ication if deemed unsafe. As many as 20% of females accessing family planning clinics who report a history of IPV also report pregnancy coercion and birth control sabotage that led to unintended or unwanted pregnancies. Over 5% of pregnant patients report IPV occurring during the pregnancy involving emotional, physical, and sexual abuse. This often resulted in delayed or no prenatal care. In addition to the risk of maternal injury, there is a risk of fetal injury or death as well as an increased risk of low-birth-weight infants (Steele-Baser et al., 2024).

Power and Control

The NDVH (n.d.-b) views the element of controlling the victim as central to understanding IPV. Whether the control is physical, emotional, mental, sexual, or financial, it leads to a lack of access to resources, services, and emotional or social support for the survivor. The Domestic Abuse Intervention Program (DAIP, n.d.-a) in Duluth, Minnesota, created a Power and Control Wheel (Figure 1) to visualize how abusers control and dominate their partners. The wheel is gender specific to females, as it was based on female victim stories of violence and survival, and demonstrates the imbalance of power in most male and female relationships. This wheel is a conceptual tool to better demonstrate how perpetrators exert control and how caregivers can effectively intervene. The outer ring includes physical and SV (or the threat of it), which is necessary for the control tactics within the wheel to work effectively. The spokes of the wheel contain various continuous ways that the individual causing abuse maintains control and power over their partner, either by economic means, intimidation, emotional abuse, isolation, coercion and threats, male privilege, via mutual children, or minimizing/denying/blaming the victim (commonly referred to now as gaslighting). The power and control obtained over the victim/partner are an indirect result of the battering behaviors, not the intention of the abuser. While the tool was originally developed in the early 1980s to describe females as victims in heterosexual relationships, the group does advise that IPV in same-sex relationships often shares many of the same characteristics. This tool can train health care and criminal justice staff to better understand the underlying patterns often seen in IPV (DAIP, n.d.-b).

Figure 1

Power and Control Wheel

(DAIP, n.d.-b)

Cultural Views of IPV

            Throughout history, females and children have fulfilled roles different from those of their male counterparts. Various cultures further view a female’s role differently from a male’s. For instance, in certain cultures, if a female spent too much money or was found to be unfaithful to their spouse, the spouse had the right to execute them. Males were permitted to sell their wives or children into slavery to pay off debts. Some historical civilizations viewed females as possessions of their husbands, and physical beatings were not uncommon. Early English law appears to have dictated to males how to beat their wives; the phrase “rule of thumb” is derived from a law permitting males to beat their wives with sticks no more than “thumb-sized.” Physical punishment of females has historically been encouraged by some cultures. If a husband failed to control their wife appropriately, they could be met with severe sanctions and legal stigma. While many of these traditional roles and behaviors may be viewed as antiquated and components potentially contributing to IPV from a modern viewpoint, historically, they were considered the norm (Criminal Justice, n.d.).

Risk and Protective Factors for Intimate Partner Violence 

            IPV results from multiple factors related to the individuals involved; the relationship, in general, the surrounding community; and the broader society. Risk factors may increase the likelihood of IPV, while protective factors may decrease it (CDC, 2024i). IPV can negatively affect the surrounding community by placing a strain on social service agencies and increasing public health costs. Within a community, poverty, violence, and a high degree of social disorder are associated with increased IPV. In a general societal view, IPV can be affected by IPV laws and the cultural norm view of aggression toward other individuals. Within a community, safe housing, physical and mental health resources, and economic support can function as protective factors in reducing IPV (Natarajan et al., 2026).

Risk Factors for IPV

                  Risk factors for IPV can be broken down into categories: perpetration, the relationship, the community, and general society.

Individual risk factors for perpetration:

low self-esteem

low education or income

young age

aggressive or delinquent behavior as a youth

heavy alcohol and drug use

depression and suicide attempts

anger and hostility

lack of nonviolent social problem-solving skills

antisocial personality traits and conduct problem

poor behavioral control and impulsiveness

traits associated with borderline personality disorder

history of being physically abusive

having few friends and being isolated from other people

economic stress (e.g., unemployment)

emotional dependence and insecurity

desire for power and control in relationships

hostility toward females

attitudes accepting or justifying violence and aggression

history of physical or emotional abuse in childhood (CDC, 2024i, para 2)

Relationship risk factors for IPV:

dominance and control of the relationship by one partner over the other

families experiencing economic stress

unhealthy family relationships or interactions

association with antisocial or aggressive peers

parents with less than a high school education

witnessing violence between parents as a child

history of experiencing poor parenting as a child

history of experiencing physical discipline as a child (CDC, 2024i, para 3)

 Community risk factors for IPV:

communities with high rates of poverty and limited educational and economic opportunities

communities with high unemployment rates

communities with high rates of violence and crime

communities where neighbors do not know to look out for each other and there is low community involvement among residents

communities with easy access to drugs and alcohol

weak community sanctions against IPV (e.g., unwillingness of neighbors to intervene in situations where they witness violence; CDC, 2024i, para 4)

Societal risk factors for IPV:

cultural norms that support aggression toward others

income inequality

weak health, educational, economic, and social policies/laws (CDC, 2024i, para 5)

Protective Factors for IPV

 Relationship factors that reduce the risk of IPV include having positive, stable relationships and strong societal support. Community factors that further deter IPV include neighborhoods with collective cohesiveness among residents who are willing to intervene for the common good. Additional protective factors include coordinating resources and services among community agencies, ensuring access to safe housing, medical and mental health services, and financial assistance (CDC, 2024i).

Special Population Groups

                  Adult females are frequently the survivors of IPV and SV; however, males can also be victims. Special populations also at risk include children and adolescents, individuals with a mental or physical disability, ill individuals, older adults, females of color, immigrant females, members of the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual, aromantic, or agender) community, those experiencing homelessness, low socioeconomic status, and those living in remote or rural areas (ACOG, 2012; CDC, 2024d, 2026b).

