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Risk Factors Associated with Different Types of Intimate Partner Violence (IPV): An Emergency Department Study
The Journal of Emergency Medicine, Vol. 47, No. 6, pp. 710–720, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.07.036
Violence: Recognition, Management and Prevention
RISK FACTORS ASSOCIATED WITH DIFFERENT TYPES OF INTIMATE PARTNER VIOLENCE (IPV): AN EMERGENCY DEPARTMENT STUDY Shahrzad Bazargan-Hejazi, PHD,* Eunjin Kim, BA,† Johnny Lin, PHD,‡ Alireza Ahmadi, MD, PHD,§k Mojdeh T. Khamesi, MD,{ and Stacey Teruya, EDD, MS# *Department of Psychiatry, Charles R. Drew University of Medicine and Science & David Geffen School of Medicine at University of California, Los Angeles, California, †Department of Psychology, University of California at Los Angeles, California, ‡Educational Testing Service, Princeton, New Jersey, §Division of Social Medicine, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, kDepartment of Anesthesiology, Critical Care and Pain Management, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran, {School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and #Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California Reprint Address: Shahrzad Bazargan-Hejazi, PHD, Charles R. Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059
, Abstract—Background: Domestic intimate partner violence (IPV) is a serious health care concern, which may be mitigated by early detection, screening, and intervention. Objectives: We examine posited predictors in IPV and nonIPV groups, and in four different IPV profiles. Possible factors include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. We also introduce a new ‘‘Five Steps in Screening for IPV’’ quick reference tool, which may assist emergency physicians in detection and treatment. Methods: This was a cross-sectional study using survey data from 412 inner-city emergency department patients. Associations were explored using a chi-squared test of independence, independent-samples t-tests, and a one-way analysis of variance. Results: Nearly 16% had experienced IPV. As a group, they were younger, and more depressed and impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. In the IPV group, 31% were perpetrators, 20% victims, and 49% both victims and perpetrators. The latter group was younger, more impulsive and depressed, used drugs, and was more likely
to have observed parental violence as a child. Conclusion: Correlates in groups affected by IPV indicate the same general risk factors, which seem to more acutely affect those who are both perpetrators and victims. Alcohol and drug use, depressive symptoms, and childhood exposure to violence may be factors and signs for which emergency physicians should screen in the context of IPV. Ó 2014 Elsevier Inc. , Keywords—intimate partner violence; IPV perpetrators; IPV victims; depression; alcohol; drug use; impulsivity; IPV screening
INTRODUCTION Domestic intimate partner violence (IPV) is characterized by physical, emotional, psychological, and sexual abuse (1,2). Its devastating impact on physical and mental health is recognized nationally and globally (3–6). IPV can contribute to maternal death, posttraumatic stress disorder (PTSD), and severely compromise the quality of life (7–9). IPV is likely to be repeated, resulting in high health care utilization by abused persons, and increased health care costs (10–13).
Approval for the study was obtained from Charles R. Drew University of Medicine and Science Institutional Review Board in Los Angeles, CA.
RECEIVED: 30 January 2014; FINAL SUBMISSION RECEIVED: 29 May 2014; ACCEPTED: 1 July 2014 710
Risk Factors of Intimate Partner Violence (IPV)
In the United States, IPV constitutes 50% of domestic violence (14). The lifetime prevalence of physical or sexual IPV is high: approximately 26.4% for women and 15.9% for men (1). In emergency departments (EDs), the lifetime and current estimated prevalence of IPV is roughly 30%, and between 11% and 14% annually for women (11,15). IPV prevalence for males in these settings is, again, surprisingly high, estimated to be between 8% and 38% (12,16). Emergency physicians often serve as primary care providers, in addition to attending to the critical and immediate needs of patients. Hospital EDs, in fact, routinely serve as a de facto primary health care resource for innercity populations who are frequent users of their services (12,17). It is intuitive that effective medical screening and prevention strategies for all patients will improve health outcomes. Million of dollars may also be saved if IPV patients are correctly screened, diagnosed, and redirected to appropriate sub-acute centers, as in the case of those with alcohol-related problems (18). Emergency Physicians and IPV In addition to providing general primary care, EDs often serve as the entry point for abused individuals seeking specialized services (19). Emergency physicians are in a unique position to immediately detect and investigate such abuse, and to refer patients to appropriate and necessary services (20,21). With regard to IPV, emergency physicians must understand and recognize its symptoms and risk factors, and facilitate access to appropriate and adequate follow-up and continuing care (22). Continuity of care, in fact, is seen as a priority for ED patients who traditionally have low compliance in referrals to outpatient services (23,24). Studies also show that ED interventions that operate closely with domestic violence, substance abuse, and mental health treatment service sectors have a better chance of reducing the morbidity, disability, and mortality burdens related to co-occurring problems (25). IPV diagnosis and treatment, however, requires specific, vigilant, and accurate screening and assessment (26). Previous studies substantiate different subtypes of IPV, indicating that prevention, detection, and treatment should consider a variety of signs, manifestations, and interventions (27,28). The bi-directionality of IPV as both male-on-female and female-on-male violence seems to be significant, and may not be routinely or adequately considered in detecting and assessing IPV (27–34). Accurate screening and detection is especially important for racial and ethnic minorities, who are more likely to present or cloak IPV as somatic complaints (35). Given the many uncertainties, it has even been suggested that asymptomatic women of reproductive age should be routinely screened for intimate partner violence (36).
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Study Objectives and Participants Our first objective was to examine differences between two groups in the sample population: those who reported involvement in any IPV episode in the past 12 months, and those who did not experience, or were not involved in, IPV. The second objective was to investigate differences in correlates of IPVamong four groups, or profiles, in the sample. These consist of 1) those who commit IPV (perpetrators), 2) victims of such violence, 3) those involved in mutual, interpersonal violence (reactors), and 4) those who had no direct involvement in IPV at all (pacifists). Because those involved in mutual violence (reactors) may be both victims and perpetrators, we sought to also determine whether differences between them and the non-IPV participant profiles (pacifists) were analogous or germane to that which may exist between IPV and non-IPV groups. Lastly, informed by previous research, we also examined the potential roles of alcohol as binge and proximal drinking, drug use, depression, impulsivity, age, and any childhood experience of observing parental violence, and IPV in different profiles. Our findings may reveal significant factors and signs of IPV risk and exposure, which would result in improved methods and guidelines for screening and assessment by emergency physicians and other personnel. METHODS Sample Population and Data Collection A total of 581 patients who received care from an ED, urgent care (UC) clinic, or trauma bay at a large inner-city teaching hospital in South Los Angeles were screened (37). Male and female patients of all races and ethnicities, 18 years of age or older, who were able to speak and write in either English or Spanish, were eligible to participate. Those who were assessed as cognitively impaired, were in police custody, or declined to sign a written consent, were excluded. Potential participants who were intoxicated or required immediate medical attention were approached at a later time, and assessed with regard to our eligibility criteria. A total of 412 eligible patients consented to participate. Besides simply being unwilling, reasons for nonparticipation (n = 169) include having an urgent medical condition, objections from family or friends, or not having sufficient time to complete the entire survey. Data were collected on a 24-hour basis for 5 weeks between March and April 2001. Interviews generally took 45 min. A questionnaire was used to solicit psychosocial characteristics, as well as sociodemographic, alcohol and drug use/ misuse, and IPV experience data. Six bilingual research assistants who had completed a 2-week training program
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gun; used a knife or gun against you; and forced you to have sex with him/her? Responses for each item were coded as Yes = 1, No = 0 for statistical analysis.
