By Rebecca Gonsalves, MD

Like many of you, my job has me up at strange hours. I come home from work in the middle of the night or I am up before the sun on my way to a shift. From a young age I was taught to be careful walking alone when the streets are empty — head up, headphones off, phone out of sight, dressed a certain way; the calculations to stay safe out in public are an ingrained and inescapable reality.

We are preoccupied with the perceived threat of violence from strangers when out in public, but women and girls are more likely to be killed or assaulted by an intimate partner or family member.[3,8] Working at Highland Hospital, a county hospital in Oakland, CA, I see victims of intimate partner violence (IPV) nearly every shift. With each person, there is so much to juggle as the treating physician--stabilize and treat injuries, offer resources, document meticulously, comply with state mandated reporting, and identify who is at risk for suffering further violence or even homicide.

Emergency Departments are uniquely situated as one of the primary institutions people who are being abused may visit. We have the opportunity to offer intervention, yet more than two thirds of acutely injured victims of IPV presenting to Emergency Departments are not identified as such.[7] 

Identifying the most at-risk patients among the many victims of intimate partner violence is even more challenging. While access to firearms and a history of nonlethal strangling are significant risk factors for domestic violence (DV) homicide, neither strangling nor guns at home will necessarily be revealed in the physical exam or be freely volunteered by patients. As physicians, we will likely miss these key pieces of history if we do not explicitly ask about them.[1,6,9]

For those patients who disclose and are open to having a conversation, there are a few things that guide me in identifying which patients are at high risk of DV homicide, a term we’ve adopted from the legal system for when someone is murdered by an intimate partner or spouse, or an ex-partner:

• An abuser having access to firearms makes DV homicide 5x more likely in abusive relationships[1]

• A history of being strangled is an independent predictor of DV homicide[4]

• People in abusive relationships are at increased risk of serious injury or death when they leave their partner/abuser

• In the U.S., intimate partner violence cuts across all genders, races, and social classes, but American Indian/Alaskan Native and non-Hispanic Black women who are poor face the highest rates of DV homicide[6]

We need more research on identifying those most at risk for DV homicide, and even more so, evidence on effective interventions. We know that approximately half of the men and women murdered by intimate partners in the U.S. are killed using a gun, yet data on frequency and characteristics of domestic violence-related gun violence, proximal risk factors, and best practices in prevention, are sparse.[5] Identifying at-risk victims is challenging enough in this environment. With the limitations of current research and available tools, are we really able to offer evidence-based interventions from the Emergency Department? I want the best possible care for our patients, to provide options and advice that are backed up by strong evidence.

Some states (including California where I practice) have ERPO laws, also referred to as red flag laws, which provide an avenue for temporarily removing guns from environments where their presence may increase the risk of violence or homicide. Common sense would suggest that this is a reasonable option for protecting vulnerable people, but we need evidence as to whether ERPO laws are indeed effective in preventing injuries and deaths.

Coming home from a night shift, just before daybreak, (head up, headphones off, phone out of sight), I turn the key and feel a sense of relief in coming home. It’s difficult to acknowledge that considering the statistics, the same cannot be said for some of the patients I discharged overnight.

References:

1. Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M. A., … Laughon, K. (2003). Risk factors for femicide in abusive relationships: results from a multisite case control study. American journal of public health, 93(7), 1089–1097. doi:10.2105/ajph.93.7.1089

2. Capaldi, D. M., Knoble, N. B., Shortt, J. W., & Kim, H. K. (2012). A systematic review of risk factors for intimate partner violence. Partner abuse, 3(2), 231-280.

3. Federal Bureau of Investigation, “Supplementary Homicide Report,” 2011.

4. Glass, N., Laughon, K., Campbell, J., Block, C. R., Hanson, G., Sharps, P. W., & Taliaferro, E. (2008). Non-fatal strangulation is an important risk factor for homicide of women. The Journal of emergency medicine, 35(3), 329-335.

5. Krisberg, K. (2018). Gun Violence Research Hurt by Shortage of Funding, Data. American Journal of Public Health, 108(8), 967-967.

6. Petrosky E, Blair JM, Betz CJ, Fowler KA, Jack SP, Lyons BH. Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence — United States, 2003–2014. MMWR Morb Mortal Wkly Rep 2017;66:741–746.

7. Rhodes, K. V., Kothari, C. L., Dichter, M., Cerulli, C., Wiley, J., & Marcus, S. (2011). Intimate partner violence identification and response: time for a change in strategy. Journal of general internal medicine, 26(8), 894–899. doi:10.1007/s11606-011-1662-4

8. Sorenson, S. B. (2006). Firearm use in intimate partner violence: A brief overview. Evaluation Review, 30(3), 229-236.

9. Wintemute, G. J., Betz, M. E., & Ranney, M. L. (2016). Yes, You Can: Physicians, Patients, and Firearms. Annals of Internal Medicine, (3), 205.