of abuse before the woman was able to end the relationship and leave. In the one-sixth of the women who ended the abuse, but remained in the relationship, they had suffered 10 years of abuse Employment and the availability and ability to use community resources played an important role in the decision to leave.32 The most likely time of leaving was after an acute battering episode and prior to the reconciliation and resumption of daily routines.34 As healthcare workers who see women for a short time in the ED, it is important to recognize all of the factors that affect the decision to leave and to be compassionate and non-judgmental.
Researchers over the past 20 years have tried to delineate the risk factors for victimization. Some studies have shown that witnessing violence at home as a child results in a twofold risk of being a victim.35,36 Other studies of battered women have shown a consistent correlation between childhood abuse (either physical or sexual) and victimization.37,38 Studies of female children living in shelters39 as well as self-reporting surveys of female college students40 show that they continue to identify with the mother and, like her, exhibit low self-esteem, helplessness, and emotional dependency. These characteristics may influence her choice of partner later in life.41
Drug and alcohol use by the victim may play a role in IPV; however, most physical abuse is unrelated to use by the victim. For the victim, it may be a form of self-medication or a coping strategy. Psychological symptoms such as PTSD, depression, and anxiety are increased among victims of IPV; however, it is difficult to assess whether these illnesses predate or postdate the violence.38
IPV has been documented in nearly every society in the world. The degree to which it is present is related to the woman's position in the relationship relative to her partner— and, some authorities suggest, to women's position in that society as a whole.42,43 Naturally, cultures comprise individuals, and while the following section discusses broad generalizations that can help healthcare practitioners understand underlying issues that might be applicable to a particular patient, it would be inappropriate to conclude that any stereotype reflects the group as a whole.
Certain women from the international community may be even less likely than American women to report IPV because of religious, economic, legal, and social constraints.42 They may have unique needs reflective of the pressures placed on them by their culture of origin.42 These pressures and expectations may conflict with American customs and even laws, and they may also inhibit women from seeking help for IPV.42
Asian women may be more reluctant to report IPV than American women. When they do enter the shelter or legal system, they may have special additional needs. They may not speak English, they may have difficulty with shelter accommodations and food, and there may be immigration issues as well.44 There may be additional cultural pressures to keep the family together in order to not bring dishonor to the family.44 Some traditional Asian cultures tend to be more rigid and patriarchal; women are taught to obey their husbands and fathers.45,46 These values may remain even after many years in the United States.44
Domestic violence in India is well-documented. Women in general have a subordinate role to men in Asian Indian society, with most women being brought up to serve their husbands as their primary focus in life.43,44 The traditions of Indian society may continue despite immigration to the United States, and the emphasis on maintaining a perfect public image of the family may keep IPV well-hidden in the Indian immigrant population in the United States.47 As a consequence, victims may not have the support of their families if they attempt to escape the violence.47
Latinos in the United States are a heterogeneous group, yet they may share certain cultural values and beliefs. Family life and ties are central to Latino families.48 The roles of males and females have been fairly rigid in the past with men assuming the dominant, authoritarian role and women being cast as the nurturers and caregivers.48
Poverty, unemployment, societal dislocation, and isolation in rural environments affect all aspects of life in the American Indian community. The degree to which these factors contribute to IPV in any particular tribe is not known.19 Alcohol use does seem to play a significant role in IPV among American Indians.19
IPV in gay relationships is just as much about coercion and control as it is in heterosexual ones, but the response of the male victim may be different. The man may not see himself as a victim and may not seek help.19,49 Homosexual men may have even fewer avenues of support because of the additional stigma of being a gay battered male in a homophobic society.19 There are few if any shelters for gay men. They may not be able to turn to their family for support and are less likely to call the police for assistance, given the widespread negative attitude of the police toward homosexuality.19 Lesbian victims may also have fewer avenues of support than heterosexual women—they may not be able to turn to their families or the police.20 There is also some evidence that the lesbian community may be reluctant to openly discuss IPV because of fears of further stigmatization and stirring of anti-lesbian sentiment.20
People with disabilities are exposed to violence—physical, sexual, and emotional—at rates above the general population.50 Women with disabilities are at high risk of abuse from their caregivers. If they live in group homes or institutional settings, they are at additional risk of exploitation by the male residents.5
Violent relationships can affect the next generation. There is an abundance of studies of children that attempt to delineate the effects of viewing IPV in the home. The studies are often small, use different outcome measures, and have conflicting results.39 The studies often rely on abused mothers' perceptions of witnessed violence or children's recollections of viewed violence. In those studies that compared the two, the inter-rater reliability was quite low.39 Surveys of children living in shelters for battered women showed a significant number with developmental delays and behavioral maladjustments.39,51 Exposure to violence may impair the child's ability to live successfully in the community and to communicate effectively with others. Young males may exhibit aggressive behavior to the rest of society, ending up in the juvenile justice system.52
The effects on children depend to some extent on the age at which the violence is witnessed and certain mitigating circumstances, such as a good relationship with one parent and support outside the home.39,51
There are a number of markers that may identify men at increased risk of becoming a batterer, but no single factor is able to identify all perpetrators of IPV. The most reliable variable for becoming a perpetrator or a victim of IPV is having been exposed to family violence as a child.41 Hampton and Gelles found an association for the male respondents: Batterers were more likely to have suffered physical abuse as a child.18 However, there are many more men who witness abuse as children who never become violent toward their spouses. Perpetrators of abuse have higher incidences of psychological problems (depression, PTSD, borderline personality), substance abuse, and problems with anger management.38 Physicians should be aware of these associations and maintain an index of suspicion to the possibility of IPV when they come across these issues in their patients.
