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Women Should Receive Routine Screen for Intimate Partner Violence

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 1/31/2012
  • Valid for credit through: 1/31/2013, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, gynecologists, obstetricians, and other specialists who care for women.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the prevalence and potential effects of intimate partner violence.
  2. Identify strategies for risk assessment and screening and counseling women who experience intimate partner violence.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author

  • Désirée Lie, MD, MSEd

    Professor of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Women Should Receive Routine Screen for Intimate Partner Violence

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 1/31/2012

Valid for credit through: 1/31/2013, 11:59 PM EST


Clinical Context

Intimate partner violence (IPV) is perpetrated by someone who is, or wishes to be, involved in an intimate relationship with an adult or adolescent and is aimed at establishing control of one partner over another. It can occur between heterosexual or same-sex partners and is experienced by both men and women.

More than 1 in 3 women in the United States has experienced rape, physical violence, or stalking by a partner in their lifetime, and the true prevalence is unknown because it is often under-reported. This opinion statement issued by the American College of Obstetricians and Gynecologists (ACOG) describes patterns of presentation of IPV and its effect on the individual experiencing IPV, with guidelines for screening and referral and management.

Study Synopsis and Perspective

Obstetricians and gynecologists should routinely and periodically screen all women for IPV, according to an ACOG Committee Opinion published in the February issue of Obstetrics & Gynecology. Screening for this significant, yet preventable, public health problem should also take place during prenatal visits, and physicians should offer support, referral, and resources, as needed, to women in abusive situations.

IPV involves control of a partner through a destructive pattern of abuse and coercion, including physical battery, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion. IPV may affect heterosexual and same-sex couples of any age, sex, societal or financial level, religion, race, ethnicity, or educational achievement.

In addition to physical injuries, presentations of IPV may include chronic headaches, chronic pelvic pain, unintended pregnancy, irritable bowel syndrome, and recurrent vaginal infections.

In the United States, about 25% of women have experienced physical and/or sexual assault by a current or former partner, but the true prevalence of IPV is unknown because it includes other forms of abuse and because victims fear disclosure.

"Women of all ages experience [IPV], but it is most prevalent among reproductive-age women," Maureen G. Phipps, MD, chair of ACOG's Committee on Health Care for Underserved Women, said in a news release. "Nearly 324,000 pregnant women are abused by their partners each year in the US.... Sadly, one of the leading causes of maternal mortality in this nation is homicide."

Other poor pregnancy outcomes linked to IPV include stillbirth, poor weight gain, infection, fetal injury, preterm delivery, and low birth weight. Among women of reproductive age, other complications may include gynecologic disorders, unintended pregnancy, and HIV and other sexually transmitted infections.

Women affected by IPV may also experience depression, anxiety, substance abuse, emotional trauma, permanent physical disability, chronic health problems, and even suicide or death from other causes.

ACOG Recommendations

"We have a prime opportunity to identify and help women who are being abused by incorporating this screening into our routine office visits with each and every patient," Dr. Phipps said.

Because of the nature of the patient–physician relationship, obstetricians and gynecologists are in a unique position to evaluate and offer management for women affected by IPV. During women's health visits for annual examinations, family planning, and pregnancy, there are many opportunities for intervention:

  • Screening at periodic intervals and counseling for IPV should be an integral part of women's preventive health visits, according to the US Department of Health and Human Services.
  • These screenings should also occur during obstetric care, at the first prenatal visit, at least once per trimester, and at the postpartum checkup.
  • Screening should take place in a private and safe setting with the woman alone, and not in the presence of her partner, friends, family, or caregiver.
  • When an interpreter is needed, this should be a professional, rather than someone associated with the patient.
  • Screening should begin with a framing statement indicating that screening is performed routinely, rather than because IPV is suspected. The patient should be reassured that the discussion is confidential and informed of specific disclosures required by state law. Most states do not mandate reporting of IPV at all, or only in certain circumstances. Physicians should familiarize themselves with the laws in their specific jurisdiction.
  • The routine medical history should incorporate IPV screening by including pertinent questions on intake forms.
  • When clinicians identify IPV, they should also provide ongoing support and discuss prevention, referral options, and other available community resources.
  • Restrooms, examination rooms, and other privately accessible areas should contain printed take-home resources including safety procedures, hotline numbers, and referral information. Posters and other educational materials should also be displayed in the office.
  • Staff training about IPV should be regularly offered.

