Abstract
Background:
This prospective cohort study determined the prevalence of intimate partner violence (IPV) across gender groups, investigated timing of disclosures during the standard-of-care follow-up period, and examined if there was an association between IPV and clinical outcomes.
Methods:
This study included 314 patients ≥18 years of age presenting with orthopaedic injuries to the fracture clinics at 2 academic hospitals. Participants were asked about experiences with IPV, return to function, and overall health at each routine clinical follow-up. Cox proportional-hazards regression models were used to explore associations between IPV status and return to work, leisure activities, home responsibilities, and overall functioning.
Results:
Of the 528 patients approached, 314 provided consent and completed at least the initial visit. Of these, 184 (58.6%) self-identified as women, 126 (40.1%) identified as men, and 3 (1.0%) self-identified as non-binary. Forty-six percent of women reported lifetime experience of IPV, compared with 35% of men and 100% of gender-diverse participants. A smaller proportion of men who disclosed IPV did so at their first visit compared with women, especially with respect to sexual IPV: 6 men (50.0%) compared with 42 women (79.2%). During follow-up, 16 participants (6.7% of 238 who returned to the clinic at least once), including 8 men, 7 women, and 1 gender-diverse participant, disclosed experiencing IPV during their recovery period. Disclosing IPV at any visit was associated with a 45% lower likelihood of returning to a pre-injury level of function with respect to work (hazard ratio [HR], 0.55 [95% confidence interval (CI), 0.33 to 0.91]; p = 0.021) and a 36% lower likelihood of returning to a pre-injury overall level of functioning (HR, 0.64 [95% CI, 0.46 to 0.90]; p = 0.01).
Conclusions:
Results showed an unacceptably high prevalence of IPV in all genders. Gender differences in timing of disclosure emphasize the need for tailored approaches in clinical settings and repeated opportunities for IPV disclosure. This study emphasizes the hidden nature of IPV among patients with orthopaedic trauma and its effects on their health and recovery.
Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
The World Health Organization reports that 30% of women globally will experience physical or sexual intimate partner violence (IPV) in their lifetime1. Men and women with a lifetime history of IPV are more likely to report frequent headaches, chronic pain, difficulty sleeping, activity limitations, and poor physical health compared with those without a history of these forms of IPV2.
Over the past decade, orthopaedic research teams have investigated IPV in orthopaedic patients, demonstrating a strong rationale for optimizing fracture clinics to assist victims of IPV3-6. Our prior research has focused on women, as they are at substantially higher risk for escalating IPV that would lead to common orthopaedic injuries6. A recent cohort study found that patients experiencing IPV may be more likely to disclose IPV at subsequent visits as they become increasingly comfortable in the orthopaedic injury clinic setting over time6. Exploratory analyses conducted in that cohort study also found that participants who experienced IPV had a lower rate of return to pre-injury function than those who had not experienced IPV.
From that research, we developed the questions that formed the basis of this study: First, what is the prevalence of IPV across all self-identified genders in the fracture clinic population? Second, do delayed disclosures of IPV represent increased comfort in sharing past events or new occurrences since the patient’s previous visit? Third, does an experience of IPV, either historical or current, correlate with a slower return to function after orthopaedic injury? Evidence that IPV directly affects patient outcomes would provide the rationale to change practice patterns of health-care professionals who treat individuals with orthopaedic injuries.
Materials and Methods
Study Setting
This prospective cohort study took place at 2 academic hospitals in Hamilton, Ontario. Research personnel enrolled eligible participants between June and December 2023 and conducted follow-up with them for up to 12 months after enrollment. Follow-up was completed by November 2024. Research personnel local to each site collected data, and those at the centralized methods center managed and analyzed the data. The Hamilton Integrated Research Ethics Board (HiREB) provided ethics approval for this study (Project #15069).
Participants
Hospital staff identified eligible participants at their first visit to the fracture clinic. All patients ≥18 years of age presenting to their first appointment at the fracture clinic with an orthopaedic injury, who were expected to return for additional clinic visits, met the inclusion criteria. Patients were excluded if they were unable to complete the study questionnaires independently and alone in a private location, were unable to speak and write in English, or were unable or unwilling to follow the study protocol or provide informed consent.
