Mednotes

L12 Psych Med Intimate partner violence

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aliasesL12 Psych Med Intimate partner violence

13 min read

Overview

This lecture covers intimate partner violence (IPV) in Aotearoa/NZ: its definition, prevalence and demographic patterns, the social-ecological model of causation, its effects on health (including a specific focus on non-fatal strangulation), how it presents and can be recognised in a health consultation (perpetrator and patient behaviour, injury patterns), the legal and information-sharing framework, the co-occurrence of IPV with child abuse, and the clinician’s role and responsibilities in responding, including the Child and Family Safety Service (VIP) that supports staff.

Definition and prevalence

  • IPV is defined as “any form of aggression and/or controlling behaviour used against a current or past intimate partner” (Dixon and Graham-Kevan, 2020). Reciprocal aggression is the most common form of IPV.
  • Data are from the 2019 New Zealand Family Violence Survey (findings based only on heterosexual couples):
    • Lifetime physical or sexual violence from a partner: 31% of women, 30% of men.
    • Physical violence in the past 12 months: 2.4% of women, 4.9% of men.
    • Lifetime psychological abuse from a partner: 48% of women, 40% of men.
    • Violence against women is more frequent and severe; women more often report multiple forms of violence, more injuries, fear of their partner, and greater physical/mental health effects.
    • Most people experiencing IPV do not seek help (34% of women, 19% of men).
  • NZ Police statistics:
    • 84% of people arrested for family violence are men, 16% are women.
    • Over a quarter of 2021 homicides were committed by family members; 74% of those killed by their partner were women.
    • 51% of women who died 2009-2018 were in the process of separating from their partner; risk is highest in the first 3 months but remains elevated up to 1 year post-separation.
    • A family-violence-related call to police occurs every 4.5 minutes on average.
    • A family-violence-related death of a child occurs on average every 6.5 weeks (Child Matters NZ, 2024).
    • The true burden is understood to be greater still, since most IPV goes unreported.

Causation and risk factors

  • There is no single cause. The social-ecological model explains IPV as arising from nested, interacting levels: Individual, Relationship, Community, Societal (innermost to outermost).
  • General risk factors (increase likelihood and/or severity): being pregnant or having recently given birth, recent separation, escalation (rising frequency/severity of abuse), substance abuse/misuse, isolation of the victim, financial difficulties in the relationship, and depression or other mental health issues.
  • Perpetrator-specific risk factors: used a weapon in the most recent event, has access to weapons, has stalked or is stalking the victim, has breached a protection order or police safety order, has ever harmed or threatened to harm the victim, has ever tried to choke the victim, has ever tried to kill the victim, has ever harmed or threatened to harm/kill children, has ever threatened or attempted suicide, has ever harmed or threatened to harm/kill pets, has ever harmed or threatened to harm/kill other family members, is unemployed, uses controlling behaviours, demonstrates obsession/jealous behaviour toward the victim, and has a history of violent behaviour (not limited to IPV).

Impact on health

Family violence is a health issue, not confined to injuries. It is associated with:

  • Health risk behaviours and chronic health problems across all body systems.
  • Medically unexplained symptoms.
  • Mental disorders: anxiety disorders, depression, PTSD, substance use disorders, eating and sleep disorders.
  • Pregnancy complications: injuries or vaginal bleeding during pregnancy, spontaneous or threatened miscarriage, low birth weight babies.
  • Mechanistically, violence-related chronic stress raises cortisol, which drives downstream effects including a weakened immune system, anxiety/depression/headaches, nerve problems, digestive issues, high blood sugar, high blood pressure and heart disease (linked to the ELM2 Stress and Coping lecture on mechanisms of chronic stress).
  • Childhood adversity (including child abuse/neglect and exposure to family violence) follows a biological pathway to adult outcomes: psychosocial adversity in childhood (prenatal maternal stress/depression, postnatal caregiver unavailability, depriving environments such as institutional care, child abuse or neglect) drives biological change (epigenetic changes such as DNA methylation of the GR promoter and IGF-2 antisense AVP, telomere shortening, and genetic variants such as 5-HTTLPR, BDNF, FKBP5 and MAOA that alter susceptibility), which causes neurodevelopmental disruption (reduced volume of key brain regions, neurotransmitter changes, altered functional activity and tract connectivity) and reprogramming of stress and immune regulatory systems (inflammation, altered HPA and sympatho-medullary axes). This biological change is embedded in adult behaviour (substance use, exercise, diet, stress management) and increases the risk of cognitive deficits, disease, psychopathology and social problems such as unemployment and incarceration. Sensitive developmental periods include 6-12 months (HPA axis/SHRP), 15 months (language), and 24 months (attachment, IQ).

