by Tia Will
Recent regional and national events have once again focused attention on a difficult subject, that of domestic violence. Within the last year we have been faced with the conviction of William Gardner for the stalking and murder of Leslie Pinkston, a former intimate partner. Regionally we have also seen the episode of domestic violence in the Jo case and the accusation of child abuse resulting in death of a local infant. Nationally we have seen multiple sports stars provide us with the spectacle of physically abusing their partners and children in public as well as in the privacy of their own homes with Ray Rice and Adrian Peterson as the most prominent examples.
One succinct description of domestic violence as found on Wikipedia is:
“Domestic violence can take a number of forms including physical, emotional, verbal, economic and sexual abuse, which can range from subtle, coercive forms to marital rape and to violent physical abuse that results in disfigurement or death.”
“Domestic violence often occurs because the abuser believes that abuse is justified and acceptable, and may produce inter generational cycles of abuse that condone violence. “
Key to the role of domestic violence in the generation and maintenance of a violent society is the normalization of the use of power of one individual over another in order to achieve the goals of the stronger individual. While the power differential in our society is more commonly that of the male over the female and children, this is not universally the case and anyone can be either the aggressor or the victim in these unhealthy relationships. Domestic violence and abuse does not discriminate. It happens among heterosexual couples and in same-sex partnerships. It occurs within all age ranges, ethnic backgrounds, and economic levels however, it does show patterns of prevalence.
Intimate partner violence (IPV), a subset of domestic violence, is characterized by episodic unpredictable outbursts by the abuser that often begin as verbal and emotional abuse but, over time, tend to become physical. Many cases have a component of isolation and dependency in which the victim has been deliberately undermined and convinced of his or her incompetency by the perpetrator.
Intimate partner violence is estimated to result in 2 million injuries to women and 600,000 injuries to men annually. In 2005, there were 1,510 IPV homicides in the United States, 78% of which were women. Women ages 20-34 are at the greatest risk thereby exposing millions of children to IPV. An estimated 15.5 million children live in homes where IPV occurs.
According to Adverse Childhood Experience studies the effects of these exposures may have profound and long lasting effects on brain development and may ultimately affect the adult mental and physical health and functioning of the exposed children.
Toxic stressors including domestic or community violence, maternal depression, parental substance abuse, food scarcity and poor social connectedness can lead to adverse changes in learning, behavior and physiology including chronic stress related illnesses throughout childhood and into adulthood.
As noted in the online medical reference Up to Date, a meta-analysis published in 2008 concluded that exposure to IPV is associated with poor emotional and behavioral outcomes in children. With regard to mental health, exposure to IPV leads to an increase in externalizing behaviors such as aggression, conduct disorders, and impulsivity such as drug use, sexually irresponsible behaviors, and petty crime. For others, it may lead to internalizing behaviors such as anxiety, sleep disturbances and depression.
Exposure to IPV has age dependent effects.
- Infants may show disrupted feeding and sleep routines, excessive crying, and developmental delay
- Toddlers may use comforting, acting out or other distracting behaviors to attempt to avert the fear producing interactions of their parents
- Preschoolers may recreate the violent act in play, through aggressive acts or may demonstrate regressive behaviors such as bed wetting or thumb sucking and may have nightmares, onset of stuttering or clinging behaviors.
- School aged children may blame themselves for the violence. The may exhibit somatic complaints such as headaches or stomach aches increasing school absenteeism and may display either aggression or depression.
- Adolescents may demonstrate depression, substance abuse, and various forms of acting out
Results of exposure to IPV have also been shown to vary by gender. One study of 6 to 11-year-olds found that girls exposed to IPV demonstrated more internalizing behaviors such as anxiety and depression while boys tended to demonstrate more externalizing behaviors such as conduct disorders, impulsiveness and poor temper control.
Exposure to IPV also affects cognitive development. Multiple factors contribute to adverse affects on school performance. Sleep deprivation, depression, PTSD, absenteeism, disruption of attendance by need for safe house placement all can contribute to disruption of cognitive development and school performance. One study showed that 40% of preschool children of IPV mothers had developmental delays. Almost 50% of school-aged children from affected homes had academic problems such as grade repetition.
