Essential Health Care Services Addressing Intimate Partner Violence (2024)

Summary¹

Intimate partner violence (IPV) refers to abuse or aggression committed by a current or former intimate partner. IPV includes, but is not limited to, physical violence, sexual violence, stalking, psychological aggression, and reproductive coercion. While estimates of IPV prevalence vary, primarily due to under-reporting and terminology inconsistencies, the data generally indicate that it is common in the United States. The most commonly used source to estimate the population-level prevalence of IPV in the United States is the Centers for Disease Control and Prevention’s (CDC’s) National Intimate Partner and Sexual Violence Survey (NISVS). The most recent survey, conducted in 2016 through 2017, estimated that nearly half of women in the United States had experienced IPV in some form during their lifetime.

A substantial body of literature has documented adverse health outcomes associated with experiencing IPV. Women with a documented history of experiencing IPV had 4.5 times more emergency department (ED) visits than those without according to an analysis of insurance claims from across the United States. Some of the most common and most serious injuries include injuries to the head, face, and neck; traumatic brain injury; injuries due to strangulation; and musculoskeletal injuries. Escalating injury severity is often a precursor to homicide at the hands of an intimate partner. Additionally, the effects of IPV on gynecologic and reproductive health can be severe. IPV is associated with numerous adverse reproductive health

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¹ This summary is intended to provide a high-level overview of the report itself. This summary does not include references. Evidence and citations to support the text and recommendations herein are provided in the body of the report.

outcomes, including abnormal vaginal bleeding, unintended and rapid repeat pregnancies, sexually transmitted infections, and HIV infection. During pregnancy, IPV increases the risk of preterm delivery, low-birthweight infants, preeclampsia, other obstetric complications, and fetal and neonatal death. Experiencing IPV is also associated with substantial adverse mental health outcomes, including post-traumatic stress disorder, anxiety, depression, substance misuse, and suicidality.

Women’s² health and well-being are disproportionately adversely affected by public health emergencies (PHEs).³ Women are at greater risk for experiencing violence, including IPV, during PHEs. Multiple studies conducted in the United States after Hurricane Katrina, after the Deepwater Horizon oil spill, and throughout the COVID-19 pandemic have found increases in the prevalence and severity of IPV against women in the aftermath of these events. Women who experience IPV during a disaster or PHE are exposed to physical and psychological trauma due to IPV and from the PHE. In light of this, the Health Resources and Services Administration’s (HRSA’s) Office of Women’s Health (OWH) identified a need to identify the essential health care services related to IPV for women and how to plan for and sustain access to essential health care services related to IPV during PHEs.

COMMITTEE’S CHARGE

HRSA’s OWH contracted with the National Academies of Sciences, Engineering, and Medicine to convene a multidisciplinary panel of experts to address the statement of task (Box S-1) and produce recommendations for delivering essential health care services for women related to IPV.

Study Scope

This study focuses on women aged 13 and older that directly experience IPV, based on guidance from the study sponsor. The committee acknowledges that the experience of IPV is not limited to women. There is a growing body of research into the effects of experiencing IPV on men, including transgender men. However, health care interventions specifically for men experiencing IPV are beyond the scope of this study. Additionally,

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² The committee used an inclusive approach to define woman/women as used throughout this report. For the purpose of this report, woman/women encompass cisgender women, transgender women, and people whose gender identity is not male, who are non-binary or otherwise gender expansive.

³ The committee applied the following definition for public health emergency throughout the report: a situation with health consequences whose scale, timing, or unpredictability threatens to overwhelm the routine capabilities of the affected geographic area.

while the committee identifies several promising prevention strategies, consideration of health care services for individuals who engage in IPV is outside of the scope of the committee’s charge. While child abuse is a serious issue that can intersect with IPV and witnessing IPV can have adverse effects on a child, addressing these issues also falls outside of the parameters of the statement of task.

