Figure

Intimate partner violence (IPV) is a significant public health issue globally with substantial morbidity and mortality. The CDC defines IPV as physical violence, sexual violence, psychological aggression, or stalking by a current or former intimate partner.1 Many survivors of IPV seek healthcare services for violence or its related sequalae, making healthcare settings an important point of intervention. By screening for IPV, healthcare providers can play an integral role in preventing and addressing IPV and promoting the health and well-being of their patients.

Purpose

The purpose of this article is to address screening and intervening for IPV in clinical settings, with a focus on unique considerations for those populations at increased risk for IPV. Although males also experience IPV, the focus of this article will be on females, given that females are more likely to experience IPV and suffer greater morbidity and mortality.

Prevalence and risk factors

The prevalence of IPV varies across studies. The National Intimate Partner and Sexual Violence Survey (NISVS), an ongoing, nationally representative survey of adults living in the US, provides data on lifetime and 12-month prevalence of various types of IPV victimization among females and males age 18 years and older. The most recent data from NISVS suggest that nearly one in two women in the US, or 59 million women, report lifetime IPV and 7.3%, or 9 million women, have experienced any type of IPV in the prior 12 months.2

Although the long-term effects of the COVID-19 pandemic are not yet fully understood, there is ample evidence that the range of public health measures enacted to prevent the spread of the virus (for example, school closures, social isolation, and remote work), as well as the loss of employment experienced by many and the limited availability of social services at the time, contributed to increased psychosocial stress among families globally. Consequently, several studies have indicated that the prevalence of IPV increased during the pandemic.3-6 An improved understanding of psychosocial stress during the COVID-19 pandemic will be critical in responding to the long-term effects of this pandemic as well as informing public health efforts for future pandemics.

Although IPV affects individuals of all genders, sexes, races, ethnicities, and socioeconomic backgrounds, research has identified risk factors associated with both IPV perpetration and victimization, including:

younger age financial stress, including financial hardship, unemployment, and poverty limited or disparate education levels history of witnessing or experiencing violence substance use mental health disorders (for example, depression, anxiety, and posttraumatic stress disorder) high levels of crime, poverty, and unemployment in the surrounding community lack of social support services for preventing IPV societal gender inequality.

It is important to note that, though these risk factors are associated with IPV, they do not cause it. Rather, IPV is a complex issue with multiple contributing factors; prevention efforts therefore must address these factors comprehensively.7

Research demonstrates that lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) experience IPV at higher rates than heterosexual or cisgender persons.8,9 This is particularly salient for LGBTQ+ persons of color, who experience significantly higher rates of IPV compared with their White counterparts. Although IPV has a multifactorial etiology, it is thought in LGBTQ+ relationships to be linked often to minority stress, as these individuals experience unique stressors related to their identities.10

Persons with disabilities represent another population at heightened risk for experiencing IPV, as they may face additional barriers to seeking help and accessing resources. Researchers examined the association between IPV and disability in a nationally representative sample of US women and men and found that women with a disability were significantly more likely to report all types of IPV measured in the study, including experiences of rape, sexual violence other than rape, physical violence, stalking, and reproductive coercion, as compared with women without disabilities. Using population-based data, researchers found that women with disabilities were 2.5 times more likely to experience IPV during pregnancy that those without disabilities.12 Risk factors such as social isolation, financial dependence, and communication barriers can increase the risk of violence for persons with disabilities. Importantly, women with disabilities may also face unique forms of violence, including physical restraint or confinement in inaccessible locations, withholding of necessary medical care or equipment, or refusal to assist with essential activities of daily living (for example, eating or getting out of bed).12

Health consequences

The physical and mental health sequelae of IPV are significant. IPV survivors may experience physical abuse and present with acute injuries such as fractures, sprains, dislocations, head injuries (including traumatic brain injury), lacerations, or strangulation sequelae. More chronic effects of IPV include headaches, insomnia, pelvic pain, and irritable bowel syndrome. There are numerous mental health conditions associated with IPV including increased risks of depression, anxiety, posttraumatic stress disorder, and suicidal ideation and suicide.13 Experiencing IPV during pregnancy is associated with an increased risk of low birth weight or preterm birth for the infant as well as an increased risk for the fetus or infant to be small for gestational age.14 This may be due to direct blunt physical trauma, negative maternal coping behaviors (for example, smoking, substance use, and disordered eating), diminished access to prenatal care, and elevated physical or psychological stress levels.15

