INTRODUCTION — Intimate partner violence (IPV) is a serious, preventable public health problem affecting more than 32 million Americans [1]. Although IPV affects all people, more women than men experience IPV. Lifetime estimates for IPV involving women in the United States range from 22 to 39 percent [2,3]. In countries around the world, 10 to 69 percent of women report physical assault by an intimate partner at some time in their life [4].
The term "intimate partner violence" describes actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse. IPV can occur among people of all gender identities and sexual orientations and does not require sexual intimacy.
Care of the person experiencing IPV requires a team approach involving medical, institutional, and community resources. The clinician's role is to make the diagnosis, provide ongoing medical care and emotional support, assess patient safety, counsel the patient about the nature and course of domestic violence, educate the patient about the range of available support services, document findings, make appropriate referrals, and assure follow-up.
This topic will discuss the clinician's role in managing the patient in whom IPV has been identified. The clinical manifestations of IPV and the screening and diagnosis of IPV are discussed separately. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence: Epidemiology and health consequences".)
INITIAL APPROACH TO THE PATIENT — Futures without Violence has identified four guiding principles of intervention for clinicians [5]:
●Survivor safety – Being always aware that the primary concern is to maximize safety and not increase risk for further harm
●Survivor empowerment – Facilitating the patient's ability to make their own choices
●Perpetrator accountability – Framing the violence as occurring because of the perpetrator's behavior and not the survivor's
●Advocacy for social change – Collaboration and advocacy beyond the healthcare setting
The World Health Organization issued guidance in 2013 for responding to intimate partner violence (IPV) and sexual violence against women [6,7]. The guidelines stress the importance of person-centered care as first-line support, including confidentiality when possible, privacy, nonjudgmental support, validation, and not pressuring the person to leave the relationship. The guidelines incorporate recommendations for initial support, care for survivors, clinician training, healthcare policy, and mandatory reporting. These guidelines should hold true irrespective of gender identity, gender expression, and sexual orientation of the patient.
When IPV has been identified, the most important first consideration is to offer support to the patient. It is crucial that providers affirm their understanding of how difficult it must be for the patient to share this information, recognize the patient's strength in doing so, and provide assurance that the provider will be available to the patient for the future. This should be immediately followed by an assessment of the victim's safety. It should be noted that these principles represent key tenets of trauma-informed care, which emphasizes patient agency and empowerment through creating a safe environment for disclosure, care, and healing.
Support — The immediate expression of empathy, acknowledgement, and continued ability to support and assist the patient are the most important components of care after a patient has disclosed abuse. Some suggest explicitly thanking the patient for the trust shown by their willingness to share difficult information [8]. Close follow-up is often warranted, especially if the patient is in crisis.
Empathy may be shared with the following comments:
●"I am very sorry this is happening to you."
●"I am glad you were able to tell me."
●"This is a common problem."
Validation may be expressed with the following statements:
●"You do not deserve this, and it is not your fault."
●"You must be very strong to have been able to go through this and now to be able to ask for help."
Assistance can be offered by the following:
●"I want to help you through this in any way I can."
●"I have worked with others with this problem and can assist you in improving your health and with resources to support you through working on this problem."
Patients may not be ready to take action at the initial disclosure, but may be helped to move toward action, with understanding of their stage of readiness on a continuum of stages:
●Pre-contemplation – The patient is not concerned about the situation.
●Contemplation – The patient has considered change but is not ready to take action.
●Determination – The patient has decided to make changes in their situation.
●Action – The patient is actively seeking help and taking steps to address the IPV.
The clinician should help the patient along this continuum and assure the patient that they will not be abandoned, regardless of where they are in the process of change. Many patients will not move in a linear fashion through these stages. Clinicians should support the patient in making changes for which they are ready, and not recreate the dynamics of power and control by insisting on unidirectional progress through the stages to departure.
Assessing for safety — The clinician must assess the safety of all patients who are experiencing IPV. Although the vast majority of patients are not in imminent danger and are not planning to leave their relationship, it should not be overlooked that IPV can result in death. Assessing for safety and making a safety plan can decrease the risk of mortal harm. (See "Intimate partner violence: Epidemiology and health consequences", section on 'Homicide'.)