Figure 1. Classification of respondents into four intimate partner violence (IPV) profiles.
interviewed every other patient from a triage list of those who were receiving care at the ED or UC clinic. Trauma bank patients, on the other hand, were selected on a consecutive basis using the daily visit log. Study Classifications and Measures IPV profile and group classifications. Through their survey responses, participants were assigned to one of four IPV profiles (Figure 1). Those who responded ‘‘Yes’’ to questions indicating that they demonstrated interpersonal violence were identified as perpetrators. Those whose responses indicated they were recipients of IPV were classified as victims. Participants whose responses indicated that they were both perpetrators and victims were identified as reactors. Those who had no involvement with IPV at all were identified as pacifists. Perpetrators, victims, and reactors together formed the IPV group, as opposed to those who did not experience IPV, who formed the non-IPV group (Figure 1). Assessing intimate partner violence (IPV). IPV was assessed using 11 items from the 19-item Conflict Tactics Scale (Cronbach’s alpha = 0.71), which explores physically and sexually violent behaviors against an intimate partner (38–40). These 11 items are reflected in two multi-faceted questions incorporated into the study questionnaire: 1. In the past year, have you ever thrown something at your (husband/wife/partner); pushed, grabbed, or shoved; slapped; kicked, bit, or hit; hit, or tried to hit with something; beat up; choked; burned or scalded; threatened with a knife or gun; used a knife or gun against; and forced to have sex with you? 2. In the past year, has your (husband/wife/partner) ever thrown something at you; pushed, grabbed, or shoved; slapped; kicked, bit, or hit; hit, or tried to hit you with something; beat you up; choked; burned or scalded; threatened you with a knife or
Alcohol use. To determine proximal drinking behavior, those in the IPV group were asked: ‘‘Were you drinking when this happened?’’ (Yes = 1, No = 0). If yes, participants were asked their frequency of alcohol consumption: Everyday, nearly every day, three or four times a week, once or twice a week, two or three times a month, about once a month, six–eleven times a year, or one–five times a year. Binge drinking was assessed through whether the participant had consumed five drinks or more on one occasion within the past 12 months (41). Those who responded affirmatively were categorized as binge drinkers, and coded as ‘‘1’’ for statistical analysis. Non-binge drinkers were coded as ‘‘0.’’ Drug use. Drug use was determined through the following question: During the last 12 months, did you take any or use anything in the following category: Sedatives, mild tranquilizers, barbiturates, Quaaludes, Librium or Valium; Analgesics; Amphetamines or other stimulants; Crack or cocaine; Marijuana or Hashish; Heroin; PCP or other hallucinogens, Angel Dust, LSD, mescaline, psilocybin mushrooms; inhalants other than cocaine? Those who responded ‘‘No’’ were coded as ‘‘0’’ and classified as ‘‘non drug users,’’ whereas those who used any of these substances were coded as ‘‘1,’’ and classified as ‘‘drug users.’’ Depressive symptoms. Participants’ depressive symptoms were assessed through 16 negative and four positive statements associated with the Center for Epidemiological Studies Depression Scale (CES-D) that were incorporated into the interview questionnaire (42). Possible responses consisted of: Rarely (less than once a day), Sometimes (1–2 times a day), Occasionally (3–4 times a day), and Most of the time. These were coded as 1, 2, 3, and 4, respectively. Higher scores indicate more, or more severe, symptoms of depression (Cronbach alpha = 0.80). The numerical total of these responses was used to assess the overall severity or degree of depressive symptoms for each participant. Impulsivity. Participants were asked how often the following described them: 1) You often act on the spur-of-the-moment without stopping to think; 2) You get a real kick out of doing things that are a little dangerous; 3) You like to test yourself every now and then by doing something a little chancy;
Risk Factors of Intimate Partner Violence (IPV)
4) 5) 6) 7) 8)
You may say you act impulsively; Many of your actions seem to be hasty; You are always up for a new experience; You like to try new things just for the excitement; You go for the thrills in life when you get a chance; 9) You like to experience new and different solutions; and 10) You don’t let the risk of getting hurt a little stop you from having a good time. Participants responded using a four-point Likert scale that ranged from ‘‘Not at all’’ (= 1) to ‘‘Quite a lot’’ (= 4). Impulsivity was measured by summing the numerical responses to each of these 10 items, with higher scores representing higher levels (43,44). Observing IPV in childhood. Two questions with a fourpoint Likert scale response were used to assess participants’ exposure to violence during their childhood and adolescence: 1. How often did you observe your parents and someone with whom she or he was involved threaten one another with violence? 2. Were you involved with each being physically violent to one another? Those who responded ‘‘very often’’ (= 4), ‘‘often’’ (= 3), or ‘‘sometimes’’ (= 2) to either of these questions were assigned to the ‘‘having childhood experiences of observing parental violence including IPV’’ group. Those who responded ‘‘never’’ (= 1) were assigned to the ‘‘not having such an experience’’ group. Other variables. Other variables of interest include sociodemographic characteristics of gender, age, ethnicity, education, and employment status. In terms of race and ethnicity, respondents self-identified using the following: 1. Asian, Asian Pacific Islander or Asian American 2. Black or African American 3. Latino, Mexican, Mexican American, Chicano, or of other Spanish Heritage 4. Middle Eastern 5. Native American Indian 6. White, Caucasian 7. Multiracial 8. Other The literature indicates that the burden of IPV remains disproportionately high among racial and ethnic minorities, who are the most frequent users of ED services (12,34,45,46). We therefore re-coded race and ethnicity into two predominant, minority groups of ‘‘African American’’ (n = 191) and ‘‘Latino,’’ (n = 203), and the
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rest (n = 14) were grouped into an ‘‘Other’’ category. Four participants did not reveal their race/ethnicity. Data Analysis A Pearson’s chi-squared test of independence was used to explore differences in binge drinking, proximal drinking, drug use, and childhood experiences of observing parental violence, including IPV. Independent-samples t-tests and a one-way analysis of variance were also used to determine any association of IPV with age and CES-D and impulsivity scores. We used an alpha level of 0.05 for all statistical tests. RESULTS Of the entire surveyed population (Table 1), 44% were ED patients, 39% were UC patients, and 17% trauma bay patients. Most were male (59%), had a high school education or less (80.6%), were unemployed (64%), unmarried (73.3%), Latino or Mexican American (49.3%), and identified the United States as their country of origin (56.6%). Mean age was 38.15 6 14.27 years. Of those who reported drinking alcohol in the preceding 12 months (45.9%), approximately 75% engaged in binge drinking. Almost 25% reported using at least one drug. Close to 15% of the entire population had observed parental violence or IPV (Table 1). Of the 16% in the sample who had experienced IPV, 31% were perpetrators, 20% were IPV victims, and 49% were reactors. Consistent with prior research, we found no significant differences between the IPV and non-IPV group in terms of gender, age, and ethnicity (41). In terms of impulsivity and depression, IPV and non-IPV respondents had similar scores, with an impulsivity mean of 19.43 (SD = 7.512) and depressive symptoms mean of 38.97 (SD = 12.356). Patterns of Violence among Perpetrators, Victims, and Reactors For those who had experienced IPV, perpetrators (65%) and reactors (75%) most commonly resorted to pushing, grabbing, and shoving. Victims (54%) reported experiencing pushing, grabbing, and shoving most frequently. In demonstrating interpersonal violence, reactors (72%) most frequently employed slapping. Correlates of IPV and Non-IPV Groups An independent-samples t-test was used to compare differences between IPV and non-IPV groups, using age, depression, and impulsivity (Table 2). Those who experienced IPV were significantly younger (t[404] = 3.608,
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Table 1. Characteristics of Participants (n = 412) Characteristic Gender Male Female Ethnicity Latino, Mexican-American African American Other Not reported Education No formal schooling High school or below Above high school Not reported Employment status Not employed Employed Not reported Marital status Not married Married Not reported Religious preference Catholic Protestant No religious preference Other Not reported Country of origin United States Other Not reported Profiles Pacifists Victims Reactors Perpetrators Not reported Binge drinking Non-binge drinker Binge drinker Non-drinker Not reported Drug use No Yes Not reported Observing parental violence No Yes Not reported
Impulsivity (valid n = 409) Age (valid n = 407) CES-D (valid n = 409)
Sample Size
Table 2. Independent Samples T-Test Comparison: IPV and Non-IPV Groups (n = 412) % Groups of IPV
243 169
59 41
203 191 14 4
49.3 46.4 3.3 1
10 332 66 4
2.4 80.6 16 1
265 143 4
64.3 34.7 1
302 106 4
73.3 25.7 1
185 168 38 17 4
44.9 40.8 9.2 4.1 1
233 174 5
56.6 42.2 1.2
342 13 32 20 5
83.0 3.2 7.8 4.9 1.2
47 142 175 48
11.4 34.5 42.5 11.7
309 101 2
75.0 24.5 .5
347 60 5
84.2 14.6 1.2
Mean
SD
19.43 38.15 38.97
7.512 14.272 12.356
CES-D = Center for Epidemiological Studies Depression Scale.
