16.4 Intimate Partner Violence (IPV), Sexual Assault & Trauma-Informed Care

Epidemiology & Systemic Health Sequelae of Intimate Partner Violence

Intimate Partner Violence (IPV)—encompassing physical violence, contact sexual assault, stalking, psychological aggression, and reproductive coercion by a current or former partner—is a pervasive public health crisis. In the United States, approximately 1 in 4 women (25%) has experienced severe physical violence by an intimate partner in her lifetime, and more than 50% of all female homicides are committed by intimate partners.

Chronic IPV induces sustained allostatic load and immune-neuroendocrine dysregulation, manifesting across organ systems:

• Gynecologic & Reproductive Sequelae: Chronic pelvic pain, deep dyspareunia, vulvodynia, recurrent vaginitis, sexually transmitted infections (STIs) including HIV, unintended pregnancies, and rapid-repeat unintended pregnancies.
• Reproductive Coercion: Explicit partner behaviors that control a woman's reproductive autonomy, such as birth control sabotage (discarding oral contraceptives, puncturing condoms, removing vaginal rings/IUDs), forced unprotected intercourse, and coercing pregnancy or abortion.
• Gastrointestinal & Central Pain Syndromes: Irritable bowel syndrome (IBS), functional dyspepsia, fibromyalgia, tension headaches, and temporomandibular joint dysfunction.
• Psychosocial Comorbidities: Major depression, generalized anxiety, panic disorder, post-traumatic stress disorder (PTSD), severe insomnia, and substance use disorders.

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Universal Screening Protocols & Safe Administration

The USPSTF (Grade B, for women of reproductive age), ACOG, and other professional groups recommend routine IPV screening for women at well-woman visits, new patient encounters, and at the initial prenatal visit, at least once per trimester, and at the postpartum visit (IPV frequently escalates during pregnancy).

The Mandatory Private Administration Protocol

Universal screening must follow strict protocols to prevent endangering the patient:

1. Screen in Complete Privacy: The patient must be ALONE. Never screen for IPV in the presence of a partner, family member, friend, or children older than 2 years. Clinics should establish standardized separation policies (e.g., obtaining vital signs or urine samples alone in the examination room).
2. Professional Medical Interpreters Only: Never use a partner or family member as an interpreter. In-person or remote certified medical interpreters bound by medical confidentiality must be used.
3. Universal Normalizing Framing: Ask routinely to reduce shame: "Because relationships affect health and violence is so common, I ask all my patients these questions."

Validated Screening Tools

• HITS (Hurt, Insult, Threaten, Scream): 4 items scored 1–5; a score >10 indicates a positive screen.
• WAST (Woman Abuse Screening Tool): Assesses relationship tension and argument difficulty.
• Direct Clinical Inquiry: "Within the past year, has a partner hit, slapped, kicked, choked, or hurt you? Do you feel safe in your relationship?"

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Behavioral Red Flags & Physical Indicators

• Partner Behaviors: Insists on remaining in the room, answers questions on the patient's behalf, hovers closely, displays hostility or excessive attentiveness, and attempts to control clinical management.
• Patient Behaviors: Avoidant eye contact, flattened affect, hypervigilance, defensive posturing, missing appointments, late entry to prenatal care, or sudden treatment non-adherence.
• Physical Exam Findings: Injuries inconsistent with reported mechanisms; variegated ecchymoses in multiple stages of healing; defensive injuries along the ulnar forearms or palms; bilateral tympanic membrane ruptures; and contusions concentrated on central body areas (head, face, neck, breasts, abdomen, genitalia).

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Lethality Assessment: The Danger Assessment & Strangulation

When IPV is disclosed, clinicians must evaluate lethality risk using evidence-based tools, such as the Danger Assessment:

Key Red-Flag Lethality Markers

1. Abuser has access to, owns, or has threatened the victim with firearms (increases homicide risk 5-fold).
2. Abuser has made explicit threats to kill the patient, her children, or himself.
3. Acute separation or attempting to leave: The period surrounding separation is the single most lethal window for intimate partner femicide.
4. Abuser forced sexual intercourse, is unemployed, or exhibits obsessive stalking and daily monitoring.

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Patient-Centered Safety Planning & Legal Frameworks

Clinicians must validate disclosures ("You do not deserve to be hurt; I am concerned for your safety; help is available") without forcing immediate departure, recognizing that abrupt separation can trigger lethal violence.