The clinician should ask the patient how afraid they are and what they think are their immediate and future safety needs. Unfortunately, many people minimize or deny their danger. Clinicians may be surprised or frustrated with the severity of abuse patients are willing to tolerate and should understand that love and other family concerns, such as children in the home and economic factors, often confound the picture and contribute to patients’ decision-making.
In an open-ended way, patients should be asked about their concerns and fears. A 20-item Danger Assessment tool has been developed and validated to predict the likelihood of lethality or near lethality in an IPV relationship [9]. In a validation study, the sensitivity of the tool for attempted femicide was 38 percent for scores between 14 and 17, and 85 percent for scores 18 to 20.
Patients should be offered referral to talk to about options and safety. For patients who are not ready or are too fearful to proceed with referral, support and concern should be discussed on subsequent visits, and the patient should again be asked to consider referral to someone to help them think about their options. Providers should become aware of clinic, hospital, local, and community resources to aid in referral. (See 'Local resources' below and 'Resources in the United States' below.)
Risk factors for escalating abuse — The Danger Assessment tool identifies risk factors for violence and includes perpetrator and victim factors.
Perpetrator factors — Perpetrator factors associated with increased danger to a patient include [9]:
●Violent outside the home
●Violent to children
●Threatening to kill victim, children, self
●Escalating threats
●Using drugs, especially phencyclidine (PCP), crack cocaine, amphetamines, or alcohol
●Abusive during pregnancy
●Obsessive, controlling relationship
●Has provoked serious prior injury
●Owns weapons, especially handguns
●Has threatened others, including friends and/or family
Victim factors — Victim factors associated with increased danger include [9]:
●Attempting to leave the relationship
●Has sought outside intervention
●Acknowledgment that they are afraid for their life
●Suicidal (with a plan, or with prior suicide attempts, or has means)
●Homicidal
Safety plan — If any significant risk factor is present, it is imperative to devise a safety plan, as the patient may be at risk of serious harm or death. Depending on availability, a hospital or community domestic violence advocate, hospital social worker, or local domestic violence hotline can provide advice about the recommended plan in the community. The patient may need access to a shelter.
A safety plan should include the following elements:
●Preparing an emergency kit with important documents, keys, money, and other essential items, to be stored outside the home in case they need to escape urgently (figure 1)
●A place to go (friends, family, shelter)
●A signal to alert children or neighbors to call 911
●During times of escalating conflict, avoiding rooms with potential weapons (kitchen) or risk for increased injury (hard bathroom surfaces)
INTERVENTION, COUNSELING, AND REFERRAL — Providers should assure the patient that they are available for support. In addition, the patient should be offered referral for counseling about options and safety, often to an onsite or local domestic violence agency where available. Patients may be reluctant or resistant to talking with anyone else besides their provider because of fears about safety. On subsequent visits, you may emphasize ongoing support and concern and ask the patient again to consider referral to expert teammates who can help them think about their options.
Caution should be taken in providing the patient with written materials since safety may be jeopardized if the abuser finds this material. One institution provides an unidentified phone number for the Family Violence Program as one of many important numbers printed on the back of clinician business cards. If brochures are distributed, it should be made clear that the patient has a place to keep them that would not be accessible to the perpetrator. The ASPIRE News App, which appears like a news site, offers a discrete way to call for help and can be downloaded onto a phone or other device [10]. Similarly, care should be taken when documenting safety advice in after-visit summaries (printed or in electronic health records) or in patient notes, as these may be viewed by perpetrators. With patient assent, it may be a best practice to un-share patient open access to the electronic medical record. (See 'Documentation' below.)
If the abuser is present in the office or in a virtual telemedicine visit, do not confront them; this can endanger patients and, potentially, providers.
Effectiveness of intervention — The effectiveness of interventions for domestic violence has been studied and have shown limited benefits for most women [11]. Some studies show benefits for pregnant women.
Studies have not shown conclusive benefits for advocacy or counseling interventions. A 2015 systematic review found insufficient evidence to determine if advocacy (providing information, support, and resource access) in healthcare settings is effective for women who have experienced intimate partner violence (IPV) [12]. Intensive advocacy may improve short-term quality of life and decrease physical abuse one to two years after the intervention for women living in shelters.
