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Course: Maternity Nursing�Topic: Intimate Partner Violence (IPV)

The Nurses International Community

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Module Goals

The learner will be able to:

Define Intimate Partner Violence (IPV)
List the risk factors for IPV
Summarize the consequences of IPV
Describe the nurses’ role in identification, prevention and treatment of IPV

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Intimate Partner Violence (IPV):

Intimate partner violence (IPV) is an act of one close partner (married/ Unmarried/ Live-in and could be former/current) to another partner that leads to the psychological, sexual and psychological harm.

(Patra et al, 2018)

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Typology of Violence (Based on Behavior)

Physical violence: Causing physical harm
Sexual violence: Physical /non physical sexual act
Stalking: Unwanted attention, follow and contact
Psychological aggression: Psychological harm caused verbal and nonverbal communication

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Physical violence: Includes hurting by kicking, hitting, pulling hair, slapping, threatening with a gun/knife, or using any physical force from one intimate partner to another intimate partner.
Sexual violence: It includes sexual touching, physical sex act, non-physical sex (e.g sexting) of one intimate partner to the other intimate partner without the want or consent of the victim.
Stalking: Unwanted attention and contact by a partner to another partner that threatens the safety of the victim or the closed/loved ones e. g. Following or spying, leave unwanted items at your office or door, standing outside school/house/workplace, vandalize property or hurt someone you love.
Psychological aggression: It is an act of causing psychological harm by one partner to the other by using verbal and nonverbal communication that hampers the mental and spiritual health.

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Typology of Violence

As per the severity, Violence can be classified into following levels:

Level I Abuse: Grabbing, Shoving, Pushing, throwing objects to intimidate or damage the property, pets

Level II Abuse: Biting, Kicking, slapping

Level III Abuse: Use of Weapon, attempts to strangulate, Choking

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Magnitude of IPV

IPV exists globally regardless of social, economic and cultural groups
IPV can be: Male to Female & Female to Male
Majority of victims & fatalities of IPV are female and doers are male
5–71% of women (15–49 Years ) reported IPV at some point in their lives

According to CDC (2019) In USA,

About 1 in 4 women experience physical, sexual or other form of violence
Over 43 million women experienced psychological aggression in their lifetime

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Most Common Form of Violence Against Women

IPV and other forms of family violence
Sexual Violence
Female Genital Mutilation (FGM)
Femicide: Dowry-related killings
Human trafficking, forced prostitution and economic exploitation
Violence against women in humanitarian and conflict settings

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What Would the Nurse Do?

A 24- year-old female comes to the clinic and expresses that her life is in danger as she is been with an abusive partner for last few months and now he often threatens to hurt her with a knife.

What should guide the nurses response to this client?

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Risk Factors of IPV

Violence towards women is a result of factors related to individual, relationship, social, culture and environment:

Individual level: Personal history and biological factors
Personal relationships: With family, friends, partner
Community: Schools, neighborhoods and workplaces, also influence violence
Societal factors: Violence is encouraged or inhibited in the society?

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At the individual level, Personal History like drug abuse, substance abuse, aggressive behavior, being a victim of abuse and Biological History Psychological or personality disorders, etc. can highly influence how a person behaves in society. It might determine an individual be a victim or perpetrator.
Personal relationships: a person is highly influenced by the act of family members, friends, intimate partners, and get influence to be a Victim or perpetrator. E.g. having a friend that frequently involves in gang fights might influence a person to get involved in or to be a victim at some point in life.
Community: E.g. A community where there is easy access to drugs and guns where crimes (Murder, fights, robbery) are common, a person can get influence by it or will understand such acts in the community are normal.

Societal: Depends upon how strict the laws and moral of society is. It influences violence, crimes are encouraged, or are inhibited. These include economic and social policies that maintain socioeconomic inequalities between people, the availability of weapons, and social and cultural norms. E.g. if male dominance over women, senior dominance over juniors are acceptable in the society, it endorses a conflict cycle.

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Risk Factors of IPV: Ecological Model

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What Would the Nurse Do?

You are a community health nurse and you come across a mother of whose daughter was raped in front of her eyes. She states that she was helpless to stop the perpetrator. Now she says she has turned into a different person; she gets angry and agitated easily and has a feeling of revenge.

What could be happening here and what is the nurse's best response?

