More than one third of women in the United States will experience some form of intimate partner violence (IPV) in their lifetime. The consequences of IPV can be lifelong and include emotional trauma, long-term physical impairment, chronic health problems, and even death. Signs of IPV can range from acute traumatic injuries to nonacute presentations of abuse. Examples of the latter include chronic headaches, sleep and appetite disturbances, sexual dysfunction, abdominal symptoms, and recurrent vaginal infections and generally are representative of clinical manifestations of internalized stress.
Obstetricians and gynecologists are uniquely positioned to assist women who experience IPV not only because of the intimate quality of the physician-patient relationship but also because of the many opportunities for intervention over the course of the patient’s life, such as annual examinations, family planning, pregnancy, and follow-up visits. The American College of Obstetricians and Gynecologists (The College) recommends that health care providers screen all women for IPV at periodic intervals because some women will not acknowledge or disclose abuse the first time they are asked.1
Poor pregnancy weight gain, infection, anemia, tobacco use, stillbirth, pelvic fracture, placental abruption, fetal injury, and preterm delivery have all been associated with IPV.1 For women who experience IPV, the violence can become more severe during pregnancy and the postpartum period, and The College recommends that screening for IPV should occur at least once each trimester and again at the postpartum checkup. In addition to the personal costs of IPV, the annual economic impact of medical and mental health care costs associated with intimate partner rape, physical assault, and stalking exceed $8 billion.1
All women are at risk for IPV. However, certain circumstances make some women more vulnerable than others. These special populations include female high school students, immigrant women, elderly women, and women with physical and developmental disabilities. Adolescents should be taught to be wary of any behavior designed to control and manipulate, especially because adolescent violence is linked to partner violence in adulthood.1
Some immigrant women may not report IPV out of fear of deportation. These women should be made aware that special visas are available that allow survivors of IPV to remain legally in the United States if it is justified on humanitarian grounds, ensures family unity, or is in the public interest.
Elderly women and women with disabilities who must rely on their partners or caregivers for help are especially vulnerable to IPV. Abuse can be physical, sexual, and psychological and includes neglect, abandonment, and financial exploitation.1 Unfortunately, most violence shelters do not accept women with disabilities because these facilities lack staff members who are trained to handle the needs of this special population.
However obstetricians and gynecologists choose to screen for IPV, they must use language and a format with which they are comfortable so their patients’ remain at ease. In addition, the language used should be free of judgment and stigmatizing terms, such as “rape,” “abuse,” “battered,” and “violence.” The College has recently published protocols for IPV screening that are designed to help facilitate assessment and information exchange (Table).
From a clinical perspective, expedited partner therapy is recommended only if there is no risk or suspicion of IPV after assessment. When IPV is reported, health care providers should acknowledge the trauma and document the patient’s injuries and overall condition, determine the immediate safety of the patient (and children if involved), and assist in the development of a safety plan, generally in the form of access to a private phone and referral to a local domestic violence agency.
|Table. Protocols to Facilitate Routine Assessment of Intimate Partner Violence (IPV)|
|Screen for IPV in a private and safe setting with the woman alone and not with her partner, friends, family, or caregiver. |
If needed, 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 in to the routine medical history by integrating question 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 that staff receives training about IPV and that training is regularly offered.
|Data from Committee opinion no. 518: intimate partner violence. Obstet Gynecol. 2012.1|
National Domestic Violence Hotline: 1-800-799-SAFE (7233)
Rape Abuse & Incest National Network (RAINN) Hotline: 1-800-656-HOPE (4673)
Futures Without Violence: www.futureswithoutviolence.org
National Coalition Against Domestic Violence: www.ncadv.org
National Network to End Domestic Violence: www.nnedv.org
National Resource Center on Domestic Violence: www.nrcdv.org
Office on Violence Against Women (U.S. Department of Justince): www.usdog.gov/ovw