Intimate Partner Violence

 

Intimate Partner Violence Course Material

Popular emphasis has tended to be on women as the victims of domestic violence although with the rise of the men's movement, and particularly men's rights, there is now some advocacy for men as victims, although the statistics concerning the number of male victims given by them are strongly contested by many groups active in research on or working in the field of domestic violence and "violence against men". Estimates are that only about a third of cases of domestic violence are actually reported in the US.

Domestic violence occurs in all cultures; people of all races, ethnicity, religions, and classes can be perpetrators of domestic violence. Domestic violence is perpetrated by, and on, both men and women, and occurs in same-sex and opposite-sex relationships.

Awareness and documentation of domestic violence differs from country to country. According to the Centers for Disease Control, domestic violence is a serious, preventable public health problem affecting more than 32 million Americans, or more than 10% of the U.S. population.

Domestic violence has many forms, including physical violence, sexual abuse, emotional abuse, intimidation, economic deprivation or threats of violence. There are a number of dimensions:

mode - physical, psychological, sexual and/or social
frequency - on/off, occasional, chronic
severity – in terms of both psychological or physical harm and the need for treatment – transitory or permanent injury – mild, moderate, severe up to homicide.

The means used to measure domestic violence strongly influence the results found. For example, studies of reported domestic violence and extrapolations of those studies show women preponderantly as victims and men to be more violent, whereas the survey based Conflict Tactics Scale, tends to show men and women equally violent.

Since the majority of studies investigate male-on-female domestic violence, information on female-on-male and same-sex violence tends to be less available.

Types

Intimate terror (or "patriarchal terror") where one partner uses violence along with emotional and psychological abuse to maintain control over the other. In heterosexual relationships, the perpetrator is most often the male partner. It is more likely than other types to be frequent and to escalate in seriousness. Intimate terror is much less common than situational couple violence, but probably dominates samples collected from agencies (police, courts, hospitals).

Violent resistance is violence used in resistance to an intimate terror. Sometimes it is self-defensive, sometimes more like payback, sometimes the act of an entrapped victim who sees no other way to escape a violently abusive relationship.

Situational couple violence arises out of conflicts that escalate to arguments and then to violence. It is not connected to a general pattern of control. Although it occurs less frequently in relationships and is less serious than intimate terror, in some cases it can be frequent and/or quite serious, even life-threatening. This is probably the most common type of intimate partner violence and dominates general surveys, student samples, and even marriage counseling samples.

The fourth type identified by Johnson is infrequent and some scholars question its existence:

Mutual violent control is when both partners are violent and controlling and they possibly battle for control in the relationship. As with intimate terrorism, violence is one form of control used by each abuser.

Physical violence

Physical violence is the intentional use of physical force with the potential for causing injury, harm, disability, or death, for example, hitting, shoving, biting, restraint, kicking, or use of a weapon.

Sexual violence and incest

Sexual violence and incest are divided into three categories:

Use of physical force to compel a person to engage in a sexual act against their will, whether or not the act is completed; attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, unable to decline participation, or unable to communicate unwillingness to engage in the sexual act, e.g., because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and abusive sexual contact.

Psychological violence

Threats of physical, psychological or sexual, or social violence that use words, gestures, or weapons to communicate the intent to cause death, disability, injury, physical, or psychological harm.

Psychological/emotional violence involves violence to the victim caused by acts, threats of acts, or coercive tactics. Psychological/emotional abuse can include, but is not limited to, humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. It is considered psychological/emotional violence when there has been prior physical or sexual violence or prior threat of physical or sexual violence. Perpetrators of this form of domestic aggression can be both users and abusers... both female and male. "The abuser recruits friends, colleagues, mates, family members, the authorities, institutions, neighbors, the media, teachers in short, third parties to do his bidding. He uses them to cajole, coerce, threaten, stalk, offer, retreat, tempt, convince, harass, communicate and otherwise manipulate his target."

Relational aggression is a form of psychological/social aggression that uses various forms of falsehood, secrecy and gossip to commit covert violence. It is often a spectacularly successful tactic because so few people know how to detect it. It is often used because it is covert, leaves no visible scars and can be done with a smile. It destroys or damages the target's reputation and ruins the target's relationships. "It is the outcome of fear. Fear of violence, fear of the unknown, fear of the unpredictable, the capricious, and the arbitrary. It is perpetrated by dropping subtle hints, by disorienting, by constant and unnecessary lying, by persistent doubting and demeaning, and by inspiring an air of unmitigated gloom and doom."

Parental alienation is another form of covert violence where children are used as a weapon of war by one parent to alienate the other parent. This covert form of domestic violence is used in high-conflict marriages. It is often devastating to the alienated spouse/parent and to the alienating/alienated children caught in the middle. Misdiagnoses of Parental Alienation can also be devastating -- this time to the parent accurately describing abuse and to the child that is placed with the abusive parent. In effect, it uses innocent, unwitting children to commit relational aggression by one parent against the other. "The abuser often recruits his children to do his bidding. He uses them to tempt, convince, communicate, threaten, and otherwise manipulate his target, the children's other parent or a devoted relative (e.g., grandparents). He controls his - often gullible and unsuspecting - offspring exactly as he plans to control his ultimate prey. He employs the same mechanisms and devices. And he dumps his props unceremoniously when the job is done - which causes tremendous (and, typically, irreversible) emotional hurt."

Economic abuse

Economic abuse is when the abuser has complete control over the victim's money and other economic resources. Usually, this involves putting the victim on a strict 'allowance', withholding money at will and forcing the victim to beg for the money until the abuser gives them some money. It is common for the victim to receive less money as the abuse continues.

This also includes (but is not limited to) preventing the victim from finishing education or obtaining employment.

Spiritual Abuse

Spiritual abuse includes:

using the spouse’s or intimate partner’s religious or spiritual beliefs to manipulate them preventing the partner from practicing their religious or spiritual beliefs ridiculing the other person’s religious or spiritual beliefs

Violence against men

Violence against men is the term known for violence that is committed against men by the man's intimate partner.

Very little is known about the actual number of men who are in a domestic relationship in which they are abused or treated violently by their male or female partners. Few incidents are reported to police, and data is limited. Dr. Richard J. Gelles contends that while "men's rights groups and some scholars" believe that "battered men are indeed a social problem worthy of attention" and that "there are as many male victims of violence as female", he states that such beliefs are "a significant distortion of well-grounded research data." In addition, researchers Tjaden and Thoennes found that "men living with male intimate partners experience more intimate partner violence than do men who live with female intimate partners.

Approximately 23 percent of the men who had lived with a man as a couple reported being raped, physically assaulted, and/or stalked by a male cohabitant, while 7.4 percent of the men who had married or lived with a woman as a couple reported such violence by a wife or female cohabitant."

The available data indicate that:

3.2 million men experience "minor" abuse (such as "pushing, grabbing, shoving, slapping, and hitting") per year.

In the United States, approximately 800,000 men per year (3.2%) are raped or physically assaulted by their partner.

At least 371,000 men are stalked annually.

3% of nonfatal violence against men stems from domestic violence.

In 2002, men comprised 24% of domestic violence homicide victims.

Over 20 years, the instances of homicide from domestic violence against men decreased by approximately 67%.

