The Role of the Physician When a Patient Discloses Intimate Partner Violence Perpetration

A Literature Review

Brian Penti, MD, MS; Joanne Timmons, MPH; David Adams, EdD

Disclosures

J Am Board Fam Med. 2018;31(4):635-644. 

In This Article

Abstract and Introduction

Abstract

Intimate partner violence (IPV) is prevalent and has lasting impacts on the health and well-being of the entire family involved. Primary care physicians often interact with male patients who perpetrate IPV and are in a role potentially to intervene, but there is very little research and guidance about how to address perpetration of IPV in the health care setting. We reviewed the existing literature research related to physicians' interactions with male perpetrators of IPV and summarize the recommendations. If a male patient discloses IPV perpetration, physicians should assess for lethality, readiness to change, and comorbid medical conditions that could impact treatment, such as substance abuse and mental illness. Experts agree that referrals to a Batterer Intervention Program should be the primary intervention. If there are no locally available Batterer Intervention Programs or the patient is unwilling to go, then a physician should refer the abuser to a therapist who has been trained specifically to work with perpetrators of IPV. In addition, physicians should be prepared to offer education about the negative impact of IPV on the victim, on any children, and on the abuser himself. Physicians should address any untreated substance abuse or mental health issues. Referral to couples therapy should generally be avoided. Physicians should continue to have regular follow-up with their male patients to support them in changing their behavior. Further research is needed to assess the role the health care system can have in preventing IPV perpetration.

Introduction

Intimate partner violence (IPV) is defined by the US Centers for Disease Control and Prevention as physical violence, sexual violence, stalking, and psychologic aggression by a current or former partner or spouse.[1] Beyond the types of violence involved, IPV is generally recognized as a pattern of coercive control on the part of the abuser that serves to undermine the victim's will or autonomy.[1] Multiple theoretic models exist to explain IPV, including feminist,[2] power,[3] social learning,[4] ecologic,[5] and psychoanalytic theories,[6] although empirical data to support these models is often lacking,[7] hence many researchers conclude that IPV results from a combination of individual, household, community, and societal factors.[5,8]

Every year in the United States, there are approximately 5 million incidents of IPV that involve female victims,[9] resulting in 1,200 deaths and more than 250,000 injuries.[10] In addition, these incidents entail economic costs to the health care system as well as to employers in terms of lost productivity. In 1995, these costs exceeded $8.3 billion.[11] Moreover, 1 in 4 children in the United States witness parental IPV during their lifetime and approximately 1 of every 15 children witness episodes on a yearly basis.[12] The impact of IPV on the health and mental well-being of survivors and children is significant and long-lasting (Table 1),[13–18] and there are negative impacts on the perpetrator.[19–21]

The United States Preventive Task Force recommends screening women of childbearing age for IPV victimization based on evidence of the effectiveness of screening and of the lack of harm.[22] However, there has been only limited research conducted on the potential benefits and harms of screening men for IPV perpetration. Although men are also victims of IPV, the majority of IPV perpetrators are men[10,23] and these men often access the health care system. According to prior studies, 13% to 23% of male patients self-report having perpetrated IPV[24–28] and 2 out of 3 male perpetrators report seeing a regular doctor for routine care.[28]

Although men often do not disclose their abusive behaviors during medical encounters, physicians may become aware that their male patients are IPV perpetrators in other ways, including disclosures by victims, documentation in medical records, and behavior directly disclosed or witnessed.[29,30] Screening protocols for perpetration of IPV have been developed[24–26,31] but, to our knowledge, screening for IPV perpetration is not commonly practiced and has not been recommended by any of the major medical societies.

The position article on violence issued by the American Academy of Family Physicians states that family physicians have a role both in recognizing perpetration of IPV and in providing appropriate referrals.[32] Despite this statement, there has been very little research into this topic, leaving physicians unprepared to interact with male perpetrators of IPV.[29] Pilot guidelines were developed by the Family Violence Prevention Fund (now known as Futures Without Violence), and other experts have offered their guidance on this topic,[30,31,33–39] but these are often based on expert opinion with limited evidence to support them and have not, to our knowledge, been formally evaluated. This review article attempts to summarize the existing literature about what physicians should do when they find themselves interacting with a male patient who discloses IPV perpetration. Of note, men may also be victims of IPV in heterosexual relationships and IPV perpetration exists in LGBTQ relationships, but these are beyond the scope of this review. In addition, we do not discuss situations where a female victim discloses IPV, in confidence, to a physician who also cares for the male perpetrator, which is also beyond the scope of this article.

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