Intimate Partner Violence

Screening and Identification in Health Care Settings

In an effort to identify more domestic violence victims, numerous screening tools have been developed for use in different clinical settings. For example, effective assessment strategies and reliable, culturally relevant screening tools can be located at the Violence Against Women Network (VAWnet),⁴⁴ a national, online resource that supports effective prevention and education activities by identifying and addressing factors that perpetuate and increase risk of domestic violence. Most screening tools ask patients to report about the frequency, severity, and type(s) of abuse experienced in past and current relationships. Expert opinion suggests that identification through screening and interventions by health care providers in situations of domestic violence may lead to reduced morbidity and mortality.⁴⁵ Models or protocols developed to prevent other chronic health problems may also be effectively applied to prevent domestic violence.¹

Evidence-based health care practice requires not only research-tested interventions, but also reliable assessment tools that are valid for use in practice.⁴⁶ As previously discussed, many written and verbal screening tools are available to facilitate the identification of domestic violence victims. Such screening tools include questions in written medical histories that patients complete during routine visits as well as verbal questions that health care providers can ask all patients to detect the presence of violence in the patients' current relationships. Some organizations use protocols requiring a simple notation on the patient's chart, assessment form, intake form, medical form, or social history form.

The most obvious signs of domestic violence include evidence of severe, recurring, or life-threatening physical abuse⁴⁷; however, screening tools for assessment can often help detect even the more subtle symptoms of domestic violence. Health care providers need validated screening tools to efficiently and reliably screen patients for domestic violence. Some available screening tools assess physical violence and injury without considering the chronic experience of battering and the psychological consequences associated with the experience of violence.⁴⁸ Other screening tools are considered too long for effective use in practice.

The Conflicts Tactics Scale⁴⁹ (CTS) was the first instrument created to identify partner violence and used for assessment of the presence of domestic violence by measuring interpersonal aggression. In addition, the CTS measures the extent to which partners in a dating, cohabiting, or marital relationship engage in psychological and physical attacks on one another, as well as their use of reasoning or negotiation skills to deal with conflicts.

Intimate Partner Violence and Child Abuse

Prior research provides an integrated conceptualization of the etiology of co-occurring IPV and child maltreatment within a given family.^6,8-10 Proposed theoretical frameworks describing this overlap include (though are not limited to) the following^8-10:

• Social cognitive theory. In IPV research, social cognitive theory proposes that a triadic relationship exists between behavior, the person, and the environment. Within this dynamic relationship, each facet actively affects the other 2 (ie, reciprocal determinism).¹¹ Considering the etiology of family violence, social cognitive theory suggests that those exposed to violence (eg, men in their families of origin, women assaulted by their partners) model this behavior as a means to resolve conflict. The perpetrator then learns through operant reinforcement that the violence works, thereby reinforcing further abusive acts.^8,10
• Ecological theory. According to ecological theory, violence in the home is rooted within the greater context of societal violence. Stressors combined with a lack of protective factors lead to family violence.¹⁰
• Antisocial personality or genetics theory. The origin of family violence in antisocial personality theory or genetics theory lies with a usually male perpetrator afflicted with an antisocial personality disorder.¹⁰
• Family systems theory. The family systems theory maintains a bidirectional view. This theory asserts that all family members contribute to general conflict within a family. Those espousing this view emphasize, though, that each individual, in particular the perpetrator, is accountable for his or her own behavior.¹⁰
• Feminist theory. The feminist theory states that both forms of violence originate from conflict about gender roles and men's need for power and control.¹²

Cited references provide a more thorough description of the above theoretical frameworks for interested readers. Alone, none of these models fully explains the complicated underpinnings of family violence; however, when taken together, they offer a rich foundation for better understanding the complexity of a child abuse-IPV association.