Risk and Protective Factors for Perpetration Against Children

About one in seven children experiences abuse and neglect yearly in the United States. In 2018, the CDC estimated the economic burden of child maltreatment at over $592 billion. Children can be survivors of neglect or physical, sexual, or emotional abuse. This can be perpetrated by a parent, caregiver, teacher, clergy member, or any other person in a position of authority over the child. Children living in a low socio-economic environment have five times the risk of abuse than children in higher socioeconomic environments. Children may not be the target of IPV, but up to 75% of the reported IPV incidents have occurred while children were present at home. Children in homes with caregiver IPV are less likely to receive preventive care and immunizations on a timely schedule. Up to 50% of children with caregiver IPV experience delays in language development or physical health problems (CDC, 2024b; Doswell et al., 2025).

            A child who witnesses IPV is at increased risk for maltreatment. Individual risk factors for child abuse are related to victimization, including age and special needs. A child under four is at a higher risk than an older child. Conditions such as autism, developmental delays, and chronic physical or mental illnesses increase the caregiver burden, increasing the risk of abuse or violence (CDC, 2024h; Doswell et al., 2025). As with adults, child abuse and neglect occur due to the same combination of factors at the individual, relationship, and community levels.

Risk Factors for Perpetration Against Children

Individual risk factors for perpetration:

caregivers with drug and alcohol abuse issues

caregivers with mental health issues, including depression

caregivers who do not understand children’s needs or development

caregivers who were abused or neglected as children

caregivers who are young or single parents or parents with many children

caregivers with low education or income

caregivers experiencing high levels of parenting stress or economic stress

caregivers who use spanking and other forms of corporal punishment for discipline

caregivers in the home who are not the biological parent

caregivers with attitudes accepting of or justifying violence or aggression (CDC, 2024h, para 3)

Relationship/family risk factors for perpetration:

families that have household members in jail or prison

families that are isolated from and not connected to other people (extended family, friends, neighbors)

families experiencing other types of violence, including relationship violence

families with high conflict and negative communication styles (CDC, 2024h, para 4)

 Community risk factors for perpetration:

communities with high rates of violence and crime

communities with high rates of poverty and limited educational and economic opportunities

communities with high unemployment rates

communities with easy access to drugs and alcohol

communities where neighbors do not know or look out for each other

communities where there is low community involvement among residents

communities with few community activities for young people

communities with unstable housing where residents move frequently

communities where families frequently experience food insecurity (CDC, 2024h, para 5)

Protective Factors for Perpetration Against Children

The goal is to prevent abuse and neglect before it happens. Among the preventive techniques is strengthening economic support for families through a family-friendly work policy or household financial security. Social norms and educational campaigns focusing on positive parenting and coaching are effective. Children should have quality care and education during their toddler, preschool, and early elementary years. These can be encouraged through state licensing and accreditation of daycare centers and early childhood programs. Initiatives such as early childhood programs and home visits can promote parenting skills and healthy child development. Finally, pediatricians and primary care providers should monitor for and intervene in high-risk situations where future abuse and neglect are suspected to minimize the effects and possibly avoid future concerns (Stirling et al., 2024; Stulz et al., 2024). Protective factors for perpetration include factors at the individual, relationship, and community levels (CDC, 2024h).

Individual protective factors for perpetration:

caregivers who create safe, positive relationships with children

caregivers who practice nurturing parenting skills and provide emotional support

caregivers who can meet basic needs of food, shelter, education, and health services

caregivers who have a college degree or higher and have steady employment (CDC, 2024h, para 6)

Relationship/family protective factors for perpetration:

families with strong social support networks and stable, positive relationships with the people around them

families where caregivers are present and interested in the child

families where caregivers enforce household rules and engage in child monitoring

families with caring adults outside the family who can serve as role models or mentors (CDC, 2024h, para 7)

 Community protective factors for perpetration:

communities with safe, stable housing

communities where families have access to high-quality preschool

communities where families have access to nurturing and safe childcare

communities where families have access to safe, engaging after-school programs and activities

communities where families have access to medical care and mental health services

communities where families have access to economic and financial help

communities where adults have work opportunities with family-friendly policies (CDC, 2024h, para 8)

Adverse Childhood Experiences

Child abuse and neglect leave a long-lasting impact on survivors. Adverse childhood experiences (ACEs) are potentially traumatic events such as experiencing violence or neglect, witnessing violence, or having a family member attempt or die by suicide. ACEs can also result from growing up in a household that experiences parental separation, mental health, or substance use issues. The majority of high school students report experiencing at least one ACE, with females, Indigenous youth, and LGBTQIA youth experiencing the highest occurrences (CDC, 2026a). The ACE Study, conducted in 1994, collected data on ACEs from over 17,000 patients. The ACE Pyramid, shown in Figure 2, was developed to demonstrate the cumulative effects of childhood stressors over a lifetime (Anda, 2020).

Figure 2

The ACE Pyramid

(National Institute of Dental and Craniofacial Research, 2021)

Laws vary in each state related to circumstances that constitute children witnessing IPV when the act is committed in the presence of a child. Nine states consider an act of violence in the presence of a child to be “aggravating circumstances” during their sentencing guidelines and may impose a harsher sentence or increased fines. In 15 states and Puerto Rico, witnessing IPV by a child occurs when the child is present or can hear or see the violent act. In 12 states, the law is broad enough to include any child, not just a child related to the IPV incident. Ten states and Puerto Rico specify that the child be related to a member of the household of the perpetrator or the victim. Some states require the perpetrator to pay for counseling services that a child who witnessed the abuse may require (Child Welfare Information Gateway, 2021).

