Amy Giles; Regina Prusinski; Laura Wallace

Learning Objectives

By the end of this section, you will be able to:

Summarize the definition and identifying signs of domestic violence and IPV
Discuss associated factors of domestic violence and intimate partner violence
Discuss how a nurse can recognize victims and perpetrators of IPV

Domestic violence occurs in the home, a place where everyone should feel safe. Domestic violence and its subcategory IPV can be difficult to identify because it often occurs behind closed doors with only people inside the family being aware of the abuse.

Abusers can incorporate physical, financial, and sexual violence into their abuse. Just as pediatric nurses are trained to notice signs of child abuse, the women’s health nurse must screen all patients for IPV and be aware of signs that a person is a victim or perpetrator of IPV. The nurse is in a special position of providing support and resources for these women.

Domestic Violence

Also known as family violence, domestic violence is a form of abuse that occurs within a family or household. It can take many forms, including physical, emotional, sexual, and financial abuse. Anyone can be at risk of family violence, regardless of their gender, age, or socioeconomic status. However, women and children are disproportionately affected, with women being the most common victims of domestic violence. Identifying family violence can be challenging. Some signs that family violence may be occurring include unexplained injuries or bruises, isolation from family and friends, changes in behavior or personality, or a partner who tries to control or dominate their partner’s thoughts or actions.

Physical or sexual violence, stalking, and psychologic or coercive aggression by a current or former intimate partner is considered intimate partner violence (IPV) and is widespread across the United States. Victims can be of any gender and sexual orientation. The nurse is often the initial health-care professional to encounter a victim of IPV, and it is often the nurse’s assessment that identifies the patient experiencing IPV. Compassion and understanding are important. Effective communication is necessary to help survivors come forward and share their experiences of abuse. IPV is a complex issue, and the patient may not initially consider leaving the abuser as an option. The nurse’s responsibility is not to advise the person to leave the abuser. It is the nurse’s responsibility to listen, be supportive, and supply resources for the time when the survivor is ready to act. In some states, nurses are required to take a course on mandatory reporting to understand instances where reporting violence is mandatory.

Associated Factors

Domestic violence and IPV are related to other types of abuse. Abusers use physical abuse to force control. They can also use sexual abuse to humiliate and physically harm persons. Financial abuse takes control of a person’s ability to leave the abuser and gains total control over that person. All of these types of abuse are focused on control of the person by the abuser.

Physical Abuse

Any use of force or violence to cause physical harm, such as hitting, kicking, or choking is called physical abuse. It can cause serious injuries or even death. Physical abuse can occur regardless of age or gender. Physical abuse may look different across the lifespan; for instance, higher rates of physical abuse are reported by pregnant women (National Partnership for Women and Families, 2021). Serious maternal and neonatal complications occur as a result of IPV during pregnancy. These risks include miscarriage, hypertension, preeclampsia, premature rupture of membranes, preterm birth, low birth weight, and perinatal death (Eikemo et al., 2023). Other risks include vaginal bleeding, vomiting, dehydration, anxiety, depression, and PTSD (Selwyn, 2020). After the birth, many women will experience postpartum depression, anxiety, and posttraumatic stress disorders due to the violence experienced during pregnancy. As with other types of IPV, women of color experience more IPV during pregnancy than any other group of women, which leads to higher rates of maternal morbidity and mortality (Selwyn, 2020). Transgender persons also have higher incidences of IPV and physical abuse. In a survey conducted in 2016, 24 percent of transgender persons reported severe physical IPV, and 16 percent reported sexual IPV (Sherman et al., 2023).

A person who is experiencing physical abuse may have visible wounds, bruising, or unexplained injuries (Washington State Department of Social and Health Services, n.d.). However, the nurse should not assume that a lack of an apparent wound means the patient is not a victim of abuse. Often abusers will purposely use force on body areas that can be covered with clothing to prevent any questions from being asked. The nurse may notice bruises in different stages of healing, a health history of frequent “falls or accidents,” and fear of answering questions especially in front of their partner. Abusers will not want their partners to be alone with health-care providers or nurses. They are afraid the person will expose the abuse. The partner might answer questions for the person, belittle the person or their symptoms, and make excuses for injuries such as the person being clumsy. Other signs of physical abuse may include social isolation and withdrawal. It is important to ensure the patient is alone when initiating any conversation about abuse to prevent angering the abuser. The nurse must also be aware of reporting requirements in their state or organization.

Legal and Ethical Issues

Law Enforcement and Domestic Violence

After the introduction of Walker’s Cycle of Violence Theory, the legal system understood more about domestic violence, specifically intimate partner violence. Persons within the legal system were taught to look for the cycle of violence to help identify when violence was occurring. Expert testimony used the cycle, specifically the honeymoon phase, to explain how a woman being abused could stay with her abuser. This theory was successful in bringing light to violence against women.

(Goodmark, 2011)

Financial Abuse

The exploitation or misuse of a person’s financial resources, often by a trusted person, such as a family member or caregiver is called financial abuse. This type of abuse can take many forms, including theft, fraud, coercion, or the misuse of financial accounts or assets. The impact of financial abuse on a person can be severe because it can leave them potentially destitute. Leaving the abusive partner may lead to poverty, debt, or even homelessness for the victim of abuse. Financial abuse can also have a significant impact on a person’s mental health and well-being because it can erode their sense of trust and security, as well as their confidence in their own judgment and decision-making abilities. Some signs of financial abuse include sudden changes in a person’s financial situation, such as unexplained withdrawals or transfers, missing funds or assets, or unpaid bills. Other red flags may include a caregiver who seems overly interested in a person’s finances, refuses to let the person make their own financial decisions, or insists on managing all financial matters without input from the person.