Studies of batterers are relatively new in IPV research. It is only in the past 10-15 years that researchers have attempted to delineate what variables might differentiate violent from non-violent men.53
Violent men differ from non-violent men in the level of psychopathology, anger and hostility, attitudes towards violence, expectations of relationships, and alcohol use. Men who batter tend to show higher levels of psychopathology on clinical personality testing, including depression, low self-esteem, and aggressiveness.53 They also tend to harbor more anger and hostility than non-violent men.53,54 In one study, 33% of batterers felt that physical violence was normal, necessary, and good.55 These same men may have unrealistic expectations of their relationships that are unlikely to be fulfilled. They may then blame their partners for the failure, fueling their chronic anger and frustration, resulting in an increased risk of violence. Some batterers may suffer from a borderline personality disorder exhibiting intense, unstable relationships coupled with anger, impulsivity, and fear of abandonment.56 There is a clear association between men who batter and alcohol use. The evidence comes from looking at alcohol and drug use among men in batterer programs as well as studying the rate of IPV in men undergoing treatment for alcohol or drug abuse. There are a number of theories that attempt to explain th relationship between alcohol and increased violence, including disinhibition, increased impulsivity, and impaired judgment.55 The important point to remember, though, is that alcohol alone is not a adequate explanation for the violence. All of the other factors come into play.
Prehospital care personnel called to the scene of an IPV incident may need to call on the police to secure the scene, so the violence isn't directed toward them.57 If possible, they should attempt to remove the victim from the scene to a safer location. They should not attempt to question the victim until she is separated from the perpetrator. Prehospital care personnel should receive education regarding IPV, so that they can understand what they witness and respond to the victims in an empathetic manner.1,58 ACEP policy also calls on prehospital care personnel to have preprinted resource materials on hand to give to the victim should she refuse transport to the hospital.58
It cannot be emphasized enough that the IPV history should be obtained in a private environment with only the patient present. Yet there may be few less private locations than most EDs. An office environment with limited personnel is easier to control than an ED; physicians in their own offices, who are attuned to IPV, may easily establish a blanket policy that all patients are brought to examination rooms unaccompanied. The ED with many part-time or agency personnel and different departments (secretarial, security, nursing) under the control of different supervisors is more difficult to control. A blanket policy of no visitors can be difficult to enforce initially. However, by thinking ahead or being creative, most physicians and nurses can find at least a few moments of privacy to ask the crucial questions.
Supporters for universal assessment for IPV, including the JCAHO, AMA, and other specialty organizations, use several arguments to bolster their position. First, the prevalence of IPV in the general population is quite high. Second, using physical injury alone as a marker for IPV will miss the majority of current victims of IPV. Third, healthcare providers have an obligation to identify and refer victims of IPV to the appropriate organizations that have been developed specifically to aid them. Fourth, victims of IPV have an expectation of help from the healthcare community.59
Recently, specialists in the field of IPV have replaced the term "screening" for IPV with "assessment" for IPV.1 Screening in medicine generally refers to the application of a clinical test to detect disease in an asymptomatic population.1 IPV falls more under the category of psychosocial issues such as sexual practices or alcohol or tobacco use.
The rationale for screening in medicine is somewhat related to the incidence and prevalence of a certain condition or habit within a given population. The incidence of the following in women 15-45 years of age is: tobacco use (27%), cervical cancer (0.0078%), hypertension (8%), and glucose intolerance during pregnancy (1%-5%).60 The incidence and prevalence of IPV—21%—exceeds that of many of the conditions for which screening is routine.60
Assessment protocols, whether designed for outpatient settings or EDs, include several key components: a set of non-judgmental questions intended to reveal the presence of IPV, a safety assessment, an intervention and referral piece, and documentation in the medical record.
