Secondary Logo

Journal Logo

Contents: Violence: Clinical Expert Series

Intimate Partner Violence and Women's Health

Lutgendorf, Monica A. MD

Author Information
doi: 10.1097/AOG.0000000000003326
  • Free
  • Editors' Pick Podcast
  • Take CME Test
  • ABOG MOC II

Intimate partner violence (IPV) has a lifetime prevalence of 15–71% and occurs in 2–13.5% of pregnancies.1,2 The Centers for Disease Control and Prevention defines IPV3 as shown in Box 1. Reproductive coercion includes behaviors that control reproductive health (see pages 5–6 from http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf).4 Intimate partner violence varies in frequency and severity, occurring as isolated incidents or cycles over years. The lifetime prevalence of IPV is 37.3% in women and 30.9% in men.5 For women, 47.1% experienced psychological violence, 32.4% physical violence (23.2% severe), 16.4% sexual violence, and 9.7% stalking.5 The prevalence of current IPV is 6.6%, with 1 in 15 women reporting IPV in the previous year.5 Of women in family planning clinics, 53% reported IPV, with 35% reporting pregnancy coercion.6

Box 1.

Centers for Disease Control and Prevention Definition of Intimate Partner Violence

Intimate Partner Violence—Overall Definition

Intimate partner violence includes physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner).

Physical Violence

Includes intentional use of physical force with the potential to cause death, disability, injury or harm. May include: hitting, pushing, punching, scratching, choking, shaking, burning, use of weapon(s) or restraints.

Sexual Violence

Includes any of the following acts, whether attempted or completed, and without the victim's freely given consent, including cases in which the victim is unable to consent as a result of being too intoxicated through voluntary or involuntary use of alcohol or drugs:

  1. Rape or penetration of victim—use of physical force to cause a person to engage in a sexual act against their will, includes forced or alcohol and drug-facilitated unwanted vaginal, oral, or anal insertion. Force includes both physical force and threats of force.
  2. Victim was made to penetrate someone else—made to sexually penetrate a perpetrator or someone else without the victim's consent.
  3. Nonphysically pressured unwanted penetration—includes verbal pressure, intimidation, or misuse of authority to cause the victim to consent or acquiesce to being penetrated.
  4. Unwanted sexual contact—includes intentional touching of the victim or making the victim touch the perpetrator either directly or through the clothing, on the genitalia, anus, groin, breast, inner thigh, or buttocks without the victim's consent.
  5. Noncontact unwanted sexual experiences—unwanted sexual experiences that are not of a physical nature that occur without a victim's consent. Includes unwanted exposure to sexual situations (eg, pornography), verbal or behavioral sexual harassment, threats of sexual violence to accomplish some other end, including unwanted filming, taking, or disseminating photographs of a sexual nature of another person.

Stalking

Includes a pattern of repeated unwanted attention and contact that causes concern for one's own safety or the safety of someone else, including repeated unwanted phone calls, emails, or texts; leaving cards, flowers, letters, or other items when the victim does not want them; watching or following from a distance; spying; approaching or showing up in places where the victim does not want to see them; sneaking into the victim's home or car; damaging the victim's personal property; harming or threatening the victim's pets; and making threats to physically harm the victim.

Psychological Aggression

The use of verbal and nonverbal communication with the intent to harm another person mentally or emotionally, and to exert control over another person.

May include expressive aggression (name-calling, humiliating), coercive control (limiting access to transportation, money, friends and family; excessive monitoring of whereabouts), threats of physical or sexual violence, control of reproductive or sexual health (refusal to use birth control, coerced pregnancy termination), exploitation of victim's vulnerability (immigration status, disability), exploitation of perpetrator's vulnerability, and presenting false information to the victim with the intent of making them doubt their own memory or perception (mind games).

Data from Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate partner violence surveillance: uniform definitions and recommended data elements, Version 2.0. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015. Available at: https://www.cdc.gov/violenceprevention/pdf/intimatepartnerviolence.pdf. Retrieved February 11, 2019.

Economic effects of IPV result in a cost of $5.8 billion annually, including health care and lost productivity.7 Victims are at increased risk for unintended pregnancy, infections, sexual dysfunction, and abortion.8 As of 2012, the Affordable Care Act requires coverage of preventive services, including IPV screening and counseling,9 and prevents victims from being charged higher premiums or denied coverage for “preexisting” IPV. Protections are needed, with victims having 42% higher annual health care costs than nonvictims.10 Intimate partner violence is the leading cause of injury to women in the United States,11 and 41.5% of female homicide victims are killed by current or former partners.12 Though IPV can affect women of all backgrounds, certain factors can increase the risk of abuse (Box 2).13–16 The cycle of intimate partner violence makes it difficult for many women to leave abusive relationships because there are periods where violence lessens, the abuser makes up with the victim and promises it won't happen again. Then tension recurs, leading to another cycle of violence17 (Fig. 1).

Box 2.

