Wednesday, September 20, 2017

Preventing Intimate Partner Violence is a Priority

Intimate Partner Violence is a Priority (IPV) is a serious preventable public health problem that affects millions of Americans and occurs across the lifespan.2-4 It can start as soon as people start dating or having intimate relationships, often in adolescence. IPV that happens when individuals first begin dating, usually in their teen years, is often referred to as TDV. From here forward in this technical package, we will use the term IPV broadly to refer to this type of violence as it occurs across the lifespan. However, when outcomes are specific to TDV, we will note that.

IPV (also commonly referred to as domestic violence) includes “physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/ girlfriend, dating partner, or ongoing sexual partner).”5 Some forms of IPV (e.g., aspects of sexual violence, psychological aggression, including coercive tactics, and stalking) can be perpetrated electronically through mobile devices and social media sites, as well as, in person. IPV happens in all types of intimate relationships, including heterosexual relationships and relationships among sexual minority populations. Family violence is another commonly used term in prevention efforts. While the term domestic violence encompasses the same behaviors and dynamics as IPV, the term family violence is broader and refers to a range of violence that can occur in families, including IPV, child abuse, and elder abuse by caregivers and others. This package is focused on IPV across the lifespan, including partner violence among older adult populations. The Centers for Disease Control and Prevention (CDC) has developed a separate technical package for the prevention of child abuse and neglect.

IPV is highly prevalent. IPV affects millions of people in the United States each year. Data from the National Intimate Partner and Sexual Violence Survey (NISVS) indicate that nearly 1 in 4 adult women (23%) and approximately 1 in 7 men (14%) in the U.S. report having experienced severe physical violence (e.g., being kicked, beaten, choked, or burned on purpose, having a weapon used against them, etc.) from an intimate partner in their lifetime. Additionally, 16% of women and 7% of men have experienced contact sexual violence (this includes rape, being made to penetrate someone else, sexual coercion, and/or unwanted sexual contact) from an intimate partner. Ten percent of women and 2% of men in the U.S. report having been stalked by an intimate partner, and nearly half of all women (47%) and men (47%) have experienced psychological aggression, such as humiliating or controlling behaviors.

The burden of IPV is not shared equally across all groups; many racial/ethnic and sexual minority groups are disproportionately affected by IPV. Data from NISVS indicate that the lifetime prevalence of experiencing contact sexual violence, physical violence, or stalking by an intimate partner is 57% among multi-racial women, 48% among American Indian/Alaska Native women, 45% among non-Hispanic Black women, 37% among non-Hispanic White women, 34% among Hispanic women, and 18% among Asian-Pacific Islander women. The lifetime prevalence is 42% among multi-racial men, 41% among American Indian/Alaska Native men, 40% among non-Hispanic Black men, 30% among non-Hispanic White men, 30% among Hispanic men, and 14% among Asian-Pacific Islander men.3 Additionally, the NISVS special report on victimization by sexual orientation demonstrates that some sexual minorities are also disproportionately affected by IPV victimization; 61% of bisexual women, 37% of bisexual men, 44% of lesbian women, 26% of gay men, 35% of heterosexual women, and 29% of heterosexual men experienced rape, physical violence, and/or stalking from an intimate partner in their lifetimes.7 In regards to people living with disabilities, one study using a nationally representative sample found that 4.3% of people with physical health impairments and 6.5% of people with mental health impairments reported IPV victimization in the past year.8 Studies also show that people with a disability have nearly double the lifetime risk of IPV victimization.

IPV starts early in the lifespan. Data from NISVS demonstrate that IPV often begins in adolescence. An estimated 8.5 million women in the U.S. (7%) and over 4 million men (4%) reported experiencing physical violence, rape (or being made to penetrate someone else), or stalking from an intimate partner in their lifetime and indicated that they first experienced these or other forms of violence by that partner before the age of 18.3 A nationally representative survey of U.S. high school students also indicates high levels of TDV. Findings from the 2015 Youth Risk Behavior Survey indicate that among students who reported dating, 10% had experienced physical dating violence and a similar percentage (11%) had experienced sexual dating violence in the past 12 months.10 In an analysis of the 2013 survey where the authors examined students reporting physical and/or sexual dating violence, the findings indicate that among students who had dated in the past year, 21% of girls and 10% of boys reported either physical violence, sexual violence, or both forms of violence from a dating partner.11 While the YRBS does not provide national data on the prevalence of stalking victimization among high school students, we know from NISVS that nearly 3.5 million women (3%) and 900,000 men (1%) in the U.S. report that they first experienced stalking victimization before age 18.3 A study conducted in Kentucky suggests that nearly 17% of high school students in that state report stalking victimization, with most students indicating that they were most afraid of a former boyfriend or girlfriend as the stalker.12 Research also indicates that IPV is most prevalent in adolescence and young adulthood and then begins to decline with age,2 demonstrating the critical importance of early prevention efforts.

IPV is associated with several risk and protective factors. Research indicates a number of factors increase risk for perpetration and victimization of IPV. The risk and protective factors discussed here focus on risk for IPV perpetration, although many of the same risk factors are also relevant for victimization.13-14 Factors that put individuals at risk for perpetrating IPV include (but are not limited to) demographic factors such as age (adolescence and young adulthood), low income, low educational attainment, and unemployment; childhood history factors such as exposure to violence between parents, experiencing poor parenting, and experiencing child abuse and neglect, including sexual violence. Other individual factors that put people at risk for perpetrating IPV include factors such as stress, anxiety, and antisocial personality traits; attitudinal risk factors, such as attitudes condoning violence in relationships and belief in strict gender roles; and other behavioral risk factors such as prior perpetration and victimization of IPV or other forms of aggression, such as peer violence, a history of substance abuse, a history of delinquency, and hostile communication styles.

