DEFINITIONS

The term family violence and sometimes domestic violence has been used to describe acts of violence between family members, including adult partners, a parent against a child, caretakers or partners against elders and between siblings. While all forms of family violence can be devastating, this monograph focuses only on domestic violence or intimate partner violence. In this monograph, intimate partner violence will be used to more specifically define a range of behaviors between intimate or dating partners: Intimate partner violence is a pattern of purposeful coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats. These behaviors are perpetrated by someone who is, was or wishes to be involved in an intimate or dating relationship with an adult or adolescent victim and are aimed at establishing control of one partner over the other Domestic violence is but one aspect of the larger set of problems related to family violence. Related problems not directly addressed in this guide, each of which requires separate analysis, include:
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parent abuse child abuse child sexual abuse elder abuse sibling violence domestic violence by police officers.

Legal definitions of domestic violence or intimate partner violence are generally more restrictive and refer specifically to threats or acts of physical or sexual violence including forced rape, stalking, harassment, certain types of psychological abuse and other crimes where civil or criminal justice remedies apply. Laws vary from state to state. Since evidence exists that non-physical intimate partner violence has many devastating physical, psychological, behavioral and developmental effects, the definition used in these Guidelines is better suited for the identification and treatment of intimate partner violence in the health care setting. Child exposure to domestic violence or intimate partner violence is a term encompassing a wide range of experiences for children whose caregivers are being abused physically, sexually, or emotionally by an intimate partner. This term includes the child who actually observes his/her parents being harmed, threatened or murdered, who overhears this behavior from another part of the home or who is exposed to the short- or long-term physical or emotional aftermath of caregivers abuse without hearing or seeing a specific aggressive act. Children exposed to intimate partner violence may see their parents bruises or other visible injuries, or bear witness to the emotional consequences of violence such as fear or intimidation without having directly witnessed violent acts.

The health care system plays an important role in identifying and preventing public health problems. Models developed to identify other chronic health problems may effectively be applied to intimate partner violence. A primary starting point to improve the medical practice approach to intimate partner violence is routine assessment, with a focus on early identification of all families and victims of intimate partner violence whether or not symptoms are immediately apparent. Since nearly all young children and teens are seen at some point in a health care setting, these settings present a compelling opportunity to identify teens, mothers and children who may be living with intimate partner violence. A 2001 study in North Carolina found that only 23 percent of women injured by a partner shortly after pregnancy received treatment for their injuries. However, almost all of these women used health care services for their infants, indicating that child health settings are potentially important for identifying intimate partner violence. Universal and regular face-to-face screening of women in adult health settings by skilled health care providers markedly increases the identification of victims of intimate partner violence, as well as those who are at risk for verbal, physical and sexual partner abuse.63,64 Expert opinion suggests that such interventions in adult health settings may lead to reduced morbidity and mortality.65 Inquiry for IPV can assist clinicians in their diagnosis and assure more appropriate care for a victims health symptoms by treating the underlying problems. Inquiry also gives victims a valuable opportunity to tell their providers about their experiences with abuse.66 Battered women report that one of the most important parts of their interactions with their physicians is being listened to about the abuse. Although there is no research as yet that proves the efficacy of assessment in child health settings, it is reasonable to assume that such inquiry would increase opportunities for identification and intervention within families, thereby enabling pediatric, family practice and primary care providers to assist both victims and their children. When child witnesses of intimate partner violence, victims or those at risk for intimate partner violence are identified early, providers may be able to intervene to help patients understand their options, live more safely within the relationship or safely leave the relationship. The child health care providers direct discussion about safety at home tells the family that this is an important topic and one that belongs in the realm of pediatric and family practice care. Even if a woman denies that she is being abused, the provider can often lay the groundwork for the possibility of future disclosure or discussion of the issue.

Surveys provide us with estimates of the level of domestic violence in the United States, but there are wide differences among them depending on the definitions of domestic violence used and populations surveyed.[5]Two large surveys provide some insight into the level of domestic violence in the United States. The first, the National Violence Against Women Survey (NVAWS), conducted in 1995 and1996, found that nearly one in four women and nearly one in 13 men surveyed experienced rape and/or physical assault by a current or former

