family violence research paper

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Intimate partner violence: A loop of abuse, depression and victimization

Marianna mazza, giuseppe marano, angela gonsalez del castillo, daniela chieffo, laura monti, delfina janiri, lorenzo moccia, gabriele sani.

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Author contributions: Mazza M and Marano G designed the study, wrote the first draft of the manuscript, and managed the literature searches; del Castillo AG, Chieffo D, Monti L, Janiri D, Moccia L, and Sani G supervised and added important contributions to the paper; all authors have read and agreed to the published version of the manuscript.

Corresponding author: Marianna Mazza, MD, PhD, Assistant Professor, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy. [email protected]

Received 2020 Dec 31; Revised 2021 Apr 25; Accepted 2021 May 17; Collection date 2021 Jun 19.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/

Intimate partner violence has been recognized as a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence, a loop that imprisons victims and perpetuates the abuse. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. In this narrative review, factors associated with intimate partner violence and consequences of exposure of children to parental domestic violence are discussed, along with possible intensification of violence against women with the spread of coronavirus disease 2019 pandemic and subsequent lockdown. Intervention programs with a multicomponent approach involving many health care settings and research have a pivotal role in developing additional strategies for addressing violence and to provide tailored interventions to victims. Prevention policy with a particular attention on healthy child and adolescent development is mandatory in the struggle against all forms of violence.

Keywords: Intimate partner violence, Women, Depression, Abuse, COVID-19, Personalized medicine

Core Tip: Intimate partner violence represents a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. Coronavirus disease 2019 pandemic is causing a tremendous impact on women's possible exposure to violence. Possible interventions against violence are discussed.

INTRODUCTION

Intimate partner violence is described as physical violence, sexual violence, stalking, or psychological aggression by a current or former intimate partner. It represents a serious public health issue. It has been estimated that more than 30% of women in the United States have experienced intimate partner violence, and it represents the leading cause of homicide death for women. Prevalence is higher among young women (18 to 24 years of age), among racial and ethnic minority groups, and among people with mental and physical disabilities[ 1 ]. Psychological violence is estimated to be the most common subtype of intimate partner violence (compared to physical and sexual violence) in the United States and Europe[ 2 ].

In women of reproductive age, intimate partner violence has been linked with poor reproductive health and poor sexual health (unintended pregnancy and sexually transmitted infections) and heightened risks of obstetrical and gynecologic complications (pregnancy-associated death, preterm birth, low birth weight) and represents a risk factor for peripartum depression and substance abuse[ 1 ]. There are specific physical injuries in women that can be considered as indicators of intimate partner violence: Contusions, lacerations, and fractures (especially in the head, neck and face) and are frequently reported by patients as domestic accidents. Partner violence has been associated with many mental health consequences: Depression, anxiety, post-traumatic stress disorder, eating disorders, suicidal behavior, alcohol or drug abuse, sexual problems, problems with concentration, somatization, social, educational, or occupational difficulties, as well as feelings of blame and guilt or reproach. It is also linked to several and often disabling physical health problems (chronic pain, gastrointestinal problems, sexually transmitted infections, traumatic brain injury, cardiovascular diseases).

Exposure to violence can contribute on one side to the genesis of psychopathological conditions or can exacerbate mental health conditions, but on the other side existing mental health problems can increase vulnerability and predisposition to partner violence.

It has been estimated that emotional violence is the most common form of intimate partner violence across all continents worldwide[ 3 ]. Factors associated with intimate partner violence originate from multiple levels: Individual, relationship, community, and societal level[ 4 ]. Subjects who are at greater risk of experiencing intimate partner violence more likely come from a lower education background and poorer socio-economic status (with difficulty of access to resources and greater acceptance towards violence), have a history or a current substance abuse, and have been exposed to prior abuse or violence (with a history of abuse reinforcing the normative nature of violence and developing violence-condoning attitude). For example, many immigrant women have to cope with issues regarding their cultural integration into another society while at the same time concurrently feeling related and profoundly bounded by cultures and traditions from their countries of origin. Dependence on one’s partner, difficulties in language proficiency, financial problems, lack of social support, and uncertain legal status can leave these subjects feeling fragile and socially isolated and can prevent them from seeking assistance; besides, women linked to particular cultural backgrounds may refuse to acknowledge certain acts and behaviors as abusive due to beliefs and traditions regarding familial obligations and culturally prescribed gender roles[ 5 ].

People with mental illness may have a heightened risk of becoming victims of domestic violence and can be reluctant to disclose abuse. On the other hand, mental ill-health can also be a consequence of victimization and can involve post-traumatic stress disorder, depression, suicidality, and alcohol or substance misuse: Physical sequalae of abuse are added to psychological morbidity[ 6 ].

