Intimate Partner Violence

Descriptive text is not available for this image BASICS

DESCRIPTION

  • Intimate partner violence (IPV) is abuse or aggression that occurs in a romantic relationship between a former or current partner.
  • May include physical, sexual, and/or emotional abuse; economic or psychological actions; stalking; or threats of actions that influence another person
  • Although women are at greater risk of experiencing IPV, it occurs among patients of any race, age, sexual orientation, religion, gender, and socioeconomic background.
  • Synonym(s): domestic violence (DV); spousal abuse; partner abuse; family violence

EPIDEMIOLOGY

Incidence

  • In the United States, women experience 4.8 million incidents of physical or sexual assault annually.
  • It is estimated that the COVID-19 pandemic has increased the incidence of IPV due to exacerbations of the risk factors that influence perpetrators of IPV.

Prevalence

  • About 1 in 4 women and nearly 1 in 10 men experience a form of IPV in their lifetime.
  • Over 43 million women and 38 million men have experienced a form of IPV in their lifetime.
  • IPV is estimated to cost the U.S. economy >$10.4 billion annually (1).

Geriatric Considerations
About 1 to 2 million U.S. citizens aged >65 have been injured, exploited, or mistreated by someone caring for them.Pediatric Considerations

  • IPV can occur in adolescence, known as teen dating violence (TDV). TDV affects millions of U.S. teens each year.
  • Approximately 1 in 5 female high school students report being physically and/or sexually abused by a dating partner; female between 16 and 24 years of age are more vulnerable to IPV than any other age group.
  • About 11 million women and 5 million men reported experiencing IPV before the age of 18 years.
  • Children living in violent homes are at increased risk of physical, sexual, and/or emotional abuse; anxiety and depression; decreased self-esteem; emotional, behavioral, social, and/or physical disturbances; and lifelong poor health.

Pregnancy Considerations

  • IPV leads to unintended pregnancies, induced abortions, and sexually transmitted infections (STIs). Pregnant women who experience IPV are twice as likely to have an abortion.
  • IPV in pregnancy also increases the likelihood of miscarriage, stillbirth, preterm delivery, and low-birth-weight babies.

RISK FACTORS

  • Patient/victim risk factors
    • Substance abuse (drug or alcohol), high-risk sexual behavior
    • Poverty/financial stressors/unemployment/less education
    • Recent loss of social support, family disruption and life cycle changes, social isolation
    • Prior history of abusive relationships or experiencing abuse as child
    • Mental or physical disability in family
    • Pregnancy
    • Transgender-identifying women
    • Attempting to leave the relationship
  • Perpetrator risk factors
    • Substance abuse, depression, personality disorders
    • Young age
    • Unemployment, recent job loss or instability, low academic achievement
    • Witnessing/experiencing violence as child
    • Threatening to self or others, violence to children or outside the home
    • Owns weapons
  • Relational risk factors
    • Marital conflict or instability, economic stress, traditional gender role norms, poor family functioning, obsessive/controlling relationship

Geriatric Considerations
Factors associated with IPV in geriatric populations: female gender, immigration stress, fear, social isolation, low income, poor physical health, low cognitive functioning, absence of social support, depressive symptoms, neglect, caregiver stress, and burdenPediatric Considerations
Factors associated with IPV in pediatric populations: transgender, adverse childhood experiences, trauma symptoms, depression, gender attitudes, and economic hardship (1)

Descriptive text is not available for this image DIAGNOSIS

  • The U.S. Preventive Services Task Force (USPSTF) in 2013 issued guidelines recommending that clinicians screen all women of reproductive age for IPV and provide or refer women to ongoing support services when appropriate (2)[A].
  • The U.S. Department of Health and Human Services has recommended that IPV screening and counseling be a core part of women’s preventive health visits.

Pregnancy Considerations
The American College of Obstetrics and Gynecologists (ACOG) recommends that physicians screen all women for IPV at periodic intervals, including during obstetric care (at the first prenatal visit, at least once per trimester, at the postpartum checkup), offer ongoing support, and review prevention and referral options.

