Intimate partner violence: Wounds are deeper.

Intimate partner violence claims millions of victims worldwide leading to infringement of fundamental human rights, serious physical and mental heath consequences and leading behind in its wake broken relationships and affected children. Despite its prevalence, its is not a well understood phenomenon. Through this article, we briefly review the literature on this subject; emphasizing on epidemiology and typologies of IPV, perpetuating factors and outcomes, the relevant legislations in India and the screening and intervention steps.

INTRODUCTION

Intimate partner violence (IPV) is defined as any behavior within an intimate relationship (married, unmarried, and live-in) that causes physical, psychological, or sexual harm to those in that relationship. This definition encompasses physical, sexual, and psychological aggression/abuse or controlling behavior of any kind.[1] IPV differs conceptually from domestic violence. Domestic violence is defined as the physical, sexual, and emotional maltreatment of one family member by another.[2] It typically includes all types of family violence such as elder abuse, child abuse, and marital rape; however, IPV is limited to acts of aggression between intimate partners.[3] As females are more likely to be hurt in cases of IPV,[45] male-to-female partner violence has been studied in much greater detail, though both male-to-female and female-to-male partner violence exist; and the rates of female-to-male partner violence equal or exceed male-to-female partner violence;[678] in general household population. Almost 50% of IPV are bidirectional, and the rest divided between male-to-female only and female-to-male only partner violence.[910]

TYPOLOGIES OF INTIMATE PARTNER VIOLENCE

(a) As per severity of the violence, IPV can be classified as follows: (i) Level I abuse: pushing, shoving, grabbing, throwing objects to intimidation or damage to property, and pets; (ii) Level II abuse: kicking, biting, and slapping; and (iii) Level III: use of a weapon, choking, or attempt to strangulate.[11] (b) As per different forms of violence, (i) intimate terrorism/patriarchal terrorism: aggression is predominantly male to female, serves to not only control and dominate the partner but also to instill fear; (ii) violent resistance: a situation where partner resists such aggression, often in self-defense, chances of injury to partner is more; and (iii) situational couple violence/common couple violence: aggression is bidirectional, low intensity and often consequent to a conflict situational rather than as a tool for controlling or self-defense.[1213] (c) As per type of male batters, (i) family-only batterers: engage in the least severe marital violence and be the least likely to engage in psychological and sexual abuse. Violence is generally restricted to family members; least likely to have related legal problems. Little psychopathology and either no personality disorder or a passive-dependent personality disorder; (ii) dysphoric/borderline batterers: engage in moderate-to-severe wife abuse including psychological and sexual abuse. They are dysphoric, psychologically distressed, and emotionally volatile. Likely to have borderline and schizoid personality characteristics and problems with alcohol and drug abuse; and (iii) violent/antisocial batterers: engage in moderate-to-severe levels of familial violence. Engage in the most extrafamilial aggression. Most likely to have related legal, alcohol, and drug-related problems. Most likely to have an antisocial personality disorder or psychopathy.[14]

EPIDEMIOLOGY

One in three ever-partnered women worldwide has experienced physical and/or sexual violence by an intimate partner. Of these women, 42% sustained immediate physical injuries, and 13% were fatally injured.[15] Nearly 13%–61% of women have experienced physical violence by a partner sometime in their lifetime. About 4%–49% have experienced severe physical violence, and 6%–59% have experienced sexual violence.[16] The incidence across South Asia ranges between 8% and 50%, and almost 31% of Indian women have experienced IPV at some point in their marital life.[1718]