EXPOSURE OF CHILDREN TO PARENTAL DOMESTIC VIOLENCE

It has been outlined by recent research that the presence of intimate partner violence often compromises a child’s attachment to primary caregivers, which results in an additional risk factor for social, emotional, and psychological impairment[ 7 ]. A child can be exposed to domestic violence also through the awareness that violence occurs between parents, regardless of whether the child directly witnesses it. Infancy is a critical period of developing a secure attachment, and infants spend most of the time with caregivers, in a relationship of close proximity to them and high and obliged dependence from them; in addition, younger children have not completely strengthened the cognitive ability to discern between intimate partner violence as a threat to caregiver or to the self. As a consequence, the situation of violence in the household can indirectly impact on the child because it compromises the caregiving system in the parent. The presence of intimate partner violence increases a child’s risk of developing a wide variety of negative outcomes (internalizing symptoms, externalizing behaviors, problems with perceptual and cognitive functioning, academic difficulties, interpersonal difficulties). Possible consequences can be affected by the child’s age, relationships with other caregivers, and period of exposure to violence.

Violence against young girls causes physical and psychological effects, which can manifest as mild anxiety symptoms, apprehension, flashbacks, or feeling ashamed or worried to more severe anxiety signs, including a variety of sleep or eating disorders, post-traumatic symptoms, and even thoughts of self-harm and suicide. The inaction of a valid support system may further worsen this complex situation[ 8 ].

Children exposed to parental domestic violence are predisposed to physical and mental health disorders and are subjected to an increased risk of become a victim or a perpetrator of intimate partner violence in adolescence and adulthood[ 9 ]. Besides, adverse childhood experiences, such as child abuse, maltreatment, substance abuse in the household, incarceration of household members, and emotional or physical neglect, have long-term consequences with poorer physical, mental, individual behavioral, and social/interactional outcomes: The larger the number of adverse childhood experiences, the higher the odds of worst physical and mental health outcomes, including heart disease, stroke, asthma, diabetes, and mental distress[ 10 ]. Adolescence is a critical developmental period characterized by puberty, progressive autonomy from parents and family, changes in social relationships, and often the beginning of romantic relationships. Child sexual abuse, child physical abuse, witnessing parental intimate partner violence, exposure to school-related violence ( e.g. , bullying), and community violence ( e.g. , racism or discrimination) during childhood are potentially related to future intimate partner violence. Recently, it has been demonstrated that adverse childhood experiences in adolescence are predictive of interpersonal violence 15 years later[ 10 ].

Teen dating violence

When male violence against females occurs within intimate relationships during youth, it is termed adolescent or teen dating violence, occurring in individuals aged 10-24 years, including early, middle, and late adolescence, and described as physical, sexual, or psychological/emotional abuse, comprising threats, towards a dating partner. Six forms of teen dating violence have been assessed: Threatening behaviors, verbal/emotional abuse, relational abuse, physical abuse, sexual abuse, and stalking.

The cultivation of emotional relationships during adolescence are pivotal to the progressive growth of interpersonal communication skills, autonomy, and self-perceived competence, but together with affective and behavioral vulnerability experienced during adolescence, a variety of individual, social, and community risk factors may favor the emergence of adolescent dating violence[ 11 ]. Victims of teen dating violence may develop adverse health outcomes such as increased sexual risk behaviors, suicidality, unhealthy behaviors ( e.g. , lack of physical activity and negative weight-controlling behaviors), inauspicious mental health outcomes, substance use, injuries, victimization, and death. Additionally, it is common for adolescents who experience dating violence to struggle with their academics, drop out of school, or skip school to avoid seeing their partner.

Risk factors for perpetration of adolescent dating violence seem to be a history of experiencing, witnessing, and/or initiating abuse within the home, school, and community; childhood trauma in the form of physical and emotional abuse or neglect (due to personality anxiety traits formed during childhood, so that the individual feels a lack of security in the relationship and worries about being left by the partner); sexism and gender roles present in society; bullying; developing and formulating ineffective interpersonal communication and conflict resolutions skills during adolescence; alcohol or substance use during adolescence; attachment insecurities (anxiety and avoidance) expressed as anger, hostility, aggression, and emotional dysregulation[ 12 ]. Recent research suggests that there are multiple form of adolescent dating violence and that males may be victimized at similar rates as females[ 13 ]. Increasingly high rates of technology usage, as well as diffusion of apps and social media platforms, has created more opportunities for cyber teen violence dating (typically people who are no longer with their dating partner perpetrate this form of violence against an ex-partner).

Abusive behavior in adolescent dating relationships is associated with a risk of intimate partner violence later in adulthood[ 14 ].

Violence during coronavirus disease 2019 pandemic

Coronavirus disease 2019 (COVID-19) has had a dreadful impact on the world’s economy, and women are forced to take on additional risks as they are already disadvantaged and vulnerable, especially in rural and remote settings[ 8 ]. Sexuality suffers because it has to deal with the arrogance of a death drive rekindled by the current pandemic condition. A life in which less libido is exchanged stably than one would like can become unbearable. But the libido, in the forms of stasis and engorgement, can turn, in the unconscious, into anguish and give rise to internal conflicts that inevitably end up resulting in the relationship with the other[ 15 ]. As the COVID-19 pandemic has intensified, its effects diversified by gender have begun to gain attention[ 16 ]. During the institutional lockdown, victims of domestic violence were required to remain closed with partners and without help or support: In such scenario there is a great chance that abusive situations can further aggravate, with a possible increase of domestic homicides or murder-suicides or deviant behaviors towards children. Increased concerns about domestic violence have been expressed in many countries. The reasons for this include social isolation, exposure to economic and psychological stressors, increase in negative coping mechanisms (such as alcohol or drugs misuse), and inability to access usual health and social services[ 6 ]. School closure due to lockdown can potentiate the risk for children to witness violence, exploitation, and abuse at home and away from help[ 8 ].

