Introduction
At its most basic level, intimate partner violence (IPV) involves the exertion of power and control by one person over another. IPV is pervasive in our society and no culture, ethnicity, or race should be considered immune. As practitioners, it is important to recognize the magnitude of the problem, to understand the complex social dynamics involved in these violent relationships, and most importantly, to appreciate the profound and long-lasting effects IPV can have on a person’s physical, emotional, and behavioral health.
Definitions
The study of IPV has, in many ways, suffered from the inability of investigators to agree on the use of consistent terminology. Although often used interchangeably, the term “intimate partner violence” is distinct from other, more inclusive terms such as “family violence” or “domestic violence,” which may encompass additional forms of violence, including child abuse and elder abuse. The term “intimate partner violence” should also be distinguished from the term “violence against women,” which includes not only IPV, but sexual violence by unknown perpetrators and other forms of violence against women as well. Additionally, research has shown a lack of consistency in what people consider acts of “violence” and who represents an “intimate partner.” Much of the early research in the field, for example, focused primarily on physical acts of aggression against women, without consideration of other forms of violence.
For the purposes of this chapter, we define IPV using the definition adopted by the World Health Organization: “Any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. ” This definition is consistent with the Centers for Disease Control and Prevention (CDC), which defines IPV as “a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation. ” What the definitions from these two organizations share is the recognition that IPV encompasses many forms of maltreatment, including physical abuse, sexual abuse, emotional abuse and neglect. Perhaps no organization has illustrated this concept better than the Domestic Abuse Intervention Project with the “Power and Control Wheel” ( Figure 4-1 ). Although the figure is specific to abusive behaviors by men against women, “intimate partners” are defined by the CDC as current, divorced, or separated spouses (including common-law), and current or former dating or nonmarital partners, irrespective of gender, history of sexual involvement, or cohabitation status.
Scope of the Issue
Given the variability in the published research, the true incidence and prevalence of IPV is difficult to determine. As a result, there are likely mixed conclusions as to the scope of the problem, and many believe that published statistics either underestimate or overexaggerate the issue. What is clear, however, is that IPV is a global health crisis. A review of 48 population-based surveys from around the world found that between 10% and 69% of women report being physically assaulted by an intimate partner at some point in their lives. When considering additional and more common forms of IPV, such as intimidation, controlling behaviors, and humiliation, it is believed one in three women worldwide will be abused in her lifetime. In the United States, it is estimated that 1.5 million women are physically or sexually assaulted by an intimate partner each year. Many of these women are assaulted more than once, raising estimates to nearly 5 million assaults each year. It is important to recognize that patterns of dating violence begin early in life. Approximately 1 in 5 female high school students report being physically and/or sexually abused by a dating partner.
Risk Factors
The risk factors leading to perpetration of and victimization by IPV are best thought of in a socioecological model that considers individual, relational, community, and societal concerns. Individually, perhaps one of the strongest risk factors for becoming a perpetrator of IPV is a history of family violence during childhood. This includes not only the child who suffers abuse, but also the child who is exposed to violence between his/her parents. Other recognized risk factors for an individual include mental health issues (specifically depression) and substance abuse. Women of lower socioeconomic status are disproportionately affected by IPV. Within relationships, risk factors for IPV include conflict, instability, or discord within the relationship, often centering around economic or job stress, or the stressors associated with pregnancy and childbirth. Communities are often poorly equipped to respond to IPV as a public health issue and may in part contribute to the issue by “refusing to take a stand” against the violence. Likewise, societies that devalue the independence of women and promote violence as a means of resolving disputes likely foster an environment where IPV can thrive.
Social Considerations
With respect to how a woman views her abusive relationship, it has been proposed that there are several cognitive stages of change through which she may pass, ranging at one end from failure to even recognize IPV as a problem to the other where she has ended a relationship and is avoiding further abuse. Because of this spectrum of response, caring for women who are in abusive relationships is a dynamic process and may be frustrating for a health care provider. For those women that do recognize abusive behavior as a problem, the decision to seek help is difficult and is compounded by numerous personal, systemic, and societal barriers. To effectively help women involved in these relationships, we must begin to understand the principal social dynamics of IPV, including the common barriers preventing victims and providers from addressing IPV and the motivating factors for a woman to disclose IPV and seek help.
Barriers to Seeking Help
Before deciding to leave an abusive relationship, a woman must recognize that her relationship is a problem. Based on a childhood exposure to violence, or experience in past violent relationships, women may believe that a normal relationship is characterized by abusive behavior. Some also downplay the abuse as a problem unless one is injured severely enough to require medical attention.
