Intimate Partner Violence: Raising Awareness, Taking Action
By Dr. Samia Noursi
Imagine a crowded sidewalk. More than 1 in 4 of the women there—walking, talking, and going about their business—have experienced intimate partner violence (IPV) at some point in their lives.1 They may have experienced physical violence (e.g., slapping, hitting, and choking), sexual contact without consent, or stalking (repeated unwanted attention and contact that causes safety concerns) by current or former intimate partners.2
More than 43 million women have experienced the most common form of IPV, psychological aggression (e.g., humiliation, coercion, and a partner’s control of reproductive health).3 The prevalence of reported IPV is breathtaking, but we know that it is highly underreported—with a little more than half of victims reporting it to police and a majority not receiving assistance from domestic violence service agencies.4
The annual October observance of Domestic Violence Awareness Month is a stark reminder of this pervasive problem and its detrimental effects on the health of girls and women across the life course. It is also an opportunity to mention the important role that health care professionals can play in identifying girls and women affected by IPV and referring them to services that can help them attain safety and support.
A crucial fact about IPV is that it often begins alarmingly early in life, just when girls and young women should be finding their voices and setting goals for the future. Among IPV victims, about 7 in 10 women experienced their first incident before age 25—with a quarter having this experience before age 18.5 Among female high school students, nearly 1 in 11 report having experienced physical dating violence, and about 1 in 9 report having experienced sexual dating violence during the past year.6 Dating violence disrupts the healthy development of girls, and those who have experienced it are more likely than peers to report depression and anxiety, use substances, perform poorly at or skip school, be overly dependent on others, and become pregnant.7, 8 These short-term effects have lifelong negative consequences on health and well-being. Notably, experiencing dating violence as an adolescent is a risk factor for IPV in adulthood.9
Research indicates that women who experience IPV bear its consequences on their physical and mental health in the aftermath of the violence and in the long term.10, 11 IPV is linked with poor functional health, chronic health conditions, and chronic pain.12 Gynecological problems and sexual and reproductive health—including risk for sexually transmitted infections and unintended pregnancies—are also associated with experiencing IPV,13, 14 particularly sexual violence.15, 16 Women who experience IPV are less likely than others to seek preventive care, which may worsen these conditions.17 IPV also increases the risk for mental health problems, such as depression, post-traumatic stress disorder, sleep disorders, and substance use.18, 19, 20 For some, domestic violence is deadly. Experiencing IPV is associated with subsequent suicide.21 Violent death at the hands of an intimate partner is common; IPV was a “known circumstance” for 45.4% of homicides involving female victims in 2015, according to data from the Centers for Disease Control and Prevention (CDC).22 CDC data also indicate that about 7% of adolescent homicides involved an intimate partner—with women and girls as the majority of victims (90%).23
IPV has significant harmful effects on women who are mothers and on their children. IPV during pregnancy—reported by 3.2% of women, according to CDC data24—negatively affects maternal health and is linked with complications such as high blood pressure, placental problems, diabetes, and premature membrane rupture.25 Infant outcomes are also negatively affected, with IPV increasing the risk of preterm birth and low birth weight.26 Children exposed to IPV are at risk for multiple problems across all developmental stages—such as difficulties forming relationships, impaired cognitive abilities and school performance, and disruptions in emotional regulation.27 Although IPV is complex and many factors interact to influence it, research suggests there is intergenerational transmission of IPV, as exposure to IPV as a child increases the risk for later perpetrating or, particularly for girls, experiencing partner violence.28
The physical and mental vulnerability of women who experience IPV is obvious, but it is also important to consider the economic harm that partner violence has on them and their children. IPV occurs across all income groups,29 although low income and economic stress increase the risk of perpetration of IPV.30 Research on IPV and associated socioeconomic factors involves more than simply identifying those at risk for IPV and includes analysis of the relationship between resources, partner violence, and its effects. One longitudinal study found that IPV increases the probability that a woman will experience material hardship—difficulty buying necessary goods and services—by 10–25%, after accounting for such factors as education and ethnicity.31 Research also suggests that the long-term health effects of severe physical violence are mitigated by women’s personal, social, and economic resources.32
Because of the impact of IPV on the health of girls and women, IPV screening by health care providers is crucial. The U.S. Preventive Services Task Force recommends that clinicians screen for IPV among women of reproductive age and provide women who screen positive with ongoing support services or refer them for such services. These services are covered by most insurance plans.33 The American College of Obstetricians and Gynecologists recommends that physicians screen all women for IPV at periodic intervals, offer ongoing support, and review available prevention and referral options.34 Federally Qualified Health Centers supported by the Health Resources and Services Administration provide primary care services in underserved areas across the country and are advised to follow specific steps to address IPV, including screening and counseling. For those working in public health, CDC released a package of strategies to help communities and states prevent IPV across the life course in 2017.
The ORWH-sponsored “Intimate Partner Violence, Consequences on Women's Health, and Promising Interventions,” a special issue of the Journal of Women’s Health, highlighted state-of-the-art research and practice on IPV screening. ORWH Associate Director for Science Policy, Planning, and Analysis Samia Noursi, Ph.D., co-guest edited the special issue. Dr. Noursi, Terri L. Weaver, Ph.D., Louisa Gilbert, Ph.D., Nabila El-Bassel, Ph.D., and Heidi S. Resnick, Ph.D., contributed an article titled “Identifying and Intervening with Substance-Using Women Exposed to Intimate Partner Violence: Phenomenology, Comorbidities, and Integrated Approaches Within Primary Care and Other Agency Settings.” In the article, the authors discuss the relationship between IPV and substance use, along with common co-occurring conditions (e.g., mental health problems) that may present barriers to intervention. They offer recommendations for bringing targeted interventions to scale in a variety of health care settings.
During Domestic Violence Awareness Month, we mourn those who have died because of domestic violence, celebrate survivors, and strengthen the networks of individuals and organizations that are working to end this appalling and often undiscussed public health problem.35 Awareness is essential but not enough. We must encourage women who experience IPV or know of another who is in a violent situation to seek help. We must also ensure that women who have experienced IPV have access to necessary services and resources. All professionals who work to improve the health of girls and women need to understand the significant effects of IPV and their role in identifying it and linking women to services.
Acknowledgment
Special thanks to Lori Whitten, Ph.D., for her research and writing support in the development of this article.
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