The committee acknowledges that the complex nature of addressing IPV may necessitate a broad array of supports and strategies to address the many effects of IPV as well as its root causes. However, the scope of this

study is limited to health care services.⁴ As such, when considering essential health care services for IPV, the committee limited its consideration to IPV care that is delivered in or referrable from a health care setting. The committee did consider a specific group of support services that are directed at protecting the immediate health and safety of women experiencing IPV and that often serve as an initial point of contact for women to access IPV-related care, including health care.

The Committee’s Approach

The statement of task emphasized the value of having an overarching conceptual framework to guide the committee’s process for identifying essential health care services related to IPV. The committee selected the Social Ecological Model as the conceptual framework to guide its understanding of the health care needs of women experiencing IPV and to identify the essential health care services related to IPV (Figure S-1).⁵ Health care services related to IPV are delivered in multiple settings within the health care system as well as in community-based settings outside of a defined health care system. Examples of these community-based settings include shelters for women experiencing IPV and community centers that provide support groups or advocacy services for women. In some cases, people experiencing IPV may be referred to community-based care from the traditional health care setting. In other cases, these community-based settings may be the first site of care. As noted in the Care Coordination Model, high-quality referrals and transitions to resources outside of the traditional health care system are a key component of effective health care delivery. Therefore, the committee felt that it was important to acknowledge the role of community-based organizations in IPV-related care and emphasize the importance of warm referrals to that care, recognizing the value and interdependence of connections between the health care system and community-based care settings.⁶

The committee recognizes that some of the essential health care services identified may be unavailable due to state-level restrictions placed on reproductive health care services or federal restrictions that may apply to the use of federal funding for such services. However, significant scientific evidence of increased risk for serious adverse maternal and fetal health outcomes,

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⁴ The committee defines health care services as care delivered in or referrable from a health care setting.

⁵ An explanation of the Social Ecological Model can be found at https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html (accessed October 20, 2023).

⁶ Warm referrals, or warm handoffs, are transfers of care between members of a health care team that occur with the patient’s permission, often with an in-person introduction. This approach can also be used when referring a patient to community-based services.

including death, as well as elevated risk for increased severity or frequency of IPV and intimate partner homicide in the perinatal period support the inclusion of these services.

Health Care Services

Health care services related to IPV are delivered in multiple settings across health care systems, including primary and specialty care, such as practices specific to women’s health (e.g., reproductive health care clinics), perinatal-specific care settings, and orthopedic clinics; emergency departments; and behavioral health care settings. Women experiencing IPV report at least 20 percent more health care utilization than those who have not reported experiencing IPV, a difference that continues after the abuse has ended.

Several federal programs have been established to deliver health care to people residing in under-resourced communities, including women from populations that are disproportionately affected by IPV. These include HRSA-supported Federally Qualified Health Centers and clinics supported

by provisions of Title X, the federal program that supports the delivery of family planning and related reproductive health care services to individuals with lower incomes.⁷

Essential Health Care Services Related to Intimate Partner Violence

The committee’s process for identifying essential health care services related to IPV during steady state conditions was informed by an extensive review of evidence from literature searches; recommendations from the U.S. Preventive Services Task Force (USPSTF), the HRSA-funded Women’s Preventive Services Initiative (WPSI), and the World Health Organization (WHO); and insight gleaned from a commissioned paper and presentations to the committee by experts in IPV-related care.

The committee identified the following criteria for identifying essential health care services related to IPV:

• evidence-based health care services that address the most common and most serious health outcomes related to experiencing IPV;
• preventive services recommended by USPSTF and WPSI; and
• specific support services required to meet the basic safety and housing needs of people experiencing IPV.

This analysis identified several serious and high-prevalence adverse health effects related to experiencing IPV. These health issues can be grouped into the general categories of acute physical injuries, gynecologic and reproductive health issues, perinatal and obstetric health issues, behavioral health issues (including mental health and substance use), and other chronic health issues that are either exacerbated by acute IPV or related to experiencing long-term IPV. The committee also prioritized health care services that facilitate disclosure and protect the safety of those experiencing IPV and their children, if needed. After reviewing the evidence with the above criteria in mind, the committee identified a list of essential health care services related to IPV.