Risk Factors for Intimate Partner Violence13–16

Individual Risk Factors

  • Younger age
  • Short-term relationships
  • Intellectual disability
  • Chronic mental illness
  • Limited education
  • Low income or socioeconomic status
  • Indigenous status
  • Drug and alcohol use disorder

Relationship Risk Factors

  • Separated relationship status
  • Marital disagreements
  • Poor parenting practices
  • Poor or disparate educational levels
  • Negative attitudes toward women
  • History of child abuse or witnessing IPV as a child
  • Having other sexual partners

Community Risk Factors

  • High levels of crime, poverty and unemployment
  • Low social cohesion
  • Lack of opportunities
  • Lack of social services for IPV victims

Social Risk Factors

  • Gender inequality
  • Devaluation of women
  • Cultural acceptance of IPV
  • Social or religious support of IPV
  • Laws against divorce

IPV, intimate partner violence.

Fig. 1.
Fig. 1.:
Cycle of violence. Reprinted with permission from American College of Obstetricians and Gynecologists. Special issues in women's health. Washington, DC: ACOG; 2005.Lutgendorf. Intimate Partner Violence. Obstet Gynecol 2019.

ADVERSE HEALTH EFFECTS

Victims of IPV may experience physical injuries related to battering, presenting with acute injuries, traumatic brain injury (TBI) (disrupted brain function resulting from a blow or jolt to the head), or unintended pregnancy or chronic conditions, such as headaches, insomnia, pelvic pain, sexual dysfunction, irritable bowel symptoms, depression, anxiety, and posttraumatic stress disorder (PTSD). Acute injuries are often seen in the emergency department, with patients presenting with injuries to the head, face, abdomen, and extremities, and can consist of scratches, contusions, lacerations, joint dislocations, bone fractures, strangulation, and head injuries. Traumatic brain injuries result in altered or diminished consciousness, with impaired cognitive function and potential long-term impairment. Sometimes victims will present with accounts of how the injury occurred that are inconsistent with the injury pattern, or they may present in a delayed fashion or with multiple injuries in various stages of healing. Victims of IPV can also present with fear of or excessive distress during vaginal examinations, particularly if they are victims of sexual abuse. Another red flag concerning for abuse is an overly solicitous partner who can be threatening, intimidating, or controlling and may refuse to leave the patient unattended.

As many as 75% of women who experienced IPV had at least one partner-related TBI, and 50% had multiple partner-related TBIs.18,19 The TBI experienced by victims of abuse may also be more severe owing to the chronicity of the trauma and exacerbation by anoxia or hypoxia from strangulation, which may be unrecognized and untreated. A recent study demonstrated an association between partner-related TBI severity and alterations in memory and learning on functional magnetic resonance imaging.20 In a recent case–control study, women with IPV and probable TBI were more likely to have central nervous system symptoms (headaches, memory loss, blacking out, tinnitus, dizzy spells, seizures, vision and hearing problems, and difficulty concentrating) than women without IPV.21 In addition to acute care for traumatic injuries, women should be asked about dizziness, seeing stars or spots, disorientation, loss of consciousness, blacking out, and memory loss surrounding an incident.

Episodes of strangulation are indicative of severe abuse, and strangulation is a harbinger of escalating violence and potential homicide. Previous studies have demonstrated that nonfatal strangulation was reported in 45% of attempted homicides and 43% of homicides. In women experiencing a prior strangulation episode, there was a sixfold increased risk of experiencing attempted homicide in the future (odds ratio 6.7, 95% CI 3.91–11.49) and a sevenfold increased risk of homicide in the future (odds ratio 7.48, 95% CI 4.53–12.35).22 Strangulation is defined as pressure around the neck with enough force to block respiration or blood flow, more commonly with manual pressure from hands than with a ligature such as a cord or rope. Suffocation results from lack of oxygen due to obstruction of the upper airway or smothering. Often victims of strangulation will describe being “choked” or “choking.” Symptoms of strangulation include breathing changes (dyspnea, hyperventilation, or asthma exacerbations) (85%), sore throat (60–70%), voice changes (50%), and difficulty swallowing.21 Victims may also have headaches, dizziness, blurry vision, and loss of bowel or bladder control. Long-term risks of strangulation include carotid artery dissection, hemorrhagic and ischemic stroke, and pulmonary edema, with increasing risks with multiple episodes of strangulation.23

Victims of IPV are also more likely to experience somatization, with clinical presentations of internalized stress. Somatization can lead to physical symptoms such as chronic pain as well as other anxiety disorders, substance use disorder, and suicide. Often, survivors of IPV can manifest avoidance behaviors or extreme anxiety associated with pelvic examinations. Studies have also shown that women with a lifetime history of IPV have increased rates of self-reported poor health, emotional distress, suicidal thoughts, and suicide attempts.24 Victims of IPV are at increased risk for mental health disorders including depression, anxiety, and PTSD.14 Posttraumatic stress disorder occurs in 31–84% of IPV survivors and is increased in settings with perceived lack of support.25 In a recent systematic review of IPV and suicidality, the authors found a strong and consistent association between IPV and suicidality.26

Intimate partner violence can also exert negative health effects on the family, with children experiencing physical, psychological, and social effects related to exposure to violence. It is estimated that up to 10 million children witness IPV each year in the United States,27 and these children may be more likely to continue the intergenerational cycle of violence as adults (either as perpetrators or victims). Childhood exposure to IPV has been linked with increased violent behavior27 and adjustment problems, including internalizing (depression and anxiety) and externalizing problems (delinquency and violence perpetration).28 The effects of witnessing violence are complex and may have a dose–response relationship, with children witnessing multiple episodes of IPV and multiple episodes of abuse more likely to experience adverse effects.27 Additionally, maternal posttraumatic stress reactions can further adversely affect their children.29 Expanding current knowledge on the effects of IPV within families will allow for improved assessments and treatments aimed at breaking the intergenerational cycle of violence.