Preschool children exposed to IPV exhibit lower self-esteem and demonstrate more behavioral problems than school-age children. Thus, exposure to IPV interferes with developing a sense of security and safety. These children develop increased attention toward threatening stimuli. This increases the risk of internalizing problems. It is associated with social withdrawal, depression, and social and general anxiety. There are more psychological adverse outcomes than in children not exposed to IPV or who have experienced physical abuse. Therefore, any childhood violence, which includes exposure to IPV within the home, can be detrimental to a child’s mental health. Studies have also shown that children and adolescents exposed to toxic stress can have negative changes in brain development. This stress can result from experiencing racism, having limited access to medical services, poverty, lack of food, living in impoverished neighborhoods, mental health issues, substance use disorder, and exposure to violence in the home (Cleaver, 2025; Doroudchi et al., 2023; Schubert, 2022).

Adolescents

            Violence in youth and adolescents is a national issue. During the period 2016 to 2022, juvenile offenders were responsible for 14% of crimes, with the use of firearms occurring more frequently (Lantz & Knapp, 2024). Bullying is reported by one in five high school students, and social media bullying is reported by one in seven. About 14 adolescents are victims of homicide each day, and 1,300 are treated at hospitals for nonfatal assaults and subsequent injuries. Youth violence can start early, with bullying and physical aggression. Exposure to IPV as an adolescent has been shown to correlate with violence into adulthood and be associated with both dating violence and IPV exposure later in life. Exposure to violence at a young age can lead to altered brain development and perpetuate the cycle of abuse (CDC, 2024e, 2024g).

Dating among adolescents is a particular concern. Adolescent dating violence can include physical, sexual, psychological, or emotional abuse by an intimate partner. It may involve stalking, with one in 12 adolescents experiencing some type of physical violence while dating. In adolescents, females experience dating and SV more than their male adolescent counterparts. LGBTQIA adolescents reported more dating violence than heterosexual students (CDC, 2025b). Peer pressure can accelerate violence in this group, combined with a social environment that may influence adolescents to remain in unhealthy relationships to fit in socially (Palumbo, 2025).

The CDC (2016a) offers a technical package on its website titled “A Comprehensive Technical Package for the Prevention of Youth Violence and Associated Risk Behaviors.” Figure 3 outlines these strategies briefly.

Figure 3

Strategies to Prevent Youth Violence per the CDC

(CDC, 2016a)

The effects of youth violence are lifelong, including adverse health and well-being, future risk of violence in relationships, victimization, smoking, substance use, obesity, high-risk sexual behavior, depression, academic difficulties, school dropout, and suicide. Youth identified as survivors or perpetrators of abuse should be assessed for previous violence and abuse by others (Staus, 2024).

People With Disabilities or Individuals Who Are Ill 

Disability affects almost 25% of adults in the form of a physical, emotional, or cognitive disability. Up to 70% of people with disabilities have experienced some form of physical or SV. A female with a disability is a victim of IPV 40% more than a nondisabled female, with up to 80% of females with disabilities reporting sexual assault. Both genders with disabilities experience higher rates of psychological abuse. Children with disabilities are physically and sexually abused more often than nondisabled children. People with disabilities often rely on caregiver assistance, which promotes a power imbalance. Disability often limits the social circle of acquaintances, allowing the vast majority of abuse against a person with a disability to be perpetrated by someone they trust. Up to 80% of abuse against a person with a disability goes unreported due to the dependence on the individual causing the abuse. Individuals with disabilities can experience abuse in a variety of ways that differ from standard abuse behavior (Sanctuary for Families, 2022).

Forms of abuse in the population of individuals with disabilities:

• invalidating or minimizing the disability
• refusing to help with necessary daily tasks (e.g., using the bathroom, dispensing medication)
• overmedicating, tampering with, and/or withholding medication
• denying access to health care appointments or disability resources
• sexual assault when a disability inhibits a person’s ability to consent
• destroying or denying access to mobility devices (e.g., wheelchairs and walkers)
• harming or threatening to harm a service animal
• using the disability to cause shame and humiliation and justify the abuse
• threats of abandonment
• intentionally ignoring personal care and hygiene (Sanctuary for Families, 2022, para 7)

Mental illness, such as major depressive disorder, bipolar disorder, and schizophrenia, has a slightly increased risk of perpetrating violence compared to individuals without mental illness. The violent behavior is often directed toward family members. Individuals diagnosed with mental illness are predisposed to abuse (D'Angelis, 2022). Exposure to repeated trauma can increase fear and social isolation, which can affect existing mental health illnesses (American Psychiatric Association [APA], n.d.).

Older Adults

            Abuse of an older adult occurs as either an intentional act or a failure to act in a manner that causes or creates harm to an adult aged 60 or older, with the abuse often perpetrated by a caregiver or trusted person. Approximately one in ten older adults living in their own homes experiences abuse or neglect. Abuse in older adults differs from that in younger adults in that the majority of the abuse is directed at males rather than females. In 2022, the economic cost of older adult violence reached almost $33 billion. For every case reported, research suggests that an estimated 20 or more cases are unreported (CDC, 2024a). Risk and protective factors previously discussed also apply to the older adult population. The HCP should understand the risk factors to identify opportunities for prevention.

