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Afrizal Eka Ramadhani 22010111140157 LapKTI Bab 2
Afrizal Eka Ramadhani 22010111140157 LapKTI Bab 2
DOI: 10.1097/TA.0000000000001842
Tanya L. Zakrison, MD, FRCSC, MPH, FACS1; Rishi Rattan, MD2; Davel Milian Valdés, MD3;
Xiomara Ruiz, MD4; Rondi Gelbard, MD, FACS5; John Cline, MSW6; David Turay, MD, PhD,
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FACS7; Xian Luo-Owen, PhD8; Nicholas Namias, MBA, MD, FACS9; Jessica George, PhD10;
Dante Yeh MD, FACS11; Daniel Pust, MD12; Brian H. Williams, MD, FACS13
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EMAIL ADDRESS OF AUTHORS:
AFFILIATIONS:
1,2,4,7,9,11,12
University of Miami Miller School of Medicine, Miami, FL
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Hospital Universitario General Calixto García, Instituto de Ciencias Médicas, Universidad de la
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6,7,8
Loma Linda University and Medical Center, Loma Linda, CA
10,13
UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
Presented at the 31st Annual Scientific Assembly of the Eastern Association for the Surgery of
None
None
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SUPPLEMENTAL DIGITAL CONTENT: None
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Tanya L. Zakrison MD MPH FACS
tzakrison@med.miami.edu,
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Ryder Trauma Center
Miami, FL 33139
A recent EAST-supported, multicenter trial demonstrated a similar rate of intimate partner and
sexual violence (IPSV) between male and female trauma patients, regardless of mechanism. Our
objective was to perform a subgroup analysis of our affected male cohort as this remains an
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Methods
We conducted a recent EAST-supported, cross-sectional, multicenter trial over one year (03/15-
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04/16) involving four Level I trauma centers throughout the United States. We performed
universal screening of adult trauma patients using the validated HITS (Hurt, Insult, Threaten,
Scream) and SAVE (sexual violence) screening surveys. Risk factors for male patients were
Results
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A total of 2,034 trauma patients were screened, of which 1,281 (63%) were men. Of this cohort,
119 men (9.3%) screened positive for intimate partner violence, 14.1% for IPSV and 6.5% for
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sexual violence. On categorical analysis of the HITS screen, the proportion of men that were
physically hurt was 4.8% compared to 4.3% for women (p = 0.896). A total of 4.8% of men
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screened positive for both intimate partner and sexual violence. The total proportion of men who
presented with any history of intimate partner violence, sexual violence or both (IPSV) was
15.8%. More men affected by penetrating trauma screened positive for IPSV (p < 0.00001).
IPSV positivity in men was associated with mental illness, substance abuse, and trauma
recidivism.
One out of every twenty men that present to trauma centers is a survivor of both intimate
partner and sexual violence, with one out of every six men experiencing some form of violence.
Men are at similar risk for physical abuse as women when this intimate partner violence occurs.
IPSV is associated with penetrating trauma in men. Support programs for this population may
potentially impact associated mental illness, substance abuse, trauma recidivism and even
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societal-level violence.
