Intimate partner violence (IPV) is defined as a systematic pattern of violence, aggression, or abuse occurring in a romantic relationship, generally within a marriage, during cohabitation, or between any formal or informal partners, including dating partners.1 Research has shown IPV to be more severe and occur more frequently in cohabiting and estranged relationships as compared with intact relationships or relationships between people who are married or dating.2 This behavior may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and coercion or reproductive coercion.3 IPV is an attempt to exert power and control over another person and has been associated with a higher likelihood of both physical and sexual violence. It's often designed to isolate, embarrass, or humiliate the other person and inevitably affect the person's sense of worth, esteem, and confidence.4 (See Types of IPV.3)

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Unfortunately, IPV is a national public health problem annually affecting millions of people.3 It's very common and is most likely to occur during times of increased stress in the lives of individuals and families. During the COVID-19 pandemic and associated lockdown period, the rate of IPV increased by 8% as people adjusted to the stress of illness and remaining at home in isolation for longer periods of time.5 IPV can happen to individuals of any sexual orientation and adults and children in every community regardless of demographic or sociocultural variables. Often, it starts early and may continue throughout a person's life with great variation in frequency and severity.

Although teen dating violence is not a separate type of violence, it's important to realize that IPV frequently occurs in this age group. Teen dating violence occurs during adolescence and can be physical, sexual, and/or psychological, just as in adult relationships. It's an adverse childhood experience affecting millions of US teens each year.1-3 About 1 in 12 young people experience physical or sexual dating violence. IPV is extremely serious and impacts lifelong health, opportunity, and an adolescent's sense of self-esteem and confidence.1

This manuscript discusses IPV as it occurs among adults and adolescents. It includes valuable information for nurses to be familiar with, such as signs and symptoms of abuse, assessment and screening measures, and supportive interventions for those who have been affected. There's controversy about whether to refer to a person who has been abused as a "victim" or "survivor." Some believe the term "victim" is necessary because IPV is a crime; others believe "survivor" is a better term, because it affirms the presence of strength.1 For the purposes of this manuscript, the term "victim" will be used.

Types of IPV

Physical violence

Physical violence includes any acts of aggression toward an intimate partner. It can include slapping or hitting, beating, kicking, suffocating, hair-pulling, or threatening to do physical harm with or without a weapon. These acts are designed to physically injure the victim and may also be designed to control or coerce.1 On average, nearly 20 people are physically abused by an intimate partner every minute in the US, which equates to more than 10 million individuals each year. One in four women and one in seven men in their lifetime have been victims of severe physical IPV such as beating, burning, or strangling.4 About 75% of female and 48% of male IPV victims experience some form of injury related to IPV, and 20% of women and 5% of men require medical care because of IPV. Every hour, six women are killed by someone they know and, in the US, 55% of all homicides are committed by an intimate partner. Globally, over 35% of all women who are murdered are murdered by an intimate partner.4

Sexual violence

Sexual violence may include acts of forced intercourse or other sexual coercion in which the victim doesn't want or is unwilling to have sex. Often, victims may comply with forced sexual contact out of fear of what the partner might do to them, their family, or others. Sometimes, the victim may be forced to do something that is degrading or humiliating.6 This type of sexual violence may include rape, attempted rape, unwanted sexual touching, forcing the victim to have sex with another person, or even noncontact sexual violence.

According to RAINN, one person in the US is sexually assaulted every 68 seconds.6 One out of every six US women has been the victim of an attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted). About 3% of US men (or 1 in 33) have experienced an attempted or completed rape in their lifetime. According to the CDC, about 25% of US men experienced some form of contact with sexual violence during their lifetime.7

The term "sexting" is a term used to describe a combination of sex and texting. It often includes a person sending nude or seminude photos or sexually explicit videos to others usually via the internet. Sexting is a newer form of aggression/violence in which the victim doesn't consent and may not even know that pictures are being sent out to others.8 There are several risks involved with sexting, including the fact that these photos may be shared with others without the person's permission.

