Intimate Partner Violence and 

VHA Medical Care

Megan Gerber, MD, MPH

Medical Director, Women’s Health

VA Boston Healthcare System
Acknowledgements

• The women Veterans whom we have the 

honor to serve.

• Thank you for teaching us about strength, 

resilience and recovery.
Acknowledgements

• Arlene Bradley, MD, MPH

• Katherine Iverson, PhD

• Molly Kessner, MPH

• Ruth Klap, PhD

• Rachel Latta, PhD

• Elizabeth Manning, PhD

• Carolyn Mason Wholley, LICSW
Goals/Objectives

• Review the basic epidemiology of Intimate Partner 

Violence (IPV).

• Understand what is known to date about women 

Veterans and IPV and understand 

challenges/opportunities for VA care delivery.

• Learn approaches to responding to IPV in primary 

care.

• Consider ways in which PACT providers and 

health services researchers may contribute to 

improving the care of Veterans impacted by IPV.
Poll #1

• What is your role within the VA?

 PCP

Mental Health Provider

Other Medical Provider (Emergency, Specialty etc)

Nurse

Researcher

Women Veterans Program Manager

Administrative/Management Staff

Other
Definition and Background
CDC Definition

• The term “intimate partner violence” 

describes physical, sexual, or psychological 

harm by a current or former partner or 

spouse. 

• This type of violence can occur among 

heterosexual or same-sex couples and does 

not require sexual intimacy.

CDC. National Center for Injury Prevention and Control. 

http://www.cdc.gov/ncipc

7
Types of IPV

• Physical violence: the intentional use of physical force with 

the potential for causing death, disability, injury, or harm.

• Sexual violence: unwanted sexual activity (attempted or 

completed).

• Emotional violence: trauma to the victim caused by acts, 

threats of acts, or coercive tactics. 

• Stalking: repeated behavior that causes victims to feel a 

high level of fear.

CDC. National Center for Injury Prevention and Control. 

http://www.cdc.gov/ncipc

8
Epidemiology

• National Intimate Partner and Sexual 

Violence Survey (NISVS) is the most recent 

population based study.

• Lifetime – 35.6%, Annual – 5.9% 

• 7 Million women experience IPV annually.

• Same-sex couples understudied; rates may 

be up to 2x higher.

– NVAWS 21.5% men and 35.4% women reported 

lifetime IPV.

– Advocacy programs: steady increase in reports.

Black 2011, Messinger 2011, NCAVP 

2010 report.
SES Risk Factors for IPV

• Younger age (highest 18-24).

• Income (all three major ethnic groups) 

especially for severe IPV.

• Unemployment.

• Black > Hispanic > White.

• ?gender preference

Capaldi 2012, Caetano 2005, Cunradi 

2002, Ellison 2007 Linder 2005
Other risk factors

• Antecedent IPV.

• IPV in family of origin.

• Experience of child abuse.

• Alcohol > drug use.

• Polysubstance use – increased risk.

• Depression. 

• PTSD.

Herrenkohl 2007, Kuijpers 2012 
Scope of the Problem for Veterans

• We are just starting to understand the true 

impact of IPV on the Veterans population.

– Unique set of challenges

– Early life circumstances

– Military Life

– Comorbid PTSD, Substance Abuse, TBI.

• HSR&D has funded two CDA: M. Dichter

PhD, MSW and K. Iverson, PhD.

• VA Guidance forthcoming.
IPV is complex

• “Victimization” and “perpetration” infer mutually 

exclusive states.

• Dynamics of abusive relationships are complex; 

bidirectional violence is common and IPV may 

range from low level to severe.

• Veteran who experiences violence: A Veteran 

who is the recipient of violent behavior. 

Traditionally referred to as victim or survivor of 

intimate partner violence.

• Veteran who uses violence: A Veteran who uses 

violence toward his/her partner. Traditionally 

referred to as batterer, abuser, or perpetrator.
Poll #2

• Among clinicians attending today’s call, 

please indicate the % of your patient panel 

comprised of Women Veterans:

1 0%

2 5-10%

3 10-30%

4 > 30%
Gender Issues

• Women are more likely to sustain physical and 

psychological consequences from IPV.