As the outbreak of COVID-19 has developed, referral rates to mental health and psychology services have declined, despite a likely increase in psychological distress, victimization, and mental illness. It is well-known that intimate partner violence has short-term and long-term effects on physical and mental-health of affected subjects and in particular might increase the risk of cardiovascular disease in women, by indirect (chronic inflammation or dysregulation of the hypothalamic pituitary axis as a consequence of chronic stress) and indirect pathways (coping strategies used by victims of abuse to deal with stress, such as smoking and overeating, and higher incidence of depressive disorders correlated to chronically elevated levels of cortisol, catecholamines, and inflammatory markers, all of which promote the development and progression of cardiovascular disease)[ 17 ].

Psychological distress linked with the pandemic itself, arising in response to fears about personal and familial infection as well as the sequelae of social distancing and quarantine measures, add worry about possible consequences of intimate partner violence during this global pandemic.

Particularly during the COVID-19 pandemic, programs are necessary to provide funding sources to guarantee telephone or remote counseling services or psychological assistance hotlines to manage and attempt to prevent crisis situations[ 18 , 19 ]. The use of mobile health and telemedicine to support safely subjects experiencing violence must be urgently improved, together with other strategies to reach women at risk in settings where access to mobile phones or the internet is limited or completely lacking. We must learn lessons from the past epidemics and also from the present about errors and defeats to recognize and address gender related effects of outbreaks[ 16 ].

Prevention and management of the violence against women of all ages should be expected and potentiated as a pivotal service in the COVID-19 response plan.

Possible interventions against violence

Lifetime and current intimate partner violence is common and unacceptably high. It has been outlined that approximately 1 in 4 women becomes a victim of violence at some point in their life regardless of their age, economic status, or ethnicity. Domestic violence against women is a well-recognized health concern and has serious negative impact on women’s lives. It is important to stress the fact that most of the factors associated with violence against women are preventable. Studies assessing screening and interventions practice in primary care services for women who experience intimate partner violence have demonstrated that clinical programs can mitigate the risk of subsequent violence[ 20 ]. In addition, interventional studies have stressed that gender-norms transformation through behavioral change and communication focused program can promote gender equality norm and avert domestic violence against women[ 21 ].

Intimate partner violence is often not obvious, and patients may present with nonspecific signs and symptoms. Clinicians must be aware of the red flags of domestic violence and incorporate the principles of trauma-informed care into their practice. This means asking about violence or risk of violence when it is safe and appropriate, in a private discussion and in a compassionate and nonjudgmental way, discussing needs, preferences, and immediate options. It is necessary to support the subject’s autonomy, provide emotional and practical support, and personalize responses and possible solutions to the individual patient[ 22 ].

For pregnant women suspected or known to be exposed to partner violence, it is mandatory to consider a pregnancy high-risk and to provide prenatal assessment and counseling for the mother and home-visitation programs in the child’s first years. Screening in primary care for mental health disorders such as depression or anxiety should reasonably include an inquiry about current and previous intimate partner violence. In parallel, current or past intimate partner violence should be appropriately included in the differential diagnosis of many medical and behavioral health conditions, particularly in women[ 1 ]. It should be taken into account the fact that violence victims may not disclose their experience immediately but in the context of multiple queries and a trusting relationship. It results important that a multicomponent approach involving many health care settings, training of staff, clinical specific tools of assessment (including multiple violence domains: Physical, sexual, emotional/psychological), established workflows, connection to follow-up social services, and legal services can be dedicated and promoted to improve the prevention and response and care to the problem of intimate partner violence and its serious consequences. It has been observed that women have the tendency to remain with violent partners due to a variety of reasons, including social norms, worry for children, and economic issues. Immigrant women require a specific culturally-tailored approach and may need specific advocacy and interventions that also focus on financial abuse and are finalized to economic empowerment, including individual mental health counseling (when the shame and stigma associated to intimate partner violence in many ethnic communities increase the reluctance to discuss in groups) and services provided in community member’s native language or in intervention delivery settings (shared community environments including churches, mosques, temples)[ 5 ].

Interventions integrating legal framework and programs that focus on transformation of traditional gender-norms are of great importance in order to prevent violence against women of all ages. There is an increasing need of intervention programs and techniques to reduce violence among offenders (group therapy or counseling aimed to work on impulsive and angry behavior or inability to control emotions) with a particular focus on trauma and substance abuse[ 23 ]. Since it has been observed that men with mental health problems (in particular depression, anxiety, alcohol or drug use disorder, attention deficit hyperactivity disorder, personality disorders) carry a higher probability to perpetrate domestic violence against women, treatment for any co-existing mental illness and in particular substance abuse or misuse should be prioritized to reduce risk[ 24 ].