Screening

Routine screening for IPV in the healthcare setting is critical for identifying women at risk of or experiencing violence. The US Preventive Services Task Force (USPSTF) updated its recommendations in 2018; healthcare providers should screen for IPV in women of reproductive age and provide or refer women who screen positive to appropriate support services.16Screening for IPV, when conducted in a private and respectful manner, is highly acceptable to women as well as feasible in the clinical setting. Normalizing statements should be used prior to assessing for IPV to reinforce the fact that screening is part of routine practice, and professional interpreters should be used as appropriate. For example, a clinician might say the following: “Because violence is a common issue in many relationships, I ask all my patients about their safety.” All patients should be informed of the confidentiality surrounding such discussions, though providers should also review with their patients mandatory reporting laws for the appropriate state.

Although multiple organizations—including the USPSTF, the American College of Obstetricians and Gynecologists, and the Association of Women's Health, Obstetric and Neonatal Nurses—recommend screening for IPV, specific measures have not yet been endorsed. Screening instruments such as the Abuse Assessment Screen (AAS); Hurt, Insult, Threaten, Scream (HITS) Score; and Women Abuse Screening Tool (WAST) include four to eight items that are either self-report or clinician-administered with sound psychometrics.13 Accurate documentation is important, as clinical encounters may become forensic evidence of IPV and its related physical sequelae. After obtaining informed consent from the patient, the provider should document direct quotations from the patient regarding their experience and include a body map or photographs in the patient's chart. Comprehensive documentation should be undertaken surrounding the history, examination, symptoms, diagnostic and lab results, witnesses to the IPV, and any referrals including those to law enforcement in accordance with the patient's desire and consent.

The implementation of IPV screening in any clinical setting requires an understanding of patient-, provider-, and system-level factors that may pose barriers to assessment and intervention. Several patient-level barriers to IPV screening are described in the literature; they include a lack of awareness of abuse, language barriers in the clinical setting, insecurity or shame, discomfort with reporting IPV to a provider of the opposite sex, and fear of the consequences of disclosure (for example, escalated abuse, consequences for the partner, and consequences for the family).17-19 For foreign-born survivors, including immigrants, undocumented immigrants, and refugees, unique barriers to screening and subsequent disclosure exist such as fear of deportation or losing custody of their children.20 Studies exploring provider-level factors have further reported that a lack of provider knowledge about IPV, low perceived self-efficacy, and a decreased sense of responsibility are important barriers to screening.17,18,21 In a qualitative meta-analysis by Tarzia and colleagues, the authors suggest that, globally, providers fear offending patients or causing patient discomfort if they ask about IPV.22 Moreover, the authors found that providers were uncertain about their responsibility to intervene in cases of IPV and were less likely to screen if they believed their efforts to intervene might be ineffective.22

Examples of system-level barriers include time constraints, a lack of privacy (for example, the presence of the abusive partner during the healthcare visit), a lack of provider training, and fragmented healthcare.23,24 In a qualitative meta-analysis, researchers found that providers felt time constraints during healthcare visits largely impeded their ability to address multiple health concerns, including IPV.24 In addition, providers felt unprepared in their education and training to address IPV if identified.24 Further, a lack of collaboration across disciplines to address IPV appropriately reduced providers' perceptions of the benefits of screening.24 Survivors of IPV may utilize urgent care or ED settings for health issues related to exposure to violence (for example, chronic pain, dizziness, irritable bowel syndrome, and gynecologic symptoms) but less commonly for physical injuries.25,26 As such, fragmented or episodic care leads to a reduction in opportunities to screen and intervene, and it diminishes opportunities for healthcare providers to establish a trusting relationship with patients who might be affected by IPV. To address barriers to IPV screening, healthcare providers should focus on building rapport, providing patient support, and providing patient education regarding available IPV services to mitigate patient-level barriers.19 In addition, continuing education and training for providers may be key facilitators to the identification of IPV and the provision of comprehensive care.27

