Intimate partner violence session highlights prevention and intervention strategies

Patricia L. Turner, MD, MBA, FACS
Patricia L. Turner, MD, MBA, FACS

Both patients and physicians are potential victims of intimate partner violence (IPV), which is a leading cause of death and disability that affects more than one in three women in the U.S. During the Intimate Partner Violence: What Every Surgeon Should Know session on October 25, panelists identified strategies for IPV screening, discussed common IPV injury patterns, and summarized resources available for both patients and physicians.

In the session’s opening remarks, Patricia L. Turner, MD, MBA, FACS, ACS Executive Director-Elect, and Co-Chair of the American College of Surgeons (ACS) Intimate Partner Violence Task Force, described the tragic death of Sherilyn Gordon, MD, FACS, who was killed in her Richmond, TX, home by her husband in 2017.

Dr. Gordon was a well-regarded transplant surgeon at the Houston Methodist J.C. Walter Jr. Transplant Center and associate professor of surgery at Houston Methodist Hospital, TX, where she served as the general surgery residency program director, and the assistant dean for graduate medical education (GME) at Texas A&M Health Science Center. She was the first physician to serve as the designated institutional official for GME at Houston Methodist Hospital.

Barbara L. Bass, MD, FACS
Barbara L. Bass, MD, FACS

“Sherilyn Gordon was tragically taken from all of us who knew and loved her in an act of intimate partner violence, Dr. Turner said. “She was killed leaving behind scores of patients, her daughter, her parents, her colleagues.” To help honor Dr. Gordon’s memory, Barbara L. Bass, MD, FACS, made addressing the issue of IPV her presidential initiative (2017-2018), Dr. Turner noted. “Coincidentally, October is National Domestic Violence Awareness Month, so it is our goal to make sure that Dr. Gordon’s name remains alive and that we assure no more surgeons are subject to these sorts of violent acts.”

“We, at the College and the Women in Surgery Committee, became aware of the horror of IPV with the loss of Sherilyn Gordon…whom we lost [in March 2017] by murder from her husband who then subsequently died by suicide,” added Dr. Bass, vice-president for health affairs, and dean, School of Medicine and Health Sciences, George Washington University, Washington, DC, and Past-President of the ACS.

Due to the fact that IPV is often “hidden behind closed doors,” one of the elements of Dr. Bass’s ACS presidential platform was to convene an ACS IPV Task Force in January 2018.

“We started the ACS IPV Task Force that Dr. Patricia Turner and I have chaired for the last four years,” she said, noting that a recent survey of ACS Fellows revealed that up to 20 percent reported being in a violent relationship.

Another survey showed that about 10 percent of physicians have approached a colleague who they thought were showing signs of IPV, noted Dr. Bass, acknowledging that it can be a difficult conversation to engage in. Her suggestions for strong peer-to-peer support include asking (and then asking again); offering nonjudgmental listening; providing empathic support without directives; and “letting the victim know that violence is never appropriate, that it is not their fault, and that help is available,” she said.

Dr. Bass described the resources available in the ACS IPV Toolkit, which includes a grand rounds presentation titled Intimate Partner Violence: Diagnosing the Hush-Hush American Epidemic in the Trauma Bay, which she said can be used to “make our students and residents and others aware of this condition as evidenced from the trauma bay.”

“This is a terribly prominent problem with a full spectrum of manifestations, but the important thing to remember is that no one is immune,” Dr. Bass said.  “Understanding the complexities of this human relationship failure may help victims and perpetrators to enter into resolution pathways.”

Erin M. Shriver, MD, FACS
Erin M. Shriver, MD, FACS

IPV is a broad umbrella that encompasses physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner, which could include a spouse, boyfriend, girlfriend, dating partner, or ongoing sexual partner, said Erin M. Shriver, MD, FACS, the Jim O’Brien Gross and Donnita Gross Chair in Ophthalmology, University of Iowa, Iowa City, and member of the ACS Intimate Partner Violence Task Force.

Citing data from a radiology study that examined the early phase of the coronavirus (COVID-19) pandemic compared with the previous three years, Dr. Shriver noted that the number of patients reporting IPV was reduced by half due to the fear of contracting COVID-19. “But the physical IPV cases nearly doubled, and there was a five-fold increase in severe and a four-fold increase in very severe injuries,” she said.

