Domestic Violence and Intimate Partner Violence

Authors: Claire N. Kaplan, PhD, Director, Sexual and Domestic Violence Services, University of Virginia Women's Center, Charlottesville; Daisy Lovelace, MEd, University of Virginia, Charlottesville; Leslie-Anne Pittard, MEd, University of Virginia, Charlottesville; Dion Lewis, MEd, University of Virginia, Charlottesville; Caitlin Corcoran, University of Virginia, Charlottesville; and Marcus L. Martin, MD, Professor and Chair, Department of Emergency Medicine, Assistant Dean, School of Medicine, Assistant Vice President, Office of Diversity and Equity, University of Virginia, Charlottesville.

Peer Reviewer: Ralph Riviello, MD, FACEP, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.

Issue Editor: John W. Hafner, Jr., MD, FACEP, Clinical Assistant Professor of Surgery, Department of Emergency Medicine, University of Illinois College of Medicine at Peoria, Director of Research, Emergency Medicine Residency, Attending Physician, OSF Saint Francis Hospital, Peoria, IL.

Domestic violence is a serious problem that, unfortunately, is seen all too commonly in our emergency departments. Statistics show, however, that physicians, including emergency physicians, are not good at identifying victims of domestic violence. In part that is because we are too busy to screen all women for domestic violence. We tend to screen those women we believe might be victims—those who are poor or those with lower educational levels. We often overlook those women who are upper class, yet they, too, can be victims of domestic violence. We consider perpetrators to be poor, substance abusers, and those living on the fringe of society. We do not consider physicians, police officers, or governmental officials as possible perpetrators. Domestic violence is a hidden disease.

Many physicians become frustrated dealing with victims of domestic violence. They do not understand why individuals remain in abusive relationships. The ED offers help, and seemingly irrationally, it is rejected. Victims return to the ED repeatedly, adding to the frustration. Understanding the psychology behind domestic violence is important as we deal with the victims. This article covers some of the important aspects of domestic violence in our healthcare system.

Domestic violence is one of the topics for the 2007 LLSA readings. This article complements the reading required for the LLSA and will be useful when taking the CONCERT exam in the future, where knowledge of domestic violence will be tested.

—Sandra M. Schneider, MD, FACEP, Editor

Case Study

A 40-year-old female presents to the emergency department (ED) around 2 p.m., stating that she fell down some steps and injured herself that morning when she awakened from sleep to go to the bathroom. She says her bedroom is upstairs and the bathroom is downstairs. She further states that she has been ordering sleep medications through an Internet service. Her vital signs are normal, but her speech is slurred and you notice bruises on her face and arms. She admits to smoking heavily at times about two packs of cigarettes per day, and she drinks about a pint of vodka daily. Although there was no evidence of suicidal ideation during the mental status exam, she appears moderately to severely depressed. She expresses concerns many times about her financial situation and says that she does not want to lose her job. She works as an accountant. Her husband started a landscaping business last year, and income from his job coupled with hers "barely makes ends meet" for the family. As you leave the patient's room, her husband, who is waiting outside, pulls you aside and asks if she is going to be alright. He seems nervous and anxious to tell you about her medication abuse and how he has not been able to stop her from ordering drugs through the Internet. You obtain a psychiatry consult to assess the patient for depression, and drug and alcohol abuse. The patient is admitted to the psychiatry service. Two weeks later, the patient returns to the ED with more bruising, and says that her husband has been physically abusing her regularly. She describes four violent attacks by her husband since her discharge from the hospital two weeks ago. The physical exam this time reveals that both wrists are broken. With the two broken wrists, she is now unable to drive to work, further exacerbating her financial woes and increasing the likelihood of more domestic violence. Patient presentations of this nature are common in emergency medicine.