Risk Factors for Perpetration Against Older Adults

Individual risk factors for perpetration:

current diagnosis of mental illness

current or past abuse of drugs or alcohol

current physical health problem

past experience of disruptive behavior

past experience of traumatic events

high levels of stress

poor or inadequate preparation or training for caregiving responsibilities

inadequate coping skills

exposure to or witnessing abuse as a child

social isolation (CDC, 2024f, para 2)

Relationship risk factors for perpetration:

high financial and emotional dependence on a vulnerable elder

past family conflict

inability to establish or maintain positive prosocial relationships

lack of social support (CDC, 2024f, para 3)

 Societal risk factors for perpetration in an institution:

staffing problems and lack of qualified staff

staff burnout and stressful working conditions (CDC, 2024f, para 4)

Protective factors for abuse of older adults have not received as much research historically. An individual protective factor is emotional intelligence. Having a strong social support system is a protective factor in relationships. A community protective factor is having the older adult feel connected and involved in the community (CDC, 2024f). HCPs can act to prevent violence against older adults by identifying signs of abuse in this patient population and how it differs from the normal aging process. The HCP can also raise awareness among the older adult population about their legal and social support options and assist them in addressing situations where their safety is questionable. It is also vital to recognize when a caregiver is feeling overburdened and provide community resources to assist with care (CDC, 2024a). Despite concerns regarding elder abuse, the US Preventive Services Task Force (USPSTF, 2025) notes insufficient evidence to routinely screen for caregiver abuse and neglect in older and vulnerable adults.

The consequences of abuse in older adults are physical and psychosocial. Abuse can show in a variety of ways, including physical injuries such as bruises, broken bones, burns, pressure injuries, anxiety, or changes in behavior such as becoming withdrawn, or changes in banking or spending patterns (National Institute on Aging, 2025). Diminishing capacity that can present in older adults can create a situation of vulnerability. Elder abuse victims often experience significant depression and are at increased risk for suicidal ideation. Identifying the presence of depression and providing psychotherapy has been shown to improve mental health in the older adult abuse patient (Burnes et al., 2022; Rollandi et al., 2025).

People of Color and Immigrants

            The effects of IPV are disproportionately borne by females of color in the United States, including immigrant and Indigenous persons. Cultural acceptance of male partner violence is present in some ethnic groups and may be accepted as normal behavior. There may be religious beliefs in the community that tolerate abusive behavior. Many barriers exist for IPV victims when considering leaving an abusive relationship. Immigrant victims may lack resources, social contacts, experience a language barrier, and fear deportation if they seek assistance. Members of minority and immigrant communities who have experienced abuse often distrust law enforcement, and may lack awareness of the legal services available to assist them (Hulley et al., 2023).

 Native American and Alaska Native (NA/AN) females experience the highest rate of IPV. Some form of violence has been experienced by over 80% of Indigenous females, with the rate of homicide 2.8 times higher than in their white female counterparts. The overwhelming majority of perpetrators of violence against Indigenous females are from outside their ethnic community. Females living on Indian reservations often face unique legal barriers due to the laws governing their territories and the rights of their residents (Indian Law Resource Center, n.d.; National Institute of Justice, 2023; Parker et al., 2024).

Most of the abuse toward native females and children relates to historical victimization. The repression of NA/AN has limited their economic resources and caused a dependency through retracting tribal rights and sovereignty. Both groups suffer from the normalization of violence and internal oppression. Many perpetrators are found to use alcohol or drugs before violent events. A higher rate of substance use is often correlated with community issues, including repression, tribal laws, lack of medical or social support, and a fundamental lack of trust outside the community. These factors can lead to alcohol and substance use, mental anguish, and suicide (Indian Law Resource Center, n.d.; National Institute of Justice, 2023; Parker et al., 2024).

African American females also experience a high rate of IPV and are victims of homicide from an intimate partner twice as often as white females. In this group of victims, racial discrimination often hinders receiving assistance (Waller & Bent-Goodley, 2023). Latin countries report a generally higher incidence of abuse against females compared to the rest of the world. Latin/Hispanic females report a higher rate of IPV, at 14%, with a reoccurrence rate as high as 59%. Many Latin females experienced an even higher rate of IPV once they immigrated to the United States, finding increased barriers to assistance due to immigrant status (Zolnikov et al., 2023). Physical and mental conditions previously discussed due to abuse are also seen in minority IPV victims. Females of color and immigrant females are more likely to live in poverty, have lower levels of education, and have less access to health care, which limits their ability to manage the adverse effects and complications of IPV (Johnson et al., 2022).

 LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and Asexual, Aromantic, or Agender)

Studies have shown that 25% of males identifying as homosexual and 37.3% of bisexual males report experiencing IPV. Bisexual males experience some form of IPV five times more than their heterosexual counterparts. Studies have documented rates of violence toward gay and bisexual males as high as rates toward females overall. Bisexual and lesbian females also experience significantly higher victimization rates compared to heterosexual females. Psychological aggression and stalking incidents of IPV are higher in sexual minority relationships. Threats to expose the victim’s sexual preference are common forms of psychological abuse. Victimization against the lesbian, transgender, gay, and bisexual population is higher for all groups than for the heterosexual population. Transgender individuals are more likely to experience IPV in public than cisgender individuals at 2.5 times the rate of violence in cisgender individuals. Ethnic groups in all LGBTQIA groups experience higher rates of violence than their cisgender counterparts. They are more likely to experience harassment, threats, or intimidation. Violence among the LGBTQIA population includes physical violence, verbal harassment, threats and intimidation, isolation, online or telephone harassment, stalking, SV, or economic/financial violence (Callan et al., 2021; Craig, 2025; Rustagi et al., 2023; Truman & Morgan, 2022).

Culturally appropriate care for the LGBTQIA community is essential to meet their unique needs. Barriers to care, vulnerabilities, and lived experiences can create a culture that diminishes the group’s needs. Education should focus on the current problems the LGBTQIA community faces and encourage awareness of these issues within health care organizations and providers. HCPs should use affirmative communication strategies and gender-inclusive language when communicating with the LGBTQIA community. Early intervention, preventive programs, and campaigns against IPV can improve outcomes for this vulnerable population (Callan et al., 2021; National LGBT Health Education Center, 2019).

