Domestic Violence Michelle Rice, Ph.D.

Domestic violence is a prominent public health issue in the United States. It is the most frequent cause of serious injury to women, more than car accidents, muggings, and stranger combined. 1 This fact sheet provides information regarding the definition of domestic violence, the prevalence of domestic violence, the dynamics of abusive relationships, the effects of domestic violence, treatment for victims and perpetrators, and resources offering assistance.

What is domestic violence? Domestic violence is defined as the use or threat of use of physical, emotional, verbal, or sexual with the intent of instilling , intimidating, and controlling behavior. 1 Domestic violence occurs within the context of an intimate relationship and may continue after the relationship has ended. The types of domestic violence are as follows 1, 2:

Physical abuse

• Verbal threats of violence, pushing, shoving, hitting, slapping, punching, biting, kicking, holding down, pinning against the wall, choking, throwing objects, breaking objects, punching walls, driving recklessly to scare, blocking exits, using weapons

Emotional/

• Name calling, coercion and threats, criticizing, yelling, humiliating, isolating, (controlling finances, preventing victim from working), threatening to hurt children or pets,

Sexual abuse

• Unwanted touching, sexual name calling, false accusations of sexual infidelity, forced sex, unwanted pregnancy, sexually transmitted diseases, HIV transmission

Researchers in the field of domestic violence have compiled characteristics of batterers, which can be utilized to predict the likelihood of battering.º The more characteristics present in a person, the greater the likelihood of battering. 1 The most predictive indicators are:

• History of past battering • Threats of violence • Breaking objects • Use of force during arguments

The following are also warning signs:

• Unreasonable jealousy • Controlling behavior • Quick involvement in the relationship • Verbal abuse, blaming others for problems • Cruelty to children and animals • Abrupt mood changes

What is the prevalence of domestic violence? It is very difficult to estimate the rate of domestic violence because the majority of victims never disclose that they are involved in partner violence. It is estimated that, regarding violent behavior toward females within the context of an intimate relationship, only 20% of all rapes, 25% of all physical assaults, and 50% of all stalking are ever reported to the police. 3 Victims may be reluctant to come forward for a variety of reasons. First, they may fear retaliation from their partner. They may have been directly threatened that if they tell anyone they will be killed, or they may just fear the worst. Second, there is associated with choosing a partner who could be violent, and there is shame associated with staying with a violent partner. Finally, some victims may have tried to seek help from the police, the courts, or others and been dissatisfied with the help they received. The following statistics as reported in Fischbach and Herbert 4 and Tjaden and Thoennes, 3 shed light on the prevalence of domestic violence (statistics are for the U.S. only):

• 20-30% of American women will be physically abused by a partner at least once in their lifetimes • 1.3 million women and 834,732 men are physically assaulted by an intimate partner annually • 201,394 women are forcibly raped by an intimate partner annually • 11% of women in homosexual relationships and 23% of men in homosexual relationships report being raped, physically assaulted, and/or stalked by an intimate partner • 503,485 women and 185,496 men are stalked by an intimate partner annually • 1-25% of all pregnant women are battered during pregnancy • 30-40% of women's emergency room visits are for injuries due to domestic violence • 30% of women killed in the U.S. are killed by their husbands or boyfriends • 50% of men who assaulted their female partners also assaulted their children • 3.3 million children witness domestic violence each year

What are the dynamics of an abusive relationship? Research focusing on the dynamics of abusive relationships has resulted in several ways of understanding the interactions between the batterer and the victim. The first conceptualization is that of the Cycle of Violence, 5 consisting of three stages: the tension building stage (tension in the relationship gradually increases over time); the acute battering stage (tension erupts, resulting in threats or use of violence and abuse); and the honeymoon stage (the batterer may be apologetic and remorseful and promise not to be abusive again). The cycle continues throughout the relationship, with the honeymoon stage becoming shorter and the episodes of battering becoming more frequent or more severe. The honeymoon stage reinforces the victim's hope that the batterer will change and contributes to the victim staying in the relationship.