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Consequences of IPV

Fatal consequences: An illness or accident that ultimately causes death by homicide, suicide, maternal mortality and AIDS-related deaths
Non-fatal consequences: Related to detrimental effects on physical and Mental health

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Consequences of IPV

Fatal consequences: An illness or accident that ultimately causes death

Homicide
Suicide
Maternal mortality
AIDS-related deaths

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Homicide: Homicide is the killing of one partner by the other, and women tend to be the victim of this than men. Such homicide usually occurs with the use of a gun, stabbing, strangulation, choking and some of the contributing factors to the homicide is dowry (south-East Asia), having a stepchild to live with, estrangement.

Suicide: Researches have shown a direct relation between Intimate partner violence and suicide. Only depression and other forms of psychological problems do not lead to suicide, the act of killing oneself tends to be higher when there is dissatisfaction, fights, different forms of abuses, assaults.

Maternal mortality: Maternal mortality including the infant mortality rate of abused mothers tends to be higher than that of a non-abused mother. An abused mother during pregnancy will go through poor prenatal care, poor nutrition, less weight gain, substance abuse, and depression leading to higher chances of maternal death (before delivery/during delivery or postpartum period).

AIDS-Related Deaths: A woman who has a history of previous IPV is an increased risk of having sexually transmitted infections, HIV/AIDS, injectable drug uses, giving or receiving money for sex/drugs, or compromise for not using condoms. The rate and severity of violence or discrimination tend to be higher in HIV positive women. They receive poor treatment and also develop other comorbid conditions leading to early deaths.

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Consequences

Non-fatal consequences: Negative effects on physical and mental health conditions

Physical injuries and disability
Unwanted pregnancy resulting in possible unsafe abortion
Pregnancy and birth complications due to trauma
Sexually Transmitted infections
Traumatic vaginal fistula

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Physical Injuries and Disabilities: IPV includes hurting, hitting, pulling, head banging, burning, etc leading to physical injuries. Some injuries might lead to neurotrauma, spinal injuries causing paralysis( complete or partial), sensory disabilities(Deafness, blindness), amputations, grafting.

Unwanted Pregnancy and Unsafe Abortion: Rape, sexual assaults can lead to unwanted pregnancies. The victim might not have enough support from others (due to modesty, stigma) to seek proper medical care and abortion facilities and end up with dangerous or risky abortion techniques. Such an abortion can bring multiple complications. It has also been found that girls who are sexually assaulted at their younger age are more likely to engage in risky behaviors like early sexual intercourse, unwanted pregnancies, unsafe abortion, substance misuse.

Pregnancy and Birth Complications: When IPV occurs during pregnancy, a woman does not receive full care and support. She receives poor nutrition, low weight gain, less antenatal visits, and high stress resulting in birth complications, surgeries, stillbirth, low birth weight of child, hemorrhages, and postpartum depression.

Sexually transmitted Infections: A history of previous exposure to the IPV can lead one into risky behaviors like multiple partner sex, trading money for sex, compromising not taking precaution which leaves higher room for Sexually Transmitted Infections.

Traumatic Gynecological fistulas: Gynecological fistulas are abnormal opening between the vagina and bladder rectum. Brutal rape, forced sex, sexual violence, forceful insertion, or thrusting of an object in the vagina can lead to such fistulas, and it needs intense surgical repair.

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Consequences

Non-fatal consequences (continued….)

Depression, anxiety, low self- esteem
Eating and sleep disorders
Harmful drug and alcohol use
Post-traumatic stress disorder (PTSD)
Self-harm
Gastrointestinal disorders
Chronic pain syndromes

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Depression and Anxiety, Low Self-Esteem: A woman who is a victim of violence have higher rates of stress, anxiety, frustration, and depression. Assaults, intimidation, threatening during violence lead to low self-esteem.

Eating and Sleeping Disorders: IPV leads to physical injuries/pain, mental stress leads to depression, Post-traumatic stress disorder, and anxiety disorder. It can lead to sleeping disabilities, eating disorders.

Harmful Drug and Alcohol Use: A victim of IPV tends to involve in harmful activities, use of illicit drugs, alcohol use, smoking, drinking.