Approximately 22% of men have experienced physical, sexual, or psychological intimate partner violence during their life.

There are many reasons why there isn't more information about domestic abuse and violence against men. A major reason is the reluctance of men to report incidents to the police, unless there are substantial injuries. Data indicate that although mutual violent behavior is quite common in intimate relationships, men are rarely seriously harmed.

Allegations of domestic violence

Many Men and Father's Rights advocates observe the use of false accusations of domestic violence in the context of divorce and child custody proceedings as re-inventing the type of hostile litigations and accusations that were intended to be eliminated by no fault divorce legislation. Thomas Kasper writes in the Illinois Bar Journal that domestic violence measures funded by VAWA readily “become part of the gamesmanship of divorce.” Phyllis Schlafly notes in her September 2006 column "Laughing at Restraining Orders" that the domestic violence injunction issued on David Letterman for sending subliminal messages to a woman 2000 miles away that he had never met, demonstrates the claim by Men's Rights advocates that many domestic violence injunctions do not even involve any actual physical violence, but are instead absurd exaggerations or fabrications.

On the other hand, not taking allegations seriously can lead to further violence, and can also be judicial misconduct. In Maryland, a judge was under investigation for his conduct in a domestic violence case. He retired and thus avoided punishment. Following his dismissal of a protective order, a woman's husband arrived at her place of work, doused her with gasoline, and set her on fire, causing serious burns.

Allegations of domestic violence are frequent in post-divorce/separation situations. Such allegations may often be third-party abuse, using third-parties such as courts to carry out untraceable abuse against a falsely-accused 'perpetrator'. The consequences of such allegations can be serious for the alleged perpetrator since occupation of the home and custody of the children may be at stake. In Australia, mandated allocation of family resources in court-supervised separation shifts automatically from 50:50 to 80:20 in favor of the alleged victim if there is any allegation of abuse; anecdotal reports and other evidence indicate that such allegations are accepted only from women, and that the allegation itself is required to be taken as its own proof, without any checks or balances. It is sometimes claimed that "less than 2% of reported domestic violence allegations are proved false", but anecdotal and other evidence suggests that this claim, as with many supposed statistics in domestic-violence 'research', is based more on wishful thinking and circular reasoning than on fact.

Causes

There are many different theories as to the causes of domestic violence. As with many phenomena regarding human experience, no single approach appears to cover all cases.

Identified and proposed causes include a need for power and control, a form of bullying and social learning of abuse. Abusers' efforts to dominate their partners have been attributed to low self-esteem or feelings of inadequacy, unresolved childhood conflicts, the stress of poverty, hostility and resentment toward women (misogyny), hostility and resentment toward men (misandry), personality disorders, genetic tendencies and sociocultural influences, among other possible causative factors. Most authorities seem to agree that abusive personalities result from a combination of several factors, to varying degrees.

Factors associated with domestic violence also include substance abuse, mental illness, classism, various political and legal characteristics such as authoritarianism and dehumanization.

"Dukes argues that all [domestic] abuse relates to men’s capacity for, and their need to, devalue women. If we can stop a man devaluing his partner, he will stop abusing her. Devaluation is defined as seeing someone in negative ways - as not being attractive, as being vicious, dangerous, threatening, ugly, boring, useless, bad. This analysis brings male violence against women back within the general domain of male violence itself. The extent to which the process of dehumanization. - the reduction of the other person to a thing that is nothing, to a valueless nothing, a contemptible nothing, a disposable nothing - has been analysed and explored by a legion of respected students of violence." Women's Aid Federation Northern Ireland

Classism

Many experts, including Lundy Bancroft and Dr. Susan Weitzman, psychotherapist and author of "Not to People Like Us: Hidden Abuse in Upscale Marriages," contend that abuse in poor families is more likely to be reported to ER staff, police and social services by victims and bystanders. Also, low-income perpetrators are more likely to be arrested and serve time in jail than are their wealthier counterparts, who have the social and financial wherewithal to evade public exposure.

The degree to which abuse correlates with poverty and the extent to which poverty causes abuse or abuse causes poverty are ambiguous. To date, more data on abuse has been collected from low-income than middle and upper income families. This does not necessarily confirm that domestic violence is more prevalent among poor families than wealthier ones, only that the population most readily available for study is predominantly low-income.

It seems premature to conclude that poverty is an important causative factor in domestic violence or that domestic violence causes poverty. Poverty increases the chances that low-income populations will be identified and studied, but this has resulted in a skewed, self-selected sample that does not reflect the incidence and demographics of abuse in the population as a whole.

Power and control

Power in a relationship is often a matter of perception. A person may perceive themselves to be put-upon when a less involved observer would disagree.

A causalist view of domestic violence is that it is a strategy to gain or maintain power and control over the victim. This view is in alignment with Bancroft's "cost-benefit" theory that abuse rewards the perpetrator in ways other than, or in addition to, simply exercising power over his or her target(s). He cites evidence in support of his argument that, in most cases, abusers are quite capable of exercising control over themselves, but choose not to do so for various reasons.

An alternative view is that abuse arises from powerlessness and externalizing/projecting this and attempting to exercise control of the victim. It is an attempt to 'gain or maintain power and control over the victim' but even in achieving this it cannot resolve the powerlessness driving it. Such behaviors. have addictive aspects leading to a cycle of abuse or violence. Mutual cycles develop when each party attempts to resolve their own powerlessness in attempting to assert control.

Questions of power and control are integral to the widely accepted Duluth Domestic Abuse Intervention Project. They developed "Power and Control Wheel" to illustrate this: it has power and control at the center, surrounded by spokes (techniques used), the titles of which include:The model attempts to address abuse by one-sidedly challenging the misuse of power by the 'perpetrator'.

Critics of this model suggest that the one-sided focus is problematic as resolution can only be achieved when all participants acknowledge their responsibilities, and identify and respect mutual purpose.

The power wheel model is not intended to assign personal responsibility, enhance respect for mutual purpose or assist victims and perpetrators in resolving their differences. It is an informational tool designed to help individuals understand the dynamics of power operating in abusive situations and identify various methods of abuse.

Sex and gender

Modes of abuse are thought by some to be gendered, females tending to use more psychological and men more physical forms. The visibility of these differs markedly. However, experts who work with victims of domestic violence have noted that physical abuse is almost invariably preceded by psychological abuse. Police and hospital admission records indicate that a higher percentage of females than males seek treatment and report such crimes.

Unless or until more men identify themselves and go on record as having been abused by female partners, and in a manner whereby the nature and extent of their injuries can be clinically assessed, men will continue to be identified as the most frequent perpetrators of physical and emotional violence.

The cycle of violence

Cycle of violence and cycle of abuse

Frequently, domestic violence is used to describe specific violent and overtly abusive incidents, and legal definitions will tend to take this perspective. However, when violent and abusive behaviors. happen within a relationship, the effects of those behaviors. continue after these overt incidents are over. Advocates and counselors will refer to domestic violence as a pattern of behaviors., including those listed above.

Lenore Walker presented the model of a Cycle of Violence which consists of three basic phases:

Honeymoon Phase
Characterized by affection, apology, and apparent end of violence.
Tension Building Phase
Characterized by poor communication, tension, fear of causing outbursts,
Acting-out Phase
Characterized by outbursts of violent, abusive incidents.