The concept of Traumatic Bonding 6 has also been developed to explain the dynamics of domestic violence relationships. Essentially, strong emotional connections develop between the victim and the perpetrator during the abusive relationship. These emotional ties develop due to the imbalance of power between the batterer and the victim and because the treatment is intermittently good and bad. In terms of the power imbalance, as the abuser gains more power, the abused individual feels worse about him- or herself, is less able to protect him- or herself, and is less competent. The abused person therefore becomes increasingly dependent on the abuser. The second key factor in traumatic bonding is the intermittent and unpredictable abuse. While this may sound counterintuitive, the abuse is offset by an increase in positive behaviors such as attention, gifts, and promises. The abused individual also feels relief that the abuse has ended. Thus, there is intermittent for the behavior, which is difficult to extinguish and serves instead to strengthen the bond between the abuser and the individual being abused.

Finally, abusive relationship dynamics can also be understood through the concepts of Approach and Avoidance. 7 The mix of pros (love and economic support) and cons (fear and ) present in the battering relationship leads to ambivalence on the part of the victim. The victim is likely to want to approach the positives in the relationship but avoid the abuse. This struggle between wanting to keep the relationship and wanting to remain safe makes it difficult to decide whether to leave or stay in the relationship. On average, women leave and return to an abusive relationship five times before permanently leaving the relationship.

What are the effects of domestic violence? Domestic violence has wide ranging and sometimes long-term effects on victims. The effects can be both physical and psychological and can impact the direct victim as well as any children who witness parental violence.

The physical health effects of domestic violence are varied. Victims may experience physical injury (lacerations, bruises, broken bones, head injuries, internal bleeding), chronic pelvic pain, abdominal and gastrointestinal complaints, frequent vaginal and urinary tract infections, sexually transmitted diseases, and HIV. 2, 8 Victims may also experience pregnancy-related problems. Women who are battered during pregnancy are at higher risk for poor weight gain, pre-term labor, miscarriage, low infant birth weight, and injury to or death of the fetus. There are also many psychological effects of domestic violence. remains the foremost response, with 60% of battered women reporting depression. 9 In addition, battered women are at greater risk for attempts, with 25% of suicide attempts by Caucasian women and 50% of suicide attempts by African American women preceded by abuse. 4

Along with depression, domestic violence victims may also experience Posttraumatic Stress Disorder (PTSD), which is characterized by symptoms such as flashbacks, intrusive imagery, nightmares, anxiety, emotional numbing, insomnia, hyper-vigilance, and avoidance of traumatic triggers. Several empirical studies have explored the relationship between experiencing domestic violence and developing PTSD. Vitanza, Vogel, and Marshall 10 interviewed 93 women reporting to be in long-term, stressful relationships. The researchers looked at the relationships among , severity of violence in the relationship, and PTSD. The results of the study showed a significant correlation between domestic violence and PTSD. In each group in the study (psychological abuse only, moderate violence, and severe violence), women scored in the significant range for PTSD. Overall, 55.9% of the sample met diagnostic criteria for PTSD. In further support of the strong relationship between domestic violence and PTSD, Mertin and Mohr, 11 interviewed 100 women in Australian shelters, each of whom had experienced domestic violence. They found that 45 of the 100 women met diagnostic criteria for PTSD.

Children may develop behavioral or emotional difficulties after experiencing in the context of domestic violence or after witnessing parental abuse. Children's responses to the violence may vary from to withdrawal to somatic complaints. In addition, children may develop symptoms of depression, anxiety, or PTSD. 1

How are the effects of domestic violence treated? Psychological treatment for victims and perpetrators can be helpful in the aftermath of domestic violence. For battered women, Hattendorf and Tollerud 5 recommend a feminist therapy approach in which traditional gender roles are challenged and empowerment of the victim is a primary focus. Individual therapy for victims of domestic violence should begin with a primary focus on safety, particularly if the woman is currently in an abusive relationship. The therapist should assess the current level of dangerousness and lethality in the relationship based on the following factors concerning the batterer: threats of homicide or suicide, possession of weapons, acute depression, alcohol/drug use, history of pet abuse, and level of rage. 1 The presence of these factors increases the level of potential lethality in the batterer.

In addition to assessing lethality, the individual therapist should develop a safety plan with the victim. A safety plan may contain a strategy for how to leave a dangerous situation; the preparation of a safety kit (clothing, medications, keys, money, copies of important documents) to be kept either near an exit route or at a trusted friend's house; and arrangements for shelter (made without the batterer's knowledge of the location). 1 Once lethality and safety have been addressed, the longer-term goals of treatment for the battered woman can be addressed. These goals include helping the woman identify the impact of abuse on her life and helping her work toward empowerment. 5 Victims can be empowered by regaining their independence and reconnecting with supports and resources that may have been cut off due to the isolation of domestic violence. In addition, the victim's children may need their own treatment to address their responses to witnessing or experiencing abuse.