Also, research has a pivotal role in developing additional strategies for addressing violence and to provide personalized interventions to victims. For example, qualitative studies exploring the emotional impacts of intimate partner sexual violence on women are scarce. Understanding should be deepened of the so-called invisible impacts of violence, described as the emotional repercussions (sense of powerlessness, helplessness, shame, ongoing fear of men) that are difficult to quantify and measure but may be a trigger for mental health outcomes, such as post-traumatic stress disorder, anxiety, and depression[ 25 ]. Research can guide attachment- and family-based interventions for families impacted by interpersonal violence. Besides, there is an urgent need for rigorous research to understand better which interventions are most effective and tailored for ethnic minority populations.

Last but not least, prevention is mandatory: Interventions focusing on community and domestic health and violence prevention and, focusing on high-risk and disadvantaged socio-economic groups (such as institutionalized children or adolescents), with a particular attention on healthy child and adolescent development, may greatly contribute to lower intimate partner violence victimization in adulthood by correcting attitudes on violence and improving help-seeking behavior (Table 1 ).

Proposed interventions against intimate partner violence

COVID-19: Coronavirus disease 2019.

Conflict-of-interest statement: Authors declare no conflict of interest.

Manuscript source: Invited manuscript

Peer-review started: December 31, 2020

First decision: April 21, 2021

Article in press: May 17, 2021

Specialty type: Psychiatry

Country/Territory of origin: Italy

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Zafrakas M S-Editor: Fan JR L-Editor: Filipodia P-Editor: Li JH

Contributor Information

Marianna Mazza, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy. [email protected].

Giuseppe Marano, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Angela Gonsalez del Castillo, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Daniela Chieffo, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Laura Monti, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Delfina Janiri, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Lorenzo Moccia, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Gabriele Sani, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

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Domestic violence.

Martin R. Huecker ; Kevin C. King ; Gary A. Jordan ; William Smock .

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Last Update: April 9, 2023 .

• Continuing Education Activity

Family and domestic violence is a common problem in the United States, affecting an estimated 10 million people every year; as many as one in four women and one in nine men are victims of domestic violence. Virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of domestic or family violence. Domestic and family violence includes economic, physical, sexual, emotional, and psychological abuse of children, adults, or elders. Domestic violence causes worsened psychological and physical health, decreased quality of life, decreased productivity, and in some cases, mortality. Domestic and family violence can be difficult to identify. Many cases are not reported to health professionals or legal authorities. This activity describes the evaluation, reporting, and management strategies for victims of domestic abuse and stresses the role of team-based interprofessional care for these victims.

• Identify the epidemiology of domestic violence.
• Describe the types of domestic violence.
• Explain challenges associated with reporting domestic violence.
• Review some interprofessional team strategies for improving care coordination and communication to identify domestic violence and improve outcomes for its victims.
• Introduction

Family and domestic violence including child abuse, intimate partner abuse, and elder abuse is a common problem in the United States. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence. [1] [2] [3] [4] [5]

Unfortunately, each form of family violence begets interrelated forms of violence. The "cycle of abuse" is often continued from exposed children into their adult relationships and finally to the care of the elderly.

Domestic and family violence includes a range of abuse, including economic, physical, sexual, emotional, and psychological, toward children, adults, and elders.

Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.

The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The number of individuals affected is expected to rise over the next 20 years, increasing the elderly population.

Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians, will evaluate and possibly treat a victim or perpetrator of domestic or family violence. [6] [7]

Definitions

Family and domestic violence are abusive behaviors in which one individual gains power over another individual.

• Intimate partner violence typically includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.
• Child abuse involves the emotional, sexual, physical, or neglect of a child under 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.
• Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.

Center for Disease Control and Prevention (CDC)

Domestic violence, spousal abuse, battering, or intimate partner violence, is typically the victimization of an individual with whom the abuser has an intimate or romantic relationship. The CDC defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."

Domestic and family violence has no boundaries. This violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.

Violence Abuse Types

The types of violence include stalking, economic, emotional or psychological, sexual, neglect, Munchausen by proxy, and physical. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.

Reason Abusers Need to Control [8] [9] [10]

• Anger management issues
• Low self-esteem
• Feeling inferior 
• Cultural beliefs they have the right to control their partner
• Personality disorder or psychological disorder
• Learned behavior from growing up in a family where domestic violence was accepted
• Alcohol and drugs, as an impaired individual may be less likely to control violent impulses

Risk Factors

Risk factors for domestic and family violence include individual, relationship, community, and societal issues. There is an inverse relationship between education and domestic violence. Lower education levels correlate with more likely domestic violence. Childhood abuse is commonly associated with becoming a perpetrator of domestic violence as an adult. Perpetrators of domestic violence commonly repeat acts of violence with new partners. Drug and alcohol abuse greatly increases the incidence of domestic violence.

Children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, gender roles can be reversed.

Domination may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.

• Epidemiology

Domestic violence is a serious and challenging public health problem. Approximately 1 in 3 women and 1 in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States. [11] [12] [13]

Domestic violence victims typically experience severe physical injuries requiring care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated at over $8 billion. If the injury results in a long-term or chronic condition, the cost is considerably higher.

Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.

Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population.

• Most perpetrators and victims do not seek help.
• Healthcare professionals are usually the first individuals with an opportunity to identify domestic violence.
• Nurses are usually the first healthcare providers victims encounter.
• Domestic violence may be perpetrated on women, men, parents, and children.
• Fifty percent of women seen in emergency departments report a history of abuse, and approximately 40% of those killed by their abuser sought help in the 2 years before death.
• Only one-third of police-identified victims of domestic violence are identified in the emergency department.
• Healthcare professionals who work in acute care need to maintain a high index of suspicion for domestic violence as supportive family members may, in fact, be abusers.