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Disclosure of IPV should be followed by validating statements such as "You don't deserve to be treated that way" or "You are not to blame."³² Such assertions from a trusted provider send an important message to women that the violence is not okay and that help is available. Women should be encouraged to discuss the violence, and the practitioner should listen nonjudgmentally.³¹

A careful safety assessment is also essential. Health care providers should ask questions about substance abuse, the woman's perception of increasing violence and risk, and the presence of weapons in the house. Often, when IPV occurs, a woman must make difficult decisions about safety and must weigh the advantages and disadvantages of leaving the perpetrator. The following are issues that contribute to these decisions:

• Knowledge that the violence generally escalates when a woman tries to leave
• Concern about obtaining the necessary financial resources and provisions for the children
• Fear that the children may be removed from her custody

A frank, but sensitive, discussion of the woman's considerations and plans may help her to take actions that increase her own and her children's safety.

Similarly, providers should ask direct questions about whether the children are being or have ever been abused and whether the woman believes that the children are in immediate danger. It is also crucial for the health care professional to conduct a thorough physical examination of the child to look for findings consistent with abuse. Discussing the effects of violence on children often motivates women to leave the relationship; giving, if needed, mental health resources for the children may help improve child outcomes even if the woman is unable to leave. Health care providers should offer help from local and national IPV agencies. Additionally, if available, assistance from social workers practicing in the provider's setting can be invaluable.

Further management varies somewhat depending upon the presence or absence of concurrent child abuse as well as upon the state's mandated reporting laws (Table 4-1). Health care providers should, therefore, consider the following scenarios:

• Response to concurrent child abuse and IPV
• Response to IPV without concurrent child abuse in a state in which providers are mandated reporters of childhood exposure to IPV
• Response to IPV without concurrent child abuse in a state that does not require practitioners to report childhood exposure

Mental Health Aspects of Intimate Partner Violence: Survivors, Professionals, and Systems

Dating violence is a serious problem among adolescents. According to Youth Risk Behavior Surveys performed in Massachusetts during 1997 and 1999, rates of physical and sexual violence by dating partners do not begin in adulthood; rather, such violence has roots in adolescent experience.

Adolescent responses obtained by the CDC in the Youth Dating Violence Survey indicated that approximately 1 in 5 female students reported being physically or sexually abused by a dating partner. The children reported experiencing many kinds of psychological and physical victimization within dating relationships, including the following:

• Their partners did something to deliberately make them feel jealous, damaged their possessions, said things to hurt their feelings, insulted them in front of others, tried to control them, threatened them, blamed them for bad things that the dating partners did, and brought up something from the past to hurt them.
• In terms of perpetrating psychological abuse in a dating relationship, more than half of the adolescents reported that they hurt their dating partner's feelings, insulted their partner in front of others, did something just to make their partner jealous, tried to control their partner, and damaged their partner's possessions.
• Some adolescents perpetrated physical violence in dating situations by scratching, kicking, slapping, biting, choking, pushing, grabbing, or shoving their partner; hitting their partner with a fist or something hard; throwing something that hit their dating partner; physically twisting their partner's arms; slamming or holding their partner against a wall; or bending the partner's fingers.

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Sexual assault is strongly associated with suicidal tendencies and other emotional problems. In one study, 22% of the women polled said that they had been forced to do sexual things against their will. Usually, an intimate partner had forced them.⁷⁵ In another study that controlled for sex, age, education, posttraumatic stress symptoms, and psychiatric disorder, the researchers associated a history of sexual assault with an increased prevalence of lifetime suicide attempts. For women, the odds of attempting suicide were 3 to 4 times greater when the first reported sexual assault occurred before the age of 16 years in comparison to a sexual assault that occurred at the age of 16 years or older.

The prevalence of PTSD after rape is very high. In a review of 9 studies that investigated the prevalence of PTSD among victims of rape or other sexual violence, 4 studies showed that the rate is greater than 70%.⁷⁶ In a survey of more than 2000 women who were asked about victimization experiences, rates of "nervous breakdowns," suicidal ideation, and suicide attempts were significantly higher for crime victims than for nonvictims. Victims of attempted rape, completed rape, and attempted sexual molestation had problems more frequently than victims of attempted robbery, completed robbery, aggravated assault, or completed molestation. Nearly 1 rape victim in 5 (19.2%) had attempted suicide, whereas only 2.2% of nonvictims had done so. Most sexual assault victims' mental health problems occurred after their victimization.⁷⁷