Sociation Today

    The Family Violence Prevention Fund (2004) refers to intimate partner violence (IPV) or domestic violence, as a pattern of coercive behaviors to exert control over an intimate partner using "physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats" (p. 2). The World Health Organization (2013:6) offers another definition of IPV as a "self-reported experience of one or more acts of physical or sexual violence by a current or former partner since the age of 15 years".

    IPV is recognized as a social and health problem globally – 35% of women in the world have experienced physical or sexual IPV and as many as 38% of female homicides are committed by intimate partners (World Health Organization 2013).   In the United States, a partner physically or sexually assaults a quarter of women; it is estimated that 1.5 million American women experience IPV each year and it is associated with morbidity, mortality, and medical costs (Chang et al. 2005; Goodman and Epstein 2008).

    Despite the mortality associated with IPV, many victims actively seek help as IPV escalates in frequency and severity over time (Campbell et al. 1998; Goodkind, Sullivan, and Bybee 2004). They may seek help informally, through friends and family, or formally, through social services, police, and healthcare. Studies find that when most women attempt to leave an abusive relationship, they seek help through formal services to ensure initial and ongoing safety (Goodkind et al. 2004; Meyer 2015). However, Meyer (2015) argues that when seeking help both formally and informally, victims often face victim-blaming attitudes where they must "prove" they have not contributed to their own victimization. Unfortunately, this may also occur in the medical field where women seeking help feel alienated, perceive the healthcare system as unhelpful, or must prove they have taken steps to leave the relationship to gain the sympathy of medical professionals (Plichta 2007; Sweet 2015).

    Healthcare is a necessary resource for abused women because they tend to frequent healthcare facilities more often than non-abused women (Plichta 2007). IPV is associated with physical injuries, gastrointestinal disorders, depression, anxiety, chronic pain, gynecological issues, sexually transmitted diseases, and suicidal ideation – all of which lead women to seek medical care (Chang et al. 2005). García-Moreno (2002) argues that women may be treated for any of these previously identified health concerns without being asked by healthcare professionals how they were caused. By ignoring the cause of health-related problems, abuse remains invisible to healthcare providers and referrals to appropriate social services are not made. Moreover, Williamson (2009) argues that the medical fields' response to intimate partner violence victims in general is insufficient.

    In the following section, I highlight the consequences associated with IPV. Next, I address the controversies surrounding screening practices and the reasons for it, including both providers' limitations to detect abuse and women's hesitance to disclose victimization. Then, I discuss ways to improve victims' healthcare, including moving towards a systems-based approach. I conclude with directions for future research.

Consequences of Intimate Partner Violence

Intimate partner violence is recognized as a public health concern in the United States (National Center for Injury Prevention and Control 2003). Women who experience IPV endure physical, mental, and sexual health problems. According to Dutton et al. (2015), abused women suffer from both direct and indirect pathways of abuse. Direct pathways involve physical injuries; whereas, indirect pathways involve prolonged stress and more severe physical and mental problems. Severe abuse has a greater impact on women's health, and the impact tends to be continuous with conditions worsening over time (Dutton et al. 2015). Black et al. (2011) argues that as conditions worsen, abused women visit health care providers more frequently than women who are not abused leading to higher healthcare utilization. Higher utilization results in higher healthcare costs for women experiencing IPV and society.

Health Consequences for Women

    IPV is a risk factor for frequently encountered health problems such as, but not limited to, headaches, back pain, vaginal infection, and digestive problems (Campbell et al. 2002). When women are physically abused, injuries most commonly occur to the face, neck, and head; less common locations are the abdomen, back, and genitals (Sheridan and Nash 2007). Plichta (2004) finds that minor injuries such as scratches and bruises are most common while more serious forms of injury such as knife wounds, broken bones, burns, and bullet wounds are less common. Furthermore, repeated force from punching or kicking to a woman's head and face may cause mild traumatic brain injury – an injury that is often unrecognized and unreported in healthcare settings (Davis 2014). Overall, injuries caused by abuse may be more prevalent than any other type of injury including car accidents, mugging, and rape combined (McLeer and Anwar 1989).