Reproductive Coercion

To establish power and maintain control in a relationship, some partners use reproductive coercion instead of or in addition to physical or sexual violence. Examples of reproductive coercion include sabotaging contraception, refusal to use condoms, or even intentional exposure of the partner to HIV or other sexually transmitted disease.

Other ways to control pregnancy outcomes may include forcing a partner to continue an undesired pregnancy or to have an abortion, and forbidding the woman to be sterilized or to use reproductive health services.

"We need to start normalizing the conversation about abuse with all of our patients, much like we've done with HIV testing," Dr. Phipps said. "Many women will not admit to being abused, but bringing up the subject in a caring and straightforward manner over time may encourage them to eventually seek help."

In collaboration with Futures Without Violence, ACOG developed a patient education card explaining IPV and reproductive coercion. It is available in Spanish, as well as English, and targets both teenagers and adults.

Obstet Gynecol. 2012;119:412-417. Abstract

Study Highlights

  • Approximately 20% of women with a history of abuse seeking care in family planning clinics also had pregnancy coercion; 15% report pregnancy sabotage.
  • Women experiencing sexual or physical IPV are less likely to report risk for a sexually transmitted infection and are afraid to notify their partners about such an infection because of fear of threat of harm or blame from their partners.
  • Some women who experience IPV present with acute injuries, including those to the head, face, breast, abdomen, or reproductive system.
  • Others present with nonacute symptoms, such as chronic headache and sleep and appetite disturbance, representing internalized stress (somatization).
  • Consequences of such stress include post-traumatic stress disorder, anxiety disorders, depression, substance abuse, and suicide.
  • In the United States, approximately 324,000 women are abused during their pregnancy, leading to poor pregnancy weight gain, infection, anemia, tobacco use, stillbirth, pelvic fracture, placental abruption, fetal injury, preterm delivery, and low birth weight.
  • Severity of violence may escalate during pregnancy, and homicide is the leading cause of maternal mortality.
  • 250,000 hospitalizations occur as a result of IPV annually in the United States.
  • The impact of IPV includes loss of the ability to live independently, alcoholism, depression, lower self-esteem, and pediatric problems including child abuse.
  • Among adolescents, 1 in 10 report physical violence from their dating partners in the previous year, and 1 in 5 sexually active adolescents report dating violence.
  • Immigrant women may be afraid to report IPV because of fear of deportation.
  • However, a nonimmigrant visa permits women who experience IPV to legally remain in the United States if justified on humanitarian grounds or to ensure family unity or in the public interest.
  • Women with physical or mental disabilities may experience IPV if their partners withhold their medications or assistive devices or equipment such as wheelchairs or canes, or if their partners sabotage their personal service needs.
  • 1 to 2 million women older than 65 years have experienced mistreatment by those caring for them, and most of these women know their perpetrators 90% of the time.
  • Healthcare providers should have written protocols to guide IPV screening and management.
  • Screening should occur with the woman alone and not in the presence of her partner, friends, family, or caregiver.
  • A professional interpreter should be used when a language barrier is identified.
  • A framing statement should be used to normalize screening, and screening should be incorporated into the routine medical history with confidentiality assurance.
  • Community resources should be made available to women.
  • Hotlines and Internet resources for IPV are available and should be offered.
  • The National Domestic Violence Hotline is a multilingual resource that can connect patients to local domestic violence programs.
  • If a clinician suspects that a patient is in a violent relationship, he or she should acknowledge the trauma, assess the safety of the patient and family, and assist in developing a safety plan.
  • Staff should receive training about IPV.
  • Questions to screen for IPV in all women should address safety, pregnancy coercion, birth control, and physical and sexual violence.
  • For women with disabilities, use of services, functions of living, and access to assistive devices should be addressed.
  • Risk factors for intimate partner homicide include previous acts of violence, previous strangulation, estrangement, threats to life, and partner availability of a weapon.
  • State laws vary, and providers need to be familiar with their own state laws for reporting of IPV and elder abuse.
  • Documentation in medical records should include careful reflection of the patient's injuries and verbal statements in quotes.
  • IPV screening should be routinely performed at periodic intervals, especially during obstetric visits.

Clinical Implications

  • The prevalence of IPV is estimated to be at 20% or higher among women. Adverse consequences include physical injury, death; and adverse psychological, economic, and family outcomes.
  • Clinician screening for IPV should occur at regular intervals in women, especially during pregnancy and in women with physical disabilities.

CME Post Test

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