Intimate Partner Abuse
Intimate partner abuse refers to physical, sexual or psychologic maltreatment by a current or prior partner or spouse. It can take place in the context of heterosexual or same-sex couples and can consist of a single incident or recurrent, severe violence lasting many years.
There are four major categories of intimate partner abuse: (1) physical abuse, whereby physical force is used to kill, disable, injure, or otherwise hurt a partner; (2) sexual abuse, which involves coercing a partner to engage in a sex act without consent; 3) threats of violence, in which verbal statements, gestures, or weapons convey a desire to kill, disable, injure, or otherwise hurt a partner; and 4) psychologic or emotional abuse, including insults, controlling behavior, deliberate damage to self-esteem, stalking, and preventing a partner from accessing family, friends, information, money, or other resources.
In the United States, there are 4.8 million physical assaults and rapes of women and 2.9 million physical assaults of men annually due to intimate partner abuse. In 2007, there were 2,340 deaths in the United States due to intimate partner violence, of which 70% were women and 30% were men.
Clinical Presentation and Diagnosis. Risk factors for intimate partner abuse include poor self-esteem, poverty, substance use disorders, minimal social supports, belief in strict gender roles, social isolation, past experience of physical or psychologic abuse, borderline personality disorder (Plate 4-18), antisocial personality disorder (Plate 4-19), relationship instability, financial stressors, and community tolerance of intimate partner violence.
Victims of intimate partner abuse can present with physical injuries, such as scratches, cuts, bruises, welts, broken bones, internal bleeding, and head trauma. The psychologic trauma from intimate partner violence can manifest as depression, suicidal ideation and attempts, flashbacks, panic attacks, and difficulty sleeping.
The pneumonic SAFE (Sebastian, 1996) is often used to facilitate the discussion of intimate partner abuse by asking about (1) Stress and Safety in the relationship, (2) being Afraid of or Abused by one’s partner, (3) having Friends or Family who can serve as social supports, and (4) having an Emergency plan if in danger.
Management. Physicians must provide victims of intimate partner abuse with an environment where they feel safe. A thorough history and physical examination are required, with detailed documentation in the medical record of all findings and interventions. Intimate partner abuse must be acknowledged to the patient, who needs to be told that there is no excuse for abuse and that he or she is not at fault.
The patient must receive medical and surgical treatment as needed for sequelae of abuse, as well as evaluation for signs and symptoms of psychologic trauma. Victims need to be warned that violence often becomes more severe with time. A risk assessment should evaluate the safety of victims and their children. Intimate partner abuse must be reported to legal authorities if appropriate. Physicians need to formulate a safety plan with the patient and offer referrals for shelter, legal assistance, and mental health services.
Course. Lenore Walker published a theory in 1979 that describes the cyclic pattern of abusive relationships: (1) the tension-building phase occurs before an abusive incident and involves mounting tension in the setting of ineffective communication and passive-aggressive behavior; (2) the acting-out phase involves violent or otherwise abusive acts; (3) the reconciliation/ honeymoon phase, which consists of statements of apology, displays of affection, or attempts to overlook the preceding abuse, followed by a “calm phase.”
In addition to an increased risk of bodily injury and even murder, intimate partner abuse can negatively impact a victim’s physical health in the form of headaches, fibromyalgia, irritable bowel syndrome, cardiovascular disorders, gastrointestinal disorders, gynecologic disorders, neurologic disorders, sexually transmitted illnesses, and obstetric complications, such as poor neonatal health and perinatal death. Psychologic sequelae can include depression, anxiety disorders, eating disorders, substance use disorders, high-risk sexual behaviors, suicidality, low self-esteem, dissociative disorders, and posttraumatic stress disorder.
Of note, more than 3 million children in the United States witness intimate partner violence each year. Observing intimate partner abuse in the home can have an adverse effect on the emotional, social, behavioral, and cognitive development of a child, as well as increasing the likelihood that the child will engage in intimate partner abuse later in life.