Psychological violence

Psychological abuse is a type of violence or aggression wherein the perpetrator uses verbal and/or nonverbal communication and/or controlling behavior with the intent to exert control over the victim or harm a partner mentally or emotionally.1 Almost half of all individuals have experienced some form of psychological abuse from an intimate partner, and it is believed to be the most common form of IPV. Most psychologically abused women have also been physically abused at some point in their life.4 Some sources also list withholding financial resources as a form of psychological abuse, because it asserts control over the victim and may prevent an individual from leaving the situation or seeking help in other ways.

Coercion is another type of psychological abuse that may include isolating a person from their family and/or friends, restricting their access to information and services, monitoring their movements, and/or not allowing them to work outside of the home.9 Twenty-five percent of women and 40% of men have experienced at least one form of coercion from their partner. Another type of coercion, reproductive coercion, may occur during pregnancy. In these cases, a partner may sabotage contraception efforts, refuse to practice safe sex, intentionally expose a partner to a sexually transmitted infection or HIV, control the outcome of a pregnancy (by forcing someone to continue a pregnancy, have an abortion, or cause a miscarriage), forbid sterilization, or control access to other reproductive health services.3

Stalking is also a form of psychological abuse. Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for a person's safety or the safety of someone close to the person. Like other forms of IPV, stalking is also about power and control.7 Examples include threatening someone or a person's friends and family; nonconsensual communication, such as repeated calls, emails, texts, or unwanted gifts; and/or repeated physical or visual closeness, such as waiting for a person to arrive at certain locations, watching someone from a distance, or following a person. Victims of physical and sexual violence are often stalked by a predator prior to the occurrence of actual aggression.1

Today, technology has created new opportunities for perpetrators to stalk their victims. They may use the internet to communicate with a person or post/deliver unwanted messages through social media; video voyeurism by installing a camera to watch another person; or using GPS to track a person's location or whereabouts.10 After learning of such a stalking incident, the victim is often fearful and will have difficulty being alone or adjusting to a normal routine. As technology continues to expand, so does the risk of new forms of stalking and the need to provide some type of control for this behavior.

The cycle of violence

IPV usually follows a systematic pattern or cycle that repeats itself in each relationship. The IPV Cycle of Violence was originally researched and developed by Dr. Lenore Walker.11 It was designed to help victims and others who have never experienced IPV to understand the situation. The cycle has three distinct phases found in most violent relationships: the tension-building phase, the explosion phase, and the remorseful/honeymoon phase.

Because IPV is repetitive and cyclic, there may not be a typical phase where violence begins. When a perpetrator's history includes any kind of abuse, low self-esteem, excessive alcohol and drug use, anger and hostility, inability to understand and solve problems in a nonviolent manner, or aggressive or delinquent behavior as a youth, the risk of IPV is high.11 Frequently, the cycle of violence begins after a courtship wherein the perpetrator becomes very loving and pays a lot of attention to the victim. As the relationship grows and commitment develops, the perpetrator's behavior often becomes more controlling and turns into monitoring or stalking. At this point, the victim believes the perpetrator's behavior will change once they are together. This, however, is rarely the case, and the situation usually unfolds in three identified phases.11 (See Cycle of violence.11)

Phase 1

Relationships can be filled with challenging and stressful interactions. These may occur due to something minor or even result from the perpetrator's jealousy over an imagined situation related to the victim. The perpetrator begins to feel tense, irritable, or frustrated, and so begins phase one, the tension-building phase. The perpetrator becomes angry, verbally abusive, or demanding with a need to control the victim. The perpetrator may criticize or blame the victim for something insignificant or something that isn't even the victim's fault. The victim may also feel angry, afraid, embarrassed, and unfairly treated, but will attempt to prevent the perpetrator from becoming even angrier or violent by being submissive, nurturing, or "walking on eggshells." This is the tension-building phase.

Phase 2

In Phase 2, the victim may not say or do anything to make the situation worse; however, the perpetrator often moves on with a desire to hurt or kill the victim. This phase describes the violent episode when the perpetrator is irrational and out of control. Without intervention, some form of violence is inevitable. The victim may self-protect by hitting or kicking back, trying to escape, seeking help, or even submitting to the violence in an effort to make it end. Regardless of the behavior, the victim may feel trapped, frightened, and helpless. This is even more serious if the victim doesn't know what to do, doesn't have a plan, and sustains injuries that prevent or make escape difficult.