For some victims, additional treatment may be needed to target symptoms of depression, PTSD, , or other disorders found to occur in the presence of domestic violence.

Batterers can also benefit from treatment, although it remains unclear exactly how effective treatment is in breaking the cycle of batterers' violence. Batterers benefit most from batterer treatment programs, which in part focus on identifying what domestic violence is. These programs also focus on helping batterers develop a sense of personal responsibility for one's actions and for stopping the violence. 1 Batterers can also be treated in individual therapy, but the focus of treatment must be on the violence. While some batterers and victims may seek to engage in couple's therapy to address the abuse in their relationship, couple's therapy is not recommended while violence is occurring in the relationship. In addition, it is recommended that each member of the couple complete their individual treatment first, before beginning any couple's therapy. 1

National toll-free Domestic Violence hotline: 1-800-799-SAFE (7233)

References 1. Harway, M. & Hansen, M. (1994). Spouse abuse: Assessing and treating battered women, batterers, and their children. Sarasota, Florida: Professional Resource Press.

2. Jones, R.F. & Horan, D.L. (1997). The American college of obstetricians and gynecologists: A decade of responding to . International Journal of Gynecology and Obstetrics, 58, 43-50.

3. Tjaden, P. & Thoennes, N. (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey. National Institute of Justice/Centers for Disease Control and Prevention.

4. Fischbach, R.L. & Herbert, B. (1997). Domestic violence and mental health: Correlates and conundrums within and across cultures. Social Science Medicine, 45, 1161-1176.

5. Hattendorf, J. & Tollerud, T.R. (1997). Domestic violence: Counseling strategies that minimize the impact of secondary victimization. Perspectives in Psychiatric Care, 33, 14-23. 6. Dutton, D.G., & Painter, S.L. (1981). Traumatic bonding: The development of emotional attachments in battered women and other relationships of intermittent abuse. Victimology: An International Journal, 1, 139-155.

7. Barnett, O.W. (2001). Why battered women do not leave, part 2: External inhibiting factors? and internal inhibiting factors. Trauma, Violence, and Abuse, 2, 3-35.

8. Bohn, D.K. & Holz, K.A. (1996). Sequelae of abuse: Health effects of childhood , domestic battering, and . Journal of Nurse-Midwifery, 41, 442-456.

9. Barnett, O.W. (2000). Why battered women do not leave, part 1: External inhibiting factors within society . Trauma, Violence, and Abuse, 1, 343-372.

10. Vitanza, S., Vogel, L.C., & Marshall, L.L. (1995). Distress and symptoms of posttraumatic stress disorder in abused women. Violence and Victims, 10, 23-34.

11. Mertin, P. & Mohr, P.B. (2000). Incidence and correlates of posttraumatic stress disorder in Australian victims of domestic violence. Journal of Family Violence, 15, 411-422.

Understanding Intimate Partner Violence

Fact Sheet 2006 Intimate partner violence (IPV) is abuse that occurs • The cost of IPV was an estimated $5.8 billion in 1995. between two people in a close relationship. The term Updated to 2003 dollars, that’s more than $8.3 billion.3,4 “intimate partner” includes current and former spouses This cost includes medical care, mental health services, and dating partners. IPV exists along a continuum and lost productivity (e.g., time away from work). from a single episode of violence to ongoing battering. IPV includes four types of behavior: How does IPV affect health? • Physical abuse is when a person hurts or tries to hurt a partner by hitting, kicking, burning, or other IPV can affect health in many ways. The longer the abuse physical force. goes on, the more serious the effects on the victim. • Sexual abuse is forcing a partner to take part in a Many victims suffer physical injuries. Some are minor sex act when the partner does not consent. like cuts, scratches, bruises, and welts. Others are more • Threats of physical or sexual abuse include the use serious and can cause lasting disabilities. These include of words, gestures, weapons, or other means to broken bones, internal bleeding, and head trauma. communicate the intent to cause harm. Not all injuries are physical. IPV can also cause • Emotional abuse is threatening a partner or his or emotional harm. Victims often have low self-esteem. her possessions or loved ones, or harming a partner’s They may have a hard time trusting others and being in sense of self-worth. Examples are stalking, name- relationships. The anger and stress that victims feel may calling, , or not letting a partner see lead to eating disorders and depression. Some victims friends and family. even think about or commit suicide. Often, IPV starts with emotional abuse. This behavior IPV is linked to harmful health behaviors as well. can progress to physical or sexual assault. Several types Victims are more likely to smoke, abuse alcohol, use of IPV may occur together. drugs, and engage in risky sexual activity.

