This document provides a brief summary with
supporting bibliography about intimate partner violence (IPV). For
please refer to the references. The outline
addresses the following: demographics, costs of IPV, health consequences
children and abuse, legal issues, screening for
abuse, what do you do once you detect IPV, documentation, education
abuse, barriers for victims, IPV in special
populations, and modern literature.
The last two parts list a selection of modern literature which depicts global violence against women. There is also a link
to further educational opportunities about IPV, using interactive videos.
LaCombe places this story of
chronic domestic abuse in a rural town, Taylor County. What are the
demographics of abuse in
the US and worldwide? Are there risk
factors that enhance the chance for abuse in a relationship?
United Nations Development Fund for Women. 2003. Not A Minute More: Ending Violence Against Women. http://www.unifem.org/resources/item_detail.php?ProductID=7
The United Nations Development Fund for
Women estimates that at least one of every three women globally will be
or otherwise abused during her lifetime.
In most cases, the abuser is a member of her own family.
WHO Multi-country Study on Women's Health and Domestic Violence Against Women. World Health Organization 2005. http://www.who.int/gender/violence/who_multicountry_study/en
A 2005 World Health Organization study of
24,000 women found that of 15 sites in ten countries - women who had
physical or sexual intimate partner
violence in their lifetimes ranged from 15 percent (Japan) to 71 percent
Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence --- United States, 2005. MMWR
Weekly. February 8, 2008 / 57(05);113-117. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm
In 2005, the Center for Disease Control
conducted a random telephone survey of non-institutionalized persons
18 years old in the US. This included an
optional IPV module. Of the 70,156 respondents, 24% women and 11% men
IPV victimization. Nearly one in four
women in the United States reported experiencing violence by a current
or former spouse
or boyfriend at some point in her life.
When Earl wants to kill his
son-in-law, the doctor dissuades him by saying that his grandchildren
will hate him. "And your
grandchildren will hate you for the rest
of their lives," I said, "for killing their father." Do you think Al
his children as well as his wife? If the
children weren't the target of abuse, do you think they were affected by
in the home? How?
Children and abuse: http://endabuse.org/userfiles/file/Children_and_Families/Children.pdf
McDonald R, Jouriles EN, Ramisetty-Mikler S, et al. Estimating the Number of American Children Living in Partner-Violent
Families. J Fam Psychol 2006;20: 137-142. http://www.ncbi.nlm.nih.gov/pubmed/16569098
A 1995 interview of 4,925 participants
(77% response rate) found that among 21% of couples in which violence
to have occurred, 60% had children living
in the household. The authors extrapolated this to 2001 US population,
that 15.5 million U.S. children live in
families in which partner violence occurred at least once in the past
year, and seven
million children live in families in which
severe partner violence occurred.
Graham-Bermann SA, Seng, J. Violence Exposure and Traumatic Stress Symptoms as Additional Predictors of Health Problems
in High-Risk Children. J Pediatr 2005; 146:309-310. http://www.ncbi.nlm.nih.gov/pubmed/15756218
A study of 160 preschool children exposed
to violence or traumatic stress had worse health outcomes compared to
Children who witness IPV are more likely
to exhibit behavioral and physical health problems like: depression,
violence towards peers; attempting
suicide, abusing drugs and alcohol; other high risk behavior.
Whitfield CL, Anda RF, Dube SR, Felittle VJ. Violent Childhood Experiences and the Risk of Intimate Partner Violence in Adults:
Assessment in a Large Health Maintenance Organization. J Interpers Viol 2003;18: 166-185. http://jiv.sagepub.com/cgi/content/abstract/18/2/166
A study of 8629 participants showed a
statistically significant graded relationship between the # of childhood
and risk of IPV. Physical abuse during
childhood increases the risk of future victimization among women and the
risk of future
perpetration of abuse by men more than
Anda R, Block R, Felitti V. 2003. Adverse Childhood Experiences Study. Centers for Disease Control and Prevention, Kaiser
Permanente's Health Appraisal Clinic in San Diego. http://www.cdc.gov/NCCDPHP/ACE/index.htm
Between 1995 and 1997, 17000 members of
Kaiser Permanente undergoing a routine physical examination completed a
survey about childhood maltreatment and
family dysfunction. Participants reported a 28% prevalence of physical
21% sexual abuse. Children who
experience childhood trauma, including witnessing incidents of domestic
violence, are at
a greater risk of having serious adult
including tobacco use, substance abuse,
obesity, cancer, heart disease, depression and a higher risk for
Kitty's physician, emergency
department staff, and hospital nurses were obviously aware of her
chronic abuse. Besides medical
care, what legal obligations do healthcare
workers have when taking care of an abuse victim? How would this be
if the abuse was not just of the spouse
but of the children too? What is the Violence Against Women Act of
1994? Are there
state to state differences with regards to
the care of the abuse victim?