Child Abuse

Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.

Each year there are over 3 million referrals to child protective authorities. Despite often being the first to examine the victims, only about 10% of the referrals were from medical personnel. The fatality rate is approximately two deaths per 100,000 children. Women account for a little over half of the perpetrators.

Intimate Partner Violence

According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.

One in 6 women and 1 in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about 6 in 10 female victims and 4 in 10 male victims.

At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape.

The incidence of intimate partner violence has declined by over 60%, from about ten victimizations per 1000 persons age 12 or older to approximately 4 per 1000.

Due to underreporting and difficulty sampling, obtaining accurate incidence information on elder abuse and neglect is difficult. Elderly abuse is thought to occur in 3% to 10% of the population of elders.

Elderly patients may not report due to fear, guilt, ignorance, or shame. Clinicians underreport elder abuse due to poor recognition of the problem, lack of understanding of reporting methods and requirements, and concerns about physician-patient confidentiality.

• Pathophysiology

There may be some pathologic findings in both the victims and perpetrators of domestic violence. Certain medical conditions and lifestyles make family and domestic violence more likely. [13] [14] [15]

Perpetrators

While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:

• Have a higher consumption of alcohol and illicit drugs and assessment should include questions that explore drinking habits and violence
• Be possessive, jealous, suspicious, and paranoid.
• Be controlling of everyday family activity, including control of finances and social activities.
• Suffer low self-esteem
• Have emotional dependence, which tends to occur in both partners, but more so in the abuser

Domestic violence at home results in emotional damage, which exerts continued effects as the victim matures.

• Approximately 45 million children will be exposed to violence during childhood.
• Approximately 10% of children are exposed to domestic violence annually, and 25% are exposed to at least 1 event during their childhood.
• Ninety percent are direct eyewitnesses of violence.
• Males who batter their wives batter the children 30% to 60% of the time.
• Children who witness domestic violence are at increased risk of dating violence and have a more difficult time with partnerships and parenting.
• Children who witness domestic violence are at an increased risk for post-traumatic stress disorder, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, academic problems, and they have a higher incidence of substance abuse.
• Children exposed to domestic violence often become victims of violence.
• Children who witness and experience domestic violence are at a greater risk for adverse psychosocial outcomes.
• Eighty to 90% of domestic violence victims abuse or neglect their children.
• Abused teens may not report abuse. Individuals 12 to 19 years of age report only about one-third of crimes against them, compared with one-half in older age groups

Pregnant and Females

The American College of Obstetricians and Gynecologists (ACOG) recommends all women be assessed for signs and symptoms of domestic violence during regular and prenatal visits. Providers should offer support and referral information.

• Domestic violence affects approximately 325,000 pregnant women each year.
• The average reported prevalence during pregnancy is approximately 30% emotional abuse, 15% physical abuse, and 8% sexual abuse.
• Domestic violence is more common among pregnant women than preeclampsia and gestational diabetes.
• Reproductive abuse may occur and includes impregnating against a partner's wishes by stopping a partner from using birth control.
• Since most pregnant women receive prenatal care, this is an excellent time to assess for domestic violence.

The danger of domestic violence is particularly acute as both mother and fetus are at risk. Healthcare professionals should be aware of the psychological consequences of domestic abuse during pregnancy. There is more stress, depression, and addiction to alcohol in abused pregnant women. These conditions may harm the fetus.

Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be similar to a heterosexual woman, approximately 25%.

• There are more cases of domestic violence among males living with male partners than among males who live with female partners.
• Females living with female partners experience less domestic violence than females living with males.
• Transgender individuals have a higher risk of domestic violence. Transgender victims are approximately two times more likely to experience physical violence.

Gay, lesbian, bisexual, and transgender victims may be reticent to report domestic violence. Part of the challenge may be that support services such as shelters, support groups, and hotlines are not regularly available. This results in isolated and unsupported victims. Healthcare professionals should strive to be helpful when working with gay, lesbian, bisexual, and transgender patients.

Usually, domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.

• Approximately 5% of males are killed by their intimate partners.
• Each year, approximately 500,000 women are physically assaulted or raped by an intimate partner compared to 100,000 men.
• Three out of 10 women at some point are stalked, physically assaulted, or raped by an intimate partner, compared to 1 out of every 10 men.
• Rape is primarily perpetrated by other men, while women engage in other forms of violence against men.

Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.

The elderly are often mistreated by their spouses, children, or relatives.

• Annually, approximately 2% of the elderly experience physical abuse, 1% sexual abuse, 5% neglect, 5% financial abuse, and 5% suffer emotional abuse.
• The annual incidence of elder abuse is estimated to be 2% to 10%, with only about 1 in 15 cases reported to the authorities.
• Approximately one-third of nursing homes disclosed at least 1 incident of physical abuse per year.
• Ten percent of nursing home staff self-report physical abuse against an elderly resident.