Why is IPV a public health Who is at risk for IPV? problem?

Many victims do not report IPV to police, friends, or Several factors can increase the risk that someone will family. 1 Victims think others will not believe them and hurt his or her partner. However, having these risk that the police cannot help.1 factors does not always mean that IPV will occur. • Each year, women experience about 4.8 million Risk factors for perpetration (hurting a partner): intimate partner related physical assaults and rapes. • Using drugs or alcohol, especially drinking heavily Men are the victims of about 2.9 million intimate • Seeing or being a victim of violence as a child partner related physical assaults.1 • Not having a job, which can cause feelings of stress • IPV resulted in 1,544 deaths in 2004. Of these deaths, Note: These are just some risk factors. To learn more, 25% were males and 75% were females.2 go to www.cdc.gov/injury.

www.cdc.gov/injury Understanding Intimate Partner Violence

Step 3: Develop and test prevention strategies How can we prevent IPV? Using information gathered in research, CDC develops and evaluates strategies to prevent IPV.

The goal is to stop IPV before it begins. Strategies that Step 4: Assure widespread adoption promote healthy dating relationships are important. In this final step, CDC shares the best prevention These strategies should focus on young people when strategies. CDC may also provide funding or technical they are learning skills for dating. This approach can help so communities can adopt these strategies. help those at risk from becoming victims or offenders For a list of CDC activities, see Preventing Violence of IPV. Against Women: Program Activities Guide (www.cdc.gov/ Traditionally, women’s groups have addressed IPV by ncipc/dvp/vawguide.htm). setting up crisis hotlines and shelters for battered women. But, both men and women can work with young people to prevent IPV. Adults can help change Where can I learn more? social norms, be role models, mentor youth, and work with others to end this violence. For example, by National Domestic Violence Hotline modeling nonviolent relationships, men and women 1-800-799-SAFE (7233), 1-800-787-3224 TTY, or can send the message to young boys and girls that www.ndvh.org violence is not okay. National Coalition Against Domestic Violence www.ncadv.org How does CDC approach National Sexual Violence Resource Center IPV prevention? www.nsvrc.org Family Violence Prevention Fund CDC uses a 4-step approach to address public health www.endabuse.org problems like IPV.

Step 1: Define the problem References Before we can prevent IPV, we need to know how big the problem is, where it is, and whom it affects. CDC 1.Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner learns about a problem by gathering and studying data. violence: findings from the National Violence Against Women Survey. These data are critical because they help decision makers Washington (DC): Department of Justice (US); 2000. Publication No. NCJ use resources where needed most. 181867. Available from: URL: www.ojp.usdoj.gov/nij/pubs-sum/181867.htm. 2.Department of Justice, Bureau of Justice Statistics. Homicide trends in the United States [online]. [cited 2006 Aug 28]. Available from URL: Step 2: Identify risk and protective factors www.ojp.usdoj.gov/bjs/homicide/intimates.htm. It is not enough to know that IPV affects certain people 3.Centers for Disease Control and Prevention (CDC). Costs of intimate partner in a certain area. We also need to know why. CDC violence against women in the United States. Atlanta (GA): CDC, National Center for Injury Prevention and Control; 2003. [cited 2006 May 22]. Available conducts and supports research to answer this question. from: URL: www.cdc.gov/ncipc/pub-res/ipv_cost/ipv.htm. We can then develop programs to reduce or get rid of 4.Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll risk factors. of intimate partner violence against women in the United States. Violence and Victims 2004;19(3):259–72.

