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Health Conditions Related to Intimate Partner Violence
MOST COMMON HEALTH CONDITIONS RELATED TO INTIMATE PARTNER VIOLENCE
ACUTE PHYSICAL INJURIES
Intimate partner violence (IPV) is a leading cause of injury among women and is associated with fractures, craniofacial injuries, traumatic brain injuries, and musculoskeletal injuries (Alessandrino et al., 2020; Arosarena et al., 2009; Colantonio and Valera, 2022).
Injuries to the Head, Face, and Neck
Facial fractures and other facial and dental injuries are among the most common forms of IPV-related physical trauma. Wu and colleagues (2010) performed a systematic review and meta-analysis of studies examining injuries in women who disclosed IPV while presenting to an emergency department (ED). Their analysis found that the injuries most frequently associated with IPV were those to the head, neck, and face. These findings have been replicated in several other studies. For example, an analysis of National Electronic Injury Surveillance System–All Injury Program (NEISS–AIP) data from 1.65 million IPV-related ED visits found that the face was the most common fracture site (48 percent of fractures; n=68,973) (Loder and Momper, 2020). Another analysis of patients disclosing IPV who presented to a hospital in Massachusetts found that the most common facial fracture site was the nasal bones, followed by the mandible and orbits, respectively (Gujrathi et al., 2022). Le and colleagues (2001) had
similar findings in their review of 236 ED admissions at a Level 1 trauma center in Oregon over 5 years in which IPV was identified (Le et al., 2001). They reported that 81 percent (n=191) of those patients presented with maxillofacial injuries. While the majority of patients (61 percent; n=143) had maxillofacial soft tissue injuries, 30 percent (n=70) had facial fractures, and 40 percent (n=28) of those fractures were nasal fractures (Le et al., 2001).
Traumatic blows to the head and face from IPV also lead to dental injuries (Alessandrino et al., 2020). The most common dental injuries due to experiencing IPV are dental fractures, tooth luxations, and tooth avulsions (Alessandrino et al., 2020). However, there is minimal information available about the prevalence of IPV-related dental injuries in the United States. For example, in an analysis of query results from a large dental data repository containing electronic health records data for over 4 million patients from 11 U.S. dental schools that are part of the Consortium for Oral Health Research and Informatics, researchers did not identify any cases of IPV noted in patient records (Banava et al., 2022). Despite limited data, the prevalence of IPV-related injuries due to trauma to the head, neck, and face suggest that it is reasonable to expect that these individuals also experience dental trauma.
Traumatic Brain Injury
Trauma inflicted to the head, face, and neck can result in traumatic brain injury (TBI). TBI, including concussion, resulting from IPV is gaining attention in the literature. However, prevalence estimates vary. Haag and colleagues (2022) found in their scoping review that reported prevalence rates of TBI due to IPV in the literature ranged from 19 to 75 percent in empirical studies, which highlights that variation. They theorized that variations in estimates may result from the lack of a standardized screening tool for TBI in people who have experienced IPV. Additionally, many studies investigating the connection between TBI and IPV rely on smaller convenience samples (Fedina, 2023).
TBI is usually the result of injury to the brain from a mechanical force that leads to motion of the head and the brain within the skull (Davis, 2000). This motion within the skull occurs more quickly than usual or in an anatomically abnormal direction, leading to injury (Davis, 2000). This force may result from a direct blow to the head or another part of the body (Davis, 2000). TBI-induced alterations in brain function lead to a variety of acute problems and chronic sequelae, including loss of consciousness, behavioral changes, neuropsychiatric disorders, post-traumatic seizures, motor deficits, sensory deficits, cognitive deficits, memory loss, headache, fatigue, insomnia, dizziness, and deficits in attention, concentration, and executive functioning (Blaya et al., 2022; Haag et al., 2022). Given the high
prevalence of head, neck, and face injuries from IPV, particularly facial fractures, it is reasonable to expect that the women sustaining those blows may also experience TBI (McCarty et al., 2020; Rajandram et al., 2014). Several studies describe symptoms reported by women experiencing physical IPV consistent with TBI, including recurrent dizziness, headache, memory loss, blackouts, cognitive function difficulty, depression, and sleep disturbances (Haag et al., 2022; Stubbs and Szoeke, 2022). However, a systematic review of 52 studies on the effects of IPV on physical health and health-related behaviors found that certain TBI-linked symptoms, including dizziness, depression, and sleep disturbances, were commonly reported by people experiencing IPV who did not have a history of TBI (Stubbs and Szoeke, 2022). Many of the symptoms related to TBIs are similar to those related to the psychological trauma of experiencing IPV (Mehr et al., 2023). Memory loss secondary to TBI may limit a woman’s ability to provide an accurate history of her injuries, which likely contributes to variations in reported prevalence of IPV-related TBI in the literature. TBI is also associated with an increased risk for substance use disorders (McHugo et al., 2017; Mehr et al., 2023). Substance use can also create challenges for obtaining an accurate injury history and mask TBI symptoms, further complicating the diagnosis of TBI (Mehr et al., 2023).
