Intimate Partner Violence
Cheryl A. Glass
Definition
A.Intimate partner violence (IPV) is defined as intentional control or victimization of a person with whom the abuser has or is currently in an intimate, romantic, or spousal relationship. Domestic-IPV violence crosses all cultures and economic boundaries; it encompasses violence between both genders, including gay and lesbian relationships. Abusive behaviors can occur in a single event or sporadically, or can be continual. The Duluth Model Power and Control Wheel from the Domestic Abuse Intervention Project illustrates the abuser’s power and control over the victim (see Figure 25.1).
B.Physical abuse, sexual assault, coercion, social isolation, emotional abuse, economic control, and deprivation are associated with IPV. There is no typical abuser, although all abusers tend to be violent in the home setting and their behavior at work is normal.
C.Forms of physical violence include threatening or assaulting with weapons, pushing, shoving, slapping, punching, choking, kicking, holding, throwing objects, and binding.
D.Psychological abuse includes threats of physical harm to the victim or others, humiliations, intimidation, degradation, ridicule, false accusations, isolation, and deprivation of food, money, access to healthcare, and transportation.
E.Psychological abuse in lesbian, gay, bisexual, and transgender (LGBT) relationships includes the threat to out
their partner as well as threats related to custody of coparented children.
F.Stalking as a form of IPV. Cyberstalking is psychological abuse via the Internet or texting. Intimate partner stalking occurs during a relationship or after the relationship ends:
1.Monitoring cell phone and Internet activity.
2.Posting photographs or other types of humiliation on social media.
G.Sexual abuse is nonconsensual (unwanted kissing or touching) or painful sexual acts.
H.Reproductive coercion is another form of IPV:
1.Partner sabotage of safe sex practices (i.e., refusal to use condoms, thus exposing the patient to sexually transmitted infections).
2.Refusal/control of contraception.
3.Forcing the woman to have an abortion, or utilizing physical violence to endanger a pregnancy.
4.Controlling access to healthcare.
Incidence
The exact incidence of IPV is unknown due to the lack of reporting. The United Nations estimates that more than 600 million women live in countries where domestic violence is not considered a crime. The most significant reason for missing the diagnosis of IPV is failure to ask the patient.
A.Girls and young women between the ages of 16 and 24 experience the highest rate of IPV.
B.Domestic violence is the leading cause of homicide death in women globally.
C.Up to 75% of domestic assaults occur after separation; women are most likely to be murdered when reporting abuse or attempting to leave an abusive relationship.
D.An estimated 81% of women stalked by an intimate partner also suffer physical assault. Stalking by an intimate partner is estimated to occur among 1 million women and 317,000 men per year.
E.An estimated 4% to 15% of women presenting in emergency rooms have situations related to domestic violence.
F.Women who separate have a risk of violence approximately three times that of divorced women:
1.Over half of the children who witness domestic violence intervene in some way, including yelling to the abuser to stop, calling for help, and trying to get away.
G.The incidence of abused men is estimated as one in three. Men are also victims of attempted or complete rape, at approximately 3% during their lifetime.
H.Pregnancy has an increased incidence of violence:
1.One in five young women and 35% of women have experienced pregnancy coercion.
2.53% of young women have experienced birth control sabotage.
3.It is estimated that 5% to 20% of intimate partner abuse occurs against pregnant women.
I.Sexual violence, rape, physical assault, or stalking by an intimate partner occurs for 43.8% of lesbians, 61.1% of bisexual women, and 35% of heterosexual women, and for 26% of men with male partners, 37.3% of bisexual men, and 29% of heterosexual men.
J.Among college women, 20% to 30% report violence during a date:
1.Approximately 70% of college students say they have been sexually coerced.
K.Women in the military are recognized as a vulnerable population susceptible to abuse due to their geographical location away from family and friends and the social isolation within the military culture:
1.In 2017 the Department of Defense (DoD) estimated that 6,769 reports of military assaults occurred.
2.One in three convicted military sex offenders remain in the military.