HISTORY

  • Physicians should introduce the subject of IPV in a general way (i.e., “I routinely ask all patients about intimate partner violence. Have you ever been in a relationship where you were afraid?”).
  • Address patient confidentiality prior to screening (i.e., “I want you to know everything you say here is confidential, meaning that I will not talk to anyone else about what is said unless you tell me [insert laws in your state about what is necessary to disclose].”).
  • Screen patient alone, without partner, parent, or others present.
  • Ask screening questions in patient’s primary language; do not use children or other family members as interpreters.
  • HITS questions: Each HITS question is scored on a 5-point scale (never, rarely, sometimes, fairly often, and frequently, with a score of >10 indicating likely victimization; sensitivity 30–100% and specificity 86–99%). “How often does your partner:
    • Hurt you physically?; Insult or talk down to you?; Threaten you with harm?; Scream or curse at you?” (3)
  • Partner Violence Scale (sensitivity 35–71%; specificity 80–94%)
    • “Have you ever been hit, kicked, punched, or otherwise, hurt by someone within the past year? If so, by whom?”
    • “Do you feel safe in your current relationship?”
    • “Is there a partner from a previous relationship who is making you feel unsafe now?”
  • SAFE questions
    • Stress/safety: “Do you feel safe in your relationship?”
    • Afraid/abused: “Have you ever been in a relationship where you were threatened, hurt, or afraid?”
    • Friends/family: “Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?”
    • Emergency plan: “Do you have a safe place to go and the resources you need in an emergency?”
  • Assess pregnancy difficulties such as poor/late prenatal care, low-birth-weight babies, and perinatal deaths as well as repeat abortions (unplanned pregnancy may be a result of sexual assault or reproductive coercion).
  • Pelvic and abdominal pain, chronic without demonstrable pathology, gynecologic disorders
  • Headaches, back pain
  • STIs
  • Depression, suicidal ideation, anxiety, fatigue, eating disorders, substance abuse
  • Overuse of health services/frequent emergency room visits
  • Nonadherence with medication/treatment plan and/or missed appointments

PHYSICAL EXAM

  • Clinical presentation/psychological signs and symptoms
    • Delay in seeking treatment, inconsistent explanation of injuries, reluctance to undress
    • Signs of battered woman syndrome and/or posttraumatic stress disorder (PTSD) (flat affect/avoidance of eye contact, evasiveness, heightened startle response, sleep disturbance, traumatic flashbacks)
    • Suspicious partner accompaniment at appointment; overly solicitous partner and/or refusal to leave exam room
  • Physical signs and symptoms
    • Tympanic membrane rupture
    • Rectal or genital injury (centrally located injuries with bathing-suit pattern of distribution—concealable by clothing)
    • Head and neck injuries (site of 50% of abusive injuries)
    • Scrapes, loose or broken tooth, bruises, cuts, or fractures to face or body
    • Knife wounds, cigarette burns, bite marks, welts with outline of weapon (such as belt buckle)
    • Defensive posture injuries
    • Injuries inconsistent with explanation or in various stages of healing
    • Malnutrition or pressure ulcers in the elderly

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Liver function tests (LFTs), amylase, lipase if abdominal trauma is suspected, BUN and creatinine if malnutrition/dehydration is suspected, pregnancy test and STI testing (HIV Ab/Ag, syphilis screen, gonorrhea and chlamydia NAAT, trichomonas) in cases of sexual abuse, X-ray if suspected fracture, radiographic skeletal survey for children <2 years old if physical abuse is suspected