Definition of Domestic Violence

Domestic violence, or intimate partner violence (IPV), is the exercise of emotional intimidation, non-consensual sexual behavior, economic abuse, or physical injury by a competent adult or adolescent that is utilized to maintain power and control in an intimate relationship with another competent adult or adolescent.1,2

The terms domestic violence and intimate partner violence often are used synonymously. Domestic violence may occur as an act perpetrated by both men and women and it can occur with same-sex or opposite-sex relationships. The perpetrator of domestic violence can be a family member, an intimate partner (married or not), ex-partner, someone of the same race, a different race, opposite gender, and in essence occurs in all cultures. Unfortunately, only about one-third of domestic violence cases in the United States are reported.3

Intimate partner violence takes many forms. The most prevalent, yet hidden form of abuse, is psychological or emotional. Survivors often state that this form of abuse is the hardest to tolerate—even more so than physical assaults. Because the need for power and control is at the root of IPV, abusers generally need to manage every aspect and every minute of their victims' lives, including increasing isolation from family and friends, using intimidation and emotional abuse, coercing and threatening, threatening to harm loved ones or pets, using the children, destroying important and sentimental objects, minimizing and denying the abuse, and shifting blame onto the victim.

Economic abuse involves controlling all the family's financial resources, even if the woman has her own income or comes from a middle- or high-income family. Often battered women are given a weekly or monthly allowance that the abuser deems is sufficient for managing household needs but rarely is. Thus she may not have access to financial resources that would allow her to leave.

Sexual abuse, including repeated rapes and sexual humiliation, often accompanies physical violence but may be the primary form of physical abuse.

The physical battering (which also may include child abuse, injuring or killing pets, and threats with weapons) reinforces the psychological and sexual abuse.2 At some point in the relationship, most victims are so tuned-in to their partners' moods and behavior that all it takes is "the look" or a clenched fist for victims to submit to the abuser's will.4

In domestic violence, patterns of behavior may be exhibited by an intimate partner using power to control the other in the relationship. In the United States, 1 out of every 4 women experiences domestic violence during her lifetime as a result of intimate partner abuse. Although men tend to be more likely victims of violence in general, women are more likely victims of intimate partner violence.3 The overwhelming majority of intimate partner violent acts are committed by men. For women between the ages 15 and 44 in the United States, domestic violence is the most frequent causative form of injury.5 Victims may be quiet about the abuse because they are embarrassed and fearful of worsening the abuse if their partner is aware of their complaint. There are no typical patterns that define the abuser or the victim. Unfortunately, domestic violence hurts the whole family.

Although domestic violence consciousness has been raised all around the world, there are still pockets where there is not even an expression like "domestic violence" but rather the use of the term "family scandal," suggesting that there are two physically equal partners within the family who argue. This is based on the assumption that women instigate domestic violence: "She provocated violence against herself by making her husband angry."5 A survivor of IPV has internalized this message—conveyed by family, friends, society, and the abuser—that she is responsible for her own predicament. To admit that she is being abused is to admit that she is a failure as a wife, a mother, a lover, and a human being. In addition, she is acutely conscious of the seriousness of her situation, even if she cannot admit it to anyone else. She knows what her abuser is capable of doing to her when there are no witnesses other than, perhaps, the children. She knows from personal intuition what mortality assessments show: that one-third of female murder victims are killed by their intimate partners.6 Often, these events occur when the victim attempts to leave the relationship.

Statistics

According to the Centers for Disease Control (CDC), most intimate partner violent acts are not reported to the police.7 About 20% of IPV involving rape or sexual assault, 25% of physical assaults, and 50% of stalking incidents directed toward women are reported.5 Nearly 5.3 million incidents of IPV occur each year among U.S. women ages 18 and older, and 3.2 million occur among men.5 Young people represent the most at-risk group: women ages 16-24 experience the highest per capita rates of intimate violence—16 per 1000 women.8

Intimate partner violence results in nearly 2 million injuries and 1300 intimate deaths nationwide every year. About 11% of homicide victims are killed by an intimate partner. Approximately 44% of women murdered by intimate partners had visited an emergency department within two years of the homicide.9