Intimate partner violence remains a significant risk factor for homicide, with intimate partners committing 14% of all homicides in the United States in 2007.30 Women are killed by intimate partners at twice the rate of men, with 40–45% of female homicide victims killed by an intimate partner.30 From 2001 through 2012, 6,410 women were murdered in the United States by an intimate partner using a firearm, and women are at increased risk of homicide when abusers have access to firearms.31 Women are most at risk for homicide after separation or after leaving a violent relationship, and homicide remains a leading cause of pregnancy-associated death, particularly in postpartum teenagers and women experiencing abuse during pregnancy.32

PREGNANCY

Pregnancy may be an especially risky time for victims of IPV, with the potential for escalating severity and frequency of violence.17 The prevalence of IPV in pregnancy is estimated to be between 4% and 20%17,33 and has been associated with adverse effects, including miscarriage, bleeding, preterm birth, low birth weight, stillbirth, neonatal death, substance use disorder, depression, and somatic disorders.34,35 Pregnancy is an opportune time for assessment and intervention owing to regularly scheduled appointments and a woman’s heightened concern for her unborn child. Regular screening is recommended in pregnancy—at the initial prenatal visit, at least once per trimester, and at the postpartum visit.17 Repeated screening in pregnancy is associated with higher prevalence rates and increased opportunities for interventions, and screening in pregnancy is effective at increasing identification of IPV.36

Intimate partner violence effects in pregnancy include direct physical attacks that can result in fetal injuries or placental abruption, preterm labor, and prelabor rupture of membranes. Common injuries in pregnancy include those to the breasts, abdomen and uterus17; maternal injuries can also include abdominal organs such as the liver and spleen, pelvic fractures, and retroperitoneal hematomas. Abdominal trauma during late pregnancy is more likely to directly injure the uterus and fetus or cause a placental abruption owing to the expansion of the uterus into the maternal abdomen after the 12th week. Psychological abuse and intimidation and sexual abuse can also be seen in pregnancy, and abusive partners may use force and intimidation to control access to health care, medications, nutrition, and financial resources, resulting in some abused women presenting late for prenatal care. Intimate partner violence may also increase postpartum, with a recent study demonstrating an increase in IPV postpartum, with increased stress and depression.37

Studies assessing the effects of different interventions in pregnancy have produced mixed results, with some evidence that counseling interventions may be more effective than resource cards, no evidence that counseling was superior to standard care, and limited evidence that mentoring was superior to counseling.36 However, there were a small number of good-quality studies on which to base these conclusions. Supported referrals may also be helpful, with the health care provider or social worker calling a shelter or IPV program for the patient or having the patient call from the clinic. This can increase the chances of patients following through with referrals and provide them additional support and comfort.4

SPECIAL POPULATIONS

Intimate partner violence may also be increased in lesbian, gay, bisexual, transgender, queer, or questioning couples, with sexual minority respondents reporting rates of IPV at least as high as those in heterosexual couples. The risk may be highest in bisexual women (61%) compared with lesbian women (44%) and heterosexual women (35%), as reported in the 2010 National Intimate Partner and Sexual Violence Survey.38 Rates of some form of sexual violence were also higher in bisexual and lesbian women than in heterosexual women, with 46% of bisexual women and 13% of lesbian women reporting rape in their lifetime.38 Bisexual women were also more likely to experience rape at an earlier age (11–17 years) and to experience stalking compared with heterosexual women.38 It is important to ensure that IPV prevention programs reach out to and support victims regardless of sexual orientation and ensure access to culturally sensitive services.

Adolescent girls are at increased risk for dating violence, which increases their risk of alcohol and drug use disorder, sexually transmitted infection, early sexual intercourse, multiple partners, unintended pregnancies, depression, suicidal ideation, and adult IPV victimization.39 Adolescent women reporting IPV are also more likely to be engaging in risky behaviors and less likely to have healthy behaviors.40 Between 10 and 20% of college students experience sexual assault, and 7% of women in the U.S. 2010–2012 National Intimate Partner and Sexual Violence Survey were victims of IPV before the age of 18.5 Experiencing IPV is more common in undergraduate sexual minorities and negatively affects performance, including grade point average and perceived academic difficulties.41

Rates of IPV in the military and in veteran populations may be affected by unique stressors such as deployments, separations, and relocations, as well as stressors related to combat. Additionally, the positive effects of universal health care and social support services within the Military Healthcare System and Veterans Health Administration must also be considered. A recent systematic review and meta-analysis reports a prevalence of lifetime IPV of 25.4–85.9% and a past-year IPV prevalence of 12–25% in military populations, both higher than the rates found in civilian population studies (37% lifetime IPV and 6.6% current IPV).42 However, in the largest study of pregnant women in the Military Healthcare System, the rates of abuse were not increased, with lifetime abuse reported by 14.5% of women and current abuse reported by 1.5%.43 In studies evaluating female veterans, past-year IPV rates in range from 8.7% to 18.5%43–46 and are associated with increased mental health morbidity47,48 and high rates of health care utilization.49

Other groups with increased rates of violence include immigrants, who may also face language barriers and fears about deportation. Women with disabilities and developmental delays are also more at risk owing to reliance on their partners and families for care, as are elderly women, who are often abused by partners or adult children.50