spouse/partner/dating partner at some time in their lifetime, with about one and one-half percent of women and about one percent of men having been so victimized in the 12 months before the survey.[6]The National Crime Victimization Surveys (NCVS) estimates, however, are about one-third lower for women and more than two-thirds lower for men. Differences in survey administration and methodology may account for the large differences in the numbers Even the lower numbers of the NCVS suggest that intimate partner violence in the United States is extensive. However, NCVS trend data through 2001 shows that partner violence between current and former intimates has declined significantly. From 1993 through 2001, the rate of reported intimate violence dropped by about 50 percent in the United States.[7]From 1994 through 2001, the rate of every major violent and property crime declined by similar percentages.[8], It is unknown whether domestic violence is paralleling these declines for the same or different reasons. Domestic violence homicides have declined in similar proportions as well. In the United States, there were about half the number of intimate partner homicides (spouses, ex-spouses, boyfriends, and girlfriends) in 2002 as there were in 1976 with the largest portion of the decline in male victims . Some commentators suggest that the decline in homicides may be evidence that abused women have developed legitimate ways to leave their relationships (e.g., divorce, shelters, police, and courts). The reasons for the decline may be even more complex because there is wide variation by race, not just by gender. Between 1976 and 2002, the number of black male victims of intimate partner homicide fell by 81 percent as compared to 56 percent for white males. The number of black female victims of intimate partner homicide fell 49 percent as compared to 9 percent for white females

Women as Offenders There is a robust debate among researchers about the level of relationship violence women are responsible for and the extent to which it is in self-defense or fighting back.[11]The NCVS and other studies have found that women are the victims in as much as 85 percent of domestic violence incidents.[12]However, there are also research findings that women in heterosexual relationships have the same, if not higher, rates of relationship violence as men.[13]Generally, studies about domestic violence fall into two categories: family conflict studies and crime victimization studies. Those that tend to show high rates of violence by women (or rates higher than men) are family conflict studies and contain questions about family conflicts and disputes and responses to these, including physical responses. These studies use a family conflict assessment tool. Those studies that show that male assaultive behavior predominates in domestic violence are criminal victimization surveys and/or studies that rely on the counting of crime reports.[14]

Critics suggest that studies finding about equal rates of violence by women in relationships are misleading because they fail to place the violence in context (Dekeseredy et al. 1997); in other words, there is a difference between someone who uses violence to fight back or defend oneself and someone who initiates an unprovoked assault. Also, the physical differences between some women and their male partners may make comparisons between equivalent types of violence (slapping, kicking, punching, hitting) less meaningful, particularly because many studies show that violence by women is less likely to result in injury. Researchers agree that women suffer the lions share of injuries from domestic violence.[15] Women living as partners with other women report lower rates of violence (11 percent) compared to women who live with or were married to men (30 percent).[16]About 8 percent of men living with or married to women report that they were physically abused by the women. About 15 percent of men cohabitating with men reported victimization by a male partner. These data suggest that men are engaged in more relationship violence. Harms Caused by Domestic Violence Domestic violence can include murder, rape, sexual assault, robbery, and aggravated or simple assault. In addition to the physical harm victims suffer, domestic violence results in emotional harm to victims, their children, other family members, friends, neighbors, and co-workers. Victims and their children experience the brunt of the psychological trauma of abuse, suffering anxiety, stress, sleep deprivation, loss of confidence, social isolation, and fear.[17]Batterers frequently also subject their victims to harassment (such as annoying or threatening phone calls), vandalism, trespassing, stalking, criminal mischief, theft, and burglary.[18] Domestic violence also has economic costs. Victims may lose their jobs because of absenteeism related to the violence, and may even lose their homes because of loss of income. Some domestic violence victims must rely on shelters or depend on others to house them, and others become part of a communitys homeless population, increasing their risk for other types of victimization. Medical expenses to treat injuries, particularly of uninsured victims, create additional financial burdens, either for the victims or for the public. Psychological theory. Battering is the result of childhood abuse, a personality trait (such as the need to control), a personality disturbance (such as borderline personality), psychopathology (such as anti-social personality), or a psychological disorder or problem (such as post traumatic stress, poor impulse control, low self-esteem, or substance abuse). Sociological theory. Sociological theories vary but usually contain some suggestion that intimate violence is the result of learned behavior. One sociological theory suggests that violence is learned within a family, and a partner-victim stays caught up in a cycle of violence and forgiveness. If the victim does not leave, the batterer views the violence as a way to produce positive results. Children of these family members may learn the behavior from their parents (boys may develop into batterers and girls may become battering victims). A different sociological theory suggests that lower income subcultures will show higher rates of intimate abuse, as violence may be a more acceptable form of settling disputes in such subcultures. A variant on this theory is that violence is inherent in all social systems and people with resources