Firearms are the most commonly used weapons in the homicide of men and women. Men are most likely to be killed in the street or other public place; women are most likely to be murdered at home by a current or former intimate partner.10 When guns are present, victims are far more likely to die—12 times more likely than when a firearm is not involved. Half the states in the country have no gun removal laws related to domestic violence, which should be appalling to all policy makers regardless of the socio-political characteristics of any state.11

Victim Presentation

Victim Presents to Emergency Department. For males and females, involvement in abusive relationships is likely to result in depression, stress, and alcohol abuse.7 These problems and their associated medical complaints often mask IPV as the cause. Similarly, women with addictions or mental health illnesses often are blamed for their abuse.

Basile, et. al.12 studied the differential association of intimate partner physical, sexual, psychological, and stalking violence and post-traumatic stress disorder (PTSD) symptoms in a nationally represented sample of women. Their findings revealed that all types of violence are associated with an increase in PTSD symptoms. There was evidence of a dose response in which the more types of violence the patient experienced, the more PTSD symptoms she exhibited.12

Intimate partner violence toward the pregnant woman has particular issues. Pregnancy can trigger acts of domestic violence or exacerbate ongoing problems, and increases the risk of homicide.13 Homicide is the leading cause of traumatic death among pregnant and postpartum women in the United States, resulting in 31% of maternal injury deaths.14 Although women appear to be at greater risk of domestic violence during the post-partum period, intimate partner violence directed against pregnant women may be more common than other generalized obstetrical complications. Patterns of violence directed toward the pregnant female include trauma to the abdomen, breasts, and genitalia. Men may be violent toward their pregnant partners because of jealousy and anger toward the unborn child, possibly attempting to cause miscarriage directly; anger against the woman for her inability to cater to his needs; and ongoing business-as-usual type violence.15 In a study, domestic violence was statistically significantly associated with educational level. Illiterate women reported domestic abuse 2.6 times more than university or more educated women. Among women reporting domestic violence, those with the lowest educational level and income were experiencing all types of domestic violence frequently.16

Women with children younger than 3 years of age who present to the ED have been found to experience past physical abuse (52%), past sexual abuse (21%), and abuse within the past year (10%). Forty percent of the past abuse perpetrators, 73% of recent abuse perpetrators, and 10% of sexual abuse perpetrators had regular contact with the children of women who presented to the ED with children younger than 3 years old.17

Physical violence occurs in 11-12% of same-gender couples, suggesting that domestic violence is an abusive power that can happen in any type of intimate partner relationship. The violence appears to be milder in same-gender couples, and it is unclear what percentage of same-gender violence can be characterized as abuse vs. intimate terrorism. Victims of same-gender violence may also have the added stress of severe isolation and the threat that the abuser may expose the victim's sexual orientation in a hostile manner.18

Abel describes the design and outcomes of a research project that investigated the similarities and differences between women adjudicated as domestic violence "batterers" and women identified as domestic violence "victims."19 Findings indicated group similarities in the areas of exposure to violence and social service utilization. Although both groups reported high levels of trauma symptomatology, victim scores were significantly higher. Abel compared a sample of women who were being treated in batterer intervention programs with another sample of women who were receiving domestic violence victim services. Trauma symptomatology includes emotional and behavioral problems such as depression, anxiety, PTSD, battered-woman syndrome, alcohol abuse, and suicidal ideation.19 Many believe that women who have been adjudicated as batterers are really victims who were fighting back in self-defense. More and more women are being seen as perpetrators of domestic violence. In Abel's study, minority group representation in the victim group was significantly lower than in the batterer sample.19 Forty-two percent of the women in the batterer group were non-white.19 In contrast, only 26% of the women in the victim group were non-white.19

