Understanding Intimate Partner Violence: How to Break the Cycle

Highlights

• Identifies key factors that contributed to high rates of IPV during COVID-19
• Summarizes a brief history of IPV attitudes and policy development
• Outlines factors that make it challenging to identify elder abuse
• Issues a call to action for surgeon participation to help break the cycle of violence

In recognition of National Domestic Violence Awareness month, this article describes Intimate Partner Violence (IPV) behavior and identifies the role of the clinician in incorporating screening tools into healthcare assessment protocols. 

What Is IPV?

IPV, or domestic violence, refers to a pattern of assaultive and coercive behaviors exhibited by a current or former partner or spouse. This behavior can occur among heterosexual or same-sex couples and does not require sexual intimacy. The World Health Organization (WHO) reports that nearly one-third of women worldwide ages 15 to 49 have been victims of physical and/or sexual violence by their intimate partner. Men are reported to be victims of IPV in similar numbers, with 1-in-4 women and 1-in-10 men reporting IPV in their lifetime. However, some researchers suggest that the incidence of IPV in men is underreported due to fear related to potential re-victimization or being misidentified as the perpetrator. 

The cost of IPV is also felt on a financial scale and has been reported to exceed $8.3 billion per year in the US and $4.4 trillion globally.

IPV is about power and control. It does not discriminate and exists across all ethnic, socioeconomic, and educational backgrounds. Nevertheless, there are certain risk factors that increase the likelihood of IPV. Being female, younger age, and lower socioeconomic status have all been shown to be important risk factors for IPV. Notably, prior exposure to IPV has been described as one of the greatest risks for IPV. In a study by Okuda and colleagues, as many as 66% of male perpetrators reported being victims of abusive behavior themselves, confirming what is often described as the “intergenerational cycle of violence.”

Certain key factors—including increased stress levels and a lack of social support—contributed to the high rates of IPV during the onset of the COVID-19 pandemic. With the onset of the pandemic, there was an amplified amount of stress experienced by all, including the abuser and the victim. This was further compounded by the sequalae of events as world events evolved. The loss of income and diminished access to social services created a perfect storm where victim and perpetrator were forced together continuously in a high-stress environment. 

At the height of the COVID-19 pandemic, several countries instituted lockdowns to help control the spread of disease. An unfortunate but expected side effect of this event was the increase in the number of IPV cases seen globally. The onset of natural or public health-related disasters has been shown to increase the prevalence and severity of IPV. The WHO reported increased reports of IPV from as early as February 2020 in Jingzhou, a city in the Hubei province of China, compared to the same period the year prior. Similar reports have been published around the globe, and in the US, there was a significant rise in domestic violence calls, with Alabama reporting upward of a 25% increase. The increase in IPV directly coincided with the stay-at-home orders, and multiple other studies reported similar trends. 

What Can Surgeons Do?

The need for the surgeon to recognize IPV and intervene has been demonstrated repeatedly. The violent loss of Sherilyn Gordon, MD, FACS, a well-regarded transplant surgeon who was killed by her husband in 2017, is a clear indicator that this public health problem affects us all. The ACS has noted in its Statement on Domestic Violence that it is “the responsibility of the treating surgeon not only to care for the immediate injury and to reassure the patient, but also to identify and report potential threats to his or her safety, and to encourage an ongoing safety strategy.” 

Nevertheless, barriers continue to prevent the average clinician from recognizing and addressing IPV, including a lack of IPV awareness and access to appropriate social services resources. One could argue that when there is a better understanding of IPV, the likelihood of social etiquette, where the physician or other healthcare provider may feel unable to address concerning issues, plays a much lesser role. 

In the area of trauma care, Kothari and colleagues found that 5% of trauma patients were admitted due to IPV-related injury. Of female admitted patients, Melnick determined that 18% had screened positive for IPV in the last year. A vast majority of IPV victims, however, go unidentified by their healthcare workers. In one chilling statistic, as many as 66% of women killed by their intimate partner had seen a health professional in the year prior. 

Ongoing education of residents and staff should be a mandatory requirement in addressing the knowledge gap. Moreover, by incorporating basic screening tools into patient evaluation and intake, victims and perpetrators would be more easily identified and offered assistance. Despite screening and interventions, some patients may still choose to not report IPV. In a study published by the author of this article and colleagues, researchers found that cisgender men* were more likely to report with a tablet rather than answer questions when screened by a person. 