Strangulation
Strangulation is an under-reported source of severe and fatal injury due to IPV (Black, 2011; Patch et al., 2021; Pritchard et al., 2017). The reported prevalence of IPV-related strangulation varies in the research literature. An analysis of data collected from 2006 to 2014 in the Nationwide Emergency Department Sample (NEDS) used diagnosis codes for IPV and non-fatal strangulation to identify prevalence in women over 18 years old who presented to an ED that submitted data to NEDS (Patch et al., 2021). Statistical analysis found that 1.21 percent of visits (602 of 49,675 visits) with an IPV diagnosis code also had a strangulation diagnosis code (Patch et al., 2021). Of note, diagnosis codes for IPV are not consistently used to identify patient visits due to IPV, which may limit the accuracy of epidemiologic estimates based on diagnosis code frequency (Adhia et al., 2023; Schafer et al., 2008). A systematic review of 23 articles investigating the epidemiology of IPV-related nonfatal strangulation in nine different countries using self-reported survey results found that 3.0–9.7 percent of women reported having been strangled by an intimate partner in their lifetime (Sorenson et al., 2014). Researchers have hypothesized that under-reporting and variations in prevalence data are likely due to a lack of clinician awareness of the signs and symptoms of non-fatal strangulation, a lack of visible signs of strangulation (such as contusions) when the woman presents for evaluation by a clinician,
fear of retaliation for seeking care for an IPV-related injury, and that the woman may not be aware of the potential negative health consequences of strangulation (Donaldson et al., 2023; Patch et al., 2018, 2021).
Strangulation involves the application of external pressure to the neck that results in occlusion of the airway and blood vessels (Valera et al., 2022). IPV-related non-fatal strangulation results in a variety of adverse outcomes, including carotid artery dissection, carotid artery stenosis, stroke, tracheal perforations, laryngeal cartilage fracture, TBI, hypoxic brain injuries, dysphagia, dysphonia, loss of consciousness, seizures, contusions, cervical musculoskeletal injuries, and post-traumatic stress disorder (PTSD) (Messing et al., 2022; Patch et al., 2018; Sorenson et al., 2014; Tang et al., 2023). IPV-related non-fatal strangulation has been described as the violent physical manifestation of coercive control and is often accompanied by violent threats (Pritchard et al., 2017; Stansfield and Williams, 2021). The most severe outcome of strangulation in IPV is death. A meta-analysis of 17 studies investigated risk factors for intimate partner homicide and found that one of the strongest predictors for intimate partner homicide was previous non-fatal strangulation by an intimate partner (Spencer and Stith, 2020).
Musculoskeletal Injuries
Radiology studies have identified a variety of musculoskeletal injuries frequently associated with IPV. Common IPV-related upper extremity fractures include ulnar shaft and medial hand fractures, which often result from attempts to shield oneself from the physical attack, as well as finger and shoulder fractures (Tang et al., 2023). Loder and Momper’s (2020) analysis of NEISS-AIP data found that IPV fractures occurred most frequently in the face, finger, upper trunk, and hand. They also found that 87.5 percent of women who presented to EDs sustained sprains or strains due to IPV (Loder and Momper, 2020). While not as common as head, neck, or upper-extremity fractures; rib, sternal, and clavicle fractures are the most common IPV-related torso fractures. Foot and ankle fractures are the most common in the lower extremities (Loder and Momper, 2020; Tang et al., 2023). The radiology literature also identified IPV-related thoracic injuries that are less common than fractures but that can have more severe consequences, including pneumothorax, hemothorax, and pneumomediastinum (Tang et al., 2023). In addition to fractures, sprains, and strains, other common health sequelae of IPV include arthritis, joint disease, and resulting difficulties with mobility (Black, 2011).