Informed Consent and Participant Privacy
As a result of the safety precautions included in the study design, all participants were required to provide informed consent for this study on their own in a private area. Furthermore, in order to facilitate an environment with maximum privacy and anonymity, participants completed all outcome questionnaires directly in the electronic data capture system without research coordinator assistance.
Follow-up Schedule
Because of the sensitive subject matter and extensive safety planning, we designed this study to gather follow-up data only during regularly scheduled patient clinic visits. Research coordinators did not collect contact information from participants and did not contact them outside of their clinic visits.
Gender
Participants self-reported their gender identity from a selection of response options, including woman, man, gender non-conforming, gender-fluid, genderqueer, non-binary, 2-spirit (as it relates to gender), not sure or questioning, or other. Participants were also asked to identify their sex assigned at birth. To ensure accurate reflection of the experience of participants whose sex assigned at birth did not correspond with their gender, we included them together with non-binary participants in a “gender-diverse” group.
Outcomes
We documented IPV prevalence at baseline and follow-up by asking participants if they had experienced emotional, physical, or sexual abuse in their lifetime or in the previous year, using questions that contained definitions and examples. We described abuse through specific behaviors rather than terms primarily associated with women, such as “physical abuse,” to facilitate disclosures across all genders. In order to distinguish between new episodes of IPV and new disclosures of historical IPV, participants who disclosed IPV at visits after their initial visit were asked whether it occurred since their previous visit.
Finally, we assessed return to function using the Return to Function (RTF) questionnaire and overall health using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Scale version 1.2 questionnaire7. The RTF questionnaire, which was used in a previous fracture trial8, documents when participants return to work, household activities, and leisure activities without limitations, as well as when they achieve 80% of their pre-injury function. The PROMIS Global Health Scale version 1.2 is a validated, fixed-length, short-form questionnaire that measures overall health in 2 subscales: global mental health and global physical health.
Sample Size
Based on previous research, we estimated that 40% of patients would report experiencing IPV in their lifetime and that there would thus be a 1.5:1 ratio of patients who did not experience IPV to patients who experienced IPV. Using these assumptions, as well as 90% power and a 2-sided significance level of 0.05, we calculated a required sample size of 270. To account for an anticipated 20% of participants not returning for future routine clinic visits, we increased the total sample size to 324.
Statistical Analysis
Baseline demographic characteristics were analyzed using descriptive statistics and reported as the count and percentage, mean and standard deviation, or median and interquartile range (IQR). The prevalence of IPV at the time of the initial orthopaedic injury and the number of incident cases and new disclosures of IPV during standard-of-care clinic visits were reported as counts and percentages stratified by gender. We used Cox proportional-hazards regression modeling to explore the association of IPV status with the probabilities of returning to work, leisure, home responsibilities, and overall functioning. Participants were censored at their last documented follow-up visit. Gender was included as an interaction term in the modeling. Results were reported as hazard ratios (HRs) with 95% confidence intervals (CIs) and p values. All p values were 2-tailed with alpha = 0.05. We did not exclude participants with incomplete data, and we did not impute missing data. All analyses were conducted in R (version 4.4.2; R Foundation for Statistical Computing).
Results
Participant Enrollment and Characteristics
During the study period, 528 patients met the eligibility criteria, and 325 patients provided consent to participate in the cohort study. Of these, 314 patients completed at least 1 set of the questionnaires and were included in the analyses (Fig. 1).
Fig. 1.
Participant flow.
The mean age of study participants was 47.4 ± 18.9 years. Participants identified their gender as follows: woman, 58.6%; man, 40.1%; and non-binary, 1%. Three of these participants (1%) who identified their gender as male or female identified a noncorresponding sex assigned at birth. Additionally, 0.3% of participants declined to disclose their gender. Further demographic details are provided in Table 1.
Table 1.
