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Sections Domestic Violence
Overview
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References

Overview

Background

The medical literature defines domestic violence in different ways. In this article, domestic violence refers to the victimization of a person with whom the abuser has or has had an intimate, romantic, or spousal relationship. Domestic violence encompasses violence against both men and women and includes violence in gay and lesbian relationships.

Domestic violence consists of a pattern of coercive behaviors used by a competent adult or adolescent to establish and maintain power and control over another competent adult or adolescent. These behaviors, which can occur alone or in combination, sporadically or continually, include physical violence, psychological abuse, stalking, and nonconsensual sexual behavior. Each incident builds upon previous episodes, thus setting the stage for future violence.

Forms of physical violence include assault with weapons, pushing, shoving, slapping, punching, choking, kicking, holding, and binding. Two forms of physical violence have been posited: occasional outbursts of bidirectional violence (ie, mutual combat) and frank terrorism, of which the "patriarchal" form has been the most researched.
Psychological abuse includes threats of physical harm to the victim or others, intimidation, coercion, degradation and humiliation, false accusations, and ridicule.
Intimate partner stalking may occur during a relationship or after a relationship has ended. Of women who are stalked by an intimate partner, 81% are also physically assaulted. A new development is psychological abuse (generally threats) expressed through the Internet, so-called cyberstalking.
Sexual abuse may include nonconsensual or painful sexual acts (often unprotected against pregnancy or disease).

Domestic violence may be associated with physical or social isolation (eg, denying communication with friends or relatives, or making it so difficult that the victim stops attempting communication) and deprivation (eg, abandonment in dangerous places, refusing help when sick or injured, prohibiting access to money or other basic necessities).

Domestic violence is not a new epidemic—it spans history and cultures. The Common Law of England permitted a man to beat his wife, provided the diameter of the stick so used was not wider than the diameter of his thumb, hence, the term "Rule of Thumb."

Domestic violence exacts a multitude of costs. Annual economic costs (in 2003 dollars) was estimated at $8.3 billion, including $6.2 billion for physical assault, $461 million for stalking, $460 million for rape, and $1.2 billion for lives lost. The Centers for Disease Control and Prevention (CDC) reports that victims of severe domestic violence annually miss 8 million days of paid work—the equivalent of 32,000 full-time jobs, and approximately 5.6 million days of household productivity.^[1]

The magnitude of the current problem may be further appreciated by examining the burden placed on law enforcement. Police in the United States spend approximately a third of their time responding to domestic violence calls. Of women presenting to the emergency department (ED), research suggests that between 4 and 15% are there because of problems related to domestic violence. Calls to the police and visits to the ED sometimes are used by victims of domestic violence to strategically manage the episode by de-escalating the violence.

When victims of domestic violence (male and female) were asked where they would go for assistance, they responded as follows:

Would seek help from the police - 31.2%
Did not know - 27.7%
Would go to a hospital - 14.7%
Would approach a family member - 10.7%
Would go to a shelter - 10.7%
Would forego assistance and simply retaliate - 3.1%

Women who are abused seek medical attention moreso than those who are not victimized. A study in the Northwest found that 95% of women with diagnosed domestic violence sought care 5 or more times per year and that 27% sought medical care more than 20 times per year. Often, these women go to the ED.

Victims of acute domestic violence are those patients in the ED whose complaints directly relate to an incident of abuse. Two to 4% of women who present for treatment of injuries, excluding those sustained in motor vehicle collisions (MVCs), are victims of domestic violence.

Of women in violent relationships, 77% who present to the ED do so for reasons other than trauma. The percentage of women with domestic violence–related symptoms who present to an ED with any complaint ranges from 22-35%, including patients requesting nontrauma, prenatal, or psychiatric care.

Abused patients who present for other medical problems resulting from a violent milieu are said to suffer from chronic domestic violence. This term applies to those patients who are victims of violence at the hands of a partner and who seek medical care for symptoms related, directly or indirectly, to the stress of the relationship.