Those Experiencing Homelessness

            IPV is cited as one of the primary causes of homelessness. Low income, unemployment, economic stress, and poverty are risk factors for IPV perpetrators (CDC, 2024i). Up to 57% of females who experience homelessness report that the immediate cause was IPV. This rate exceeds 80% among women with children. Staying in an abusive situation due to lack of alternative housing was reported by 45% of IPV survivors. Barriers for the unhoused population include a lack of affordable housing, financial insecurity, a lack of transportation, and a lack of childcare. The unhoused population is generally economically disadvantaged, with inconsistent employment and a lack of rental history affecting the ability to secure housing. The Supreme Court’s 2024 ruling that cities could prohibit sleeping and camping in public spaces is expected to increase the risk for violence in the unhoused population (Arismendy, n.d.; Stulz et al., 2024).

Socioeconomic Status and Rural Communities

             Higher levels of violence are associated with financial strain and lower economic status. A loss of employment also contributes to the rates of IPV. A female living in low-income housing or lower economic neighborhoods is more likely to experience IPV. Poverty is a major reason for continuing a relationship where IPV exists because the abuser has power and control over the victim. Unfortunately, individuals with low to no income may feel trapped in an abusive relationship, especially if children are involved. They rarely have the necessary resources to leave the violent situation. If they leave the relationship, many will return to the abusive partner to obtain the resources needed to care for their children (Connections for Abused Women and Their Children, 2024).

            The effects of IPV and SV in rural communities are directly related to geographical isolation as well as limited access to resources/services, distance/transportation barriers, a lack of acceptance of alternative lifestyles, and a relative paucity of shelters and affordable housing. Children in rural areas experience almost twice the rate of maltreatment as urban children. Pregnant rural residents also experience physical violence more often than urban residents. Survivors in small towns are less likely to report abuse if they or their abuser are familiar with their HCPs and law enforcement officers, citing concerns about not being believed, breaches in confidentiality, tarnished reputation, or escalated violence/retaliation (Kozhimannil et al., 2023; Rural Health Information Hub, 2026).

Male Victims/Survivors

Very few studies focus on the male survivor of IPV or SV, and male victimization is underreported, undertreated, and underrecognized by HCPs. Domestic abuse does not discriminate and occurs to male individuals from all cultural backgrounds and occupations. Within any vulnerable group, males or females may be the victims; however, specific instances and situations relate to male individuals who experience IPV and SV. When a victim is male, and the perpetrator is female, there is a stronger social stigma associated with IPV. Domestic abuse is typically portrayed as a gender crime perpetrated by males toward females. The abuse can be psychological, physical, sexual, financial, or emotional. Statistics vary according to reporting agencies, but as many as one-third of male individuals report being a survivor of IPV or SV during their lifetime. Male survivors may not report abuse, feeling isolated in this experience, embarrassed by it, and fearful that they will not be believed. Male victims have reported that law enforcement has not been supportive of their reports of IPV. Unfortunately, males are less likely to be suspected of being a victim or asked about abuse, less likely to seek help, and less likely to be believed when reporting abuse than their female counterparts. Even when HCPs recognize abuse among males, the survivor may not realize it is abuse. Often, the provider fails to offer support and empathy, which prevents the victim from seeking help; thus, the abusive cycle continues (Domestic Violence Services Network, 2024; McLeod et al., 2024).

There are significant consequences for the male survivor of IPV and SV. The effects may be emotional, behavioral, or social. Sexually abused males have higher rates of PTSD, substance use, and suicide. High-risk sexual behavior, fighting, and dating violence are also common among survivors of SV. Perpetrators of male IPV and SV may be male or female, regardless of sexual orientation. Males are more likely to report sexual abuse where the perpetrator is a family member; however, most SV in males is from nonfamily members. Given the low rates of self-disclosure of IPV and SV among males, HCPs must be trauma-informed and do their part to create a culture that gives male survivors the same considerations as female survivors. However, gender-specific care should be administered to create a safe and supportive environment for male survivors of IPV and SV (Domestic Violence Services Network, 2024; McLeod et al., 2024).

The Effects of the COVID-19 Pandemic on IPV

History has shown that during periods of crisis or instability, IPV rates have increased. This was again demonstrated during the COVID-19 pandemic, with rates of IPV increasing during the quarantine period. Rates of abuse toward children decreased during the same period, which was felt to be related to a lack of reporting due to school closures. Factors contributing to the rise include unemployment, lower socioeconomic status (compared to prepandemic), family mental illness, overcrowding, and a COVID-19 diagnosis within the family unit. Measures implemented to control the spread of COVID-19, such as social distancing and stay-at-home orders, increased the vulnerability to IPV and decreased access to support networks. These measures were implemented to protect individuals from infection; however, they forced victims to be quarantined with their abusers. Unfortunately, the pandemic caused increased unemployment, especially among immigrants, females of color, and individuals without a college degree, exacerbating financial stress and entanglement. Public health measures implemented to limit the spread of COVID-19 reduced access to alternative housing, as hotels and shelters reduced capacity or shut down (Kourti et al., 2023). The pandemic resulted in quarantine, but it also caused an increase in alcohol use, PTSD, and depression, all of which exacerbated IPV (Newman, 2021). The pandemic also forced many providers to use telemedicine, thereby reducing the number of face-to-face encounters. This also created barriers to assessing IPV and to screening the patient alone. Providers should screen for IPV during telemedicine appointments and discuss safety planning with the patient (Kourti et al., 2023).

Prevention of IPV/SV

                  According to the CDC (2024j, 2025b), prevention is key to reducing IPV. Encouraging the development of respectful, nonviolent relationships, and broader communities can reduce the incidence of IPV. The details of these prevention steps are shown in Figure 4 (CDC, 2024j).