The National District Attorneys Association lists state laws regarding domestic violence http://www.ndaa.org/apri/programs/vawa/dv_reporting_requirements.html
Local laws vary state by state. There may
be mandatory reporting laws of documented or suspected IPV. Reporting
when there is deadly weapon used, child
abuse or vulnerable adult abuse occurs. Providers must know their local
laws or else they may be held liable for
"The 1994 Violence Against Women Act
(VAWA), with additions passed in 1996, outlined grant programs to
prevent violence against
women and established a national domestic
violence hotline. In addition, new protections were given to victims of
abuse, such as confidentiality of new
address and changes to immigration laws that allow a battered spouse to
apply for permanent
residency. According to the VAWA Act, a
domestic violence misdemeanor is one in which someone is convicted for a
by an intimate partner, parent, or
guardian of the victim that required the use or attempted use of
physical force or the
threatened use of a deadly weapon'
(Section 922g). Under these guidelines, an intimate partner is a spouse,
a former spouse,
a person who shares a child in common with
the victim, or a person who cohabits or has cohabited with the victim.
area this act addresses is interstate
traveling for the purposes of committing an act of domestic violence or
order of protection. A convicted abuser
may not follow the victim into another state, nor may a convicted abuser
force a victim
to move to another state. Previously,
orders of protection issued in one jurisdiction were not always
recognized in another
jurisdiction. The VAWA specifies full
faith and credit to all orders of protection issued in any civil or
or by any Indian tribe, meaning that those
orders can be fully enforced in another jurisdiction. Forty-seven
states have now
passed legislation that recognizes orders
of protection issued in other jurisdictions. Three states, Alaska,
Pennsylvania, require that an out of state
order be filed with an in state jurisdiction before the order can be
Kitty's father, physician,
and the town were all aware of her abuse. This is often not the case.
Do physicians have a role
in screening for abuse? How can
physicians uncover and screen for abuse? What are some warning signs
that could hint at
RADAR: Remember to ask, Ask directly; Document findings; Assess safety; Refer to community services.
Questions to ask routinely: Have you been
hit, kicked, punched or otherwise hurt by someone in the past year? If
so, by whom?
Do you feel safe in your current
relationship? What happens when you and your partner disagree? Do any
in your relationships in which you have
felt afraid? Has partner ever prevented you from leaving the house or
friends or family?
Kitty's physician hospitalized her several times for abuse. When a physician treats an abuse victim, how should s/he correctly
document abuse? How does this affect confidentiality?
Isaac NE, Enos VP. Documenting Domestic Violence. How Health Care Providers Can Help Victims. National Institute of Justice
Research in Brief. September 2001. 1-5. http://www.ncjrs.gov/pdffiles1/nij/188564.pdf
Medical records can be used as evidence
for obtaining protective services. Use images such as photographs of
body maps to document extent of injury.
In your note: write legibly, record the patient's own words in
quotations and use
"patient states...", avoid phrases such as
"patient claims or alleges...," use medical terms and avoid legal
patient's demeanor, record time of
examination and time since abuse last occurred. Document how she was
injured and who caused
her injuries with specific details. If
there are any witnesses with the victim, document quotations from those
Note past history of violence.
"Each time we got the town
police involved, had Earl arrested, had the complaint papers all filled
out. All sealed, and delivered,
except that Kitty would never sign the
papers. And she always went back to him." Why do victims return to
What are the barriers to leaving? What is
the power wheel? What powerful holds do abusers have over their
"Soon Kitty did go back with
Earl. You had trouble saying whose sickness was worse. ...And she
always went back to him."
What is the cycle of violence: tension
building, acute battering, and honeymoon stage? How can the physician
to stop this cycle? In an effort to help
the victim, how can the doctor unknowingly worsen the situation?
Warshaw C. Domestic Violence: Challenges to Medical Practice. J of Women's Health. 1993; 2(1):73-80. http://www.liebertonline.com/doi/abs/10.1089/jwh.1993.2.73
Healthcare workers need to appreciate the
cycle of violence. Patients may be more amenable to intervention during
building and battering phases. During
reconciliation the victim is showered with apologies and expressions of
love and affection
and assurance that the violence will never
happen again. The patient may be less willing to seek help during this
If/when the victim decides to leave, there
is often an escalation of violence. This is the most dangerous time
for the victim.
In addition to physical and sexual
violence, the abuser may exert his power in other ways - this is known
as the Power Wheel.
The abuser uses intimidation, social
isolation, coercion, threats, economic dependence, and the children to
and power over the victim. Thus, the
victim is helpless in escaping or leaving because she is completely
dependent on him.