ROLE OF OBSTETRICIAN–GYNECOLOGISTS

As women’s health care practitioners, obstetrician–gynecologists are in a unique position to identify, support, and treat women in abusive relationships. It is recommended that health care providers screen women for abuse at periodic intervals, including at routine annual examinations, during pregnancy, and at new-patient visits. Physician responsibilities are outlined in Box 3 and include screening and identification of IPV, documentation and reporting (if required by state law), and supportive assessment of the patient’s readiness to leave the relationship.17 Physicians should also assess the immediate safety of the patient and any children, help her establish a safety plan, and provide referrals and resources. Often victims of IPV are fearful or not yet ready to leave an abusive relationship. Ongoing compassionate care and support are important to help patients work toward leaving their abusers.

Box 3.

The Physician's Responsibility in Addressing Intimate Partner Violence and Domestic Violence

  • Implement universal screening
  • Acknowledge the trauma
  • Assess immediate safety of patient and children
  • Help establish a safety plan
  • Review options
  • Offer educational materials and a list of community and local resources (including toll-free hotline)
  • Provide referrals
  • Document interactions
  • Provide ongoing support at subsequent visits

Reprinted with permission from American College of Obstetricians and Gynecologists. Special issues in women's health. Washington, DC: ACOG; 2005.

The American College of Obstetricians and Gynecologists recommends that the routine assessment process include screening in a private setting away from the patient’s partner, family, and friends.17,50 Normalizing statements should be used at the beginning of the assessment to reinforce that screening is part of routine practice, with professional interpreters used as needed. Health care providers should discuss limits of confidentiality before screening or assessments, including information about any mandatory reporting requirements and reporting requirements for minors exposed to or witnessing violence. Additional information is available at https://www.acf.hhs.gov/sites/default/files/fysb/state_compendium.pdf. All staff should be trained regularly to identify and care for victims of IPV, and offices should keep take-home safety and resource information in offices and in private areas such as restrooms and examination rooms. An outline of the routine assessment process is listed in Box 4.50

Box 4.

Protocols for a Routine Intimate Partner Violence Assessment

  • Screen for IPV in a private and safe setting with the woman alone and not with her partner, friends, family, or caregiver.
  • Use professional language interpreters and not someone associated with the patient.
  • At the beginning of the assessment, offer a framing statement to show that screening is done universally and not because IPV is suspected. Also, inform patients of the confidentiality of the discussion and exactly what state law mandates that a physician must disclose.
  • Incorporate screening for IPV into the routine medical history by integrating questions into intake forms so that all patients are screened whether or not abuse is suspected.
  • Establish and maintain relationships with community resources for women affected by IPV.
  • Keep printed take-home resource materials such as safety procedures, hotline numbers, and referral information in privately accessible areas such as restrooms and examination rooms. Posters and other educational materials displayed in the office also can be helpful.
  • Ensure staff receives training about IPV and that training is regularly offered.

IPV, intimate partner violence.

Data reprinted with permission from Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:412–7.

SCREENING

It is important to remember that IPV can occur in any patient; thus, screening is recommended at routine appointments, and regular screening is recommended in pregnancy. Screening for IPV identifies women with a lifetime history of violence and also those currently in abusive relationships, with the goal being to support and refer victims to social services and other interventions to improve outcomes.51,52 Intimate partner violence is a complex social relationship rather than a disease process; therefore, some of the classic screening criteria do not directly apply. Screening is recommended by the U.S. Preventive Services Task Force53 as well as the American College of Obstetricians and Gynecologists,32,50 the Association of Women’s Health, Obstetrics and Neonatal Nurses,54 the American Medical Association, the American Academy of Family Physicians, and the Agency for Healthcare Research and Quality. Before 2013, the U.S. Preventive Services Task Force did not recommend screening for IPV owing to a lack of effective screening instruments and a lack of evidence that screening improved outcomes. Current guidance from the U.S. Preventive Services Task Force recommends that clinicians screen for IPV in reproductive-aged women and refer women who screen positive to support services with a grade of B (high certainty that the net benefit is moderate or that there is moderate certainty that the net benefit is moderate to substantial). These recommendations are based on the evidence that screening instruments can identify abused women and that there is evidence of benefit when abused women are referred for ongoing support services, with overall small risk of harm due to screening and intervention for IPV.53 The U.S. Preventive Services Task Force notes that, although screening identifies abused women, the published trials do not show reductions in violence or improved quality of life over 3–18 months and that counseling and home visitation programs reduced violence in pregnant and postpartum women.55

A recent large randomized controlled trial evaluated the effects of screening compared with no screening and found reduced IPV recurrence, PTSD, and alcohol problems and improved quality of life and mental health in both screened and nonscreened women, though all women received information on local resources for abused women.56 For women who screen positive, counseling interventions reduced IPV, improved birth outcomes, and reduced pregnancy coercion.51 Generally, studies indicate low levels of harm from IPV screening53,56 and that women may prefer self-completed screening over face-to-face screening.57 Available screening tools with high diagnostic accuracy are shown in Table 1.52,53,58–61 Health care providers should screen with framing statements that acknowledge the effects of abuse on women’s health and that screening is routine. Health care providers should address privacy and confidentiality and disclose any mandatory reporting requirements. Example screening questions are include: “Do you feel safe in your current relationship?”; “Has your current partner ever threatened you or made you feel afraid? (Threatened to hurt you or your children if you did or did not do something, controlled who you talked to or where you went, or gone into rages?)”; and “Has your partner ever hit, choked, or physically hurt you? (‘Hurt’ includes being hit, slapped, kicked, bitten, pushed, or shoved).”4 The components of effective ongoing support services recommended by the U.S. Preventive Services Task Force are shown in “Box. Components of Effective Ongoing Support Services for Intimate Partner Violence” by Curry et al (Available at: http://dx.doi.org/10.1001/jama.2018.14741).53