Although it is easy to see the outbursts of the Acting-out Phase as abuse, even the more pleasant behaviors. of the Honeymoon Phase serve to perpetuate the abuse.

Statistics

Domestic violence is a significant problem. Measures of the incidence of violence in intimate relationships can differ markedly in their findings depending on the measures used. Survey approaches tend to show parity in the use of violence by both men and women against partners, whereas research using data from reports of domestic violence tend to show women experiencing violence from male partners as the majority of cases (over 80%). Further discussion of this occurs in the next section on gender differences.

Cost

In the U.S., between 3 and 5 billion dollars are spent annually on medical expenses related to domestic violence. Also, approximately 100 million dollars is lost by businesses annually though lost productivity, sick leave and absenteeism due to domestic violence.

Gender differences

The discussion of domestic violence needs to include a discussion of the role of gender.

Erin Pizzey, the founder of an early women's shelter in Chiswick, London, has expressed her dismay at how she believes the issue has become a gender-political football, and expressed an unpopular view in her book Prone to Violence that some women in the refuge system had a predisposition to seek abusive relationships. She also expressed the view that domestic violence can occur against any vulnerable intimates, regardless of their sex. In the same book, Erin Pizzey stated that, of the first 100 women to enter the refuge, 62 were as violent, or more violent, than the men they were, allegedly, running away from.

There are women and men who seek to put forward the idea that abusive men are sexy. This can be shown in the media with the genre of bad boy romance novels.

In the United States, the bulk of the decrease in rates of intimate partner homicides is accounted for the dramatic decrease in women's murders of their male intimate partners. Murders of female intimate partners by men have dropped, but not nearly as dramatically. Men kill their female intimate partners at about four times the rate that women kill their male intimate partners. Research by Jacquelyn Campbell, PhD has found that at least two thirds of women killed by their intimate partners were battered by those men prior to the murder. She also found that when males are killed by female intimates, the women in those relationships had been abused by their male partner about 75% of the time.

Some researchers have found a relationship between the availability of domestic violence services, improved laws and enforcement regarding domestic violence and increased access to divorce, and higher earnings for women with declines in intimate partner homicide.

Gender roles and expectations can and do play a role in abusive situations, and exploring these roles and expectations can be helpful in addressing abusive situations, as do factors like race, class, religion, sexuality and philosophy. None of these factors cause one to abuse or another to be abused.

Domestic violence in same-sex relationships

Domestic violence also occurs in same-sex relationships. In an effort to be more inclusive, many organizations have made an effort to use gender-neutral terms when referring to perpetratorship and victimhood.

Historically domestic violence has been seen as a family issue and little interest has been directed at violence in same-sex relationships. It has not been until recently, as the gay rights movement has brought the issues of gay and lesbian people into public attention, when research has been started to conduct on same-sex relationships. Several studies have indicated that partner abuse among same-sex couples (both female and male) is relatively similar in both prevalence and dynamics to that among opposite-sex couples. Gays and lesbians, however, face special obstacles in dealing with the issues that some researchers have labeled "the double closet": not only do gay and lesbian people often feel that they are discriminated against and dismissed by police and social services, they are also often met with lack of support from their peers who would rather keep quiet about the problem in order not to attract negative attention toward the gay community. Also, the supportive services are mostly designed for the needs of heterosexual women and do not always meet the needs of other groups.

Response to domestic violence

The response to domestic violence is typically a combined effort between law enforcement agencies, the courts, social service agencies and corrections/probation agencies. The role of each has evolved as domestic violence has been brought more into public view. Historically, law enforcement agencies, the courts and corrections agencies treated domestic violence as a personal matter. For example, police officers were often reluctant to intervene by making an arrest, and often chose instead to simply counsel the couple and/or ask one of the parties to leave the residence for a period of time. The courts were reluctant to impose any significant sanctions on those convicted of domestic violence, largely because it was viewed as a misdemeanor offense. This mind set of treating family violence as a personal problem of minor consequence permeated the system's response, and potentially allowed the perpetrator to continue acting violently. Another response, while infrequent and ill regarded, is the homicide of the abuser by the abused, where the abused is usually a woman. The mind set of treating domestic violence as a family issue is brought into this aspect of domestic violence as well, ensuring that the women who kill their husbands/boyfriends/abusers are marginalizes in society and usually thrown in prison for homicide or manslaughter.

Activism, initiated by victim advocacy groups and feminist groups, has led to a better understanding of the scope and effect of domestic violence on victims and families, and has brought about changes in the criminal justice system's response.

Trainer and municipal court judge Richard Russell quoted in New Jersey Law Journal. April 24, 1995: "when you say to me, am I doing something wrong telling these judges they have to ignore the constitutional protections most people have, I don't think so. The Legislature described the problem and how to address it and I am doing my job properly by teaching other judges to follow the legislative mandate.....Your job is not to become concerned about all the constitutional rights of the man that you're violating as you grant a restraining order. Throw him out on the street, give him the clothes on his back and tell him, 'See ya' around.' " Moreover, Russell says there is nothing wrong with the teaching approach. Abuse victims, he says, may apply and relinquish TROs repeatedly before they finally do something about breaking away. Once they do so, he says, the Legislature's prevention goal has been met.

Several projects have aided in filling the voids in the justice system as it pertains to the protection of victims. One such initiative, The Hope Card Project, makes an attempt to remedy several problems through the issuance of an ID card to victims of abuse. The card is used to identify both parties in a domestic violence protection order and provides additional resources to the victim through a voucher program for services. "There is no photograph on a protection order, so a photograph is a bonus, not a necessity. There are several methods used to obtain the photograph. Some jurisdictions have a photograph taken of the offender during the first hearing while both parties are present. Another method is for officers to take a photograph in the field or retrieve a booking photograph from their local jail. In a lot of cases the victim brings a photograph and it is scanned. Lastly, the new online site has some state motor vehicle department photograph databases connected for that purpose. This is the ideal method."

The Duluth Domestic Abuse Intervention Project

In 1981, the Domestic Abuse Intervention Project was the first multi-disciplinary program designed to address the issue of domestic violence. This experiment, conducted in Duluth, involved coordinating the actions of a variety of agencies that deal with domestic situations. The policies and activities of diverse elements of the system, from police officers on the street, to shelters for battered women and probation officers supervising offenders, were coordinated with each other. This program has become a model for other jurisdictions seeking to deal more effectively with domestic violence. More and more jurisdictions are mandating that suspects in domestic violence incidents be arrested if there is probable cause to believe that an assault occurred. Victim advocates intervene directly with victims by providing them with counseling about the court process, how to obtain and use restraining orders and how to formulate and implement safety plans. Corrections/probation agencies in many areas supervise domestic violence offenders more closely, and pay attention to the victim's needs and safety issues.

It should be noted, however, that the Duluth framework depends on a strict "patriarchal violence" model and presumes that all violence in the home and elsewhere has a male perpetrator and female victim. It explicitly rejects any concept of mutuality or symmetry in abusive relationships.