IPV has a complicated relationship to parent-child relations. In one study, 20% of affected women reported that the presence of the child or children was the source of parental conflict. The mother’s attitude about the source of conflict can lead to self-blame on the part of the child. IPV may also have direct effects on parenting consistency and style. In another study, some mothers reported being harsher with their children when their abuser was present hoping to spare the children from worse treatment from the abuser, while others reported being more lenient hoping to compensate for harsh treatment from the abuser. Both strategies lead to inconsistency and uncertainty regarding expectations and consequences on the part of the child.
There is a consistent finding of a relationship between IPV and child abuse. Although the degree varies, multiple studies have shown that 30-60% of homes where either child abuse or IPV is present, the other form of abuse is also found.
Many of the adverse effects of IPV persist into adulthood. These include higher incidences of depression, Post-Traumatic Stress Disorder, poor social adjustment, conduct disorders, antisocial behaviors, self injurious behaviors, increased risks of becoming a perpetrator of IPV or child abuse, or becoming either a perpetrator or victim of violent behavior oneself. Finally children from IPV families are at increased risk of substance abuse, high-risk sexual behaviors, and other high-risk behaviors.
As with any multifactorial problem there are many possible approaches and interventions. I believe there is room for intervention at many different levels of society including extended families, neighbors, churches, schools, social services and the medical field. Since the latter is my area of expertise, I am going to focus the rest of this piece on what I see as the potential contribution of health care providers.
- Screening: Many major medical associations encourage routine screening for IPV and domestic violence. Among them are the American Academy of Family Physicians, the American Academy of Neurology, the American Academy of Pediatrics, the American College of Emergency physicians and the American College of Obstetrician Gynecologists, as well as the American Medical Association. The 2013 the U.S. Preventive Services Task Force recommended routine screening for all females ages 14-46 for IPV with referral for all those who screen positive. This recommendation is based on studies showing that interventions can improve both the safety of these women and their children both in terms of short-term physical safety and long term improved outcomes.
- Use of a specific screening and intervention designed by the Massachusetts Medical Society: Routinely screen, Ask direct questions, Document in chart or as restricted access documentation as needed, Assess safety, and Real time referral (RADAR).
Safety assessment questions include: Are you afraid to go home? Are there guns in your home? Is there a threat of homicide or suicide? Have you ever been choked? Has the violence increased? Do you have a safe place to stay?
- Real time referral is critical when there is an imminent threat. This includes the provision of numbers for local shelters and/or the National Domestic Violence Hotline number 1-800-799-SAFE, mental health referrals as needed, and reporting to police and or social service agencies as indicated.
- Home prevention can also be taught and reinforced in the medical setting at the time of appointments and should be a routine part of adult and pediatric care. Simple suggestions will sometimes make a huge difference in the life of a child. Children should be kept separated from heated discussions between parents. Parents should enforce consistent, agreed upon rules for behavior. Each parent should maintain good communication with each child. Negative impacts of domestic conflicts on children should be reviewed with parents when identified and more productive alternative behaviors suggested.
It is my belief that for too long the issue of domestic and intimate partner violence has been kept in the closet as a dirty little secret that families and our society wish to avoid. We continue this belief that it is the exclusive purview of the family to our own harm and expense as a society on many levels, both economic and social. I believe that this is a subject that should be openly discussed and addressed with a view not towards demonization and finger pointing, but rather with an attempt to understand how each of us can contribute to lessening this widespread and pernicious problem that affects us all.
Thank you Tia for this informative and well-done article.
As you would expect, I have observations and opinions that challenge some of this.
First, I think we should focus on violence and abuse done to children. I would expect that a percentage of parents being violently abusive to each other are also abusive to their children. However, it should not be assumed.
Second, there is a lot of “may cause” information above. I believe that many children are much more resilient dealing with life-stress and that adults should not be so quick to project their own anxiety onto situations. In fact, I think children are more often impacted by the projected emotional stress of people responding to a situation. For example, a child born into a low income family that gets hand-me-down clothes might be perfectly happy until he/she hears someone commenting about the tragedy of his/her family’s inability to afford suitable clothing. A child born into a family of conflict might learn to cope until others project their opinions of abusive or hostile environment.