A Brief History of IPV

It is said that British common law in the 18th century allowed a husband to physically chastise his wife, “provided that the stick used was ‘no thicker than his thumb.’” While this assertion has been largely debunked as myth, there are many supporting documents that confirm that—although this perceived common law may not have been completely factual—it was widely acceptable for a man to discipline his wife as he saw fit. The origins of the phrase have been attributed to the legal commentaries of William Blackstone (1723–1780), although this has never been clearly verified. Nevertheless, a husband or father, as the head of the household, was recognized by early law as having authority to discipline the members of his family. He might administer to his wife “moderate correction” and “restrain” her by “domestic chastisement.” For a long time, violence against women was considered a private issue and the public essentially looked away at signs of domestic abuse. 

These actions continued despite advances in the courts. In the Americas, Alabama and Massachusetts made “wife beating” illegal in 1871, and early Puritans openly banned family violence. Violence against women continued to be tolerated until certain significant events in history. In 1978, the New York State Coalition Against Domestic Violence was founded, and marital rape became a crime in 1984, in People v. Liberta, a case in which a wife sued her estranged husband for forcibly having sexual intercourse with her. The ruling was against the defendant and marital rape was made a crime by New York’s highest court. The Federal Office of Domestic Violence was established in 1979 but closed in 1981. 

The United Nations considers domestic violence an international human rights issue and adopted the Declaration on the Elimination of Violence Against Women without a vote in 1993. In the US, the Violence Against Women Act (VAWA—Public Law 103-322) was passed by Congress and signed into law by President Clinton on September 13, 1994. The VAWA was reauthorized in 2000, and again in 2005 and in 2013, where provisions were made for services for immigrant, rural, disabled, and elderly women. 

Learn more about developing intimate partner violence prevention strategies at this Clinical Congress 2022 Town Hall Session in San Diego, CA: 

• Intimate Partner Violence Prevention Strategies (TH303)
• Town Hall Session
• Moderator: Tanya L. Zakrison, MD, MPH, FACS
• Wednesday, October 19, 7:00-7:45 am

The Lost Voices

One of the largely unrecognized groups that experience IPV is the elderly population. Elder abuse is reported as anywhere from 3% to 10% in that population. However, some reports believe this to be much higher due to underreporting and a lack of understanding on the part of the healthcare provider. Moreover, difficulties such as complicating comorbid issues and fear on the part of the individual due to dependency on the abuser, increase the likelihood that the abuse will go unrecognized. 

With the number of Americans over the age of 65 expected to double over the next 40 years to reach 80 million by 2040, it is imperative that there be better understanding and more research applied to this population. Per the latest census data, currently, 16.5% of the US population of 328 million people, or 54 million, are over the age of 65. 

It is important to recognize that elderly patients are subject to the same types of IPV with an annual report of approximately 2% experiencing physical abuse, 1% sexual abuse, 5% neglect, 5% financial abuse, and 5% suffering emotional abuse. Factors that make it challenging to diagnose and engage the victim (dementia, dependency, and social isolation) are the same factors that increase the risk for IPV in that population. This does not absolve the clinician of the responsibility of investigating, however. 

Steps Forward

Understanding the impact of IPV and the recognition as a public health emergency is the role of every clinician. The surgeon has a unique opportunity to engage and help break the cycle of violence. In particular, the trauma surgeon may find that the presenting injury is the sentinel event and, therefore, has a responsibility to consider IPV in all patients seen in the trauma bay. At our institution, the division of trauma and acute care surgery has taken the unique step of incorporating IPV screening tools into the trauma tertiary survey in addition to the initial assessment. The hope is that this one small step can help decrease the possibility of overlooking the victim of IPV or the perpetrator.

*Cisgender people have a gender identity that aligns with the sex that a doctor assigned them at birth.

Dr. D’Andrea Joseph is chief of trauma and acute care surgery, Department of Surgery, at New York University (NYU) Langone Hospital-Long Island, and an associate professor of surgery, NYU Long Island School of Medicine. She is a member of the ACS Intimate Partner Violence Task Force.

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