FACTORS THAT PERPETUATE INTIMATE PARTNER VIOLENCE

(a) Cultural: religious and historical traditions in the past have sanctioned the chastising and beating of wives particularly under the notion of entitlement and ownership of women. This, in turn, legitimizes control over women's sexuality. In many societies, a women's sexuality is linked to family honor. Traditional norms in these societies allow the killing of women who have been deemed to have brought dishonor to the family. Furthermore, acts of sexual violence against women are seen as a way of defiling enemies honor. Adverse childhood experiences, particularly witnessing domestic violence and experiencing physical and sexual abuse, have been identified as factors that put children at risk. Excessive consumption of alcohol and other drugs has also been noted as a consistent factor incident of IPV. (b) Economic: the link between violence and lack of economic resources and dependence is very evident. Risk and threat of violence prevent women from seeking jobs, and because of lack of financial independence, they are stuck in an abusive relationship. (c) Legal: law enforcement agencies frequently reinforce the batterers’ attempts to control and demean their victims. In many cases, despite the legislation in place, the perpetrators of IPV are dealt with more leniently compared to perpetrators of similar violence with strangers. (d) Political: there is a false notion of family being private and beyond control of the state. The problem is compounded by the underrepresentation of women in power, politics, the media, and in the legal system.[1920] (e) Role of alcohol as follows: (i) Cultural factors: there is strongly prevalent belief in society that alcohol can encourage violent behavior after drinking and there is increasing the use of alcohol as an excuse for violent behavior. Discriminatory upbringing with poor self-esteem also condone abuse of females.[21] Furthermore, it may be that the association of IPV and alcohol is more concurrent and a manifestation of expression of masculinity on part of men.(ii) Personal factors: Heavy drinking, by itself can be a source of marital conflict and dissatisfaction which may lead to IPV. Alcohol per se may increase the distortions of power and control motives.[22] (iii) Pharmaco-Cognitive factors: Alcohol can by itself directly increase aggressiveness or can lead to various cognitive changes in the individual that make him prone to aggressiveness. Alcohol impairs one's ability to exert self-control, learning, and impair the ability to delay gratification which can lead to aggression.[2223] It also leads to severe difficulties in attention, concentration, cognitive flexibility, and executive cognitive functioning.[2425] (iv) Proximal and distal factors: proximal factors, such as pharmaco-cognitive effects of alcohol, social, and environmental cues, state anger can trigger IPV. Distal factors are those may themselves may not cause violence but under influence of proximal factors may lead to violence. Examples are personality, relationship characteristics, and traits such as anger and hostility.[222627] (v) Contextual Factors: excessive alcohol drinking by one partner may precipitate or exacerbate marital disharmony, thereby increasing the risk of IPV.[2228] Alcohol may just be like adding fodder to a fire, that it be contributing rather than causing IPV.[29]

CONSEQUENCES/OUTCOMES OF INTIMATE PARTNER VIOLENCE

(a) Denial of fundamental rights and undermining of human development goals; (b) Health consequences lead to far-reaching physical and psychological consequences, some with fatal outcomes. IPV may result in injuries ranging from bruises and fractures to chronic disabilities, such as partial or total loss of hearing or vision, and burns may lead to disfigurement. Violence during pregnancy results in risk to the health of both the mother and the unborn fetus. Sexual assaults and rape can lead to unwanted pregnancies, and the dangerous complications that follow from resorting to illegal abortions. Girls, who have been sexually abused in their childhood, are more likely to engage in risky behavior such as early sexual intercourse and are at greater risk of unwanted and early pregnancies. Women in violent situations are less able to use contraception or negotiate safer sex, and therefore, run a high risk of contracting sexually transmitted diseases and HIV/AIDS. Furthermore, the victims have a high incidence of stress and stress-related illnesses.[2030] (c) Impact on children: children, who have witnessed violence or have themselves been victims, suffer adverse consequences. They may find difficulty in forming trusting bonds, may learn violence as a legitimate may of resolving conflicts and may end up accepting violence more easily than others.[2031] (d) Socioeconomic costs of violence: it includes both the direct and the indirect costs of the medical, legal, and community system involved in prevention, detection, and management of IPV.

RELEVANT LEGISLATIONS IN INDIA

(a) Rights enshrined in the constitution: Part III of the Constitution protects fundamental rights, including the right to life, which is the right to live a life with dignity and free from violence. (b) The Dowry Prohibition Act of 1961 and The Dowry Prohibition (Amendment) Acts in 1984 and 1986 (c) Section 498A to the Indian Penal Code (1983). Under this provision, husband (or his relatives) could face a fine and jail for up to 3 years. (d) In 1986, Section 304B was added to the IPC. It holds a woman's husband and in-laws criminally responsible for death under suspicious circumstances within 7 years of marriage (e) In 2005, the Parliament passed the Protection of Women from Domestic Violence Act. It allows women to seek injunctions and protective orders. It also offers criminal provisions for imprisonment and fines, which come into play when a perpetrator breaches a civil order. It covers all women in abusive relationships, regardless of the relationship of the perpetrator.[3233]