GYNECOLOGIC, REPRODUCTIVE HEALTH, PERINATAL, AND OBSTETRIC CONDITIONS
Gynecologic and Reproductive Health
IPV is associated with several adverse sexual and reproductive health outcomes, including unintended pregnancy, rapid repeat pregnancies, sexually transmitted infections (STIs), and HIV infection (El-Bassel et al., 2022; Ely and Murshid, 2018; Moore et al., 2010). During pregnancy, birth-giving people experiencing IPV have a higher risk of adverse outcomes such as preterm delivery, low birthweight babies, preeclampsia, other obstetric complications, and fetal/neonatal death (Alhusen et al., 2014; Auger et al., 2020; Loeffen et al., 2016).
A systematic review and meta-analysis of 57 studies investigating the signs and symptoms of women experiencing IPV who presented to primary care found that gynecologic infections, STIs, and unwanted pregnancy were the gynecologic and reproductive health conditions most often associated with IPV (Vicard-Olagne et al., 2022). Additional research has found that abnormal vaginal discharge or bleeding, dyspareunia, abnormal cervical screening tests, chronic pelvic pain, STIs, and HIV infections (as well as lower CD4+ counts in those who are HIV+), painful menses, and genital injuries are often associated with IPV (Black, 2011; Dillon et al., 2013; Stubbs and Szoeke, 2022; Vicard-Olagne et al., 2022). Reproductive and sexual health outcomes associated with teen dating violence or IPV among adolescents include unintended pregnancy, STIs, and HIV infection (Decker et al., 2005; Exner-Cortens et al., 2013; Miller et al., 2010b, 2014).
Studies investigating increased abnormal cervical cancer screening tests and increased cervical cancer rates associated with IPV have noted that women experiencing IPV tend to be less likely to undergo cervical cancer screening (Bagwell-Gray and Ramaswamy, 2022). Researchers hypothesize that increased STIs, particularly human papillomavirus, may also be a contributing factor (Stubbs and Szoeke, 2022).
Analysis of data from a survey of 1,262 women seeking care in family planning clinics found that those who had recently experienced IPV were more likely to pursue one or more pregnancy tests and use emergency contraception at least once (Kazmerski et al., 2015). This analysis also found that the combination of experiencing recent IPV and reproductive coercion increased the likelihood of seeking multiple pregnancy tests, using emergency contraception multiple times, and seeking STI testing (Kazmerski et al., 2015). A meta-analysis of 38 studies also found that experiencing IPV was associated with unwanted pregnancy, abortions, and the use of emergency contraception (Vicard-Olagne et al., 2022).
Unintended Pregnancy
An analysis of data collected from 20,252 women who gave birth between 2012 and 2015 and completed the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey within 9 months of giving birth found that those who experienced IPV were almost eight times more likely to experience reproductive coercion than those who did not experience IPV (Samankasikorn et al., 2019). IPV, including reproductive coercion, is associated with unintended pregnancy (Miller et al., 2010a, 2014; Samankasikorn et al., 2019).
Women experiencing IPV are less likely than other women to be in control of their fertility regulation due to manipulation tactics and fear of physical abuse from their partners. A cross-sectional cohort study of women seeking services from an IPV shelter or a district attorney’s office in a large U.S. metropolitan area identified several commonly reported barriers to the use of contraception by women reporting experiencing IPV and reproductive coercion (Liu et al., 2016). The most common barriers included partners refusing to use contraception, partners would not allow women to use contraception, fear of discussing contraception, experiencing IPV for discussing using contraception, and experiencing IPV for using contraception (Liu et al., 2016). People engaging in IPV and reproductive coercion also sabotage contraception (Baird et al., 2017). These findings were consistent with barriers identified in a systematic review of 42 studies examining the relationship between IPV and condom and oral contraceptive use (Bergmann and Stockman, 2015).