Questions should be tailored to the individual clinical situation. The National Consensus Guidelines suggest that practitioners begin with a "framing" or general statement such as: "Because violence is common in the lives of the patients I see, I have begun asking everyone the following questions."1 This can then be followed up with more specific questions. (See Table 3.)
Many formal screening tools for IPV have been introduced, although strong evidence showing their accuracy is lacking. Examples include "Woman Abuse Screening Tool (WAST)," the "Partner Violence Screen (PVS)," the "HITS (hurt, insult, threaten, scream) Scale," "Emergency Department Domestic Violence Screening Questions," "Women's Experience with Battering (WEB) Scale," and many others. According to a systematic review by the USPSTF, newer, brief instruments compare well with lengthier, previously validated instruments—and they are certainly more conducive to use in busy EDs. Studies indicate that self-administered questionnaires elicit more positive responses than interviewer administered questionnaires in ED settings.5
Brown et al successfully used the WAST and the WASTshort in a family practice setting.61 Feldhaus et al's three brief screening questions in the ED performed as well as the longer previously validated Conflicts Tactics Scale.62 Sherin et al used HITS, a written questionnaire. Respondents circled never, rarely, sometimes, fairly often, or frequently. Each response was given a number value of 1 through 5 for each of the four elements, resulting in a minimum score of 4 and a maximum of 20. A value above 10 was considered to indicate current IPV.63 Furbee et al found no difference between physician face-to-face interview and a taperecorded questionnaire that the patient listened to independently.64 Waller et al used a silent triage screen of physical and emotional indicators that the triage nurse would apply during the course of routine triage. The primary nurse would then follow up with active questions and intervention.65 Waller et al found an increased specificity but not an increased sensitivity with the silent screen—the opposite of what was intended.65 This is not entirely surprising considering that using only trauma or obvious situations to identify IPV will miss the majority of victims. Outpatient studies at primary care offices and OB/GYN clinics all found increased identification rates once protocols were in place.66-68
An anonymous survey of 4641 female ED patients documented that fewer than 25% of patients were asked about IPV.69 Both physician attitudes and the dynamics of practicing in the ED may play a role in the low screening rate for IPV.
During the process of developing a protocol, Waller et al identified five barriers (triage design, staffing levels, referral services, visitor policy, and ED staff buy-in) to successful screening in their hospital ED.65 They attempted to start the screening process in triage, only to find a fundamental lack of privacy. As in many hospitals, triage was designed as an open area with easy access by walk-in patients, ambulances, and ED personnel. Family members or others accompanying the patient were all within earshot of the triage encounter. The second problem they encountered was current staffing levels. These levels would be inadequate to deal with the counseling and referral of the number of victims they anticipated they would identify by implementing screening of all patients. They planned to refer all patients to hospital social services, which were eager to help but were not a 24/7 hospital service. The local IPV shelter agreed to provide back-up emergency referral service but was also concerned about the impact of increased demand for their services. The visitor policy in place at the time of the study allowed one pass to be given automatically to one family member or friend to accompany the patient directly back to the ED. The final over-riding problem was that of ED buy-in.65
There are several well-described preconceptions that physicians, as part of society in general, may possess. Physicians may not think that IPV is present in their middle or upper-class practice. They may view IPV as merely a lower socioeconomic problem. While certain groups may be at higher risk, this does by no means exclude the more educated or privileged. There are many external pressures placed on physicians: offices are busier and EDs are overcrowded, requiring more patient evaluations in a shorter time. Physicians may feel that they do not have the time or are inadequately prepared to deal with an affirmative answer to IPV. Or they may feel that they as physicians will have little effect—that the woman will just return to her abusive partner.6,27,70
A review article of published evaluations of training programs for health care professionals between 1989 and 1999 highlights some additional issues. Most of the published studies used short (one- to four-hour) training programs with before-and-after questions on attitude and perceptions rather than measuring effects on clinical practice. The follow-up period was also short. Those studies that included follow-up evaluations beyond nine months to over one year found a significant denigration of skills.71
Intervention programs need to be reinforced periodically to continue their effectiveness.
For a protocol to function as designed, it must be integrated into the fabric of the ED, and the staff must perceive its value. Whichever protocol is put in place must be time-efficient and not overstrain resources.65
The medical literature has not addressed the screening of IPV until relatively recently. Studies that attempted to evaluate the performance of ED screening programs generally were able to show some improvement in the acute care of victims of IPV—72,73 that is, increased identification of victims,66,74,75 increased referrals to IPV agencies or social services, and perhaps increased satisfaction.23,75 However, no study has attempted to assess the ultimate outcome: Does screening result in a positive outcome for victims of IPV? That is, is there a significant reduction in violence in their lives? There are only anecdotal testimonials and the reports of IPV workers that victims want to be asked about IPV.
