Intimate Partner Violence

Physical abuse is the most obvious form of intimate partner violence. It may include hitting, slapping, kicking, punching, breaking bones, pulling hair, pushing, twisting arms, or throwing objects at the victim. The victim may be deprived of food, sleep, or medical care. Weapons, such as a gun or knife, may be used to threaten or cause injury.

Sexual abuse or coercion is also common; many women who are physically assaulted by their partner are also sexually assaulted by their partner. Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault involves the use of threats or force to coerce sexual contact and includes unwanted touching, grabbing, kissing, or penetrative sexual contact. Sexual coercion can range from begging and persuasion or making someone feel obligated to engage in sexual contact to forced sexual contact (1).

Reproductive coercion is a form of power and control where one partner strips another of the ability to control their own reproductive system (1). It may appear as pressure, guilt, or shame about having or wanting children (or not having or wanting them).

Emotional or psychological abuse may be even more common than physical abuse and may precede it or occur at the same time. Emotional or psychological abuse involves any nonphysical behavior that undermines or belittles the victim or that enables the perpetrator to control the victim. Emotional or psychological abuse can include:

• Abusive language

• Social isolation

• Financial control

• Technology-facilitated abuse

Frequently, perpetrators use language to demean, degrade, humiliate, intimidate, or threaten victims in private or in public. Perpetrators may emotionally or psychologically abuse victims so that victims start to question their own feelings, instincts, and sanity (gaslighting) and may make victims feel guilty or responsible for the abusive relationship.

The perpetrator may try to partly or completely isolate the victim by controlling the victim’s access to friends, relatives, and other people. Control may include forbidding direct, written, telephone, or e-mail contact with others. The perpetrator may manipulate the victim into thinking that others cannot or will not help, or use jealousy to justify these actions. The perpetrator may also prevent the victim from accessing medical care.

Often, the perpetrator withholds money to control the victim. The victim may depend on the perpetrator for most or all of their money. The perpetrator may maintain control by preventing the victim from getting a job, by withholding information about their finances, and by taking money.

Technology-facilitated abuse (online abuse) is the use of technology to communicate with a partner in a way that is emotionally or psychologically abusive or using images created. delivered, or shared using technology to bully, harass, humiliate, or intimidate a partner (1).

After an incident of abuse, the perpetrator may beg for forgiveness and promise to change and stop the abusive behavior. However, typically, the abuse continues and often escalates.

The perpetrator's outbursts of violence tend to be episodic and unpredictable. Thus, victims may live in near-constant fear of the next outburst.

Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim. Stalking can include:

• Unwanted phone calls, emails, messages through social media, mail, or presents (eg, flowers)

• Watching, spying on, or following the victim from a distance

• Intruding into the victim's home, workplace, or school

Perpetrators may use technology (eg, social media web sites, phones) to post videos or monitor or stalk the victim (2, 3). Also, perpetrators may monitor the victim's devices, often without the victim knowing it.

Survivors of all types of intimate partner violence are at high risk of developing mental health issues, including post-traumatic stress disorder (PTSD), substance use disorders, anxiety, depression (1, 2), self-harm, and suicide. Even when physical abuse decreases, emotional or psychological abuse often continues, reminding victims that they can be physically abused at any time.

Injuries may negatively affect the victim's ability to work, possibly leading to loss of income. Injuries, as well as the abusive situation, may embarrass victims, or perpetrators may attempt to avoid detection by preventing a victim with a visible physical injury from going to work or social gatherings, causing victims to isolate from family and friends. To escape the perpetrator, victims may move or change jobs often or suddenly, which can be a financial or social burden or a disruption in the education of victims or their children.

Intimate partner violence may be fatal and may result in short-term musculoskeletal injuries or persistent disability. Physical injuries can include bruises, black eyes, cuts, scratches, broken bones, lost teeth, burns, and lacerations or other injuries to genitals. Injuries may not heal properly if victims do not receive appropriate medical care because of embarrassment or being prevented from receiving health care by the perpetrator.

Victims of intimate partner violence also have increased rates of reproductive and sexual health impacts, including sexually transmitted infections, menstrual disorders, pelvic pain, dyspareunia, menopausal symptoms, and preterm birth (3).