Even after recognizing the abuse as a problem, women often continue in the relationship. The decision to leave is confounded by conflicting emotional states. While recognizing the need to leave, many women continue to feel love for the perpetrator. Remembering the “good times” of the relationship, they hope for change and protect the perpetrator. Additionally, low self-esteem, guilt, shame, and self-blame, all of which are often fostered by the perpetrator, prevent women from accessing help. Fear of perpetrator reprisal against efforts to leave is an immense barrier.
Practical concerns also impede leaving an abusive relationship. Many women are without jobs or access to household accounts and are therefore financially dependent upon their abuser. There is the potential to lose the home and current lifestyle. Social isolation is a common weapon of abuse. Women may be separated emotionally or geographically from friends and family and they often do not know who to turn to for help. ,
Women with children cite several unique barriers to accessing help, including the need to keep the family together and have the children know their father, not disrupting their children’s lives, and fear of child protective services involvement and possible resultant loss of custody.
In addition to the personal reasons cited above, women face societal and cultural barriers as well. Many women perceive a lack of community openness and support in discussing IPV. They feel there is a stigma associated with shelter living. Religious communities, families, and friends may invalidate the victim’s disclosure by blaming her or refusing to believe her. , Cultural norms may condone IPV. Immigrant women face a unique set of barriers. In addition to the typical isolation of an abusive relationship, they must overcome language and cultural barriers as well. Concern about consequences related to immigration status also hinder disclosure.
Finally, women may perceive barriers within the very systems intended to provide help. In regard to the criminal justice system, women are prevented from accessing help by the belief that, ultimately, the legal system is not helpful. Women cite the delay between a call to the police and their arrival, a bureaucratic system that is difficult to navigate, uncertain outcome, lack of support for victims, and the presence of a “good ol’ boys” network as reasons for anticipating a lack of efficacy and therefore underutilization of the resources the criminal justice system offers. , With respect to health care resources, women cite the lack of health care providers’ (HCP) understanding of the complexity of IPV, the lack of HCP knowledge of appropriate referral resources, lack of efficacy, fear that a disclosure of IPV will lead to a police or CPS report, cost of medical care, lack of knowledge that HCP can address IPV, and failure of the HCP to directly ask women about IPV.
As evidenced by the discussion above, the barriers to leaving an abusive relationship are numerous and provide multiple areas where access to care can be improved.
Motivators for IPV Victims to Seek Help
Simply understanding and removing the barriers to IPV help-seeking is often not enough to convince a woman to leave an abusive relationship. Like many public health issues, before someone can access help, he or she must be willing and motivated to do so. Although not as well studied, the motivators for IPV help-seeking are no less important than the barriers to IPV help-seeking. In fact they may be interrelated and addressing the motivators may decrease certain barriers.
Many women cite increasing knowledge as a motivator for leaving an abusive relationship. This knowledge encompasses multiple domains: dynamics and definitions of IPV, availability and types of resources, and self-awareness. Additionally, reaching an emotional or physical breaking point often triggers help-seeking. For women with children, the many consequences of IPV for their children may be powerful motivators. These consequences include endangered physical safety, short and long-term effects of children’s witnessing IPV on their emotional well-being, and CPS involvement with potential loss of custody. A final motivator for leaving the abusive relationship is outside intervention. Interveners take many forms: legal professionals, friends, family, health care providers, and neighbors. One study suggests that the majority of women in shelter homes did not seek out information on resources on their own, but acted on information and suggestions provided by outside individuals.
Understanding the motivators for help-seeking discussed previously allows directed interventions with the goal of increasing both disclosure and action.
Provider Barriers
Not only do women face barriers in discussing IPV, but there are well-documented barriers preventing health care providers from addressing the issue as well. Despite the overwhelming evidence to the contrary, many providers fail to recognize that IPV is an issue in their patient population. Even when IPV is suspected, a provider may contextualize the issue as “nonmedical” and therefore be reluctant to directly question a patient. The belief that direct questioning regarding IPV is somehow offensive or angering remains prevalent, despite a wealth of research that demonstrates the majority of women are comfortable with being screened for IPV. Some providers feel that patients would willingly volunteer a history of abuse if present, while others simply forget to ask. Other common barriers that providers experience include limited time to conduct IPV assessments, lack of formal training in evaluation and referral for IPV, and concern with an inability to provide resources to those who disclose IPV.