Third, I worry that we go too far in this assessment of what harms children born into dysfunctional or high-conflict families. We hear more and more about cases where children are removed from parents for absurd reasons because some government official can’t apply appropriate nuance to the rules or is risk-averse in consideration of trial lawyers willing to sue for anything and everything.
But of course we also hear the stories of the tragic death of children from a parent that was known to demonstrate violence or mental health problems. And here again there is an example of government officials failing to apply appropriate nuance to a situation.
The welfare of children in families is a very complex consideration. My personal belief is that we would do better focusing on the challenge developing the individual self-worth of family members that comes from striving and succeeding. I think 4% economic growth solves a lot of problems in dysfunctional families because parents work and improve the family economic prospects. Handouts don’t do it because the do not help develop self-worth.
I’ve also heard and read that violence towards women tends to be much higher in “cohabiting” relationships, versus marriage. Something worth exploring.
CITIZENLink: The Truth About Domestic Violence in Marital Versus Cohabitational Relationships
A Public Police Partner of Focus on the Family
How Safe is Marriage?
• ” According to the National Crime Victimization Survey, of all violent crimes against women by their intimate partners between 1979 and 1987, about 65 percent were committed by either a boyfriend or ex-husband, while only 9 percent were committed by husbands.1
• “Another study, published in the Journal of Family Violence, explains the following regarding the association between batterer and victim, “The most frequently cited relationship was cohabitation, with close to one-half (48 percent) of the couples living together.”2
• “The Family Violence Research Program at the University of New Hampshire conducted a study of more than two thousand adults concerning this subject. It was concluded that the overall rates of violence for cohabiting couples was twice as high and the overall rate for “severe” violence was nearly five times as high for cohabiting couples when compared with married couples.3
• “ ‘Aggression is at least twice as common among cohabiters as it is among married partners,” states yet another expert, Dr. Jan E. Stets, in a major study comparing cohabitational and marital aggression. In a one year period, 35 out of every 100 cohabiting couples have experienced some form of physical aggression, compared to 15 out of every 100 married couples. The lowest percent was found among married couples at 19 percent.4
• “A study published by the University of Chicago found that of women who had reportedly been forced to perform a sexual act, 46 percent reported that the aggressor was someone they were in love with but not married to, while only 9 percent reported that the aggressor was a spouse.5…”
Marriage Is Protective
“It is clear from these facts that marriage truly is a safe haven for women. It is here that the permanence of lifelong commitment meets the proper confines of responsibility. The act of marriage provides the necessary stability and pledge of endurance required to maintain a healthy intimate relationship.
“Rather than a “hitting license,” the marriage license is one that demands and affords mutual respect and security.”
http://www.citizenlink.com/2010/06/14/the-truth-about-domestic-violence-in-marital-versus-cohabitational-relationships/
I’m wondering how much of the difference in these statistics is because of lower levels of reporting violence in a married relationship, perhaps due to a number of reasons (being economically dependent upon a spouse, not wanting to give children a “broken home,” etc.).
Also, it’s not like a marriage certificate provides any kind of magical protection against violence, nor does it necessarily confer “the permanence of lifelong commitment,” since about 50% or more marriages end in divorce. The “act of marriage” itself doesn’t provide this stability; I would argue that the individuals’ personal commitment, coping skills, communication skills, etc. have much more to do with stability and whether or not a marriage (or cohabitating relationship) endures and is successful.
Did you read the full article? It gave some insightful and illustrative real explanations why marriages are safer – by immense numbers – than cohabiting.
Did you read how women view cohabiting, and how men view it? The mindset?
Yes, I did read the entire article and am unconvinced that a marriage certificate magically confers any of these benefits. I maintain that this has more to do with the individuals involved and their temperaments, etc.
The portion where the article discussed the mindset was published back in 1989–so almost 30 years ago. There have been a lot of changes since then–particularly in how the younger generations view marriage.
I remember reading that more younger people are getting into cohabitating relationships that they view as the same as marriage. Many couples in my cohort (Gen X), including myself, have this mindset–and don’t subscribe to the mindset that you are talking about or that is mentioned in the article. I can tell you that my partner of over 13 years isn’t out on weekends getting wild with his buddies, nor is he smacking me around just because we don’t have a marriage certificate.
