Intimate Partner Violence
[dropcap]N[/dropcap]early 1 in 3 women and 1 in 10 min in the United Sates have experienced domestic violence, according to the Center for Disease Control. These statistics are staggering! Domestic violence has started to gain attention in the mainstream media, especially around the sexually assault of women domestically and internationally, but resolving a societal problem of this magnitude is going to require more than just the occasional medical spotlight. Education is critical, especially of health care providers who are often in a pivotal position to identify domestic violence and to offer support and resources. This article intends to illuminate some of the various aspects of this pervasive issue.
What is domestic violence?
Better known as Intimate Partner Violence (IPV), is violence, or threat of violence, by a current or former partner. No section of society is immune to IPV – it doesn’t matter if a couple is gay or straight, wealthy or poor, Jewish or atheist, teenage or elderly – all communities are impacted by IPV. We need to understand that IPV is not gendered, and that men are oftentimes on the receiving end of violence. While we may think of IPV as incidental episodes of kicking or slapping a partner, IPV is much more than that. It’s about coercive control. IPV is a pattern of behavior used to establish power and control over another person, in the context of current or previous intimate relationships.
National toll-free domestic violence hotline
1- 800 799 SAFE
1-800 787 3224
The Cycle of Violence
The Cycle of Violence originated in the 1970’s. The cycle begins with the Honeymoon phase, in which the batterer wins over the victim with compliments, flowers and other expression of affection. This is the infatuation phase. As the relationship continues, the Tension stage ensures. The batterer begins to verbally abuse the victim, and control who the victim associates with, what to wear, etc. This phase is often described by victims as “walking on eggshells.” The tension builds, and eventually there is an explosion of violence. The batterer will apologize profusely, make excuses for the episode of violence, and send flowers and gifts. The victim usually forgives the perpetrator, for many numbers of reasons. Perhaps they blame the outburst on drugs or alcohol. Maybe they believe they truly love their partner, or maybe they are financially are dependent of their partner or don’t know that leaving the situation is an option. Regardless, the cycle repeats again and again, with the Honeymoon and Tension stages becoming shorter over time, and the violent episodes becoming more frequent. Meanwhile, the batterer, the victim and society at large is minimizing the violence; nobody wants to address IPV as it’s considered “private” business. Denial, by all of us, allows the cycle to continue.
Forms of IPV
Intimate Partner Violence can be expressed through many types of violent behavior. While many of us readily identify physical and sexual assault as IPV, psychological and emotional abuse are also forms of violence and should be treated as such
Physical violence is the unintentional use of force against a victim such as slapping, kicking, chocking, burping or using a weapon. It also includes coercing the victim to commit such acts.
Sexual abuse is the actual or threatened abuse of physical force to compel a person to engage in sexual activities against their will. Examples include: unwanted touching or fondling, and sexual contact that does not necessarily involve intercourse. Keep in mind that rape with an object is included in this type of violence.
Physiological and emotional abuse are much more subtle means of violence, but just as valid as other kinds of violence This form of abuse usually goes unrecognized since it doesn’t leave marks on the victim’s body. A perpetrator of psychosocial violence will humiliate their partner and call them derogatory names. They’ll often control the victim’s movements and activities, which serve to isolate the victim from their friends and family making the victim more dependent on the batterer. The perpetrator will usually control all financial resources, sometimes even limiting or forbidding the victim’s employment. Psychological and emotional abuse is powerful. Breaking an object or threatening to harm a child/pet may be just as effective at controlling a victim as physical injury.
Underlying all of these forms of abuse is a pattern of coercive control, and it’s imperative that we as heath care providers (and members of society!) identify and address IPV regardless of whether the victim is experiencing rape or name-calling by their intimate partner.
