Violence

Question 1

Epidemiology of intimate partner violence (IVP)

Answer 1

Lifetime prevalence of sexual assault: 20% for women, 1.4% for men

Lifetime prevalence of severe IPV physical violence: 25% for women, 14% for men

Homicide by an intimate partner: 33% of all female homicides, 4% of male

IPV during pregnancy: 10% of women; #1 cause of maternal death during pregnancy (US)

Question 2

Risk factors for being a victim of intimate partner violence (IPV)

Answer 2

Risk factors:
• Pregnancy
• Young age
• Single, separated or divorced status

NOT risk factors
•	Socioeconomic status
•	Race
•	Level of education
•	Employment 
•	Insurance status

Associated characteristics (association≠causation)
• Mental illness
• Drug and alcohol abuse (by the victim)
• Poor general health or chronic pain
• Health-seeking behavior

Question 3

Risk factors for being a perpetrator of intimate partner violence (IPV)

Answer 3

Risk factors:
• Being male
• Alcohol, firearms, drugs (esp. stimulants like cocaine, amphetamines)
• Exposure to abuse or battering as a child
• Social isolation
• Less than high school education
• Prior arrests
• Young age
• Low income, economic stress
• Community with traditional gender norms or weak sanctions for IPV

Question 4

Clinical signs of intimate partner violence

Answer 4

TRAUMA (similar to child abuse)- especially defensive injuries

MEDICAL (more common and harder to spot)
• Repeated or recurrent complaints
• Non-specific complaints without clear etiology (marker of stress, somatic focus, need for safe space)
• Headaches, chest pain, GI problems, sleep disturbances
• “Poorly controlled” chronic condition
• Pelvic trauma or pain, request for STD check
• Mental health complaints: depression, substance abuse

Question 5

Why don’t victims disclose abuse?

Answer 5

Love of partner, concern for children

Need for relationship (emotionally, financially, other)

Self-denial

Cultural norms/acceptance

Never asked…or feel physician not interested

Prior bad experiences with the law/establishment

Question 6

Why don’t victims leave?

Answer 6

Fear, guilt, shame, feeling of failure

Depression, low self-esteem

“Cycle of violence” involves good times

Social isolation, economic isolation

Gender roles, cultural expectations

Question 7

What are the stages of change

Answer 7

Precontemplation (Don’t see the problem behavior)

Contemplation (See the problem behavior, considering change)

Preparation/Determination (Wants to change behavior, getting ready)

Action/Willpower (Active steps to change)

Maintenance (Maintain new behavior)

Relapse (Abandons changes, returns to old behavior)

Question 8

What to do if a patient says yes to being abused?

Answer 8

1. Ask (even if no disclosure, this may help progression through stages of change)
2. Identify (diagnose)
3. Validate patient’s experience (IPV as not normal or healthy)
4. Assess safety/immediate risk
   o Risks: stalking, threats to kill, firearm in home, escalating patterns, substance abuse
   o Safety check: keys, phone numbers, cell phone, place for kids, “safe haven,” cash, neighbors or work aware, kids trained in calling for help, IDs in safe place
5. Joint planning: is the law aware, do you want a shelter now, where are the kids?
6. Document current and past events (“patient states” or “alleged” are ok)
7. Refer to IPV counselors and resource centers (know your local resources)
8. Report when legally required (know your local laws)
9. Schedule follow-up (keep lines of inquiry and support open)

Question 9

What is the Colorado law on reporting of abuse?

Answer 9

All acute injuries thought to be due to injury due to an intimate partner must be reported to the police in jurisdiction of your office (not the jurisdiction of the assault)

What are the exceptions to patient confidentiality in IPV?

All physicians have competing responsibilities where “imminent threat” is disclosed (i.e., if reporting will directly increase risk to a victim, it may be reasonable to defer report…but you must document this clearly, and it should be rare)

FVPF: “If you practice in a state with a mandated reporting law, inform patients about any limits of confidentiality prior to conducting assessment.”

Question 10

“Batterer Intervention Programs (BIPs)”

Answer 10

12 to 52 weeks; often a group format; combination of punishment and rehabilitation

Content basis (often mix of both):
1.	Feminist (Duluth model): target men’s view of women and their belief about a right to control relationships; examine sexist/patriarchal assumptions; interventions help men examine their beliefs, their methods of control, and how society may sanction this behavior 

2. Cognitive Behavioral Therapy: based on assumption that batterers lack skills in relationships, communication and anger management, and relationships

Effect? Possible 5% decrease in recidivism with interventions; Most men (53-85%) who complete programs remain nonviolent for up to 2 years; BUT high drop-out rates (up to 50%), and many who are referred never enroll

Problems: “forced” treatment, denial remains intact, no specific treatment of co-existing substance abuse, psychopathology, no outcomes studies, poor funding

Best programs:
• Longer periods (rather than shorter)
• Change batterers’ attitudes enough that they will/can discuss their behavior
• Work together with criminal justice system (to enforce program participation)

Question 11

Components of the definition of intimate partner violence

Answer 11

Must be a pattern

Must be intention behind violence- to establish power and control over partner

Significant negative impact from it

Question 12

What are the three stages of the cycle of violence?

Answer 12

1. Tension Building
2. Acute Battering Incident
3. Re-engagement (hearts and flowers)

Might not be the most accurate model. In reality, the power and control struggle is happening all the time in different ways (sexual, physical, isolation, economic abuse, coercion, threats, etc)