Criticism

The exclusive focus on men as perpetrators and the rejection of system dynamics models has been criticized from perspectives influenced by psychology, education or remedial therapy. The fields of psychology, psychiatry, and social work all provide for application of skill learning, improved social understanding and practiced behavioral mastery to provide for corrected and alternative behaviors. By contrast, the Duluth Model presents only "once an abuser, always an abuser" constructions to this important social problem. However, the inconvenient fact, as reported by FBI crime statistics, is that 65 to 70% of all child (abuse-related) deaths occur at the hands of their mothers or female caretakers. This very broad and clear example of female initiated violence clearly moderates any "anti-patriarch" model of interpersonal violence.

More states are now recording abuse statistics regarding the marital state of both the perpetrator and the victim. In all jurisdictions with reports available, the rate of interpersonal violence for co-habiting couples exceeds that of married couples by a margin of ten to one.

The Duluth program is widely used but clear evidence of success is limited.

Treatment and support

Publicly available resources for dealing with domestic violence have tended to be almost exclusively geared towards supporting women and children who are in relationships with or who are leaving violent men, rather than for survivors of domestic violence per se. This has been due to the purported numeric preponderance of female victims and the perception that domestic violence only affected women. Resources to help men who have been using violence take responsibility for and stop their use of violence, such as Men's Behavior Change Programs or anger management training, are available, though attendees are ordered to pay for their own course in order that they should remain accountable for their actions.

Men's organizations, such as ManKind in the UK, often see this approach as one-sided; as Report 191 by the British Home Office shows that men and women are equally culpable, they believe that there should be anger management courses for women also. They accuse organizations such as Women's Aid of bias in this respect saying that they spend millions of pounds on helping female victims of domestic violence and yet nothing on female perpetrators. These same men's organizations claim that before such help is given to female perpetrators, Women's Aid would have to admit that women are violent in the home. This they seem reluctant to do.

One of the challenges for lay observers, victims, perpetrators and treatment providers is demonstrated by the tendency to describe perpetrator treatment as men's "anger management" groups.

Comprehensive and accountable behavior change programs are seen as far more appropriate and effective interventions in male violence in the home than anger management groups.

Inherent in anger management only approaches is the assumption that the violence is a result of a loss of control over one's anger. While there is little doubt that some domestic violence is about the loss of control, the choice of the target of that violence may be of greater significance. Anger management might be appropriate for the individual who lashes out indiscriminately when angry towards co-workers, supervisors or family. In most cases, however, the domestic violence perpetrator lashes out only at their intimate partner or relatively defenseless child, which suggests an element of choice or selection that, in turn, suggests a different or additional motivation beyond simple anger. Most experienced treatment providers have probably observed that for various reasons, many of which may be cultural, the perpetrator has a sense of entitlement, sometimes conscious, sometimes not, that leads directly to their choice of target.

Men's behavior change programs, although differing throughout the world, tend to focus on the prevention of further violence within the family and the safety of women and children. Often they abide by various standards of practice that includes 'partner contact' where the participants female partner is contacted by the program and informed about the course, checked about her level of safety and support and offered support services for herself if she requires them. Many of these programs have both a male and female facilitator and follow a program designed to highlight the impact of his behavior, examine the attitudes, values and behaviors. that lead to his choice to use violence and aim to support and challenge the man to take responsibility for his use of violence.

Although modern understanding of relational aggression arose from the study of cliques of girls in school, and despite the fact that the term "female bullying" is often used synonymously with "relational aggression", relational aggression is seen at times in women and men of all ages in spousal, familial, sexual, social, community, political, and religious settings.

The Violence Against Women Act of 1994 (VAWA) is a United States federal law. It was passed as Title IV and signed as Public Law by President Bill Clinton on September 13, 1994. It provided $1.6 billion to enhance investigation and prosecution of the violent crime perpetrated against women, increased pre-trial detention of the accused, provided for automatic and mandatory restitution of those convicted, and allowed civil redress in cases prosecutors chose to leave unprosecuted.

The National Organization of Women heralded the bill as "the greatest breakthrough in civil rights for women in nearly two decades." The American Civil Liberties Union derided the Act as "troubling", saying that the increased penalties were rash, the increased pretrial detention was "repugnant" to the US Constitution, the mandatory HIV testing of those only charged but not convicted is an infringement of a citizen’s right to privacy and the edict for automatic payment of full restitution was non-judicious in their paper "Analysis of Major Civil Liberties Abuses in the Crime Bill Conference Report as Passed by the House and the Senate", dated September 29, 1994. However, the ACLU has supported its reauthorization on the condition that the "unconstitutional DNA provision" be removed.

VAWA and the 1994 Crime Bill in general was supported by Congressional Democrats and President Clinton and opposed by then minority Congressional Republicans with a few exceptions.

Ironically, Paula Jones' attorneys Susan Carpenter-McMillan, Gilbert Davis and Joseph Cammarata would use VAWA in winning arguments one year later to allow a civil suit against President Clinton for sexual harassment to proceed. Eventually President Clinton paid an out of court settlement of $850,000 for the harassment of Jones.

In 2000, the Supreme Court of the United States held part of VAWA unconstitutional in United States v. Morrison. Only the civil rights remedy of VAWA was struck down. The provisions providing program funding were unaffected.

VAWA was reauthorized by Congress in 2000, and again in October 2005, when it passed the Senate unanimously. The bill was signed into law by President George W. Bush on January 5, 2006. It is due for further reauthorization in 2010.

World Health Organization Multi-country Study on Women's Health and Domestic Violence against Women 2005

The World Conference on Human Rights, held in Vienna in 1993, and the Declaration on the Elimination of Violence against Women in the same year, concluded that civil society and governments have acknowledged that violence against women is a public health policy and human rights concern. Work in this area has resulted in the establishment of international standards, but the task of documenting the magnitude of violence against women and producing reliable, comparative data to guide policy and monitor implementation has been exceedingly difficult. The World Health Organization Multi-country Study on Women’s Health and Domestic Violence against Women is a response to this difficulty. Published in 2005 it is a groundbreaking study which analysed data from 10 countries and sheds new light on the prevalence of violence against women. It seeks to look at violence against women from a public health policy perspective. The findings will be used to inform a more effective response from government, including the health, justice and social service sectors, as a step towards fulfilling the state’s obligation to eliminate violence against women under international human rights laws.

In the summary publication of the first World Report on Violence and Health, the authors see their mission clearly: ‘the purpose of the first World report on violence and health is to challenge the secrecy, taboos and feelings of inevitability that surround violent behavior’. It is a thoughtful exposition, recognizing the difficulties of such basic demands as defining and measuring violence. Furthermore, while ambitious in proclaiming the message that violence can be prevented, it is modest in recognizing that ‘[r]aising awareness of the fact that violence can be prevented is, however, only the first step in shaping the response to it’.

THE PUBLIC HEALTH APPROACH

The crucial stance of the public health approach is to focus on prevention: that is, preventing disease or illness from occurring, rather than dealing with the health consequences. The further shift is to try to think of violence in these terms. The arguments are seductive and it would be churlish for someone who has advocated more ‘upstream’ thinking (to use a term pervasive in the report) to challenge the basic tenets of the report — that is, that prevention is better than cure. However, mission statements are produced by missionaries, and missionaries rarely point out the underlying problems of their mission. In this respect, in reading the report, I realized that I am an academic, not a missionary and perhaps not even a scientist. A scientist, as Kuhn (1962) has explained, works within a paradigm, and challenges to a paradigm — especially a new one — are often met with stiff resistance. The task of an academic is perhaps rather different. Irritatingly, the academic will tend to identify tensions and problems rather than consensus and solutions. For the missionary and perhaps for the scientist, in contrast, all will be resolved if one accepts their vision of the world.