Phase 3

If the victim survives the abuse and remains in the situation, Phase 3, the remorseful/honeymoon phase, may occur minutes or hours after the end of Phase 2. The perpetrator may forget or not realize how severe the violence was and feels remorseful with apologies and promises to change or "never let it happen again." Often, the victim is angry over the incident, relieved to have it over, and feels guilty, but hopeful that the perpetrator is sincere. Often, despite the seriousness of the situation or injuries sustained, the victim makes excuses for the perpetrator's behavior. Sometimes, in Phase 3, the perception of tension and danger remains high without ever returning to baseline. When this happens, the risk of a lethal incident is extremely high, as the cycle may repeat itself. The victim feels hopeless, anxious, and depressed, waiting for another violent outburst to occur.

IPV vs. other types of violence

IPV is unique. It always occurs between people who have a personal relationship or know each other in some way prior to the violence. This relationship can develop quickly, as in a dating relationship, but the perpetrator and the victim know each other before the cycle of violence starts. Rape, for example, is not always IPV. It may occur suddenly and without warning when a perpetrator sees the opportunity. It can also occur within the context of other behavior, such as a robbery or even a verbal discussion that becomes "overheated." These crimes may be premeditated and are often planned.12

IPV is sometimes called a "crime of passion." In criminal law, a "crime of passion" is a crime committed in the "heat of passion" or in response to provocation, as opposed to a crime that was premeditated or deliberated. Although domestic violence murders are often thought of this way, the evidence does not support this conclusion. Instead, most IPV-related murders demonstrate careful planning wherein the perpetrator monitored and/or stalked the victim. Among homicides of women killed by an intimate partner, 81% of perpetrators were the victim's current partner.13

Consequences of IPV

IPV affects all age groups. Sometimes, children witness IPV in the home or other settings. Exposure to IPV can have long-lasting effects on a child's emotional and neurologic development resulting in serious behavioral and mental health problems.14,15 They may develop anxiety, have difficulty sleeping, and experience nightmares. Difficulty concentrating and worry about their own safety or the safety of a parent is also common. Children may also display other significant changes in behavior including a decrease in school performance, lack of interest in school or outside activities, and increased aggression with their peers or others. The longer the period of violence, the more serious the consequences are likely to be.7

Depending upon factors such as length of time exposed to abuse, type of abuse, and other social determinants of health, each victim is also affected differently by IPV. Approximately 20% of all IPV adult victims report the onset of new psychiatric disorders such as anxiety, depression, and posttraumatic stress disorder. Substance use disorders in victims are also linked to IPV in that they may attempt to medicate themselves and improve their emotional state using alcohol or drugs. Some victims may escape or leave home to avoid ongoing violence and thus experience homelessness. If the victim continues to feel hopeless, helpless, and trapped, chronic abuse may result in severe depression and suicide.1

IPV victims often consider themselves to be medically unhealthy, and they have higher rates of health problems such as headaches, insomnia, chronic pain in a variety of locations, hyperventilation, and gastrointestinal symptoms. Victims may have unplanned pregnancies and are at high risk of sexually transmitted diseases, including HIV/AIDS.16

IPV can also impact the victim's other relationships and home life. Often, work is also impacted if the victim can't work due to physical injury. Mental health issues may also impact the victim's ability to concentrate on work, get along with others, or perform various tasks needed on the job. Those in college may not report or seek help for fear that they won't be able to continue their education (see Consequences of IPV).17

Warning signs of abuse

People who are new to relationships may find it difficult to tell the difference between healthy behaviors designed to show love and caring and unhealthy behaviors intended to control the other person in the relationship. Recognizing the signs that someone may be an abuser is the first step to ending it. IPV is never the fault of a victim, and there are ways to find safety and many resources for support when a person finds themselves in this situation. Behavior is not healthy if it attempts to control another person's life and interactions (see Warning signs of an abusive partner).18 Individuals who ask questions about whether a specific behavior is healthy or unhealthy should be encouraged to talk either to a healthcare provider or a trusted family member or friend. If an abusive partner is suspected, the provider should discuss warning signs with the patient and attempt to provide resources, if possible.