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⁷ Title X of the Public Health Service Act 42 USC § 300 to 300a-6.

• Forensic medical examinations
• Emergency medical care
• Treatment of physical injuries
• Reproductive health care, including all forms of Food and Drug Administration–approved contraception and pregnancy termination
• Screening and treatment of sexually transmitted infections and HIV
• Treatment for substance use disorders and addiction care
• Pharmacy and medication management
• Obstetric care, including perinatal home visits
• Primary and specialty care
• Mental health care
• Support services, including shelter, nutritional assistance, and child care
• Dental care

Universal IPV screening and education often serve as the point of entry for accessing IPV-related health care services. Pairing education with screening can help women understand the health effects of IPV and increase their awareness of the resources available to them. It can also provide an opportunity for women who may not be ready to disclose to a clinician that they are experiencing IPV to become aware of their options and available resources. Universal education involves offering information about healthy relationships, the intersections of IPV and health, and relevant supports and services during all clinical encounters. It can be delivered through prominently displayed posters and brochures as well as patient education discussions during the clinical encounter. Universal screening for IPV is an established standard of routine preventive health care for women in the United States. It involves inquiring about IPV with all women, regardless of the presence of signs, symptoms, or health conditions. The USPSTF and WPSI recommendations for IPV screening also recommend that those who screen positive should be provided with or referred to care and support services. Connecting women who screen positive for IPV with person-centered support and interventions that reduce exposure to IPV and improve health outcomes is critical. Safety planning is one of those crucial interventions. This is the process of collaborating with the woman experiencing IPV to empower her to develop strategies that increase safety by enhancing situational awareness of IPV-related risks in a manner that is consistent with her identified concerns and priorities. It is also an urgently important harm reduction strategy for women who do not feel they can leave an abusive relationship. Notably, when a woman leaves a partner who is engaging in IPV, this can be a period of increased risk for her, including escalating violence that can lead to her being killed by her partner.

Health Inequities and Barriers to Care

Health inequities and other barriers can make accessing essential health care services related to IPV even more challenging. Data indicate that many populations experiencing health inequities also report higher prevalence of IPV. These populations include non-Hispanic Black women; American Indian and Alaska Native women; Hispanic women; multiracial women; lesbians, bisexual, and transgender women; women from immigrant populations; and women with disabilities. When women experiencing health inequities also experience IPV, poor health outcomes are more likely.

Women face a variety of barriers to disclosing that they are experiencing IPV and to accessing needed care. For example, some women may face pressure from family members or their community to stay silent so as not to bring shame to the community by making what is considered a private problem public. Women from minoritized populations that have historically experienced discrimination and abuse when they sought medical care may distrust the health care system and be reluctant to disclose that they are experiencing IPV or seek care. Women who are immigrants often face additional hurdles when trying to access IPV-related health care services due to language barriers.

Maldistribution of health care and mental health providers, in which the distribution of providers does not match the health care needs of a geographic area, has led to health care deserts across the United States. These health care deserts have created additional barriers for women experiencing IPV to access the care that they need.

Health care systems have a responsibility to reduce barriers to IPV care by taking steps informed by the communities that they serve to reduce health inequities.

Prevention

Primary prevention of IPV is crucial for reducing IPV, its consequences across the lifespan, and for promoting healthy families and communities. A key component of primary prevention is promoting healthy, respectful, and nonviolent relationships. Services for supporting survivors to increase their safety and reduce harm are key components of secondary prevention of IPV. Tertiary prevention strategies seek to address the long-term effects of experiencing IPV. Comprehensive approaches for IPV prevention combine these three components.