Participant Baseline Characteristics (N = 314)*
| Age (yr) | 47.4 ± 18.9 |
| Gender | |
| Woman | 184 (58.6%) |
| Man | 126 (40.1%) |
| Non-binary | 3 (1.0%) |
| Did not disclose | 1 (0.3%) |
| Sex | |
| Male | 130 (41.4%) |
| Female | 183 (58.3%) |
| Did not disclose | 1 (0.3%) |
| Race/ethnicity | |
| Black | 10 (3.2%) |
| East Asian | 7 (2.2%) |
| Indigenous | 2 (0.6%) |
| South Asian | 16 (5.1%) |
| White | 269 (85.7%) |
| Mixed ethnicity | 2 (0.6%) |
| Middle Eastern (including Arab) | 5 (1.6%) |
| West Indian | 1 (0.3%) |
| Did not disclose | 2 (0.6%) |
| Latin or Hispanic origin | 6 (1.9%) |
| Employed prior to injury | |
| Yes | 208 (66.2%) |
| No | 101 (32.2%) |
| Did not disclose | 5 (1.6%) |
| Household income | |
| <$20,000 | 34 (10.8%) |
| $20,000 to <$40,000 | 41 (13.1%) |
| $40,000 to <$60,000 | 49 (15.6%) |
| $60,000 to <$80,000 | 56 (17.8%) |
| $80,000 to <$100,000 | 45 (14.3%) |
| ≥$100,000 | 80 (25.5%) |
| Did not disclose | 9 (2.9%) |
| Highest level of education | |
| No high school | 6 (1.9%) |
| Some high school | 27 (8.6%) |
| High school diploma | 90 (28.7%) |
| College diploma† | 97 (30.9%) |
| Bachelor’s degree | 52 (16.6%) |
| Master’s degree | 20 (6.4%) |
| Doctorate | 6 (1.9%) |
| Professional degree | 13 (4.1%) |
| Did not disclose | 3 (1.0%) |
The values are given as the mean and the standard deviation or as the number of participants, with the percentage in parentheses.
In Canada, a college diploma is generally similar to an associate’s degree in the United States.
Participant injuries were primarily fractures, with 297 participants (94.6%) having at least 1 fracture, including 7 (2.4%) with at least 1 open fracture. Injuries were split between upper-extremity injuries (137 participants [43.6%]) and lower-extremity injuries (174 participants [55.4%]), with the remaining 3 participants (1%) having injuries to both upper and lower extremities. None of the participants indicated that the presenting injury was caused by IPV.
Participants attended at least 1 clinic visit, with a range of 1 to 12 (median, 2 [IQR, 2 to 3]) (Fig. 1).
Prevalences of IPV and IPV Disclosure at the Initial Fracture Clinic Visit
At the initial fracture clinic visit (e.g., the first time that participants were asked about their experience with IPV), 134 (42.7%) of the participants reported experiencing any form of IPV in their lifetime, with 118 participants (37.6%) reporting having experienced emotional IPV, 82 (26.1%) reporting having experienced physical IPV, and 69 (22.0%) reporting having experienced sexual IPV.
The gender-diverse participants of this cohort had the highest reported rate of lifetime IPV, with all participants indicating such an experience (Table 2). Women experienced the second-highest rate, with 84 (46.4%) reporting having experienced any form of IPV in their lifetime.
Table 2.
Prevalence of IPV by Self-Reported Gender at the Initial Fracture Clinic Visit (Study Enrollment)*
| Prevalence of IPV | Total (N = 314) | Self-Reported Gender† | ||
|---|---|---|---|---|
| Women (N = 181) | Men (N = 126) | Gender-Diverse (N = 6) | ||
| Any IPV type | ||||
| Lifetime | 134 (42.7%) | 84 (46.4%) | 44 (34.9%) | 6 (100.0%) |
| 12 months | 37 (11.8%) | 22 (12.2%) | 13 (10.3%) | 2 (33.3%) |
| Emotional IPV | ||||
| Lifetime | 118 (37.6%) | 72 (39.8%) | 41 (32.5%) | 5 (83.3%) |
| 12 months | 27 (8.6%) | 15 (8.3%) | 10 (7.9%) | 2 (33.3%) |
| Physical IPV | ||||
| Lifetime | 82 (26.1%) | 53 (29.3%) | 25 (19.8%) | 4 (66.7%) |
| 12 months | 24 (7.6%) | 14 (7.7%) | 10 (7.9%) | 0 (0%) |
| Sexual IPV | ||||
| Lifetime | 69 (22.0%) | 53 (29.3%) | 12 (9.5%) | 4 (66.7%) |
| 12 months | 10 (3.2%) | 9 (5.0%) | 1 (0.8%) | 0 (0.0%) |
The values are given as the number of participants, with the percentage in parentheses.