Interventions may be effective in pregnant women. In a 2012 meta-analysis of four trials, counseling interventions reduced IPV, improved birth outcomes for pregnant women, reduced IPV in the postpartum period, and reduced unsafe relationships and pregnancy coercion for women seen in family planning clinics [2]. However, a subsequent 2014 systematic review looking at nine studies concluded that there was insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes due to the heterogeneity and poor quality of studies overall [13].
The 2013 World Health Organization guidelines concluded that, except for women who have spent at least one night in a shelter or for pregnant women experiencing IPV, there is insufficient evidence that interventions for IPV improve health outcomes [6,7].
It is worth noting that quality research studying people exposed to violence is fraught with issues related to ongoing patient safety and coercion, which may limit/bias enrollment, participation, and follow-up. There are no large studies of the effectiveness of interventions in men or LGBTQII persons.
Counseling the survivor — Counseling may strengthen the survivor's sense of self-worth and provide ongoing support, although objective evidence to support these benefits is limited. Counseling can also assess the degree of danger for survivors and their children and help them develop a safety plan. Brief advocacy has been shown to increase the use of safety behaviors by abused women [12].
Many people experiencing abuse are not ready to leave their abusers because of fear of reprisal; economic dependence on the abuser, especially if there are children; no acceptable place to go; belief that the abuse will stop; or belief that the abuse is their fault. Victims may believe expressions of remorse and promises that the abuser will change their behavior. Dropout rates from treatment programs are high [14].
Attempting to or leaving a relationship with a perpetrator often increases the risk of injury. Providers should not encourage their patients to leave a relationship [15]. If patients come to their own decision to terminate a relationship, close attention should be paid to devising and implementing a safety plan and seeking assistance from hospital and community resources where available.
Clinicians should screen the patient for possible psychologic issues (depression and anxiety) as well as substance use [8]. Many centers are now routinely screening for depression and assessing for anxiety and substance use in patients at risk. Co-locating behavioral health care within primary care clinics may enable more vulnerable patients to benefit from care with medications and counseling without referral to other providers [16]. In addition to concerns about the patient, clinicians should consider whether child protective services are required. (See "Intimate partner violence: Childhood exposure".)
Local resources — If a patient appears in danger, referral to in-house and/or community resources is important. Referral should also be considered, in the absence of imminent danger, for those who screen positive for current IPV. (See 'Assessing for safety' above.)
Familiarize yourself with local resources for referral. These may include:
●Hospital programs
●Community hotlines
●Shelters
●Group support, including batterers' groups
●Legal aid
●Social welfare services
●Support for specific groups: immigrants requiring interpreters, survivors in same sex relationships, survivors with physical or intellectual disabilities
Resources in the United States — Governmental resources at the state and federal level are available. Some helpful web-based resources include:
●www.futureswithoutviolence.org/
●www.ncadv.org/learn-more/resources
●www.womenshealth.gov/relationships-and-safety/get-help
●www.cdc.gov/ViolencePrevention/intimatepartnerviolence/index.html
Telephone resources include:
●National Domestic Violence Hotline: 1-800-799-SAFE (1-800-799-7233)
●The National Sexual Assault Hotline: 1-800-656-4673
●The National Teen Dating Abuse Hotline: 1-866-331-9474
Intervention for the perpetrator — Court-mandated interventions to assist batterers have been minimally successful, decreasing recidivism by only 5 to 7 percent according to two meta-analyses [17,18]. Attrition rates from batterer intervention programs are high (about 50 percent), and those who drop out are most likely to be involved in IPV again [19].
Suggestions for improvement of these programs include shifting the program from court-mandated group therapy to models based on stages of change or individually tailored treatment. Further suggestions include concurrent substance use and/or mood disorder therapy or treatment of couples together [18,20].
LEGAL ISSUES
Documentation — Careful documentation is important if the patient seeks legal redress. Reports of abuse need to be specific and detailed.
The following data should be recorded:
●Quotes from the patient about the occurrence, nature, and time of abuse.