Women report to the police only 20% of all rapes, 25% of all physical assaults, and 50% of all stalkings perpetrated by intimate partners. Even fewer men who are victims of such crimes at the hands of an intimate partner report them to law enforcement. Thus, the emergency clinician is often the first professional from whom an abused person seeks help. In fact, more than 85% of Americans indicated they could tell a physician if they had been a victim or perpetrator of family violence, slightly more than those who would tell their priest, pastor, or rabbi and considerably more than those who would tell a police officer.

Yet, if a request for help is not explicit, the opportunity to intervene in domestic violence often is not addressed. The following elements may deter interceding in domestic violence:

Social factors, such as implicit and explicit social norms, societal tolerance of violence, and desensitization through exposure
Personal factors, such as sex bias, personal history of abuse, idealized concepts of family life, concerns over privacy, and perceived powerlessness
Professional factors, such as time constraints, inadequate skills, professional detachment, and professional relationships with abusers or victims
Institutional and legal factors such as inadequate or unclear policies and fear of legal reprisal
Additional barriers including blaming the victim, disapproving of her or his decisions and circumstances, questioning patients in an inappropriate manner, and failing to query middle-class or affluent patients in the mistaken belief that such individuals are not victims of domestic violence

If the emergency clinician is to recognize occult domestic violence and correctly interpret its associated behavior, a high index of suspicion is necessary, and battering must be entertained in the differential diagnosis of a wide variety of presenting complaints. In this regard, much improvement is needed. An accurate diagnosis of battering is estimated in less than 1 of 25 women. Data from another study documented that 23% of women presented 6-10 times and another 20% sought medical attention on 11 occasions before a diagnosis of abuse finally was made.

Why would domestic violence consistently be unrecognized over so many ED visits? The most significant reason for missing the diagnosis of domestic violence simply may be failure to ask. Limiting inquiry about domestic violence to patients with specific complaints fails to identify many victims of abuse.

The largest ED-based study to date (n = 4501) discovered that 6 diagnoses were more common in women in physically abusive relationships compared with women not in such relationships. However, the low sensitivity and positive predictive value of these diagnoses made the findings clinically useless in detecting most women in violent relationships—those who do not present with injuries resulting from acute battering.

The US Preventive Services Task Force states that it cannot, at this time, determine the balance between the benefits and the harms of screening for family and intimate partner violence among children, women, and older adults. However, given the substantial percentage of patients seeking care in the ED who are abused by their partners, considering a context of violence in assessing all types of ED patients would seem prudent. Patients may be males or females from any socioeconomic group, and their injuries may or may not be related to trauma. Moreover, the incidence and prevalence of domestic violence, coupled with its morbidity and potential mortality, strongly militate in favor of routinely screening most adult or adolescent emergent patients.

Recognition of domestic violence and employment of appropriate management strategies may well have even broader implications. Domestic violence fits within a spectrum of family violence that also includes elder abuse, child sexual abuse, and child abuse and neglect.

These forms of violence share many similar root causes, thus interventions directed at one may positively influence other forms of violence as well.

The practitioner in the emergency department is on the front line of interpersonal violence and is thus in a unique and vital position to initiate the process that may stop the cycle of violence in all of its familial expressions.

Pathophysiology

As with organic pathology, an archetypical abnormal behavioral function characterizes domestic violence. The term cycle of violence is descriptive of the pattern of abuse and consists of the following 3 components:

Tension building
Explosion, acute battering
Absence of tension, also called loving respite, reconciliation, or the "honeymoon phase"

An appreciation of the cycle of violence is essential to understanding the nature of domestic violence, its clinical presentation, and appropriate intervention.

During the tension-building phase, the battering victim frequently tries to be particularly compliant and kind in an attempt to avoid violence. Irrespective of any special efforts, the abuser still becomes angry with increasing frequency and intensity. Paradoxically, the abused person may be so frightened during this tension-building phase that she or he attempts to precipitate abuse, just to be done with the episode. When battering does occur, it frequently is followed by a period of indefinite length during which the batterer is contrite and demonstrates loving behavior.