p < 0.01), and had higher CES-D mean scores (t[405] = 4.990, p < 0.01) and impulsivity mean scores (t[405] = 3.960, p < 0.01) (Table 2). A Pearson’s chi-squared test of independence was used to determine associations in the IPV and non-IPV groups with binge drinking, proximal drinking, drug use, and
Age Non-IPV group IPV group CES-D Non-IPV group IPV group Impulsivity Non-IPV group IPV group
n
Mean
SD
341 65
39.23 32.35
14.459 11.809
342 65
37.68 45.77
11.514 14.250
342 65
18.83 22.78
7.183 8.347
Mean Difference 6.872* 8.094* 3.954*
CES-D = Center for Epidemiological Studies Depression Scale; IPV = intimate partner violence. * p < 0.01.
childhood experiences of observing parental violence. Our findings revealed significant associations in the IPV group with binge drinking (c2 [2, n = 360] = 6.317, p = 0.042), drug use (c2 [1, n = 407] = 8.054, p < 0.01), and childhood experiences of observing parental violence (c2 [1, n = 406] = 4.232, p = 0.04). Table 3, below, details factors associated with the four profiles of IPV groups (Table 3). A Pearson’s chi-squared test of independence revealed a significant relationship between drug use and the four IPV profiles (c2 [3, n = 407] = 12.734, p = 0.005) (Table 4). Over 40% of reactors and perpetrators used drugs, compared to < 22% among pacifists and victims. We also found significant differences (c2 [3, n = 406] = 10.954, p = 0.012) between the four IPV profiles in observing parental violence toward another person, including IPV. Over 34% of reactors had such experiences, compared to <16% in all other groups (Table 4). Binge drinking was not found to be a significant IPV factor in any of the four profiles. However, more reactors (34.4%) reported using alcohol than perpetrators (10%) during IPV perpetration (c2 [1, n = 52] = 3.900, p < 0.05). A high percentage of reactors (31.3%) also Table 3. Chi-squared Test Comparison: IPV and Non-IPV Groups (n = 412) Standard Residual Yes Binge drinking Non-IPV group IPV group Drug use Non-IPV group IPV group Observing parental violence Non-IPV group IPV group
.8 1.7
No .0 .0
1.0 2.3*
.6 1.3
.8 1.7
.3 .7
IPV = intimate partner violence. p < 0.05 for all; *standard residual 6 1.96.
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Table 4. Chi-squared Test Comparison: Four IPV Profiles (n = 412) Standard Residual
Binge drinking (1) Pacifist Victim Reactor Perpetrator Drug use (2) Pacifist Victim Reactor Perpetrator Observing parental violence (3) Pacifist Victim Reactor Perpetrator
Yes
No
.8 .1 1.9 .8
.0 .5 1.0 .9
1.0 .7 2.2* 1.8
.6 .4 1.2 1.1
.8 .7 2.9* .0
.3 .3 1.2 .0
IPV = intimate partner violence. p < 0.05 for (2) & (3); *standard residual 6 1.96.
reported using alcohol, compared to victims (7.7%), during IPV victimization. However, this difference was not statistically significant (c2 [1, n = 45] = 2.778, p = 0.096). A one-way analysis of variance was used to determine differences in perpetrator, victim, and reactor profiles, compared to pacifists, with regard to age, depression, and impulsivity (Table 5). Age was found to be significant (F[3,402] = 5.517, p = .001). Post hoc comparisons using the Tukey HSD (honest significant difference) test also revealed that the mean age for the reactor group was significantly lower than that of the pacifist group (Table 5). Those in the reactor group also had significantly higher average impulsivity scores (F[3,403] = 6.005, Table 5. Tukey HSD Comparison: Four Profiles of IPV (n = 412) IPV Profile Age Pacifist Victim Reactor Perpetrator CES-D Pacifist Victim Reactor Perpetrator Impulsivity Pacifist Victim Reactor Perpetrator
n
Mean
SD
Mean Difference from Pacifist
341 13 32 20
39.23 35.08 29.06 35.85
14.459 10.866 10.934 12.803
0 4.149 10.163* 3.376
342 13 32 20
37.68 46.54 47.16 43.05
11.514 13.764 15.079 13.489
0 8.863* 9.481* 5.375
342 13 32 20
18.83 20.31 23.97 22.50
7.183 5.893 9.139 8.357
0 1.477 5.138* 3.670
HSD = honest significant difference; IPV = intimate partner violence; CES-D = Center for Epidemiological Studies Depression Scale. * p < 0.05.
Figure 2. Tukey honest significant difference comparison: four intimate partner violence profiles (n = 412). CESD = Center for Epidemiological Studies Depression Scale.