    Dutton et al. (2015) argues that not only do women suffer immediate physical consequences, but the effects of abuse may persist once it has ended. For example, women tend to experience mental health problems during and after abuse including: depression, anxiety, post-traumatic stress disorder, and suicide ideation (Coker et al. 2004). Martin (2009) suggests that in addition to mental health issues, women may struggle with emotional problems, such as fear, guilt, and self-blame. And according to Haeseler (2013), the psychological stress that accompanies abuse can lead to suicide ideation and estimates that as many as 35% to 40% of abused women attempt suicide in the United States. Thus, IPV results in physical and emotional consequences, and both can be exacerbated by sexual violence.

    Studies estimate that as many as one in ten women have been raped by an intimate partner (Dutton et al. 2015). Women raped by an intimate partner are more likely to experience psychological distress and are often found to have concurrent physical abuse (Brown, Burnette, and Cerulli 2014). Brown, Burnette, and Cerulli (2014) argue that sexual IPV is a risk factor for post-traumatic stress disorder (PTSD), and the severity of abuse –such as the combination of physical and sexual abuse –correlates with the severity of PTSD symptoms. Sexual violence is yet another form of abuse that may have profound negative impacts on women's health.

    In most severe cases of abuse, mortality is an associated risk. When femicide occurs, high rates of IPV are documented prior to a woman's death (Plichta 2004). Goodman and Epstein (2008) estimate that approximately 30% of women murdered in the United States are killed by a current or ex-partner. Campbell (2004) also finds that the majority of women killed by their partners could have been identified in the healthcare sector prior to their death. Campbell argues that most women murdered by their partners had been in the healthcare system for general health problems, mental health problems, substance abuse, or injuries before they were killed. These findings stress the importance of IPV screenings in the healthcare sector to (1) detect intimate partner violence and (2) help victims of IPV find resources to prevent further abuse.

Consequences for Society

High rates of healthcare utilization by victims of IPV is associated with increased healthcare costs. For example, women who are abused exceed $5.8 billion annually and incur 2-2.5 times the cost as non-abused women (Bonomi et al. 2009; Chang et al. 2005; National Center for Injury Prevention and Control 2003). In a study that compared health plans, women exposed to IPV generated 92% more costs per year than non-abused women (Waetchter and Van 2015). Additionally, studies find that healthcare costs continue once violence has ended. For example, Bonomi et al. (2009) finds that women who suffered from physical violence for five or more years prior to their study spent 19% more on healthcare per year after abuse ended than women who were never abused.

Work absenteeism is another cost associated with IPV. Martin (2009) argues that IPV has negative effects on women's health, and it also influences their ability to work and provide for themselves. Other scholars argue that low income and unemployment are often reasons why women stay in abusive relationships (Lacey, Saunders, and Zhang 2011). Collectively, women miss nearly 8 million days of paid work annually which leads to lost labor for employers (Modi, Palmer, and Armstrong 2014). Lost productivity and wages averages about $1.8 billion per year (Dagher, Mary, and Kozhimannil 2014). These findings suggest that IPV is associated with elevated healthcare costs, lost wages for women, and lost productivity for employers.

Intimate Partner Violence and The Health Care Sector

Studies estimate as many as 54% of all women seeking healthcare in emergency departments have experienced IPV in their lifetime, and healthcare facilities are often the first point of formal contact for IPV victims (Bacchus et al. 2003; Hugl-Wajek et al. 2012; Othman, Goddard, and Piterman 2014). Thus, health care professionals come in frequent contact with victims of IPV. However, among scholars studying IPV, there is a growing recognition that the healthcare sector needs to improve its role in addressing IPV (Ghandour et al. 2015; Parsons, Goodwin, and Peterson 2000). It is important to address IPV in healthcare settings because studies suggest when violence goes undetected, health-related conditions can worsen (Chrisler and Ferguson 2006). In addition to health concerns, documenting abuse in healthcare settings is important for legal reasons. For example, when abuse is not documented, women may not have written documentation for court, which is often used to verify injuries (Glass, Dearwater, and Campbell 2001). This suggests a lack of coordination among various services including healthcare and legal help.