Table 1.
Table 1.:
Screening Tools52,59–61

Barriers to screening include the health care provider’s personal discomfort with discussing IPV; concern for misdiagnosis; lack of knowledge, education, or training; time constraints; lack of knowledge of referral options; and lack of protocols.62 Health care providers may have attitudes that create barriers, including fears of offending patients or disrupting their relationship with the patient and fear of the partner’s reaction and creating stress.62 Effective interventions improve health care provider education, increasing awareness and knowledge of resources.

DOCUMENTATION

Accurate and timely documentation is important, because encounters may become forensic evidence of the abuse. The history and physical findings and injuries should be thoroughly and objectively documented. Direct quotations using the patient’s own words and descriptions, as well as a body map or photographs of injuries, should be included after informed consent is given by the patient. Complete documentation should include the history, timeline, examination, symptoms, witnesses, and results of imaging and laboratory studies, as well as referrals and law enforcement notification. Document any weapons used and threats or psychological abuse. With patient access to charting, health care providers should be sensitive to patient privacy and take steps to prevent unauthorized access, including safety planning for accessing records on personal devices that abusers may be able to access.

REPORTING

Health care providers should be familiar with relevant state privacy laws and federal regulations on privacy for victims of IPV. All 50 states require reporting of child abuse; however, state laws vary regarding reporting requirements for IPV. Most states require reporting of specific injuries and wounds. Some states require reporting of injuries caused by weapons such as firearms, knives, or other sharp objects or injuries resulting from criminal activity or general violence. Additional information is available at http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Compendium%20Final.pdf.63

Mandatory reporting of IPV is controversial. Laws requiring reporting of IPV are aimed at identifying and protecting victims; however, this may place victims in danger of retaliation or increased abuse. Mandatory reporting also supersedes a women’s autonomy and could negatively affect the patient–physician relationship and decrease disclosure of abuse by patients.64 In states with mandatory reporting, patients should be provided information about requirements for mandatory reporting and limitations on confidentiality. Generally, state laws provide immunity from civil or criminal liability for filing reports of abuse if completed in good faith.17

MANAGEMENT AND INTERVENTIONS

Current U.S. Preventive Services Task Force recommendations on screening for intimate partner violence state that women who screen positive should be referred to intervention services.53 Current evidence supports various interventions, including counseling, resource cards (an example is available from the National Domestic Violence Hotline at http://www.thehotline.org/wp-content/uploads/sites/3/2015/05/Hotline-personalsafetyplan.pdf), home visitation, and referral to community services and mentoring. More comprehensive interventions involving support services with empowerment, home visitation, mentoring, and counseling are more effective in reducing violence, abuse, and harm to women.53,65,66

When a patient acknowledges abuse, physician responsibilities include: 1) providing support and validation—listen without judgment, affirm that she is not to blame and that help is available; 2) provide information on the effects of abuse on her health and risks of escalating abuse; 3) assess immediate safety—review safety planning, inquire about safety of any children and presence of weapons in the home, and assess risk of suicide a homicide; 4) refer to local advocacy and support services, including the National Domestic Violence Hotline: (800) 799-SAFE, TTY (800) 787-3224; 5) report to law enforcement or social services agencies—know state requirements and laws regarding reporting (if mandatory reporting is required in your state, ensure familiarity with the laws and requirements). Partners and families can face significant consequences if children are taken (“abducted”) across international borders, because the Hague Convention allows the “left-behind” parent legal recourse, even if this parent is abusive.67 Patients in these situations should seek legal counsel and assistance. If patients disclose past abuse, provide support and offer referral to support services or advocacy services as needed. Should a patient deny abuse but concern remains, respect her response and let her know you are available if things should change; reassess for abuse at regular intervals and provide ongoing support. Additional resources are available in Box 5.

Box 5.

Support and Resources

National Coalition Against Domestic Violence

National Domestic Violence Hotline

Futures Without Violence

National Health Resource Center on Domestic Violence

  • Supports health care providers improve responses to intimate partner violence; offers free, culturally competent materials appropriate for a variety of settings
  • www.endabuse.org/health
  • 888-Rx-ABUSE (888-792-2837) Mon–Fri, 9 am–5 pm PST
  • TTY 800-595-4889
  • email: health@endabuse.org

The trauma-informed approach to counseling and care increases health care providers’ awareness and understanding of how trauma affects victim’s lives and provides support while minimizing re-traumatization in a safe environment. The focus of trauma-informed care is on resiliency, coping skills, building on individual strengths, listening to victims’ choices, and restoring power and control in victims’ lives. One of the main goals is to guide victims to understand that they have a choice in how they respond to situations and can choose when to leave an abusive relationship.66 Continuing to provide support and access to resources in a nonjudgmental fashion is also important, and, even if interventions do not reduce IPV victimization, awareness of resources and increased ability to seek safety is important.68