Batterers tend to want to control their partners through exertion of physical dominance and to hold their partners responsible for the violence in their relationships.20 Lorber and O'Leary assessed prediction of husband to wife physical aggression in which the husband had engaged in at least one act of physical aggression toward his partner during their engagement period.21 Predictors were measured approximately one month prior to marriage, and physical aggression was assessed again at 6, 18, and 30 months post-marriage. They found that more than 76% of the men who were physically aggressive during the engagement period were physically aggressive at one or more of the next three assessments across the initial 30 months of marriage.19 Nearly 62% of the participants were severely aggressive at one or more assessments.19

Victim Presents to Doctors' Offices. Only one in four victims of domestic violence who come to EDs actually report domestic violence abuse, and one in three victims of domestic violence report abuse to their primary care provider.3 The American College of Emergency Physicians has had a long-standing policy advocating for screening for domestic violence in the ED. It also calls for training of all ED staff in domestic violence. Yet, nearly 25% of patients presented to family practice clinics had incidents of intimate partner violence in the past year, with about 40% lifetime prevalence.5

The American College of Obstetricians and Gynecologists and the American Medical Women's Association recommend that physicians screen all patients for intimate partner violence. For women who are not pregnant, this should occur at routine ob/gyn visits, family planning, or preconception visits.22,23 Women who are pregnant should be screened regularly over the course of the pregnancy, including post-partum, since some women do not disclose abuse the first time they are asked. Abuse can also occur later in pregnancy.22 Family practice physicians can emulate this practice as well by routinely screening for IPV at annual physical exams or other periodic visits.

Victim Presents to Police Department. Victims often have a history of calling for help from law enforcement. Many states have laws mandating arrest if the responding officers determine that an assault occurred. However, enforcement of these laws varies and may result in the arrest of both perpetrator and victim if the officer is not trained to evaluate the difference between an offensive and defensive injury, or the officer has not been adequately trained on domestic violence issues in general. Stuart et. al.24 studied reasons for intimate partner violence perpetration among arrested women. They administered to 87 women in violence intervention programs a questionnaire assessing 29 reasons for violence perpetration. They found self-defense, poor emotion regulation, provocation by the partner, and retaliation for past abuse as the most common reasons for violence perpetration.22 Women victims of severe partner violence were significantly more likely than victims of minor partner violence to report self-defense as a reason for their violence perpetration.22

Racist and discriminatory practices within community services, such as police departments, government organizations, and shelter facilities may be discouraging to both immigrants and racially visible abused women in reporting the violence and seeking help. Immigrant and racially visible women must contend with the dominant cultural paradigm in neglecting and sometimes even denouncing their lived reality and belief systems.25

When the police are contacted, whether by a telephone call or in person, the abuse becomes public. Just as the privatization of domestic violence contributes to its continuation, perhaps public knowledge can prevent occurrence.26 In their study, Gracia and Herrero, using a national probabilistic of a Spanish adult population, tested a hypothesis regarding correlates of public attitudes toward reporting partner violence against women.27 Results indicated that low tolerance of partner violence against women was significantly associated with a positive attitude toward reporting partner violence against women. Interestingly, the odds of having a positive attitude toward reporting were almost two times as high for people not personally exposed to partner violence against women as they were with people personally exposed.26

Domestic violence thrives on a social climate of secrecy, tolerance, passivity, and victim inhibition.27,28 Gracia and Herrero state that unreported cases of domestic violence against women are the result of social silence, tolerance, and inhibition. In their study, Anderst, Hill, and Siegel documented that women are less likely to disclose domestic violence if they are informed of state-mandated reporting laws before the domestic violence screen takes place and even less likely to report domestic violence if the screening utilizes a written self-administered survey.29 Victim retraction is almost universally viewed by criminal justice officials as a problematic outcome in cases of domestic violence.28 The nature of institutional responses to victims can leave them feeling isolated and vulnerable. Often, victims' frustration associated with the criminal justice system, coupled with pressure from the abuser, leads them to recant or drop charges. In a study of those victims who retracted, almost half retracted before trial (44%) and more than one-third (35%) retracted before the defendant entered a plea.30 Seven percent retracted on the day of the trial. The most common way the victims retracted was through the police.26 Thus, multi-agency coordination in domestic violence cases is essential to preventing victim retractions.

