Applied Evidence

It’s time to start asking all patients about intimate partner violence

J Fam Pract. 2019 April;68(3):152-154,156-161A

Author(s):

Many people endure a menacing or violent romantic partner—yet few physicians ask about this risk, or actual harm. Here is a roadmap for screening.

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PRACTICE RECOMMENDATIONS

› Perform annual screening for intimate partner violence of all female patients of childbearing age; strongly consider a pilot program of universal screening (all male and female patients, across the lifespan). B

› Establish a protocol for intimate partner violence screening and referral—possibly the most effective means of identifying intimate partner violence at early and severe stages. B

› Collaborate with the patient in the safety planning and referral process; benefits include improved likelihood that the patient will adhere to a safety plan and follow through with the referral. B

› Utilize online resources to 1) ease the process of establishing relationships with local intimate partner violence referrals and 2) facilitate warm handoffs to increase the likelihood of patient engagement. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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2. Black MC, Basile KC, Breiding MJ, et al. National Intimate Partner and Sexual Violence Survey: 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011:113. www.cdc.gov/violenceprevention/pdf/NISVS_Report2010-a.pdf. Accessed February 20, 2019.

3. West CM. Partner abuse in ethnic minority and gay, lesbian, bisexual, and transgender populations. Partner Abuse. 2012;3:336-357.

4. Hines DA, Malley-Morrison K. Psychological effects of partner abuse against men: a neglected research area. Psychology of Men & Masculinities. 2001;2:75-85.

5. Houston E, McKirnan DJ. Intimate partner abuse among gay and bisexual men: risk correlates and health outcomes. J Urban Health. 2007;84:681-690.

6. Carvalho AF, Lewis RJ, Derlega VJ, et al. Internalized sexual minority stressors and same-sex intimate partner violence. J Fam Violence. 2011;26:501-509.

7. Nicholls TL, Pritchard MM, Reeves KA, et al. Risk assessment in intimate partner violence: a systematic review of contemporary approaches. Partner Abuse. 2013;4:76-168.

8. Intimate partner violence: definitions. Atlanta, GA: National Center for Injury Prevention and Control, Division of Violence Prevention, Centers for Disease Control and Prevention, August 22, 2017. www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html. Accessed February 20, 2019.

9. Archer J. Sex differences in aggression between heterosexual partners: a meta-analytic review. Psychol Bull. 2000;126:651-680.

10. Baron RA, Richardson DR. Human Aggression. New York, NY: Springer Science+Business Media; 2004.

11. Breiding MJ, Basile KC, Smith SG, et al. 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.

12. Murphy CM, Eckhardt CI. Treating the Abusive Partner: An Individualized Cognitive-Behavioral Approach. New York, NY: Guilford Press; 2005.

13. Straus MA, Hamby SL, Boney-McCoy S, et al. The revised Conflict Tactics Scales (CTS2): development and preliminary psychometric data. J Fam Issues. 1996;17:283-316.

14. West CM. Partner abuse in ethnic minority and gay, lesbian, bisexual, and transgender populations. Partner Abuse. 2012;3:336-357.

15. Desmarais SL, Reeves KA, Nicholls TL, et al. Prevalence of physical violence in intimate relationships. Part 1: rates of male and female victimization. Partner Abuse. 2012;3:140-169.

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28. Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-295.

29. Sherin KM, Sinacore JM, Li XQ, et al. HITS: A short domestic violence screening tool for use in a family practice setting. Fam Med. 1998;30:508-512.

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Intimate partner violence (IPV) is a serious public health problem with considerable harmful health consequences. Decades of research have been dedicated to improving the identification of women in abusive heterosexual relationships and interventions that support healthier outcomes. A result of this work has been the recommendation of the US Preventive Services Task Force that all women of childbearing age be screened for IPV and provided with intervention or referral.¹

The problem extends further, however: Epidemiologic studies and comprehensive reviews show: 1) a high rate of IPV victimization among heterosexual men and lesbian, gay, bisexual, and transsexual (LGBT) men and women^2,3; 2) significant harmful effects on health and greater expectations of prejudice and discrimination among these populations^4-6; and 3) evidence that screening and referral for IPV are likely to confer similar benefits for these populations.⁷ We argue that it is reasonable to ask all patients about abuse in their relationships while the research literature progresses.

We intend this article to serve a number of purposes:

support national standards for IPV screening of female patients
highlight the need for piloting universal IPV screening for all patients (ie, male and female, across the lifespan)
offer recommendations for navigating the process from IPV screening to referral, using insights gained from the substance abuse literature.

We also provide supplemental materials that facilitate establishment of screening and referral protocols for physicians across practice settings.

^{© Joe Gorman}

What is intimate partner violence? How can you identify it?

Intimate partner violence includes physical and sexual violence and nonphysical forms of abuse, such as psychological aggression and emotional abuse, perpetrated by a current or former intimate partner.⁸ TABLE 1^9-14 provides definitions for each of these behavior categories and example behaviors. Nearly 25% of women and 20% of men report having experienced physical violence from a romantic partner and even higher rates of nonphysical IPV.¹⁵ Consequences of IPV victimization include acute and chronic medical illness, injury, and psychological problems, including depression, anxiety, and poor self-esteem.¹⁶

Intimate partner violence is heterogenous, with differences in severity (eg, frequency and intensity of violence) and laterality (ie, is one partner violent? are both partners violent?).

Intimate partner violence is heterogeneous, with differences in severity (eg, frequency and intensity of violence) and laterality (ie, is one partner violent? are both partners violent?). A recent comprehensive review of the literature revealed that, for 49.2%-69.7% of partner-violent couples across diverse samples, IPV is perpetrated by both partners.¹⁷ Furthermore, this bidirectionality is not due entirely to aggression perpetrated in self-defense; rather, across diverse patient samples, that is the case for fewer than one-quarter of males and no more than approximately one-third of females.¹⁸ In the remaining cases, bidirectionality may be attributed to other motivations, such as a maladaptive emotional expression or a means by which to get a partner’s attention.¹⁸

Women are disproportionately susceptible to harmful outcomes as a result of severe violence, including physical injury, psychological distress (eg, depression and anxiety), and substance abuse.^16,19 Some patients in unidirectionally violent relationships experience severe physical violence that may be, or become, life-threatening (0.4%-2.4% of couples in community samples)²⁰—victimization that is traditionally known as “battering.”²¹

Continue to: These tools can facilitate screening for IPV