CDC developed guidance that highlights evidence-based prevention strategies to address known risk and protective factors for IPV. These include specific prevention strategies for adolescents that can disrupt the developmental pathways toward IPV. Sadly, IPV is not uncommon among adolescents, and many adults report that they first experienced IPV when they were younger than 25. The CDC guidance highlights strategies for adolescents that teach safe and healthy relationship skills and engage influential adults and peers in IPV education and prevention programs. Prevention strategies that are evidence based, easily implemented, and scalable are important tools for preventing IPV in this age group.

INTIMATE PARTNER VIOLENCE AND PUBLIC HEALTH EMERGENCIES

PHEs include infectious disease outbreaks; extreme weather events such as hurricanes, heat waves, and wildfires; earthquakes; and technological disasters such as mass power outages or oil spills. PHEs disrupt and stress communities and individuals, adversely affecting health and well-being at all levels of society. As previously noted, PHEs are associated with increased severity and frequency of IPV. The committee concluded that essential health care services are determined by the health care needs of the affected populations and not the ability to provide them. Therefore, essential health care services retain their designation of essential, regardless of whether a PHE has occurred. In light of this, as well as the serious adverse health effects associated with experiencing IPV, the committee determined that the essential health care services related to IPV during steady state conditions remained essential during PHEs.

The committee sought to address the balance between essential services and the substantial service obstacles created by a PHE. This led them

to draw on the Federal Emergency Management Agency’s Community Lifelines approach as an organizing framework for sustaining essential health care services for IPV during a PHE. This approach prioritizes ensuring the delivery of services that are critical to protecting life safety, followed by those services that are essential but less time sensitive given the resource constraints during various points of the PHE.

The committee recognizes that not all essential health care services related to IPV can be restored simultaneously in the immediate wake of a disaster or during a PHE. Therefore, it recommends a phased approach to restoration of services. The committee defined three phases within the response phase of emergency management for the purpose of this report, described below, and delineated which essential services to reestablish during each phase of PHE response (Figure S-2).⁸

The initial or immediate response phase occurs while the situation is unstable and before supplementary resources can be deployed to the affected area or resources within the community can be redirected. During this phase, disaster health responders’ efforts are focused on saving and sustaining life using limited resources.⁹ The response operations phase occurs once the health care system and associated jurisdictional authorities have assessed the incident and have stood up relevant incident coordination structures. During this phase, disaster health responders have begun to receive additional resources, such as supplies and staff to support temporary care delivery sites. At this point, while health care delivery capacity has increased beyond lifesaving and -sustaining activities, resources are not adequate to support the full delivery of all essential health care services related to IPV for all individuals. The stabilization phase occurs when basic lifeline services have been provided to PHE survivors, either by rapid reestablishment of lifeline services or through the employment of a contingency response solution. At this point all essential health care services related to IPV are available for all individuals.

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⁸ Emergency management generally involves five phases, prevention, mitigation, preparedness, response, and recovery. The committee divided the response phase into three parts to organize its phased approach to restoration of essential health care services related to IPV during PHEs.

⁹ For the purposes of this report, disaster health responders are the leaders and staff with expertise in public health and health care who are working and providing care in those settings during response to a PHE.

TABLE S-1 Essential Health Care Services for IPV During Public Health Emergencies—A Phased Return to Steady State

The committee prioritized the delivery of essential health care services related to IPV that are most integral to protecting life safety during the initial phase of PHE response. In some cases, specific components of an essential health care service are essential for protecting life due to the severity and time-sensitive nature of certain IPV-related health conditions. In other cases, these components are critical for women from groups that have an elevated risk for serious or life-threatening outcomes, such as pregnant women. Those components should be available during the initial phase of PHE response with delivery efforts focused on those presenting with an immediate need. Then, as health care staff and supplies become more available, the full essential health care service can be delivered more broadly. For example, unintended pregnancy, as well as IPV during pregnancy, are associated with serious adverse health outcomes, including fetal death and intimate partner homicide. Thus, women who have experienced IPV-related rape or IPV-related unintended pregnancy that need to prevent or terminate a pregnancy have a time-sensitive need to access care.