For more information, please contact: Centers for Disease Control and Prevention National Center for Injury Prevention and Control 1-800-CDC-INFO • www.cdc.gov/injury • [email protected] Understanding Teen Dating Abuse

Fact Sheet 2006

Unhealthy relationships can start early and last a How does dating abuse lifetime. Dating abuse occurs when harmful behaviors are repeated, creating a pattern of violence. There are affect health? three common types of dating abuse. Dating abuse has a negative effect on health throughout • Physical abuse occurs when a teen is pinched, hit, life. Teens who are abused are more likely to do poorly shoved, or kicked. in school. They often engage in unhealthy behaviors, like drug and alcohol use. The anger and stress that • Emotional abuse means threatening a teen or victims feel may lead to eating disorders and harming his or her sense of self-worth. Examples depression. Some abused teens even think about or include name calling, , threats, , or attempt suicide. Abused teens often carry the patterns keeping a teen away from friends and family. of violence into future relationships. Physically abused teens are three times more likely than their non-abused • Sexual abuse is forcing a teen to engage in a sex act. peers to experience violence during college.4 In This includes fondling and rape. adulthood, they are more likely to be involved in intimate partner violence. Dating abuse often starts with teasing and name calling. These behaviors are often thought to be a “normal” Who is at risk for part of a relationship. But these behaviors can lead to dating abuse? more serious abuse like physical assault and rape. Teens report dating abuse more often than other age groups. Among teens, boys often start the violence and Why is dating abuse a public use greater force. Girls are more likely than boys to be health problem? the victims of sexual abuse. Studies show that people who abuse their dating Dating abuse is a serious problem in the United States. partners are more depressed, have lower self-esteem, Many teens do not report abuse because they are afraid and are more aggressive than peers. Other “red flags” to tell friends and family. for dating abuse include: • 72% of 8th and 9th graders reportedly “date”.1 • Use of threats or violence to solve problems • Alcohol or drug use • 1 in 4 adolescents reports verbal, physical, emotional, • Inability to manage anger or frustration or sexual abuse each year .1,2 • Poor social skills • Association with violent friends • 1 in 11 high school students reports being physically • Problems at school 3 hurt by someone they were dating. • Lack of parental supervision, support, or discipline • Witnessing abuse at home

www.cdc.gov/injury Understanding Teen Dating Abuse

How can we prevent Step 3: Develop and test prevention strategies Using information gathered in research, CDC develops dating abuse? and evaluates strategies to prevent violence. The ultimate goal is to stop dating abuse before it Step 4: Assure widespread adoption starts. Strategies that promote healthy relationships are In this final step, CDC shares the best prevention vital. During the preteen and teen years, young people strategies. CDC may also provide funding or technical are learning skills they need to form positive help so communities can adopt these strategies. relationships with others. This is an ideal time to promote healthy relationships and prevent patterns of For a list of CDC activities, see Preventing Violence that can last into adulthood. Against Women: Program Activities Guide (www.cdc.gov/ ncipc/dvp/vawguide.htm). Prevention programs address the attitudes and behaviors linked with dating abuse. One example is Safe Dates, a school-based program that is designed to Where can I learn more? change gender norms and improve problem solving skills. Choose Respect Initiative Community efforts such as parenting support and www.chooserespect.org mentoring programs have also been shown to prevent National Domestic Violence Hotline violence. 1-800-799-SAFE (7233) National Sexual Assault Online Hotline 1-800-656-HOPE (4673) How does CDC approach National Sexual Violence Resource Center prevention? www.nsvrc.org National Youth Violence Prevention Resource Center CDC uses a 4-step approach to address public health www.safeyouth.org problems like dating abuse. Love Is Not Abuse www.loveisnotabuse.com Step 1: Define the problem Before we can prevent dating abuse, we need to know how big the problem is, where it is, and whom it affects. References CDC learns about a problem by gathering and studying data. These data are critical because they help decisions 1. Foshee VA, Linder GF, Bauman KE, et al. The Safe Dates project: theoretical makers send resources where they are needed most. basis, evaluation design, and selected baseline findings. American Journal of Preventive Medicine 1996;12(Suppl 2):39–47. Step 2: Identify risk and protective factors 2. Avery-Leaf S, Cascardi M, O’Leary KD, Cano A. Efficacy of a dating violence It is not enough to know that dating abuse is affecting a prevention program on attitudes justifying aggression. Journal of Adolescent Health 1997;21:11–7. certain group of people in a certain area. We also need 3. Centers for Disease Control and Prevention. Physical dating violence among to know why. CDC conducts and supports research to high school students—United States, 2003. MMWR 2006;55:532-535. answer this question. We can then develop programs to 4. Smith PH, White JW, Holland LJ. A longitudinal perspective on dating violence reduce or get rid of risk factors. among adolescent and college-age women. American Journal of Public Health. 2003;93(7):1104–9.

For more information, please contact: Centers for Disease Control and Prevention National Center for Injury Prevention and Control 1-800-CDC-INFO • www.cdc.gov/injury • [email protected]