Also, the article you presented is sponsored in part by Focus on the Family, a notoriously partisan evangelical religious organization, so I’m not entirely sure about what I’m reading and the spin that may be put on this information. Part of this spin I’m assuming is the underlying warrant that if you’re cohabitating, you’re having sex “out of wedlock” which is a no-no according to their religious view. So some of the statistics (or how they’re being presented) could be implicitly inflating the “dangers” of being in a non-marriage, cohabitating relationship.
The Bureau of Justice Statistics is non-partisan, here is their study on violence from 1993-2010.
The great news is that it appears that all groups have seen a substantial drop in violence!
Page 6 covers marital status.
http://www.bjs.gov/content/pub/pdf/ipv9310.pdf
TBD
I read all of the article that you cited. Unfortunately it did not include any comments about the methodology of the study. It also may not be reflective of current societal trends since it ended in the 1980’s. This is one of the main reasons that I rely fairly heavily on Up to Date for the studies that I include. I can be assured that they have been vetted usually within the last year for articles published in peer reviewed journals and often scored for the strength of evidence presented. While I cannot speak to the validity of the article that you cited, I did note that it was from a source with a Christian bias which could unduly influence how the authors interpret their data.
I think that one needs to be very careful when looking at studies that draw conclusions about what types of relationships ( marriages vs domestic partnerships for example ) are more likely to be associated with domestic violence.
For example, doing my research through Google, I found the following:
http://www.buffalo.edu/news/releases/2014/08/031.html
I am not sure that I would hang my hat on this research when making recommendations to my patients about marriage vs
cohabitation ; )
Regardless of the validity of any one individual study, what I was hoping to focus on with my article was what we, as community members not involved in domestic or child abuse could do to help prevent and mitigate domestic violence and child abuse when we suspect they are happening. For me, as a mandated reporter, this is fairly straight forward. I am obligated to report any suspected abuse. My hope was to provoke thought, not about what we could tell others to do ( namely get married, which we have no ability to impose on others) but rather what we could do from our own position in the society whatever that might be.
Since I do not know you, I have no idea of how you might contribute, but would be very interested to hear your thoughts on that since I truly appreciate the fact that you took the time to read and respond.
Frankly has responded from his point of view as a businessman. While I agree that being financially stable doubtless contributes to a family’s overall stability, it should be noted that domestic violence does occur in very wealthy families as it does in those of more modest economic resources. Having a lot of money simply does not solve all social and individual problems as the HBO documentary The Jinx aptly illustrated.
I’m not trying to sell this one viewpoint, but I thought it would also broaden the conversation to include other important related topics. BTW, the statistics from the The Bureau of Justice (see above link) also seem to show some similar disparities through 2010.
Interestingly, I don’t see any protest when we see that women with an education suffer less domestic violence than those don’t have an education; or when we see that women with a higher income level do better than those who have a lower level. Especially given these dramatic numbers, I wouldn’t ignore it.
I personally have added some new relationships in my life over the past few years, and in a few of those scenarios I have noticed that there were some couples and former couples where yelling, raised voices, and harsh feelings were communicated. I believe I deftly took a stand, and noted that what was going on wasn’t appropriate. Once “the light went off” in one woman’s head, she was then able to explore her dynamic, and she has changed some of her ways – not playing into conversations that ramp up over normal day-to-day life issues. She had expressed concerns that these heated conversations could escalate, and she’s learned how to not contribute, or to walk away / hang up the phone. On occasion I will hear young boys / men speaking inappropriately, and I’m not averse to putting them in check, in public.
Sadly, years ago when traveling in southern and eastern Europe I heard blood-curtling shouting at a woman (in a different language), and could do nothing about it. (In a hotel, not sure where they were.) And I saw several women with visible bruises on their arms / face that were astonishing to see in a modern world.
Frankly
Thank you for taking the time to read, consider, and respond. I also have some thoughts about your comments.
1. “ I think we should focus on violence and abuse done to children”
If I were limited to addressing violence and abuse to only one group, I also would focus on children since they have less ability to remove themselves from dangerous situations. However, we are not so limited and I believe that we can, as a society attempt to address and attempt to reduce violence where ever it is occurring. Of course, as a gynecologist, my greatest personal impact will probably be on prevention of violence to women, however, if I am open minded about my possibilities, I may also elicit the history that my patient is herself the abuser, refer her to anger management or other appropriate interventions and thus prevent further abuse of a man. I just don’t think that we should artificially limit our possibilities for making a positive contribution.