• IPV disproportionately affects women’s health.

• Current research identifies women who experience IPV as the 

highest risk group.

• When women use IPV, it tends to be lower severity.

• However, it can be difficult for men to disclose receipt of 

IPV.

• NISVS lifetime experience of physical IPV: women (32.9%) and 

men (28.5%).

• Older studies have shown lower rates in males.

• Use (“perpetration”) of IPV has health consequences of 

its own.

Bureau of Justice Statistics. National Crime Victimization 

Survey; Rennison and Planty, 2003., CDC NISVS 2010.

15
IPV and Military Personnel

• Rates range from 13.5-58%.

• Active duty personnel are at much higher 

risk of being perpetrators of IPV.

• PTSD incidence correlates with higher risk 

of IPV perpetration.

Marshall et al, 2005; National Coalition Against 

Domestic Violence Report 2001.

16
Women Veterans

• Higher rates of child abuse and pre-military trauma.

• 23-30% report IPV during active duty.

• Mental health: 70% lifetime rate of IPV.

• Primary Care

– Of 91 patients 24-95, 46% reported current or past IPV.

– Of 20 OIF/OEF veterans screened, 50% reported current 

or past IPV.

• BRFSS data: 1⁄3 veterans experience lifetime IPV compared 

to < 1⁄4 non-veterans.

• IPV associated with increased odds of heart health risks.

Campbell et al, 2003; Sadler et al, 2004; O’Campo et al, 2006; Iverson (National 

Center for PTSD); Latta and Ngo (unpublished, VA Bedford); Dichter et al, 2011. 17
OEF/OIF Veterans

• Data is limited to date.

• Study of recently returned veterans screened in 

primary care (recently separated at < 2 years):

– 75% reported family readjustment issues.

– 60% reported any IPV; however, the 

researchers’ definition included “shouting” so 

this may be an overestimate.

– No difference in rates by branch of service.

– 1⁄4 reported guns in the home.

Sayers et al, 2009.

18
Health Impact of IPV
IPV in Medical Practice

Primary Care Prevalence:

• 12-month 5.5-14%

• Lifetime 21-60%

Ob/Gyn Prevalence:

• 12 month 4-15%

• Lifetime 35%

• During pregnancy 6-20%

Emergency Department Prevalence:

• 12 month 11-19%

• Lifetime 11-54%
IPV is a Medical Issue!

• In a multi-city study of femicides, 41% had been in 

contact with a health care provider prior to death, 

while only 3% accessed an advocacy or shelter 

program.

• You are in routine contact with affected patients!

• However... while nearly 50% of women who 

experience physical IPV report being injured 

by the abuse, only 20% actually seek 

medical care for their injuries

Sharps et al, 2001; National Coalition Against Domestic 

Violence Report 2001.

21
Physical Health Effects

• Linked to increased incidence of:

– Headaches

– Pelvic pain

– Abdominal pain

– Chest pain/palpitations

– Gastrointestinal problems/IBS

– Chronic pain/Fibromyalgia

– Medically unexplained symptoms

• Your patient with the “list” may be in a 

relationship impacted by IPV!
Reproductive Health

• Women who report abuse are more likely to 

have:

– STI/PID.

– Repeat vaginal or urinary tract infections.

– Unwanted pregnancies.

– Premenstrual symptoms: mood swings, irritability, 

etc. 

– Adverse pregnancy outcomes

• Low birth weight.

• Pre-term labor.

– Miscarriage in prior 6 mos.

Kovac et al, 2003, Yost 

2005.
IPV and Pregnancy

• Women at higher risk of experiencing IPV 

during pregnancy

• Changes in type of IPV (i.e., from emotional 

abuse to physical abuse)

• IPV is leading cause of maternal mortality 

and adverse maternal outcomes in the U.S.

• Increasing recognition of women’s use of IPV 

during pregnancy.

Chambliss LR, 2008, Hellmuth 2012

24
Mental Health and IPV

• PTSD

• Depression

• Anxiety

• Substance abuse

• Suicidality

25
IPV and Adverse Health Behaviors

• Women who smoke are 2x as likely to report 

IPV.