Friends and family of victims, as well as experts, frequently ask victims of domestic violence why they stay in such apparently horrible situations. A nonexhaustive list of reasons includes love, hope, dependence, fear, and learned helplessness.

With reference to love, domestic violence often occurs in a relationship in which at least one partner loves the other. This partner wants things to be all right again and does not want to lose the other person's (perceived) love.

Hope is an operative corollary to love. The abused partner wants to believe the batterer's promises made during the increasingly frequent honeymoon periods of ever-decreasing duration as the cycle of violence deepens.

Dependence is an additional barrier to seeking help and most commonly is observed in women who may have a sense of emotional dependency with reluctance to expose batterers to punishment. In fact, few victims cooperate in the prosecution of arrested assailants. After only a few days, many victims even deny that they have been assaulted. Women are also more likely to rely on their partner for financial support. The abused person may feel there are no options but to stay and tolerate the violence, especially if children are involved.

Fear is a powerful factor. Victims repeatedly emphasize that seeking care or assisting in prosecution of their assailants would escalate the violence, and their fears are based in fact. Batterers often escalate violence when their partners increase help-seeking measures or attempt separation. During prosecution, approximately half of batterers threaten retaliatory violence, and more than 30% actually commit assaults.

The most dangerous time for battered women is during attempts to leave relationships. Women who are separated from their husbands have a risk of violence about 3 times more than that of divorced women and approximately 25 times more than that of married women. Up to 75% of domestic assaults reported to law enforcement agencies occur after separation of the couple, with women most likely to be murdered when reporting abuse or attempting to leave an abusive relationship.

Another fear experienced by victims of domestic violence is loss of children; batterers often retaliate by abducting offspring, especially during the early period of separation.

Finally, learned helplessness may be a factor. People exposed to unpredictable and inescapable negative stimuli may become passive and unable to protect their lives. A stress response syndrome has been described, which consists of self-blame, chronic anxiety, extreme passivity, denial of anger toward others while directing anger inwardly, and paralyzing terror at the first sign of danger.

Keeping the above factors in mind, attention now turns to the patient's willingness to accept help and take steps to extricate himself or herself from the environment of domestic violence. Recalling the cycle of violence previously addressed, the patient may be amenable to intervention during both the tension-building phase and the battering phase. During the reconciliation phase, the battered person typically is showered with expressions of love and apology and with assurances that the abuse will never happen again. Given the dynamics of this stage, the patient is much less willing to seek or receive help.

Insight into a further consideration of behavioral change is offered by the Transtheoretic Model of Change described by Proschaska and DiClemente. They posit a 5-stage dynamic model characterized by the following: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Adapting this model to the setting of domestic violence, in Precontemplation, the patient may not recognize the abusive state (feeling he or she deserves such treatment or that such treatment is normal) and, therefore, has no thoughts of change; those unwilling or unable to make the requisite behavioral change are also placed in this stage.

Inquiry at this stage serves to raise awareness of the abnormal state.

In the Contemplation stage, which can last for years, the victim sees the problems created by the abuse and begins to think about the advantages and disadvantages of making a change. The Contemplation stage may begin with a nondisclosure phase, in which the patient is unwilling or unable to disclose the abusive relationship to others. This may be followed by a disclosure phase, when the patient is ready to discuss abuse with a clinician or other person. A study of patients who discussed abuse with a physician identified 4 expectations of significance: affirm the abuse is real, inform the patient about local resources for victims of domestic violence, educate patients about the effects of abuse on them and their children, and document injuries in the medical record.

The Preparation stage is marked by active planning for change, as manifested by telling family and friends of the abuse, calling hotlines, and making a plan for leaving. The Action stage speaks for itself and is frequently reached when violence is witnessed by or directed at children. This stage is reached when the victim makes the determination that the violence must end, and he or she assesses the presence of adequate support and resources. Maintenance involves solidifying the change and working to prevent relapse. Relapse is commonly seen as the patient moves through the stages of change and is most common in the action stage.