Studying whether increased screening results in more women leaving their abusive partners or an overall reduction in violence would be difficult. It would require tracking down a large number of women after discharge and following them for a long period of time.
While the mandate to screen is essentially a leap of faith rather than based on firm evidence, it at least represents a logical step toward identifying this subset of patients who are suffering a great deal.
The rationale for screening for battering is increased identification, increased referral to appropriate services (i.e., battering programs), and presumably decreased perpetuation of violence. Little outcome evidence exists. The assessment could begin with the same type of "framing" statement as for IPV in women, then follow with a series of open-ended questions. (See Table 3)
Historically, clinicians have attempted to predict lethality or life-threatening actions using experience and intuition, with poor or inconsistent results.76 In 1991, Straus et al used data from the 1985 National Family Violence Survey to develop criteria for identifying "life-threatening" behavior among violent men.77 They used a validated measure of violence (the Conflict Tactics Scale) and applied it to a representative national sample of 8145 families. Risk of life-threatening behavior is likely when three or more of the variables in Table 4 are present.
The ability to predict lethality prospectively in each clinical situation continues to be an imprecise science.76 If a physician chooses to screen for battering, specific referral information should be available regarding batterer programs in the area. Therapists with specific training in the handling of perpetrators of violence are preferable.78 The physician should also be aware that he or she might also have a duty to warn the female partner if there is a real fear of violence to the woman (as discussed later in this article).
The physical examination should be thorough, with particular attention to "high-risk" areas of injury. Completely undress the patient and thoroughly examine her so as not to miss contusions of the thorax and abdomen.
Certain patterns of injury or inconsistencies should raise the level of suspicion for the presence of IPV.
A prospective cross-sectional study by Muelleman et al of approximately 9000 women presenting to 10 acute care urban hospitals in the Midwest found a prevalence of battering of 3.1% among all women, but a prevalence of 11.3% of all injured women seen in those EDs over a oneyear period.79 They identified certain patterns of injury that were more common among battered women. Victims of IPV were more likely to suffer injuries to the head, face, thorax, and abdomen than to other parts of the body, with contusions of the face being the most common injury. Some of these delineated injuries had higher positive predictive values than others. Comparing injuries in 237 battered women vs. 2211 controls, the positive predictive value for ruptured tympanic membrane (2 battered women, 0 controls) was 100%, whereas upper-extremity contusion (67 battered vs. 240 controls) was only 20%, but the presence of any characteristic injury pattern had a positive predictive value of nearly 30% for the presence of IPV. The absence of any physical injury in this study did not rule out IPV, because almost 20% of women in this study who were in a battering relationship did not have any physical injury.79
Other studies have estimated the acute ED presentation for IPV at approximately 2%.80 However, an additional 10%-15% of women feel that IPV has contributed to their current illness or levels of stress that resulted in the ED visit. Certain authors have suggested that somatic complaints, like frequent headaches, abdominal pains, and chest pains of non-organic etiology, are related to IPV, but consistent study results are hard to find.70,80
There are certain clues from the history and the appearance of the patient and the partner that may tip off the clinician to the presence of IPV. The most obvious is a stated mechanism of injury that is inconsistent with the clinical appearance. For instance, a patient with a black eye may say that she was clumsy and fell. The victim may delay obtaining care for an injury or may minimize it for fear of retribution. A patient may present with an advanced medical condition because her partner had prevented her from seeking medical care, isolating her from anyone who might have helped, as described in the introductory case scenario. Certain behavior by the patient's significant other should raise the clinician's index of suspicion for IPV. A partner who continually hovers around the patient, refusing to leave, answering questions for the patient, or following the patient to radiology or even to the bathroom should raise one's suspicions. Without advanced planning, it may be difficult to separate the patient from the partner without raising the batterer's suspicions.81
If injuries are present (life-threatening or other), treatment should follow accepted standards of care. In the case of a severely injured or unstable patient, the components of safety assessment, intervention, and referral would need to be deferred to a later date. Victims of potentially lethal IPV can be admitted to the hospital under an alias to protect them from further injury. Something of a dilemma may arise if the clinician strongly suspects IPV and the patient denies that abuse was the cause of the injury. In that case, the clinician should not force the issue, but should advise the patient to contact social services at the hospital or call the local IPV shelter. The following section refers to patients who acknowledge IPV and are stable for discharge.