p = 0.001) and CES-D (depression) mean scores than the pacifist group (F[3,403] = 8.793, p < 0.001). The victim group also had significantly higher CES-D mean scores than the pacifist group. However, the victim and perpetrator groups did not differ significantly from other groups with regard to age or impulsivity (Figure 2). DISCUSSION Of those who reported experiencing IPV (16%), the majority were reactors (49%), or those who both demonstrated and were victims of IPV. The number of reactors was more than twice that of victims, and over one and a half times larger than perpetrators. The size of the reactor group alone tends to confirm the prevalence of reciprocal act(s) of IPV in both uni- and bi-directional forms found in previous research (47,48). There are considerable medical and social implications: for one battered wife treated in an ED, for example, there may be a battered husband or significant other being seen at another location. Previous studies have also reported a small to moderate effect size in the association between alcohol use/ abuse and IPV for both male and female perpetrators, depending on the sample and type of alcohol measure selected (29,49). Our findings did indicate that the IPV group was more likely to engage in binge drinking than the non-IPV group (52.5% vs. 36.1%). However, 45.9% of the entire surveyed population – both IPV and nonIPV – reported drinking alcohol in the preceding 12 months. Of these, approximately 75% engaged in binge drinking. It is therefore not surprising that binge drinking was not found to be statistically significant between the four IPV profiles. Sixty percent of reactors, however, engaged in binge drinking (standardized residual of 1.9) in comparison to 50% of perpetrators and 36.4% of victims. Reactors were also more prone to alcohol use than victims when
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demonstrating IPV (34.4% vs. 10%), and when they themselves were being victimized, compared to all other IPV profiles (31.3% vs. 7.7%). These findings are not surprising, given empirical studies that report that alcohol consumption, chronic or acute, can trigger a person to act more violently or to react more acutely to violence with an intimate partner (38,39,49–53). One study found that drinking malt liquor beer in combination with other types of alcohol increased the risk of IPV (54). Both IPV perpetrators and victims more often use drugs, including crack and cocaine, than those not involved in IPV (46,51). In the current study almost 40% of the IPV group used at least one drug, compared to 25% in the entire surveyed population. This is consistent with a report that cocaine users are most at risk for IPV perpetration, whereas the use of cannabis is most strongly associated with IPV victimization (51). We found, in particular, that reactors are more likely to be drug users. Their standardized residual of 2.2 is large compared to that of victims (.7) and perpetrators (1.8). These findings may even suggest that IPV participants essentially double their risk of using drugs in their roles as both victims and perpetrators, as drug use may be both a risk factor and a consequence of IPV (19,46,55,56). These risk factors and relationships underscore the need to screen for and assess drug and alcohol use in ED settings when IPV is suspected (57). The link between depression and IPV is well substantiated in previous research (58). Depressive symptoms are seen as a risk factor for both IPV perpetrators and victims (45,51,59–61). It is not surprising that IPV group respondents report being more depressed than those in the non-IPV group, and that reactors report being more depressed than victims. Both reactors and victims, though, were found to be significantly more depressed than those who had never experienced any form of IPV. Age has been reported as not being specifically related to unidirectional IPV, but is negatively associated with mutual IPV (56). Our findings are somewhat confirmatory. The IPV group was younger (mean age 32.35 years, SD 11.809) than the non-IPV group (39.23 years, SD 14.459). In terms of mutual or bi-directional IPV, reactors were the youngest profile, with a mean age of 29.06 years (SD 10.934). However, with regard to unidirectional IPV, the age of both victim and perpetrator profiles (approximately 35 years) fell between pacifists (no IPV) at 39.23 years, and reactors (approximately 29 years). The literature and these findings suggest that those who engage in bi-directional IPV are likely to be younger than those who exclusively demonstrate or are victims of IPV, and those who experience no IPV at all. Impulsivity has been associated with violence and crime with high impulsivity and a lack of self-control specifically associated with IPV events (62–65). As
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expected, those in our IPV group did indeed report higher impulsivity than their non-IPV peers, and reactors were found to be more impulsive than pacifists. Impulsivity among perpetrators and victims, however, did not differ significantly from pacifists. Overall, these findings tend to confirm that impulsivity and the lack of selfcontrol are, in general, significant risk factors for IPV. With regard to observing parental, nonspousal violence and other IPV in childhood, our findings are generally consistent with those of previous studies. The age at which such violence is observed was shown to be significant in both perpetration and victimization (50,51,66). In our study, the IPV group reported more such experiences (standard residual 1.7) than the non-IPV group (.8). In terms of IPV profiles, reactors had much higher rates of observing parental violence (standard residual 2.9), compared to pacifists (.8), victims (.7), and perpetrators (.0). The literature and our findings would seem to indicate that exposure to such violence during childhood is a general risk factor for IPV, especially for those who would engage in bi-directional or mutual forms. Limitations In this cross-sectional study, demonstrating causal linkages is problematic. Reactors, for example, may be both perpetrators and victims, the dynamics of which can lead to, as well as possibly be exacerbated by, drug use and depression. Alternatively, analysis suggests that those who are highly impulsive and have depressive symptoms, and witness IPV as children, may be more likely to become reactors. The generalizability of our findings is also constrained by combining non-African American and non-Hispanic participants into an ‘‘Other’’ racial/ethnic category, although the latter group represents only about 3% of our surveyed population. Our analyses, in fact, did not reveal any statistically significant variability in the predictors of different profiles of IPV by ethnicity, which contradicts previous reports (33). This may be attributed, though, to our small sample size. Our exploration of gender differences is limited. In addition, because most participants were identified as non-IPV, statistical power was clearly an issue. As a result, we employed yes or no categories, and disregarded frequency and quantity data, acknowledging the small size of the IPV population. Because data are selfreported, it is also possible that IPV, and what may be considered socially questionable behavior such as drug and alcohol use, are underreported. Although data for this study were collected in 2001, we could find no additional or more recent ED-based literature on this important topic. We recommend updated, follow-up research to confirm and augment our findings.
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Figure 3. ‘‘Five Steps in Screening for IPV’’ quick reference tool. IPV = intimate partner violence; Px = patient. Adapted from Bernstein E, Bernstein J, Levenson S (21).
CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH Using data collected from inner-city ED patients, we found that, in general, respondents who experienced IPV tend to be younger, have had more childhood exposure to such violence, were more depressed and
impulsive, reported more binge drinking, and were more likely to use drugs. More specifically, we found that those involved in mutual interpersonal violence (reactors) were younger, more likely to use drugs, were more depressed, more impulsive, and were more likely to have observed IPV or other violence in childhood.
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In busy EDs, concise and straightforward screening for IPV may be best implemented through tools such as the 5- to 10-min ‘‘Five Steps in Screening for IPV’’ instrument (Figure 3). This quick-reference guide employs an evidence-based Brief Negotiation Interviewing technique that is widely used in substance abuse interventions with a patient-participatory, decision-making therapeutic approach (20,21,67). It integrates elements of motivational interviewing, carefully considering a patient’s readiness to change (Figure 3) (68,69). Physicians first establish a relationship of trust with a patient and gently broach the subject of possible interpersonal violence (Steps 1–3). For those who are experiencing IPV, emergency physicians may intervene in the following ways, based on the patient’s willingness and readiness to receive help. In Steps 4 and 5, physicians may 1) offer concern, education and information; 2) suggest options that can resolve the patient’s ambivalence, or 3) refer the patient for further treatment. Findings from our study are expected to help emergency physicians detect and treat IPV. However, more research is needed, especially in areas that will enhance emergency physicians’ self-efficacy and competence in detecting various types of IPV. Future studies are needed to determine and validate the feasibility and effectiveness of the ‘‘Five Steps in Screening for IPV’’ instrument and similar tools in real-life ED settings (70). Acknowledgments—This paper was supported in part by the National Institute on Alcohol Abuse and Alcoholism (grant U24AA11899-05), by the Endowment Grant S21MD000103, and by the Accelerating Excellence in Translational Science AXIS Grant (U54MD007598). The authors would also like to acknowledge the valuable efforts of Ranna El Naga in the preparation of this manuscript.