Frequency

United States

According to the CDC's National Intimate Partner and Sexual Violence Survey report published in 2017, 1 in 4 women and 1 in 7 men have experienced severe physical violence by an intimate partner during their lifetime. In the US, about 1 in 3 women (36.3%) and nearly 1 in 6 men (17.1%) experienced some form of contact sexual violence (SV) during their lifetime.^[2]

Lifetime and one-year estimates for intimate partner violence (IPV), sexual violence (SV), and stalking are alarmingly high for adult Americans, with IPV alone affecting more than 12 million people each year.^[2]

Stalking statistics are also quite high; about 1 in 6 women (15.8%) and 1 in 19 (5.3%) men in the US have experienced stalking victimization at some point during their lifetime.^[2]The majority of stalking victims are stalked by someone they know. About 6 in 10 (61.5%) female victims and 4 in 10 (42.8%) male victims were stalked by a current or former intimate partner.^[2]

Nearly 5.3 million incidents of domestic violence occur annually among US women aged 18 years and older, with 3.2 million occurring among men. Of these incidents, most are relatively minor, such as pushing, grabbing, shoving, slapping, and hitting. Serious consequences certainly do, however, result.

Every year approximately 1.5 million intimate partner rapes and physical assaults are perpetrated against women, and approximately 800,000 are committed against men. About 1 in 5 women (19.1% or an estimated 23 million women) have experienced completed or attempted rape at some point in their lives. Completed or attempted rape was experienced at some point in life by 1.5% of men or an estimated 1,692,000 men in the US.^[2]

From 1994 to 2010, according to a 2012 special report from the US Department of Justice, the overall rate of IPV in the United States declined by 64%, from 9.8 victimizations per 1,000 persons age 12 or older to 3.6 per 1,000.^[3]Females and males experienced similar overall declines in IPV during the same time period. From 2000 to 2005, the rate of IPV for females continued to decline (down 31%), while male victimization rates remained stable. This pattern differed between younger and older females, however. From 2000 to 2005, rates of IPV continued to decline for females ages 12 to 17 (down 52%), 18 to 24 (down 40%), and 25 to 34 (down 40%), while rates for females ages 35 to 49 and 50 or older remained stable.^[3]

Mortality/Morbidity

Almost 2 million injuries occur each year as a result of domestic violence, of which approximately one third of patients will seek care in an ED. Reported injuries include 43,000 patients with gunshot wounds, stab wounds, fractures, internal injuries, and loss of consciousness; 53,000 injured as a result of intimate partner rape or sexual assault; and 390,000 with soft tissue trauma, such as contusions and cuts.

Over the past 20 years, the number of intimate partner homicides has decreased by about 14% overall for men and women.

In 2002, approximately 11% of homicide victims were killed by an intimate partner, accounting for 1,300 deaths.

In the United States, most intimate partner murders are committed with firearms, as is the case for murder in general.

Women were the victims in 76% of intimate partner murders in 2002. Of women murdered by an intimate partner, 44% had visited an ED within 2 years of the homicide, with 93% having had at least 1 visit for injury.

Four to 8% of women are abused at least once during pregnancy. A study in Maryland found that homicide was the leading cause of death among pregnant women in that state, whereas for nonpregnant women of child-bearing age, murder ranked as the fifth cause of death.

Nearly half of the estimated annual 4400 intrafamily murder victims are spouses. Fifty to 75% of the 1500 annual deaths resulting from murder-suicide occur in spousal or consortial relationships. More than 90% of such acts are perpetrated by the male partner, who often has a history of domestic violence. In these incidents, children and other family members may be murdered as well.

A home in which anyone has been hit or hurt in a family fight is 4.4 times more likely to be the scene of a homicide than is a violence-free home.

According to US Department of Justice data for 1998, women were the victims in 85% of nonlethal intimate violence.