Warning signs for nurses

Healthcare providers, including nurses, play a key role in the detection of IPV among their patients. The assessment for IPV for people who present to the ED or for a clinic visit with concerns or findings that appear related to abuse is considered a diagnostic evaluation. On the other hand, a screening evaluation involves questioning all persons who are seen for care, regardless of whether they present with a history or examination that raises concerns about possible abuse. A provider can sometimes sense a problem by observing interactions between the patient and partner. The partner may do all the talking or interrupt the patient or the patient may repeatedly look to her partner for approval after speaking. In this situation, it's best to try to separate them, usually by telling the partner that you need to speak to the patient alone. If the abuser is reluctant or refuses to leave, ask the abuser to leave per the clinic policy. If the perpetrator won't leave, the provider should advise the patient that an examination can't be completed until their partner leaves.

Every effort should be made to provide a private environment for appointments, especially when IPV is thought to be an issue. Certain aspects of the history or observations made during the clinic visit should heighten the clinician's concern about IPV (see Warning signs of IPV in a victim).19,20

Screening tools

The American College of Obstetricians and Gynecologists, in line with the US Department of Health and Human Services, Agency for Healthcare Research and Quality, and the Institute of Medicine/National Academy of Medicine, recommends that IPV screening and counseling should be a fundamental part of women's preventive health visits and at periodic intervals, including obstetric care (at first prenatal visit, at least once per trimester, and at the postpartum checkup, as disclosure may not occur at the first attempt).3,23,24 Providers should also offer ongoing support, and review available prevention and referral options.4

All the screening tools evaluated by the US Preventive Services Task Force are directed at patients and can be self-administered or used in a clinician interview format (see Screening tools).25

Barriers to screening

Five categories of IPV screening barriers have been identified in the literature: personal barriers, resource barriers, perceptions and attitudes, fears, and patient-related barrier. The most frequently reported barriers for healthcare providers included personal discomfort with the issue, fear of offending the patient, lack of knowledge, time constraints, and perceived lack of power to change the problem.25 Provider-related barriers were reported more often than patient-related barriers. Despite the recommendations for routine IPV screening in various medical settings, healthcare providers do not routinely screen for IPV.26 Increased education and training regarding IPV are necessary to address perceptions and attitudes to remove barriers that delay IPV screening by healthcare providers.

IPV prevention and intervention

The risk of IPV has increased significantly over recent years, especially since the onset of the COVID-19 pandemic when victims were forced to be confined with their aggressor for extended periods of time.20 Those who present to healthcare facilities often have a variety of physical injuries; many of whom are victims of sexual assault and according to Tennakoon et al.,27 sexual assault ranks among the highest.

When providing care to IPV victims, it may be difficult to know the "right" thing to say. Providers can provide support in many ways, but the most important is listening. Specific phrases that are also helpful include "I believe you," "It's not your fault," and "You are not alone." Avoiding judgment and offering supportive resources are also vital when caring for victims. To protect the victim and children from witnessing or being exposed to violence, the provider should encourage the victim to find another living situation, such as family, friends, or a shelter. Other resources include, but are not limited to, mental health evaluation and suicide prevention, safety hotlines, housing/shelter, counseling, and providing food and clothing.6

Encourage IPV victims to leave the abusive situation as soon as possible, especially if physical or sexual violence is involved or children are present in the home. Providing resources for victims of IPV can be difficult because the victim often can't secure information safely, in a location "hidden" from the perpetrator (see Victims resources). Discuss options for transportation and housing with the victim, including the importance of preparing a "go bag" with important items such as identification, medication, and cash, even if the victim is not yet ready to leave (see Recommendations for "go bag" contents). This bag will be invaluable when leaving the abusive situation becomes an option. The victim should be encouraged to leave the bag somewhere where it can be quickly taken in an emergency (trunk of the car, friend's house), as well as the importance of keeping a cell phone charged and the car full of gas for a quick exit, if needed.

Avenues of support

IPV is a serious problem worldwide affecting millions of adults and children. National healthcare organizations advocate screening for everyone who is seen in a healthcare setting. Numerous resources are available for people who wish to leave a dangerous and abusive situation, but the person must first make the decision to leave. With ongoing support and encouragement, a victim can often find support and strength to leave and live a normal, safe life.