Elder domestic violence may be financial or physical. The elderly may be controlled financially. Elders are often hesitant to report this abuse if it is their only available caregiver. Victims are often dependent, infirm, isolated, or mentally impaired. Healthcare professionals should be aware of the high incidence of abuse in this population.

• History and Physical

The history and physical exam should be tailored to the age of the victim.

The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated.

Children who are abused may be unkempt and/or malnourished. They may display inappropriate behavior such as aggression, or maybe shy, withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. School attendance is usually poor.

Intimate Partner Abuse

Approximately one-third of women and one-fifth of men will be victims of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the history is not consistent with the injury. Defensive injuries may be present on the forearms and hands. The patient may have psychological signs and symptoms such as anxiety, depression, and fatigue.

Medical complaints may be specific or vague such as headaches, palpitations, chest pain, painful intercourse, or chronic pain.

Intimate Partner Abuse: Pregnancy and Female

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are a number of historical and physical findings that may help the provider identify individuals at risk.

If the examiner encounters signs or symptoms, she should make every effort to examine the patient in private, explaining confidentiality to the patient. Be sure to ask caring, empathetic questions and listen politely without interruption to answers.

Intimate Partner Abuse: Same-Sex

Same-sex partner abuse is common and may be difficult to identify. Over 35% of heterosexual women, 40% of lesbians, 60% of bisexual women experience domestic violence. For men, the incidence is slightly lower. In addition to common findings of abuse, perpetrators may try to control their partners by threatening to make their sexual preferences public.

The provider should be aware there are fewer resources available to help victims; further, the perpetrator and victim may have the same friends or support groups.

Intimate Partner Abuse: Men

Men represent as much as 15% of all cases of domestic partner violence. Male victims are also less likely to seek medical care, so that the incidence may be underreported. These victims may have a history of child abuse.

Elderly Abuse

Health professionals should ask geriatric patients about abuse, even if signs are absent.

• Pathologic characteristics of perpetrators including dementia, mental illness, and drug and alcohol abuse
• A shared living situation with the abuser
• Social isolation

Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are the priority. After stabilization and physical evaluation, laboratory tests, x-rays, CT, or MRI may be indicated. It is important that healthcare professionals first attend to the underlying issue that brought the victim to the emergency department. [1] [16] [17] [18]

• The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence and refer females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up.
• Health professionals and administrators should be aware of challenges such as barriers to screening for domestic violence: lack of training, time constraints, the sensitive nature of issues, and a lack of privacy to address the issues.
• Although professional and public awareness has increased, many patients and providers are still hesitant to discuss abuse.
• Patients with signs and symptoms of domestic violence should be evaluated. The obvious cues are physical: bruises, bites, cuts, broken bones, concussions, burns, knife or gunshot wounds.
• Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Abuse victims tend to have multiple injuries in various stages of healing, from acute to chronic.
• Domestic violence victims may have emotional and psychological issues such as anxiety and depression. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes.

Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.

• If there is no immediate danger, the assessment should focus on mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention.
• During the initial assessment, a practitioner must be sensitive to the patient’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of being victims of domestic violence may allow more effective treatment.
• Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being. They hence may be weighing the tradeoff in leaving the abuser leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, and enhance support.
• If the patient elects to leave their current situation, information for referral to a local domestic violence shelter to assist the victim should be given.
• If there is a risk to life or limb, or evidence of injury, the patient should be referred to local law enforcement officials.
• Counselors often include social workers, psychiatrists, and psychologists that specialize in the care of battered partners and children.

A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings similar to child abuse. As a consequence, they must be ruled out.

• A urine test may be used as a screen for sexually transmitted disease, bladder or kidney trauma, and toxicology screening. 

If bruises or contusions are present, there is no need to evaluate for a bleeding disorder if the injuries are consistent with an abuse history. Some tests can be falsely elevated, so a child abuse-specialist pediatrician or hematologist should review or follow-up these tests.

Gastrointestinal and Chest Trauma

• Consider liver and pancreas screening tests such as AST, ALT, and lipase. If the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, consider an abdomen and pelvis CT with intravenous contrast.
• The highest-risk are those with abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15.

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults, such as cranial sutures and incomplete bone growth. A fracture can be misinterpreted. If there is a concern for abuse, consider consulting a radiologist.

Imaging: Skeletal Survey

A skeletal survey is indicated in children younger than 2 years with suspected physical abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused children younger than 2 years. The clinician should consider screening all siblings younger than 2 years.

The skeletal survey should include 2 views of each extremity; anteroposterior and lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist should review the films for classic metaphyseal lesions and healing fractures, most often involving the posterior ribs. A “babygram” that includes only 1 film of the entire body is not an adequate skeletal survey.

Skeletal fractures will remodel at different rates, which are dependent on the age, location, and nutritional status of the patient.

Imaging: CT

If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged six months or younger or children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.

CT of the abdomen and pelvis with intravenous contrast is indicated in unconscious children, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Special Documentation

Photographs should be taken before treatment of injuries.

Intimate Partner and Elder

Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition. 

• X-rays of bruised of tender body parts to detect fractures
• Head CT scan to evaluate for intracranial bleeding as a result of abuse or the causes of altered mental status
• Pelvic examination with evidence collection if sexual assault

Evidence Collection

Domestic and family violence commonly results in the legal prosecution of the perpetrator. Preferably, a team specializing in domestic violence is called in to assist with evidence collection.

Each health facility should have a written procedure for how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection and provide specific kits.

It is important to avoid destroying evidence. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.

Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.

• Treatment / Management

The priority is the ABCs and appropriate treatment of the presenting complaints. However, once the patient is stabilized, emergency medical services personnel may identify problems associated with violence. [19] [20] [21]

Emergency Department and Office Care

Interventions to consider include:

• Make sure a safe environment is provided.
• Diagnose physical injuries and other medical or surgical problems.
• Treat acute physical or life-threatening injuries.
• Identify possible sources of domestic violence.
• Establish domestic violence as a diagnosis.
• Reassure the patient that he is not at fault.
• Evaluate the emotional status and treat.
• Document the history, physical, and interventions.
• Determine the risks to the victim and assess safety options.
• Counsel the patient that violence may escalate.
• Determine if legal intervention is needed and report abuse when appropriate or mandated.
• Develop a follow-up plan.
• Offer shelter options, legal services, counseling, and facilitate such referral.

Medical Record

The medical record is often evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again.

Charting should include detailed documentation of evaluation, treatment, and referrals.

• Describe the abusive event and current complaints using the patient's own words.
• Include the behavior of the patient in the record.
• Include health problems related to the abuse.
• Include the alleged perpetrator's name, relationship, and address.
• The physical exam should include a description of the patient's injuries including location, color, size, amount, and degree of age bruises and contusions.
• Document injuries with anatomical diagrams and photographs.
• Include the name of the patient, medical record number, date, and time of the photograph, and witnesses on the back of each photograph.
• Torn and damaged clothing should also be photographed.
• Document injuries not shown clearly by photographs with line drawings.
• With sexual assault, follow protocols for physical examination and evidence collection.

Disposition

If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.

• A referral should be made to primary care or another appropriate resource.
• Advise the patient to have a safety plan and provide examples.
• Forty percent of domestic violence victims never contact the police.
• Of female victims of domestic homicide, 44% had visited a hospital emergency department within 2 years of their murder.
• Health professionals provide an opportunity for victims of domestic violence to obtain help.
• Differential Diagnosis

The differential diagnosis varies with the injury type of injury and age.

Head Traum a

• Accidental injury
• Arteriovenous malformations
• Bacterial meningitis
• Birth trauma
• Cerebral sinovenous thrombosis
• Solid brain tumors

Bruises and Contusions

• Accidental bruises
• Bleeding disorder
• Congenital dermal melanocytosis (Mongolian spots)
• Erythema multiforme
• Accidental burns
• Atopic dermatitis
• Contact dermatitis
• Inflammatory skin conditions
• Congenital syphilis
• Osteogenesis imperfecta
• Osteomyelitis
• Toddler’s fracture

Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity. [3] [22] [23]

• Of those injured by domestic violence, over 75% continue to experience abuse.
• Over half of battered women who attempt suicide will try again; often they are successful with the second attempt.

In children, the potential for poor outcomes is particularly high as abuse inflicts lifelong effects. In addition to dealing with the sequelae of physical injury, the mental consequences may be catastrophic. Studies indicate a significant association between child sexual abuse and increased risk of psychiatric disorders in later life. The potential for the cycle of violence to continued from childhood is very high.

Children raised in families of sexual abuse may develop:

• Attention deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Bipolar disorder
• Panic disorder
• Sleep disorders
• Suicide attempts
• Post-traumatic stress disorder (PTSD)

Health Outcomes

There are multiple known and suspected negative health outcomes of family and domestic violence. There are long-term consequences to broken bones, traumatic brain injuries, and internal injuries.

Patients may also develop multiple comorbidities such as:

• Fibromyalgia
• High blood pressure
• Chronic pain
• Gastrointestinal disorders
• Gynecologic disorders
• Panic attacks
• Pearls and Other Issues

Screening: Tools

• The American Academy of Pediatricians has free guides for the history, physical, diagnostic testing, documentation, treatment, and legal issues in cases of suspected child abuse.
• The Center for Disease Control and Prevention (CDC) provides several scales assessing family relationships, including child abuse risks.
• The physical examination is still the most significant diagnostic tool to detect abuse. A child or adult with suspected abuse should be undressed, and a comprehensive physical exam should be performed. The skin should be examined for bruises, bites, burns, and injuries in different stages of healing. Examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury.

Screening: Recommendations

• Evaluate for organic conditions and medications that mimic abuse.
• Evaluate patients and caregivers separately
• Clinicians should regularly screen for family and domestic violence and elder abuse
• The Elder Abuse Suspicion Index can be used to assess for elder abuse
• Screen for cognitive impairment before screening for abuse in the elderly
• Pattern injury is more suspicious
• Failure to report child abuse is illegal in most states.
• Failure to report intimate partner and elder abuse is illegal in many states.

It is important to be aware of federal and state statutes governing domestic and family abuse. Remember that reporting domestic and family violence to law enforcement does not obviate detailed documentation in the medical record.