Descriptive text is not available for this image TREATMENT

  • Treatment includes initial diagnosis; ongoing medical care; emotional support, counseling, and patient education regarding the DV cycle; referrals to community and supportive services as needed.
  • On diagnosis, use the SOS-DoC intervention:
    • S: Offer Support and assess Safety:
      • Support: “You are not to blame. I am sorry this is happening to you. There is no excuse for you to be treated this way.”
      • Remind patient of your commitment to confidential communication.
      • The objective is to maximize safety as IPV can result in death. Making a safety plan can decrease the risk of mortal harm.
      • Safety assessment involves inquiring patients about their concerns and fears.
      • Victim factors associated with increased risk of danger:
        • Attempting to leave the relationship
        • Seeking outside intervention
        • Suicidal
        • Homicidal
      • Safety: Listen and respond to safety issues for the patient: “Do you feel safe going home?”; “Are your children safe?”
    • O: Discuss Options, including safety planning and follow-up:
      • Provide information about IPV and help when needed. Make referrals to local resources.
      • “Do you need or want to access a safety shelter or IPV service agency?”
      • “Do you want police intervention and if so, would you like me to call the police, so they can make a report with you?”
      • Offer numbers to local resources and National IPV Hotline: 1-800-799-SAFE (open 24/7; can provide physicians in every state with information on local resources)
    • S: Validate patient’s Strengths: It is crucial that providers affirm understanding of the patient’s difficulty.
      • “It took courage for you to talk with me today. You have shown great strength in very difficult circumstances.”
    • Do: Document observations, assessment, and plans:
      • Use patient’s own words regarding injury and abuse. Language should be chosen carefully; “patient reports” as opposed to “patient denies/claims,” which may suggest the clinician does not believe the patient
      • Legibly document injuries: Use a body map.
      • If possible, photograph patient’s injuries if given consent. Photographs must include the patient’s face or identifying features with the injury in order to be useful as legal evidence.
      • Make patient safety plan. Prepare patient to get away in an emergency:
      • Encourage patient to prepare an emergency kit to keep in a safe place: keys (house and car); important papers (Social Security card, birth certificates, photo ID/driver’s license, passport, green card); cash, food stamps, credit cards; medication for self and children; children’s immunization records; important phone numbers/addresses (friends, family, local shelters); personal care items (e.g., extra glasses)
      • Encourage patient to arrange a signal with someone to let that person know when she or he needs help
    • C: Offer Continuity:
      • Offer a follow-up appointment and assess barriers to access.

GENERAL MEASURES

  • Reporting child and elder abuse to protective services is mandatory in most states. Several states have laws requiring mandatory reporting of IPV.
  • National Domestic Violence Hotline: 1-800-799-SAFE (7233)
  • Post resources and posters in both English and Spanish in exam rooms, bathrooms, waiting rooms; available at https://www.thehotline.org/stakeholders/download-and-request-materials/

ADDITIONAL THERAPIES

Rape Abuse & Incest National Network (RAINN) Hotline: 1-800-656-HOPE (4673)

Descriptive text is not available for this image ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Schedule prompt follow-up appointment. Inquire about what occurred since last visit. Offer ongoing support and resources.

PATIENT EDUCATION

PROGNOSIS

Victims of IPV can suffer from PTSD, anxiety, and depression. Counseling, support, and resources can improve their prognosis.

Authors

Rhonda A. Faulkner, PhD
Alyssa Jeanne Vest Hart, DO
Zehra Khan, MD

REFERENCES

  1. Kyle J. Intimate partner violence. Med Clin North Am. 2023;107(2):385–395.  [PMID:36759104]
  2. Moyer VA; for U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478–486.  [PMID:23338828]
  3. Dicola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94(8):646–651.  [PMID:27929227]

ADDITIONAL READING

  • Thackeray JD, Hibbard R, Dowd MD; for Committee on Child Abuse and Neglect, Committee on Injury, Violence, and Poison Prevention. Intimate partner violence: the role of the pediatrician. Pediatrics. 2010;125(5):1094–1100.  [PMID:20421260]
  • Perone HR, Dietz NA, Belkowitz J, et al. Intimate partner violence: analysis of current screening practices in the primary care setting. Fam Pract. 2022;39(1):6–11.  [PMID:34184740]

Descriptive text is not available for this image CODES

ICD10

  • T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • T74.31XA Adult psychological abuse, confirmed, initial encounter
  • T74.21XA Adult sexual abuse, confirmed, initial encounter

SNOMED

  • 406138006 Domestic abuse of adult
  • 371778002 Physical abuse of adult
  • 371774000 Emotional abuse of adult
  • 432527004 Domestic sexual abuse of adult
  • 242039002 Abuse of partner

CLINICAL PEARLS

  • Display resource materials in the office (e.g., posting abuse awareness posters/National Domestic Violence Hotline, 1-800-799-SAFE, in both English and Spanish, in all exam rooms and restrooms).
  • Given the high prevalence of IPV and the lack of harm and potential benefits of screening, routine screening is recommended.
  • For those who screened positive, offer resources, reassure confidentiality, and provide close follow-up.

Last Updated: 2026

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