DISCUSSION

In conclusion, IPV is an important problem in women’s health. Continued vigilance and support of our patients and their families is the first step in addressing this epidemic. Obstetrician–gynecologists have the knowledge and the tools to make a difference. As women’s health practitioners, we are uniquely equipped to hear our patient’s stories and guide them on their journey of healing. We should always remember that, “It takes courage to change your life. Day in and day out, over and over, you have to decide to take the small brave steps that change your future.”69

REFERENCES

1. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet 2006;368–1260–9.
2. World Health Organization; United Nations Development Programme; United Nations Office on Drugs and Crime. Global status report on violence prevention. Available at: http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/. Retrieved November 1, 2018.
3. Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate partner surveillance: uniform definitions and recommended data elements, version 2.0. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
4. Chamberlain L, Levenson R. Reproductive health and partner violence guidelines: an integrated response to intimate partner violence and reproductive coercion. Futures without violence. Available at: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf. Retrieved November 1, 2018.
5. Smith SG, Chen J, Basile KC, Gilbert LK, Merrick MT, Patel N, et al. National Intimate Partner and Sexual Violence Survey (NISVS): 2010–2012 state report. Available at: https://www.cdc.gov/violenceprevention/pdf/nisvs-statereportbook.pdf. Retrieved June 12, 2019.
6. Miller E, Decker MR, McCauley H, Tancredi DJ, Levenson RR, Silverman JG. Pregnancy coercion, intimate partner violence, and unintended pregnancy. Contraception 2010;81:316–22.
7. National Center for Injury Prevention and Control. Costs of intimate partner violence against women in the United States. Available at: https://www.cdc.gov/violenceprevention/pdf/IPVBook-a.pdf. Retrieved November 1, 2018.
8. Pallitto CC, Garcia-Moreno C, Jansen HAFM, Heise L, Ellsburg M, Watts C, et al. Intimate partner violence, abortion, and unintended pregnancy: results from the WHO multi-country study on women’s health and domestic violence. Int J Gynecol Obstet 2013;120:3–9.
9. Liebschutz JM, Rothman EF. Intimate-partner violence—what physicians can do. N Engl J Med 2012;367:2071–3.
10. Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Serv Res 2009;44:1052–67.
11. Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner violence. Available at: https://www.ncjrs.gov/pdffiles1/nij/181867.pdf. Retrieved June 12, 2019.
12. Cooper AD, Smith EL. Homicide trends in the United States, 1980–2008. Available at: http://www.bjs.gov/index.cfm?ty=pbdetail&iid=4944. Retrieved November 1, 2018.
13. Cook J, Bewley S. Acknowledging a persistent truth: domestic violence in pregnancy. J R Soc Med 2008;101:358–63.
14. Stewart DE, Vigod SN. Mental health aspects of intimate partner violence. Psychiatr Clin N Am 2017;40:321–34.
15. Khalifeh H, Oram S, Trevillion K, Johnson S, Howard LM. Recent intimate partner violence among people with chronic mental illness: findings from a national cross-sectional survey. Br J Psychiatry 2015;207:207–12.
16. Rezy ML. Separated women’s risk for intimate partner violence: a multiyear analysis using the National Crime Victimization Survey. J Interpers Violence 2017:1–26.
17. American College of Obstetricians and Gynecologists. Special issues in women’s health. Washington, DC: American College of Obstetricians and Gynecologists; 2005.
18. Valera EM, Berenbaum H. Brain injury in battered women. J Consult Clin Psychol 2003;71:797–804.
19. Kwako LE, Glass N, Campbell J, Melvin KC, Barr T, Gill JM. Traumatic brain injury in intimate partner violence: a critical review of outcomes and mechanisms. Trauma Violence Abuse 2011;12:115–26.
20. Valera E, Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an “invisible” trauma. Brain Imaging Behav 2017;11:1664–7.
21. Campbell JC, Anderson JC, McFadigion A, Gill J, Zink E, Patch M, et al. The effects of intimate partner violence and probable traumatic brain injury on central nervous system symptoms. J Womens Health 2018;27:761–7.
22. Glass N, Laughon K, Campbell J, Wolf A, Block CR, Hanson G, et al. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med 2008;35:329–35.
23. Foley A. Strangulation: know the symptoms, save a life. J Emerg Nurs 2015;41:89–90.
24. Ellsberg M, Jansen HAFM, Heise L, Watts C, Garcia-Moreno C. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008;371:1165–72.
25. Cohen LR, Field C, Campbell AN, Hien DA. Intimate partner violence outcomes in women with PTSD and substance use: a secondary analysis of NIDA clinical trials network “women and trauma” multi-site study. Addict Behav 2013;38:2325–32.
26. McLaughlin J, O’Carroll RE, O’Connor RC. Intimate partner abuse and suicidality. Clin Psych Rev 2012;32:677–89.
27. Wood SL, Sommers MS. Consequences of intimate partner violence on child witnesses: a systematic review of the literature. J Child Adolesc Psychiatr Nurs 2011;24:223–36.
28. Vu NL, Jouriles EN, McDonald R, Rosenfield D. Children’s exposure to intimate partner violence: a meta-analysis of longitudinal associations with child adjustment problems. Clin Psych Rev 2016;46:25–33.
29. Greene CA, Chan G, McCarthy KJ, Wakschlag LS, Briggs-Gowan MJ. Psychological and physical intimate partner violence and young children’s mental health: the role of maternal posttraumatic stress symptoms and parenting behaviors. Child Abuse Negl 2018;77:168–79.
30. Catalano S, Smith E, Snyder H, Rand M. Female victims of violence. Available at http://www.bjs.gov/index.cfm?ty=pbdetail&iid=2020. Retrieved November 1, 2018.
31. National Network to End Domestic Violence: domestic violence and women’s homicides. Available at https://nnedv.org/mdocs-posts/guns-domestic-violence-and-homicide/. Retrieved June 12, 2019.
32. Shadigian E, Bauer ST. Pregnancy-associated death: a qualitative systematic review of homicide and suicide. Obstet Gynecol Surv 2005;60:183–90.
33. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275:1915–20.
34. Van Parys AS, Deschepper E, Michelsen K, Galle A, Roelens K, Temmerman M, et al. Intimate partner violence and psychosocial health, a cross-sectional study in a pregnant population. BMC Pregnancy Childbirth 2015;15:278.