• Battering is a crime, and the patient should be made aware that help is available. If the patient wants legal help, the local police should be called.
• In some jurisdictions, domestic violence reporting is mandated. The legal obligation to report abuse should be explained to the patient.
• The patient should be informed how local authorities typically respond to such reports and provide follow-up procedures. Address the risk of reprisal, need for shelter, and possibly an emergency protective order (available in every state and the District of Columbia).
• If there is a possibility the patient’s safety will be jeopardized, the clinician should work with the patient and authorities to best protect the patient while meeting legal reporting obligations.
• The clinical role in managing an abused patient goes beyond obeying the laws that mandate reporting; there is a primary obligation to protect the life of the patient.
• The clinician must help mitigate the potential harm that results from reporting, provide appropriate ongoing care, and preserve the safety of the patient.
• If the patient desires, and it is acceptable to the police, a health professional should remain during the interview.
• The medical record should reflect the incident as described by the patient and any physical exam findings. Include the date and time the report was taken and the officer's name and badge number.

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA)

Each state has specific child abuse statutes. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure recent act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.

Elder Justice Act

The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes three significant approaches:

Patient Safety and Abuse Act

The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner; or enter or leave the country violating a protective order. It is a violation to possess a firearm or ammunition while subject to a protective order or if convicted of a qualifying crime of domestic violence.

• Enhancing Healthcare Team Outcomes

Domestic violence may be difficult to uncover when the victim is frightened, especially when he or she presents to an emergency department or healthcare practitioner's office. The key is to establish an assessment protocol and maintain an awareness of the possibility that domestic and family violence may be the cause of the patient’s signs and symptoms.

Over 80% of victims of domestic and family violence seek care in a hospital; others may seek care in health professional offices, including dentists, therapists, and other medical offices. Routine screening should be conducted by all healthcare practitioners including nurses, physicians, physician assistants, dentists, nurse practitioners, and pharmacists. Interprofessional coordination of screening is a critical component of protecting victims and minimizing negative health outcomes. Health professional team interventions reduce the incidence of morbidity and mortality associated with domestic violence. Documentation is vital and a legal obligation.

• Healthcare professionals including the nurse should document all findings and recommendations in the medical record, including statements made denying abuse
• If domestic violence is admitted, documentation should include the history, physical examination findings, laboratory and radiographic finds, any interventions, and the referrals made.
• If there are significant findings that can be recorded, pictures should be included.
• The medical record may become a court document; be objective and accurate.
• Healthcare professionals should provide a follow-up appointment.
• Reassurance that additional assistance is available at any time is critical to protect the patient from harm and break the cycle of abuse.
• Involve the social worker early
• Do not discharge the patient until a safe haven has been established.

The following agencies provide national assistance for victims of domestic and family violence:

• Centers for Disease Control and Prevention (800-CDC-INFO (232-4636)/TTY: 888-232-6348
• Childhelp: National Child Abuse Hotline: (800-4-A-CHILD (2-24453))
• The coalition of Labor Union Women (cluw.org): 202-466-4615
• Corporate Alliance to End Partner Violence: 309-664-0667
• Employers Against Domestic Violence: 508-894-6322
• Futures without Violence: 415-678-5500/TTY 800-595-4889
• Love Is Respect: National Teen Dating Abuse Helpline: 866-331-9474 /TTY: 866-331-8453
• National Center on Domestic and Sexual Violence
• National Center on Elder Abuse
• National Coalition Against Domestic Violence (www.ncadv.org)
• National Network to End Domestic Violence: 202-543-5566
• National Organization for Victim Assistance
• National Resource Center on Domestic Violence: 800-537-2238 
• National Sexual Violence Resource Center: 717-909-0710
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Disclosure: Martin Huecker declares no relevant financial relationships with ineligible companies.

Disclosure: Kevin King declares no relevant financial relationships with ineligible companies.

Disclosure: Gary Jordan declares no relevant financial relationships with ineligible companies.

Disclosure: William Smock declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Huecker MR, King KC, Jordan GA, et al. Domestic Violence. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Domestic Violence and Its Effects on Women, Children, and Families

Affiliations.

• 1 Department of Pediatrics, Maimonides Children's Hospital of Brooklyn, 4802 Tenth Avenue, Brooklyn, NY 11219, USA. Electronic address: [email protected].
• 2 Department of Pediatrics, Maimonides Children's Hospital of Brooklyn, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
• 3 City University of New York (CUNY) - Graduate School of Public Health and Health Policy, 235 West 102nd Street, New York, NY 10025, USA.
• PMID: 33678299
• DOI: 10.1016/j.pcl.2020.12.011

Men and women experience severe domestic violence (DV) and intimate partner violence (IPV); however, women and children remain especially vulnerable. Violence along the DV/IPV continuum has been recognized as a type of child maltreatment and a child's awareness that a caregiver is being harmed or at risk of harm is sufficient to induce harmful sequelae. Consequences of these abusive behaviors are associated with mental and physical health consequences. Health care professionals can screen, identify, and manage this pathology in affected families while educating communities to these pernicious effects.

Keywords: Child abuse; Domestic violence; Intimate partner violence; Pandemic preparedness.

Copyright © 2021 Elsevier Inc. All rights reserved.

Publication types

• Child Abuse / psychology*
• Child, Preschool
• Domestic Violence / psychology*
• Intimate Partner Violence / psychology
• Mental Health