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ARTICLE SUMMARY 1. Why is this topic important? Domestic intimate partner violence (IPV) is a serious health care concern often encountered in emergency departments (EDs). Its effects may be mitigated by early screening, detection and intervention. 2. What does this study attempt to show? In a cross-sectional study using survey data from 412 inner-city ED patients, we examine posited predictors in IPV and non-IPV groups, and in four different IPV profiles. These include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. 3. What are the key findings? Nearly 16% of the surveyed population had experienced IPV, and were younger, more depressed, and more impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. Thirty-one percent perpetrated IPV, 20% were victims, and 49% were both victims and perpetrators. Perpetrators were younger, more impulsive and depressed, used drugs, and were more likely to have observed parental violence as a child. 4. How is patient care impacted? Our study goal was to guide and inform practices and future research in the detection, treatment and referral for IPV in ED settings. Our findings enable emergency physicians to not only better understand and recognize its symptoms and risk factors, but also facilitate access to appropriate and adequate follow-up and continuing care. We also introduce a new ‘‘Five Steps in Screening for IPV’’ quick reference tool, which may assist ED physicians in detection and treatment.
http://dx.doi.org/10.1016/j.jemermed.2014.07.036
Violence: Recognition, Management and Prevention
RISK FACTORS ASSOCIATED WITH DIFFERENT TYPES OF INTIMATE PARTNER VIOLENCE (IPV): AN EMERGENCY DEPARTMENT STUDY Shahrzad Bazargan-Hejazi, PHD,* Eunjin Kim, BA,† Johnny Lin, PHD,‡ Alireza Ahmadi, MD, PHD,§k Mojdeh T. Khamesi, MD,{ and Stacey Teruya, EDD, MS# *Department of Psychiatry, Charles R. Drew University of Medicine and Science & David Geffen School of Medicine at University of California, Los Angeles, California, †Department of Psychology, University of California at Los Angeles, California, ‡Educational Testing Service, Princeton, New Jersey, §Division of Social Medicine, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, kDepartment of Anesthesiology, Critical Care and Pain Management, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran, {School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and #Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California Reprint Address: Shahrzad Bazargan-Hejazi, PHD, Charles R. Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059
, Abstract—Background: Domestic intimate partner violence (IPV) is a serious health care concern, which may be mitigated by early detection, screening, and intervention. Objectives: We examine posited predictors in IPV and nonIPV groups, and in four different IPV profiles. Possible factors include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. We also introduce a new ‘‘Five Steps in Screening for IPV’’ quick reference tool, which may assist emergency physicians in detection and treatment. Methods: This was a cross-sectional study using survey data from 412 inner-city emergency department patients. Associations were explored using a chi-squared test of independence, independent-samples t-tests, and a one-way analysis of variance. Results: Nearly 16% had experienced IPV. As a group, they were younger, and more depressed and impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. In the IPV group, 31% were perpetrators, 20% victims, and 49% both victims and perpetrators. The latter group was younger, more impulsive and depressed, used drugs, and was more likely
to have observed parental violence as a child. Conclusion: Correlates in groups affected by IPV indicate the same general risk factors, which seem to more acutely affect those who are both perpetrators and victims. Alcohol and drug use, depressive symptoms, and childhood exposure to violence may be factors and signs for which emergency physicians should screen in the context of IPV. Ó 2014 Elsevier Inc. , Keywords—intimate partner violence; IPV perpetrators; IPV victims; depression; alcohol; drug use; impulsivity; IPV screening
INTRODUCTION Domestic intimate partner violence (IPV) is characterized by physical, emotional, psychological, and sexual abuse (1,2). Its devastating impact on physical and mental health is recognized nationally and globally (3–6). IPV can contribute to maternal death, posttraumatic stress disorder (PTSD), and severely compromise the quality of life (7–9). IPV is likely to be repeated, resulting in high health care utilization by abused persons, and increased health care costs (10–13).
Approval for the study was obtained from Charles R. Drew University of Medicine and Science Institutional Review Board in Los Angeles, CA.
RECEIVED: 30 January 2014; FINAL SUBMISSION RECEIVED: 29 May 2014; ACCEPTED: 1 July 2014 710
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In the United States, IPV constitutes 50% of domestic violence (14). The lifetime prevalence of physical or sexual IPV is high: approximately 26.4% for women and 15.9% for men (1). In emergency departments (EDs), the lifetime and current estimated prevalence of IPV is roughly 30%, and between 11% and 14% annually for women (11,15). IPV prevalence for males in these settings is, again, surprisingly high, estimated to be between 8% and 38% (12,16). Emergency physicians often serve as primary care providers, in addition to attending to the critical and immediate needs of patients. Hospital EDs, in fact, routinely serve as a de facto primary health care resource for innercity populations who are frequent users of their services (12,17). It is intuitive that effective medical screening and prevention strategies for all patients will improve health outcomes. Million of dollars may also be saved if IPV patients are correctly screened, diagnosed, and redirected to appropriate sub-acute centers, as in the case of those with alcohol-related problems (18). Emergency Physicians and IPV In addition to providing general primary care, EDs often serve as the entry point for abused individuals seeking specialized services (19). Emergency physicians are in a unique position to immediately detect and investigate such abuse, and to refer patients to appropriate and necessary services (20,21). With regard to IPV, emergency physicians must understand and recognize its symptoms and risk factors, and facilitate access to appropriate and adequate follow-up and continuing care (22). Continuity of care, in fact, is seen as a priority for ED patients who traditionally have low compliance in referrals to outpatient services (23,24). Studies also show that ED interventions that operate closely with domestic violence, substance abuse, and mental health treatment service sectors have a better chance of reducing the morbidity, disability, and mortality burdens related to co-occurring problems (25). IPV diagnosis and treatment, however, requires specific, vigilant, and accurate screening and assessment (26). Previous studies substantiate different subtypes of IPV, indicating that prevention, detection, and treatment should consider a variety of signs, manifestations, and interventions (27,28). The bi-directionality of IPV as both male-on-female and female-on-male violence seems to be significant, and may not be routinely or adequately considered in detecting and assessing IPV (27–34). Accurate screening and detection is especially important for racial and ethnic minorities, who are more likely to present or cloak IPV as somatic complaints (35). Given the many uncertainties, it has even been suggested that asymptomatic women of reproductive age should be routinely screened for intimate partner violence (36).
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Study Objectives and Participants Our first objective was to examine differences between two groups in the sample population: those who reported involvement in any IPV episode in the past 12 months, and those who did not experience, or were not involved in, IPV. The second objective was to investigate differences in correlates of IPVamong four groups, or profiles, in the sample. These consist of 1) those who commit IPV (perpetrators), 2) victims of such violence, 3) those involved in mutual, interpersonal violence (reactors), and 4) those who had no direct involvement in IPV at all (pacifists). Because those involved in mutual violence (reactors) may be both victims and perpetrators, we sought to also determine whether differences between them and the non-IPV participant profiles (pacifists) were analogous or germane to that which may exist between IPV and non-IPV groups. Lastly, informed by previous research, we also examined the potential roles of alcohol as binge and proximal drinking, drug use, depression, impulsivity, age, and any childhood experience of observing parental violence, and IPV in different profiles. Our findings may reveal significant factors and signs of IPV risk and exposure, which would result in improved methods and guidelines for screening and assessment by emergency physicians and other personnel. METHODS Sample Population and Data Collection A total of 581 patients who received care from an ED, urgent care (UC) clinic, or trauma bay at a large inner-city teaching hospital in South Los Angeles were screened (37). Male and female patients of all races and ethnicities, 18 years of age or older, who were able to speak and write in either English or Spanish, were eligible to participate. Those who were assessed as cognitively impaired, were in police custody, or declined to sign a written consent, were excluded. Potential participants who were intoxicated or required immediate medical attention were approached at a later time, and assessed with regard to our eligibility criteria. A total of 412 eligible patients consented to participate. Besides simply being unwilling, reasons for nonparticipation (n = 169) include having an urgent medical condition, objections from family or friends, or not having sufficient time to complete the entire survey. Data were collected on a 24-hour basis for 5 weeks between March and April 2001. Interviews generally took 45 min. A questionnaire was used to solicit psychosocial characteristics, as well as sociodemographic, alcohol and drug use/ misuse, and IPV experience data. Six bilingual research assistants who had completed a 2-week training program
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gun; used a knife or gun against you; and forced you to have sex with him/her? Responses for each item were coded as Yes = 1, No = 0 for statistical analysis.