Pathogenesis
Intrapartner violence is not associated with an underlying medical condition. The cycle of abuse has three phases:
A.Tension building: The victim tries to avoid violence and is described as walking on egg shells,
unsure what will trigger an abusive incident.
B.Explosion and acute battering.
C.Honeymoon phase,
noted for the absence of tension and reconciliation
D.Victims stay with their partners for multiple reasons, including fear, shame, denial, religious reasons, lack of resources, custody and other legal issues, fear of being outed,
and family pressures.
Predisposing Factors
A.Gender: Females are predominantly the victim.
B.Race: African Americans, American Indians, Hispanic women, and Alaskan Natives.
C.Higher incidence in interracial couples.
D.Pregnancy.
E.History of violence:
1.Family domestic violence.
2.Abuse as a child: 50% report abuse as an adult.
FIGURE 25.1Abuser’s power and control wheel. Source: Domestic Abuse Intervention Programs. (n.d.) Retrieved from https://www.theduluthmodel.org/wp-content/uploads/2017/03/PowerandControl.pdf
F.History of drug use.
G.Posttraumatic stress disorder (PTSD).
H.Lack of social support systems.
I.Impulse control disorders.
J.Poor economic status.
K.LGBT.
Common Complaints
A.Vague complaints.
B.Sexual problems.
C.Depression.
D.Chronic pain inconsistent with organic disease.
E.Chronic headaches/migraines.
F.Stress:
1.Anxiety.
2.Panic attacks.
G.Alcohol or drug abuse (the batterer, victim, or both).
H.Current or past self-mutilation.
I.Gynecologic and obstetric complaints:
1.Dyspareunia.
2.Frequent vaginal or urinary tract infections.
3.Pelvic pain/infection.
4.Recurrent sexually transmitted infections.
5.Unintended pregnancy.
6.Late prenatal care.
7.Miscarriage.
8.Preterm bleeding/delivery.
J.Complaints of falls and other recurrent accidents.
K.Eating disorders.
L.Gastrointestinal complaints/irritable bowel syndrome.
M.Musculoskeletal complaints.
Other Signs and Symptoms
A.Multiple prior visits to the emergency room for traumatic and nontraumatic complaints
B.A delay between injury and office visits (may result from lack of transportation or inability to leave the house)
C.Noncompliance with the treatment or missed appointments (lack of access to money or telephones)
D.Suicide attempt (25% higher in women with IPV).
E.The partner accompanies the patient at all visits.
Subjective Data
The gold standard
research method to document the prevalence of women’s exposure to violence includes conducting the interview one on one, in private, and asking specific direct questions.
A.The batterer often refuses to leave the patient alone and may answer questions for the patient. Translators should not be members of the patient’s or suspected abuser’s family.
B.Use direct questions: Women-validated Partner Violence Screen (PVS):
1.Have you been hit, punched, kicked, or otherwise hurt by someone in the past year? If yes, by whom and were you injured?
2.Do you feel safe in your current relationship?
3.Is a partner from a previous relationship making you feel unsafe now?
4.Are you here today due to injuries from a partner?
5.Are you here today because of illness or stress related to threats, violent behavior, or fears due to a partner?
C.Assess if the patient has ever told family or friends, called hotlines, or attempted to leave the abuser.
D.Has the patient sought help with law enforcement or legal help, that is, filed a criminal complaint or got an order of protection?
E.Are there any weapons in the home?
1.Has the abuser ever threatened or tried to kill you?
2.Are you thinking of suicide? Have you ever considered or attempted to commit suicide because of problems in your relationship?
3.Have you ever considered or attempted killing your batterer?
4.Do you have a plan?
Physical Examination
A.Enforce the need to interview and do physical examinations in private. Do a full body examination, including the head/scalp:
1.Most injuries are to the central (breast, chest, and abdomen) area, which is easily concealed by clothing.
2.Other frequent sites of injury include the head, face, throat, and genitals.
3.Explain the physical examination and touch with permission.