Women who experience domestic violence often report prior exposure to other episodes of interpersonal violence. In their study of female residents in a domestic shelter in New York City, Griffing, et. al., in their exploration of the prevalence of prior abuse found that more than one-half of the sample reported past violence exposure, which included either personal victimization, maternal domestic violence, or both.31 The most frequently reported form of personal abuse was childhood sexual assault.

Victim Presents to Other Community Settings. Victims of abuse, especially women, often suffer substantial physical injuries as well as elevated rates of depression and other mental health problems, substance abuse, and suicide. They may feel entrapped and unable to access support services available in their communities for these problems, and in turn, these agencies may not screen for domestic violence, or if they are aware of the abuse, may not be trained to respond appropriately—or the agencies may have their own agendas that conflict with strategies for empowering victims to get free of the abuse.

Ellison and Anderson studied the religious involvement and domestic violence among U.S. couples.32 They found that regular religious attendance is inversely associated with the perpetration of domestic violence.32 Among men who attend religious services weekly and women who attend at least monthly, there tends to be a protective effect of the religious involvement against domestic violence. Often women receive significant social and spiritual support from their religious organizations. This is particularly true for immigrant women and African American women. Yet, if they receive negative responses, such as from trusted clergy who offer harsh admonitions to be submissive wives regardless of the behavior of their husbands, victims' isolation and alienation from existing community resources multiplies. Their feelings of shame and self-blame reinforce their silence.

Frequently, victims of IPV seek help via domestic violence hotlines run by domestic violence programs. The anonymity of these hotlines often provides a feeling of safety for women who are terrified that their abusers will find out they are seeking assistance from the outside world. But because shelter locations are rarely made public, each program must arrange with either law enforcement or an emergency department, for example, to be a staging location where victims may safely come and then be transported to the venue of the emergency shelter. Shelters aren't always safe for lesbian victims, however. While many are open and welcoming to victims of same-sex IPV, others have not trained their staff to be sensitive to this issue, or to be aware that the abuser might show up at the shelter also claiming to be a victim.

Victim Discusses Domestic Violence with Family Member or Friend. Women tend to use more avoidance strategies when they are remaining in abusive relationships and they try to cope with ongoing violence. Women who receive positive responses from help sources such as friends, family, police, and the courts have greater confidence in their abilities to change their situation and are more likely to access the support services as opposed to remaining in the relationship that results in continued battering.33 Sagrestano, et. al. studied the associations between demographic, psychological, and relationship factors in domestic violence during pregnancy.34 Their results indicated that controlling for demographics, more frequent violence was associated with less support and satisfaction with support from the baby's father, more negative interaction with the baby's father, and more verbal aggression in their relationships than those who did not report violence.

Challenges Faced by Healthcare Providers

Unfortunately, some women will never talk to anyone about being abused because of the significantly high rate of homicide associated with intimate partner violence. Ramsden and Bonner suggest that EDs are key players in the health system for identifying and intervening early for domestic violence.35 In describing their experience with screening for domestic violence in an ED in Sydney, Australia, they caution that the screening process can be a challenge. In their study, ED staff members identified lack of time to ask questions, lack of privacy and confidentiality for patients, and no after-hours social worker for referrals as significant problems. Inappropriate questions are not infrequently asked of patients during the history taking, based on the type of presentation.35

The general lack of domestic violence education of doctors and nurses in health systems is the first challenge to effectively addressing IPV in this setting. In EDs there generally is a lack of time (the "Pandora's box" problem: open it and a host of other issues will pour out). A feeling of powerlessness on the part of healthcare providers regarding issues of intimate partner violence may be due in part to the vague fear that in the end there is little that can be done. Screening is not performed for fear of offending the patient, or staff is concerned about invading a patient's privacy.22 In addition, staff may become frustrated when a victim repeatedly rejects help. In addition, the absence of adequate alternatives for battered individuals may be problematic in some areas.