Health Inequities, Public Health Emergencies, and Intimate Partner Violence

Historically and structurally marginalized populations experience worse outcomes than many other populations during PHEs. There is a substantial overlap between populations that are likely to experience worse outcomes during PHEs and populations that are more likely to experience health inequities. The interaction of weather- and climate-related disasters with the built environment causes damage to critical infrastructure that is essential for the health of communities, such as access to food, water, shelter, health care, transportation, and electrical power. Widening social inequalities, increasing urbanization, and rapid population growth—particularly in coastal areas—predispose certain groups to disaster-related disparities. Women who experience IPV in this context are more vulnerable to serious adverse health outcomes, particularly if the disaster health responders who they encounter are not adequately prepared to care for them.

Planning and Operationalization of Intimate Partner Violence Care During Public Health Emergencies

Immediately following a disaster, emergency health care may be delivered by federal and state, local, tribal, and territorial (SLTT) response teams or volunteer organizations active in disasters. These teams have diverse health care backgrounds, so IPV training may not be a requirement of their usual role. Additionally, local health care providers, emergency medical services staff, police officers, and community health workers

could all be considered disaster health responders during a PHE. Given the increased severity and prevalence of IPV associated with PHEs, disaster health responders need to be able to recognize the signs and symptoms of IPV and feel confident in addressing IPV. This requires education, training, and protocols for IPV care during PHEs.

Scant evidence exists among federal disaster response entities and national volunteer organizations regarding training, protocols, or guidance for IPV care during PHEs. The committee found that most public-facing federal PHE preparedness and response guidance did not address protocols related to IPV. Some guidance mentioned IPV as part of domestic violence, but that guidance framed violence in the context of families with children, which can lead planners and disaster health responders to overlook the possibility of IPV in families that do not have children, couples that do not live together, or former intimate partners. The public-facing federal preparedness and response guidance that did address IPV did not offer specific guidance for development of IPV care protocols, but rather mostly encouraged planners and responders to have domestic violence hotline numbers available and to know the hours and contact information for local domestic violence shelters.

Education and training focused on IPV recognition and care is important for developing the capacity for disaster health responders to care for people experiencing IPV during PHEs. Despite preparedness planning, disaster health responders may need more preparation for the setting and type of care needs of the affected community. This is often addressed through just-in-time training. Just-in-time training is an opportunity to reinforce prior disaster knowledge and convey other vital information about the PHE. This training represents a unique opportunity to provide IPV-specific education and training.

The 2023–2025 HRSA Strategy to Address Intimate Partner Violence recommends integrating training for IPV care into existing programs and providing training and technical assistance specific to IPV for the health care workforce. One of HRSA’s National Training and Technical Assistance Programs, Health Partners on IPV and Exploitation, provides training about trauma-informed services during steady state conditions, education and tools for building partnerships, policy development, and integration of processes to promote prevention and increase referrals to services for individuals at risk for and experiencing IPV. The Administration for Strategic Preparedness and Response (ASPR) collaborates with SLTT governments, hospitals, community members, and other members of the private sector to improve their medical and public health PHE readiness and response capabilities. ASPR has developed a collection of technical resources, including guidance on training and protocol development for PHE preparedness and response. The committee concluded that ASPR

and HRSA were well suited to developing and disseminating training and guidance for IPV care during PHEs.

International guidance, such as that developed by WHO and the United Nations Population Fund (UNFPA) can also be used to inform development of domestic protocols. Additionally, collaboration with IPV care providers outside of health care institutions to develop plans before PHEs occur is important to ensuring safety, security, and community acceptance.

• At all levels, jurisdictional emergency planning teams should include representation from social service providers and IPV-related community-based organizations to ensure that strong partnerships exist between disaster health responders and the organizations providing care for IPV survivors.