Recognising family violence in a consultation

Perpetrator behaviour that may be observed: dehumanises or pathologises the patient, criticises their decisions and actions, restricts access to services or controls finances/other resources, always accompanies the patient to appointments, speaks for the patient rather than letting them answer, is clearly intent on getting their own way, and tries to get the clinician to agree with negative views about the patient.

Patient behaviour that may be observed: a time delay between injury and seeking treatment, hesitance or evasiveness when describing injuries, distress disproportionate to the injury (either extreme distress over a minor injury or apparent lack of concern about a serious one), an explanation that does not account for the injury (e.g. “I walked into a door”), and different explanations for the same injury at different presentations.

Recognising family violence from injuries

  • Injuries are usually central on the body, bilaterally distributed, or affect multiple sites.
  • Types: contusions, lacerations, abrasions, bruising, stab wounds, burns, human bites, fractures (particularly of the nose and orbits), and spiral wrist fractures.
  • Sexual assault, including unwanted sexual contact by a partner.
  • Multiple injuries in different stages of healing; tufts of hair pulled out.
  • Injuries sustained in a single-vehicle crash can also be a marker.
  • Strangulation/choking is a key marker: it raises the odds of homicide by 750%, and even in fatal cases only 50% of victims show external signs of injury. See FVAIG (2016) appendix K (patient discharge information) and appendix L (documentation).
  • Regional signs of strangulation/asphyxial injury by body area:
    • Neurological: loss of memory, loss of consciousness, behavioural changes, loss of sensation or extreme weakness, difficulty speaking, fainting, urination/defecation, vomiting, dizziness, headaches.
    • Eyes and eyelids: petechiae to eyeball and eyelid, bloody red eyeballs, vision changes, droopy eyelid.
    • Voice and throat: raspy or hoarse voice, unable to speak, troubled or painful swallowing, frequent throat clearing, coughing, nausea, drooling, stridor.
    • Face: petechiae, scratch marks, facial drooping, swelling.
    • Scalp: petechiae, bald spots, bumps and bruises.
    • Ears: ringing in the ears, bruising behind the ears, bleeding in the ear.
    • Mouth: bruising, swollen tongue, swollen lips, cuts/abrasions.
    • Chest: chest pain, redness, scratch marks, bruising/abrasions.
    • Breathing: difficulty breathing, respiratory distress, unable to breathe.
    • Neck: redness, scratch marks, fingernail impressions, bruising, swelling, ligature marks.
  • Consequences of strangulation:
    • Psychological: PTSD, depression, suicidal ideation, memory problems, nightmares, anxiety, severe stress reactions, amnesia and psychosis.
    • Delayed fatality: death can occur days to weeks after the event from complications such as respiratory issues, pneumonia, and blood clots.
    • Other: miscarriage, heart attack.

Non-fatal strangulation and/or suffocation (NFSS)

  • The most lethal form of IPV in New Zealand.
  • People who experience NFSS face a significantly increased risk (750%) of severe injury or death.
  • Law change in 2018 made NFSS a stand-alone charge, punishable by up to seven years in jail.
  • NFSS can have significant long- and short-term psychological and physical impacts.
  • Police can lay charges without the consent of the victim.

Where victims seek help and how IPV presents

  • Victims seek help outward from themselves in expanding rings: friends and family/neighbours; employers, health providers, religious communities, schools; social service agencies, counsellors, therapists; police and domestic/child abuse specialists.
  • How family violence may present to health, using an iceberg model:
    • Above the waterline (typical/visible presentations): chronic health conditions, presenting with a child’s health need, injuries, pregnancy, self-harm and suicidality, substance misuse and dependency, mental health exacerbation, panic attack/anxiety, sexual assault.
    • Below the waterline (hidden/underlying issues): physical harm with no evident injury (e.g. strangulation), resistance, threats, fear, emotional and psychological abuse, control, isolation, gaslighting, social inequalities.

