Domestic & Intimate Partner Violence: A Clinical Guide
Recognizing, screening for, and responding to abuse — with dedicated attention to pregnancy, older adults, and other vulnerable populations
Domestic and intimate partner violence sits in the blind spot of routine clinical care: it is extraordinarily common, it drives a large share of the depression, anxiety, PTSD, substance use, chronic pain, and suicidality we treat, and yet it is rarely named in the room. Clinicians see the sequelae constantly and the cause almost never. This guide is a practical reference for physicians, residents, pharmacists, and students on how to recognize abuse, screen for it safely, assess dangerousness, and respond in a way that is trauma-informed rather than harmful — with particular attention to the populations in whom abuse is most common, hardest to disclose, and most lethal: pregnant and postpartum patients, older adults, people with disabilities or serious mental illness, and immigrants.
Language note
This chapter uses intimate partner violence (IPV) for abuse by a current or former romantic/sexual partner, and domestic violence (DV) as the broader umbrella that also includes family and household violence (e.g., abuse of an elder by an adult child). Most screening evidence concerns IPV, but the clinical response overlaps. We refer to people who have experienced abuse as survivors or patients rather than "victims," and avoid the passive framing ("Why doesn't she just leave?") that obscures the abuser's agency and the real dangers of separation.
What Counts as Abuse: Beyond Physical Violence
Abuse is a pattern of coercive behavior used by one partner to gain and maintain power and control over another. Physical assault is only one tactic, and often not the most damaging. The CDC recognizes four principal forms of IPV, but coercive control is the connective tissue that binds them into a pattern.
Forms of intimate partner violence
- Physical violence: hitting, slapping, choking/strangulation, use of weapons, restraint. Strangulation and head trauma deserve special attention (see below).
- Sexual violence: forced or coerced sexual contact, reproductive coercion (sabotaging contraception, forcing or preventing pregnancy, controlling reproductive decisions).
- Stalking: a pattern of unwanted contact, surveillance, or threats causing fear — increasingly technology-facilitated (tracking apps, spyware, GPS, social-media monitoring).
- Psychological aggression: verbal and non-verbal acts intended to harm or exert control — humiliation, intimidation, threats, isolation, and gaslighting.
Coercive control reframes abuse from discrete incidents to an ongoing strategy that constrains a person's liberty. Its tactics — isolating the partner from friends, family, and work; monitoring movements and communications; controlling money, transportation, documents, and medications; degradation; and micro-regulation of daily life — can be devastating even when no physical assault has occurred, and are strongly associated with escalation to serious violence. Several jurisdictions now recognize coercive control in law. Clinically, the key point is that a patient who reports no "hitting" may still be living under severe, health-damaging control. Financial abuse (restricting access to money or employment) and technology-facilitated abuse are common modern expressions of the same strategy and are frequently what traps a person economically.
Scope of the Problem
Intimate partner violence is among the most prevalent forms of violence, and by definition it occurs in the relationships where people are supposed to be safest. Data below are drawn from the CDC's National Intimate Partner and Sexual Violence Survey (NISVS).
Abuse frequently begins young: roughly 16 million women and 11 million men in the US first experienced intimate partner violence before age 18, underscoring the continuity between teen dating violence and adult IPV. Violence exists across every demographic, but prevalence and lethality are not evenly distributed — sexual and gender minorities, people with disabilities, and some racial and ethnic groups report higher rates, and structural factors (poverty, housing instability, immigration status) shape both risk and the ability to leave safely. Men are also victimized, most often experiencing physical violence and psychological aggression, and face particular barriers to disclosure and to being believed. IPV is likely under-reported in every group.
Why This Belongs in Psychiatric and Medical Care
The health consequences of abuse are the reason clinicians encounter survivors so often without recognizing them. Experiencing IPV roughly doubles to triples the risk of depression and is one of the strongest environmental correlates of PTSD in women. The relationship with mental illness is bidirectional: abuse causes and worsens psychiatric symptoms, and pre-existing mental illness increases vulnerability to abuse and makes disclosure less likely to be believed.