Figure 4 

Preventing IPV

 

(CDC, 2024j)

The CDC (2024d) also developed the Public Health Approach to Violence Prevention (PHAVP), which outlines four clear steps to prevent violence:

1. define and monitor the problem
2. identify risk and protective factors
3. develop and test prevention strategies
4. assure widespread adoption (CDC, 2024d)

Health care facilities can adopt this approach through ongoing surveillance and reporting to the appropriate agencies. The first two steps focus on defining the problem by sharing statistics and understanding the risk and protective factors. PHAVP can create a trauma-informed culture that readily identifies survivors and patients at risk for victimization. Violence prevention aims to decrease the risk factors and increase protective factors. In the third step, strategies are explored and defined to develop the optimal interventions to reduce or prevent violence. Finally, in step four, proven strategies are shared within health care communities, leading to the broad adoption of best practices. Ongoing monitoring, assessment, and evaluation are necessary to stay ahead of trends or identify opportunities to improve interventions (CDC, 2024c).

To prevent SV, the CDC developed the STOP SV acronym, whose components are depicted in Figure 5 (CDC, 2016b).

Figure 5

 STOP SV

(CDC, 2016b)

 

 Common Indicators of IPV and SV

                  To identify patients potentially experiencing IPV or SV, the HCP must first be educated to recognize the signs and symptoms in all groups, including females, males, children, and all the vulnerable populations discussed in this module (Suniega et al., 2022). The following list of signs and symptoms notes common indicators of abuse that HCPs should be watchful for when caring for patients:

injuries that point to a defensive position over the face (bruises and marks on the inside of the arms or back)

injuries to the chest and stomach, reproductive organs, and anus

illness or injuries that do not match the cause given

a delay in requesting medical care

injuries and bruises of various colors, indicating that they did not occur together

repeat injuries, or someone who is “accident prone” with evidence of multiple healed fractures on radiograph

ruptured eardrums

injuries during pregnancy

repeated reproductive health problems, such as repeated miscarriages, early delivery, STIs, vaginal discharge, or sexual dysfunction

psychological or behavioral problems

suicide attempts or signs of depression

repeat and chronic medical concerns, pelvic issues and pains, psychological diseases, chronic headaches (including migraines)

repeatedly missing work, school, or social obligations without explanation

behavioral signs such as multiple visits seeking medical care; a lack of commitment to appointments; not displaying any emotion or crying very easily; an inability to undertake daily interactions; negligence; defensive positions; stilted speech; avoiding eye contact; discomfort in the presence of their partner; acting nervous or anxious; attempting to hide injuries with sunglasses, scarfs, or outerwear; and animosity in body language (Suniega et al., 2022; van Houten et al., 2022; Washington State Department of Social and Health Services, n.d.).

If present, the abuser/partner may display extreme or irrational jealousy or possessiveness. Abusers may attempt to control the time spent with the provider or nurse by insisting on staying close to the patient and speaking on their behalf (Kippert, 2022). Injuries may be physical, including bruises and fractures, and can be quickly recognized by an HCP. However, the abused individual may exhibit various cardiovascular, gastrointestinal, reproductive, musculoskeletal, or central nervous system conditions, typically chronic and less obvious to the HCP. Mental health conditions such as depression and anxiety may be related to current or previous IPV or SV. Survivors of IPV or SV may present with reports of poor appetite, disturbed sleep, or mood disorder symptoms. Warning signs of abuse may also include asthma, stress-related illnesses, anxiety/panic attacks, vague aches and pains, chronic diarrhea, abdominal pain, bladder/kidney infections, joint pain, or muscle pain (Weil, 2025a).

Screening Tools

The primary role of HCPs is to recognize potential survivors of IPV and SV, provide screening, and offer interventions and resources. The USPSTF (2025) recommends universal screening of all females of reproductive age for IPV (grade B) but did not find sufficient evidence to recommend screening for/against older or vulnerable adults. Various screening tools are available for HCPs. There is no preference for a single instrument but rather a consistent pattern of patient screening with an organizational culture of trauma awareness. Privacy should be provided when screening for violence (National Sexual Violence Resource Center [NSVRC], 2024; Weil, 2025a).

Medical interpreters (MIs) should be covered/reviewed with HCPs as a component of cultural competency training. It is especially pertinent when screening for IPV in those patients who do not speak English as their first language. The HCP should assess whether an MI is needed and discuss it with the patient to ensure the patient consents to its use. HCPs should brief the MI on the most crucial aspects before the patient arrives to ensure efficient transfer of information (NSVRC, 2024; Victim Rights Law Center, 2019). When using an MI, it is important to remember the following:

• MIs utilize conduit-style interpretation, a literal translation delivered in the first person without clarification, summarization, or omission.
• HCPs should speak in short sentences and avoid extensive medical jargon except when necessary.
• HCPs should sit across from the patient at eye level and speak directly to the patient, allowing a clear and unobstructed view of the patient and the HCP by the MI.
• When doing a physical examination, a curtain should be used to protect the patient’s privacy while allowing the MI to hear and continue interpreting during the examination.
• A short debrief with the MI following the examination should occur, thanking them for their assistance; the medical record should include the MI’s name and any other prudent agency contact information (Asian Pacific Institute on Gender-Based Violence, 2015; NSVRC, 2024; Potter et al., 2026; Victim Rights Law Center, 2019).

The Humiliation, Afraid, Rape, Kick (HARK); Hurt/Insult/Threaten/Scream (HITS); Extended-Hurt/Insult/Threaten/Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST) are validated screening tools to assess for IPV and SV. The HARK has four questions assessing for emotional and physical abuse in the past year. The HITS has four items that determine the frequency of IPV, and the E-HITS includes additional SV-related issues. The PVS has three questions that assess for physical abuse and the safety of the individual. The WAST assesses for physical and emotional IPV via eight questions (Weil, 2025a).