The public health approach is not new, as McKeown (1976) pointed out when he first stimulated the debate in the 1970s about the effects of medical intervention on human health. In fact, over the past 150 years or so, one can identify three phases of activity. The first phase began in the industrialized cities of northern Europe as a response to the appalling toll of death and disease among the working classes living in abject poverty. The response to this situation was the gradual development of the public health movement, such as the appointment of sanitary inspectors and their staff, supported by legislation such as the National Public Health Acts of 1848 and 1875 in England and Wales. The second phase was a more individualistic approach ushered in by the development of the germ theory of disease and the possibilities offered by immunization and vaccination. The third phase has been identified as the therapeutic era, dating from the 1930s, with the advent of insulin and other drugs. The beginning of this era coincided with the apparent demise of infectious diseases on the one hand and the development of ideas about the welfare state on the other. This all meant a shift of power and resources to hospital-based services and the downgrading of the public health approach. In fact, the individualization of illness — whether orchestrated by the medical profession or by the government — was one of the crucial ingredients of the health policies of the 1980s and early 1990s. Such an approach masks the social causes of ill-health. However, the Acheson Report (Acheson, 1998) laid the foundations for a wider and more inclusive approach emphasizing a variety of solutions to health problems. The World Report on Violence and Health is part of the recent shift of focus towards seeing problems within a wider framework.

THE PREVENTION MODEL

At first glance violence would seem to excite less controversy than health. After all, the ‘health police’ encouraging us to stop smoking seem to be on a stickier wicket than anyone trying to prevent violence. More will support the freedom to continue smoking than to continue committing violence. However, psychiatrists have recognized that espousing the prevention model is perhaps not so straightforward as some missionaries would have us believe. Locking up people who are highly likely to commit serious violence but who have not yet done so is a facet of the prevention model. In doing so, however one dresses up the language, there is some compromise to the notion that everyone is innocent until proven guilty. This strikes at the heart of the underlying philosophical assumptions that a prevention model appeals to.

A prevention model is essentially forward-looking, whereas a more reactive model, where symptoms or injuries are presented, is backward-looking. This is familiar territory in discussing philosophies of punishment where normative theories of punishment are typically classified as either ‘consequentialist’ or ‘non-consequentialist’. As Duff & Garland remind us, a consequentialist holds that the rightness or wrongness of any action or practice depends solely on its overall consequences. It is right if its consequences are good (at least, as good as those of any available alternative) and wrong if its consequences are bad (worse than those of some available alternative). This is utilitarianism, in which practices are seen as right or wrong in so far as they promote or destroy ‘the greatest happiness of the greatest number’. It is to this philosophy that one might appeal if a potential serial killer were to be incarcerated prior to committing an actual crime. In contrast, a non-consequentialist insists that actions may be right or wrong by virtue of their intrinsic character, independently of their consequences. In this approach it is the guilty, and only the guilty, who deserve to be punished. The potential serial killer must be allowed to become an actual killer, in the absence of overt evidence of any suffering that the person has actually caused.

Forensic psychiatrists know that neither of the alternative stances produces much comfort. The protection of civil liberties, may seem a high price to pay for local carnage. However, at the national and international level the dilemmas and tensions are even more stark. The problem here is that it is the powerful who may be the perpetrators of the most violence, just as it is at the domestic level.

DENYING REALITY

In a groundbreaking study which is as thought-provoking as it is disturbing, Stanley Cohen's book States of Denial: Knowing about Atrocities and Suffering deals with public reactions to information, images and appeals about inhumanities. He explores the various states of denial that exist in modern society. ‘Turning a blind eye’ and ‘burying one's head in the sand’ are two expressions of denial frequently used at an individual and societal level. With worrying regularity, we are saturated with media images of atrocities and suffering from all over the world. These images have become normalized. They are commonplace. So, too, is our apparent indifference.

Moving from the personal to the political, Cohen examines how organized atrocities, such as the Holocaust and other genocides, are denied by both perpetrators and bystanders. Bystander nations are those who do nothing, frequently claiming in the aftermath of an event that they were unaware of what was taking place. As for the perpetrators, one of the strategies they use is what Cohen describes as ‘interpretive denial’, claiming that what is happening is really something else. This is particularly evident in the euphemistic language used by organizations devoted to committing atrocities. The Nazi ‘euthanasia’ program for killing those with mental disabilities and other supposedly unworthy people was renamed the Charitable Foundation for Institutional Care. Such deliberate misrepresentation is not unique.

There is much else that is unpleasant and questionable in the exercise of power beyond genocide alone. Mary Daly, a radical feminist, in a classic study pointed to the male domination of women (patriarchy), which she suggests is everywhere expressed through the systematic destruction or mutilation of women. Different cultures express this — both historically and in the contemporary world — in different ways: suttee (the burning alive of widows) in India; foot-binding in China; female circumcision in Muslim Africa; the burning of witches in Europe; and gynecological therapies such as hysterectomy in modern America (‘genocide’, as Daly terms it). Perhaps more universally there is domestic violence, which is still frequently denied. Should there be international intervention to stop practices that reflect the male domination of women?

Concerns over the threats posed by international terrorist organizations took center stage with the horrific events at the World Trade Center and the Pentagon in the USA on 11 September 2001. Terrorists represent a real threat to us all, yet there is a danger that politicians will use this to justify introducing increased powers of surveillance for the state, which may be at the expense of individual civil liberties. Here, we are perhaps less comfortable about intervention that affects our own lives. International terrorism is being fought by global alliances, a reminder that we have newer versions of crimes committed against the physical environment itself: for instance, pollution, the threat of chemical warfare, the aftermath of weapons used in previous engagements such as the Gulf War and Kosovo. Is this violence against humanity? These are complex matters (Soothill et al, 2002).

Although the World Report on Violence and Health provides an invaluable and welcome service in trying to strip away some of the myths about violence and to expose the facts about violence, this is — as the authors recognize — only a beginning. So what is the warning? The warning is that there are massive moral and political issues to confront in shaping our response to violence. Assuming that consensus is easily achieved — or even achievable — may be a way of burying our head in the sand and turning a blind eye to some very real issues.

Stalking

Stalking is causing pervasive and intense personal suffering and is an area of psychiatry that is currently overlooked. Stalkers are best thought of as a heterogeneous group whose behavior can be motivated by different forms of psychopathology, including psychosis and severe personality disorders.

There is a clear need to arrive at a consensus on a typology of stalkers and associated diagnostic criteria. The effectiveness of psychological and pharmacological treatments have not yet been investigated. Treatment may need to be supplemented with external incentives provided by the legal system.