Unintended pregnancy is significantly associated with adverse maternal and infant outcomes, including maternal depression during pregnancy, postpartum depression, preterm birth, and low birthweight (Nelson et al., 2022). Unintended pregnancy has also been identified as a risk factor for experiencing IPV during pregnancy (D’Angelo et al., 2023; E. J. Smith et al., 2023). Experiencing IPV during pregnancy is associated with several serious adverse maternal and infant health outcomes, as well as intimate partner homicide (D’Angelo et al., 2023; Donovan et al., 2016; Guo et al., 2023). Researchers have found that women who became pregnant as a result of reproductive coercion are more likely to continue to experience abuse throughout their pregnancy and to miscarry or experience a stillbirth (Liu et al., 2016). Roberts and colleagues analyzed data from 956 women who participated in the University of California, San Francisco’s Turnaway Study, a prospective study of women seeking abortions at 30 different clinics across the United States from 2008 to 2010 (Roberts et al., 2014). Their analysis found that among women experiencing IPV prior to being pregnant, continuing an unintended pregnancy and giving birth was not associated with a decrease in physical IPV (Roberts et al., 2014). However,
among women experiencing IPV prior to being pregnant, terminating an unintended pregnancy was associated with a decrease in physical violence (Roberts et al., 2014).
Sexual Assault
Estimates from the 2016–2017 National Intimate Partner and Sexual Violence Survey (NISVS) data indicated that approximately 19.6 percent of U.S. women had experienced contact sexual violence (in the survey this included rape, sexual coercion, and unwanted sexual contact) by an intimate partner in their lifetime (Leemis et al., 2022). An analysis of the use of ICD-10-CM codes for IPV from 2 years of data from electronic health records from 15 different California hospitals found that 33.3 percent (n=5,773) of visits to the ED and 23.1 percent (n=330) of hospital visits for IPV included the IPV ICD-10-CM code for confirmed sexual abuse (Adhia et al., 2023). An analysis of data from the 2010–2012 NISVS survey found that 26.2 percent of respondents that reported rape-related pregnancy identified a current or former intimate partner as the perpetrator (Basile et al., 2018). Bagwell-Gray and colleagues (2015) noted substantial variation in the reported prevalence of sexual IPV in their systematic review of 43 peer-reviewed articles investigating the prevalence of sexual IPV. They noted that inconsistency in the terminology used in the studies and hesitancy on the part of the person experiencing intimate partner sexual assault due at least in part to the existing intimate relationship may contribute to underestimates of prevalence (Bagwell-Gray et al., 2015). IPV-related sexual assault, including rape, may also be under-reported due to legal and social barriers. Marital rape did not become illegal in all 50 states until the early 1990s, and its definitions continue to vary between states (Wright et al., 2022). Additionally, the false beliefs that sex is a duty within intimate relationships such as marriage or that rape can only be perpetrated by a stranger persist (Wright et al., 2022).
IPV sexual assault, including rape, results in psychological trauma, physical injury, STIs, HIV infection, and unplanned pregnancy (Wright et al., 2022). IPV sexual assault is associated with PTSD, depression symptoms, and suicidality (Wright et al., 2022). It is also associated with adverse gynecological outcomes, such as miscarriage, and STIs and HIV infection (Wright et al., 2022). An analysis of data collected from 741 women by sexual assault nurse examiners in New Hampshire from 1997 to 2007 found that women sexually assaulted by a current or former intimate partner were more likely to experience genital injuries than those assaulted by a stranger (Murphy et al., 2011). Increased frequency, duration, and severity of IPV sexual assault are associated with increased use of legal, medical, and social services (Wright et al., 2022).
HIV Infection
The existence of a relationship between IPV and HIV infection has been well documented in the literature (Campbell et al., 2008; El-Bassel et al., 2022; Gielen et al., 2007; Li et al., 2014; Willie et al., 2018). Women living with HIV are at heightened risk for IPV, and women experiencing IPV are at a greater risk for contracting HIV (Marshall et al., 2018). Women experiencing IPV are less likely to have control over a partner’s condom use, a key method for protecting them from HIV infection (Bergmann and Stockman, 2015). State-level IPV prevalence is also positively associated with higher rates of HIV diagnosis among women in the United States (Willie et al., 2018).
An analysis of data from the Medical Monitoring Project survey of adults with HIV in the United States found a lifetime prevalence of IPV of 35.6 percent (n=1,060) and a previous 12-month prevalence of 4.5 percent (n=132) for women with HIV (Lemons-Lyn et al., 2021). This study found statistically significant differences in the lifetime prevalence of IPV in people with HIV by gender/sexuality, with bisexual HIV-positive women more likely to experience IPV than heterosexual women and lesbians (Lemons-Lyn et al., 2021). The analysis also found that treatment for HIV can be affected by experiencing IPV. Those who tested positive for HIV and had experienced IPV in the past 12 months were less likely to be retained in HIV medical care, had lower HIV medication regimen adherence, were less likely to have sustained viral suppression, and were more likely to have missed HIV-related medical appointments in the past year than those who did not experience IPV (Lemons-Lyn et al., 2021).
The most direct mechanism linking IPV to HIV susceptibility is forced sex or sexual IPV (i.e., condomless vaginal or anal sex via physical force, coercion, or threat) with a partner living with HIV (Dunkle and Decker, 2013; Li et al., 2014; Maman et al., 2000; Stockman et al., 2013; Tsuyuki et al., 2019). Researchers have posited that indirect mechanisms occur at the biological (e.g., chronic stress response, chronic inflammation, immune dysfunction), behavioral (e.g., individual and perpetrator sexual- and drug-related risk behaviors), and societal levels (e.g., social norms, gender power imbalances) (Campbell et al., 2008; Dunkle and Decker, 2013; El-Bassel et al., 2022; Maman et al., 2000). The intersection of IPV and HIV particularly affects certain populations, including women engaged in sex work, women who use drugs, transgender women, and adolescent girls and young women (aged 15–24 years) (El-Bassel et al., 2022). IPV often interferes with women’s engagement in and adherence to HIV care (Sullivan, 2019). Meta-analysis findings showed IPV to be significantly associated with lower use of antiretroviral therapy (ART), poorer self-reported ART adherence, and worsened viral suppression among women (Hatcher et al., 2015).
Perinatal Health
Experiencing IPV in the perinatal period is associated with an increased risk for numerous adverse maternal, neonatal, and infant health outcomes. Pregnant people who experience IPV are more likely to have high blood pressure, edema, vaginal bleeding in the second or third trimester, severe nausea, vomiting, dehydration, kidney infection or urinary tract infection, premature rupture of membranes, and premature birth. They are less likely to achieve gestational-age-appropriate weight and more likely to give birth to low birthweight babies (Alhusen et al., 2014). A 2020 systematic review of 50 global studies found that IPV during pregnancy was associated with adverse health effects for pregnant and postpartum people, fetuses, and infants (Pastor-Moreno et al., 2020). These health effects include premature rupture of membranes, spontaneous abortion, inadequate weight gain during pregnancy, urinary tract infections, and miscarriage, as well as preterm birth, low birthweight, and neonatal death (Pastor-Moreno et al., 2020). The review also found an association between IPV and health care usage, including late entry into prenatal care, longer postpartum hospitalization, and fewer antenatal visits (Pastor-Moreno et al., 2020). Experiencing IPV is also associated with delayed and inadequate prenatal care, which in turn is associated with preterm delivery and low birthweight infants (Cha and Masho, 2014).
BEHAVIORAL HEALTH CONDITIONS
Mental Health
IPV is associated with adverse mental health outcomes such as anxiety, PTSD, depression, substance misuse, suicidality, and eating disorders (Beydoun et al., 2017; Black, 2011; Dichter et al., 2017; Dokkedahl et al., 2022; Lacey et al., 2015; Termos et al., 2022; White et al., 2023). The relationship between IPV and mental health outcomes is complex and bidirectional (Bacchus et al., 2018; Oram et al., 2022). While exposure to IPV increases the risk of developing mental health problems, mental health problems have also been shown to increase women’s vulnerability to experiencing IPV (Bacchus et al., 2018; Oram et al., 2022). A recent systematic review and meta-analysis about mental health outcomes of IPV among women globally found increased odds of adverse mental health outcomes associated with IPV, including depression, PTSD, and suicidality (White et al., 2023). Furthermore, physical violence and sexual violence were associated with an increased likelihood of depression and anxiety, respectively (White et al., 2023). Another systematic review and meta-analysis highlighted the role of psychological IPV, particularly experiences of coercive
control, in the development of PTSD among women (Dokkedahl et al., 2022). Of note, researchers have indicated that variations in terminology for psychological IPV and variations in psychologic measurement instruments in many of the research studies limit the ability to make comparisons among the studies and to apply their results broadly (Dokkedahl et al., 2022).