4.Forensic exams need thorough documentation of injuries:
a.Use color photographs before any treatment is started.
b.Photograph damaged clothing.
c.Take at least one full body photograph and a facial photograph.
d.Take close-up photographs of all injuries.
e.Use a ruler to identify/document the size of injuries.
f.Documentation on the back of the photographs should include the patient’s name, date, photographer’s name, as well as any witnesses to the examination. The photographer should also sign each photograph.
g.Use direct quotes of the patient’s history of the violence.
B.Check blood pressure, pulse, and respirations.
C.General observation: Observe for depression/withdrawal, flat affect, anxiousness, fear, evasiveness, poor eye contact, and wearing of heavy makeup or clothing to conceal signs of abuse. Evaluate voice changes: Dysphonia and aphonia. Observe for difficulty breathing.
D.Inspect:
1.Dermal exam for the presence of cigarette burns, impression marks, rope burns, welts, abrasions, scratch marks, claw marks, bite marks, ligature marks, petechiae, and contusions at multiple sites (e.g., back, legs, buttocks).
2.Eye exam:
a.Observe subconjunctival hemorrhages from strangulation/struggle.
b.Perform a funduscopic examination (if indicated secondary to trauma).
3.Evaluate the genitals for lacerations and hematomas of the vagina or labia.
E.Auscultate:
1.Auscultate all lung fields.
2.Auscultate the bowel sounds in all four quadrants of the abdomen.
F.Palpate:
1.Evaluate skull/facial trauma to the maxillofacial area, eye orbits, mandible, and nasal bones. Facial injuries are reported in 94% of victims.
2.Evaluate for dislocations, fractures (including spiral fractures), sprains, and contusions to the wrists, forearms, and shoulders.
G.Percuss: Abdomen, chest, and areas of injury (if indicated secondary to trauma).
H.Neurological examination (if indicated secondary to trauma).
I.Genital/rectal examination:
1.Evaluate genitals/anal area for redness, swelling, bruising, hematomas, abrasions, or lacerations.
2.Perform bimanual examination (females).
3.Perform an anoscopy (if indicated).
4.Evaluate for evidence of sperm (recto/vaginal).
5.Evaluate for the presence of condyloma (perineum, rectum, vagina).
6.Evaluate for the presence of foreign bodies (recto/vaginal).
Diagnostic Tests
Diagnostic tests and x-rays are ordered dependent on the type of presenting complaints and physical examination.
A.Administer a domestic abuse assessment screening tool and have the victim mark a body map of injuries (see Figure 25.2).
B.Complete blood count (CBC) with differential and peripheral smear, bleeding evaluation, including prothrombin time/partial prothrombin time (PT/PTT), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) to evaluate injury to the liver, serum amylase, or lipase to rule out pancreatic injury.
C.Urinalysis.
D.Drug/toxicology screen (urine and blood).
E.Obtain forensic DNA samples from the skin, under nails, and within the vagina and rectum, as well as saliva from bite marks using sterile cotton-tipped applicators that have been moistened with sterile saline. These should be sent to a crime laboratory as soon as possible.
F.Test for sexually transmitted infections/HIV.
G.Pregnancy test (if indicated).
H.Radiographs: Facial injury, anteroposterior (AP) and lateral radiograph for any areas of bone tenderness, swelling, deformity, or limited range of motion (ROM).
I.Ultrasounds as indicated.
J.Neuroimaging CT/MRI for any suspected nonaccidental head injury (i.e., head trauma or scalp hematoma).
Differential Diagnoses
A.Domestic violence:
1.Intimate partner abuse.
2.Elder abuse.
B.Rape.
C.Other: Related to presenting symptoms.
Plan
A.General interventions:
1.Provide a safe environment. Assess for immediate danger.
2.Clearly document the history, physical findings, and interventions.
3.Determine the risk to the victim and any children.
4.Evaluate the need for emergency room/hospital admission.
5.Battery is a crime; assess the victim’s readiness for police intervention and need for a court order of protection.
6.Help develop a safety plan.
FIGURE 25.2 Abuse assessment screening tool with body map.
