Journal of Trauma and Acute Care Surgery, Publish Ahead of Print

DOI: 10.1097/TA.0000000000001842

Universal Screening for Intimate Partner and Sexual Violence in Trauma

Patients – What About the Men? An EAST Multicenter Trial

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:

tzakrison@med.miami.edu, rrattan@miami.edu, davel12825@gmail.com,

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xiomara.ruizbaez@gmail.com, rondi.beth.gelbard@emory.edu, jdcline@llu.edu, dturay@llu.edu,

XLuoowen@llu.edu, nnamias@med.miami.edu, jessica.george@phhs.org,

dxy154@med.miami.edu, gpust@med.miami.edu, Brian.Williams@UTSouthwestern.edu

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AFFILIATIONS:
1,2,4,7,9,11,12
University of Miami Miller School of Medicine, Miami, FL
3
Hospital Universitario General Calixto García, Instituto de Ciencias Médicas, Universidad de la
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Habana, La Habana, Cuba

5
Emory University School of Medicine, Atlanta, GA
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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

Trauma, Jan. 09-13th, 2018 in Lake Buena Vista, Florida.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

DISCLOSURES OF FUNDING RECEIVED FOR THIS WORK:

None

CONFLICT OF INTEREST WITH ALL SOURCES OF SUPPORT:

None

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SUPPLEMENTAL DIGITAL CONTENT: None

CORRESPONDING AUTHOR AND CONTACT INFORMATION:

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Tanya L. Zakrison MD MPH FACS

tzakrison@med.miami.edu,
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Ryder Trauma Center

1800 NW 10th St.

Miami, FL 33139

Office phone: 305-585-1868

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Introduction

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

understudied group in the trauma literature.

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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

identified. Chi-squared test compared categorical variables with significance at p<0.05.

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Parametric data is presented as mean +/-standard deviation.

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.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Conclusions

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

STUDY TYPE: Diagnostic

KEY WORDS: Intimate partner violence, men, universal, trauma, sexual violence
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Introduction:

According to the Centers for Disease Control and Prevention, intimate partner violence

constitutes physical, emotional or psychological harm perpetrated by a current or former partner

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

emergency departments with such violence contributing to the bi-directionality of future

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

inclusive service provision and consideration of sexual orientation in population-based research.

Intimate partner violence against men is underreported in the medical literature.(11) This is

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

because women are generally more frequently affected than men.(12) Nonetheless, a study of

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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reported on a recent EAST-supported, multicenter trial which demonstrated a similar rate of

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

as this remains an understudied and neglected group in the trauma literature.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Patients and Methods:

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

were children, incarcerated or pregnant patients, or individuals incapable of consenting due to

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altered sensorium, traumatic brain injury, or intubation for any reason. Outpatients were

excluded. Patients who were transported immediately to the operating room for surgical

intervention were also excluded.

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Patient Screening Process:

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

patient, gender, race and ethnicity and mechanism of injury.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 The HITS (Hurt, Insulted, Threatened with harm or Screamed at) and SAVE (sexual

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

predominantly Spanish-speaking patients.(20),(21) Similarly, the SAVE screening method was

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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

regarding „trauma co-morbidities‟. These included binary-answer questions on i) a previous

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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center standard of care.

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

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

distribution. Categorical data analysis was performed using chi-squared testing or Fisher‟s exact

test, as appropriate. Parametric data were presented as mean +/-standard deviation. Distribution

was determined by skewness. Significance was considered p < 0.05.

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%

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

of men with IPSV, followed by „screamed at‟ with 52%. The rate of men that were forced into

sex was 3.9% compared to 12.9% for women (p<0.001).

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

each trauma center, as available.

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Discussion:

“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.

Health-care research on IPSV in men is quite limited with no comprehensive healthcare

guidelines on screening men specifically.(24) It is thought that the identification and intervention

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of IPSV involving men may lead to equally positive health outcomes and lower recidivism rates,

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

violence, far eclipses that of men by a factor of 4.3. (28)

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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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against their female intimate partners, the reverse gender model has not been described or

investigated to our knowledge.(30) (See Figure 4)

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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population unaccustomed to such interventions.

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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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regardless of mechanism of injury. This rate is likely to be higher, if and when universal

screening for IPSV in trauma centers becomes standardized.

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

controversial assertion remains consistently unsupported by peer-reviewed, evidence based

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literature.(9) Conversely, this may be the result of under reporting of such violence due to a lack

of statues in certain jurisdictions that legitimize or recognize same-sex relationships.(34)

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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

relationships, supporting the notion of universal screening in trauma centers.

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

and even societal-level violence.

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ACKNOWLEDGMENTS:

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:

Conceptual Design: BW, TZ, RG, DT, XLO, JG

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Data Extraction: XR, JC, JG TZ, DT, XLO, BW, RG

Manuscript preparation: DMV, TZ, RG, BW, DY, NN, RR, BW

Critical Revisions to Manuscript: All

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Figure legends:

Figure 1: HITS screening tool – an initial, written Likert scale tool was converted to the

validated yes / no verbal screening tool.

Figure 2: the SAVE screening tool.

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Figure 3: Positive Screens of Male Trauma Patients for Intimate Partner & Sexual Violence

TE
Figure 4: Bi-directional vs. multidirectional model of intimate partner and interpersonal violence

Tables:
EP
Table 1: Demographic distribution of male trauma patients and positive IPSV screens

Table 2: Association of IPSV with Trauma Co-morbidities in Men

C
C
A

19

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Figure 1: HITS screening tool – an initial, written Likert scale tool was converted to the
validated yes / no verbal screening tool.

D
TE
EP
C
C

Yes or No
A

20

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Figure 2: the SAVE screening tool.

D
TE
EP
1.“Have you ever been touched sexually against your will or without your

consent?”

2.“Have you ever been forced or pressured to have sex?”

C

3.“Do you feel that you have control over your sexual relationships and will be
C

listened to if you say “no” to having sex?”

A

21

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Figure 3: Positive Screens of Male Trauma Patients for Intimate Partner & Sexual Violence

Distribution of Positive Screens

[CATEGORY
NAME] (31%)
[CATEGORY

D
[CATEGORY NAME] (59%)
NAME] (10%)

TE
EP
C
C
A

22

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Figure 4: Bi-directional vs. multidirectional model of intimate partner and interpersonal violence

versus

D
TE
EP
C
C
A

23

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Table 1: Demographic distribution of male trauma patients and positive IPSV screens

(N) % IPSV+

Gender:

D
Male: (1281) 63% (119) 9% (p<0.001)

Race:

TE
White (359) 28% (39) 11% (p = 0.098)

Black (410) 32% (53) 13%

Hispanic (448) 35% (49) 11%

EP
Other (64) 5% (1) 1%

Mechanism of

Injury:

Blunt (692) 54% (76) 11% (p<0.001)

C

Penetrating (371) 29% (70) 19%

Other (205) 16% (8) 4%

C
A

24

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Table 2: Association of IPSV with Trauma Co-morbidities in Men

IPSV- IPSV+

Substance Abuse + 14% 36% (p<0.001)

Mental Illness + 17% 49% (p<0.001)

Trauma Recidivism + 13% 32% (p<0.001)

Any trauma co-morbidity + 15% 60% (p<0.001)

D
TE
EP
C
C
A

25

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