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LEVEL OF EVIDENCE: III
KEY WORDS: Intimate partner violence, men, universal, trauma, sexual violence
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According to the Centers for Disease Control and Prevention, intimate partner violence
or spouse. This type of violence can occur among heterosexual or same-sex couples and does not
require sexual intimacy.(1) This form of assault constitutes the leading cause of injury to women
aged 15 to 44 years in the United States.(2) Sexual violence is defined as a sexual act committed
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against someone without that person‟s freely given consent.(3) This is also a significant source
of morbidity for women with 1 in 5 women in the US experiencing rape in her lifetime.(2)
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According to the National Intimate Partner and Sexual Violence Survey of 2010, men across the
United States also experience sexual violence victimization, with similar rates compared to
women (5.3% and 5.6%, respectively).(4) Sexual violence (IPSV) is a significant aspect of
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intimate partner violence. Both men and women present after IPSV to trauma centers and
IPSV.(5) While intimate partners commit one third of sexual assaults, IPSV is often overlooked
in studies about intimate partner violence and in research on sexual violence. Precise definitions
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remain challenging.(6)
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Most research on IPSV has largely focused locally and globally on women to the
exclusion of men.(7) Studies analyzing this in men have generally focused on same-sex trauma
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and not unidirectional female to male intimate partner violence.(8)(9) This is despite the
validation of screening tools for male survivors.(10) These studies emphasized that same-sex and
opposite-sex survivors experienced similar poor health outcomes, underscoring the need both of
Intimate partner violence against men is underreported in the medical literature.(11) This is
male and female survivors of intimate partner violence across six European cities demonstrated a
similar or higher rate of psychological, physical and sexual victimization of men when compared
to women.(13) One study out of Ireland of men experiencing intimate partner violence from their
female partners demonstrated conflicting discourses and identities of masculinity and of abused
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persons.(14) This conflict thus disadvantaged men in identifying intimate partner violence and
responding appropriately to such violence. It is important to study the prevalence and effect on
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men due to the implicated bi-directionality of overall IPSV.(5) The „cycle-of-violence‟
potentially may be broken if men who are both survivors and perpetrators of IPSV are identified
and receive intervention in a timely fashion.(15)(16) Also, IPSV in both male and female
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patients has been linked to harmful behaviors including the abuse of drugs and / or alcohol,
which may lead to trauma recidivism.(17) The psychological toll of IPSV is important for trauma
surgeons to consider as well as this is a known risk factor for mental illness.(18) It is only logical
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and equitable that support programs provided to women after such violence be similarly
provided to men.
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We are not aware of any male-only studies in the United States on intimate partner
violence in the trauma population, or the associated sequela of such violence. We previously
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intimate partner and sexual violence (IPSV) between male and female trauma patients, regardless
of mechanism.(19) Our objective was to perform a subgroup analysis of our affected male cohort
Patient Selection:
This prospective, multicenter, observational cohort study was conducted through the
Eastern Association for the Surgery of Trauma (EAST) Multicenter Trials section. Patients were
enrolled from four participating Level I trauma centers over a one-year period. Institutional
Review Board approval was obtained at the University of Miami and all participating trauma
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centers. Eligibility criteria included all adult (>= 18 years of age) male, female or transgender
patients meeting regional trauma triage criteria (meaning having been transported to a trauma
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center and alerted participating trauma center activations). Patients were required to have a clear
sensorium at the time of screening to participate and to give informed consent. Consent was
explained then implied by agreeing to participate in the screening process. Exclusion criteria
excluded. Patients who were transported immediately to the operating room for surgical
Screening of trauma patients occurred at each center anytime during the initial
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assessment in the Emergency Department or trauma bay, or at any feasible time prior to patient
discharge after admission as an in-patient. Patients deemed eligible for screening were
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approached at each site after initial trauma resuscitation or stabilization. Screening was largely
done by clinical social workers, but included behavioral psychologists or trauma registered
nurses, depending on institutional norms. Screening for IPSV was encouraged at the time of
screening for Brief Alcohol Intervention. If a language barrier existed, local translation services
were used as per standard of care. Patient demographics were collected including the age of the
violence) validated screening tools were used. The HITS screen has good construct validity and
internal consistency having been tested in emergency room populations, including after
trauma.(19) (See Figure 1) This tool was used to explore any intimate partner violence with the
current or most recent partner. This screening tool has also been validated in men and for use in
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developed by the Florida Council Against Sexual Violence.(22) It recommends the Screening of
all patients for sexual violence, Ask patients in a non-judgmental way, Validate their responses
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and Evaluate and Educate the patient while making appropriate referrals. (See Figure 2) This
tool was used to screen for any lifetime history of sexual violence. Any positive answer for the
verbal HITS or SAVE screens produces a positive screen, which merits further exploration.