This is a crucial part of the evaluation, because the ED visit may indicate an escalation of violence and the woman may be at real risk of more severe harm or even death. Experts in the field have been struggling with delineating danger assessments and predictions of homicide for at least two decades. While there are strong correlates to risk of homicide, the positive predictive value of each is as yet undefined. Table 5 lists risk factors for severe future violence identified by a majority of experts.
Questions during the safety assessment should be geared at exposing the presence of these risk factors. Inquiries can again begin with the general and proceed to the specific. (See Table 6.)
During the entire assessment process, the safety questions and intervention statements need to be conducted in a non-judgmental fashion, and the messages should be delivered empathetically; however, the decision for action must remain with the victim.
This portion is specifically designed to give the victim certain messages about IPV. Remember that victims may be suffering psychological abuse and isolation as well as physical abuse, that they may suffer from low self-esteem, and that you, the healthcare provider, may be the first person to tell them that what has happened to them is wrong and does not have to occur. It is important to reinforce the following messages:
In legal proceedings, because IPV is so commonly a private crime, the medical record can provide objective evidence of the abuse. Precise descriptions of the injuries, or better yet photographs, dated and signed by the patient, provide a clear record of the findings. As much as possible, quote directly from the victim. (For instance, "He punched me in the eye," "He kicked me in the abdomen," etc.) Accurate, complete documentation may help the patient in the future during legal proceedings and could also help other healthcare providers in the future.7,60
It is important to become aware of the IPV services within your community. The structures of the services vary greatly. Many local shelters offer brochures or small "palm" cards (designed to be hidden in the palm of the hand) printed with their toll-free telephone number. Local hotline numbers are also listed in the front page of telephone books. The national hotline number is 1-800-799-SAFE (TTY: 1-800-787-3224). It may be sufficient just to allow the victim to call the number from the ED.
The decision to accept referral, to contact a shelter, to seek refuge with a family member, or to return home must rest with the victim. To facilitate this, healthcare professionals should be familiar with the resources of the local community.
The Family Violence Prevention Fund publishes a number of papers and packets designed to aid practitioners in developing screening and referral programs (see http://endabuse.org/). Local resources vary, but information is usually available through social services departments in the hospital or by contacting the local IPV shelter or service provider. Many local organizations are eager to provide brochures, fliers, educational leaflets, or palm cards, often free of cost.
The first shelters began as exactly that: physical locations that would "shelter" women and their children. Many of these shelters began through local, grass-roots efforts of coalitions of social service agencies. The location of the houses was kept secret. These coalitions were instrumental in lobbying for federal and state funding to improve services for victims of IPV. While actual housing of victims and their families is still a function of most shelters, they have developed many more services for their housed victims as well as for non-resident women in the community. Shelter workers serve as counselors and advocates for the women. They accompany them to welfare offices, court, the hospital, and so forth. The women participate in various group therapies aimed at building up their self-esteem. Access to legal services, support counseling, job training, children's programs, and employment services are some of the services offered. Federal funding for these services is contained in Violence Against Women Act first passed by Congress in 1994 as well as money allocated for aid to dependent children and legal aid services administered by the states. The states either license shelters or contract with larger non-profit organizations (for instance, Catholic Charities or YWCA) to operate the shelters. The last national survey of shelter services was conducted 10 years ago. It found that eligibility criteria (often tied to income) and services varied from state to state.82 This study also identified a "service gap." They identified significant inadequacies in the system, among them unstable funding sources for shelters, inadequate transition housing, inadequate shelter housing in rural areas, and inadequate funding for counseling and job training programs.82 With many states grappling with large budget deficits, it is possible that funding for these types of programs will be in jeopardy.