Gender considerations

  • Men are primarily the perpetrators; women and people of diverse genders are primarily the victims.
  • Not all men abuse their partners, and male victims are no less deserving of safety and support.
  • Some women do abuse their partners, but ‘abuse’ must be separated from ‘acts of resistance’.
  • It is rare for men to fear a female partner, or to be severely injured or killed by a female partner.

Relevant legislation: Family Violence Act 2018, Children’s Act 2014, Oranga Tamariki Act 1989/Children’s and Young Person’s Wellbeing Act 1989, Health Act 1956, Privacy Act 1993.
Justifications for sharing information include the need to: mitigate risk and protect a child/adult from harm or ensure safety, practise safely, and act on information that indicates a serious crime has been or will be committed.

Co-occurrence of IPV and child abuse

  • The international estimated co-occurrence of child physical abuse and intimate partner violence is 30-60%.
  • In 2013, children were present at over 63% of all family violence incidents attended by police.
  • IPV and child abuse are interconnected, not separate phenomena; children are legally recognised as victims of family violence in their own right.
  • Children assessed for physical abuse often live in households where IPV is present; adult disclosures of IPV can trigger concerns for child abuse.
  • Elderly people and adults with disabilities are also recognised as vulnerable groups.
  • Regardless of who the patient is, child safety is the paramount consideration.

Roles, responsibilities and support services

  • Clinician roles and responsibilities: consult (never manage this alone), get curious, ask/see/hear/tell, and use expert teams that exist for this purpose. “We don’t expect you to be the answer, but we do expect you to be part of a team.”
  • The Child and Family Safety Service runs the VIP (Violence Intervention Programme), a national programme covering child abuse, IPV, family violence and vulnerable adults, from Ōamaru to Wānaka/Queenstown and the bottom of the South Island. It operates Monday to Friday (it is not an emergency service), provides staff with guidance and support through consultation and training, and ensures interagency collaboration and information sharing. The service never meets patients directly.
  • The critical practice resource is the Family Violence Assessment and Intervention Guideline: Child Abuse and Intimate Partner Violence (Fanslow & Kelly, 2016), free to download from the Ministry of Health, covering health effects of violence, the role of health in responding, routine enquiry/response/risk assessment/safety planning/referral and follow-up/documentation for both IPV and child abuse and neglect, and relevant legislation and ethical principles.
  • Support service contacts given in the lecture: Associate Dean Student Affairs, Student Health Services, Shine helpline (family violence), Women’s Refuge Crisis Line, Family Violence Information Line (Are You OK), Safe to Talk (sexual harm), Elder Abuse Response Service, and Netsafe (online safety).

Self-test

  1. Define intimate partner violence (IPV) as given in this lecture, and state what is the most common form of IPV.
  2. List the four levels of the social-ecological model of family violence, from innermost to outermost.
  3. A patient presents with an injury and their partner insists on staying in the room, answers questions on the patient’s behalf, and is clearly intent on getting their own way. Describe three further perpetrator behaviours from the lecture that would raise your suspicion of IPV.
  4. List four features of an injury pattern (other than strangulation-specific signs) that should raise suspicion of family violence.
  5. Explain why strangulation/choking is considered a particularly high-risk sign in IPV, including the relevant statistics.
  6. Distinguish the “above the waterline” and “below the waterline” presentations of family violence to health services, using the iceberg model, and give two examples of each.
  7. What is the international estimated co-occurrence of child physical abuse and intimate partner violence, and what proportion of family violence incidents attended by police in 2013 had children present?
  8. Describe the biological pathway by which childhood psychosocial adversity leads to adult health and social outcomes, according to the diagram in this lecture.
  9. What change did the 2018 law make regarding non-fatal strangulation and/or suffocation (NFSS), and why is police consent from the victim not required to lay charges?
  10. Outline the clinician’s expected role and responsibilities when they suspect a patient is experiencing IPV, according to this lecture.

Answers

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