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Patients, once screened using the HITS and SAVE tools, then proceeded to answer questions
history of trauma (requiring admission to hospital in the last ten years), ii) substance abuse
(defined as personal concern regarding the use of drugs and/or alcohol) and iii) any mental health
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issues or illnesses.
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Patients who screened positive for either intimate partner, sexual violence (or both) or
trauma co-morbidities were referred on to the appropriate support services as per local trauma
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Statistical Analysis:
De-identified data from each center were concatenated into a Microsoft Excel
spreadsheet, with statistical analysis performed using SPSS version 22 statistical software (SPSS,
Inc., Chicago, IL). Parametric and non-parametric testing occurred depending on normality of
test, as appropriate. Parametric data were presented as mean +/-standard deviation. Distribution
Results:
A total of 2,034 eligible trauma patients were adequately screened for IPSV in four
trauma centers across the United States over one year. Of our initial cohort, 1,281 male patients
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were identified, the mean age was 40.6 ± 16.4. Latino men were the largest ethnic group at 35%
followed by „Black‟, denoting African American, Haitian or Black Latino, at 32%. White, non-
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Latino men had a prevalence of 28%. There was no significant difference between ethnicities
and positive IPSV screens in men. The most common mechanism of injury for men was blunt
trauma (54%) with a rate of penetrating trauma of 29%. Men admitted for penetrating trauma had
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a significantly higher rate of IPSV (19% vs. 11%), (p < 0.00001) (see Table 1).
While the proportion of positive screens for men overall was 9.3%, there existed wide
variability between centers (3.8%-72.7%). The center with dedicated behavioral psychologists
performing the screening had the highest rate of positive screens for both men and women
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(72.7% and 50%, respectively), with men screening significantly higher for IPSV (p = 000831).
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Overall, the rate of HITS positive, intimate partner violence for men was 9.3%, all HITS positive
(+/- SAVE positive, meaning IPSV) was 14.1%, while for sexual violence it was 6.5% (see
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Figure 3). The total proportion of men who presented with any history of intimate partner
violence, sexual violence or both (IPSV) was 15.8%. On analysis of the HITS responses, the rate
of men that were physically hit was 4.8% overall compared to 4.3% for women (p = 0.896). The
„insult‟ portion of the HITS screen had the highest rate of positive screens, being positive in 89%
Trauma co-morbidity was commonly associated with IPSV in our male population.
Specifically, the association of substance abuse, mental illness and trauma recidivism were all
significantly associated with a positive screen for IPSV. Of men that screened positive for IPSV,
60.0% had one or more trauma-associated comorbidity compared to 15% of patients that
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screened negative (p<0.001) (see Table 2). The most commonly associated trauma co-morbidity
for men with IPSV was mental illness. Support resources and materials for both positive IPSV
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screens or the presence of trauma co-morbidities were provided as per local standard of care in
“Not even my wife knows.” – 52-year-old male trauma patient, s/p MVC screening positive for
IPSV.
In this multicenter trial, we demonstrated that intimate partner violence affects one out of
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every seven male trauma patients who present to a trauma center, regardless of mechanism of
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injury. Male trauma patients are not immune to physical violence and we found no significant
difference in the rate of this when compared to women. Penetrating trauma is associated with
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IPSV in men. Furthermore, one out of every twenty men that present to trauma centers is a
survivor of both intimate partner and sexual violence. We also demonstrated that men who
screened positive for IPSV have a higher rate of trauma co-morbidities, especially mental illness.