The first programs were established in the late 1970s. Many cities and counties in the United States have programs with linkages to the courts, social service agencies, and women's shelters. Some states have published standards for batterer programs. Most receive the majority of their referrals (80%-90%) from the courts as part of sentencing or probationary requirements. The remaining 10%-20% are referred to as "voluntary" participants, referred by their partners, family, or friends. These programs usually consist of weekly group sessions led by a qualified psychologist. They may be structured, covering a prescribed format of information as well as anger-resolution techniques, or unstructured allowing the participants' issues of the previous week to dictate the direction of the session. Programs may last 2-6 months. Emerge (the first program established in the United States) consists of two phases: an eight-week introductory class followed by a 40-week second phase. The men sign a contract with regard to behavior expectations, reporting of violence, attendance, and payment. They also sign an informed consent allowing the counselors to be in regular contact with the victims, probation officers, child protective services, and other service providers.78
Since the mid-1980s, researchers have attempted to gauge the effectiveness of batterer programs. Most of the initial studies were small, from single programs with only short-term follow-up. Some of the barriers they encountered were difficulties with defining recidivism, high program dropout rates, reluctance of victims to be interviewed, and variability of treatment design. It is essential to contact victims, because batterers consistently under-report incidents.78,83 A small 1992 study from Ontario, Canada, compared 59 men mandated to treatment with an equivalent number of control subjects. The study reported a significant reduction in violent episodes: 10% vs. 30% at one year.83
In the largest comparison study to date, Gondolf et al recruited over 800 batterers from four well-established urban programs. They interviewed the men as well as their victims every three months for 15 months. They also had access to arrest records in three of the four locations (they were prevented by local statute in one of the cities). They were able to interview a female partner at least once for 79% of the batterers, and 66.8% of the female sample completed the 15-month interview. They found that nearly one-third of batterers re-assaulted their partners and that 60% of those assaults involved physical injury (including two murders). Over half of the recidivists committed more than one assault. Alcohol abuse was involved in over half of the incidents. A significant amount of other types of abuse were also reported by the women, including verbal abuse (70%), controlling behaviors (45%), destruction of property (28%), and threats (43%).
The researchers had theorized that they would find an immediate reduction of violence due to the program's intervention followed by a gradual increase in violence. What they found was quite different: 14% of women reported a first-time assault in the first three months of treatment; 8% in the second three months followed by a plateau at 3%-4% per three-month period for the remainder of the study. What this timing shows is that there is a subgroup of batterers who re-assault early and repeatedly. Other factors associated with increased recidivism were voluntary participation (44%), program dropout (45%), and living together with the victim (35% vs. 26%). In spite of the relatively high proportion of women reporting non-physical abuse, 66% of the women reported that their quality of life was improved, and 73% felt that they were "very safe" during the follow-up period. However, there remained a small proportion of women (12%) who felt that they were worse off as a result of the batterer program. It is likely that these are the women subjected to early and repeated abuse.
The implication for batterer programs is a need to be more vigilant early on and to provide more intensive treatment or exert better control on a significant subset of their population. The high incidence of verbal and nonphysical forms of abuse is also quite disturbing.84
Most states have enacted legislation that considers many of the acts of IPV crimes. These crimes may include assault, battery, stalking, harassment, rape, sexual assault, kidnapping, destruction of property, assault with a weapon, forcible entry of a residence, and sometimes specific "domestic violence" crimes.85 The Family Violence Prevention Fund publishes a "State by State Legislative Report Card on Health Care Laws and Domestic Violence."86 (See also Table 7.)
Social service agencies or battered women's shelters generally have legal information as well as links with legal services. They often provide transportation and support during each step of the legal process. There are several legal recourses for victims of IPV. The particular details may vary from county to county and state to state, so the following is merely a general guide.
What happens when a woman calls the police during a violent episode varies by locale. Some states or cities mandate that police arrest the perpetrator when they believe a crime has been committed. Other states only authorize police, leaving it up to the judgment of the individual officers. This in turn reflects the overall department policy toward prosecution of the crime, which is a function of the attitude of the police, prosecutors, and judges ultimately involved in the adjudication.85 The more a victim knows about her legal rights and the details of how the police and the system function, the more empowered she will be.
Formally referred to as civil protection orders, restraining orders are available to victims in every state and the District of Columbia. There are different types of orders; for example, eviction from the household, prevention of contact with the victim, awarding custody and/or support, ordering the perpetrator into a batterer program, or prohibition of possession of weapons by the batterer. Who is eligible for a protection order also varies from state to state. Some states may permit only spouses or ex-spouses to apply. Other states may include domestic partners of opposite or same-sex relationships as well as relatives. In general, the person petitioning must prove that she is in danger of being abused or threatened. Many jurisdictions offer temporary or emergency restraining orders during offhours. A formal hearing then occurs subsequently for a more permanent order.