Dutton et al. (2015) argue that healthcare screenings and assessments are the first steps to identify IPV. There are two approaches to screening – universally screening all women, or only screening those determined at risk (O'Campo et al. 2011). Plichta (2004) recommends that universal screening techniques be used to detect abused women in lieu of selecting women based on injuries because the patterns of injuries have proven to have a low predictive validity. Nevertheless, research shows various results when it comes to the effectiveness of IPV screening which has led to a debate in the field over its implementation (Carroll 2016; MacMillen et al. 2009).

Controversy over Universal Screening

    The Affordable Care Act includes screening and brief counseling as free preventive services to women (Miller et al. 2015). Despite this and evidence that IPV presents health risks to women, medical providers disagree over the need to routinely screen women for IPV. Those against screening cite a lack of evidence that screening results in reduced violence or enhanced health for those affected by IPV (MacMillen et al. 2009). In 2004, the U.S. Preventive Task Force declared there was insufficient evidence that screening was effective, thus preventing them to recommend screening in medical settings (McCloskey et al. 2006). In 2013, the U.S. Preventive Task Force renounced their conclusion from 2004, to recommend universal screening in healthcare settings (Moats, Edwards, and Files 2014).

    Despite their recommendation, a universal screening policy has not been adopted by healthcare facilities. Ghandour, Campbell, and Lloyd (2015) suggest there are structural barriers to adoption such as (1) inadequately trained medical personnel, (2) organizational cultures unfavorable to screening, and (3) the absence of protocols and processes necessary for providers to screen. Additionally, Young-Wolff et al. (2016) argue that clinical guidelines and training professionals have shown little improvement in identification, intervention, and referral. Consequently, women often find the healthcare system unhelpful or feel alienated by healthcare providers (Plichta 2007).

    Current research continues to find contrasting results regarding the effectiveness of screening interventions – some find interventions to be successful, others do not. For example, a study by McCloskey et al. (2006) finds positive results associated with screening, including that: 1) disclosing violence to health professionals is associated with women's use of interventions; 2) women are more likely to leave their abuser if they receive interventions; and 3) exiting an abusive relationship is linked with improved health. While MacMillen et al. (2009) did not find support to implement screening in health care settings, concluding that screening leads to few benefits.

    More recently Carroll (2016) argues that there is research that supports the effectiveness of universal screening and screening can help identify abuse, and identification can lead to preventive strategies. And although most healthcare organizations promote the use of screening, actual practices remain low (Waalen et al. 2000). A commonly cited reason for low screening practices is accounted for by the screening barriers health professionals face.

Barriers to Screening

    Research identifies potential barriers that impede health professionals' ability to detect abuse. One of the most common barriers is a lack of knowledge and training regarding how to address intimate partner violence; consequently, Hamberger and Phelan (2006) suggest that training gaps leave providers unprepared to both identify and help victims of IPV. In cases where providers do identify patients as an IPV victim, they lack knowledge about effective interventions and referral services (Waalen et al. 2000). Proper interventions upon identification are necessary, because without them, identification is useless. For example, Garg, Boynton-Jarrett, and Dworkin (2016) argue that screening for abuse must be met with the capability to refer and link patients to appropriate services.

   However, education and training are not the only barriers for addressing IPV. For example, research suggests that medical staff do not have sufficient time to question patients about IPV, nor do they have time to provide emotional support to patients (Beynon et al. 2012). Additional studies find that other barriers include: (1) the patient is always with her partner, (2) cultural and language barriers, (3) fear of own safety, (4) viewing screening as outside of one's professional responsibility, (5) fast-paced work environments, (6) multiple priorities, (7) high workloads, and (8) viewing abuse as a psychological issue, rather than a medical concern (Jeanjot, Barlow, and Rozenberg 2008; Minsky-Kelly et al. 2005; Waalen et al. 2000).

    Young-Wolff et al. (2016) argue that in healthcare, IPV has been described as a "wicked problem" because it is difficult to address, complex to understand, stigmatized by society, and a seemingly unmanageable condition. Some medical professionals use metaphors to describe asking patients about IPV, including "opening Pandora's Box" and "opening a can of worms" (Sweet 2015; Williston and Lafreniere 2013). IPV creates challenges for professionals regarding how to best serve women's needs (Williston and Lafreniere 2013). IPV disclosure changes the nature of the patient-provider relationship, and practitioners may avoid asking about IPV because if it is not identified, it remains invisible.