Cassel C. Reflections on Playing God. Ann Int Med 1992;116:163-164.
Victims often blame themselves and think
that violence is normal "if only I did ...better, then he wouldn't have
to hit me."
"The passivity that Kitty exhibits in the
face of such abuse, her unwillingness to bring charges against her
her seemingly inevitable return to him are
behaviors that are common among abused women, often attributed to a
child abuse and eroded self-esteem leading
to masochism and codependency. Another way of understanding why women
put up with
abuse is sociologically, observing that
women without the skills to earn a living may see no options to support
outside the abusive relationship and thus
are socioeconomically 'trapped,' especially if they have children."
"This was probably the first
time in her life she had made up her mind and stuck to it." What are
some of the dilemmas and
major hardships a victim faces in
confronting and leaving her abused situation? What resources can
physicians provide to their
patients to help
them reach this stage of separation
Validate & support (abuse is not
acceptable and the victim is not to blame, help is available, you are
not alone). Assess
for immediate danger.
Be aware of firearms and objects
potentially used as weapons. Do not challenge the partner. Document
the abuse (photos,
Does the victim have a safe place to go
and the resources they need in an emergency? Start safety planning:
(1) escape plan, neighbors/friends, use of
code word; (2) secure documents (banking account books, birth
license, insurance, title or deeds,
passport, etc; (3) gather essentials (suitcase with clothes and
keys, prescriptions, eyeglasses or
contacts, etc.). Provide referrals/resources (shelters, crisis centers,
programs & support
groups, counseling). Provide ongoing
support and follow up. Inform the children's school. Teach children
"It was the same scenario for
some ten years, Kitty coming into the emergency room, badly beaten,
meekly asking to see me."
"Two other times Kitty had been so
severely beaten that she required hospitalization." What are the health
chronic medical, and psychological
consequences of abuse? What are the costs to society at large?
Costs of IPV
Costs of Intimate Partner Violence Against Women in the United States. 2003. Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control. http://www.cdc.gov/violenceprevention/pdf/IPVBook-a.pdf
In the United States, the health care cost
of intimate partner rape, physical assault and stalking totals $5.8
nearly $4.1 billion of which is for direct
medical and mental health care services. Lost productivity from paid
work and household
lifetime earnings lost by homicide victims
total nearly $1.8 billion.
Wisner C, Gilmer TP, Saltzman LE, Zink TM. Intimate Partner Violence Against Women: Do Victims Cost Health Plans More?
J Fam Pract 1999;48: 439-443. http://www.ncbi.nlm.nih.gov/pubmed/10386487
A study of 226 victims of IPV in
Minneapolis & Minnesota in 1994 found that compared to a general
similar sample, IPV victims
health plan 92% more/$1775 more.
Varjavand N, Cohen DG, Novack DH. An Assessment of Residents' Abilities to Detect and Manage Domestic Violence. J Gen Int
Med. 2002;17:465-468. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495067/
A study of 71 internal medicine residents
going through standardized patient exercises found that residents who
did not diagnose
DV spent nearly twice as much per patient
on work-up (mean, $942.00), compared to those who diagnosed DV (mean,
Health Consequences of IPV
Coker AL, Smith PH, Bethea L, McKeown RE. Physical Health Consequences of Physical and Psychological Intimate Partner Violence.
Arch Fam Med 2000;9:451-457. http://www.ncbi.nlm.nih.gov/pubmed/10810951
A cross sectional survey of 1152 women,
ages 18-65, between 1997-1999, noted that 54% had ever experienced
physical IPV and
only psychological IPV. Women
experiencing psychological IPV were significantly more likely to report
poor physical and mental
Psychological IPV was associated with a
number of adverse health outcomes, including a disability preventing
migraine and other frequent headaches,
stammering, sexually transmitted infections, chronic pelvic pain,
spastic colon, frequent
indigestion, diarrhea, or constipation.
Psychological IPV was as strongly associated with the majority of
outcomes as was physical
Bonomi AE, Anderson ML, Reid RJ, et al. Medical and Psychosocial Diagnoses in Women with a history of IPV. Arch of Intern
Random telephone survey of 3568 women from
a US health plan (not seeking medical care nor identified as IPV in
between past year IPV and a variety of
medical/psychosocial conditions in 18 major areas. Abused women had
relative risks of these disorders:
psychosocial/mental; musculoskeletal; and female reproductive. Abused
women had a more
than 3-fold increased
risk of being diagnosed with a sexually
transmitted disease and a 2-fold increased risk of lacerations as well
risk of acute
respiratory tract infection,
gastroesophageal reflux disease, chest pain, abdominal pain, urinary
tract infections, headaches,
Violence Against Women: Effects on Reproductive Health. Outlook 2002 http://www.path.org/files/EOL20_1.pdf
Sexual and domestic violence are linked to
a wide range of reproductive health issues including sexually
transmission, miscarriages, risky sexual
health behavior and more. This article provides a summary of global
consequences on reproductive health.