Relationship level factors include hostility or conflict in the relationship, separation/ending of the relationship (e.g., break-ups, divorce/separation), aversive family communication and relationships, and having friends who perpetrate/ experience IPV.15-16 Although less studied than factors at other levels of the social ecology, community or societal level factors include poverty, low social capital, low collective efficacy in neighborhoods (e.g., low willingness of neighbors to intervene when they see violence), and harmful gender norms in societies (i.e., beliefs and expectations about the roles and behavior of men and women).

Additionally, a few protective factors have been identified that are associated with lower chances of perpetrating or experiencing TDV. These include high empathy, good grades, high verbal IQ, a positive relationship with one’s mother, and attachment to school.15 Less is known about protective factors at the community and societal level, but research is emerging indicating that environmental factors such as lower alcohol outlet density18 and community norms that are intolerant of IPV19 may be protective against IPV. Although more research is needed, there is some evidence suggesting that increased economic opportunity and housing security may also be protective against IPV.

IPV is connected to other forms of violence. Experience with many other forms of violence puts people at risk for perpetrating and experiencing IPV. Children who are exposed to IPV between their parents or caregivers are more likely to perpetrate or experience IPV, as are individuals who experience abuse and neglect as children.13,15,23 Additionally, adolescents who engage in bullying or peer violence are more likely to perpetrate IPV.15,24 Those who experience sexual violence and emotional abuse are more likely to be victims of physical IPV.14 Research also suggests IPV may increase risk for suicide. Both boys and girls who experience TDV are at greater risk for suicidal ideation.25-26 Women exposed to partner violence are nearly 5 times more likely to attempt suicide as women not exposed to partner violence.27 Intimate partner problems, which includes IPV, were also found to be a precipitating factor for suicide among men in a review of violent death records from 7 U.S. states.28 Research also shows that experience with IPV (either perpetration or victimization) puts people at higher risk for experiencing IPV in the future.

The different forms of violence often share the same individual, relationship, community, and societal risk factors.29 The interconnections between the different forms of violence suggests multiple opportunities for prevention.30 Many of the strategies included in this technical package include example programs and policies that have demonstrated impacts on other forms of violence as reflected in CDC’s other technical packages for prevention of child abuse and neglect, sexual violence, youth violence and suicide.6,31-33 Recognizing and addressing the interconnections among the different forms of violence will help us better prevent all forms of violence. Research

The health and economic consequences of IPV are substantial. Approximately 41% of female IPV survivors and 14% of male IPV survivors experience some form of physical injury related to their experience of relationship violence.2 IPV can also extend beyond physical injury and result in death. Data from U.S. crime reports suggest that 16% (about 1 in 6) of murder victims are killed by an intimate partner, and that over 40% of female homicide victims in the U.S. are killed by an intimate partner.34 There are also many other adverse health outcomes associated with IPV, including a range of cardiovascular, gastrointestinal, reproductive, musculoskeletal, and nervous system conditions, many of which are chronic in nature.35 Survivors of IPV also experience mental health consequences, such as depression and posttraumatic stress disorder (PTSD).36 Population-based surveys suggest that 52% of women and 17% of men who have experienced contact sexual violence, physical violence or stalking by an intimate partner report symptoms of PTSD related to their experience of relationship violence.3 IPV survivors are also at higher risk for engaging in health risk behaviors, such as smoking, binge drinking, and HIV risk behaviors.
A substantial proportion of survivors also report other negative impacts as a result of IPV, and there is wide variation in the proportions of female and male survivors reporting these impacts. Populationbased surveys indicate that among women and men in the U.S. who have experienced contact sexual violence, physical violence, or stalking by an intimate partner during their lifetimes, 73% of the women and 36% of the men report at least one measured negative impact related to these victimization experiences (e.g., fear, concern for safety, missing school or work, needing services).3 Among the female IPV survivors, 62% reported feeling fearful, 57% reported being concerned for their safety, 25% missed at least one day of school or work from the IPV, 19% reported needing medical care, and 8% needed housing services. Among the male survivors, 18% reported feeling fearful, 17% reported being concerned for their safety, 14% missed at least one day of school or work from the IPV, 5% reported needing medical care, and 2% needed housing services.
Although the personal consequences of IPV are considerable, there are also considerable societal costs associated with medical services for IPV-related injury and health consequences, mental health services, lost productivity from paid work, childcare, and household chores, and criminal justice and child welfare costs. The only currently available estimates of societal costs of IPV are from the mid-1990s, but suggest that the annual costs even 20 years ago were estimated at $5.8 billion based on medical and mental health services and lost productivity alone.
IPV can be prevented. Primary prevention of IPV, including TDV, means preventing IPV before it begins. Primary prevention strategies are key to ending partner violence in adolescence and adulthood and protecting people from its effects. Partner violence in adolescence can be a pre-cursor or risk factor for partner violence in adulthood. Many strategies to prevent IPV therefore see adolescence as a critical developmental period for the prevention of partner violence in adulthood. It is also important to assist survivors and their children and protect them from future harm. Although there is less evidence of what works to prevent IPV compared to other areas of violence, such as youth violence or child maltreatment, a growing research base demonstrates that there are multiple strategies to prevent IPV from occurring in the first place and to lessen the harms for survivors.39 Strategies are available that can benefit adolescents and adults regardless of their level of risk as well as individuals and environments at greatest risk. A comprehensive approach that simultaneously targets multiple risk and protective factors is critical to having a broad and sustained impact on IPV. Even though more research is needed (e.g., to strengthen the evidence addressing community and societal level factors), we cannot let the need for further research impede efforts to effectively prevent IPV within our communities.


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