Addressing Intimate Partner Violence in Primary Care Practice

Leigh Kimberg, MD

In This Article

Health Effects of Intimate Partner Violence

Although intimate partner violence results in significant morbidity and mortality, no large, prospective study has been conducted specifically on the health outcomes associated with intimate partner violence. Most studies of the health effects are retrospective, fairly small, and use different definitions of intimate partner violence and different methods of detection.

Recent cross-sectional studies done in the primary care setting have found intimate partner violence to be significantly associated with reports of more physical symptoms, worse overall mental health, and worse overall physical health (as measured by standardized health survey tools).[15,18,20] Notably, the 2 studies that measured psychological as well as physical and sexual intimate partner violence found that poor health outcomes were just as significantly associated with psychological intimate partner violence as with physical and/or sexual intimate partner violence.[18,20] Various specific physical complaints have been studied in relation to intimate partner violence,[23,24,25] and the health effects of intimate partner violence have been reviewed elsewhere.[26,27] The relationship between HIV and violence is beginning to be explored.[28,29] A higher prevalence of substance abuse in victimized patients has been found in cross-sectional studies,[15,19,24] but the relationship between substance use and intimate partner violence is complex[30] and needs further study.

Studies have found an association between intimate partner violence and suicide. In the emergency room study by Abbott and colleagues,[8] the suicide risk for women who had never been in an abusive relationship was 8% as compared with 26% for women who reported a history of intimate partner violence.A retrospective study[31] done in Sweden documented an 8-fold increase in the risk of a suicide attempt serious enough to require hospitalization in abused women.Another study[32] found that current adult women victims of intimate partner violence were 4 times more likely to have attempted suicide than nonabused women.

In the United States, it is estimated that 30% of the homicides of women are committed by their intimate partner or ex-partner.[33]

Injuries. Intimate partner violence obviously results in direct injuries. Of the women presenting to the emergency room with violence-related injuries, one study found that 37% of these women had been injured by an intimate partner.[34] Yet, even in the emergency room, most of the women victims of intimate partner violence are not injured -- only 19% of those presenting due to acute intimate partner violence and 2.6% of those who had ever been victims of intimate partner violence.[8]

The study of the effects of intimate partner violence on reproductive health is far from complete.[35] The relationships of contraceptive use and abortion to intimate partner violence have hardly been studied. Unintended pregnancy does seem related to intimate partner violence,[35,36] but studies of the effects of intimate partner violence on pregnancy outcomes are inconclusive.[35] Gynecologic problems (sexually transmitted diseases [STDs], menstrual problems, and urinary tract infections) have been found, in a cross-sectional study,[37] to be associated with intimate partner violence.

Cross-sectional studies have found associations between intimate partner violence and an increased prevalence of overall worsened mental health status,[18,20] depression,[32,38] anxiety,[32,38] somatization,[32,38] and posttraumatic stress disorder.[39,40] Most studies do not address the distinct contributions of childhood abuse and adulthood abuse nor the effect of the "cumulative dose" or severity of abuse on health outcomes. Because childhood victimization may have long-term psychiatric effects[4,32,41] and put an affected person at increased risk for future victimization, this omission may cause confounding.[40]

One study did examine the contributions of both childhood and adulthood victimization and found that past childhood abuse and current adulthood abuse were equivalently associated with more physical symptoms, higher scores for depression, anxiety, somatization, low self-esteem, and higher rates of attempted suicide and substance abuse. Women who had experienced childhood abuse and who were also experiencing current adulthood abuse had the highest levels of these poor health outcomes.[32]

There is an expanding body of literature that describes the connection between intimate partner violence and child abuse. When cases of child abuse are identified, it has been estimated (by chart review of the mother's chart) that 59% of the mothers of abused children have also been victimized.[42] Straus and Gelles,[43] who have studied violence in the American family for many years, found that in a national random telephone survey of 6002 adults, 50% of the fathers who frequently beat their wives also frequently abused their children. Edleson[44] has compiled all the literature in this area and estimates that in "30%-60% of families where either child maltreatment or woman battering is identified it is likely that both forms of abuse exist." There is compelling evidence that childhood abuse results in long-lasting health problems.[4,45,46]

Even when children are not directly victimized, they may suffer greatly from witnessing violence. In a study of police calls for domestic assault, the domestic assaults were witnessed by a child in 85% of cases.[47] It is extremely traumatic for a child to witness his or her parent being abused emotionally, physically, and/or sexually -- often by the other parent.[48] Witnessing violence has been shown to result in emotional and developmental problems in children, even those in infancy.[48,49,50]

It is becoming evident that healthcare utilization is increased in patients who are current or past victims of intimate partner violence. For example, in a Swedish study[51] involving 117 battered women and 117 controls studied retrospectively for 10 years and prospectively for 8 years, healthcare utilization as evidenced by hospitalization due to a broad variety of physical and mental health problems was significantly higher in the battered women at both the 5-year follow-up point[52] and the 8-year follow-up point.

In a study of criminal victimization of women enrolled in an HMO, Koss and colleagues[53] found that in the 3 years following a rape, visits to a physician increased by 18% (in the first year), 56% (second year), and 31% (third year) over pre-rape healthcare visits. A retrospective study of abused and nonabused HIV-positive women revealed higher healthcare utilization among the abused HIV-positive women.[54]

There is also a growing body of data about the costs of victimization. Victimization results in healthcare costs for both mental healthcare and medical care, individual costs because of decreased quality of life for victims and their friends and families, and societal costs due to decreased productivity, increased use of social services and police services, and property damage. The NIJ, in a comprehensive report on the costs of victimizations, estimates the cost of "domestic crime against adults" as $67 billion per year (in 1993 dollars) and the cost of "domestic crime" against children at $65.6 billion per year (in 1993 dollars).[55] A more recent study[56] in a large health plan in Minnesota found that an additional $1775 annually was spent on female victims of intimate partner violence compared with female nonvictims.


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