Current or past intimate partner violence is associated with increased risk of developing severe or chronic disease, including cancer, diabetes, cardiovascular disease, and respiratory disease (4, 5).

Many expert organizations recommend routine screening of all patients or those at highest risk at least at the following points in health care (1, 2, 3):

• Initiation of health care with a new primary care or obstetrics and gynecology clinician

• During pregnancy at the first prenatal visit, at least once per trimester, and during the postpartum visit

• During an emergency department visit

• Upon hospital admission

Victims of intimate partner violence often present to emergency departments with physical injuries or other complaints. In one study of 964 victims of intimate partner violence in a police database, 64% had received care at an emergency department within one year prior to the index assault (4).

• History and physical examination

• Screening questionnaires

• Sometimes imaging studies

Clinicians may suspect intimate partner violence based on injuries, inconsistent or puzzling symptoms, and/or behavior of the victim and/or partner (eg, a partner is reluctant to leave the victim alone with the clinician). Or, a victim may report the abuse.

Victims of intimate partner violence present with injuries that may have patterns of anatomic distribution that can guide clinical recognition. The face, particularly the midface (nasal bones, orbits, mandible), is the most frequent site of injury (1). Injuries may also occur to the head, neck (including strangulation), thorax (rib, sternum, and clavicular fractures are common), and injury to abdominal organs. Injuries to the extremities are also common, with fractures of the fingers, hand, and forearm considered to be typical of defensive injuries (injuries occurring when victims raise their hand to protect themselves).

Known or suspected physical trauma is evaluated. Sexual assault, if suspected, is also appropriately evaluated. Patients who screen positive for intimate partner violence should also be screened for mental health conditions, because their risk is increased.

If clinicians suspect intimate partner violence, they should use the same approach as in routine screening.

Clinicians should also try to determine whether the victim can safely return home before leaving the health care facility. Safety is in doubt in the following circumstances:

• The victim has threatened to leave the relationship (most common precipitant for homicide) (2, 3).

• Violence has been increasing in risk of injury or death (eg, assaults escalate to involve choking).

• The partner has access to weapons.

• The partner has threatened to kill or injure the victim.

If intimate partner violence is suspected, clinicians should provide information about resources to help. If intimate partner violence is confirmed, clinicians may be required to document the evidence of abuse, often by photographing the injuries. This documentation can be used to support a legal case against the perpetrator. Laws about reporting intimate partner violence vary by state and sometimes by type of clinician (see MandatedReporter.com).

If intimate partner violence is known or suspected, the first priority is to treat acute injuries and ensure the patient's safety.

Physical injuries are treated. If there has been exposure to sexually transmitted infections or a risk of unintended pregnancy, measures to prevent these are offered. Mental health counseling is provided, if appropriate.

Clinicians should connect the patient with health care professionals and organizations to provide immediate and subsequent help to ensure physical and emotional or psychological safety. Multicomponent interventions for intimate partner violence combine aspects that specifically address the violence with those that support the patient with contextual factors, including health, family, or social needs (1). 

Patients may need help with developing a safety plan. Clinicians may collaborate in this but should respect patients' autonomy and let the them take the lead. It should include how the patient (and children, if they are also at risk) can get away from the perpetrator if needed, where to go for help, and how to access money and other types of support (eg, housing).

Sometimes the only solution is to leave the abusive relationship permanently because intimate partner violence continues, especially among very aggressive perpetrators. Also, even when physical abuse decreases, emotional or psychological abuse may persist. The decision to leave is not simple or easy. Victims often feel unable to leave an abusive relationship for multiple reasons, including fear of retaliation and economic dependence on the abuser.

After the perpetrator knows the victim has decided to leave, the victim’s risk of serious harm and death may be greatest. At this time, victims should take additional steps to protect themselves and their children—for example, by obtaining a restraining or protection order (although such an order does not guarantee safety).

In the United States, help is available through shelters for intimate partner violence survivors (including those in LGBTQ+ communities), support groups, the courts, and a national hotline (1-800-799-SAFE or, for TTY, 1-800-787-3224). The National Domestic Violence Helpline also has chat options if the victim is unable to make a voice call.