Supplies for Intimate Partner Violence Care in Emergencies

Emergency medical supply caches are a key component of PHE preparedness and response. Several federal systems exist to supply disaster health responders during emergencies, including the Strategic National Stockpile, supplies deployed with Disaster Medical Assistance Teams, and resources included as part of a Federal Medical Station’s deployment kit. While these caches are typically supplemented by supplies maintained by private and SLTT actors, kits meant for acute deployment are pre-packaged and standardized. Many of the essential health care services related to IPV during PHEs are the same as those for individuals not experiencing IPV, but there are some unique supply considerations, particularly related to caring for a woman who has experienced IPV-related sexual assault or rape. However, standard protocols to guide the allocation of resources, such as supplies and medications, when providing IPV care in austere settings or in disrupted health care environments during PHEs are not currently widely available in the United States. UNFPA maintains guidelines, the Inter-Agency Emergency Reproductive Health Kits for Use in Humanitarian Settings, which describe necessary supplies and their use across a variety of women’s health needs. Emergency reproductive health kits are designed for use in conditions similar to those of the initial response phase of a PHE and are tailored to the knowledge, competencies, and qualifications required to use each of the supplies in the kit. Different kits exist for different types of care. Examples include a post-rape treatment kit, oral and injectable contraception kit, and sexually transmitted infection kit. The committee acknowledges that those located in certain geographic areas in the United States may encounter challenges procuring specific and vital supplies for IPV care, such as emergency contraception. However, it emphasizes that caches should include the necessary supplies to support delivery of all essential health care services related to IPV regardless of location.

• Establish logistics and procurement plans for needed supplies for all entities that will be responsible for delivering that care, including disaster health responders, emergency shelter staff, and community-based support service providers engaged in IPV care.

Intimate Partner Violence Research

As previously noted, the committee engaged in an extensive review of the literature to inform its work. However, it encountered difficulties when attempting to compare data and findings across studies. Most studies and surveys, including different years of the NISVS, differed in terms of the terminology used related to IPV, demographic categories, and approaches to data collection. These inconsistencies were also noted in IPV research that used clinic-based data, such as that extracted from electronic health records. This included variations in the definitions and descriptions used for the different forms of IPV (physical violence, sexual violence, stalking, psychological aggression, and reproductive coercion). Most systematic reviews of IPV-related research identified inconsistencies in terminology among studies as a substantial limitation to drawing strong conclusions.

Without comparable data sets, it is difficult to develop accurate estimates of IPV prevalence and identify temporal trends, particularly among different populations and geographic areas that may be under-represented in a single study’s data collection. Furthermore, demographic data collection and analysis approaches are often inconsistent. Thus, data specific to some smaller populations in a data set may not be represented accurately or at all. Inconsistencies in terminology and data also make it difficult to compare effectiveness of different IPV interventions across studies. These data inconsistencies undoubtedly have slowed the process of identifying effective, scalable interventions for IPV and led to an incomplete understanding of its prevalence. CDC developed its Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements to reduce these inconsistencies, but it has not been widely adopted.

The committee recognized several challenges in conducting high-quality studies involving women experiencing IPV. These women navigate complex and evolving circumstances related to their safety when they disclose IPV and seek care. Often these circumstances are beyond their control. For example, a study participant may experience a change in her safety during the study, requiring services that differ from the intervention to which she was randomized. Failure to modify the intervention would pose an unethical risk to the participant’s safety. Moreover, people experiencing IPV may need to relocate for their safety, which disrupts the administration of the intervention, long-term follow-up, and outcome measurement. These challenges likely contribute to the relatively small study populations of many IPV-related studies and many of the gaps in IPV-related research specific to this study’s statement of task. The committee concluded that HRSA is well-positioned to support efforts to address these gaps and build a more robust evidence base.

CONCLUDING THOUGHTS

Women who experience IPV have complex and substantial health care needs. Women experiencing IPV and their clinicians face barriers to accessing and delivering evidence-based IPV-related care. When IPV occurs in the context of a PHE, the challenges encountered by both the women experiencing IPV and the disaster health responders who must care for them become more complex. The recommendations put forth by this committee outline critical measures that, if acted on, will increase access to essential health care services related to IPV and ultimately save lives.

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