These concerns can be assuaged by adequate training and strong leadership on the part of the managing medical staff. Listening to the staff members' concerns and responding to these issues will go a long way toward gaining their commitment to this problem.

Additional Challenges and Considerations

Women of color experience an element of distrust, lack support systems and find it more difficult to discuss IPV with their medical professionals who appear to be irritated with IPV issues.36 And yet, rates of IPV are no different than rates among white women.

Violence in families and in intimate relationships is widespread in Latin America and the Caribbean. Arscott-Mills studied intimate partner violence in Jamaica.37 Results revealed a high level of physical injury (89%) and a low level of reporting violent incidents to the police (26%). Although 75% of these women sought medical care, they also report first turning to look for assistance from their pastors and counselors.37

In comparing lesbian and heterosexual women regarding physical and sexual violence, Bernhard found that significantly more lesbians (51%) than heterosexual women (33%) had experienced non-sexual physical violence and there was no difference between groups in the prevalence of sexual violence (lesbians 54%, heterosexual 44%).38 Because lesbians are also at greater risk of hate violence than heterosexual women, lesbians may experience more violence than heterosexual women, experience cultural barriers, language barriers, physical and social isolation, and lack links to community support systems. Traditional resources may not be lesbian- or gay-friendly, and may be unprepared for assisting transgender victims. The organization Communities United Against Violence states that from 2002-2003, domestic violence reports from gay men and lesbians increased 21%, and reports from transgender people increased as well.39

Immigrant women experience cultural and language barriers, physical and social isolation, and lack links to community support systems. An undocumented woman also faces the possibility of arrest and deportation if she reports her abuse, even if her spouse is a legal resident, because he controls her application for a work permit and can withdraw it at any time.40

IPV often is overlooked in the elderly because healthcare workers are concerned for the particular presenting medical conditions that affect the elderly and do not seriously consider IPV.

Older women often are not identified as victims of intimate partner violence in the medical setting because providers think of IPV as a problem of younger of women. Providers are encouraged to identify signals of potential abuse, to create privacy for all patients, and to be on the alert for signals of abuse among older women.

People with disabilities are oft-overlooked victims of domestic violence. While all people with disabilities are at risk for abuse, women with mental and physical disabilities are particularly at risk. In Virginia, 46% of domestic violence program advocates reported that many of their clients had mental health disabilities. In the same study, 7% of disability service providers said that most of their women clients had experienced IPV, while 29% said many clients, and 25% of them said that some of their female clients were victims of domestic violence.41 Many providers search for domestic violence in people of lower socioeconomic class. Domestic violence, however, can occur in all social classes and among professionals, including physicians.42 Both victims and perpetrators can also be found among the powerful and wealthy of our society.

How to Screen

Healthcare workers must remember to ask about IPV, document findings, assess the safety, and refer patients for care as needed. A number of screening tools are available on the web that are designed for use by healthcare professionals.

Screening for domestic violence need not be complicated. Considering that victims rarely are asked simple, gentle, yet direct questions about these issues, and the very act of asking may provide relief and comfort, the simplest approach is best. The American College of Obstetricians and Gynecologists22 suggests that the healthcare provider state the following:

"Because violence is so common in many women's lives and because there is help available for women being abused, I always ask these questions…"

The ACOG screening tool is designed so that a "yes" response to any question prompts a referral. As indicated by the concerns of particular populations described above, this tool is most effective when used with all ED patients—women and men alike.

Table 1. IPV Screening Questions
1. Within the past year—or since you have been pregnant—have you been hit, slapped, kicked, or otherwise physically hurt by someone?;
2. Are you in a relationship with a person who threatens or physically hurts you?
3. Has anyone forced you to have sexual activities that made you feel uncomfortable?
Additional questions may further assist in IPV screening, for example:
1. Have you ever felt unsafe or been fearful of anyone (such as your partner/husband/child/relative)?
2. Is anyone trying to control you (such as monitoring how far you drive in the car by tracking the mileage, how much money you spend, what you wear)?43

Common Presenting Complaints

Patients with a history of domestic violence typically provide numerous clues to their situation. However, they do not reveal these clues easily, particularly if the department environment is unsafe for them. An understanding of the dynamics of abuse on the part of the entire medical staff is key to establishing safety.