• Women who experience IPV are 5x as likely to 

engage in problem drinking 

– It has been argued that alcohol and substance misuse 

increase IPV risk.

– But alcohol and substance use have been shown to 

increase from a baseline level when new abuse occurs. 

• Predicted probability of IPV is higher with 

alcohol use and even higher when the patient 

smokes and drinks. 

Hathaway et al 2000; Vest et al 2002; Lemon et al 2002; Kilpatrick et al1997; Gerber et 

al 2005.

26
Long-Term Health Effects

• A relationship exists between severity of 

abuse and degree of physical health 

problems.

• Even women who have experienced 

psychological abuse and/or low level 

abuse report significantly increased 

physical health symptoms.

• Many chronic diseases more prevalent or 

more severe.
Abusive Relationship Dynamics

• Women can experience IPV in the absence 

of physical violence.

• Women experiencing IPV are often isolated.

• Partners can interfere with receipt of 

healthcare.

• Poorly compliant patients may be suffering 

abuse.

• A controlling partner may refuse to leave the 

room.
Patients with a “list” may have 

abuse histories...

• Greater abuse severity and exposure to 

multiple forms of abuse is associated with 

more physical symptoms

• Women experiencing ongoing IPV report 

more somatic symptoms over time 

Nicolaidis et al, 2004; Gerber et al, 2008.

29
Healthcare Response
Poll #3

• How comfortable do you feel addressing 

IPV in your VA role?

 Very uncomfortable

 Uncomfortable

 I can do it if I have to

 Comfortable

 Very comfortable
PACT and IPV

• Complex issue that no single provider can 

‘manage’ or fix.

• Patient preferences/needs of family critical.

• Requires knowledge of community and VA 

resources.

• Patients experiencing IPV...

– Are often isolated from social networks.

– Ashamed of the abuse. 

– In poor health.

– In need of a team approach.
Patient’s Voices

I asked my patients the following question:

“What would you like your VA provider to know 

about intimate partner violence and the abuse 

you’ve experienced?”
WT

• Patient came to Boston with children to 

escape an abusive partner. He doesn’t 

know where she is. She is living in a 

shelter and hopes to start a new life here. 

She has diabetes and recently started 

insulin.

• “You’re looking at me now, your body is 

turned toward me. I feel safe with you.”
Patients expectations...

• A meta-analysis of studies looking at women’s 

expectations of clinicians also found that women 

wanted clinicians to:

– Be non-judgmental and individualized.

– Not pressure the victim to talk about abuse, or 

pressure her to leave the situation.

– Not pressure her to prosecute the abuser.

Women want you to understand the complexity of a violent relationship 

and to meet them where they are in the continuum of deciding what to do.

Feder et al, 2006.

35
Can We Help?

• Qualitative studies demonstrate that abused 

women want their providers to query them 

about IPV.

• Studies also show that abused women 

believe medical providers can help.

• Asking is an intervention.

• Frame IPV as part of SH, an adverse health 

exposure.

36
Common Clinician Barriers

• Fear of opening “Pandora’s box.”

– Time constraints

• “I don’t know what to do if she says yes.”

• “I can’t fix it.”

– No quick fix

• Does not follow traditional biomedical 

model.

– VA care models ideal for complex issues!
Addressing Barriers

• It’s not your role to “fix it.”

• You can:

– Provide support and validation

– Offer education and resources, referrals

– Address safety

– Document and treat injuries

• Adopt a patient-centered team approach; 

use existing VA resources.
Benefits of Routine Inquiry

• Communicates that you believe this is a 

health issue for patient (“bringing it into the 

exam room”)

• Over time, you will become more 

comfortable talking about IPV.

• Hopefully, as the patient comes to trust 

you, she may disclose experience of 

violence.

39
How To Identify IPV?

• Directly inquire about IPV

– Many individuals will not spontaneously disclose 

abuse.

– When asked directly, many patients are willing to 

discuss IPV.

• Asking = intervention and begins a process.

• Assessment validates abuse as a legitimate 

health care issue and enables teams to 

assist.