Health sequelae to keep on the differential
- Psychiatric: depression, PTSD and complex PTSD, anxiety and panic, substance use disorders (often as coping or as a tactic of control), sleep disturbance, suicidal ideation and attempts, and worsening of any pre-existing psychiatric illness.
- Neurological: traumatic brain injury from blows to the head and from strangulation-related hypoxia — an under-recognized cause of persistent cognitive complaints, headaches, and "treatment-resistant" symptoms.
- Somatic and chronic: chronic pain, headaches, pelvic pain, gastrointestinal and functional disorders, and poorly controlled chronic disease (when a partner restricts access to medication or care).
- Reproductive: unintended pregnancy, sexually transmitted infections, and pregnancy complications tied to reproductive coercion and to violence during pregnancy.
Two clinical implications follow. First, IPV belongs on the differential for common presentations — new or worsening depression, anxiety, PTSD, substance use, insomnia, chronic pain, poor adherence, and frequent missed appointments. Second, treatment that ignores an ongoing abusive relationship will underperform: antidepressants and therapy work poorly against an active, ongoing traumatic stressor, and safety must be part of the treatment plan.
Screening: What the Evidence Supports
In 2025 the US Preventive Services Task Force reaffirmed and updated its guidance. The two statements matter for different populations and pull in different directions.
USPSTF 2025 recommendations
- Grade B — screen women of reproductive age, including those who are pregnant and postpartum, for intimate partner violence, and provide or refer those who screen positive to ongoing support services. Evidence is strongest in the perinatal period, where effective interventions are typically multi-session with ongoing support.
- Grade I (insufficient evidence) for screening for caregiver abuse and neglect of older or vulnerable adults. This is not a recommendation against asking — it reflects a gap in trial evidence and a call for research. Clinical suspicion, mandatory-reporting duties, and Adult Protective Services referral still apply.
The USPSTF names three brief instruments with acceptable performance for IPV: HITS (Hurt, Insult, Threaten, Scream), HARK (Humiliation, Afraid, Rape, Kick), and the WAST (Woman Abuse Screening Tool). PsychoPharmRef includes an interactive DV / IPV Assessment tool built around the HITS items plus an evidence-based lethality-risk review, generating an EMR-ready summary.
How you screen matters more than the specific instrument. A positive screen means little if it was obtained unsafely, and screening done in front of an abuser can escalate danger.
Screening safely — non-negotiables
- Screen the patient alone. Ask the accompanying partner, family member, or friend to step out — normalize it ("I ask everyone privately"). Be alert to a partner who refuses to leave or answers for the patient.
- Never use a family member or the partner as interpreter. Use a professional interpreter, ideally by phone/video, and never children.
- Frame it universally and without judgment: "Because abuse is so common and affects health, I ask all my patients about it." Consider a universal-education approach — giving every patient information about abuse and resources regardless of disclosure.
- Ask directly and simply: "Do you feel safe at home?" is a start but misses coercive control; add "Has a partner ever hurt, threatened, frightened, or controlled you?"
- Mind the chart and the device. A partner may have access to the patient portal, phone, or after-visit summary. Discuss what is safe to document and to send home.
Recognizing Abuse When It Is Not Disclosed
Most survivors will not disclose on first asking. Recognition therefore depends on pattern recognition and a low threshold for concern.
Clinical red flags
- Injuries inconsistent with the stated mechanism, injuries at different stages of healing, or central/"bathing-suit" pattern injuries.
- Delay between injury and presentation; repeated visits for vague somatic complaints.
- A partner who is overly attentive, controlling, answers for the patient, or will not leave the room.
- Reproductive coercion clues: multiple unintended pregnancies, repeat STIs, requests for covert contraception.
- Poor adherence or missed appointments that may reflect a partner restricting access to care, money, or transportation.