“Physicians are not immune to IPV,” Dr. Shriver added. Citing data from a survey of 400 doctors from four physician groups, she noted that 25 percent of surveyed physicians reported that they are currently experiencing IPV. “If it hasn’t happened to you, it’s happening to a friend, a colleague, a partner, a sibling, a parent—and it’s definitely happening with our patients,” she said.

Physicians have an opportunity to intervene with patients before their IPV-related injuries escalate, noted Dr. Shriver. Nearly half of the women who are killed by an intimate partner in the U.S. each year present to an emergency department within two years before their death.

“Another study found that women who talk to their health care provider about IPV are 3.9 times more likely to use an intervention and 2.6 times more likely to exit the abusive relationship,” she said.

It is also important to note that beyond the physical trauma related to IPV, the psychological trauma can also have health implications, including cardiovascular disease, hypertension, mental health problems, substance abuse, and issues related to maternal health, prenatal health, and sexual reproductive health concerns.

IPV screening

Susan E. Pories, MD, FACS
Susan E. Pories, MD, FACS

“The clues pointing to abuse may be subtle or absent, and for this reason, many groups advocate screening for all patients, or all female patients, for IPV,” said Susan E. Pories, MD, FACS, medical director of the Hoffman Breast Center, chief of breast surgery, Mount Auburn Hospital, Cambridge, MA, an ACS Governor, and Chair of the ACS Women in Surgery Committee.

According to Dr. Pories, one IPV screening tool recommended by the ACS Committee on Trauma is HITS, which features four simple questions: Does your partner Hurt, Insult, Threaten you with harm, or Scream at you—with a “yes” response to any question indicating a positive score.

Additional signs of potential IPV include: inconsistent explanation of injuries, delay in seeking treatment, frequent emergency department or urgent care visits, missed appointments, repeated abortions, nonadherence to medication, a flat or inappropriate affect, social isolation, and a reluctance to undress.

Injury patterns that physicians should be aware of include head, neck or facial injuries; abdomen and thorax injuries; and multiple occurrences of injuries.

“In terms of legal responsibilities—before reporting suspected violence or abuse—inform patients about the requirements to report the behavior; obtain informed consent when reporting is not required by law; and protect patient privacy when reporting by disclosing only the minimum information necessary,” advised Dr. Pories.

If patients feel they are in danger, they may consider initiating a Domestic Violence Protective Order, which would legally prevent perpetrators from contact with the patients. Dr. Pories suggested using a community advocate or legal advisor to assist the patient with obtaining the protective order.

She noted that surgeons are not immune to being victims of IPV. According to a survey of 882 surgeons and trainees, 536 reported experiencing some form of behavior consistent with IPV; 74 percent of the respondents were women, and 58 percent reported experiencing emotional abuse, including controlling behavior, Dr. Pories noted.

“Work is often the only space where victims are free to seek help, and a coworker may be their only ally,” she said. With that in mind, hospitals and surgery departments should empower surgeons to support each other, educate surgeons to notice signs of abuse in their colleagues, and integrate learning from bystander intervention work to train coworkers.

Cynthia V. Plate, MD, FACs
Cynthia V. Plate, MD, FACS

Cynthia V. Plate, MD, FACs, breast oncology surgeon, Maryland Oncology Hematology–White Oak Cancer Center, Silver Spring, and a member of the ACS Intimate Partner Task Force, discussed strategies for identifying IPV in the emergency department and in the practice setting, noting that 81 percent of IPV injuries are maxillofacial injuries, with 67 percent of facial fractures involving the middle third of the face, 45 percent involving orbital and ocular injuries, and 40 percent are nasal fractures.

If a patient presents with 12 specific injury types—including tympanic membrane rupture, rectal/perineal injury, face and/or neck abrasion/contusion, abdomen laceration/penetration—there is a 29.7 percent positive predictive value for IPV, according to research cited by Dr. Plate.

“Most females expect their health care provider to initiate a conversation about IPV,” according to findings from the U.S. Preventive Services Task Force, Dr. Plate said. “So that’s why we need to be much more aggressive about this…because patients are not going to come to you with this most of the time.” She recommends health care providers engage in the following: become educated on IPV and its sequelae, establish contacts with community-based organizations, ask direct questions about IPV and safety, and endorse the patient’s wishes on whether to take action.

This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform.