Understanding Intimate Partner Violence

1. Understanding Intimate Partner Violence M. Christine King, EdD, RN University of Massachusetts

2. Guiding Principle 1 • The presentation of information about violence and abuse in women’s lives is necessary but not sufficient to change practice. Personal belief systems must be examined and altered so that new information can be incorporated into one’s practice behavior.

3. Guiding Principle 2 • Health Care Providers, and most members of the culture, have beliefs that may be erroneous about the extent, prevalence, and severity of violence and abuse in women’s lives.

4. Guiding Principle 3 • All practitioners make attributions about the cause of violence against women. • These attributions affect how, and under what circumstances, they offer and continue to provide help.

5. Guiding Principle 4 • Structural variables within the practice setting enhance or hinder the identification of and intervention with abused women. • It is extremely difficult for individual practitioners to manage this task alone.

6. Intimate Partner Violence Myths • Battering and abuse of women only affects a small percentage of the population • Abuse only occurs in certain ethnic or social classes • Abuse only occurs in “problem” or “dysfunctional” families • Violence in families is a private matter

7. Intimate Partner Violence Myths • Strong, protective men engage in forms of abuse and control; it is a part of the “male role” and demonstrates love and concern • Only men with psychological problems or who are under stress abuse women • Only people who come from families in which abuse existed end up in abusive relationships

8. Intimate Partner Violence Myths • Women would leave the relationship if it was really that bad • Women can control the level or even end the abuse by attending to their partners • Women are responsible for their own abuse and victimization

9. Intimate Partner ViolenceIPV • At least 1.8 million woman are battered by a husband, boyfriend or same sex partner or ex-partner in the United States each year, and almost all experts agree that the actual figure is closer to 3-4 million (Tjaden & Thoennes, 2000; Plichta & Falik, 2001).

10. Intimate partner violence (or battering) is defined as a pattern of physical and/or sexual assault from an intimate partner within a context of coercive control (Humphreys & Campbell, 2004; Saltzman et al, 1999). • The terminology intimate partner abuse also includes emotional or psychological abuse which has also been demonstrated to be detrimental to women’s health (Basile, Arias, Desai, & Thompson, 2004).

11. Although the majority of IPV and the worst injuries are incurred by female partners (Tjaden & Thoennes, 1998), mutual violence also occurs with ramifications for women's health.

12. The lifetime prevalence of IPA among American women based on population based studies is estimated to be 25-35%, with past year prevalence at 3-8% (Tjaden & Thoennes, 2000; Plitcha & Falik, 2001; Straus & Gelles, 1990). • Such abuse has been identified as a significant risk factor for a variety of physical and mental health problems seen frequently in outpatient and primary health care settings.

13. Vast Public Health Implications • Violence against women has been identified as a significant public health problem in the United States, with a specific objective to reduce the rate of intimate partner physical assaults 20% by 2010. (U.S. Dept. Health and Human Services, 2000.)

14. International Concerns • Intimate partner violence has been identified as an international health priority associated with significant physical and psychological health consequences, mortality, and increased health care costs. (Krug, Dahlberg, Mercy, Zwi, & Loranso, 2002; Campbell et al., 2003)

15. Primary Care Incidence • In recent studies in primary care settings, prevalence of battered women based on self-report has ranged from 20-51% for lifetime prevalence and 8-29% for prevalence in the past year (Bauer, Rodriguez & Perez-Stable, 2000; Hegarty & Bush, 2002; Naumann, Langford, Torres et al, 1999).

16. In obstetric/gynecologic services including prenatal care, prevalence has ranged from 6-21% during pregnancy and 13-21% in the postpartum period (Anderson, Marshak & Hebbeler, 2002; Campbell, Garcia-Moreno & Sharps, 2005; Gazmararian, Lazorick, & Spitz, 1996; Harrykissoon, Rickert & Wiemann, 2002).

17. In studies of abused women in primary care or HMO settings, the prevalence of battered women based on self report has ranged from 25% assaulted once during the past year and 7% assaulted often (Saunders, Hamburg & Hovey, 1993) to 15% current and 42% lifetime physical and/or sexual assault (Coker et al, 2000) to 44% with minor physical abuse and 28% with severe physical abuse (Rath, Jaratt & Leonardson, 1989).

18. When psychological abuse is added prevalence increases to 20% current and 55% lifetime (Coker et al, 2000).

19. Over the last decade, violence against women has received increased attention among health care researchers and practitioners (IOM NRC, 2002; Humphreys, Campbell, & Parker, B, 2001). This increased attention is related to viewing violence against women as a complex health problem as well as a criminal or social problem (Gerlock, 1999).

20. Data from two major national population-based surveys have shown that violence perpetrated by intimates i.e., spouses, ex-spouses, boyfriends and ex-boyfriends, accounted for 21-25% of the violent crime experienced by women and 2-8% of violent crime experienced by men (Moffitt, & Caspi, 1999, Tjaden & Thoennes, 2000).

21. Recent data also indicated that the rates of non-lethal IPV are highest among women aged 16 – 24 and women residing in low-income households, (Greenfeld, Rand, Craven, et.al.1998).

22. Among African American women between the ages of 15 – 24 years, IPV is the leading cause of premature death from homicide, and injury from non-lethal causes (Rennison & Welchans, 2000).

23. Several population based surveys also have found that IPV is significantly more common among all women of color, although when differences in income, education and/or employment are considered, the differences attributable to race decrease or disappear (Jones, Campbell, Schollenberger, et.al.,1999; Tjaden & Thoennes, 2000; Walton-Moss et al, 2005).

24. Health Effects of Intimate Partner Violence • IPA has been shown to be a risk factor for a variety of physical and mental health problems in several major controlled studies conducted in the US (Campbell, 2002; Campbell et al, 2002; Coker et al., 2004). • Battered women and their children have been found to use health care services 6-8 times more often than non-abused controls and have incurred significantly greater health care costs (Coker et al, 2003; Rath, Jaratt & Leonardson, 1989).

25. IPV has been determined as a significant risk factor for a variety of physical health problems frequently treated in outpatient, primary care settings. • From US national random survey data, it was found that severely battered women had almost twice the number of days in bed due to illness than other women and were significantly more likely to describe their health as fair or poor (Gelles & Straus, 1990).

26. Injuries or the aftermath of injuries from abuse such as pain, broken bones, gunshot wounds, facial trauma (e.g. fractured mandibles), and tendon or ligament injuries have been identified in outpatient settings (Grisso et al, 1991; Zachariades & Koumara et al, 1990).

27. Since battered women frequently report untreated loss of consciousness as a result of abuse, the chronic headaches often described by battered women may be an inadequately diagnosed sequelae of neurological damage from battering (Campbell, 2002). • Undiagnosed hearing, vision and concentration problems reported by battered women also suggest possible neurological problems from injury (Campbell, 2002; Eby et al, 1995).

28. Other symptoms and conditions associated with physical violence from intimate partners, either from medical record data or self-report, include symptoms usually associated with stress such as chronic irritable bowel syndrome, sleep disorders and hypertension (Campbell, 2002). • These symptoms may indicate the degree of stress associated with intimate partner abuse (Breslau et al, 1991; Campbell & Soeken, 1999b; Woods, Page et al, 2005).

29. Although the suppression of the immune system from chronic stress has been investigated in other populations, the role of stress in the etiology of the frequent communicable diseases of battered women and their children (Kerouac et al, 1986) has only started to be investigated (Woods, A., Page, O’Campo et al, 2005; , Woods, S., Wineman, Page et al, 2005).

30. At least two studies have linked IPV to fibromyalgia (Alexander et al, 1998; Walker et al, 1997), a condition with autoimmune system alterations. Another avenue for investigation is the relationship of stress from battering to lupus, another autoimmune disorder.

31. Approximately 40-45% of all battered women are forced into sex by their male partners (Campbell & Soeken, 1999). • This forced sex probably results in the increased risk of pelvic inflammatory disease, increased risk of sexually transmitted diseases, including HIV/AIDS, vaginal and anal tearing, dysmennorhea, bladder infections, sexual dysfunction, pelvic pain and other genital-urinary related health problems documented in several studies of battered women (Campbell, 2002; Coker et al, 2003).

32. STD’s/HIV and IPV • Eby et. al. (1995) documented that the increased risk for STD's, including HIV/AIDS, in a community sample of battered women was related to the lack of using protection during intercourse (67%), primarily at the male partner's insistence, or when sex was forced, rather than other risky behavior by the women such as multiple casual sexual partners or IV drug usage.

33. This study also specifically linked violent, forced sex by batterers with physical health problems of the women in their sample, a link not demonstrated elsewhere because of a general failure to examine sexual abuse within an intimate partner abuse context.

34. Interface of HIV and IPV • Epidemiological studies report a significant overlap in prevalence (Greenwood, Relf, Huang et. al, 2002). • IPV as a risk factor for HIV among women and men (e.g. Dunkle, Jewkes, Brown et. al., 2004; Greenwood, Relf, Huang et. al, 2002). • Violence or fear of violence impeding or as a consequence of HIV testing (Gielen, McDonnell, Burke, & O'Campo, 2000; Maman et. al., 2001; Maman et. al., 2002).

35. Interface of HIV and IPV • IPV is a risk factor for STD’s, which increases the rate of transmission of HIV (Thompson, Potter, Sanderson & Maibach, 2002). • Abusive men are more likely to have other sexual partners unknown to their wives (Garcia-Moreno & Watts, 2000). • Abused women have difficulties negotiating safe sex behavior for abused partners (Davila & Brackley, 1999; Wingood & Clemente, 1997).

36. Mental Health and IPV • Mental health sequelae to abuse are significant and prompt women to seek health care services as frequently as physical health problems. • The primary mental health response of women to ongoing intimate partner abuse is depression. In a sample of 394 adult women seeking medical care at a Family Practice medical center, depression was the strongest indicator of intimate partner abuse (Saunders, Hamburger & Hovey, 1993).

37. In controlled studies from a variety of settings, battered women are consistently found to be more depressed than other women on various instruments (Campbell, Kub, Belknap et al, 1997; Campbell, R, Sullivan & Davidson, 1997; Cascardi & O’Leary, 1992; Ratner, 1993).

38. In these studies which explored the dynamics of depression in battered women, significant predictors include the frequency and severity of abuse, stress, and women's ability to care for themselves. These were more strongly related to depression than prior history of mental illness or demographic, cultural or childhood characteristics. • In addition, there is evidence that as the abuse abates, so does the depression (Campbell & Soeken, 1999; Sullivan & Bybee, 1998).

39. However, in most of the studies of depression in abused women, comorbidity was not assessed. In more recent research, PTSD and comorbidity between the two conditions is more common than depression alone (e.g. O’Campo, Kub, Woods et al, 2006; Nixon, Resick, & Nishith, 2004).

40. PTSD has consistently been found to be more common in abused women than those not abused with an average prevalence of 63.8% among abused women. • Longitudinal evidence suggests that while depression lessens with decreasing intimate partner violence, PTSD appears to be more persistent.

41. Among a community sample of 160 abused, postabused, and nonabused women, up to 66% continued to have PTSD symptoms in spite of the fact that they had been out of the abusive relationship an average of 9 years (range 2 – 23 years) (Woods, 2000). This finding is consistent with population based studies of PTSD persistence (Breslau, Kessler, Chilcoat et al, 1998; Kessler, Sonnega, Bromet et al., 1995).

42. Pregnancy and IPV • There are now many studies of abuse in pregnant women, with prevalence of abuse during the current pregnancy ranging from 1% to 17% and the prevalence of abuse prior to pregnancy (within the past year) ranging from to 3% to 9% (Gazmararian et al, 1996; McFarlane, Parker et al, 1996; O’Campo, Gielen et al, 1994).

43. The prevalence rates varied according to how the question was asked, who made the inquiry and demographics of the sample. • The highest prevalence was found by a study that used the regular prenatal care nurse for a face to face oral inquiry, asked at each prenatal care visit, and used the Abuse Assessment Screen, four questions that ask about violent tactics and fear as well as emotional, sexual and physical "abuse" (McFarlane, Parker et al, 1992).

44. In terms of pregnancy outcomes, a meta analysis has established an association of low birthweight (LBW) with battering during pregnancy, from a review of controlled studies for other risk factors (Murphy et al, 2001).

45. Indirect causes of LBW from abuse could be through the mechanisms of stress and through the association of abuse with other risk factors for LBW noted above such as smoking and substance abuse (McFarlane, Parker & Soeken, 1996). • Campbell, King, and colleagues (1999) found that the association of abuse and birthweight was mediated by low weight gain of the mother, again perhaps a stress response.

46. There have also been indications of abuse being related to inadequate prenatal care in at least two studies (Gielen, O’Campo, 1994; McFarlane, Parker et al, 1992) another potential indirect pathway for the battering LBW connection.

47. Health Disparities and IPV • Further, it has been demonstrated that IPA is related to health disparities for women of color in the US (Sharps & Campbell, 2006; Schollenberger, Campbell et al, 2003), and a significant risk factor for HIV/AIDS in developing countries. • The context of their lives, which often includes lower levels of education, higher rates of poverty, and higher vulnerability to intimate partner violence (IPV) contributes significantly to these health disparities.

48. Health disparities are defined as differences in access to care, processes of health care or health outcomes. • The gap between health care access and health outcomes continues between minority and non-minority populations in the US. Women of color and their children compared to non-minority families are at great risk for health disparities, including access to care, processes of health care and health outcomes.

49. Health Care Costs of IPV • In one of the most definitive health care cost studies, Wisner and colleagues (1999) found that abused female members of an HMO incurred $1775 more in health care costs than nonabused women and that mental health care costs were 800% higher.

50. These findings highlight the cost of domestic violence in dollars. The costs of personal suffering and disability for individuals and families with intimate partner abuse are also significant. Early identification and interventions can prevent further stress and injury and thereby significantly reduce suffering, disability and health care costs.