- Symptoms of PTSD, depression, or substance use with hints of fear, isolation, or control at home.
- Strangulation signs: neck petechiae, subconjunctival hemorrhage, voice change, difficulty swallowing, or reported loss of consciousness.
Assessing Danger and Lethality
Not all abuse carries the same risk of homicide, and the clinician's job at disclosure includes a proportionate danger assessment. Decades of femicide research (notably Campbell's work on the Danger Assessment) identify factors associated with intimate partner homicide. These are risk markers to review and document — not a checklist that "clears" anyone, and the survivor's own assessment of danger is itself an important predictor and should be weighed heavily.
Evidence-based lethality risk factors
- Access to a firearm — one of the strongest predictors; a gun in the home dramatically increases the risk of intimate partner homicide.
- Prior non-fatal strangulation ("choking") — associated with roughly a sevenfold increase in the odds of later attempted or completed homicide; a sentinel event.
- Threats to kill the partner, children, or self; the survivor's belief that the partner is capable of killing them.
- Escalation in frequency or severity of violence over the past year.
- Recent or attempted separation — the period during and after leaving is the most dangerous; risk rises rather than falls.
- Stalking and obsessive jealousy / controlling behavior.
- Forced sex, violence during pregnancy, and threats or violence toward children.
- Perpetrator factors: unemployment, substance misuse, suicidality, and a stepchild in the home.
Because separation is a peak-danger window, "just leave" is not neutral advice — leaving without a plan can increase risk. The clinician's role is to name the danger, support the patient's autonomy, and connect them to advocates who specialize in safety planning.
Responding: A Trauma-Informed First Response
How a clinician responds to a first disclosure shapes whether a survivor ever discloses again. The goal is not to "rescue" or to extract a decision to leave, but to make the visit safe, validating, and useful. A widely taught structure is to believe, validate, assess safety, and connect.
| Do | Avoid |
|---|---|
| Believe the patient and say so: "I believe you. This is not your fault." | Expressing doubt, minimizing, or asking "Are you sure?" |
| Affirm autonomy: the patient decides the pace and the plan. | Pressuring the patient to leave, call police, or take steps they are not ready for. |
| Assess immediate danger and children's safety. | Interrogating for forensic detail the patient isn't ready to give. |
| Make a warm referral to a DV advocate and offer the hotline. | Handing over a pamphlet with no conversation, or a resource that isn't safe to carry home. |
| Ask what is safe to document and to send in the after-visit summary. | Documenting details that could endanger the patient if the abuser sees the chart. |
| Address strangulation and possible TBI medically. | Assuming "no visible injury" means no serious harm. |
Safety planning, in brief
Safety planning is best done with a trained advocate, but every clinician should understand the elements: recognizing warning signs of escalation; identifying safe places and trusted people; keeping essential documents, medications, money, and a packed bag accessible; planning for children and pets; digital safety (checking devices for tracking, using a safer phone/computer); and knowing that the highest-risk period is during and just after leaving. Give patients the patient handouts only when it is safe to carry them, or point them to resources they can access privately.
Documentation and Mandatory Reporting
Documentation serves the patient's health and can later serve their legal protection — but only if it is accurate and safe. Record the history in the patient's own words where possible ("Patient states…"), document objective findings and a body map of injuries, note the time and, with consent, photograph injuries per institutional protocol. Avoid conclusory or editorializing language, and remember that the record may be read by the abuser through a shared portal.
Mandatory reporting — know your jurisdiction
- Reporting duties vary by state and by situation. Many states mandate reporting of injuries caused by weapons or by crime; some have broader clinician reporting duties for IPV, which advocates note can conflict with survivor autonomy and safety.
- Child abuse and exposure: children who witness IPV may fall under child-welfare reporting requirements in some jurisdictions; clinicians are near-universally mandated reporters of suspected child abuse or neglect.