A concerted effort should be made to conduct screening for IPV and SV in private, which may be difficult with children, people with disabilities, and other vulnerable populations who depend on caregivers for transport and assistance within the health care system. Language barriers or other communication disabilities should also be considered, such as blindness or hearing impairment. Privacy allows the survivor to respond to screening questions without fear of retaliation. In addition to using a screening tool(s), HCPs should assess for the physical and emotional signs of abuse. Health centers across the country are advised to build partnerships with local IPV/SV programs; implement new/updated policies to prevent, identify, and care for IPV/SV survivors in collaboration with local IPV/SV programs; adopt the evidence-based intervention to educate patients on the connection between IPV and their health to promote wellness and safety; train providers/staff regarding the impact of IPV/SV on health outcomes and how to assess/care for survivors of IPV/SV; and evaluate and sustain progress through diligent quality improvement (Blumenfeld & Baca, 2021).

Despite being asked directly by an HCP about violence, survivors may choose not to disclose due to distrust or fear of subsequent violence. A study based on survivors’ advice suggests that the HCP alleviates the patient’s suspicions and stigma by explaining why they are asking. They also recommend creating a supportive, safe atmosphere and providing information and resources, regardless of disclosure status. The act of asking about IPV raises awareness, educates, and transmits compassion (NSVRC, 2024). Interviewing adolescent victims of abuse requires forming a connection with the victim and assessing their developmental stage, providing a sense of independence and control. HCPs should promote a sense of genuineness and be transparent in the proceedings (Deck et al., 2024).

Females of reproductive age have the highest prevalence of IPV, leading to unintended pregnancies, pregnancy complications, STIs, and other gynecological disorders and injuries related to IPV. An excellent opportunity exists for gynecologists and all HCPs providing care to females to assess, intervene, and provide resources for female patients experiencing IPV. It is important to screen all patients at various times throughout pregnancy because many females do not disclose IPV the first time they are questioned about it. IPV screening and counseling should be part of all preventive health and obstetric care for females. For pregnant patients, an assessment should occur at least once per trimester and again during the postpartum visit (ACOG, 2012; Lutgendorf, 2019).

Establishing Trauma-Informed Care for IPV/SV Survivors

Creating a culture of trauma-informed care or practice (TIC or TIP) can facilitate early recognition and intervention to decrease victimization. TIC addresses the concept that trauma affects the brain and can often have victims existing in survival mode even after the danger has resolved. The focus shifts to understanding how the experience affects the victim both mentally and physically. The focus with TIC becomes building trust in the victim and providing them with the space to make their own decisions. Health care organizations and teams must develop a complete picture of a patient’s past and present life situation to care for the entire patient with a healing orientation. If implemented optimally, TIC can improve patient outcomes, advance treatment adherence, and reduce health care and social services costs. Multiple principles underpin TIC (National Network to End Domestic Violence [NNEDV], n. d.). These include:

awareness of the effect trauma has on survivors

safety must be provided to survivors on both a physical and an emotional level

trustworthiness needs to be rebuilt in relationships

empowerment needs to be given to the survivors in the decision-making process (NNEDV, n. d.).

TIC requires a comprehensive approach that must include both the clinical and organizational levels. HCPs can provide TIC by focusing on:

realizing the widespread impact of trauma and understanding paths for recovery for the survivor

recognizing the signs and symptoms of trauma in patients, families, and staff

integrating knowledge about trauma into clinic policies, procedures, and practices

actively avoid retraumatization by recognizing triggers (Center for Healthcare Strategies, n.d.)

 

Within these principles, establishing emotional safety includes creating a physical environment that minimizes triggers. For example, this might consist of an area for children to play or a comfortable waiting area with minimal stimulation. Staff should adopt a nonjudgmental approach to all interactions, including questions. Programs should have well-developed policies related to TIC and communicate these policies clearly and effectively to all staff involved. Restoring choice and control allows the survivor to tell their “story” in their way within the time and space they choose. Facilitating connection also supports healing by encouraging the survivor to connect with staff, other survivors, their families, and community friends. One of the most challenging aspects of this particular skill for staff is learning to interact with the survivor and form mutual relationships. Supporting coping validates the survivor’s coping style without judgment. There is no specific way for a survivor to move through healing; this step facilitates progress without dictating how it is done. The survivor should understand that their response to the trauma is appropriate as long as it is helping them move through the healing process. Responding to identity and context may facilitate IPV survivors accessing available services. A lack of cultural inclusivity often retraumatizes survivors and prevents them from feeling safe. Most importantly, this step allows the survivor to understand what happened to them. The questions are designed to prompt the survivors to look within themselves and consider who they are and what happened during the abusive episode (Davies et al., 2025; NNEDV n.d.; Wathen & Mantler, 2022).

Barriers to delivering TIC may be within an individual or an organization. One potential individual barrier is a lack of confidence in confronting survivors about their experiences. HCPs have reported fears of offending survivors when asking screening questions. Identification of this fear further supports the need for a culture where assessment for IPV and SV is universal and not isolated to those perceived to be at risk. Consistently, nurses cite a lack of training as a barrier to screening for IPV and SV. Additional training, with opportunities for role-play or simulation, will increase comfort and confidence when addressing these issues with patients. Institutional barriers may include a lack of time, perceived powerlessness to help, or marginalization by colleagues or the organization. Improved identification of abuse can be achieved through increased training, robust policies and procedures, and an expectation of universal screening of all patients (Davies et al., 2025; Wathen & Mantler, 2022).

If an HCP determines that a patient is a victim or survivor of violence, they should acknowledge the trauma and assess the immediate safety of the patient and any children involved. A safety plan using local resources specific to their area is essential. The survivor should be given information on mental health services, crisis hotline numbers, rape relief centers, shelters, legal aid, and police contact information. It is incumbent upon each HCP to have this information prepared in advance or to be able to access it quickly if needed. The survivor should not be forced to accept assistance, and information should not be placed in their pocket or purse without their knowledge, as the perpetrator may find this information and escalate the violence. This mandate also further diminishes the survivor’s sense of control and autonomy. It is optimal to offer a private phone call for the survivor to connect with a local IPV agency, shelter, or the National Domestic Violence Hotline (NDVH). Particularly if the survivor needs an interpreter, the NDVH is multilingual and can support survivors whose primary language is not English. Since an abusive partner may monitor the survivor’s call logs, their personal phone should not be used (Blumenfeld & Baca, 2021; Weil, 2025b).