35. de Oliveira Fonseca-Machado M, Camargo Alves L, Scotini Freitas P, Dos Santos Monteiro JC, Gomes-Sponholz F. Mental health of women who suffer intimate partner violence during pregnancy [in English, Portuguese]. Invest Educ Enferm 2014;32:291–305.
36. O’Reilly R, Beale B, Gillies D. Screening and intervention for domestic violence during pregnancy care: a systematic review. Trauma Violence Abuse 2010;11:190–201.
37. Agrawal A, Ickovics J, Lewis JB, Magriples U, Kershaw TS. Postpartum intimate partner violence and health risks among young mothers in the United States: a prospective study. Matern Child Health J 2014;18:1985–92.
38. Walters ML, Chen J, Breiding MJ. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 findings on victimization by sexual orientation. Available at: https://www.cdc.gov/violenceprevention/pdf/nisvs_sofindings.pdf. Retrieved November 1, 2018.
39. Sugg N. Intimate partner violence prevalence, health consequences, and intervention. Med Clin N Am 2015;99:629–49.
40. Hanson M. Health behavior in adolescent women reporting and not reporting intimate partner violence. JOGNN 2010;39:363–276.
41. Brewer N, Thomas KA, Higdon J. Intimate partner violence, health, sexuality, and academic performance among a national sample of undergraduates. J Am Coll Health 2018;22:1–10.
42. Sparrow K, Dickson H, Kwan J, Howard L, Fear N, MacManus D. Prevalence of self-reported intimate partner violence victimization among military personnel: a systematic review and meta-analysis. Trauma Violence and Abuse 2018 Jan 1 [Epub ahead of print].
43. Lutgendorf MA, Busch JM, Doherty DA, Conza LA, Moone SO, Magann EF. Prevalence of domestic violence in a pregnant military population. Obstet Gynecol 2009;113:866–72.
44. Dichter ME, Haywood TN, Butler AE, Bellamy SL, Iverson KM. Intimate partner violence screening in the Veterans Health Administration: demographic and military service characteristics. Am J Prev Med 2017;52:761–8.
45. Dichter ME, Wagner C, Borrero S, Broyles L, Montgomery AE. Intimate partner violence, unhealthy alcohol use, and housing instability among woman veterans in the Veterans Health Administration. Psychol Serv 2017;14:246–9.
46. Kimerling R, Iverson KM, Dichter ME, Rodriguez AL, Won A, Pavao J. Prevalence of intimate partner violence among women veterans who utilize Veterans Health Administration primary care. J Gen Intern Med 2016;31:888–94.
47. Geirisch JM, Shapiro A, Grant NN, King HA, McDuffie JR, Williams JW. Intimate partner violence: prevalence among U.S. military veterans and active duty servicemembers and a review of intervention approaches. VA-ESP Project #09-010. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0066989/pdf/PubMedHealth_PMH0066989.pdf. Retrieved November 1, 2018.
48. Dichter ME, Sorrentino A, Bellamy S, Medvedeva E, Roberts CB, Iverson KM. Disproportionate mental health burden associated with past-year intimate partner violence among women receiving care in the Veterans Health Administration. J Trauma Stress 2017;30:555–63.
49. Dichter ME, Sorrentino AE, Haywood TN, Bellamy SL, Medvedeva E, Roberts CB, et al. Women’s healthcare utilization following routine screening for past-year intimate partner violence in the Veterans Health Administration. J Gen Intern Med 2018;33:936–41.
50. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:412–7.
51. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings. The Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD007007. DOI: 10.1136/bmj.g2913.
52. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the 2004 U.S. Preventive Services Task Force recommendation. Ann Intern Med 2012;156:796–808; W279–82.
53. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: U.S. Preventive Services Task Force recommendation statement. JAMA 2018;320:1678–87.
54. AWHONN position statement. Intimate partner violence [published erratum appears in J Obstet Gynecol Neonatal Nurs 2017;46:e125]. J Obstet Gynecol Neonatal Nurs 2015;44:405–8.
55. Feltner C, Wallace I, Berkman N, Kistler CE, Middleton JC, Barclay C, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults. JAMA 2018;320:1699–701.
56. MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, Ford-Gilboe M, et al. Screening for intimate partner violence in healthcare settings. J Am Med Assoc 2009;302:493–501.
57. MacMillan HL, Wathen CN, Jamieson E, Boyle M, McNutt LA, Worster A, et al. Approaches to screening for intimate partner violence in health care settings. JAMA 2006;296:530–6.
58. Arkins B, Begley C, Higgins A. Measures for screening for intimate partner violence: a systematic review. J Psychiatr Ment Health Nurs 2016;23:217–35.
59. Bianchi AL, Cesario SK, McFarlane J. Interrupting intimate partner violence during pregnancy with an effective screening and assessment program. J Obstet Gynecol Neonatal Nurs 2016;45:579–91.
60. Haggerty LA, Hawkins JW, Fontenot H, Lewis-O’Connor A. Tools for screening for interpersonal violence: state of the science. Violence Vict 2011;26:725–37.
61. Rabin RF, Jennings JM, Campbell JC, Bair-Merritt MH. Intimate partner violence screening tools: a systematic review. Am J Prev Med 2009;36:439–45.
62. Sprague S, Madden K, Simunovic N, Godin K, Pham NK, Bhandari M, et al. Barriers to screening for intimate partner violence. Women Health 2012;52:587–605.
63. Durborow N, Lizdas KC, O’Flaherty A, Marjavi A. Compendium of state statutes and policies on domestic violence and health care. Available at: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Compendium%20Final.pdf. Retrieved December 6, 2018.
64. Gilen AC, O'Campo PJ, Campbell JC. Women's opinions about domestic violence screening and mandatory reporting. Am J Prev Med 2000;19:279–85.
65. O'Campo P, Kirst M, Tsamis C, Chambers C, Ahmad F. Implementing successful intimate partner violence screening programs in health care settings: evidence generated from a realist-informed systematic review. Soc Sci Med 2011;72:855–966.
66. Anyikwa VA. Trauma-informed approach to survivors of intimate partner violence. J Evid Inf Soc Work 2016;13:484–91.
67. Hague Conference on Private International Law. 28: Convention of 25 October 1980 on the civil aspects of international child abduction. Available at: https://www.hcch.net/en/instruments/conventions/full-text/?cid=24. Retrieved July 19, 2019.
68. Miller E, Tancredi DJ, Decker MR, McCauley HL, Jones KA, Anderson H, et al. A family planning clinic-based intervention to address reproductive coercion: a cluster randomized controlled trial. Contraception 2016;94:58–67.
69. Latus J. If I am missing or dead: a sister's story of love, murder. New York (NY): Simon & Schuster; 2007. p. 306.

CME FOR THE CLINICAL EXPERT SERIES

Learning Objectives for “Intimate Partner Violence and Women's Health”

After completing this learning experience, the involved learner should be able to:

  • Describe the spectrum of intimate partner violence
  • List characteristics associated with reproductive coercion
  • Discuss two or more screening tools
  • Implement an effective screening and intervention strategy for their practice

Instructions for Obtaining AMA PRA Category 1 CreditsTM

Continuing Medical Education credit is provided through joint providership with The American College of Obstetricians and Gynecologists.

Obstetrics & Gynecology includes CME-certified content that is designed to meet the educational needs of its readers. This article is certified for 2AMA PRA Category 1 CreditsTM This activity is available for credit through September 30, 2022.

Accreditation Statement

ACCME Accreditation

The American College of Obstetricians and Gynecologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credit(s)TM

The American College of Obstetricians and Gynecologists designates this journal-based CME activity for a maximum of 2 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

College Cognate Credit(s)

The American College of Obstetricians and Gynecologists designates this journal-based CME activity for a maximum of 2 Category 1 College Cognate Credits. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 CreditsTM to be equivalent to College Cognate Credits.

Disclosure of Faculty and Planning Committee Industry Relationships

In accordance with the College policy, all faculty and planning committee members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to article topics. Such disclosures allow the participant to evaluate better the objectivity of the information presented in the articles.

How to Earn CME Credit

To earn CME credit, you must read the article in Obstetrics & Gynecology and complete the quiz, answering at least 70 percent of the questions correctly. For more information on this CME educational offering, visit the Lippincott CMEConnection portal at https://cme.lww.com/browse/sources/196 to register and to complete the CME activity online. ACOG Fellows will receive 50% off by using coupon code, ONG50. In addition, a free one-time CME coupon is available to participants by using the coupon code, ONGFREE.

Hardware/software requirements are a desktop or laptop computer (Mac or PC) and an Internet browser. This activity is available for credit through September 30, 2022. To receive proper credits for this activity, each participant will need to make sure that the information on their profile for the CME platform (where this activity is located) is updated with 1) their date of birth (month and day only) and 2) their ACOG ID. In addition, participants should select that they are board-certified in obstetrics and gynecology.

The privacy policies for the Obstetrics & Gynecology website and the Lippincott CMEConnection portal are available at http://www.greenjournal.org and https://cme.lww.com/browse/sources/196, respectively.

Contact Information

Questions related to transcripts may be directed to educationcme@acog.org. For other queries, please contact the Obstetrics & Gynecology Editorial Office, 202-314-2317 or obgyn@greenjournal.org. For queries related to the CME test online, please contact ceconnection@wolterskluwer.com or 1-800-787-8985.

Supplemental Digital Content

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.