guidelines on screening men specifically.(24) It is thought that the identification and intervention
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similar to women.(25) This is of particular importance given the evidence that shaming,
victimization and abuse in men can lead to the perpetuation of the same, by the survivor
himself.(26) While understudied, limited data indicate that in fact, women perpetrate as much, or
more, physical and psychological aggression in their intimate relationships as their male
counterparts.(27) In fact, it is possible that intimate partner violence in men is overlooked in the
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literature as the rate of intimate partner homicide in women, the ultimate outcome of such
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Recent work on male survivors of intimate partner violence indicates that certain
programs may interrupt the bi-directionality of ongoing intimate partner violence.(15) Given the
societal stigma associated with men identifying as survivors of intimate partner, and especially
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sexual violence, a gap remains in the scientific literature on this.(29) Our cohort of male trauma
patients who screened positive for intimate partner violence had a significant association with
penetrating injury. This merits further exploration. Many of these men were admitted after
firearm-related injuries. One hypothesis is that (public) shaming by female partners in the form
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of insults or screaming may lead to behavior that reaffirms male gender schemas in society and
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traditional role assertions. Some of this behavior may, thus, be violent in nature.(30) It is
plausible that the linear bi-directionality of IPSV may be interrupted in men, leading to
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improvements in intimate partner treatment and thus family life.(31) It is also plausible that
IPSV in men may contribute, in fact, to interpersonal violence which may manifest as
exponential, multi-directional violence among partners and peers, impacting neighborhood and
societal life. Succinctly put, male shaming may lead to gun play. While there is some evidence
that men engaged in community-level, interpersonal violence are more prone to being violent
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There are several limitations to this study. Overall, during this multicenter trial of IPSV
screening, we discovered that universal screening remains challenging. This is likely even more
challenging for the male patient given that this is not a group historically targeted for screening
and intervention in IPSV. Our study demonstrated that when appropriate resources are available
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for screening, the prevalence of IPSV in male trauma patients may in fact be as high as 73%.
When they are lacking, the prevalence in men drops to 4%. While it is possible that this is indeed
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a true reflection of variance in the geographic prevalence of IPSV, this remains unlikely. Despite
calls for standardized approaches to screening for intimate partner violence for both men and
women, each trauma center that participated screened in variable ways. Two centers did not
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formally screen trauma patients universally for IPSV prior to study implementation. Variability
also depended on what patients were screened for, who did the screening and where the
screening occurred. Predictably, centers with dedicated and motivated behavioral therapists had
the highest rates of positive screens. This is important to consider when screening a patient
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Structural and cultural barriers are known to affect the success of screening for intimate
partner violence in surgical milieus (29) and these would be worthwhile to formally explore
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within a trauma context. Language is also listed as a top barrier to screening for intimate partner
violence (30), thus this is a significant consideration in diverse, multicultural centers such as
Miami, where translation services may be available in one predominant language, but not in
others. While there existed significant variability in screening at each center, reinforcing external
validity, this study still demonstrated that IPSV is prevalent in all types of male trauma patients,
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Another limitation of this study is that we were unaware if the screened male trauma
patient was describing IPSV experienced by male or female perpetrators, or both. While it is
possible that intimate partner violence is more prevalent in same-sex male relationships, this
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literature.(9) Conversely, this may be the result of under reporting of such violence due to a lack
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Nonetheless, there are no rigorous data to support the opinion that sexually diverse or gender-
nonconforming individuals have an inherent predilection towards violence, rather they tend to be
the recipient of such, including as hate crimes, which are currently on the rise in the United
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States.(35)(36) Thus, we did not feel the need to ascertain information about the sexual
orientation of the patient being screened. Nonetheless, IPSV remains a possibility in all
In conclusion, one out of every twenty men that present to trauma centers is a survivor of
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both intimate partner and sexual violence, with one out of every six a survivor of some form of
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violence. They are at similar risk for physical abuse as women when this intimate partner
violence occurs. IPSV is associated with penetrating trauma in men. Support programs for this
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population may potentially impact associated mental illness, substance abuse, trauma recidivism
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We wish to thank the EAST Multicenter Trials committee, in particular Drs. Zarzaur and Pascual
for continued support of this research. We would also like to thank the EAST Manuscript and
Literature Review Section for the opportunity for pre-submission peer-review. We would also
like to thank our male, female and transgender patients for their bravery in sharing their
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experiences of violence with us.