Types of IPV3

* Physical violence

* Sexual violence

* Psychological violence

Cycle of violence11

* Phase 1: Tension-building phase

* Phase 2: Explosion phase

* Phase 3: Remorseful/honeymoon phase

Consequences of IPV1,7,14-16

* Poor physical health

* Depressed mood and/or anxiety

* Trauma and posttraumatic stress disorder

* Feelings of guilt or shame

* Increased risk of substance use disorder

* Cardiac symptoms

* Chronic disorders and chronic pain

* Gastrointestinal problems due to stress

* Reproductive problems

* Unsafe sexual behavior

* Low self-esteem

* Self-harm and suicide

* Inability to trust others

* Difficulty maintaining a job

Warning signs of an abusive partner18

* They use physical aggression. They often slap, hit, shove, or push their partner.

* They are unpredictable. Their moods tend to change rapidly and radically.

* They are often jealous, suspicious, and/or angry-even if they have no reason to be.

* They control their partner's time. They monitor and control their partner's activities, including whether they go to work or school and how much they see their family and friends.

* They control their partner's money. They make important financial decisions about shared money by themselves, or they take their partner's money without permission.

* They use verbal threats. They are not afraid to name-call, swear, and yell at their partner.

* They isolate their partner. They may limit their partner's use of the phone or other sources of communication or may force their partner to stay at home.

* They minimize their partner's feelings. They may also make their partner feel guilty or ashamed.

* They blame. They often try to blame their partner or others for their problems.

* They threaten-a lot. They may threaten to hurt themselves, their partner, or their partner's loved ones if their partner tries to leave.

* They may force their partner to have sex-even if their partner does not want to.

Warning signs of IPV in a victim19,20

* Inappropriate affect. Victims may appear jumpy, fearful, or cry readily. They may avoid eye contact and seem evasive or hostile. A flat affect or dissociated appearance may be present and could suggest posttraumatic stress disorder.

* Delay in seeking treatment.

* Frequent ED or urgent care visits. Typically, abusers do not want their victims to form an ongoing allegiance with one clinician.

* Missed appointments. The patient may not keep appointments because the abuser will not allow medical attention/travel outside of the home. In one study, 17% of victims of IPV felt that their partner interfered with their access to practitioner visits, compared with 2% of those not living with abuse.20

* In pregnancy, seeking prenatal care late in their pregnancy.

* Social isolation

* Repeated abortions. Unplanned pregnancy may result from sexual assault and/or not being allowed to use birth control (reproductive coercion).21

* Medication nonadherence. Victims may not take medicines because an abuser has taken them away, not allowed the partner to fill prescriptions, or disposed of them.

* Overly attentive or verbally abusive partner. The clinician should be concerned if the partner is overly attentive or answers questions for the patient. If the partner refuses to leave the examination room, the clinician should find a way to get the partner to leave before questioning the patient. Partner hesitancy to leave the patient alone is an important sign.

* An inconsistent explanation of injuries.

* Reluctance to undress or have a genital, rectal, or oral examination, or difficulty with other examinations.

Screening tools25

* HITS (Hurt, Insult, Threaten, Scream)

* OVAT (Ongoing Violence Assessment Tool)

* STaT (Slapped, Threatened, and Throw)

* HARK (Humiliation, Afraid, Rape, Kick)

* CTQ-SF (Childhood Trauma Questionnaire-Short)

* WAST (Woman Abuse Screen Tool)

Victim resources

* The National Domestic Violence Hotline - 1-800-799-SAFE (7233)

* The National Sexual Assault Hotline - 1-800-656 HOPE (4673)

* The National Domestic Violence Hotline - 1-800-799-7233 (SAFE)

* National Dating Abuse Helpline - 1-866-331-9474

* National Center for Victims of Crime - 1-202-467-8700

* Love is respect - 1-866-331-9474

* Break the Cycle - 202-824-0707

Recommendations for "go bag" contents

* Birth certificates and social security cards for victim and children

* Driver's license and/or passports

* Marriage, divorce, or custody papers

* Legal protection or restraining orders

* Health insurance cards and medical records

* Immunization records

* Car title, registration, and insurance documentation

* Cash and prepaid credit cards that can't be traced

* Charged prepaid cell phone or a cell phone with a new contract and number.

* Current medications and prescriptions for victim and children

* Clothing for victim and children

* Keepsakes

* Spare set of keys

INSTRUCTIONS Intimate partner violence: Warning signs and interventions

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REFERENCES