Impact of IPV on Pregnancy
The consequences of pregnancy-related violence are profound. They include:
- Delayed prenatal care
- Low birth weight
- Premature labor
- Fetal trauma (miscarriage, placental abruption)
- Unhealthy maternal behaviors
- Tobacco, alcohol, and drug use
- Difficulty fulfilling prenatal care recommendations
- Health issue for mothers
- STI’s, vaginal/urinary infections
- Unhealthy diet
- Poor weight gain
- Severe postpartum depression
- Breastfeeding difficulties
- Lower self-esteem
Screening IPV in the Antepartum Period
Providers should screen every woman for IPV – survivors come from every age group, religion, ethnic/racial group, socioeconomic level, educational background sexual orientation.
Prenatal care is a window of opportunity to accomplish screening because:
- 96% of women receive prenatal care
- Average of 12-13 prenatal care visits
- Opportunity to develop trust in health care provider
- For survivors of IPV, the desire to be a good parent and to protect her child from possible abuse can be a powerful motivator for change in her life.
Barriers make screening more difficult. They are as follows:
- Time constraints
- Discomfort with the topic
- Fear of offending the patient or partner
- Perceived powerlessness to change the problem
Use of RADAR will help interview the client
R – Routinely screen every patient
A – Ask directly, kindly, non-judgmentally
D – Document your findings
A – Assess the patient’s safety
R – Review options and provide referrals
Routinely screen every patient
- At first prenatal visit
- Al least once per trimester
- At postpartum checkup
- At routine OB-GYN visit
Components of screening
- Warning signs of IPV
- Previous medical visits with injuries
- History of abuse/assault
- Repeated visits
- Chronic pelvic pain, headaches, vaginitis, irritable bowel syndrome
- History of depression, substance abuse, suicide attempts, anxiety
Pregnancy-related factors such as
- Unintended pregnancy
- Unhappiness about being pregnant
- Young maternal age
- Late entry into care and missed appointments
- Substance abuse
Observe woman’s behavior
Fright, depression anxiety
PTSD symptoms – dissociation, startle response
Observe partner’s behavior
Being overly solicitous
Answering questions for the patient o
Monitoring woman’s response
Being hostile or demanding
Never leaving the patient’s side
Questions to asks in your abuse assessment
- In the last year (since I saw you last), have you been it, slapped, kicked or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of the injury?)
- Since you’ve been pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone? (? (If yes, by whom? Number of times? Nature of the injury?)
- Within the last year has anyone made you do something sexual that you didn’t want to do? (if yes, who?)
- Are you afraid of your partner or anyone else?
- Does your partner ever humiliate you? Shame you? Put you down in public? Keep you from seeing friends or doing the things you want to do?
Questions not to ask
- Why don’t you just leave?
- Why did you make him/her angry?
- Why do you go back?
Reasons for “No” response
Fear of retaliation by partner
Lack of trust in others
Unaware of alternative
Desire to keep family together
Responding to “No”
Always chart the woman’s response – even when she says “no.”
Your questions may help those experiencing abuse to move closer to disclosure
Your questions indicate your willingness to help
Your questions let the woman know you are available as a resource
Woman will choose when to disclose
Appropriate response to “Yes.”
This is not your fault
No one deserves to be treated this way\I’m sorry you/ve been hurt
Do you want to talk about it?
I’m concerned about your children’s safety
Help is available to you
Document your findings
- In patient’s chart
- In patient’s own words
- With a body map of injuries
- With photographs of injuries (get consent)
Assess patient safety
- Is either the woman or the children in danger
- Has violence escalated recently
- Are there weapons in the home
- If not safe, does she have safety plan
Components of a safety plan
- Pack a bag in advance
- Have personal documents ready
- Plan where to go
- Hide extra set of house and car keys
- Establish a code with family or friends.
- Stay with abuser and formulate a safety plan
- Remove abuser through arrest or protective orders
- Leave the relationship temporally or permanently
- Keep a current list of local resources
- Office and hospital personnel with special training
- Law enforcement (police, lawyers, advocates)
- Shelters (housing, support groups, advocates)
- Local hotlines
- Child protective services
- Legal services
- Social worker
National toll-free domestic violence hotline
1- 800 799 SAFE
1-800 787 3224