How effective is a protection order? Most IPV advocates counsel victims to take additional safety measures and not to rely only on the restraining order. Studies show that the majority of perpetrators obey a restraining order; however, there are plenty of incidents of violation of protection orders, and the perpetrator is seldom sent to jail as a result. Advocates suggest that a woman keep a copy of the protection order with her at all times and that she have copies at work, with friends, and at the local police station for rapid verification.85
Abusers often use children to control or gain access to their victims. Explicit custody orders and spelled-out visitation protocols can limit the damage. Courts have recently recognized the detrimental effects of IPV on children and are not likely to award custody or give unlimited unsupervised visitation to the perpetrator.85
Under the Violence Against Women Act, originally passed in 1994 and subsequently renewed by Congress in 2000, a battered woman who has conditional status in the United States may apply for a waiver of the requirement that she and her spouse apply for permanent residency jointly. In the past, a U.S. citizen or legal resident had been able to threaten to report the battered undocumented spouse to the Immigration and Naturalization Service, which could result in possible deportation.85,86
State regulatory agencies and the JCAHO have imposed requirements on hospitals and EDs regarding education and screening protocols and documentation requirements. Lack of compliance usually carries consequences for the institution, but not for the individual provider. The majority of states have enacted some form of reporting statutes for IPV. No state is exactly the same as the others, and the individual practitioner should be familiar with the requirements of his or her particular community. The Family Violence Prevention Fund offers a "State-By-State Legislative Report Card on Health Care Laws and Domestic Violence" available at http://endabuse.org/.87
For example, in California, healthcare providers must report to the police if they have provided medical services to a patient who may be suffering from "a physical injury caused by assaultive or abusive conduct."88 They do not have to report if they were screening the patient routinely in the setting of an office visit or ED visit for another reason.1 In Kentucky, on the other hand, "any person" who has reasonable cause to suspect an adult has suffered abuse, neglect, or exploitation must report it to the Cabinet for Human Resources, a social service agency. That agency must then notify police, investigate the incident, and provide appropriate services, except if the adult refuses the services. New Mexico is similar to Kentucky, except that the report goes to the police. Subsequent action is not defined. New Hampshire mandates reporting of injuries thought to be caused by criminal acts except if it is a sexual assault or if a victim older than 18 years objects to the reporting. Rhode Island requires reporting of IPV, without identifying information, for data collection purposes only.88
In the states that require "any person" to report suspected IPV, it is not always clear how that applies to the healthcare professional and depends on whether reporting laws supersede provider-patient confidentiality statutes.88
Most states provide immunity from prosecution for good-faith reporting, as well as penalties for failing to report.88 Those penalties range from $10 to $1000 and occasionally carry a jail sentence.88 However, there has not yet been a prosecution for failure to report IPV, unlike for failure to report child abuse.89 It is conceivable with the promulgation of guidelines from many different professional and accreditation organizations that screening may become the standard of care for the "reasonable practitioner."90
Mandatory reporting of IPV remains controversial, as discussed later in this article.
Confidentiality may be breached if the healthcare provider determines, from information obtained during the care of the batterer, that the intended victim is in danger. That provider then has a duty to warn the potential victim.89
In the early 1990s, some health insurers denied coverage for battered women on the grounds that IPV was a pre-existing condition. In response to this, many states have enacted statutes preventing insurance companies from discriminating against battered women in health or life insurance.89
The intended objectives of these laws are to improve the care and safety of the patient, collect incidence and prevalence data, provide improved documentation to strengthen the legal case, improve healthcare providers' response to IPV, aid law enforcement officials in the prosecution of perpetrators of IPV, remove the responsibility of contacting law enforcement away from the victim, and make clear that the healthcare system and society in no way condone IPV.90 There is considerable controversy surrounding the appropriateness, ethics, and effect of mandatory reporting. Table 8 presents the arguments against mandatory reporting, and Table 9 presents the ethical issues inherent in mandatory reporting.
Sachs et al studied dispatches by the Los Angeles Sheriff Department to reports of IPV for a year before and approximately two years after enactment of a mandatory reporting law in California. The original law mandated reporting of all IPV, but it was quickly amended to include only injuries resulting from IPV.91 The authors found no significant increase in dispatches as a result of the law. However, dispatches increased significantly after the Simpson/ Goldman murders, which occurred halfway through the study period.67 The authors offer four reasons why reporting did not increase after the law: ignorance of the law; intentional noncompliance by healthcare personnel because of ethical conflicts; increased self-reporting by victims to the police, so that there would be no need for the healthcare provider to make the report; and a reluctance of women to seek medical care because of fears about the reporting law.91 Shelters throughout the country reported increased telephone calls and increased numbers of women using services during the months following the Simpson/Goldman murders.92
Several studies have shown that women want to be asked about IPV; however, there is a difference of opinion between non-abused and abused women regarding mandatory reporting. In the largest of five published studies that examined this issue, 92% of non-abused women favored mandatory reporting, vs. only 76% of acutely abused women.93 Smaller studies of abused women have shown equivocal feelings: While they were in favor of reporting as a general concept, when it came to themselves, far fewer of them felt it would have been helpful.94 In another small study, women expressed fears about the negative consequences of screening and reporting, and two-thirds of the sample said they would be less likely to reveal IPV if there was mandatory reporting.95 In a study of 243 women, Hayden et al found that among all the victims of IPV, 36% would only divulge it if asked directly, 25% would volunteer the information, and 11% would not report it even if asked. Of current and past victims, 39% would deny IPV if they knew it would be reported.59
In 1999, the CDC sponsored a National Convention on Violence and Reproductive Health. Although the conference centered on women during the reproductive years (also the peak years of IPV), the recommendations that ensued can be generalized to all populations that suffer IPV. Some of the directives seek inclusion of women's perspective in future research, practice, and policy; formation of collaborativem partnerships among the different disciplines concerned with women's health, and translation of research findings into effective interventions. Currently little is known about what happens to women after they are screened and referred to IPV service providers. More needs to be known about the needs of special populations, such as the disabled, those with HIV, and minority women.96 Individual hospital systems have embarked on forward-thinking, coordinated responses to IPV. The published reports are from the consortium of Boston teaching hospitals (1997) and the Allina Health System in Minnesota (1998). The latter has implemented a hospital-wide intervention and education program that includes "resource" people who serve as role models and mentors, 24-hour on-site IPV services in coordination with the local community IPV shelter, educational brochures, newsletters, and videos and active ongoing evaluation. Employees are made aware of the program during hospital orientation. Ongoing task forces meet regularly to problem-solve and network among the many units within the hospital.97 These programs illustrate that for a program to work, there must be buy-in at all levels and continued commitment both in dollars as well as in time.