The literature is contradictory as to the proportion of males and females who sustain injuries as a result of domestic violence. While the conventional wisdom is that women are more likely to be injured than are men, some reports suggest that the frequencies of male and female victims of domestic violence are equal.

In 1996, McCoy reported that, in mixed-sex domestic violence, the female is 13 times more likely to be injured than is the male.^[4]In 1995, Bachman and Saltzman indicated that, in violent incidents committed by intimates, women sustained injury in 52% of cases, with 41% of those patients requiring medical care.^[5]

Contrary findings come from a study of 516 patients presenting to an inner-city ED, in which high rates of domestic violence were nearly equal between men and women. Males and females had the following rates of domestic violence, respectively:

Past nonphysical violence - 14% versus 22%
Past physical violence - 28% versus 33%
Present nonphysical violence - 11% versus 15%
Present physical violence - 20% versus 19%

In an ED study of 1003 patients reported by Sachs et al, no significant sex difference was noted in the rate of patients acutely injured by intimate partner violence. No such difference was found in patients reporting abuse within the past year, abuse with a weapon, or abuse with a weapon within the last year.^[6]

With reference to serious injury, in a small study (n = 37) reported by Vasquez and Falcone, victims of domestic violence admitted to one trauma center were just as likely to be male as female.^[7]Males were more likely to be seriously injured than were females, with average Injury Severity Scores of 11.4 versus 6.9.

While males were less likely than females to be victims of gunshot wounds (6% vs 21%) or to be injured in an assault (22% vs 53%), they were more likely to be stabbed (72% vs 26%).^[7]

Race

The National Violence Against Women Survey found that African American and American Indian and Alaskan Native women and men, and Hispanic women, report higher rates of domestic violence than do other minority groups; whereas Asian and Pacific Islander women and men tend to report lower rates of intimate partner violence than other minority groups. However, differences among minority groups diminish when other sociodemographic and relationship variables are controlled.

In 1998, Salber and Taliaferro reported that the spousal homicide rate among African Americans is 8.4 times more than for whites; however, the US Department of Justice reports that between 1976 and 1998, a 74% reduction occurred in the number of black men murdered by intimates.

The incidence of spousal homicide is 7.7 times higher in interracial marriages compared with intraracial marriages.

Sex

Much of the data concerning domestic violence are based on involvement of the criminal justice system. When interpreting reports from law enforcement agencies, the following caveat should be noted: In 1997, Ernst and colleagues reported a significant difference in reports of past abuse to the police, with 19% of women having made such reports versus only 6% of men.^[8]

Females are more likely to be repeatedly attacked, injured, or raped by their male partners than by any other perpetrators. The US Department of Justice estimates that females are 6 times more likely than males to experience violence committed by an intimate (eg, spouse or ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend). Of all violence against females that is committed by a lone offender, an intimate is the perpetrator in 29% of cases.

Half of homeless women and children are fleeing domestic violence.

Battered lesbians report high levels of sexual violence, in the range of 30-40%. Some experts believe that homosexual men also experience high levels of sexual violence, although little documentation can be found in the literature. Data from the National Coalition of Anti-Violence Programs report the rate of domestic violence in same-sex couples increased by 29% in 2000.

Approximately 11% of women living with female intimate partners report being raped, physically assaulted, or stalked by their cohabitant. (In comparison, 30.4% of women living with a male partner, reported such victimization by their male cohabitant.)

Approximately 15% of men living with male intimate partners report being raped, physically assaulted, or stalked by their cohabitant. (In comparison, 7.7% of men who have lived with a female partner experienced such problems.)

Age

Women aged 16-24 years are more likely than other women to be victims of violence at the hands of an intimate. Twenty to 30% of university women report violence during a date.

The rates of spousal homicide for all groups peak in the 15- to 24-year-old age category. Rates decline with age in African Americans but not in whites.

As the age differential between husband and wife increases, so does the risk of spouse homicide.

Clinical Presentation

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