Figure 1. Classification of respondents into four intimate partner violence (IPV) profiles.
interviewed every other patient from a triage list of those who were receiving care at the ED or UC clinic. Trauma bank patients, on the other hand, were selected on a consecutive basis using the daily visit log. Study Classifications and Measures IPV profile and group classifications. Through their survey responses, participants were assigned to one of four IPV profiles (Figure 1). Those who responded ‘‘Yes’’ to questions indicating that they demonstrated interpersonal violence were identified as perpetrators. Those whose responses indicated they were recipients of IPV were classified as victims. Participants whose responses indicated that they were both perpetrators and victims were identified as reactors. Those who had no involvement with IPV at all were identified as pacifists. Perpetrators, victims, and reactors together formed the IPV group, as opposed to those who did not experience IPV, who formed the non-IPV group (Figure 1). Assessing intimate partner violence (IPV). IPV was assessed using 11 items from the 19-item Conflict Tactics Scale (Cronbach’s alpha = 0.71), which explores physically and sexually violent behaviors against an intimate partner (38–40). These 11 items are reflected in two multi-faceted questions incorporated into the study questionnaire: 1. In the past year, have you ever thrown something at your (husband/wife/partner); pushed, grabbed, or shoved; slapped; kicked, bit, or hit; hit, or tried to hit with something; beat up; choked; burned or scalded; threatened with a knife or gun; used a knife or gun against; and forced to have sex with you? 2. In the past year, has your (husband/wife/partner) ever thrown something at you; pushed, grabbed, or shoved; slapped; kicked, bit, or hit; hit, or tried to hit you with something; beat you up; choked; burned or scalded; threatened you with a knife or
Alcohol use. To determine proximal drinking behavior, those in the IPV group were asked: ‘‘Were you drinking when this happened?’’ (Yes = 1, No = 0). If yes, participants were asked their frequency of alcohol consumption: Everyday, nearly every day, three or four times a week, once or twice a week, two or three times a month, about once a month, six–eleven times a year, or one–five times a year. Binge drinking was assessed through whether the participant had consumed five drinks or more on one occasion within the past 12 months (41). Those who responded affirmatively were categorized as binge drinkers, and coded as ‘‘1’’ for statistical analysis. Non-binge drinkers were coded as ‘‘0.’’ Drug use. Drug use was determined through the following question: During the last 12 months, did you take any or use anything in the following category: Sedatives, mild tranquilizers, barbiturates, Quaaludes, Librium or Valium; Analgesics; Amphetamines or other stimulants; Crack or cocaine; Marijuana or Hashish; Heroin; PCP or other hallucinogens, Angel Dust, LSD, mescaline, psilocybin mushrooms; inhalants other than cocaine? Those who responded ‘‘No’’ were coded as ‘‘0’’ and classified as ‘‘non drug users,’’ whereas those who used any of these substances were coded as ‘‘1,’’ and classified as ‘‘drug users.’’ Depressive symptoms. Participants’ depressive symptoms were assessed through 16 negative and four positive statements associated with the Center for Epidemiological Studies Depression Scale (CES-D) that were incorporated into the interview questionnaire (42). Possible responses consisted of: Rarely (less than once a day), Sometimes (1–2 times a day), Occasionally (3–4 times a day), and Most of the time. These were coded as 1, 2, 3, and 4, respectively. Higher scores indicate more, or more severe, symptoms of depression (Cronbach alpha = 0.80). The numerical total of these responses was used to assess the overall severity or degree of depressive symptoms for each participant. Impulsivity. Participants were asked how often the following described them: 1) You often act on the spur-of-the-moment without stopping to think; 2) You get a real kick out of doing things that are a little dangerous; 3) You like to test yourself every now and then by doing something a little chancy;
Risk Factors of Intimate Partner Violence (IPV)
4) 5) 6) 7) 8)
You may say you act impulsively; Many of your actions seem to be hasty; You are always up for a new experience; You like to try new things just for the excitement; You go for the thrills in life when you get a chance; 9) You like to experience new and different solutions; and 10) You don’t let the risk of getting hurt a little stop you from having a good time. Participants responded using a four-point Likert scale that ranged from ‘‘Not at all’’ (= 1) to ‘‘Quite a lot’’ (= 4). Impulsivity was measured by summing the numerical responses to each of these 10 items, with higher scores representing higher levels (43,44). Observing IPV in childhood. Two questions with a fourpoint Likert scale response were used to assess participants’ exposure to violence during their childhood and adolescence: 1. How often did you observe your parents and someone with whom she or he was involved threaten one another with violence? 2. Were you involved with each being physically violent to one another? Those who responded ‘‘very often’’ (= 4), ‘‘often’’ (= 3), or ‘‘sometimes’’ (= 2) to either of these questions were assigned to the ‘‘having childhood experiences of observing parental violence including IPV’’ group. Those who responded ‘‘never’’ (= 1) were assigned to the ‘‘not having such an experience’’ group. Other variables. Other variables of interest include sociodemographic characteristics of gender, age, ethnicity, education, and employment status. In terms of race and ethnicity, respondents self-identified using the following: 1. Asian, Asian Pacific Islander or Asian American 2. Black or African American 3. Latino, Mexican, Mexican American, Chicano, or of other Spanish Heritage 4. Middle Eastern 5. Native American Indian 6. White, Caucasian 7. Multiracial 8. Other The literature indicates that the burden of IPV remains disproportionately high among racial and ethnic minorities, who are the most frequent users of ED services (12,34,45,46). We therefore re-coded race and ethnicity into two predominant, minority groups of ‘‘African American’’ (n = 191) and ‘‘Latino,’’ (n = 203), and the
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rest (n = 14) were grouped into an ‘‘Other’’ category. Four participants did not reveal their race/ethnicity. Data Analysis A Pearson’s chi-squared test of independence was used to explore differences in binge drinking, proximal drinking, drug use, and childhood experiences of observing parental violence, including IPV. Independent-samples t-tests and a one-way analysis of variance were also used to determine any association of IPV with age and CES-D and impulsivity scores. We used an alpha level of 0.05 for all statistical tests. RESULTS Of the entire surveyed population (Table 1), 44% were ED patients, 39% were UC patients, and 17% trauma bay patients. Most were male (59%), had a high school education or less (80.6%), were unemployed (64%), unmarried (73.3%), Latino or Mexican American (49.3%), and identified the United States as their country of origin (56.6%). Mean age was 38.15 6 14.27 years. Of those who reported drinking alcohol in the preceding 12 months (45.9%), approximately 75% engaged in binge drinking. Almost 25% reported using at least one drug. Close to 15% of the entire population had observed parental violence or IPV (Table 1). Of the 16% in the sample who had experienced IPV, 31% were perpetrators, 20% were IPV victims, and 49% were reactors. Consistent with prior research, we found no significant differences between the IPV and non-IPV group in terms of gender, age, and ethnicity (41). In terms of impulsivity and depression, IPV and non-IPV respondents had similar scores, with an impulsivity mean of 19.43 (SD = 7.512) and depressive symptoms mean of 38.97 (SD = 12.356). Patterns of Violence among Perpetrators, Victims, and Reactors For those who had experienced IPV, perpetrators (65%) and reactors (75%) most commonly resorted to pushing, grabbing, and shoving. Victims (54%) reported experiencing pushing, grabbing, and shoving most frequently. In demonstrating interpersonal violence, reactors (72%) most frequently employed slapping. Correlates of IPV and Non-IPV Groups An independent-samples t-test was used to compare differences between IPV and non-IPV groups, using age, depression, and impulsivity (Table 2). Those who experienced IPV were significantly younger (t[404] = 3.608,
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Table 1. Characteristics of Participants (n = 412) Characteristic Gender Male Female Ethnicity Latino, Mexican-American African American Other Not reported Education No formal schooling High school or below Above high school Not reported Employment status Not employed Employed Not reported Marital status Not married Married Not reported Religious preference Catholic Protestant No religious preference Other Not reported Country of origin United States Other Not reported Profiles Pacifists Victims Reactors Perpetrators Not reported Binge drinking Non-binge drinker Binge drinker Non-drinker Not reported Drug use No Yes Not reported Observing parental violence No Yes Not reported
Impulsivity (valid n = 409) Age (valid n = 407) CES-D (valid n = 409)
Sample Size
Table 2. Independent Samples T-Test Comparison: IPV and Non-IPV Groups (n = 412) % Groups of IPV
243 169
59 41
203 191 14 4
49.3 46.4 3.3 1
10 332 66 4
2.4 80.6 16 1
265 143 4
64.3 34.7 1
302 106 4
73.3 25.7 1
185 168 38 17 4
44.9 40.8 9.2 4.1 1
233 174 5
56.6 42.2 1.2
342 13 32 20 5
83.0 3.2 7.8 4.9 1.2
47 142 175 48
11.4 34.5 42.5 11.7
309 101 2
75.0 24.5 .5
347 60 5
84.2 14.6 1.2
Mean
SD
19.43 38.15 38.97
7.512 14.272 12.356
CES-D = Center for Epidemiological Studies Depression Scale.