(financial, social contacts, prestige) use these to control family members, while those without resort to violence and threats to accomplish this goal. Feminist or societal-structural theory. According to this theory, male intimates who use violence do so to control and limit the independence of women partners. Societal traditions of male dominance support and sustain inequities in relationships. Violent individuals theory. For many years it was assumed that domestic batterers were a special group, that while they assaulted their current or former intimates they were not violent in the outside world. There is cause to question how fully this describes batterers. Although the full extent of violence batterers perpetrate is unknown, there is evidence that many batterers are violent beyond domestic violence, and many have prior criminal records for violent and nonviolent behavior.[20]This suggests that domestic violence batterers are less unique and are more accurately viewed as violent criminals, not solely as domestic batterers. There may be a group of batterers who are violent only to their current or former intimates and engage in no other violent and non-violent criminal behavior, but this group may be small compared to the more common type of batterer.[21] Why Some Women Batter Some women batter their current or former intimates. Less is known about women who use violence in relationships, particularly the extent to which it may be in self-defense, to fight back, or to ward off anticipated violence. When asked in a national survey if they used violence in their relationships, many Canadian college women said they did. However, the majority of these women said it was in self-defense or to fight back and that the more they were victimized the more they fought back.[22]One researcher suggests that women should be discouraged from engaging in minor violence because it places them at risk for retaliation from men and men are more likely to be able to inflict injury.[23] Clearly, there are women who use violence in relationships provocatively outside the context of fighting back or self-defense. The extent of this problem, as we noted earlier, remains unknown but is ripe for additional study. The theories explaining male violence cited earlier may also have some relevance for women, although the picture is not clear. Why Some Women are Reluctant to End Abusive Relationships Police commonly express frustration that many of the battered women they deal with do not leave their batterers. Although many women do leave physically abusive relationships, others remain even after police intervene. There is no reliable information about the percentage of women who stay in physically abusive relationships. Researchers offer a number of explanations for the resistance by some to leave an abuser.[24] Cycle of violence. Three cyclical phases in physically abusive intimate relationships keep a woman in the relationship: 1) a tension-building phase that includes minor physical and verbal

abuse, 2) an acute battering phase, and 3) a makeup or honeymoon phase. The honeymoon phase lulls an abused woman into staying and the cycle repeats itself. Battered woman syndrome. A woman is so fearful from experiencing cycles of violence that she no longer believes escape is possible. Stockholm syndrome. A battered woman is essentially a hostage to her batterer. She develops a bond with and shows support for and kindness to her captor, perhaps because of her isolation from and deprivation of more normal relationships. Traumatic bonding theory. A battered woman experienced unhealthy or anxious attachments to her parents who abused or neglected her. The woman develops unhealthy attachments in her adult relationships and accepts intermittent violence from her intimate partner. She believes the affection and claims of remorse that follow because she needs positive acceptance from and bonding with the batterer. Psychological entrapment theory. A woman feels she has invested so much in the relationship, she is willing to tolerate the battering to save it. Multifactor ecological perspective. Staying in physically abusive relationships is the result of a combination of factors, including family history, personal relationships, societal norms, and social and cultural factors. Who most often commits domestic violence? Overwhelmingly, it's heterosexual men in relationships. However, if we refer just to the act of hitting or physically hurting another person, research statistics from the 1980's and early 1990's shows women are as likely or more likely than men to hit or physically harm a partner. But what is not well explained is many of these women who strike out are responding to a violent situation which has already been created by the male in the relationship. We must also understand on average men are much larger and better trained to physically defend themselves than women are; and therefore do not have the same reaction to violence directed at them. This is a very important part of battering, which for a lot of men is hard to understand. It is certainly just as wrong for a woman to hit a man as for a man to hit a woman. It's simply wrong, and no one should have to tolerate being hit by another person. However, in comparison, a man's reaction to a woman's violence is usually far less emotionally traumatic than a woman's reaction to a man's violent acts. The emotional reaction for men being hit by a woman is usually annoyance, anger and self-righteousness. The male might think, "She's got a lot of nerve, who does she think she is laying her hands on me". In contrast, the reaction for women is far more traumatic, most often involving varying amounts of fear or terror. When a 180-lb man who's been trained to punch, punches a 130lb woman, she's going to feel a lot different than when the 130-lb woman punches the 180lb man. Both because

of physical size, and because of mind-set; women are not trained to think they can defend themselves; men are trained to think they can. To point out an important statistic for women: in 1994, domestic violence was the leading cause of injury to women. Causing more injuries than muggings, stranger rapes, and car accidents combined. There are no such figures like that for men.

