CHAPTER 49. Intimate Partner Violence
Mary Jagim
Although recognizing, assessing, and intervening with victims of intimate partner violence in the emergency department (ED) can be challenging, the emergency nurse has an opportunity to affect the victim’s outcome. Intimate partner violence (IPV) is defined as “a pattern of assaultive and coercive behaviors including inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate dating relationship with an adult or adolescent, and are aimed at establishing control by one partner over the other.”19
INCIDENCE
IPV occurs in adolescents and adults, in all social and cultural groups, among lesbian and gay, heterosexual, and transgendered couples, and in married and unmarried relationships. The most prevalent incidence of IPV is among women. The National Crime Victimization Survey found that 85% of IPV victims were women. 3 Nearly 5.3 million incidents of IPV occur each year among U.S. women ages 18 and older, and 3.2 million occur among men. 3 Approximately 1.5 million women and more the 800,000 men have been victims of sexual or physical assault by an intimate partner. National studies have shown that 29% of women and 22% of men have experienced physical, sexual, or psychologic IPV during their lifetime. 4
IPV impacts women of all ages. In a study of older adult women age 65 and older, 18% reported that they had suffered sexual or physical abuse by intimate partners at some point in their lives, and 22% said they been victims of nonphysical abuse, including being threatened, called names, or having their behavior controlled by a partner. 1
Higher incidence of risk for IPV exists for women of certain racial, ethnic, and socioeconomic groups. The ethnic groups most at risk are Native American/Alaskan Native women and men, African American women, and Hispanic women. 21 Also, young women and those below the poverty line are disproportionately victims of IPV. 21
Pregnant women also note a higher incidence of IPV. A review of 13 studies found the prevalence of IPV ranging from 0.9% to 20.1%. One study, using a three-question screening tool, revealed a 17% prevalence of physical or sexual abuse during pregnancy with 60% of abused pregnant women reporting two or more occurrences. Common sites of physical abuse in pregnancy include the face, head, breasts, and abdomen. IPV may be a contributing risk factor for low birth weight and delays in prenatal care. 20
IPV results in nearly 2 million injuries and 1200 deaths nationwide every year. At least 42% of women and 20% of men who were physically assaulted since age 18 sustained injuries during their most recent victimization. Most of the injuries were minor such as scratches, bruises, and welts. More severe physical consequences of IPV are dependent upon the severity and frequency of abuse. 3
Alcohol and drug abuse are comorbidity factors to IPV. Sixty to seventy percent of violent men assault their partners while drunk. Another 13% to 20% of violent men assault their partners while on drugs. Overall, the presence of an alcohol or drug problem increases the risk for severe violence by 70% to 158%. 11
The economic impact of IPV is notable. IPV costs exceed $8.3 billion, which includes $460 million for sexual assault, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in value of lost lives. In addition, victims of severe IPV lose nearly 8 million days of paid work annually. 3
RISK FACTORS
Associated risk factors identified as contributing to a greater likelihood of being a victim of IPV include but are not limited to the following:
• Prior history of IPV
• Witnessing or experiencing violence as a child
• Low self-esteem
• Low academic achievement
• High-risk sexual behavior
• Heavy alcohol and drug use
The following are relationship factors:
• Couples with income, education, or job status disparities
• Dominance and control of the relationship by the male
Community and societal factors include the following:
• Poverty and associated factors
• Low social capital; lack of institutions, relationships, and norms that shape the quality and quantity of a community’s social interactions
• Weak community sanctions against IPV
• Traditional gender norms (e.g., belief that women should stay at home and not enter workforce, should be submissive) 3
Rural Victims
Victims of IPV who reside in rural areas may have an additional risk factor related to increased availability of weapons. Rural victims of IPV may also have greater challenges in seeking help. There are often geographic isolation, very traditional gender roles, poverty, shortage of health providers, lack of public transportation systems, and decreased access to resources and other opportunities. In small communities where everyone knows everyone, seeking confidential assistance may be nearly impossible. 15 Victims may have limited ability to go to another location to seek assistance. In some cases the abuser could be a local person of authority.
CYCLE OF VIOLENCE
The central functions of intimate partner violence are intimidation and control. Control is accomplished by the perpetrator through physical, sexual, and emotional abuse; social isolation; and financial dependency. Several theories exist as to the development of a batterer. One of the primary explanations centers on borderline personality organization. Borderline personality organization is characterized by intense and unstable interpersonal relationships coupled with intense anger, impulsivity, and fear of abandonment. It is thought that early attachment difficulties, primarily surrounding parental rejection, later develop into an excessive dependency and abandonment anxiety with their adult partner. Other contributing factors may be an exposure to physical or sexual abuse, either as a direct victim or a witness to interfamilial conflict. Batterers come to see violence as necessary, normal, and good. They often have traditional sex role expectations about acceptable behavior in women. 11
The cycle of intimate partner violence is repeated by the batterer until it is disrupted. The cycle consists of three phases:
Impact on the Victim
Battering can have a physical, emotional, and psychologic impact on the victim. As a result, the victim may exhibit depression, antisocial behavior, suicidal behavior in females, anxiety, low self-esteem, inability to trust men, and a fear of intimacy.
Due to the social isolation batterers often impose, victims are isolated from social networks such as family or friends, have restricted access to services, and may experience strained relationships with health care providers and employers.
Women experiencing IPV are more likely to display negative health behaviors that present further health risks. Some noted behaviors are engaging in high-risk sexual behavior such as unprotected sex or multiple partners, using or abusing harmful substances such as alcohol or drugs, and unhealthy diet-related behaviors such as vomiting after eating or overeating. 3
Impact on Children
The long-lasting ramifications of IPV on children are difficult to measure. Children who may become injured include those who witness IPV incidents between their parents. There is also a positive correlation between IPV and child maltreatment. One study found that children of abused mothers were 57 times more likely to have been harmed because of IPV incidents between their parents, compared with children of nonabused mothers. 3 Children whose lives are touched by IPV may have resultant low self-esteem, depression, ineffective coping, higher levels of aggression, oppositional behavior, fear, anxiety, withdrawal, and poor peer and other social relationships. Also noted are lower cognitive functioning, poor school performance, lack of conflict resolution skills, limited problem-solving skills, proviolence attitudes, and belief in rigid gender stereotypes and male privilege. 2
Why Do Women Stay?
Understanding why a woman chooses to stay in a violent relationship is probably the most challenging aspect of providing care for the victims of IPV. It would seem obvious that the solution to the violence is to just “get out.” But for the victim of IPV, this is often the solution that seems most out of reach or inconceivable. As awful as their world is, it is the world they know versus the unknown should they choose to leave. Women feel they are the “victim” and feel a loss of control over their lives. They often believe that if they just love their abuser enough and behave appropriately, things will change. Many have a negative self-concept, and they doubt they can manage on their own. These victims may be afraid they will be unable to financially support themselves or their children and that they will be stigmatized. There may also be cultural factors that shape what is considered acceptable and unacceptable behaviors. 12 Victims may be justifiably afraid of retaliation. The greatest risk for homicide often occurs when the victim has decided to leave or just after the victim has left. 2 The emergency nurse needs to repeatedly ask the questions and assist victims with knowing what options exist until they are ready to take action.
Treatment of Batterers
Legal interventions, such as being arrested and/or prosecuted, are often the primary impetus for batterers to receive treatment. Treatment of batterers is focused on prevention and decreased recidivism. Interventions are tailored to a specific type of batterer based on psychologic factors, risk assessment, or substance abuse history. 13 The effectiveness of batterer treatment programs remains in question because of variable results. 14
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