p < 0.01), and had higher CES-D mean scores (t[405] = 4.990, p < 0.01) and impulsivity mean scores (t[405] = 3.960, p < 0.01) (Table 2). A Pearson’s chi-squared test of independence was used to determine associations in the IPV and non-IPV groups with binge drinking, proximal drinking, drug use, and
Age Non-IPV group IPV group CES-D Non-IPV group IPV group Impulsivity Non-IPV group IPV group
n
Mean
SD
341 65
39.23 32.35
14.459 11.809
342 65
37.68 45.77
11.514 14.250
342 65
18.83 22.78
7.183 8.347
Mean Difference 6.872* 8.094* 3.954*
CES-D = Center for Epidemiological Studies Depression Scale; IPV = intimate partner violence. * p < 0.01.
childhood experiences of observing parental violence. Our findings revealed significant associations in the IPV group with binge drinking (c2 [2, n = 360] = 6.317, p = 0.042), drug use (c2 [1, n = 407] = 8.054, p < 0.01), and childhood experiences of observing parental violence (c2 [1, n = 406] = 4.232, p = 0.04). Table 3, below, details factors associated with the four profiles of IPV groups (Table 3). A Pearson’s chi-squared test of independence revealed a significant relationship between drug use and the four IPV profiles (c2 [3, n = 407] = 12.734, p = 0.005) (Table 4). Over 40% of reactors and perpetrators used drugs, compared to < 22% among pacifists and victims. We also found significant differences (c2 [3, n = 406] = 10.954, p = 0.012) between the four IPV profiles in observing parental violence toward another person, including IPV. Over 34% of reactors had such experiences, compared to <16% in all other groups (Table 4). Binge drinking was not found to be a significant IPV factor in any of the four profiles. However, more reactors (34.4%) reported using alcohol than perpetrators (10%) during IPV perpetration (c2 [1, n = 52] = 3.900, p < 0.05). A high percentage of reactors (31.3%) also Table 3. Chi-squared Test Comparison: IPV and Non-IPV Groups (n = 412) Standard Residual Yes Binge drinking Non-IPV group IPV group Drug use Non-IPV group IPV group Observing parental violence Non-IPV group IPV group
.8 1.7
No .0 .0
1.0 2.3*
.6 1.3
.8 1.7
.3 .7
IPV = intimate partner violence. p < 0.05 for all; *standard residual 6 1.96.
Risk Factors of Intimate Partner Violence (IPV)
715
Table 4. Chi-squared Test Comparison: Four IPV Profiles (n = 412) Standard Residual
Binge drinking (1) Pacifist Victim Reactor Perpetrator Drug use (2) Pacifist Victim Reactor Perpetrator Observing parental violence (3) Pacifist Victim Reactor Perpetrator
Yes
No
.8 .1 1.9 .8
.0 .5 1.0 .9
1.0 .7 2.2* 1.8
.6 .4 1.2 1.1
.8 .7 2.9* .0
.3 .3 1.2 .0
IPV = intimate partner violence. p < 0.05 for (2) & (3); *standard residual 6 1.96.
reported using alcohol, compared to victims (7.7%), during IPV victimization. However, this difference was not statistically significant (c2 [1, n = 45] = 2.778, p = 0.096). A one-way analysis of variance was used to determine differences in perpetrator, victim, and reactor profiles, compared to pacifists, with regard to age, depression, and impulsivity (Table 5). Age was found to be significant (F[3,402] = 5.517, p = .001). Post hoc comparisons using the Tukey HSD (honest significant difference) test also revealed that the mean age for the reactor group was significantly lower than that of the pacifist group (Table 5). Those in the reactor group also had significantly higher average impulsivity scores (F[3,403] = 6.005, Table 5. Tukey HSD Comparison: Four Profiles of IPV (n = 412) IPV Profile Age Pacifist Victim Reactor Perpetrator CES-D Pacifist Victim Reactor Perpetrator Impulsivity Pacifist Victim Reactor Perpetrator
n
Mean
SD
Mean Difference from Pacifist
341 13 32 20
39.23 35.08 29.06 35.85
14.459 10.866 10.934 12.803
0 4.149 10.163* 3.376
342 13 32 20
37.68 46.54 47.16 43.05
11.514 13.764 15.079 13.489
0 8.863* 9.481* 5.375
342 13 32 20
18.83 20.31 23.97 22.50
7.183 5.893 9.139 8.357
0 1.477 5.138* 3.670
HSD = honest significant difference; IPV = intimate partner violence; CES-D = Center for Epidemiological Studies Depression Scale. * p < 0.05.
Figure 2. Tukey honest significant difference comparison: four intimate partner violence profiles (n = 412). CESD = Center for Epidemiological Studies Depression Scale.