Domestic Violence General Statistics

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Nearly one-third of American women (31 percent) report being physically or sexually abused by a husband or boyfriend at some point in their lives. Source: Commonwealth Fund survey, 1998 In the United States, 76 percent of women who experience rape or physical assault are assaulted by an intimate partner. (Fineman, Martha Albertson. Domestic Violence, Custody, and Visitation. Family Law Quarterly, Spring 2002). Over 4.4 million physical assaults are committed against women by an intimate partner annually. (Center for Disease Control and Prevention, "Cost of Intimate Partner Violence Against Women In The United States", 2003). In 2000, Arizona was second in the nation for rate of women murdered by men. (Violence Policy Center, "When Men Murder Women: An Analysis of 2000 Homicide Data," October 2002). Nationally, health related costs of intimate partner violence against women exceeds $5.8 billion annually, with $4.1 billion spent on direct medical and mental health care. (Center for Disease Control and Prevention, Costs of Intimate Partner Violence Against Women in the United States, April 2003). Every year, domestic violence results in almost 100,000 days of hospitalizations, almost 30,000 emergency department visits, and almost 40,000 visits to a physician. Source: American Medical Association. 5 issues American Health. Chicago 1991. Studies by the Surgeon Generals office reveal that domestic violence is the leading cause of injury to women between the ages of 15 and 44, more common than automobile accidents, muggings, and cancer deaths combined. Other research has found that half of all women will experience some form of violence from their partners during marriage, and that more than one-third are battered repeatedly every year. Source: Journal of American Medical Association, 1990. Battering may be the single most important context for female alcoholism, attempted suicide by women, rape and child abuse, homelessness for women and children and a major contributor to a range of mental health problems. Source: U.S. Surgeon General, 1989. A woman is beaten every 15 seconds by her partner; it happens at some time in 25-35% of American homes; 4,000 women die from such abuse each year FBI. Each year about 324,000 pregnant women in the U.S. are battered by the men in their lives. (Gazmararian, JA., Petersen, R., Spitz, AM., Goodwin, MM., Saltzman, LE.,

Matks, JS> 2000. Violence and Reproductive Health: Current Knowledge and Future Research Direction. Maternal and Child Health Journal.

Domestic Violence and Children

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A child exposed to the father abusing the mother is at the strongest risk for transmitting violent behavior from one generation to the next. Source Report of the American Psychological Association Presidential Task Force on Violence and the Family. APA, 1996. Approximately 50% of men who abuse women also abuse children. (Ver Steegh, Nancy, The Silent Victims: Children and Domestic Violence. William Mitchell Law Review 2000.) During visitation, five percent of abusive fathers threaten to kill the mother, 34 percent threaten to kidnap their children and 25 percent threaten to hurt their children. (National Coalition Against Domestic Violence, "Child Visitations Offer Opportunities for Domestic Violence," Womensnews, 2003.) Studies suggest that between 3.3 and 10 million children are exposed to domestic violence annually. (Carlson, Bonnie E., Battered Women and Their Families, Report of the Twenty-third Ross Roundtable, 1984.) Men who as children were exposed to their parents domestic violence are twice as likely to abuse their own wives as sons of nonviolent parents. (Strauss, Murray A., Gelles, Richard J. and Smith, Christine. 1990. Physical Violence in American Families; Risk Factors and Adaptations to Violence in 8,145 Families. Transaction Publishers. One study of 2,245 children and teenagers found that recent exposure to violence in the home was a significant factor in the home was a significant factor in predicting a childs violent behavior. (Singer, M.I, Miller, D.B., Guo, S., Slovak, K. & Frieson, T. 1998. Mental Health Consequences of Childrens Exposure to Violence. Case Western University. Children who are exposed to domestic violence are more likely to exhibit behavioral and physical health problems including depression, anxiety, and violence toward peers. They are also more likely to attempt suicide, abuse drugs and alcohol, run away from home, engage in teenager prostitution, and commit sexual assault crimes. (Jaffe and Sudermann. Child Witness of Women Abuse: Research and Community Responses in Stith, S. and Straus, M., Understanding Partner Violence: Prevalence, Causes, Consequences and Solutions. 1995. National Council on Family Relations.

Domestic Violence and Housing y In a 1998 study, 22 percent of homeless women have experienced severe physical and/or sexual assault at some point in their lives. (Ten Cities 1997-1998: A Snapshot of Family Homelessness Across America. Homes for the Homeless.)

In a 2002 report by the US Conference of Mayors, 44 percent of the cities surveyed identified domestic violence as the primary cause of homelessness. (The United States Conference of Mayors. 1999. A Status Report on Hunger and Homelessness in Americas Cities.) Victims and survivors of domestic violence have trouble finding apartments because they may have poor credit, rental and employment histories as a result of their abuse. (Susan A. Reif and Lisa J. Krisher. 2000. Subsidized Housing and the Unique Needs of Domestic Violence Victims. Clearing House Review. National Center on Poverty Law.