Nearly all practicing healthcare professionals see patients who are either abused in a current relationship, are distressed by abuse in a prior relationship, or who suffer adult health effects that stem from witnessing IPV. 3 Yet, fewer than 9% of women are asked about IPV in the primary care setting. 4 In view of the prevalence and scope of intimate partner violence, it is prudent for clinicians to inquire routinely about a history of trauma and/ or abuse across the lifespan, across genders, and across variations in sexual orientations. Extensive literature describes the “dose effect” of early childhood trauma on later adverse health outcomes. 5 A history of trauma is a risk factor for current trauma. By addressing trauma and IPV, healthcare providers can address and, perhaps, prevent potentially severe physical and mental health consequences. A clinician intervention may simultaneously help a patient in an acute situation and uncover the root causes of health consequences due to IPV in that patient. As noted below, unaddressed or treatment non- responsive health conditions (e.g., delayed dental, neurological, gynecological, gastroenterological, or mental health conditions) may be due to underlying IPV 6,7 . The prevention and treatment of IPV should thus be an integral component of routine medical practice. Prevalence of IPV According to the most recent data from the National Intimate Partner and Sexual Violence Survey, conducted by the Centers for Disease Control and Prevention (CDC), 41% of women and 26% of men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner at some point during their lifetimes. 6 Over 53 million American men and 61 million women have experienced psychological aggression by an intimate partner in their lifetime 6 . Other measures of the problem in the United States include: • Over half of female homicides in the United States were committed by a current or former male intimate partner. 6 • Women between the ages of 18 – 24 experience the highest rates of IPV. 8 • IPV is involved in 1 of every 4 women who attempt suicide. 9 • The average healthcare cost of each incident of IPV for women was $4273. 10 • Overall costs related to IPV are estimated to exceed $9.3 billion each year, which includes medical and mental health care and lost productivity. 10 Although IPV affects both women and men, and cuts across all age, racial, ethnic, religious, educational, and socioeconomic strata, research indicates a higher prevalence in certain groups: 11 • Women who are single, separated, or divorced. • Individuals who have recently sought a restraining/vacate order. • Individuals who abuse alcohol or other drugs, or whose partners do.
• Those with a partner: ° who are excessively jealous or possessive experiencing unemployment or job instability • Women who are pregnant and have been previously abused. • Low-income individuals, especially those in financial distress. • Adolescents and young adults. • Ethnic minorities. • Non-U.S.-born (immigrant) women. • Being gender non-conforming or a gender sexual minority. • Vulnerable groups such as those who are sex workers or disabled. ° Consequences of IPV The physical and psychological consequences of intimate partner violence can be profound. 12,13 Injuries from physical and sexual assault affect approximately 75% of female survivors and 48% of male survivors 6 . Female survivors have higher risks of sexually transmitted infections, including HIV, pelvic inflammatory disease, unintended pregnancy, and psychological distress. 7 Long-term conditions associated with IPV include chronic pain, neurologic disorders, gastrointestinal disorders, migraine headaches, and other physical disabilities, as well as post-traumatic stress disorder, depression, and anxiety. 7 Theoretical Models Several models describe the dynamics of abusive relationships, two of which – The Duluth Power and Control Wheel, and Johnson’s Typology of Domestic Violence, are summarized here. The Duluth Power and Control Wheel In 1984, the Duluth Domestic Abuse Intervention Project developed a framework to describe the behavior of men who physically and emotionally abuse their female partners. 14 Derived from the experiences of women living with men who batter, the Power and Control Wheel was developed to graphically represent the idea that acts of physical or sexual violence are part of a more general pattern of controlling behaviors, rather than isolated incidents of abuse, or as cyclical expressions of pent-up anger, frustration, or painful feelings. Johnson’s Typology of Domestic Violence : Although the perpetrators of IPV are most often men, research that defines “violence” more broadly than just physical violence, finds that men and women use “violent” tactics equally often in relationships. 15 Michael Johnson’s research divided couples into those who use what he terms “intimate terrorism,” in which an abuser (usually male) uses violence and power and control tactics that usually escalate. Their targets are the women most often seen in hospital emergency departments with severe injury, those likely to be abused during pregnancy, those most often forced into sex, and those with severe psychological trauma.
Introduction Intimate partner violence (IPV) is a serious public health issue in the United States, affecting approximately 36% of American women and 33% of American men in their lifetime. 1 IPV is defined as deliberate coercive and harmful control by someone who is currently, or was previously, in an intimate relationship with another person, regardless of the duration or significance of the relationship. The term “intimate partner violence” is preferred to “domestic violence” because IPV is more inclusive—it doesn’t imply a shared residence between the two people. 2 IPV covers a spectrum of assaultive and coercive behaviors that can occur in any combination, in sporadic episodes or chronically, over a period of days, months, or even decades. They may include, but are not limited to: • Actual or threatened physical assault • Sexual violence, including forced sexual intercourse and other forms of sexual coercion or exploitation • Psychological/emotional abuse such as insults, belittling, constant humiliation, intimidation, threats of harm, or threats to take away children • Controlling behaviors, including isolating a person from family and friends, monitoring movements, or restricting access to financial resources, employment, education or medical care • Destruction of property or personal possessions • Sustained social isolation • Spiritual abuse (i.e., coercion or manipulation justified by religious or spiritual beliefs) • Maltreatment of dependents including children, other family members, or animals/ pets Although most intimate partner violence is against women in heterosexual relationships, violence can be directed at any individual in any kind of relationship. Both survivors and perpetrators of abuse may self-identify as male, female, transgender, gender non-conforming, or as a member of another gender or sexual minority. 2 Because the bulk of violence occurs against women in heterosexual relationships, however, this guide focuses primarily on cis-heteronormative IPV. Clinicians may take an overly narrow view of IPV, seeing it only in terms of physical or sexual abuse in a relationship. IPV is not a situation where a couple is arguing or having a disagreement. It is a chronic and potentially life-threatening interpersonal situation. A broader view of IPV as a dysfunctional situation involving misuse of power and control is preferable. 3 How this dysfunction plays out – physically, emotionally, financially, or through isolation or other forms of mistreatment, varies widely and may not conform to stereotypical ideas of “violence.” For example, perpetrators of IPV may harass a partner hundreds of times a day with phone calls, demand online access to passwords, or relentlessly stalk a partner or former partner in threatening or intimidating ways.
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