- Elder and vulnerable-adult abuse: suspected abuse or neglect of older or dependent adults triggers Adult Protective Services reporting in most states.
- Know your local rules and tell the patient what you are and are not required to report before they disclose, so consent is informed and trust is preserved.
Vulnerable Populations
The general principles above apply to everyone, but several populations carry higher prevalence, greater lethality, or steeper barriers to disclosure and escape. These deserve specific clinical attention.
Pregnant and postpartum patients
Pregnancy is a period of heightened risk, not protection. Violence often begins or worsens in pregnancy, and homicide — overwhelmingly by an intimate partner and frequently involving a firearm — is a leading cause of death among pregnant and postpartum people in the United States. This is why the USPSTF's evidence is strongest here and why screening is recommended across pregnancy and the postpartum period.
- Reproductive coercion is central: contraceptive sabotage, pressure to become or stay pregnant or to terminate, and control of reproductive decisions. Offer contraception that can be used covertly when appropriate.
- Screen at multiple prenatal visits and postpartum, always in private, because a controlling partner often attends appointments.
- Integrate with perinatal mental health care — IPV, perinatal depression, and substance use frequently co-occur. (See the Pregnancy & Breastfeeding chapter for medication considerations.)
Older adults
Abuse of older adults blurs the line between IPV that has aged with the couple and elder abuse by an adult child or other caregiver. The abuser is often the person the patient depends on for care, transportation, finances, or medication, which makes both disclosure and leaving especially fraught. Cognitive impairment complicates capacity, consent, and the reliability of history.
- Watch for financial exploitation, medication mismanagement or withholding, neglect, and injuries attributed vaguely to "falls."
- Interview the patient alone; caregivers who answer for the patient or refuse to leave are a red flag.
- The USPSTF I statement on caregiver-abuse screening does not remove clinical or legal duties: suspected abuse or neglect generally triggers Adult Protective Services reporting. (See Geriatric Psychiatry.)
People with disabilities
People with physical, sensory, intellectual, or developmental disabilities experience IPV and caregiver abuse at higher rates and often over longer periods. Abuse can take disability-specific forms: withholding medications, mobility devices, or assistive technology; refusing or manipulating personal care; and controlling access to communication.
- Dependence on the abuser for essential care is a powerful barrier to leaving — safety planning must address continuity of care and accessible shelter.
- Ensure accessible communication and, where relevant, a professional interpreter or communication support — never the caregiver.
- Assess decision-making capacity thoughtfully; disability is not incapacity, and autonomy must be respected.
People with serious mental illness or substance use disorders
Serious mental illness and substance use disorders substantially raise the risk of victimization, and simultaneously make survivors less likely to be believed — by partners, systems, and sometimes clinicians. Abusers exploit this: threatening to report the partner as an "unfit" parent, controlling access to psychiatric medication, sabotaging treatment or recovery, or using the partner's diagnosis to discredit them.
- Take disclosures seriously regardless of diagnosis; do not let psychosis, personality disorder, or intoxication history discount a credible account.
- Consider that non-adherence, relapse, or "treatment resistance" may reflect an abuser controlling medication or destabilizing recovery.
- Coordinate safety planning with the treatment team; abrupt separation can itself precipitate psychiatric crisis, and shelters vary in their capacity to support active SMI or SUD.
Immigrants and refugees
Immigration status is a potent instrument of coercive control. Abusers threaten deportation, withhold or destroy immigration documents, refuse to file promised paperwork, and exploit fear of authorities and unfamiliarity with US systems. Language barriers and social isolation deepen dependence.
- Never use family (especially the partner) or children as interpreters; use professional interpretation.
- Know that legal protections exist independent of the abuser — such as VAWA self-petitions and the U visa for victims of certain crimes — and refer to immigration legal aid and DV advocates familiar with these pathways.
- Reassure patients about confidentiality within the limits of mandatory reporting, and connect them to culturally and linguistically specific services where available.