An emerging body of literature explores the mental health impacts of IPV in different groups, such as adolescents, racial and ethnic minorities, and lesbian, bisexual, and transgender people. Mental health consequences for adolescents identified in the literature include depression, suicidality, substance abuse, and disordered eating (Exner-Cortens et al., 2013). A systematic review found that experiencing IPV significantly negatively affects the mental health of Black and Hispanic women (Stockman et al., 2015). A large cross-sectional study examined the relationship between IPV exposure, lethality risk, and mental health outcomes among African American women, African Caribbean women, and Black women of mixed ethnicity in the United States and the U.S. Virgin Islands (Sabri et al., 2013). This study found that while African American and African Caribbean women who experienced severe IPV were more likely to experience substantial adverse mental health outcomes, they were not more likely to use mental health resources (Sabri et al., 2013). The researchers also found that Black women, regardless of ethnicity, with mental health problems tended to underutilize mental health services, which echoes the findings of other studies (Sabri et al., 2013). Several studies have noted that Hispanic women who have experienced IPV tend to exhibit higher rates of mental health problems than non-Hispanic women (Reyes et al., 2023). Several studies of Asian American women have also documented the relationship between IPV experiences and adverse mental health, such as depression, anxiety, and suicidality (Hurwitz et al., 2006; Lee et al., 2007; Maru et al., 2018).
American Indian/Alaska Native (AI/AN) women are disproportionately affected by mental health problems (Brave Heart et al., 2016; Duran et al., 2004). However, research into the effects of experiencing IPV on the mental health of AI/AN women is limited, and many studies rely on small samples. A study that analyzed data collected in the 2010 NISVS survey found that experiencing IPV was related to poor mental health in AI/AN women (Fedina et al., 2022). However, when the additional factors of food insecurity, housing insecurity, and health care access were introduced, the relationship between IPV and poor mental health was no longer statistically significant in this population (Fedina et al., 2022).
Among lesbians and bisexual women, experiencing IPV is associated with multiple adverse mental health outcomes, including depression, anxiety, difficulties with emotional regulation, and internalized homophobia (Porsch et al., 2022). An analysis of 2010 NISVS survey data found that
bisexual women who had experienced IPV were significantly more likely to report PTSD symptoms than heterosexual women who had (46.2 vs. 22.1 percent) (Walters et al., 2013). In a systematic review, Peitzmeier and colleagues (2020) found that experiencing IPV was associated with poor mental health among transgender individuals (Peitzmeier et al., 2020). They also found that psychological IPV in the form of leveraging transgender-specific vulnerabilities to gain power and control was associated with excess mental health burden in transgender individuals experiencing IPV (Peitzmeier et al., 2020).
The perinatal period is of particular importance when discussing mental health outcomes related to IPV. Adverse mental health outcomes for people experiencing IPV in the perinatal period include higher rates of PTSD, major depressive disorder, suicide ideation, and problematic substance use (Alhusen et al., 2015; Connelly et al., 2013; Kastello et al., 2015; Martin et al., 2003). IPV in the perinatal period has also been found to be associated with postpartum depression (Garabedian et al., 2011). Prevalence of both postpartum depression and IPV are disproportionately high among AI/AN women (Heck, 2021). However, a scoping review published in 2021 found that many studies do not include postpartum depression when examining the mental health effects of perinatal IPV (Heck, 2021). The authors hypothesized that this may contribute to the inconsistent findings of a relationship between IPV and postpartum depression in the literature (Heck, 2021).