Sexual Violence

The continuum of sexual activity that ranges from unwanted kissing, touching, or fondling to sexual coercion and rape is considered sexual violence. It can expose a partner to a sexually transmitted infection (STI) or human immunodeficiency virus (HIV) infection. Reproductive coercion refers to behavior by the perpetrator that leads to power and control over reproductive health, such as control of a pregnancy (forcing the woman to continue the pregnancy, have an abortion, or miscarry because of injury), forbidding of sterilization, or control over access to family planning (American College of Obstetricians and Gynecologists [ACOG], 2012). A partner may sabotage contraception by intentionally not using a condom (ACOG, 2012). Of women seeking care in a family planning clinic, 20 percent reported a history of abuse through pregnancy coercion, and 15 percent reported birth control sabotage (ACOG, 2012).

Misinformation about Intimate Partner Violence

Because many survivors of IPV do not report violence for fear of retribution, misinformation regarding IPV occurs. Common myths include that IPV is a private family matter, that it is not a serious problem in the United States, that IPV is an anger management problem, or that it is easy for a victim to leave their partner. Other misinformation is that IPV occurs only in younger women; however, IPV occurs at all ages. Sometimes people do not consider IPV abuse unless it includes physical violence. The most common myth is that the woman did something to provoke the partner. This type of thinking is detrimental to women and perpetuates the cycle of abuse.

Link to Learning

The Danger Assessment Tool is a self-administered survey that is free to use and is available in several languages. Nurses can refer patients experiencing IPV to the National Center on Domestic Violence, the Trauma and Mental Health database for resources, and the National Domestic Violence Hotline for free, confidential support.

How Nurses Can Recognize Victims and Perpetrators of IPV

Health-care providers and nurses screen women for IPV; however, many women are afraid or ashamed to admit to being victimized. Therefore, when assessing every patient, the nurse should be alert to signs of IPV, such as unexplained contusions, lacerations, bite marks, or burns (Cleveland Clinic, 2023). Other signs may be less obvious, such as delay in seeking care, repetitive medical visits for chronic complaints, or repeat visits for anxiety or depression (Cleveland Clinic, 2023). The nurse can recognize a potential perpetrator if the partner speaks for the patient or does not leave the patient alone at any time. Perpetrators of IPV are usually hostile toward women, jealous, controlling, hypersensitive, and critical of the partner (Kippert, 2022).

Several organizations have published opinions on screening for IPV. The U.S. Preventive Services Task Force recommends IPV screening for all women of childbearing age at any clinic visit; the Association of Women’s Health, Obstetric, and Neonatal Nurses adds that women should be screened in private annually; and the Joint Commission requires hospitals to have written criteria for IPV screening (Bermele et al., 2018). ACOG (2012) recommends that all women be screened for IPV regardless of their reason for the health-care visit. See Table 9.2 for recommendations on screening women for IPV.

Clinic Procedure	Sample Statements and Questions
Screen in a private, safe setting with the woman alone, away from her partner, friends, family, or caregiver; to get the person alone, ask the patient to follow you to the restroom.	Framing statement: “We’ve started talking to all of our patients about safe and healthy relationships because it can have such a large impact on your health.”
Use professional language interpreters, not family members.	Confidentiality: “Before we get started, I want you to know that everything said here is confidential, meaning that I won’t talk to anyone else about what is said unless you tell me that … [insert the laws in your state about what is necessary to disclose].”
At the beginning of the assessment, tell the woman this screening is universal and confidential.	Sample questions: “Has your current partner ever threatened you or made you feel afraid?” (That is, has your partner ever threatened to hurt you or your children if you did or did not do something, controlled whom you talked to or where you went, or gone into rages?) “Has your partner ever hit, choked, or physically hurt you?” (“Hurt” includes being hit, slapped, kicked, bitten, pushed, or shoved.)
Incorporate IPV screening into routine medical history questions.	For women of reproductive age: “Has your partner ever forced you to do something sexually that you did not want to do, or refused your request to use condoms?” “Does your partner support your decision about when or if you want to become pregnant?” “Has your partner ever tampered with your birth control or tried to get you pregnant when you didn’t want to be?”
Establish relationships with community resources.	For women with disabilities: “Has your partner prevented you from using a wheelchair, cane, respirator, or other assistive device?” “Has your partner refused to help you with an important personal need such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink, or threatened not to help you with these personal needs?”
Keep printed resource material with hotline numbers and safety procedures in a privately accessible area only available to patients.
Ensure all staff receives IPV training.

Table 9.2 Suggestions for Screening for IPV (ACOG, 2012)

How a Nurse Can Help a Person Being Abused

An important role of the nurse is to show empathy and support. The most essential way the nurse can help is to assist the person with creating a safety plan. A safety plan is a practical, specific plan to prepare the person to leave the abusive situation. The nurse can also assist the person in considering where to live once they have left, what to do about children and their school, what to do about pets, and what safety precautions may be needed at the person’s place of work. The nurse can offer resources to shelters or counselors specializing in IPV or provide a social worker consult. Nurses should never tell the patient to leave the partner; instead, providing resources will empower the person to make her own plans and decisions regarding her future.