Kerr, Levine, and Woolard1 state that historical clues to IPV include: a delay in requesting care, a history inconsistent with injury, vague or nonspecific complaints, multiple physician visits, ED visits at odd times for chronic complaints, and injuries during pregnancy. Behavioral clues to domestic violence include: an overly protective or controlling partner, an evasive patient who is reluctant to speak in front of partner, and who is inappropriately unconcerned with obvious problems. Physical clues to domestic violence include multiple injuries, injuries of different ages, central distribution of injuries, and injuries suggesting a defensive posture (i.e., forearm bruises or fractures).1 (See Table 2.)

Table 2. Common Presenting Complaints
Migraine and other frequent headaches
Gastrointestinal disorders
Premenstrual syndrome
Back pain
Disability preventing work
Confusion, anxiety, withdrawal, guilt, nervousness, distrust of others
Post-traumatic stress disorder, including emotional attachment, sleep disturbances, flashbacks, mental replay of assaults
Depression, attempted or completed suicide, alienation
Unhealthy diet-related behavior such as fasting, vomiting, abusing diet pills, overeating
Strained relationships with family, friends, and intimate partners

Intervention and Referral

An established protocol and treatment plan is essential for all staff to feel confident in their ability to respond appropriately to the need of a victim of IPV, and makes it clear that domestic violence is considered a high priority. The process of developing a safety plan should involve local agencies as part of a coordinating council or domestic violence response team. This will ensure that the victim receives appropriate support following her ED visit, whether from the local domestic violence program (including but not limited to an emergency shelter), child protection agencies, TANF (Temporary Assistance for Needy Families), and that any evidence collected for a possible criminal case is preserved properly for admissibility in court. These local agencies also can provide wisdom and support to the ED staff, who may be quite anxious about these cases, or even question the appropriateness of directly addressing these issues with patients for fear of offending them.

1. Establishing patient safety is critical to any further attempts at assistance. Immediately upon suspecting that abuse is a possibility, ensure that the abuser is not in the examination room and is sufficiently distracted so that the victim will not fear his return.

2. Screen the patient for IPV using a verified screening tool such as the one above, with which staff have been trained.

3. If the patient confirms that she is being abused, or if she denies it despite present indicators, contact the social worker for immediate intervention. A danger assessment must be done in order to proceed.43,44

4. Use body diagrams to document injuries to establish a history of injuries for criminal prosecution. Evaluate and treat patient for life-threatening injuries as well as possible fractures. If the patient discusses coercive sex as part of the abuse (which would include "making love" after a violent episode), consider rape kit collection as well.

5. Consideration of patient safety must include that of her children who may be at home with the abuser.

6. If an immediate threat is present, security must be notified and the patient must be moved to a room with a door, if this isn't the case already.

7. If an immediate threat is not present, the physician then obtains a more complete patient history, diagnoses the current medical or surgical issues, and thoroughly documents the abuse (through photographs as well as written notes).

8. The social worker will discuss the patient's options, such as a safety plan, emergency housing, legal advocacy, hotlines, and emotional support and counseling referrals. If police have been notified (only with the patient's permission), they will need to interview the patient as well. Ideally, these two discussions can occur simultaneously so that the patient does not have to repeat her story.

9. If shelter space is unavailable and the patient is at risk, consideration for hospital admission should be made until further social service intervention is possible.