Substance Use
A bidirectional relationship exists between substance use disorder (SUD) and IPV. Women who use drugs may be at greater risk of experiencing IPV because partners may perceive them as vulnerable to victimization and they may not be able to leave violent partners (Burke et al., 2005; Martin et al., 2003; Testa et al., 2003). Some researchers theorize that women with experiences of IPV may engage in drug use as a coping mechanism (Gilbert et al., 2015; P. H. Smith et al., 2012). However, other researchers have found the temporal relationship between SUD and IPV difficult to delineate (Mehr et al., 2023). Partner interference can serve as a barrier for women experiencing IPV to access and remain engaged in SUD treatment programs, increasing the potential for relapse (Ogden et al., 2022). A systematic review that sought to investigate the prevalence of opioid use among people who have experienced IPV noted that a limited number of studies have investigated the prevalence of opioid use among people who had experienced IPV (Stone and Rothman, 2019). The authors noted that opioid use was defined differently in all of the studies and that there was substantial variation in how IPV was reported in all of the studies, which prevented meta-analysis and limited data comparison (Stone and Rothman, 2019). Another systematic review of
articles published between 2010 and 2020 also noted that inconsistencies in measurement of both substance use and IPV limited the number of studies that met criteria for inclusion to 10 (Ogden et al., 2022).
Several small studies of women who were in substance abuse treatment programs or reported a history of substance use when they sought care in a hospital or ED have noted high rates of reported prior or current IPV (El-Bassel et al., 2005, 2019). A longitudinal study of 241 women with low incomes receiving care in a Bronx, New York, ED found that women who used heroin were twice as likely to experience IPV and 2.7 times more likely to report IPV-related injury (Gilbert et al., 2012). A study of 81 women admitted to a Level 1 trauma center in rural North Carolina over 6 months found a significant relationship between experiencing IPV during their lifetime and substance use (Hink et al., 2015). Experiencing IPV is also associated with higher alcohol consumption (Mehr et al., 2023; Waller et al., 2012). A study that analyzed survey data from 1,863 women living in a large Midwestern metropolitan area found that a history of experiencing physical IPV was associated with heavy drinking (Ullman and Sigurvinsdottir, 2015).
There are few large population-based studies of prevalence of IPV related to substance use in the United States. The results of one large study that analyzed data from the 2004–2005 wave of the National Epidemiological Study on Alcohol and Related Conditions offered useful insight, despite the age of the data (P. H. Smith et al., 2012). The analysis of data from 25,778 respondents who reported being married, dating, or in a relationship in the past year found that women who had an opioid use disorder were more likely to experience IPV (P. H. Smith et al., 2012). Their analysis also found that marijuana use was associated with experiencing IPV (P. H. Smith et al., 2012). They also found that while cocaine use was not related to experiencing IPV, it was associated with using IPV (P. H. Smith et al., 2012). Another study analyzed data from 4,481 female-identified veterans over the age of 45 who were screened for IPV in Veterans Health Administration clinics in 11 different states between 2014 and 2016 (Makaroun et al., 2020). The analysis found that screening positive for IPV was associated with a subsequent diagnosis of SUD (Makaroun et al., 2020).
Given the limited availability of population-based studies that investigate the prevalence of IPV related to substance abuse and the variations in terminology and measurement related to both in other studies, it is difficult to identify clear evidence of a relationship among IPV, substance use, and different demographics. One population-based study that was identified was an analysis of data collected during the 2001–2002 and 2007–2008 waves of the National Longitudinal Study of Adolescent Health, which investigated the role of race, ethnicity, and temporality in the bidirectional relationship between IPV and substance use among 2,959 White, Black, and Hispanic
women in early young adulthood (18–26 years old) and young adulthood (24–32 years old), respectively (Nowotny and Graves, 2013). Their analysis found that experiencing IPV in any form during early young adulthood (18–26 years old) was associated with an increased likelihood of marijuana use during young adulthood (24–32 years old) among Hispanic women (Nowotny and Graves, 2013). They also found that experiencing physical IPV during early young adulthood increased the likelihood of marijuana use in young adulthood among White women. There was no relationship identified between experiencing IPV in early young adulthood and any subsequent substance use among Black women (Nowotny and Graves, 2013). Binge drinking during early young adulthood was associated with an increased likelihood of experiencing an IPV-related injury in young adulthood for Hispanic women, and early young adulthood drug use increased the likelihood of experiencing an IPV-related injury in young adulthood among Black women (Nowotny and Graves, 2013). The limited number of population-based studies investigating the relationship between IPV, substance use, and different demographics highlights the need for additional research in this area to better guide targeted interventions.