• Primary care/PACT ideal for building 

trust/extending support.
Screening for IPV

• USPSTF

– Recommends that clinicians screen women of 

childbearing age for intimate partner violence and 

provide or refer women who screen positive to 

intervention services (level B)

• Reasons to screen include:

– High prevalence

– Decreases stigma by normalizing discussion of violence

– Potential to moderately reduce exposure to abuse, 

physical and emotional injury, and mortality (USPSTF).

*VA guidelines are forthcoming.

Nelson et al, 2012; Tjaden and Thoennes , 

2000.

41
Best practice for asking about IPV?

• Develop your own routine for asking that 

makes it comfortable for you

• Introduce the questions:

– “Because violence in relationships is so 

common, I have begun asking all my patients 

about it” 

• Consider assessing for both current and 

lifetime IPV.

• Short validated screens exist.
Examples of questions

• Ask behaviorally specific questions, such as:

– “Have you been physically harmed or threatened 

by your partner?"

– “Have you been hit, kicked, punched, choked, or 

otherwise hurt by an intimate partner?”

– “Do you (or did you ever) feel controlled or 

isolated by your partner?”

– “Do you feel frightened by what your partner says 

or does?”

– “Has your partner ever forced you to have sex 

when you didn’t want to? Has your partner ever 

refused to practice safe sex?”
Setting and Timing for Inquiry

• Private setting – partner should be asked 

to leave the room.

• Family, friends, and children over the age 

of 3 should not be present.

• Get into a routine/combine with social 

history.

• When signs and symptoms raise concern 

(‘red flags’).

• During pregnancy. 
Potential Clinical Markers for IPV

• Secrecy or obvious discomfort when asked 

about intimate relationships.

• Unexplained injuries or injuries that are 

inconsistent with the explanation of the injury.

• Medically unexplained symptoms (MUS).

• Chronic pain without apparent etiology.

• An unusually high number of health care 

visits.

• Tobacco and alcohol use.
Targeted Inquiry/Case Finding

• When injuries don’t fit the history given by 

the patient.

• Chronic pain, multiple somatic issues.

• Depression, anxiety, PTSD.

• ETOH or other drug abuse.

46
Patient Disclosure – Step 1

• Stop what you are doing.

• Turn away from the computer.

• Make eye contact.

• Respond with empathy and compassion.

• Validate what she is saying. 

Always be ready for an affirmative response; 

often it will be a surprise, coming after 

recurrent denials.

47
Examples of “First Responses”

• I believe you. That must be a horrible experience.

• I’m sorry that you have to experience that. I would like to 

help.

• The abuse is not your fault. It is wrong for one person to 

hurt another person.

• You didn’t do anything to deserve to be treated this way.

• I am worried about your safety. 

• I’m glad you told me. Let’s think about ways to get this 

behavior to stop.

• Unfortunately, you are not alone. Many of my patients have 

experienced abuse.

48
Patient Disclosure Step 2

• Your role now:

– Non-judgmental, supportive, and concerned

– Provide validation

– Treat health problems and injuries

• Provide education/palm card.

• Evaluate whether patient is in immediate 

danger (use your team).

• Make referrals within the VA and for services 

in the community.
Risk Assessment

• Women may not realize they are in imminent danger

– Over half of the victims of a completed or attempted 

homicide did not think that they were in danger.

• Danger increases if:

– Abuser has access to weapons.

– Abuser uses alcohol or other drugs.

– There is past history of severe abuse (with serious injuries).

– History of stalking.

– Recent escalation of the abuse.

– Unemployment.

– Partner controls daily activities.

Campbell et al, 2002. 50
Documentation 

• Document your assessment.

• Document in specific detail what the 

patient has told you – be specific; include 

name of perpetrator, specific instances, 

and timing.

• Document injuries and physical findings.

• Comply with state mandated reporting 

laws.
Your Patient Might Not Leave...

• It’s hard to leave a relationship.

• Info or kind words may help down the line.

• You haven’t failed if your patient doesn’t 

leave the relationship.

• Remember that survivors of IPV have lost 

their sense of agency and autonomy –

support patient’s choices even if you don’t 

agree with them.