Stalking gained major media attention by the often-spectacular accounts of celebrity stalking. Well-known cases from the United States include the stalkers of Madonna and Jodie Foster. However, repeated intrusive communication and harassment is by no means limited to fans targeting the rich and famous. Much more common is the scenario in which stalker and ‘stalkee’ had some sort of ‘real’ prior relationship: they were often prior acquaintances or intimates, but professional contacts can also give rise to stalking later (e.g. by clients of psychiatrists or lawyers; or by rejected job applicants).

Forensic psychiatry has given scant attention to the phenomenon of stalking. Few studies have investigated the psychological make-up of stalkers, and to date only one study has reported on the psychological impact of stalking on its victims. There are no reports of the development of any specific treatment programs, either for stalkers or for their victims. This article aims to give an overview of stalking and its clinical ramifications. 
 
Partly as a result of publications in the media on stalking of celebrities, research into marital violence, and anti-stalking laws in some countries, mental health workers have recently started to study stalkers. It became apparent that a proportion of stalkers suffered from erotomania. Originally, erotomania was a term reserved for women who held the delusional belief that a man, typically of a higher social class or social esteem, was deeply in love with them. However, a delusional disorder of the erotomanic type, as it is currently classified in DSM-IV (American Psychiatric Association, 1994), only accounts for a very limited subset of episodes of stalking; stalking can result from many different motivations and constellations of psychopathological symptoms.

As often found with recently developed behavioral concepts, there is no consensus about the exact definition of stalking. Most of the disagreement seems to center on the degree of emphasis placed on the extent to which the stalking evokes a subjective sense of threat. Generally, the various definitions have the following elements in common: (a) a pattern of intrusive behavior, akin to harassment; (b) an implicit or explicit threat that emanates from the behavioral pattern; and (c) as a result, the target experiences considerable real fear. In this article we use Meloy and Gothard's definition: "Stalking is typically defined as the wilful, malicious, and repeated following or harassing of another person that threatens his or her safety".

NATURE AND PREVALENCE OF STALKING 
 
Stalking behavior typically consists of intrusive following of a ‘target’: for example, by placing one's self in front of the target's home, or other unexpected and unwelcome appearances in their private domain. Stalkers most often persecute their targets by unwanted communications, which can consist of frequent (often nightly) telephone calls, letters, e-mail, graffiti, notes (e.g. left on the target's car), or packages (e.g. gifts, pictures). Somewhat more extreme forms include ordering goods and services in the victim's name and charging to the victim's account, placing false advertisements or announcements, ordering funeral wreaths, spreading rumors about the victim, starting numerous frivolous law suits, smearing the victim's home or destroying or moving their property, threatening the victim with violence, or actually attacking them. Stalkers sometimes involve third parties, which leads to victimization by association of their family, friends, colleagues, lawyers, psychiatrists or psychologists, etc. Stalking can be of brief duration, but it can also last for many years. Research from the United States shows that in slightly over half the cases, stalking ceases within one year, while in one-quarter of the cases it lasts for 2-5 years.

In some cases, the violence may escalate until the stalker actually murders the victim and/or his/her children. In the United States, it is estimated that between 21% and 25% of forensic stalking cases culminate in significant violence. The incidence of murder or manslaughter in stalking cases in the United States is estimated at 2%. Fritz (1995) showed that 90% of women killed by their ex husband had previously been stalked. These numbers should probably not be extrapolated unreservedly to the European situation: for one reason, because of differences in the availability and possession of firearms.

Obtaining reliable data regarding the prevalence and incidence of stalking is a formidable international problem. Inconsistent definition and demarcation of the concept is partly responsible for this state of affairs. In some European countries stalking by itself is not considered a distinct legal offence which compounds the problem of monitoring and tracking cases for both police and forensic researchers. As a result, estimates of prevalence and incidence are based on very few, predominantly American studies. The US National Violence Against Women Survey contacted 8000 women and 8000 men by telephone, and asked them about stalking experiences: 8% of the women and 2% of the men had been stalked at some point in their life. This research also illustrates that criminal stalking cases merely reflect the tip of the iceberg: only 50% of stalking cases were reported to the police, of which 25% led to an arrest, and only 12% resulted in criminal prosecution.

Some research has focused on the prevalence of stalking within specific groups. Among 178 randomly sampled American university counseling center professionals, one in every 18 therapists reported having been harassed or stalked by a previous or current patient (Romans et al, 1996).

In sum, there is a great international need for systematic monitoring of stalking cases, based on some consensual definition, to arrive at reliable estimates of the magnitude of the problem.

Zona et al (1993) distinguished the following stalkers: (a) the ‘classic’ erotomanic stalker, who is usually a woman with the delusional belief that an older man of higher social class or social esteem is in love with her; (b) the love-obsessional stalker, who is typically a psychotic stalker targeting famous people or total strangers; and, most common, (c) the simple obsessional stalker, who stalks after a ‘real’ relationship has gone sour, leaving him with intense resentment following perceived abuse or rejection. Wright et al (1996) present a slightly different classification. They distinguish the domestic stalker and the nondomestic stalker: the former is comparable to Zona et al's ‘simple obsessional stalker’, whereas the non-domestic stalker comes in two types: the organized stalker and the delusional stalker. The delusional stalker corresponds with Zona et al's ‘erotomanic stalker’ and ‘love obsessional stalker’. The organized stalker targets previously unknown persons through anonymous communication. The victims usually have no knowledge of the identity of the stalker. Finally,

Mullen et al (1999) distinguish five types of stalkers: (a) the rejected stalker, who has had a relationship with the victim and who is often characterized by a mixture of revenge and desire for reconciliation; (b) the stalker seeking intimacy, which includes individuals with erotomanic delusions; (ac) the incompetent stalker — usually intellectually limited and socially incompetent individuals; (d) the resentful stalker, who stalks to frighten and distress the victim; and finally (e) the predatory stalker, who is preparing a sexual attack. In addition to these categories, there are reports on the so-called ‘false victimization syndrome’, during which the ‘victim’ pretends to have been stalked, by pursuing herself, in order to gain attention.

There is a clear need to derive a consensus on a typology of stalkers, with associated diagnostic criteria. At present, there is no evidence that one proposed typology is superior to another. The typology eventually agreed upon should have clear implications for treatment.

Personality of stalkers

To date, no systematic research has investigated the motivations and personality of stalkers. Reconciliation and reunion on the one hand v. revenge and intimidation on the other, are frequently mentioned as motivating stalkers. Tjaden & Thoenness found that stalkers' most common motivation was the desire to maintain control over their victims. Again, it deserves mention that most of these findings are based on stalking cases associated with ‘romantic relations gone sour’. Reflections on the personality and intrapsychic functioning of stalkers are predominantly psychodynamic in nature, and are focused on the simple obsessional subgroup. The central feature in these theories is an intense narcissistic reaction to rejection and loss, in combination with borderline defence mechanisms such as splitting, initial idealization, subsequent devaluation, projection and projective identification. The stalker is thought to defend him/herself against intense feelings of humiliation, shame and sadness by narcissistic rage, during which he/she starts devaluing and torturing the love object to maintain the narcissistic linking fantasy (Meloy, 1996).