One participant did not disclose their gender.
Men also reported a high rate of IPV, with 44 (34.9%) indicating that they experienced IPV in their lifetime, including 13 (10.3%) who had experienced IPV in the previous year. Men reported lifetime emotional IPV at rates (32.5%) similar to those of women (39.8%), but a lower proportion of men compared with women reported experiencing physical IPV (19.8% compared with 29.3%) or sexual IPV (9.5% compared with 29.3%) (Table 2).
IPV Disclosure at Subsequent Routine Fracture Clinic Visits
Of the 314 participants who completed baseline forms, 238 returned for at least 1 follow-up visit. Table 3 details all reports, separately across clinic visits, of IPV that the participants experienced since their last clinic visit. The total number of individuals who reported any new episode of any type of IPV at a subsequent follow-up visit was 16 (6.7% of 238). Of these, 8 (50%) were men, 7 (43.8%) were women, and 1 (6.3%) was gender-diverse.
Table 3.
New Episodes of IPV*
| New Episodes of IPV | Total | Self-Reported Gender | ||
|---|---|---|---|---|
| Women | Men | Gender-Diverse† | ||
| All episodes of IPV | 50 | 16 | 32 | 2 |
| Emotional IPV episodes | 31 | 6 | 23 | 2 |
| Clinic visit 1 | 5 (16.1%) | 2 (33.3%) | 2 (8.7%) | 1 (50.0%) |
| Clinic visit 2 | 7 (22.6%) | 3 (50.0%) | 3 (13.0%) | 1 (50.0%) |
| Clinic visit 3 | 5 (16.1%) | 0 (0.0%) | 5 (21.7%) | 0 (0.0%) |
| Clinic visit 4 | 1 (3.2%) | 0 (0.0%) | 1 (4.3%) | 0 (0.0%) |
| Clinic visit 5 or later | 13 (42.0%) | 1 (16.7%) | 12 (52.2%) | 0 (0.0%) |
| Physical IPV episodes | 13 | 5 | 8 | 0 |
| Clinic visit 1 | 2 (15.4%) | 2 (40.0%) | 0 (0.0%) | 0 (0.0%) |
| Clinic visit 2 | 6 (46.2%) | 3 (60.0%) | 3 (37.5%) | 0 (0.0%) |
| Clinic visit 3 | 1 (7.7%) | 0 (0.0%) | 1 (12.5%) | 0 (0.0%) |
| Clinic visit 4 | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Clinic visit 5 or later | 4 (30.8%) | 0 (0.0%) | 4 (50.0%) | 0 (0.0%) |
| Sexual IPV episodes | 6 | 5 | 1 | 0 |
| Clinic visit 1 | 2 (33.3%) | 2 (40.0%) | 0 (0.0%) | 0 (0.0%) |
| Clinic visit 2 | 3 (50.0%) | 3 (60.0%) | 0 (0.0%) | 0 (0.0%) |
| Clinic visit 3 or later | 1 (16.7%) | 0 (0.0%) | 1 (100.0%) | 0 (0.0%) |
The table only includes individuals who completed >1 clinic visit. The values are given as the number of participants, with the percentage in parentheses.
The gender-diverse participant who experienced ongoing IPV during the study period has not been separated out to preserve anonymity.
A larger proportion of participants who identified as men delayed disclosure of previous physical and sexual IPV experiences beyond the initial opportunity at the first fracture clinic visit. For example, 16 (64%) of the 25 men who disclosed having experienced physical IPV did so at the first clinic visit, compared with 42 (79.2%) of the 53 women who disclosed physical IPV at the first clinic visit. Although the sample size was small, this effect was even more pronounced for sexual abuse, with a smaller proportion of men (6 [50.0%] of 12), compared with women (42 [79.2%] of 53), disclosing sexual IPV at the first opportunity.
IPV and Patient-Important Outcomes
Experiencing IPV was associated with a 45% lower rate over time of returning to work with the pre-injury level of function and no restrictions or limitations (HR, 0.55 [95% CI, 0.33 to 0.91]; p = 0.021) and a 36% lower rate over time of returning to the pre-injury overall level of functioning with no restrictions or limitations (HR, 0.64 [95% CI, 0.46 to 0.90]; p = 0.01). A full analysis of these data can be found in Table 4. The interaction terms between IPV experience and gender were not significant.