Also at elevated risk — brief notes
- LGBTQ+ people: comparable or higher IPV rates; abuse may include threats to "out" the partner, and survivors face shelter access barriers and the myth that abuse cannot occur in same-sex relationships or that it is "mutual."
- Adolescents and young adults: teen dating violence is common and predicts adult IPV; confidentiality rules and parental involvement require special care.
- Men: frequently victimized, rarely screened, and face stigma and disbelief; screening and resources should be inclusive.
Special Clinical Situations
Strangulation. Non-fatal strangulation is both a medical emergency and a lethality marker. It can cause delayed airway edema, carotid injury, stroke, and anoxic brain injury, and external signs are often absent. Take reported "choking" seriously, examine the neck and eyes, ask about loss of consciousness and incontinence, image when indicated, and document meticulously — it is a sentinel event for future homicide.
Traumatic brain injury. Repeated blows to the head and strangulation-related hypoxia make IPV a major hidden cause of TBI, presenting as headaches, cognitive complaints, mood changes, and "poor response to treatment." Keep it on the differential in survivors. (See TBI & CTE.)
When your patient is the person using violence. Clinicians sometimes treat perpetrators. Do not collude with minimization or blame-shifting, hold the person accountable while treating co-occurring conditions, and refer to evidence-informed battering-intervention programs rather than couples therapy, which is generally contraindicated while abuse is ongoing because it can endanger the survivor.
Clinician and staff safety. Abusers may target the clinical setting. Follow institutional protocols for threats, be cautious about documentation the abuser can access, and involve security and DV advocates when danger extends into the clinic.
Resources
Give patients a way to reach help
National Domestic Violence Hotline — call 1-800-799-SAFE (7233), text START to 88788, or chat at thehotline.org (24/7, confidential, interpretation available). Deaf/hard of hearing: video phone 1-855-812-1001.
StrongHearts Native Helpline — 1-844-762-8483. love is respect (teens/young adults) — 1-866-331-9474. 988 Suicide & Crisis Lifeline for co-occurring crisis. In immediate danger, call 911.
Safety reminder for patients: internet and phone use can be monitored. Encourage use of a safer device and clearing history, and offer PsychoPharmRef's patient handouts — Understanding Abuse and Getting Help & Resources — only when it is safe to carry them home.
Key Takeaways
- Abuse is a pattern of power and control — physical violence is one tactic among many; coercive control can be devastating without any assault.
- IPV drives a large share of the depression, PTSD, anxiety, substance use, and suicidality clinicians treat; put it on the differential and treat safety as part of the plan.
- Screen women of reproductive age, including pregnant and postpartum patients (USPSTF Grade B), using HITS, HARK, or WAST — always in private, never with family as interpreter.
- Assess lethality: firearms, prior strangulation, threats to kill, escalation, and recent separation are the highest-risk markers; leaving is the most dangerous time.
- Respond by believing, validating, respecting autonomy, and making a warm referral — not by pressuring the patient to leave.
- Pregnant patients, older adults, people with disabilities or serious mental illness, and immigrants face higher risk and steeper barriers; tailor screening, safety planning, and referrals accordingly.
- Document objectively and safely, and know your jurisdiction's mandatory-reporting duties.
References & Further Reading
- Centers for Disease Control and Prevention. About Intimate Partner Violence and the National Intimate Partner and Sexual Violence Survey (NISVS). cdc.gov.
- US Preventive Services Task Force. Screening for Intimate Partner Violence and Caregiver Abuse of Older or Vulnerable Adults: Recommendation Statement. JAMA, 2025.
- Campbell JC, et al. Risk factors for femicide in abusive relationships (Danger Assessment). Am J Public Health. 2003.
- Glass N, et al. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med. 2008.
- Wallace M, et al. Homicide during pregnancy and the postpartum period in the United States. Obstet Gynecol and related analyses.
- Futures Without Violence; National Domestic Violence Hotline (thehotline.org). Clinical and safety-planning resources.
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