A related perspective is to describe the stalker's dynamics from the point of view of pathological mourning: stalkers cannot adequately process the traumatic object loss, and as a result cannot move on to build new connections, and thus they remain ‘stuck’. Several authors have proposed that attachment pathology underlies the disturbed behavior Most notably, Meloy (1998) has formulated a tentative model which assigns to attachment pathology the pivotal role in developing stalking behaviors. Some evidence consistent with this line of theorizing comes from inspection of stalkers' childhood histories and life-events which immediately preceded stalking. For example, Kienlen found that a large proportion of stalkers had experienced significant discontinuity in their childhood (e.g. loss of a carer) and that many incidences of stalking immediately follow object loss.

Despite considerable effort, the current body of evidence is insufficient for the accurate prediction of stalking cases and of subsequent violent behavior (including murder). Some stable risk factors have been identified: a history of (domestic) violence, psychiatric history, antisocial personality disorder and a criminal record. An expert witness testimony predicting violence is not to be recommended, given the current shortage of research data. This statement signals no more than one of the most urgent and difficult problems in forensic psychiatry: how to predict dangerousness.

Numerous movies (e.g. Fatal Attraction, Play Misty for Me), documentaries and books give (often quite dramatic) accounts of the experience of being harassed, followed or stalked. The ‘typical’ victim of stalking is a woman of approximately the same age as the stalker, with whom he previously had a superficial relationship. Another frequent and particularly pernicious scenario is stalking following a history of domestic violence. Research by Wilson & Daly shows that the probability of getting killed by a spouse is 2-4 times as great after a divorce or separation than when continuing to live together.

It is not hard to imagine that months or years of exposure to persecution and threats can lead to serious psychological consequences. In particular, it is the constancy of threat into the private domain that causes the greatest distress to victims of stalking. The protracted and intense sense of intrusion and violation, by definition without an escape haven, is what seems to set stalking distress apart from other more or less traumatic types of stress. However, there is a remarkable lack of solid data on victim psychomorbidity following stalking. In their sample of stalking victims, Pathé & Mullen found predominantly depression, anxiety and traumatic psychomorbidity. On the basis of self-reports, 37% of the respondents qualified for a diagnosis of post-traumatic stress disorder (PTSD). This percentage is much the same as the proportion of PTSD cases in victims of domestic violence, which varies from 40% to 60% between different studies. Hall found that victims of stalking perceived personality changes in themselves as a result of the ordeal they had suffered. Increases in caution, suspiciousness, anxiety and aggression were noted most frequently.

Victims of stalking also reacted by making significant changes in their social and professional life. Nearly all victims adjusted their daily routines (routes, habits), and a majority took additional safety precautions such as getting a secret telephone number, house alarm, etc. Four out of ten stalking victims changed their job or moved away in order to escape the stalking terror. About half reported a partial or total loss of productivity (work or study) and decreased social activity. The perceived lack of safety also led many to carry weapons, including firearms.

As was emphasized earlier, stalking describes a behavioral problem, not a psychiatric classification per se. Several authors have reflected on the diagnostic assessment of stalkers, and generally made a distinction between psychotic stalkers (Axis I) and stalkers with severe personality pathology (Axis II). The psychotic stalker can exhibit primary erotomania, but erotomanic delusions can also result from multiple other DSM-IV disorders, including schizophrenia, bipolar disorder, and major depression (American Psychiatric Association, 1994). Stalking is predominantly associated with cluster B personality pathology (narcissistic and borderline personality disorders) and to a lesser extent with dependent, schizoid, and paranoid features. There are relatively few reports of stalking by classic psychopaths, and these cases are almost without exception extensions of (long) histories of domestic violence. In addition to these primary disorders, comorbid conditions, such as substance abuse or dependence and affective disorders, are frequently mentioned. It is worth noting that almost all diagnostic hypotheses were based on clinical impressions from uncontrolled studies. Controlled research into personality characteristics and psychopathology (based on, for example, structured interviews and standard personality inventories) is sorely lacking.

Since research into the treatment of stalkers is notably absent, there are no clear guidelines for treatment. The best methods of opposition to, and treatment of, stalking will depend on the stalker's idiosyncratic psychological profile. Erotomanic or otherwise psychotic stalkers will prove to be extraordinarily resistant to treatment. Primary erotomanic delusions are typically unflagging, which leads one to believe that investment in legal means for deterring such stalkers would probably be the most efficient. Involuntary commitment, trespassing orders and street prohibitions are among the options available in several European countries. Unfortunately, such interventions often appear to incense the stalkers and stimulate them to even more malicious and intense persecutory behavior To stop stalking in secondary erotomania, the treatment will have to focus on the underlying disorder, and probably involve neuroleptics. Neither of these types of stalker is likely to benefit from psychotherapy. However, the third and most prevalent group consists of obsessed, rejected stalkers with (usually) severe personality disorder; and this group is likely to be best served with a mix of judicial and psychotherapeutic interventions.

A primary problem in treating stalkers is to motivate them for therapy. By the very nature of the problem, stalkers are unlikely to report themselves for psychiatric or psychological treatment. In sum, there is a clear need for controlled studies into the effectiveness of psychotherapy and drug therapy for stalkers.

Primary prevention should receive more attention in one particular subset of stalking cases. As discussed, a large proportion of stalking cases follows from histories of domestic violence (Kurt, 1995). Earlier intervention in domestic violence and family counseling can promote a more satisfactory end to relationships and thus prevent subsequent resentment spilling over in stalking.

Required Reading: Measuring Intimate Partner Violence Victimization and Perpetration: A Compendium of Assessment Tools

Intimate Partner Violence

Occurrence

Statistics about intimate partner violence (IPV) vary because of differences in how different data sources define IPV and collect data. For example, some definitions include stalking and psychological abuse, and others consider only physical and sexual violence. Data on IPV usually come from police, clinical settings, nongovernmental organizations, and survey research.  

Most IPV incidents are not reported to the police. About 20% of IPV rapes or sexual assaults, 25% of physical assaults, and 50% of stalkings directed toward women are reported. Even fewer IPV incidents against men are reported (Tjaden and Thoennes 2000a). Thus, it is believed that available data greatly underestimate the true magnitude of the problem. While not an exhaustive list, here are some statistics on the occurrence of IPV. In many cases, the severity of the IPV behaviors is unknown.

• Nearly 5.3 million incidents of IPV occur each year among U.S. women ages 18 and older, and 3.2 million occur among men. Most assaults are relatively minor and consist of pushing, grabbing, shoving, slapping, and hitting
• In the United States every year, about 1.5 million women and more than 800,000 men are raped or physically assaulted by an intimate partner. This translates into about 47 IPV assaults per 1,000 women and 32 assaults per 1,000 men
• IPV results in nearly 2 million injuries and 1,300 deaths nationwide every year
• Estimates indicate more than 1 million women and 371,000 men are stalked by intimate partners each year.
• IPV accounted for 20% of nonfatal violence against women in 2001 and 3% against men
• From 1976 to 2002, about 11% of homicide victims were killed by an intimate partner (Fox and Zawitz 2004).
• In 2002, 76% of IPV homicide victims were female; 24% were male .
• The number of intimate partner homicides decreased 14% overall for men and women in the span of about 20 years, with a 67% decrease for men (from 1,357 to 388) vs. 25% for women .
• One study found that 44% of women murdered by their intimate partner had visited an emergency department within 2 years of the homicide. Of these women, 93% had at least one injury visit .
• Previous literature suggests that women who have separated from their abusive partners often remain at risk of violence.
• Firearms were the major weapon type used in intimate partner homicides from 1981 to 1998.
• A national study found that 29% of women and 22% of men had experienced physical, sexual, or psychological IPV during their lifetime.
• Between 4% and 8% of pregnant women are abused at least once during the pregnancy.