SCREENING OF INTIMATE PARTNER VIOLENCE

Up to 77% of women are often not screened for IPV.[34] It is more so when women are from lower economic strata and have no social support.[2135] As per a study majority (92%) of physically abused women do not report it to their physician.[36] But in few studies many of the abused women expressed the desire that their physicians should have enquired about any abuse suffered by them at the hand of their partners.[373839] Low level of awareness about IPV and its magnitude, among the medical practitioners can be gauged from the fact that only 10% of primary physicians routinely screen for it.[40] IPV can have serious mental and physical health consequences for the victim.[4142] It also adds a great financial burden to the society at large.[43] Screening for IPV will enable the victim to recognize the problem even if they may not be ready to accept help at that point of time,[44] leads to improved quality of life and fewer violence-related injuries,[4546] and reduces the financial strain[43] on a developing economy such as ours.

WHOM TO SCREEN

Victims of IPV are not limited by cast, creed, and demographic profile or sociodemographic profile. It is not practical to predict the victims of IPV.[4647] Medical personnel must be aware of the risk factors of IPV and be adequate empowered to screen it. Risk of IPV does not increase with screening.[48] In fact, screening provides the victims an early opportunity to be aware and utilize the community resources.[4950] Hence, it is a desirable practice to screen all patients for partner violence, especially ones, with history and physical findings suggestive of abuse such as frequent visits to the emergency room,[51] inconsistent explanation of injuries or delay in seeking treatment,[52] head and neck injuries,[53] and vague somatic complaints.[54]

HOW TO SCREEN

Screening can be either an interview by the medical personnel or a questionnaire filled by the patient, although some studies have indicated the superiority of questionnaires.[5556] Some of the common questionnaires/tools for screening are as follows: (a) The HITS screen.[57] It is a four-item scale (hurt, insult, threaten, and scream). It has a Likert scoring system (1–5). The score ranges from four to a maximum of 20. A score of 10 or more is considered diagnostic of abuse. (b) STaT screen (slapped, threatened, and throw) – this is a highly sensitive tool to screen IPV. A score of ≥1 is positive screening 95% for detection of lifetime IPV.[58] (c) Other similarly useful tools are as follows: Woman Abuse Screening Tool, Women's Experience with Battering scale,[59] Conflicts Tactics Scale,[60] and The Abuse Assessment Scale.[55] It is a five-item scale specially made to detect abuse among pregnant women.

INTERVENTIONS/REPORTING

Listen in an empathetic, nonjudgmental manner. Confiding in someone itself is associated with reduced rates of abuse.[61] Victims are more empowered to help themselves if they have a healthy trusting relationship with the doctor.[62] Awareness and implementation of safety behavior protocol help in reducing the incidents of abuse.[63] It is essential for both the doctor and the victim to be able to access the immediate and long-term risk[45] from the perpetrator and take necessary legal steps such as obtaining a protection order as studies have shown that victims with protection order are less likely to be attacked again.[6465] Furthermore, utilizing community resources, such as nongovernmental organizations or shelters, reduce the risk of further abuse.[46] It must be explained to victims that the abuse is against the law. While police contact must be offered, the healthcare professional must not impose on the patient to make any decisions about who they disclose the information to. Furthermore, it is much easier to contact the police from the relative safety of the A and E Department than at home. Although refusal of police contact is common, the healthcare professional must guard against frustration as the cause could range from fear of further abuse, financial dependence, concerns about children, and self-blame.[46] In addition, there are many agencies who offer help to the victims without the necessity of police intervention. Making available leaflets with details of such agencies and other useful advices, in public places such as malls, public transportation systems, and bathrooms may go a long way in improving the plight of the victims.

CONCLUSION

IPV is a serious and widely prevalent problem which is usually underrecognized. It puts the victim at risk for physical and psychological harm in addition of draining the limited resources of a developing country such as ours. The problem is compounded by various cultural, political, legal, and economic factors. Substance abuse, especially alcohol, is closely relayed to incidents of IPV. There is a need to sensitize the community, especially the medical system, which will enable prevention, early screening, and intervention in such cases.

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Conflicts of interest

There are no conflicts of interest.