Resources

Given the prevalence of IPV, healthcare providers must remain committed to the IPV screening process, drawing upon the latest guidelines related to screening and intervening. Numerous resources are available for advanced practice registered nurses (APRNs) who wish to improve their competency in trauma- and violence-informed care. For example, the nonprofit Futures Without Violence offers free webinars, educational videos geared toward healthcare professionals, and toolkits for providers interested in learning how to use their clinical practice to address better the needs of those suffering from IPV and other forms of violence.28 In addition, the International Association of Forensic Nurses (IAFN), renowned for its Sexual Assault Nurse Examiner (SANE) certification, offers a 15-hour online program through which a participant can become a certified Intimate Partner Violence Nurse Examiner (IPVNE).29

Because IPV is a complex issue, caring for patients experiencing it requires a holistic, team-based approach that includes advocacy for equitable access to healthcare as well as institutional and community resources. The primary role of the APRN is to identify patients at risk of IPV via assessment and subsequently to provide ongoing, supportive care, including evaluation of patient safety; provision of education on additional support services and resources; provision of ongoing emotional support; and completion of adequate documentation, referrals, and follow-up visits.23 Drawing on the principles and guidelines of trauma-informed care from agencies such as the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA), among others, can help guide APRNs as they navigate patient interactions. For ease of reference, SAMHSA released the “Four R's” of trauma-informed care: 1) realizing the widespread impact of trauma; 2) recognizing the signs and symptoms of trauma; 3) responding by fully integrating knowledge about trauma into policies, procedures, and practices; and 4) resisting re-traumatization of the patient.30

Interventions

Interventions for IPV survivors should largely be guided by the individual's wishes and other contextual factors. Factors such as immediate and long-term safety, confidentiality, and legal considerations should be included in any intervention. When IPV is suspected or disclosed, a key consideration is the individual's safety. With the patient's consent, an IPV danger assessment should be administered whenever an individual discloses information during a clinical encounter that raises imminent harm or safety concerns. The danger assessment assists the healthcare provider in determining the degree to which an individual may be at risk for severe violence, including homicide. Substantial research has identified multiple risk factors that place an individual at heightened risk for severe IPV and intimate partner homicide.31 Factors such as the partner or former partner's access to a firearm or previous threats by the partner or former partner to use a weapon to kill the individual place that individual at significant risk.31 There are several brief risk assessment measures that can be used to evaluate the patient. The Danger Assessment, a 20-item measure widely used by healthcare providers as well as law enforcement, is now available as a 5-item measure known as the Danger Assessment-5 (Table 1).32 In addition to assessing an individual's level of danger, safety planning should include a conversation that helps an individual both anticipate situations that may elevate their risk of violence while also developing a plan aimed at reducing their risk of violence. Table 2 outlines elements of safety planning. Numerous online resources for safety planning exist including the National Domestic Violence Hotline (www.thehotline.org/plan-for-safety/create-a-safety-plan/), which offers an interactive guide to safety planning, and the National Center on Domestic and Sexual Violence (ncdsv.org), which provides individuals with a template to use in developing a personalized safety plan.33,34 Additionally, there are a variety of apps that can help individuals assess their own health and safety, and some can also help an individual assess the risk of a friend or loved one. myPlan (myplanapp.org), for example, is an interactive safety decision aid app that has been found to increase the use of safety strategies, reduce decisional conflict, and increase the likelihood of safely ending a violent relationship.35,36

Table 1. - Danger Assessment-5 (DA-5)

This brief risk assessment identifies women who are at high risk for homicide or severe injury by an intimate partner or former intimate partner.a,b

Mark Yes or No for each of the following questions.

____ 1. Has the physical violence increased in frequency or severity over the past year?

____ 2. Has your partner (or ex) ever used a weapon against you or threatened you with a weapon?

____ 3. Do you believe your partner (or ex) is capable of killing you?

____ 4. Has your partner or ex ever tried to choke (strangle) you?∗

If yes, did he ever choke you? ______

About how long ago? ______

Did it happen more than once? ______

Did you ever lose consciousness or think you may have?______

____ 5. Is your partner or ex violently and constantly jealous of you?

∗This can be asked instead of or in addition to: Have you ever been beaten by him while you were pregnant?