• Never tell a patient impacted by IPV what to 

do.
Be supportive

• Understand the barriers to each woman’s 

decision to leave or not and respect her 

decision. (Be patient-centered).

• Respect the victim’s timetable.

• Help the victim gain self-esteem by 

validating her actions, while at the same 

time being honest about your concern for 

her safety.

53
Next Steps

• If no immediate danger...

• If affected patient is not ready to leave the 

situation...

•Provide local resources:

– Hotlines all states have these – may be used 

from your facility 1-800-799-SAFE. 

– VA Social work and mental health referrals.

– Women Veterans Program Manager.

54
Children and Reporting

• Some states have mandatory reporting for 

IPV. The majority do not.

• Many women fear that their children will be 

placed in protective custody.

• What if there are children in the home?

– You may need to report.

– Social work consult is advisable. 

55
Safety Planning

• Process similar to “harm reduction” strategy.

• Provides a back-up plan for any escalation of violence.

• Pack a bag and keep it in a safe place, copy important 

documents (DD214).

• Code word that friends, neighbors, or family will 

recognize to prompt them to call the police. Protection 

order information.

• Safety plan available from National Coalition Against 

Domestic Violence

– http://www.ncadv.org/protectyourself/SafetyPlan_130.html

– YOUR TEAM CAN HELP.

56
What if My Patient Endorses Past IPV?

• Provide validation and education. 

• Discuss the impact of past IPV on mental 

and physical health.

• Inquire about current mental health 

symptoms.

• Offer appropriate mental health referrals.
Helping Veterans Who Use Violence

• Screening issues

– No good evidence for screening for use of IPV. 

– Targeted inquiry is warranted when patient shows signs of chronic pain, mental health 

issues, substance abuse.

– Study of screening for perpetration showed low rates of disclosure with direct inquiry 

by PCP

• Interventions for use of violence/perpetration alone lack evidence of 

efficacy.

- Treat co-morbid PTSD, substance abuse 

- Veterans with PTSD 2-3x more likely to perpetrate and interventions for this 

group show reductions in IPV.

• Self-identified perpetrators

– Respond in non-judgmental manner that supports disclosure, and does not cut off 

further discussion, but also does not condone the behaviors

– Refer to an expert in dealing with perpetrators.

58

Ferris 1997, Gerlock, Jaeger 2008; Smedslund 2007, Taft.
Efficacy of Advocacy and Referrals

• Advocacy is very helpful to victims of IPV

• Research shows that patients who talk to 

their health care provider about IPV had 

higher likelihood of using an intervention 

(e.g. shelter, restraining order, IPV hotline)

– Qualitative and RCT data.

• Our conversations and referrals do help!
National Hotlines and Helplines

• National IPV Hotline

– 1-800-799-SAFE 

– English and Spanish (24 hr)

• National IPV website

– ndvh.org

– Resource list: www.ndvh.org/resources/

• National Center for PTSD: 

http://www.ptsd.va.gov/public/pages/domesticviolence.asp
Summary

• IPV is prevalent in medical populations and is 

a significant issue for Veterans.

• Some of your most vexing patients could be 

abused or have a history of abuse.

• You are in regular contact with patients who 

have experienced (used) IPV. 

• Your patient care skills, PACT team and 

existing VA resources can help.

• With practice, addressing this issue becomes 

more routine.

61
What questions do you have?
Military/DoD Resources

• Military Home Front

– http://www.militaryhomefront.dod.mil/tf/domestica

buse 

• Family Advocacy Program (FAP) service providers

– Search by military installation and program type 

online at http://www.militaryinstallations.dod.mil/

– Every installation has a FAP or access to one.

• Battered Women’s Justice Project - Military 

Advocacy Resource Network 

– http://www.bwjp.org/military_advocate.aspx

• Military OneSource 

– 1-800-342-9647, 24 hours a day, 7 days a week 
References

• Bachman & Saltzman. Violence against women. Washington DC: US Department of Justice, 1995.

• Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, Mt et. al. The national 

intimate partner and sexual violence survey (NISVS): 2002 Summary Report. Atlanta, GA: National 

Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

• Blosnich JR, Bossarte RM, Comparisons of intimate partner violence among partners in same-sex 

and opposite sex relationships in the United States. Am J Pub Health 2009; 99 (12): 2182-2184.