2. “ I believe that many children are much more resilient dealing with life-stress and that adults should not be so quick to project their own anxiety onto situations. “
I agree that children are quite resilient. However, I do not believe that domestic abuse falls into the category of “projection of their own anxiety”.Domestic violence is real, it is physically dangerous both the the targeted individual and to children who can and do attempt to put themselves in the middle of a conflict to protect a parent or sib. When I am talking about violence, I am not talking about the “horrors” of having to wear hand me downs, or of occasional raised voices. I am talking about situations in which there is real potential harm and I do not believe that these situations should be trivialized even if some children manage to emerge relatively unscathed.
3. “Handouts don’t do it because the do not help develop self-worth.”
While I do not believe that domestic violence is primarily an economic issue, I do believe that there is some truth that economic stability probably does make it easier for a family to establish stability in other areas as well. You have stated on several occasions that you believe in “a hand up, not a hand out”. What I have never seen you state is exactly how you define the difference between these two and who gets to decide what is a handout vs what is that proverbial hand up.
TBD
“I believe I deftly took a stand, and noted that what was going on wasn’t appropriate”
“On occasion I will hear young boys / men speaking inappropriately, and I’m not averse to putting them in check, in public.”
I very much appreciate your sharing this. It is exactly the kind of intervention that I would hope we would all feel comfortable making when we see it happening. Or in situations where we may not be safe ourselves, I would hope that we would pick up our cell and call 911 and let the authorities handle the situation.
“I don’t see any protest when we see that women with an education suffer less domestic violence than those don’t have an education”
I did not find anything specific about the economic variation when I wrote the article. I do not know whether or not your comment is accurate, or whether wealthy families just cover their tracks better. I am wondering if you have any credible research that demonstrates that this is the case. I am personally aware, because of my position of a number of cases in which middle and upper economic group women were involved and one case in which a Family Practice doctor was killed by her husband. This however is anecdotal information biased by the specific group of patients with whom I work. I would be interested to see your evidence that this widely held perception is actually true.
It’s a tad outdated (2000), but still very illuminating.
Extent, Nature, and Consequences of Intimate Partner Violence: Findings From the National Violence Against Women Survey
Risk Factors Associated With Intimate Partner Violence (page 33-36)
“Numerous studies have examined risk factors associated with intimate partner violence. Results from these studies show that unmarried, cohabiting couples have higher rates of intimate partner violence than do married couples(1) ; minorities have higher rates of intimate partner violence than do whites (see note 5 in “Introduction”); lower income women have higher rates of intimate partner violence than do higher income women(2) ; less educated women have higher rates of intimate partner violence than do more educated women(3) ; and couples with income, educational, or occupational status disparities have higher rates of intimate partner violence than do couples with no status disparity.(4) Research also shows that experiencing and/or witnessing violence in one’s family of origin increases one’s chances of being a perpetrator or victim of intimate partner violence.(5) In addition, research shows that wife assault is more common in families where power is concentrated in the hands of the husband or male partner and the husband makes most of the decisions regarding family finances and strictly controls when and where his wife or female partner goes.(6) Finally, research suggests that persons with a disability are at greater risk of violence,(7) although there is no empirical evidence that having a disability increases one’s risk of intimate partner violence.”
Also, see page 43.
“4. Studies are needed to determine why the prevalence of intimate partner violence varies significantly among women of different racial and ethnic backgrounds. The survey found that American Indian/Alaska Native women report significantly more intimate partner rapes than do women from other racial backgrounds, and Asian/Pacific Islander women report significantly fewer intimate partner physical assaults. In addition, Hispanic women report significantly more intimate partner rapes than do non-Hispanic women. However, differences between minority groups diminish when certain demographic and relationship variables are controlled.” (page 56.)
https://www.ncjrs.gov/pdffiles1/nij/181867.pdf
Correlation does not equal causation.
True, true. And it’s better than flying in the dark chasing shadows.