    Sweet (2015) suggests that IPV has been increasingly medicalized. Medicalization is a "process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness and disorders" (Conrad 2007:4). When confronted with IPV, health providers may address physical symptoms of abuse rather than the underlying cause of symptoms. Medicalization of IPV grants health professionals the authority to treat abuse with medicine while simultaneously minimizing the social context behind it. This is problematic because victims of IPV may want providers to understand the complexity of abuse which cannot be done without addressing underlying causes of symptoms.

    Scholars suggest that there are gender differences regarding physicians' likelihood of screening patients for IPV. For example, Jonassen and Mazor (2003) find that compared to male physicians, female physicians are more likely to screen women for IPV. Not only do female physicians screen more, but they detect abuse earlier, assess the history of abuse more thoroughly, and are more likely to make referrals than their male counterparts (Saunders and Kindy 1993). This is significant because men dominate the healthcare sector (Ballou and Landreneau 2010). Rose and Saunders (1986) critique the patriarchal nature of medicine arguing that gendered norms create health care environments that (1) avoid addressing abuse, (2) only treat physical injuries, and (3) tend to rely on prescriptions for addressing insomnia, depression, or anxiety.

    Despite the barriers that professionals face in their jobs such as lack of education, training and time, another commonly cited obstacle is patient nondisclosure and noncompliance (Waalen et al. 2000). When women do not disclose abuse to professionals, they are unable to detect it. Thus, women's discloser is important for IPV intervention to take place within the medical field.

Barriers to Disclosure

    It is often difficult for IPV victims to disclose the abuse they experience. Spangaro et al. (2011) estimate that 20% of victims never tell anyone about their abuse. The stigma surrounding IPV may lead women to view themselves negatively and blame themselves for staying in an abusive relationship making it hard to disclose abuse to others (Enander 2010). Thus, studies suggest that some of the barriers to disclose IPV to health care professionals include fear of their abuser, shame, feeling trapped, fear of being reported to statutory officers, not viewing the abuse as serious, and not feeling comfortable with the health provider (Spangaro et al. 2011; Spangaro et al. 2010). Further, some women fear disclosing abuse will allow health providers to discount their physical symptoms, which can lead to feelings of frustration when providers do not try to understand the complexity of violence (Nicolaidis et al. 2008). According to Othman et al. (2014), there is an unspoken agreement between providers and abused women not to address IPV.

    However, Plichta (2007) finds when health providers probe about IPV women are more likely to disclose. In fact, 80% of victims will disclose abuse if asked, but are unlikely to disclose without direct questioning (Plichta 2007). Research suggests that most women want to be asked about IPV, but some continue to be wary of health providers' intentions for asking (Chang et al. 2015). To combat this, Chang et al. (2015) argues that healthcare professionals should provide a reason for asking about IPV, which increases the likelihood for women to disclose. Other studies indicate that even if women do not disclose the first time they are asked, they would like repeated opportunities to disclose because they might be ready to upon persistent inquiries (Spangaro et al. 2011).

    Nevertheless, disclosure can yield positive outcomes for victims of IPV if it is met with positive responses from health care providers, such as understanding and making referrals to social services (Spangaro et al. 2015). For example, Feder et al. (2006) argues that IPV victims want healthcare professionals to be nonjudgmental, understanding, and sensitive when confronted with IPV. Other studies suggest that there may be benefits to offering all women information about IPV, including brochures, flyers, or posters (Chang et al. 2005).   Yet research shows that because of issues like physician and victim related barriers, screening practices and intervention rates have remained low, with recent slight improvements (Hamberger, Rhodes, and Brown 2015).

Improving Care

    Identifying IPV in healthcare settings has the potential to improve health outcomes for women (McCall-Hosenfeld et al. 2014). Ambuel et al. (2013) argues that failure to screen represents a lost opportunity to intervene and help victims, so the they suggest that making small changes such as prompting professionals to ask patients about abuse while looking at their medical record, and placing a screening tool on patients' charts may improve screening rates. Moreover, the use of structured screening tools increases the rate of detection of victims while being cost-effective (Bacchus et al. 2003; Norman et al. 2010).