p = 0.001) and CES-D (depression) mean scores than the pacifist group (F[3,403] = 8.793, p < 0.001). The victim group also had significantly higher CES-D mean scores than the pacifist group. However, the victim and perpetrator groups did not differ significantly from other groups with regard to age or impulsivity (Figure 2). DISCUSSION Of those who reported experiencing IPV (16%), the majority were reactors (49%), or those who both demonstrated and were victims of IPV. The number of reactors was more than twice that of victims, and over one and a half times larger than perpetrators. The size of the reactor group alone tends to confirm the prevalence of reciprocal act(s) of IPV in both uni- and bi-directional forms found in previous research (47,48). There are considerable medical and social implications: for one battered wife treated in an ED, for example, there may be a battered husband or significant other being seen at another location. Previous studies have also reported a small to moderate effect size in the association between alcohol use/ abuse and IPV for both male and female perpetrators, depending on the sample and type of alcohol measure selected (29,49). Our findings did indicate that the IPV group was more likely to engage in binge drinking than the non-IPV group (52.5% vs. 36.1%). However, 45.9% of the entire surveyed population – both IPV and nonIPV – reported drinking alcohol in the preceding 12 months. Of these, approximately 75% engaged in binge drinking. It is therefore not surprising that binge drinking was not found to be statistically significant between the four IPV profiles. Sixty percent of reactors, however, engaged in binge drinking (standardized residual of 1.9) in comparison to 50% of perpetrators and 36.4% of victims. Reactors were also more prone to alcohol use than victims when
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demonstrating IPV (34.4% vs. 10%), and when they themselves were being victimized, compared to all other IPV profiles (31.3% vs. 7.7%). These findings are not surprising, given empirical studies that report that alcohol consumption, chronic or acute, can trigger a person to act more violently or to react more acutely to violence with an intimate partner (38,39,49–53). One study found that drinking malt liquor beer in combination with other types of alcohol increased the risk of IPV (54). Both IPV perpetrators and victims more often use drugs, including crack and cocaine, than those not involved in IPV (46,51). In the current study almost 40% of the IPV group used at least one drug, compared to 25% in the entire surveyed population. This is consistent with a report that cocaine users are most at risk for IPV perpetration, whereas the use of cannabis is most strongly associated with IPV victimization (51). We found, in particular, that reactors are more likely to be drug users. Their standardized residual of 2.2 is large compared to that of victims (.7) and perpetrators (1.8). These findings may even suggest that IPV participants essentially double their risk of using drugs in their roles as both victims and perpetrators, as drug use may be both a risk factor and a consequence of IPV (19,46,55,56). These risk factors and relationships underscore the need to screen for and assess drug and alcohol use in ED settings when IPV is suspected (57). The link between depression and IPV is well substantiated in previous research (58). Depressive symptoms are seen as a risk factor for both IPV perpetrators and victims (45,51,59–61). It is not surprising that IPV group respondents report being more depressed than those in the non-IPV group, and that reactors report being more depressed than victims. Both reactors and victims, though, were found to be significantly more depressed than those who had never experienced any form of IPV. Age has been reported as not being specifically related to unidirectional IPV, but is negatively associated with mutual IPV (56). Our findings are somewhat confirmatory. The IPV group was younger (mean age 32.35 years, SD 11.809) than the non-IPV group (39.23 years, SD 14.459). In terms of mutual or bi-directional IPV, reactors were the youngest profile, with a mean age of 29.06 years (SD 10.934). However, with regard to unidirectional IPV, the age of both victim and perpetrator profiles (approximately 35 years) fell between pacifists (no IPV) at 39.23 years, and reactors (approximately 29 years). The literature and these findings suggest that those who engage in bi-directional IPV are likely to be younger than those who exclusively demonstrate or are victims of IPV, and those who experience no IPV at all. Impulsivity has been associated with violence and crime with high impulsivity and a lack of self-control specifically associated with IPV events (62–65). As
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expected, those in our IPV group did indeed report higher impulsivity than their non-IPV peers, and reactors were found to be more impulsive than pacifists. Impulsivity among perpetrators and victims, however, did not differ significantly from pacifists. Overall, these findings tend to confirm that impulsivity and the lack of selfcontrol are, in general, significant risk factors for IPV. With regard to observing parental, nonspousal violence and other IPV in childhood, our findings are generally consistent with those of previous studies. The age at which such violence is observed was shown to be significant in both perpetration and victimization (50,51,66). In our study, the IPV group reported more such experiences (standard residual 1.7) than the non-IPV group (.8). In terms of IPV profiles, reactors had much higher rates of observing parental violence (standard residual 2.9), compared to pacifists (.8), victims (.7), and perpetrators (.0). The literature and our findings would seem to indicate that exposure to such violence during childhood is a general risk factor for IPV, especially for those who would engage in bi-directional or mutual forms. Limitations In this cross-sectional study, demonstrating causal linkages is problematic. Reactors, for example, may be both perpetrators and victims, the dynamics of which can lead to, as well as possibly be exacerbated by, drug use and depression. Alternatively, analysis suggests that those who are highly impulsive and have depressive symptoms, and witness IPV as children, may be more likely to become reactors. The generalizability of our findings is also constrained by combining non-African American and non-Hispanic participants into an ‘‘Other’’ racial/ethnic category, although the latter group represents only about 3% of our surveyed population. Our analyses, in fact, did not reveal any statistically significant variability in the predictors of different profiles of IPV by ethnicity, which contradicts previous reports (33). This may be attributed, though, to our small sample size. Our exploration of gender differences is limited. In addition, because most participants were identified as non-IPV, statistical power was clearly an issue. As a result, we employed yes or no categories, and disregarded frequency and quantity data, acknowledging the small size of the IPV population. Because data are selfreported, it is also possible that IPV, and what may be considered socially questionable behavior such as drug and alcohol use, are underreported. Although data for this study were collected in 2001, we could find no additional or more recent ED-based literature on this important topic. We recommend updated, follow-up research to confirm and augment our findings.
Risk Factors of Intimate Partner Violence (IPV)
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Figure 3. ‘‘Five Steps in Screening for IPV’’ quick reference tool. IPV = intimate partner violence; Px = patient. Adapted from Bernstein E, Bernstein J, Levenson S (21).
CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH Using data collected from inner-city ED patients, we found that, in general, respondents who experienced IPV tend to be younger, have had more childhood exposure to such violence, were more depressed and
impulsive, reported more binge drinking, and were more likely to use drugs. More specifically, we found that those involved in mutual interpersonal violence (reactors) were younger, more likely to use drugs, were more depressed, more impulsive, and were more likely to have observed IPV or other violence in childhood.
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In busy EDs, concise and straightforward screening for IPV may be best implemented through tools such as the 5- to 10-min ‘‘Five Steps in Screening for IPV’’ instrument (Figure 3). This quick-reference guide employs an evidence-based Brief Negotiation Interviewing technique that is widely used in substance abuse interventions with a patient-participatory, decision-making therapeutic approach (20,21,67). It integrates elements of motivational interviewing, carefully considering a patient’s readiness to change (Figure 3) (68,69). Physicians first establish a relationship of trust with a patient and gently broach the subject of possible interpersonal violence (Steps 1–3). For those who are experiencing IPV, emergency physicians may intervene in the following ways, based on the patient’s willingness and readiness to receive help. In Steps 4 and 5, physicians may 1) offer concern, education and information; 2) suggest options that can resolve the patient’s ambivalence, or 3) refer the patient for further treatment. Findings from our study are expected to help emergency physicians detect and treat IPV. However, more research is needed, especially in areas that will enhance emergency physicians’ self-efficacy and competence in detecting various types of IPV. Future studies are needed to determine and validate the feasibility and effectiveness of the ‘‘Five Steps in Screening for IPV’’ instrument and similar tools in real-life ED settings (70). Acknowledgments—This paper was supported in part by the National Institute on Alcohol Abuse and Alcoholism (grant U24AA11899-05), by the Endowment Grant S21MD000103, and by the Accelerating Excellence in Translational Science AXIS Grant (U54MD007598). The authors would also like to acknowledge the valuable efforts of Ranna El Naga in the preparation of this manuscript.
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ARTICLE SUMMARY 1. Why is this topic important? Domestic intimate partner violence (IPV) is a serious health care concern often encountered in emergency departments (EDs). Its effects may be mitigated by early screening, detection and intervention. 2. What does this study attempt to show? In a cross-sectional study using survey data from 412 inner-city ED patients, we examine posited predictors in IPV and non-IPV groups, and in four different IPV profiles. These include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. 3. What are the key findings? Nearly 16% of the surveyed population had experienced IPV, and were younger, more depressed, and more impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. Thirty-one percent perpetrated IPV, 20% were victims, and 49% were both victims and perpetrators. Perpetrators were younger, more impulsive and depressed, used drugs, and were more likely to have observed parental violence as a child. 4. How is patient care impacted? Our study goal was to guide and inform practices and future research in the detection, treatment and referral for IPV in ED settings. Our findings enable emergency physicians to not only better understand and recognize its symptoms and risk factors, but also facilitate access to appropriate and adequate follow-up and continuing care. We also introduce a new ‘‘Five Steps in Screening for IPV’’ quick reference tool, which may assist ED physicians in detection and treatment.