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AUTHOR CONTRIBUTIONS:
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Sept. 12, 2015)
4. Centers for Disease Control and Prevention. National Intimate Partner and Sexual Violence
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Survey 2010 Summary Report.
2014.)
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Differences in Female and Male Victims and Perpetrators of Partner Violence With Respect to
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2009;99(12):2182–2184.
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12. Centers for Disease Control and Prevention. Costs of intimate partner violence against
women in the United States, Atlanta, GA: US Department of Health and Human Services; 2003.
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13. Costa D, Soares J, Lindert J, Hatzidimitriadou E, Sundin Ö, Toth O, Ioannidi-Kapolo E,
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Associated with Different Types of Intimate Partner Violence (IPV): An Emergency Department
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Profile Analysis of Intimate Partner Victimization and Aggression and Examination of Between-
Class Differences in Psychopathology Symptoms and Risky Behaviors. Psychol Trauma Theory
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George J, Williams BH. Universal screening for intimate partner and sexual violence in trauma
patients: An EAST multicenter trial. J Trauma Acute Care Surg. 2017 Jul;83(1):105-110.
20. Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. HITS: a short domestic violence
screening tool for use in a family practice setting. Fam Med. 1998 Aug;30(7):508–12.
21. Shakil A, Donald S, Sinacore JM, Krepcho M. Validation of the HITS domestic violence
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screening tool with males. Fam Med. 2005 Mar;37(3):193–8.
22. Chen P-H, Rovi S, Vega M, Jacobs A, Johnson MS. Screening for domestic violence in a
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predominantly Hispanic clinical setting. Fam Pract. 2005 Dec;22(6):617–23.
23. The Florida Council Against Sexual Violence, SAVE - Screening your Patients for
25. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks
JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of
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May;14(4):245–58.
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differences in depression and anxiety among victims of intimate partner violence: the moderating
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Partner Violence Perpetration, Victimization, and Mental Health among Women Arrested for
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29. Hines DA, Malley-Morrison K. Psychological effects of partner abuse against men: A
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Aggression on Intimate Partner Violence Against Women. Prev Sci (2015) 16:881–889.
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Annan J, Lehmann H, Watts C. Working with men to prevent intimate partner violence in a
conflict-affected setting: A pilot cluster randomized controlled trial in rural Cote d‟Ivore. BMC
Understanding the barriers among orthopedic surgery residents to screening female patients for
33. Waalen J, Goodwin MM, Spitz AM, Petersen R, Saltzman LE. Screening for intimate
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partner violence by health care providers: Barriers and interventions. American Journal of Prev
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34. Burke LK, Follingstad DR. Violence in lesbian and gay relationships: theory, prevalence,
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35. Gordon AR, Meyer IH. Gender nonconformity as a target of prejudice, discrimination,
36. http://avp.org/wp-content/uploads/2017/06/NCAVP_2016_HVReport_Media-
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Figure 1: HITS screening tool – an initial, written Likert scale tool was converted to the
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Figure 3: Positive Screens of Male Trauma Patients for Intimate Partner & Sexual Violence
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Figure 4: Bi-directional vs. multidirectional model of intimate partner and interpersonal violence
Tables:
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Table 1: Demographic distribution of male trauma patients and positive IPSV screens
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Yes or No
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1.“Have you ever been touched sexually against your will or without your
consent?”
3.“Do you feel that you have control over your sexual relationships and will be
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[CATEGORY NAME] (59%)
NAME] (10%)
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versus
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(N) % IPSV+
Gender:
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Male: (1281) 63% (119) 9% (p<0.001)
Race:
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White (359) 28% (39) 11% (p = 0.098)
Mechanism of
Injury:
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IPSV- IPSV+
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