●Quotes that identify the perpetrator, where permitted by the patient. Patients do have the right to ask that information regarding intimate partner violence (IPV) not be included in their chart. Often information in the chart can help with incriminating the perpetrator; however, in situations where perpetrators have access to the records (shared children), this information may increase danger to victims. Patients can often request that information about IPV not be visible on an electronic patient portal or any paperwork provided to them.
●Findings from the physical examination.
●If possible, photographs of any physical injuries after obtaining the patient's signed consent. The photograph must include the patient's face or identifying features with the injury to be useful as evidence. If a camera is not available, the clinician should make a sketch of the injuries.
●Orders for appropriate laboratory and radiology studies.
●Comments on comorbidities, if present, and degree of disability.
Language should be chosen carefully. Words such as denies or claims, although commonly used in medical records, suggest the clinician may not believe the patient. It is helpful to state: "Patient reports that she does not drink or use drugs" in lieu of "Patient denies alcohol or drug use."
Where relevant, rape kits such as those facilitated by Sexual Assault Nurse Examiners (SANE nurses) should be obtained and documented.
Mandatory reporting — The clinician needs to be familiar with state or country law regarding situations for which reporting is mandated. Requirements for reporting vary by state, with mandatory reporting required in only a minority of states as of 2012.
Domestic violence programs, either hospital-based or in the community, can often provide assistance with reporting and/or guidance about whether reporting is indicated.
Situations that commonly require reporting are:
●Abuse of disabled persons – Harm to disabled persons must be reported to the Disabled Persons Protection Commission.
●Weapon use – In most states, injury resulting from assault with a firearm or knife or causing "grave bodily harm" is reportable.
●Elder abuse – Many states have mandatory reporting laws for elder abuse. (See "Elder abuse, self-neglect, and related phenomena".)
Abuse involving children — Within the United States, domestic violence involving a child, including children who are witnesses to domestic violence, must be reported if the following criteria are met:
●Under the age of 18; and
●Abuse or neglect of the child is suspected
State-specific guidelines about what constitutes the need to report and who is mandated to report are available through the Child Welfare Information Gateway.
Health providers and law enforcement officers, as well as teachers and child care providers, are mandated reporters in most states. State policies differ on whether the situation in which a child witnesses a parent being abused is considered child abuse. There has been concern that mandated reporting may be a barrier to the parent's being willing to reveal abuse or even be a barrier to clinic attendance by parents. (See "Child abuse: Social and medicolegal issues" and "Intimate partner violence: Childhood exposure".)
Protection order — Patients who feel they are in danger may consider initiating a Domestic Violence Protective Order (DVPO), legally preventing perpetrators from contact with patients. In general, a community advocate or legal advisor will assist the patient with obtaining this document. Evidence of the effectiveness of protection orders in preventing recurrent violence is inconsistent [21,22]. In one US retrospective study, compared with abuse survivors who did not obtain a protection order, women who were granted a temporary (usually two-week) restraining order were more likely to be subsequently psychologically abused in the 12 months following the index incident, while women who obtained a permanent protection order (12 months) were less likely to be physically abused in the 12 months [23].
MANAGING THE PATIENT WITH A HISTORY OF ABUSE/TRAUMA — Patients with a history of prior, rather than current abuse, may present with chronic health problems [24]. It should be recognized that it is generally difficult for patients to disclose prior abuse situations.
Some patients with an abuse history present with comorbid depression and somatic complaints, including chronic pain. It is important not to abandon these patients, even if their problems continue to be difficult to solve. There is some evidence that somatic complaints may decrease after disclosure and that wellbeing may improve when root causes are addressed [25].
Clinicians should follow basic tenets of trauma-informed care, fostering a healthy patient-provider relationship and taking care not to recreate the dynamics of power and control that are typical of classic intimate partner violence (IPV). The clinician must ensure trust and continuity and be mindful of maintaining appropriate boundaries.
Patients should be encouraged to make autonomous decisions regarding health advice. Focusing care on the patient's safety and health, rather than life choices, can be helpful. Understanding the intersection of multiple layers of trauma in many of these patients, including those from other forms of oppression (including racism, sexism, xenophobia, heterosexism), and the role of “maladaptive coping” for survival (eg, with substance use or other unhealthy behaviors) may offer insight that enables providers to provide nonjudgmental care and foster a healing relationship.