IPV is a major public health concern, with both short- and long-term physical and mental effects on its victims. It occurs in all communities; no socioeconomic group is immune. Screening and referral of potential IPV victims in the ED is recommended by many professional societies. While domestic violence as a whole has generated a lot of publicity over recent years, much research on approaches to IPV in the ED is still required. Sound clinical judgment and attention to potential warning signs remain the most valuable tools in helping the ED practitioner identify and manage IPV.
1. "I didn't think to interview her alone."
Interviewing the victim in the presence of the batterer is unlikely to result in the truth and may put the victim at increased risk of abuse.
2. "When she told me about the beating she received, I called the police."
There are very few situations and very few locations in the United States that mandate a direct report to the police. Each healthcare professional needs to become familiar with the laws of the state in which he or she practices.
3. "She had a black eye, but she said she fell."
Inconsistencies between the injury and the mechanism are red flags for IPV. If the victim is not be ready to admit the violence, the physician should still attempt to counsel the patient or at least indicate an openness to discuss IPV at any time in the future.
4. "I practice in a wealthy, upper-class area—IPV doesn't happen here."
While the prevalence of IPV may be higher among certain populations, IPV occurs in every socioeconomic and ethnic group.
5. "She told me about the abuse—now what do I do?"
Prepare yourself and your ED in advance. Know how to counsel a victim, perform a safety assessment, and refer to local IPV agencies in your area.
6. "I'm not going to screen, because it doesn't do any good. She's just going to go back to him anyway."
Understanding the dynamics of abuse and all of the factors involved in staying and leaving is important in being able to take care of a victim properly and with compassion. A belief in the woman's ability to determine the right time to leave is also critical.
7. "Gee, he seemed like a regular guy."
Batterers rarely abuse in public. They are not interested in exerting control over you, usually only over their victim(s).
8. "I wish I had taken a picture."
Many EDs and practices have a digital camera for taking pictures of interesting cases. This camera may be used to document the injuries of IPV.
9. "The ED is just so busy these days. I have to worry about so many things: throughput, time to admission, holding patients. I just don't have the time to screen for yet another social problem."
Screening for IPV may actually shorten the time to disposition or eliminate unnecessary testing—for instance, in the cases of somatic complaints or multiple visits for the same complaint.
10l. "I didn't know she had a history of multiple previous visits to the ED for injuries or medical complaints."
Reviewing old records may reveal an escalation in the pattern of violence and aid greatly in the safety assessment.
1. Incorporate screening questions for IPV into every patient history.
If you don't ask, you may never know. Asking the right question may uncover abuse and eliminate the need for unnecessary diagnostic testing.
2. Review past medical records.
Documentation of previous episodes of IPV may yield a diagnosis or detect an escalation in the pattern of violence. It may also aid in a lethality assessment.
3. Fully examine the patient.
This includes having the patient undress and examining highrisk areas such as the torso for bruising or other lesions.
4. Document carefully and completely.
Use direct quotes, measure lesions, document on a figure template, or take photographs. The medical record is considered a legal document and may lend added weight in a "he said/she said" situation.
5. Keep a list of IPV resources handy.
Local resources or even simply the national hotline number should be available at all times. You never know when you may need this information—it could be at 3 a.m. on a Saturday, when social services are unreachable.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Janet G. Alteveer
September 1, 2004
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