Post-Traumatic Stress Disorder, GI disorders, chronic pain syndrome: A woman experience moderate to severe tend to be aggressive, violent later in their life. They also have higher chances of involving in self-harm due to a higher amount of stress. They also tend to develop a chronic type of pain or Gastrointestinal disorder. Such pain may persist in body pain, neck pain, frequent headaches, pelvic during their life.

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What Would the Nurse Do?

You are a nurse in a rural clinic where you received a female patient who has multiple cigarette burn wounds (fresh and at different stages of healing) on her arms, bruises on her back and thighs.

She shared that she thinks that killing herself is the only way to escape the excessive torture from her husband and family members because she bought less cash to the family as dowry.

(She has a history of attempted suicide three months ago).

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Nurses’ Role in IPV (Disclosed Information)

Psychological Therapy

Refer for appropriate Treatment

Offer first-line support at a minimum

Offer adequate information

If IPV is disclosed, identify the type, severity of Abuse/violence

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Identification, IPV disclosed? If Yes, Identify the type, severity of violence
Give information on available services: Patients should not be forced or pressurized to disclose information, information on health consequences of IPV on victims and children has to be provided. A nurse can also offer a follow-up appointment.
Offer first-line support at a minimum: any woman who discloses any form of IPV, she should be offered support like ensuring her confidentiality, interview in a private room, presenting oneself in a non-judgmental and supportive way, validate her concerns, provide necessary providing care and support related to her issues (but do not intrude). Ask her history of violence without pressuring her to talk. After, a nurse can help her get the information about the legal services that might be helpful to the victim. The safety of a victim is important thus help her and her children (if any) to increase safety. Provide her social support. As a nurse, if you are unable to provide her first-line support, she should be immediately referred to someone else who is available instantly to do so.
Refer for appropriate treatment: If children are exposed to IPV, psychotherapeutic interventions have to be offered. There could be sessions for children alone and sessions along with the mothers should be offered (However, it might be difficult for the low and middle-income settings).

IPV Advocacy: It plays a vital role for the women who encountered IPV. The victim woman who has already spend one night in the shelter/refuge/safe house should be provided with a structured program of advocacy, support, and empowerment. Likewise, if a pregnant woman who disclosed IPV, should be offered brief to medium duration empowerment counseling, advocacy/ support ensuring her safety.

5. Psychological therapy: A woman with a previous history of mental disorders who are is a victim of IPV should receive mental health care for such disorders (Depressive Disorder, Alcohol Use Disorder, Drug Abuse) from health care professionals with an excellent understanding of violence against women. Cognitive-behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) interventions are recommended for women who are no longer experiencing violence but are suffering from post-traumatic stress disorder (PTSD).

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Nurses’ Role in IPV (Information not Disclosed)

1

Identify the severity of abuse/violence type,

2

Offer adequate information on IPV in private room

3

Are there clinical symptoms of IPV or concerns about IPV?

4

Give information on services if available

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Identification, IPV disclosed? If No, try identifying the type and severity
The victim has to be given adequate information about IPV in a private setting,
Are there clinical symptoms of IPV or concerns about IPV? A nurse has to watch out for clinical conditions associated with the IPV. Look for the signs and symptoms of depression, anxiety, post-traumatic stress disorders, eating disorders, sleep disturbances, substance use, and misuse. The patient’s suicidal ideation or self-harm has to be assessed. Patients with IPV might experience chronic pain, pelvic pain, headaches, gastrointestinal symptoms, genitourinary symptoms, kidney infections, urinary tract infections, vaginal bleedings, sexually transmitted infections has to be assessed and documented. Multiple unintended pregnancies, miscarriages, abortion, adverse birth outcomes sexual dysfunction has to be assessed. Traumatic injury, problems with the central nervous system (hearing loss, cognitive problems) have to be assessed. A nurse has to find out if the victim has any health consultation with no clear diagnosis.
Give information on available services: A patient should not be forced or pressurized to disclose information, information on health consequences of IPV on victim and children has to be provided. A nurse can also offer a follow-up appointment if she does not want to talk about her problem in this appointment (trust issues: a therapeutic relationship is essential).

https://drive.google.com/file/d/1TQcM_1IY82BXkfQaw-RUg-O2UIj2Oli-/view?usp=sharing please click the link for the diagrammatic representation of Care Pathway for Intimate partner Violence provided by WHO (2013).