Table 4.
Analysis of Return to Pre-Injury Function with No Restrictions or Limitations by IPV Status
| Function Category | No. of Participants | HR (95% CI) | P Value |
|---|---|---|---|
| Work* | |||
| IPV status vs. no IPV status | 165 | 0.55 (0.33 to 0.91) | 0.021 |
| Leisure activities | |||
| IPV status vs. no IPV status | 238 | 0.64 (0.30 to 1.38) | 0.253 |
| Responsibilities around the home | |||
| IPV status vs. no IPV status | 238 | 0.71 (0.42 to 1.19) | 0.192 |
| Overall level of functioning | |||
| IPV status vs. no IPV status | 238 | 0.64 (0.46 to 0.90) | 0.01 |
Participants who were unemployed at the time of their injury were excluded from this analysis.
Discussion
Inclusion of Gender Diversity
This study’s findings on the prevalence of IPV in women are consistent with previous research, including the landmark PRAISE study of patients at a fracture clinic4. Although the participants in the gender-diverse category represent a small sample size, 1.9% represents a higher proportion of gender-diverse participants than the 0.33% elicited by the most recent Canadian census9. Notably, all 6 gender-diverse participants reported experiencing IPV in their lifetime. Although we are cautious not to overstate findings based on a limited sample, this aligns with other research suggesting increased rates of IPV among gender-diverse individuals. These findings underscore the importance of inclusive sex and gender data collection in future research.
Men and IPV: Distinct Experiences and Delayed Disclosures
The findings of IPV prevalence in men underscore the importance of asking men about IPV using specific behaviors of concern, as they may be more likely to view IPV exclusively as physical abuse or may be reticent to identify with terms such as “domestic violence.”
Differences between men and other genders continued into patterns of disclosure. A larger proportion of men delayed disclosure of IPV beyond the initial opportunity, particularly in the case of sexual violence. Several factors may account for this, including the importance of rapport before addressing IPV in men or a reluctance to identify as a victim of IPV.
IPV Affects Return to Function and Other Practice Considerations
These findings have several implications for clinical practice. First, they reiterate the importance of IPV training for all health-care professionals and continuing education on the long-term health effects of IPV. Training should include non-physical forms of IPV, such as harassment and stalking, and how they may present in patients.
Those experiencing IPV often hide it well, a skill that many survivors develop to stay safe. This finding emphasizes the need for health-care professionals to be aware that IPV can be present even when it is not visibly apparent. Clinicians should avail themselves of evidence-based IPV training programs, such as IPV EDUCATE (https://ipveducate.com). Repeated opportunities to disclose should be offered to patients, as disclosure does not always happen at the first clinical encounter.
Limitations
This study had some limitations. First, it took place at 2 academic centers in the same mid-sized city. Second, although the design prioritized participant safety and privacy, that also limited the participation of some patients. The requirement that participants provide consent and complete the surveys independently effectively excluded some marginalized groups: those who did not speak or read English, those with cognitive disabilities, and those whose partner or caregiver did not permit them to be alone. Third, the design eliminated the ability to follow up with a substantial number of participants. Finally, this study exclusively collected self-reported data, which may have introduced the risk of recall bias or social desirability bias. However, self-reported data remain the most reliable way to determine IPV prevalence.
Conclusions
Although none of the presenting injuries in this study was directly caused by IPV, the results bring attention to the need for intentional approaches to addressing IPV in fracture clinics. The evidence of the pervasiveness of IPV among gender-diverse individuals is a call to all health-care professionals to engage in supportive and inclusive research and clinical practices. Creating environments in which all patients can present their authentic identities alongside their full life experience is essential to providing effective health care.
Footnotes
Investigation performed at Hamilton Health Sciences, Hamilton, Ontario, Canada, and St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
A commentary by Joshua L. Gary, MD, is linked to the online version of this article.
Disclosure: Funding for this study, used for participant payments, was provided by Physicians’ Services Incorporated (PSI) Grant Number 22-12. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I949).
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