PROTOCOL SUGGESTIONS FOR USE OF DANGER ASSESSMENT-5

Use 5-item version in the Emergency Department and other healthcare settings, at protective order hearings, child custody, and other settings once intimate partner violence has been identified.

If 4 or 5 yes responses, tell the victim s/he is in danger, allow the victim to choose reporting to the police &/or to domestic violence advocacy program &/or confidential hotline (eg, 800-799-7233). Follow through by calling with the victim &/or with an in-person hand-off to a knowledgeable advocate.

If 3 yes responses, do the full Danger Assessment (DA) with the calendar and weighted scoring if the victim is female; inform the victim of level of danger and do safety planning based on the DA or refer and hand-off to someone certified in administrating the DA and proceed based on results and best practice. An in-person or voice-to-voice hand-off on the phone (eg, 3-way-call or speaker phone) is preferable.

If 2 yes responses, tell the victim there are 2 risk factors for serious injury/assault/homicide present and recommend further advocacy. If the victim agrees, follow through with a referral and hand-off to a knowledgeable advocate. An in-person or voice-to-voice hand-off on the phone (eg, 3-way-call or speaker phone) is preferable.

If 0-1 yes responses, proceed with normal referral/procedural processes for domestic violence.

BRIEF STRANGULATION PROTOCOL

If yes to 4a. If strangulation was a week ago or less, examine the inside of the throat, neck, face and scalp for physical signs of strangulation. See strangulation assessment and radiographic evaluation information at www.strangulationtraininginstitute.com. Proceed with emergency medical care for strangulation, especially if loss of consciousness or possible loss of consciousness (victims are often unsure, but if the victim lost consciousness, s/he will have become incontinent—ask if the victim “wet her/himself”). If the victim reports more than one strangulation, conduct neurological exam for brain injury or refer for examination and inform her/him of increased risk of homicide. Notify police and/or prosecutors if the victim wants this action (know state/local law on strangulation and mandatory reporting so that the victim can be informed).

a.This is a brief adaptation of the Danger Assessment (2003). It is designed for use by a health care provider following a positive screen for intimate partner violence. The full Danger Assessment with weighted scoring provides the most accurate assessment of risk.

b.Snider, C., Webster, D., O'Sullivan, C. S. and Campbell, J. (2009), Intimate Partner Violence: Development of a Brief Risk Assessment for the Emergency Department. Academic Emergency Medicine, 16: 1208-1216.

Used with permission. Source: Messing JT, Campbell JC, Snider C. Validation and adaptation of the danger assessment-5: A brief intimate partner violence risk assessment. J Adv Nurs. 2017;73(12):3220-3230. doi:10.1111/jan.13459.

Table 2. - Basic safety planning tips for patients33,37

If in danger or feeling threatened, call 911 and/or remove yourself from the situation if safe to do so.

Practice where and how you will leave the house in an emergency.

If applicable, teach children how to contact 911 and what to do in an emergency.

Teach children, trusted family members, or friends a code word that signals them to call 911.

Keep a “go bag” packed and accessible if you need to leave unexpectedly. Keep this bag in a safe place that you can easily access such as in your car, at work, or with a close friend. Items may include:

important documents such as social security cards, birth certificates, passports, marriage license, relevant military paperwork, insurance cards, school and health records, welfare and immigration documents, and divorce or other documents

credit cards, bank account numbers, and ATM cards as well as some cash or money cards

prepaid cell phone

medications and prescriptions

clothing and comfort items.

Maintain gas in the car or know your transportation options.

In addition to assessing for immediate danger and safety planning, healthcare providers should provide all individuals with a list of community and local resources as well as contact information for telephone, online chat, or text assistance that is available 24 hours per day.37 The National Domestic Violence Hotline website provides an option for individuals to search their local areas for shelter information as well as additional services such as emergency financial assistance, food assistance, health services, transitional housing, domestic violence prevention counseling, and transportation assistance. The organization also provides information specific to protective orders and restraining orders.

Conclusion

IPV is a significant and growing public health issue with adverse physical and mental health consequences. Healthcare providers are often the first, and potentially the only, points of contact for individuals seeking care related to IPV. As such, they are ideally positioned to screen for IPV and provide care and information about support services that align with the individual's needs and preferences.

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