    To increase identification and prevention, healthcare professionals need to be equipped to do so and they need to be trained on how to respond to IPV. There are currently 17 states with laws that require IPV training for healthcare professionals, but these requirements vary by state (Dagher et al. 2014). However, scholars argue that education is typically not enough. For example, Waalen et al. (2000) underscore that there is an initial, statistically significant increase in provider screening practices after training, but afterwards screening tends to decrease back to its baseline. According to Ambuel et al. (2013), successful interventions include three elements: (1) training/education for health professionals; (2) clinical changes such as ongoing improvement strategies and administrative buy-ins; and (3) cultural changes that make prevention part of the values and norms of the healthcare system. Therefore, this suggests that interventions should extend beyond training for health professionals alone.

    A common conception is that IPV screening should be evaluated on its ability to reduce IPV; however, O'Campo et al. (2011) argue that this may not be the most appropriate outcome of screening. Rather, a more useful evaluation would examine the program's entire process of responding to IPV, from screening and interventions to making referrals to social services (O'Campo et al. 2011). Studies focusing on screening only, in the absence of intervention, reflects the practice of medicine to focus on symptoms and acute problems, rather than the underlying context of IPV (Hamberger et al. 2015). Therefore, it may be more useful to look at comprehensive approaches to care that go beyond screening and intervention to incorporate a systems-based response to IPV.

Systems-based Approaches

    It is crucial that health professionals are able to link IPV victims to appropriate services, one way to ensure this is through a systems-based approach. Systems-based approaches, sometimes referred to as comprehensive approaches, highlight a cross-sector collaboration where healthcare systems can be connected to community and advocacy providers (Miller et al. 2015). Systems-based approaches incorporate screening at multiple levels and have institutional support; this is important because O'Campo et al. (2011) find that systems-based approaches have effective screening protocols, ongoing training for staff members, and immediate access and referrals to onsite or offsite support services. Systems-based approaches yield more successful outcomes than those that are not (O'Campo et al. 2011).

    Most systems-based approaches are still in early developmental stages. One example of a healthcare organization utilizing a systems-based approach is Kaiser Permanente Northern California (KPNC). This organization serves 3.9 million patients. KPNC addresses IPV through: 1) visible messages such as posters; 2) routine inquiry, intervention, and referral; 3) safety planning, triage for mental health, and follow-ups by behavioral health clinicians; 4) partnerships with IPV advocacy organizations; and 5) local leadership and oversight (Young-Wolff et al. 2016). This approach has experienced success as Miller et al. (2015) find that because of their initiatives, since 2000, identification of abuse has increased eightfold.

    While a systems-based approach within healthcare facilities is ideal; unfortunately, studies suggest that full implementation of this approach has not yet been achieved in the United States (Sumner et al. 2015). Violence remains hidden in most healthcare settings and women who experience abuse are not identified (Plichta 2007). Identification of IPV is largely left to the discretion of healthcare professionals and idiosyncratic decisions to inquire about abuse.

    Thus, teams of health providers and social service providers at the state level can help to create policies to coordinate the care given to IPV victims in women's health programs (Dutton et al. 2015). Programs similar to Project Connect, led by Futures Without Violence, can also help to promote change. Project Connect helps to promote positive responses to IPV in health care settings and is currently involved in 13 states and 7 health programs (Dutton et al. 2015). It is important to continue to research and evaluate systems-based programs that are successful, as well as those that are not, to find interventions to be adopted universally in healthcare settings.

Conclusion

Othman et al. (2014) argue that healthcare professionals are in positions to intervene in cases of IPV, as health care facilities are often the first point of formal contact for victims. Providers have the potential to identify women that may be at risk for serious forms of abuse, including femicide, as women can often seek health care prior to their death (Campbell 2004). To best serve women beyond their immediate physical needs, providers need to be equipped to screen and refer women to necessary social services. Thus, the research consistently finds that a systems-based approach may be most beneficial to women.

Moving forward, research should consider evaluating different healthcare screening processes to examine what methods and services are best-suited for addressing this social problem. One goal of future research should be to evaluate new policies and procedures to improve the care given to victims of IPV. Additionally, scholars should consider a longitudinal approach to follow up with IPV victims. This will allow researchers to evaluate both the short and long-term effectiveness of systems-based approaches.

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