Mandatory Reporting

State and local reporting requirements vary by jurisdiction, and the nurse or HCP should be familiar with their local and state expectations. Some states designate school personnel, social workers, law enforcement, clergy, and therapists as mandatory reporters. Any known or suspected violence against vulnerable populations must be reported in the United States, although specific regulations will vary by state. Vulnerable individuals include children, older adults, and individuals with mentally disabilities. Incidents that involve adults who do not fall into a vulnerable population category do not always meet the requirement for mandatory reporting. Most states require that injuries caused in violation of criminal law by intentional or nonaccidental means or involving the use of a weapon be reported to the proper authorities. Failure to report suspected abuse can lead to fines or incarceration for the nurse or other HCP. To ensure compliance with state and federal reporting laws, local law enforcement or IPV agencies can help guide the nurse or HCP to the specific jurisdiction (Child Welfare Information Gateway, 2023; HeadStart.gov, 2025; National Center for Elder Abuse, 2019; Thomas & Reeves, 2023). HCPs should be aware of the reporting requirements in their state (World Population Review, 2026).

Reporting suspected abuse of a child is mandatory in all states. Child abuse and neglect must be reported to the relevant local and/or state department if there is reasonable cause to believe a child may be suffering physical or emotional abuse by specified mandated reporters in 46 states and the District of Columbia; the remaining four states, Indiana, New Jersey, North Carolina, and Wyoming, require all persons to report regardless of profession. Reporting should include harm or substantial risk of harm to a child’s health or welfare, sexual abuse, neglect, malnutrition, or physical dependence on a drug at birth. Reporting can be confidential in most states, although 19 states currently require mandatory reporters to provide their identity to assist in the investigation (Child Welfare Information Gateway, 2023).

Human Trafficking

                  Human trafficking is considered a violent crime and should be addressed when discussing IPV and SV. Human trafficking is modern slavery and may take the form of labor trafficking or sex trafficking. It is characterized by exploiting an individual with force, fraud, or coercion to either work or perform sexual acts. Risk factors for human trafficking targets include living in unsafe situations, poverty, being members of vulnerable populations, or being in an environment of abuse at home. Sex trafficking affects the survivor’s health, including increased risk for HIV/AIDS, STIs, pelvic pain, rectal trauma, or urinary difficulties. Potential long-term consequences for survivors of sex trafficking also include pregnancy secondary to rape or prostitution; infertility related to chronic, untreated STIs or unsafe abortions; infections or mutilations caused by sex traffickers’ “doctors”; chronic back pain; malnourishment; dental problems; diabetes; cancer; or infectious diseases such as tuberculosis. Physical signs of abuse, such as bruises, bites, and scars, may be present. The injuries may be in areas not readily visible, such as the lower back. Substance use is common in sex workers as they may be forced to take them by their perpetrators or use them voluntarily to cope with the situation. Mental health issues such as depression, panic attacks, shock, denial, or shame are common among survivors of human trafficking (Bradley & Macias-Konstantopoulos, 2026; CDC, 2024c).

 There has been an increased awareness of human trafficking in recent years. The Trafficking Victims Protection Act was originally developed in 2000 to train and outline services needed for survivors of human trafficking; it was reauthorized in 2017 to expand resources and further address the needs of survivors. Prevention efforts should emphasize encouraging healthy relationships, fostering safe homes and neighborhoods, identifying vulnerabilities during health care visits, reducing the demands for commercial sex, and ending business profits from trafficking-related transactions (CDC, 2024c).

PTSD and IPV

The long-term effects of IPV and SV may include PTSD. The American Psychiatric Association (APA, 2025) defines PTSD as “a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, serious accident, terrorist act, war/combat, rape or other violent assault.” Those experiencing PTSD have distressing thoughts and feelings toward their experience that last long after the event is over. The individual could experience flashbacks, nightmares, sadness, fear, anxiety, anger, poor interpersonal relationships, or attachment issues. A person with PTSD can have strong adverse reactions to loud noises or accidental touch. Symptoms of PTSD have four categories: intrusive thoughts, avoiding reminders, negative thoughts and feelings, or arousal and reactive symptoms. To be diagnosed with PTSD, these symptoms should be exhibited for over a month and may persist for years. PTSD may occur with other mental health conditions, such as depression or substance use disorder (APA, 2025).

            Anyone impacted by IPV or SV can develop PTSD, and in most cases, the condition is complex. The factors related to PTSD in IPV and SV survivors can include the following:

feelings of guilt related to the violence

the age of the survivor

the duration of the trauma or abuse

the survivor’s perception of the trauma

a lack of social support

an inability to stop the abuse or violence (APA, 2025; Fernández-Fillol et al., 2021)

PTSD can also occur from perceived threats, and early recognition can avoid many of the long-term implications of PTSD. Children who are survivors of IPV or SV do not respond well to the standard treatment of reliving their experience during therapy. This group responds best to emotional regulation and group therapy that allows them to discuss their feelings. Adults with a history of abuse as children may also benefit from this treatment. A multi-faceted approach to caring for survivors of IPV and SV with PTSD is vital to promote safety, self-care, and protection from further violence (APA, 2025; Fernández-Fillol et al., 2021).

National Resources:

National Domestic Violence Hotline-

Call (800) 799-SAFE (7233)

Text START to 88788

Visit www.thehotline.org

International Resource: The WHO (2023) has provided an extensive checklist for national statistics offices, national research and data institutions, and research teams to guide future data collection and research to obtain high-quality survey data on IPV.

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