Safety Plan Components

• Escape Route & Safe Destination: Identify safe exits and a secure destination (shelter, trusted friend).
• Distress Code Word: Establish a code word with trusted contacts or children signaling an immediate 911 call.
• Emergency Go-Bag: Store vital documents (birth certificates, passports, social security cards, driver's license, cash, medications, keys) with a trusted contact outside the home.
• Digital Safety: Check smartphones for spyware or tracking devices; browse in private windows on public devices.
• Crisis Resources: Direct connection to the National Domestic Violence Hotline (1-800-799-SAFE [7233], text "START" to 88788).

Mandatory Reporting Distinctions in Competent Adults

• Competent Adults: In the vast majority of U.S. states, IPV disclosures by competent adult patients are NOT mandatorily reportable to police without patient consent. Reporting against a patient's will violates autonomy, destroys clinical trust, and can provoke retaliatory homicide.
• Statutory Exceptions: Specific state laws mandate reporting injuries resulting from firearms (gunshots), knives/sharp weapons (stabbings), or severe burns/felony trauma.
• Mandatory Reporting Populations: Every state requires clinicians to report suspected child abuse or neglect. Most states also require reporting of suspected abuse, neglect, or exploitation of older adults and vulnerable adults with disabilities, but the age threshold, who must report, and the receiving agency vary by state, so know your state's adult protective services law.

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Acute Sexual Assault Care & Post-Assault Prophylaxis

Care is optimally delivered by a Sexual Assault Nurse Examiner (SANE). Forensic evidence collection (SAECK) should occur within 72 to 120 hours (up to 5 days), preserving strict chain of custody. The patient maintains autonomy to accept medical care while declining forensic collection or police involvement.

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Principles of Trauma-Informed Care & Pelvic Examinations

Trauma-Informed Care (TIC) shifts perspective from "What is wrong with you?" to "What happened to you?" SAMHSA establishes Six Core Principles: Safety, Trustworthiness & Transparency, Peer Support, Collaboration & Mutuality, Empowerment/Voice/Choice, and Cultural/Historical/Gender Humility.

Trauma-Informed Pelvic Examination Techniques

• Explicit Step-by-Step Consent: Seek permission before each maneuver: "You are in complete control of this exam. If you want me to pause or stop, let me know, and I will stop immediately."
• Table Elevation: Elevate the examination table backrest to 30 to 45 degrees rather than leaving the patient supine. This maintains eye contact, situational control, and prevents feelings of helpless subjugation.
• Preparation & Touch: Never touch without verbal warning. Warm the speculum with warm water or lubricant. Touch the inner thigh with the back of a gloved hand first to provide sensory grounding before approaching the genitalia.
• Empowering Language: Avoid commands like "Just relax" or "Open your legs." Use collaborative phrasing: "When you are ready, let your knees fall gently outward."
• Grounding: If panic or dissociation occurs, stop immediately. Re-anchor the patient in the present using sensory grounding (holding cold water, naming objects in the room, deep breathing).

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Family Violence, Child Maltreatment & Elder Mistreatment

IPV rarely occurs alone. Children in homes with IPV are more likely to be abused themselves and to witness violence, which is an adverse childhood experience (ACE) linked to later depression, substance use, and chronic disease.

Child Maltreatment

• Forms: Physical abuse, sexual abuse, emotional abuse, and neglect (the most common form).
• Red flags: Injuries that do not match the history or the child's developmental stage, delays in seeking care, patterned bruises or burns, bruising in an infant who is not yet cruising, and sexually transmitted infections in a prepubertal child.
• The WHNP's role: Ask a parent experiencing IPV about the children's safety, report reasonable suspicion to child protective services (proof is not required), and connect the family with home-visiting and parenting support. Reporting in good faith is legally protected.

Elder Mistreatment

• Forms: Physical, sexual, and psychological abuse; neglect (including self-neglect); and financial exploitation, one of the most common forms in older women.
• Red flags: Unexplained bruises or fractures, poor hygiene or weight loss, missed appointments, a caregiver who answers for the patient or refuses to leave the room, sudden changes in finances or legal documents, and untreated pressure injuries.
• Assessment: Interview the patient alone and assess cognition and decision-making capacity. Brief tools such as the Elder Abuse Suspicion Index (EASI) help structure questions. USPSTF finds the evidence insufficient to recommend for or against routine screening of older or vulnerable adults for abuse and neglect, so the WHNP stays alert to signs and asks when they appear.
• Response: Treat injuries, address safety, involve social work, and report to adult protective services as state law requires. A competent older adult may decline services, just as a competent younger adult experiencing IPV may.