Source: Reprinted with permission from Parker, B., McFarlane, J., Soeken, K., Torres, S., & Campbell, D. (1993). Physical and emotional abuse in pregnancy: a comparison of adult and teenage women. Nursing Research, 42(3), 173–78. doi:10.1097/00006199-199305000-00009
7.Assess readiness to leave: Collection of important papers (e.g., birth certificates, custody papers, divorce papers, legal agreements, address book, and copies of restraining orders), access to money/credit cards, and telling family and friends.
8.Provide contact numbers for shelters. Have the patient hide information in her shoes.
9.Counsel that violence may escalate.
B.Patient teaching:
1.Reinforce the fact that the violence is not the victim’s fault. IPV is very common and the victims do not deserve to be abused. Discuss the cycle of abuse.
2.Violence increases in frequency and severity.
3.Help is available.
4.The DoD has a self-help phone app created by the Rape, Abuse & Incest National Network (RAINN) for sexual assault survivors to create a customized self-care plan. This app is available through the iTunes store. The app is a resource for Active Duty, National Guard, and Reserve service members:
a.RAINN has adapted the National Sexual Online Hotline to provide specialized live help online at SafeHelpline.org to members of the DoD community who have been sexually assaulted.
b.The Safe Helpline is also available by calling 877-995-5247.
c.All Safe Helpline staff members have been trained to answer questions related to military-specific topics such as restricted and unrestricted reporting and how to contact relevant military resources such as the installation or base’s Sexual Assault Response Coordinator (SARC) if their services are requested.
C.Pharmaceutical therapy:
1.Prescriptions are related to physical injuries.
2.Treatment for sexually transmitted infections in the oral, anal, and genital areas.
3.Tranquilizers may impair the victim’s ability to flee or defend herself and should not be prescribed.
Follow-Up
A.Develop a follow-up plan:
1.What type of help does the patient want?
2.Does the patient have a plan for returning? Is the batterer home? Does she think it is safe?
3.Does she have a place to stay with family or friends; or does she want to go to a shelter?
4.Give the telephone numbers for shelters and crisis hotlines.
B.Screen the patient for abuse at all subsequent visits.
C.Mandatory reporting:
1.States require reporting when domestic violence involves a child under the age of 18 and abuse or neglect of the child is suspected.
2.Abuse of a disabled person must be reported to the Disabled Persons Protection Commission.
3.Reporting elder abuse may be mandatory in your state.
D.Your state may mandate reporting and intervention with law enforcement. Refer to the Domestic Violence, Sexual Assault, and Stalking Data Resource Center: www.jrsa.org/projects/domviol.html.
E.The 2013 National Protocol for Sexual Assault Medical Forensic Examination for Adults and Adolescents is available at ncjrs.gov/pdffiles1/ovw/241903.pdf.
Consultation/Referral
A.Facilitate referrals to a shelter, counseling, and legal services.
B.Contact a sexual assault nurse examiner (SANE) qualified healthcare provider if indicated.
C.Refer to community or private support groups and agencies.
D.Refer for a consultation with a psychiatrist if the victim is homicidal or suicidal.
E.Refer for a neurological or neurosurgical consultation for intracranial injuries or focal neurological findings.
F.Refer for an orthopedic consultation for fractures.
Individual Considerations
A.Pregnancy:
1.Pregnancy is a known period of increased risk of violence.
2.The genitals, breast, and abdomen are common sites targeted for trauma.
3.Women may present with a miscarriage or premature labor.
4.Blunt trauma is a common injury in pregnancy.
5.Perform universal screening at each trimester and postpartum since abuse often begins during pregnancy.
Resources
Dating Abuse Stops Here: www.datingabusestopshere.com
Domestic Violence, Sexual Assault and Stalking Data Resource Center: www.jrsa.org/projects/domviol.html
Futures Without Violence (formerly Family Violence Prevention Fund): www.futureswithoutviolence.org
National Domestic Violence Hotline: 1-800-799-7233
National TEEN Dating Abuse Helpline: 1-866-311-9474
Rape Abuse & Incest National Network (RAINN) Hotline: 1-800-656-4693