Effect of Intimate Partner Violence on Children
Children represent a special population at risk from IPV, both as victims of abuse and as witnesses to it. Rates of IPV are increased among households with children, and it is estimated that 3.3 to 15.5 million children are exposed to IPV in the United States each year. , Over the last several years, research has focused on the negative impact that IPV may have on a child’s physical, emotional, and behavioral health. Recognizing the potential negative health outcomes for children, the American Academy of Pediatrics deemed the abuse of women a “pediatric issue” and recommended IPV screening for all female caregivers at well-child visits and the development of intervention plans for caregivers with positive screens.
While estimates of the co-occurrence vary depending on study methodology, IPV is clearly associated with psychological, physical, sexual child maltreatment, and neglect. A large review found a median co-occurrence of 40% among battered women and abused children. Community samples show co-occurrence rates of 5.6% to 55%. A longitudinal study of at-risk families demonstrated an increased risk for physical and psychological abuse and neglect that persisted up to 5 years of age after IPV exposure in the first 6 months of life. Evidence suggests that the combination of IPV exposure and child maltreatment has synergistic negative effects. ,
Children also are at risk for physical harm as bystanders. A retrospective review showed that children of all ages are inadvertently injured during episodes of IPV. Forty percent of the patients in this review had injuries requiring medical treatment. Young children were disproportionately represented among these patients and were more likely to incur head and facial injuries. It is likely that more children are accidentally injured during IPV episodes than health care providers recognize, as many may not come in for medical care and those that do may not disclose the true mechanism of injury for fear of reprisal.
Children of all ages, from infancy to adolescence, are affected by IPV exposure. Children exposed to IPV are at risk for internalizing and externalizing behavior problems, decreased cognitive performance, and suicide. Internalizing problems include depression, anxiety, and social withdrawal. Externalizing problems include aggression, hyperactivity, and defiance of authority. Both internalizing and externalizing behaviors may negatively affect peer relationships, parent-child bonds, and school performance.
Additionally, childhood IPV exposure is a marker for other risk exposures. In the Adverse Childhood Experiences (ACE) study, 95% of respondents with histories of childhood IPV exposure experienced at least one additional adverse experience, including parental separation/divorce, household substance abuse, mental illness, and criminal activity. These children are more likely to be exposed to other types of community violence as well. Increasing numbers of adverse exposures are associated with increasing negative outcomes.
It is important to recognize that the negative effects of IPV exposure are not limited to childhood and can have serious health implications for the adult. Evidence links such exposure, alone and in combination with other adverse childhood experiences, with increased incidence of smoking, alcoholism, severe obesity, and diseases such as diabetes, ischemic heart disease, and depressive disorders.
The degree to which each child is affected by IPV exposure depends upon a number of mediating factors: mother-child attachment, parenting styles, maternal depression, socioeconomic status, shelter status, child’s temperament, and age at time of exposure. However, children exposed to IPV are clearly at risk for both current and future problems in multiple areas. Identification of children exposed to IPV allows targeted interventions for at-risk children and the potential to ameliorate negative outcomes.
Strength of the Medical Evidence
Intimate partner violence is inherently a difficult issue to study in that there is no gold standard test to measure its prevalence. With rare exceptions, the detection of IPV is the result of a complex dynamic between provider and patient, and ultimately the provider relies on the patient to disclose that IPV is present. True prevalence and incidence of the condition is therefore difficult to estimate. Further complicating the issue have been variations in study populations and a general inability of researchers to consistently define who constitutes an intimate partner and what constitutes a violent or abusive act. For all these reasons, the validity of conclusions that can be drawn from the research is, at the very least, subject to scrutiny. Only recently has the Centers for Disease Control published recommendations designed to promote consistency in the use of terminology and data collection related to intimate partner violence. In the coming years, researchers will be challenged to incorporate consistent study methodologies to improve the value of the data collected.
Directions for Future Research
There remain many unexplored territories for IPV research. Despite a large body of work looking at how and when providers should best assess for IPV, there is almost no research that demonstrates improved outcomes when doing so. Could there potentially be harm caused by asking a woman about IPV? What can be done for those women who disclose IPV and for their children? These questions remain largely unanswered.
Despite ample research, which has traditionally focused on the subset of IPV that is violence perpetrated by males against females, there is a relative paucity of studies examining violence perpetrated by females against males or the dynamics of violence in gay, lesbian, bisexual, or transgender relationships. Targeted studies looking at these specific populations will be necessary in the coming years. Finally, it is becoming increasingly obvious that IPV is not just an issue that affects adult relationships, but also is pervasive in the adolescent population as well. Patterns of dating violence behavior often begin early and further work is needed to help pediatric/adolescent practitioners identify and address this issue with their patients and families.
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