Violence affects specific populations including immigrants, teenagers dating, and homosexuals.
What further consequences can intimidation and violence have on these specific groups?
Orloff L, Kaguyutan JV. Offering a Helping Hand: Legal Protections for Battered Immigrant Women:
A History of Legislative Responses. J Gender, Social Policy, Law. 2002;10: 95-183. http://www.wcl.american.edu/journal/genderlaw/10/10-1orloff.pdf?rd=1
Immigrant women may face a more difficult
time escaping abuse. In addition to the extensive common issues of
immigrant women face social isolation,
language barriers, and family repercussions. Batterers often exert
control over their
immigration status in order to force her
to remain in the relationship.
Orloff LE, Jang D, Klein C. With No Place to Turn: Improving Advocacy for Battered Immigrant Women. Fam Law Quart 1995;
Battered immigrant women who attempt to flee may not have access to bilingual shelters,
financial assistance, or food. It is also unlikely that they will have the assistance of a
certified interpreter in court, when reporting complaints to the police or a 911 operator, or
even in acquiring information about their rights and the legal system.
Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating Violence Against Adolescent Girls and Associated Substance Use, Unhealthy
Weight Control, Sexual Risk Behavior, Pregnancy, and Suicidality. JAMA 2001;286:572-579. http://jama.ama-assn.org/cgi/reprint/286/5/572.
A study of female 9th- through 12th-grade
students who participated in the 1997 and 1999 Massachusetts Youth Risk
Surveys (n=1977and 2186, respectively)
found that approximately 1 in 5 female students (20.2% in 1997 and 18.0%
in 1999) reported
being physically and/or sexually abused by
a dating partner. Furthermore, they found that teen victims of
violence are more likely than their
non-abused peers to smoke, use drugs, engage in unhealthy diet behaviors
pills or laxatives and vomiting to lose
weight), engage in risky sexual behaviors, and attempt or consider
Violence in the Gay population
Greenwood GL, Relf MV, Huang B, et al. Battering Victimization Among a Probability-Based Sample of Men Who Have Sex With
Am J Public Health. 2002;92:1964-1969. http://www.ncbi.nlm.nih.gov/pubmed/12453817
Men who have sex with men experience
violence - perhaps more than heterosexual men. A telephone survey of
2880 men from 4
cities from 1996-1998 found a prevalence
estimate of 34% for psychological/symbolic battering, 22% for physical
and 5% for sexual battering.
Trafficking in Persons Report 2008. Available at http://www.state.gov/g/tip/rls/tiprpt/2008/
"Human trafficking is a modern-day form of
slavery. Victims of human trafficking are subjected to force, fraud, or
for the purpose of sexual exploitation or
forced labor. Victims are young children, teenagers, men and women."
"Annually, according to U.S.
Government-sponsored research completed in 2006, approximately 800,000
people are trafficked
across national borders, which does not
include millions trafficked within their own countries. Approximately 80
transnational victims are women and girls
and up to 50 percent are minors. The majority of transnational victims
trafficked into commercial sexual
Does literature have a role in educating about patient care? What other pieces of popular literature address violence in
Infidel by Ayaan Hirsi Ali. Illustrated. Free press. 353 pages. ISBN: 0743289684
My Forbidden Face. Growing up Under the Taliban: A Young Woman's Story. Latifa. Hyperion. Memoir. ISBN: 0786869011
Burned Alive: A Survivor of an "Honor Killing" Speaks Out. Souad. ISBN: 0446694878
The Road of Lost Innocence: As a girl she
was sold into sexual slavery, but now she rescues others. The true story
of a Cambodian
heroine. Somaly Mam. ISBN:
Tears of the Desert: A Memoir of Survival in Darfur. Halima Bashir. ISBN: 978-0-345-50625-2 (0-345-50625-1)
Sold: One Woman's True Account of Modern Slavery. Zana Muhsen. ISBN: 9780751509519
More Educational Opportunities about IPV: An Interactive Video
Varjavand N, Novack D. Domestic Violence.
Module 28 in Novack DH, Clark WD, Saizow RB, Daetwyler C (Eds.) doc.com
- An interactive
learning resource for healthcare
communication. [Internet]: American Academy on Communication in
College of Medicine; 2005. Accessible at:
http://webcampus.drexelmed.edu/doccom/user/ and scroll down to Module 28 on login page. Login not required, it is a "free" module.