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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- USPSTF: screen women of reproductive age, including pregnant and postpartum persons, for intimate partner violence and provide or refer those who screen positive to ongoing support services
- Screen privately without partner, family, or children old enough to interpret; use professional interpreters, not companions
- Validated tools include HITS, WAST, HARK, and Partner Violence Screen
- First response: validate, assess immediate safety, offer resources, document carefully, and respect autonomy unless mandatory reporting applies
- Mandatory reporting varies by state but generally applies to child abuse, vulnerable adult abuse, elder abuse, and some weapon-related injuries
Overview
Intimate partner violence includes physical violence, sexual violence, stalking, coercive control, reproductive coercion, psychological aggression, and financial abuse by a current or former partner. Domestic violence is broader and may involve household or family members. Step 2 CK emphasizes safety, privacy, trauma-informed communication, and patient autonomy. The best next step is rarely to confront the partner or tell the patient what to do; it is to speak privately, validate, assess danger, provide resources, and involve emergency services only when immediate safety or legal mandates require it.
Epidemiology
IPV is common and affects people of all genders, sexual orientations, ages, and socioeconomic groups, but screening evidence is strongest for women of reproductive age. Risk is higher during pregnancy and postpartum, and IPV is associated with depression, anxiety, PTSD, chronic pain, substance use, unintended pregnancy, STIs, poor prenatal outcomes, traumatic injury, homicide, and suicide. Barriers to disclosure include fear of retaliation, financial dependence, immigration concerns, shame, disability, language barriers, mistrust, and prior harmful healthcare encounters.
Screening Features and Red Flags
Symptoms
Patient reports fear of partner, controlling behavior, humiliation, threats, forced sex, reproductive coercion, or restricted access to money/medications
Injuries inconsistent with history, delayed presentation, repeated ED visits, or vague explanations should prompt private screening
Pregnancy with late prenatal care, frequent missed appointments, or partner refusing to leave room may be a clue
Depression, anxiety, PTSD symptoms, substance use, chronic pelvic pain, headaches, or abdominal pain may be associated with IPV
Threats with weapons, strangulation, escalating violence, stalking, forced sex, or threats to kill are high-lethality danger signs
Signs
Bruises in different healing stages, defensive injuries, facial/neck injuries, or patterned injuries may be present
Strangulation signs: neck bruising, hoarseness, dysphagia, petechiae, neurologic symptoms — high risk even if external signs are subtle
Partner answers for patient, refuses privacy, monitors phone, or appears excessively controlling
Normal exam does not exclude IPV; coercive control may occur without visible injury
Screening and Safety Assessment
First-line
Private screeningAsk in a safe, confidential setting without partner/family. Use professional interpreter if needed. Normalize: "Because violence is common, I ask everyone..."
Validated IPV toolsHITS (Hurt, Insult, Threaten, Scream), WAST, HARK, or Partner Violence Screen. Positive screen requires safety assessment and resources
Immediate danger assessmentAsk about escalating violence, weapons, strangulation, stalking, threats to kill, forced sex, pregnancy, separation, and children at risk
Second-line
Injury evaluationImaging, pregnancy test, STI testing, sexual assault forensic exam, strangulation assessment, or head/neck vascular imaging depending on presentation
Mental health and substance assessmentScreen for depression, PTSD, suicidality, alcohol/substance use, and self-harm risk
DocumentationUse patient quotes, body maps/photos with consent, objective injury descriptions, and avoid judgmental language
Specialist
Advocacy and social work referralConnect to IPV advocate, safety planning, shelter, legal resources, financial support, and confidential hotlines
Emergency servicesIf imminent danger, serious injury, sexual assault requiring urgent care, or mandated reporting threshold is met
Trauma-Informed Response
USPSTF Intimate Partner Violence Screening Recommendation 2025; CDC violence prevention principles1
Initial response to disclosure
- Validate: "I am sorry this is happening. You do not deserve this."
- Assess immediate safety: Is the patient safe to leave? Are children or dependents at risk? Are weapons involved?
- Offer choices and preserve autonomy; do not pressure the patient to leave immediately if not ready
- Avoid confronting the suspected abuser or documenting in a way that increases danger through patient portal access
2
Safety planning and resources
- Develop a personalized safety plan: emergency contacts, packed documents/medications, code word, transportation, safe device use
- Provide discreet resources such as National Domestic Violence Hotline and local IPV advocacy services
- Discuss technology safety: monitored phones, shared accounts, location tracking, and portal notifications
- Arrange close follow-up in a safe communication format chosen by the patient
3
Mandatory reporting and confidentiality
- Explain confidentiality limits before detailed disclosure when possible
- Report child abuse, elder/vulnerable adult abuse, and certain serious injuries according to state law
- Adult IPV alone is not universally mandated to be reported; forcing police involvement can increase harm if not legally required
- Use professional interpreters; never use the partner or family member as interpreter
4
Medical and psychological care
- Treat injuries, pain, pregnancy concerns, STI risk, sexual assault needs, and strangulation complications
- Screen for depression, anxiety, PTSD, suicidality, substance use, and reproductive coercion
- Offer emergency contraception, STI prophylaxis, HIV PEP, or forensic exam when indicated after sexual assault
- Coordinate with social work, advocacy, behavioral health, and legal aid when patient agrees
Complications
- Physical injury: Fractures, traumatic brain injury, strangulation injury, chronic pain, sexual assault, and homicide
- Pregnancy harms: Miscarriage, preterm birth, low birth weight, delayed prenatal care, and reproductive coercion
- Mental health: PTSD, depression, anxiety, substance use disorder, self-harm, and suicide
- Social consequences: Homelessness, financial dependence, immigration vulnerability, isolation, and interrupted healthcare
- System harms: Unsafe documentation, partner confrontation, or forced reporting when not legally required can escalate danger
USMLE Step 2 CK Exam Tips
- 1Always interview the patient alone if IPV is suspected
- 2Do not confront the partner; this can escalate violence
- 3Use a professional interpreter, never the partner or child
- 4First response to disclosure: validate, assess immediate safety, provide resources, and safety plan
- 5Strangulation is high risk even with minimal external findings
- 6Mandatory reporting is clear for child abuse and vulnerable adult/elder abuse; adult IPV reporting varies by state
- 7Respect adult patient autonomy unless imminent danger or mandatory reporting applies
- 8Be careful with after-visit summaries and patient portals if the abuser may monitor access
practicetest your knowledge on domestic violence & intimate partner violence screeningApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — preventive medicine and beyond.
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