• Bullock et al. Abuse disclosure in privately and Medicaid-funded pregnant women. J Midwifery

Women's Health 2006;51:361-9.

• Campbell et al. Research results from a national study of intimate partner femicide: danger 

assessment instrument. Washington, DC: National Institute of Justice, 2002. 

http://www.ncjrs.gov/pdffiles1/nij/199710.pdf

• Campbell et al. The relationship between adult sexual assault and prostitution. Violence Vict 

2003;18:299-317.

• Canadian Centre for Justice Statistics. Family violence in Canada: a statistical profile. Ottawa (ON): 

Statistics Canada, 2000.

• Chambliss LR. Intimate partner violence and its implication for pregnancy. Clin Obstet Gynecol 

2008;51:385-97.

• Daigneault et al. Men's and women's childhood sexual abuse and victimization in adult partner 

relationships: a study of risk factors. Child Abuse Neglect 2009;33: 638-47.

• Dichter et al. Intimate partner violence victimization among women veterans and associated heart 

health risks. Womens Health Issues. 2011;21(4S):S190-4.
References

• Feder et al. Women exposed to intimate partner violence: expectations and experiences when they 

encounter health care professionals. Arch Intern Med 2006;166:22-37. Ferris et al. Guidelines for 

managing domestic abuse when male and female partners are patients of the same physician. 

JAMA 1997;278:851-7.

• Gerber et al. Adverse health behaviors and the detection of partner violence by clinicians. Arch 

Intern Med 2005;165:1016-21.

• Lemon et al. Preventive healthcare use, smoking, and alcohol use among Rhode Island women 

experiencing intimate partner violence. J Womens Health Gend Based Med 2002;11:555-62.

• Marshall et al. Intimate partner violence among military veterans and active duty servicemen. Clin 

Psychology Rev 2005;25:862-76. 

• McCloskey et al. Abused women disclose partner interference with health care: an unrecognized 

form of battering. J Gen Intern Med 2007;22:1067-72

• McCloskey et al. Intimate partner violence and patient screening across medical specialties. Acad 

Emerg Med 2005;12:712-22.

• McFarlane et al. Assessing for abuse during pregnancy. JAMA 1992; 267:3176-8.

• Messinger, AM, Invisible victims: same sex IPV in the NVAWS. J interpersonal Violence 2011; 26 : 

11 2228-2243.

• Nelson et al. Screening women for intimate partner violence: a systematic review to update the 

2004 US Preventive Services Task Force recommendation. Ann Intern Med 2012;156:1-13.

• Nicolaidis et al. Violence, mental health, and physical symptoms in an academic internal medicine 

practice. J Gen Intern Med 2004;19:819-27. 
References

• O’Campo et al. Depression, PTSD and comorbidity related to intimate partner violence in civilian 

and military women. Brief Treat Crisis Int 2006;6:99-110.

• Rennison & Planty. Nonlethal intimate partner violence: examining race, gender, and income 

patterns. Violence Vict 2003;18:433-43.

• Sadler et al. Life span and repeated violence against women during military service. J Womens 

Health 2004;13:799-811.

• Sayers et al. Family problems among recently returned military veterans referred for a mental health 

evaluation. J Clin Psychiatry 2009;70:163-70.

• Sharps et al. Health care providers' missed opportunities for preventing femicide. Prev Med 

2001;33:373-80.

• Smedslund et al. Cognitive behavioural therapy for men who physically abuse their female partner. 

Cochrane Syst Rev 2007;(3): CD006048.

• Tjaden & Thoennes. Full Report of the Prevalence, Incidence, and Consequences of Violence 

against Women. National Institute of Justice and CDC, 2000.

• Vest et al. Multistate analysis of factors associated with intimate partner violence. Am J Prev Med

2002;22:156-64.

• Zink T. The challenge of managing families with intimate partner violence in primary care. Primary 

Care Companion J Clin Psychiatry 2007;9:410-12.

• Zink et al. Medical management of intimate partner violence considering the stages of change. 

Annals Fam Med 2004;2:231-9.