10. The patient is discharged, either to return home or preferably to a safer environment, such as a domestic violence shelter.

a. If the patient does not accept a referral to a shelter, she should be provided written material and should understand that she is returning to the unsafe environment of her home (even if her partner is arrested, he will be released within hours, more than likely). She should understand that she will have to hide any evidence that others know of the abuse. Written materials must be in a format that can be hidden. For example, she could keep information in a tampon box (even if she is post-menopausal, she might have an old box in a cabinet), or give it to a trusted neighbor or friend.

b. If she does accept a referral to shelter, then the social worker will arrange for her transport to the facility.

11. The social worker should follow up with the patient after discharge.

Treatment

Whatever constructs might be applied in understanding domestic violence, mental health professionals, counselors and therapists do well to apply contextual analysis in examining both individuals and environmental factors.45 Taft, et. al.,46 studied race and demographic factors in treatment attendance for domestically abusive men. Treatment dropout is an area of great concern in counseling programs for domestically abusive men.46 The authors enrolled 101 male participants (40 African American and 61 Caucasians) in the study. These men electively sought treatment for domestically abusive behavior. The study showed that self-referred African American males were at the greatest risk for dropout.46 Clinical treatment programs have shown that there are lower rates of violence recidivism in males who complete the program vs. those who drop out.46

Feminist therapy can be a counseling means of helping abused women. However, many feminist theories of therapy make the assumption that societal power imbalances are based primarily on gender and equality and, consequently, fail to consider the other forms of oppression abused women experience.25 In this context feminist therapy may not be effective for women not of the dominant culture. Acknowledging this disparity, domestic violence programs have increasingly integrated issues relevant to women from non-dominant cultures, sexual minorities, and women with disabilities into their counseling programs. This commitment to ensuring that programs are open to all victims of abuse varies from state to state and program to program. However, there is much to learn from the process by which the anti-violence movement includes survivors of IPV, consumers of mental health care, women of color, people with disabilities, non-English speakers, LGBT people, and others in the effort to strengthen outreach.

As stated above, any attempt to treat battered women is only as effective as the system that is established to assist them. If the family remains intact, a network of support still is necessary to support the victim and monitor the behavior of the batterer. The most successful programs appear to be those that involve all the stakeholders: medical care providers, criminal justice agencies, domestic violence programs, social services, churches, attorneys, and others.

Conclusion

Recognizing IPV can be challenging to healthcare providers. Despite this challenge, key professional healthcare associations support and offer screening processes and protocols for addressing IPV in EDs and other medical settings.22,47-49 Several admirable models exist for others to emulate. Domestic violence screening and intervention must be a priority of healthcare providers at all levels, especially by those who are on the frontline and who see first-hand the damage IPV causes. Appropriate intervention and referral may prevent serious injury, trauma, and death to victims and their children, and may break the cycle of violence.

References

1. Kerr H, Levine D, Woolard B. Domestic violence. In: Training Module. Society for Academic Emergency Medicine Public Health and Education Committee: CavNet: 27. 2006

2. National Center on Sexual and Domestic Violence, Power and Control Wheel. 2006, http://www.ncdsv.org/images/PowerControlwheelNOSHADING.pdf.

3. Centers for Disease Control and Prevention. CDC Fact Sheet: Intimate Partner Violence. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. www.cdc.gov/ncipc/factsheets/ipvfacts.htm. 2006.

4. Lominack MC. Lecture: Domestic violence. Gender Violence and Society Course. 1998: Charlottesville, VA.

5. Parti K. Domestic violence in Hungary, concerning the public opinion, the researchers and the data available. Acta Juridica Hungarica 2001;42:245-254.

6. Bureau of Justice Statistics. Homicide Trends in the U.S. 2005. U.S. Department of Justice, Office of Justice Programs.

7. Huan CJ, Gunn T. An examination of domestic violence in an African American community in North Carolina—Causes and consequences. Journal of Black Studies 2001;31:790-811.

8. Rennison CM. Bureau of Justice Statistics Special Report: Intimate Partner Violence and Age of Victim, 1993-99. Washington, D.C.: U.S. Department of Justice; 2001:1-12.

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