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Nurses’ Role in IPV

Present with empathy and non-judgemental attitude
Identifying Abuse
Taking Care of the Physical Health Needs of Patients
Attending to Women’s Safety
Making Referrals
Providing Support
Providing Advice

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Red Flags

A teenage girl who presents at the clinic with vesico-vaginal fistula
A husband who appears excessively jealous
A partner who hurts children and pets when he is upset
An 8- year-old of female presents with partial removal of clitoral hood

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Cultural Considerations

Some Cultures Tolerate violence against women:

“Stone keeps a knife in good form and beating keeps a woman in good form.” (Proverb: Assam, India)
“Rearing a woman is same as rearing a hen in a Muslim's house”. (Proverb: Bangladesh)
“The man is the woman’s honor.”- (Proverb: Africa)
Sexual activity, including rape, is a marker of masculinity and girls are responsible for controlling a man’s sexual urges
A man is socially superior and has the right to assert power over a woman
Physical violence is an acceptable way to resolve conflict in a relationship

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Cultural Considerations

In India, Bangladesh, and Nepal, people prefer not to speak about about the ongoing violence due to modesty, stigma and fear of losing favor in the family
Vietnamese women believe that men have the right to be abusive and prefer to remain silent about abuse

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Glossary

Female Genital Mutilation: It is a process where all or partial female genital organ are removed for any non-medical reason
Femicide: Killing of Female in account of gender.
Vesico-vaginal fistula: An abnormal opening between vagina and bladder resulting to the leakage of urine from vagina.

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References:

Center for Disease Control (2019). Violence prevention: preventing Intimate Partner Violence. Retrieved on 30^th of August 20202 from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

Devi. B. (2003). WOMEN IN THE MIRROR OF INDIAN LANGUAGES: PROVERBS IN INDIAN LANGUAGES AND THE STATUS OF WOMEN. Retrieved on 27th of October 2020 from http://www.languageinindia.com/jan2003/womeninindianlanguages.html#:~:text=There%20is%20another%20proverb%20in,hen%20in%20a%20Muslim's%20house%22.&text=It%20implies%20that%20a%20woman%20is%20poor%20in%20her%20intellectual%20abilities.

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References:

Donnelly.P.D., Ward. C.L. (2015). Oxford Textbook of Violence Prevention: Epidemiology, Evidence, and Policy. (1st Edition). Great Clarendon Street: United United Kingdom. Oxford University Press. pp. 186. (https://books.google.com.np/books?id=0y4DBQAAQBAJ&pg=PA186&dq=Sexual+activity,+including+rape,+is+a+marker+of+masculinity+and+girls+are+responsible+for+controlling+a+man%E2%80%99s+sexual+urges&hl=en&sa=X&ved=2ahUKEwjD5tvkj9XsAhWjkOYKHc2nB6UQ6AEwAnoECAEQAg#v=onepage&q&f=false)

Guruge. S. (2012). Nurses’ Role in Caring for Women Experiencing Intimate Partner Violence in the Sri Lankan Context. International Scholarly Research Notices. Vol. 2012, Article ID 486273. https://www.hindawi.com/journals/isrn/2012/486273/

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References:

James-Hawkins, L., Hennink, M., Bangcaya, M., & Yount, K. M. (2018). Vietnamese Men’s Definitions of Intimate Partner Violence and Perceptions of Women’s Recourse-Seeking. Journal of Interpersonal Violence. https://journals.sagepub.com/doi/full/10.1177/0886260518817790

Patra, P., Prakash, J., Patra, B., & Khanna, P. (2018). Intimate partner violence: Wounds are deeper. Indian journal of psychiatry, 60(4), 494–498. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278226/

UNFPA (2014). Gender-based violence in humanitarian settings. Retrieved on 30^th of August 20202 from https://www.unfpa.org/resources/gender-based-violence-humanitarian-settings

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References:

World Health Organization (2012). Understanding and addressing violence against women. Retrieved on 30^th of August 20202 from https://apps.who.int/iris/bitstream/handle/10665/77433/WHO_RHR_12.35_eng.pdf?sequence=1

World Health Organization. (‎2013)‎. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. World Health Organization. https://apps.who.int/iris/handle/10665/85240

WHO (2009). Violence Prevention The Evidence: Changing cultural and social norms that support violence. Retrieved on 27th of October 2020 from https://www.who.int/violence_injury_prevention/violence/norms.pdf

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