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Consequences

In general, victims of repeated violence over time experience more serious consequences than victims of one-time incidents. The following list describes just some of the consequences of IPV.

Physical

At least 42% of women and 20% of men who were physically assaulted since age 18 sustained injuries during their most recent victimization. Most injuries were minor such as scratches, bruises, and welts (Tjaden and Thoennes 2000a).

More severe physical consequences of IPV may occur depending on severity and frequency of abuse; These include:

• Bruises
• Knife wounds
• Pelvic pain
• Headaches
• Back pain
• Broken bones
• Gynecological disorders
• Pregnancy difficulties like low birth weight babies and perinatal deaths
• Sexually transmitted diseases including HIV/AIDS
• Central nervous system disorders
• Gastrointestinal disorders
• Symptoms of post-traumatic stress disorder
  • Emotional detachment
  • Sleep disturbances
  • Flashbacks
  • Replaying assault in mind
• Heart or circulatory conditions

Children may become injured during IPV incidents between their parents. A large overlap exists between IPV and child maltreatment (Appel and Holden 1998). One study found that children of abused mothers were 57 times more likely to have been harmed because of IPV between their parents, compared with children of non-abused mothers.

Psychological

Physical violence is typically accompanied by emotional or psychological abuse. IPV—whether sexual, physical, or psychological—can lead to various psychological consequences for victims:

• Depression
• Antisocial behavior
• Suicidal behavior in females
• Anxiety
• Low self-esteem
• Inability to trust men
• Fear of intimacy

Social

Victims of IPV sometimes face the following social consequences:

• Restricted access to services
• Strained relationships with health providers and employers
• Isolation from social networks

Health Behaviors

Women with a history of IPV are more likely to display behaviors that present further health risks (e.g., substance abuse, alcoholism, suicide attempts).

IPV is associated with a variety of negative health behaviors. Studies show that the more severe the violence, the stronger its relationship to negative health behaviors by victims.

• Engaging in high-risk sexual behavior
  • Unprotected sex
  • Decreased condom use
  • Early sexual initiation
  • Choosing unhealthy sexual partners
  • Having multiple sex partners
  • Trading sex for food, money, or other items
• Using or abusing harmful substances
  • Smoking cigarettes
  • Drinking alcohol
  • Driving after drinking alcohol
  • Taking drugs
• Unhealthy diet-related behaviors
  • Fasting
  • Vomiting
  • Abusing diet pills
  • Overeating
• Overuse of health services

Economic

• Costs of IPV against women in 1995 exceed an estimated $5.8 billion. These costs include nearly $4.1 billion in the direct costs of medical and mental health care and nearly $1.8 billion in the indirect costs of lost productivity.
• When updated to 2003 dollars, IPV costs exceed $8.3 billion, which includes $460 million for rape, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in the value of lost lives.
• Victims of severe IPV lose nearly 8 million days of paid work—the equivalent of more than 32,000 full-time jobs—and almost 5.6 million days of household productivity each year.
• Women who experience severe aggression by men (e.g., not being allowed to go to work or school, or having their lives or their children’s lives threatened) are more likely to have been unemployed in the past, have health problems, and be receiving public assistance.

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Groups at Risk

Certain groups are at greater risk for IPV victimization or perpetration.

Victimization

• The National Crime Victimization Survey found that 85% of IPV victims were women.
• Prevalence of IPV varies among race. Among the ethnic groups most at risk are American Indian/Alaskan Native women and men, African-American women, and Hispanic women.
• Young women and those below the poverty line are disproportionately victims of IPV.

Perpetration

• Studies show that for low levels of physical violence, men and women self-report perpetrating physical IPV at about the same rate. However, a common criticism of these studies is that they are generally lacking information on the context of the violence (e.g., whether self-defense is the reason for the violence).

Risk Factors for Victimization and Perpetration

Risk factors are associated with a greater likelihood of IPV victimization or perpetration. Risk factors are not necessarily direct causes of IPV—these may be contributing factors to IPV. Not everyone who is identified as "at risk" becomes involved in violence.

Some risk factors for IPV victimization and perpetration are the same. In addition, some risk factors for victimization and perpetration are associated with one another; for example, childhood physical or sexual victimization is a risk factor for future IPV perpetration and victimization.

The public health approach aims to moderate and mediate those contributing factors that are preventable, and to identify protective factors which can reduce the risk of victimization and perpetration.

A combination of individual, relational, community, and societal factors contribute to the risk of being a victim or perpetrator of IPV. Understanding these multilevel factors can help identify various points of prevention intervention.

Risk Factors for Victimization

Individual Factors

• Prior history of IPV
• Being female
• Young age
• Heavy alcohol and drug use
• High-risk sexual behavior
• Witnessing or experiencing violence as a child
• Being less educated
• Unemployment
• For men, having a different ethnicity from their partner’s
• For women, having a greater education level than their partner’s
• For women, being American Indian/Alaska Native or African American
• For women, having a verbally abusive, jealous, or possessive partner

Relationship Factors

• Couples with income, educational, or job status disparities
• Dominance and control of the relationship by the male

Community Factors

• Poverty and associated factors (e.g., overcrowding)
• Low social capital—lack of institutions, relationships, and norms that shape the quality and quantity of a community’s social interactions
• Weak community sanctions against IPV (e.g., police unwilling to intervene)

Societal Factors

• Traditional gender norms (e.g., women should stay at home and not enter workforce, should be submissive)
  Risk Factors for Perpetration
  
  Individual Factors

• Low self-esteem
• Low income
• Low academic achievement
• Involvement in aggressive or delinquent behavior as a youth
• Heavy alcohol and drug use
• Depression
• Anger and hostility
• Personality disorders
• Prior history of being physically abusive
• Having few friends and being isolated from other people
• Unemployment
• Economic stress
• Emotional dependence and insecurity
• Belief in strict gender roles (e.g., male dominance and aggression in relationships)
• Desire for power and control in relationships
• Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration)

Relationship Factors

• Marital conflict—fights, tension, and other struggles
• Marital instability—divorces and separations
• Dominance and control of the relationship by the male
• Economic stress
• Unhealthy family relationships and interactions

Community Factors

• Poverty and associated factors (e.g., overcrowding)
• Low social capital—lack of institutions, relationships, and norms that shape the quality and quantity of a community’s social interactions
• Weak community sanctions against IPV (e.g., unwillingness of neighbors to intervene in situations where they witness violence)

Required Reading:

Husband Abuse: An Overview of Research and Perspectives

Family Violence and Substance Abuse

Health Effects of Family Violence

References:

Leslie Tutty; Husband Abuse:An Overview of Research and Perspectives Family Violence Prevention Prevention Unit, Canada, 1999

National Clearinghouse on Family Violence

U.S. Department of Justice

Center for Disease Control and Prevention

Intimate Partner Violence Ceus

U.S. Department of Health and Human Services