The intersection of IPV and substance use or abuse results in adverse health outcomes of varying severity. Substance abuse is associated with adverse health effects including mental health disorders, bacterial infections such as streptococcal and staphylococcal infections, acute and chronic cardiac conditions, stroke, organ damage, seizures, and dental disorders (Fox et al., 2013; Khalsa et al., 2008; Meyer et al., 2011). IPV and substance abuse are associated with a higher likelihood of sexual risk taking behaviors, which in turn is associated with greater risk for STIs and HIV (Meyer et al., 2011).
CHRONIC HEALTH CONDITIONS
Chronic Pain
Chronic pain is one of the most common adverse health effects of IPV (Walker et al., 2022). Among women who have experienced IPV, the most common forms of chronic pain are frequent headaches, migraines, chronic back pain, pelvic and abdominal pain, and fibromyalgia (Poleshuck et al., 2018; Walker et al., 2022). In their systematic review, Stubbs and Szoeke (2022) reported that multiple U.S.-based and international studies found that chronic pain was more common in women who experienced IPV (Stubbs and Szoeke, 2022). The increased prevalence of chronic pain among those experiencing IPV was echoed in another systematic review conducted by Vicard-Olagne and colleagues (2022). While there is a logical relationship between the physical injuries sustained due to IPV and chronic
pain, experiencing psychological IPV is also associated with chronic pain (Spencer et al., 2022). Smaller studies have investigated the interaction between experiencing IPV and chronic pain. In a study of 108 women seeking treatment at a Midwestern specialty pain rehabilitation and treatment center, 56 percent (n=60) reported having experienced IPV at some point in their lifetimes, and 28.7 percent (n=31) reported having experienced IPV within the past year (Craner et al., 2020). A recently published Canadian longitudinal study of 309 women who had separated from partners who used IPV found that chronic pain remained at significant levels by the end of the 4-year study (Ford-Gilboe et al., 2023).
Women experiencing chronic pain are less likely to receive appropriate care and more likely to have their reports of pain dismissed or misdiagnosed by health care professionals as being solely of psychological origin (Samulowitz et al., 2018; Walker et al., 2022). Women experiencing chronic pain often do not feel believed or understood, a concern that can be compounded by experiencing IPV. This intersects with other disparities in pain management. For example, patients who are not White are more likely to report discrimination, bias, and unsatisfactory treatment in pain management than White patients (Morales and Yong, 2021; Mossey, 2011, Trost et al., 2019).
A systematic review investigating the relationship between IPV and chronic pain found conflicting findings in the literature about the nature of the role of PTSD and depression in the relationship between experiencing IPV and chronic pain (Walker et al., 2022). However, it did find that the literature was consistent in finding that IPV, chronic pain, and PTSD, depression, and anxiety frequently co-occur (Walker et al., 2022). Of note, IPV-related chronic pain does not necessarily translate into increased use of pain medication, particularly opioids. Wuest and colleagues (2007) found that despite higher levels of chronic pain among those experiencing IPV, those individuals were less likely to take over-the-counter nonsteroidal anti-inflammatory drugs and were no more likely to take opioid pain medications than women in the general Canadian population (Wuest et al., 2007). Dillon and colleagues (2013) and Stubbs and Szoeke (2022) reported similar findings.
Cardiovascular Disease
Some studies have indicated that there may be an association between experiencing IPV and developing cardiovascular disease (Stubbs and Szoeke, 2022; Wright et al., 2019, 2021). In general, the findings in the literature were mixed in regard to identifying a direct relationship between IPV and cardiovascular disease. The committee reviewed studies examining an association between IPV and cardiovascular disease and concluded that there is currently not enough compelling evidence to link the two.
CHAPTER SUMMARY
The most common health conditions related to IPV include acute physical injuries; gynecologic, reproductive, and obstetric conditions; behavioral health conditions; and other chronic conditions. Some health conditions associated with experiencing IPV, such as TBI or the adverse health effects of strangulation, can have serious or fatal outcomes. Unintended pregnancy due to IPV is associated with serious adverse maternal and infant health outcomes. A person experiencing unintended pregnancy is also more likely to experience IPV during that pregnancy, which is also associated with serious adverse maternal and infant health outcomes. The adverse health conditions related to experiencing IPV do not occur in isolation. Treating these conditions is key to treating IPV in steady state conditions and in PHEs. The next chapter will discuss the essential health care services related to IPV.
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