Frequent scheduled follow-up as well as referral to mental health clinicians for cognitive behavioral (CBT) or dialectical behavioral (DBT) therapies may be helpful, as can ongoing contact with community or hospital-based advocates. (See "Somatic symptom disorder: Treatment".)
CURBING SOCIETAL VIOLENCE — There is an increasing move to work at the societal level to change cultural norms (or structures) that perpetuate violence [26,27]. Legal and policy reforms have little impact without first addressing change in cultural attitudes and institutional practices [14].
Attempts to impact cultural norms include efforts targeted by and for men such as the White Ribbon campaign to change social norms away from power and control and towards equality. The White Ribbon campaign has organizations in multiple countries, including the United States, Canada, Scotland, England, and Australia.
Increasingly, culturally specific community-based groups are trying to assist their members in ways that are acceptable within their life contexts. Partner violence organizations geared to specific groups include SEARAC for intimate partner violence (IPV) survivors of Asian descent, Wafa House in New Jersey for survivors who are Muslim, and Alianza for Latina women.
Worldwide, there has been attention given to stiffen penalties for violence and so decrease its occurrence. As an example, legislative action has been proposed in the United States to evaluate country-specific policies about violence against persons in making decisions about foreign aid and diplomacy [28]. In 2012, the US Department of State and the US Agency for International Development (USAID) announced an official strategy to prevent and respond to gender-based violence globally, to coordinate efforts between multiple governmental groups, to integrate gender violence prevention in US government work, and to improve data collection and research efforts [29].
SUMMARY
●The expression of empathy, acknowledgement, and continued ability to support and assist the patient are the most important components of care immediately after a patient has disclosed trauma. Close follow-up is often warranted, especially if the patient is in crisis. (See 'Support' above.)
●All intimate partner violence (IPV) patients should be assessed for safety. Many people experiencing IPV minimize or deny their danger. In an open-ended way, patients should be asked about their concerns and fears. Patients should be offered referral to someone to talk to about options and safety. For patients who are not ready or are too fearful to follow through with referral, support and concern should be ongoing and referral options discussed on subsequent visits. (See 'Assessing for safety' above.)
●If any significant risk factor for escalating abuse is present, it is imperative to devise a safety plan as the patient may be at risk of harm or death. A hospital or community domestic violence advocate, hospital social worker, or local domestic violence hotline can provide advice about the recommended plan in the community. (See 'Safety plan' above.)
●Counseling may strengthen the victim's sense of self-worth and provide ongoing support, although objective evidence to support these benefits is limited. Counseling can also assess the degree of danger for victims and their children. The person experiencing abuse should be reassured that the provider is available for support. Caution should be taken in providing the patient with written materials, since safety may be jeopardized if the batterer finds this material. DO NOT confront the perpetrator, as this can endanger the patient and, potentially, the provider. (See 'Intervention, counseling, and referral' above.)
●Careful documentation is important if the patient seeks legal redress. Reports should specify quotes from the patient about the occurrence, nature, and time of abuse, findings from the physical examination, and photographs if consented. Patients do have the right to ask that information regarding IPV not be included in their chart and/or not be visible on an electronic patient portal or any paperwork provided to them. Often information in the chart can help with incriminating the perpetrator; however, in situations where perpetrators have access to the records (shared children), this information may increase danger to victims. (See 'Documentation' above.)
●The clinician needs to be familiar with state or country law regarding situations for which reporting is mandated. Requirements for reporting vary by state in the United States. Abuse involving disabled persons, older adults, children under the age of 18, or weapon use commonly require reporting. Protection orders are intended to legally prevent perpetrators from contact with victims, but evidence of their effectiveness is inconsistent. (See 'Legal issues' above.)
●A trauma-informed approach to care that emphasizes safety and agency, rather than power and control, can be a key to gaining the trust of a patient with multiple traumatic exposures. Understanding the cause of unhealthy behaviors as “maladaptive coping” for survival may offer insight which enables providers to provide nonjudgmental care of patient choices and also enables providers to be more effective, empathic, and healing advocates for these vulnerable patients. (See 'Managing the patient with a history of abuse/trauma' above.)
