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Domestic violence research topics.

The list of domestic violence research paper topics below will show that domestic violence takes on many forms. Through recent scientific study, it is now known that domestic violence occurs within different types of households. The purpose of creating this list is for students to have available a comprehensive, state-of-the-research, easy-to-read compilation of a wide variety of domestic violence topics and provide research paper examples on those topics.

Domestic violence research paper topics can be divided into seven categories:

• Victims of domestic violence,
• Theoretical perspectives and correlates to domestic violence,
• Cross-cultural and religious perspectives,
• Understudied areas within domestic violence research,
• Domestic violence and the law,
• Child abuse and elder abuse, and
• Special topics in domestic violence.

100+ Domestic Violence Research Topics

Victims of domestic violence.

Initial research recognized wives as victims of domestic violence. Thereafter, it was acknowledged that unmarried women were also falling victim to violence at the hands of their boyfriends. Subsequently, the term ‘‘battered women’’ became synonymous with ‘‘battered wives.’’ Legitimizing female victimization served as the catalyst in introducing other types of intimate partner violence.

• Battered Husbands
• Battered Wives
• Battered Women: Held in Captivity
• Battered Women Who Kill: An Examination
• Cohabiting Violence
• Dating Violence
• Domestic Violence in Workplace
• Intimate Partner Homicide
• Intimate Partner Violence, Forms of
• Marital Rape
• Mutual Battering
• Spousal Prostitution

Read more about victims of domestic violence .

Part 2: Research Paper Topics on

Theoretical Perspectives and Correlates to Domestic Violence

There is no single causal factor related to domestic violence. Rather, scholars have concluded that there are numerous factors that contribute to domestic violence. Feminists found that women were beaten at the hands of their partners. Drawing on feminist theory, they helped explain the relationship between patriarchy and domestic violence. Researchers have examined other theoretical perspectives such as attachment theory, exchange theory, identity theory, the cycle of violence, social learning theory, and victim-blaming theory in explaining domestic violence. However, factors exist that may not fall into a single theoretical perspective. Correlates have shown that certain factors such as pregnancy, social class, level of education, animal abuse, and substance abuse may influence the likelihood for victimization.

• Animal Abuse: The Link to Family Violence
• Assessing Risk in Domestic Violence Cases
• Attachment Theory and Domestic Violence
• Battered Woman Syndrome
• Batterer Typology
• Bullying and the Family
• Coercive Control
• Control Balance Theory and Domestic Violence
• Cycle of Violence
• Depression and Domestic Violence
• Education as a Risk Factor for Domestic Violence
• Exchange Theory
• Feminist Theory
• Identity Theory and Domestic Violence
• Intergenerational Transfer of Intimate Partner Violence
• Popular Culture and Domestic Violence
• Post-Incest Syndrome
• Pregnancy-Related Violence
• Social Class and Domestic Violence
• Social Learning Theory and Family Violence
• Stockholm Syndrome in Battered Women
• Substance Use/Abuse and Intimate Partner Violence
• The Impact of Homelessness on Family Violence
• Victim-Blaming Theory

Read more about domestic violence theories .

Part 3: Research Paper Topics on

Cross-Cultural and Religious Perspectives on Domestic Violence

It was essential to acknowledge that domestic violence crosses cultural boundaries and religious affiliations. There is no one particular society or religious group exempt from victimization. A variety of developed and developing countries were examined in understanding the prevalence of domestic violence within their societies as well as their coping strategies in handling these volatile issues. It is often misunderstood that one religious group is more tolerant of family violence than another. As Christianity, Islam, and Judaism represent the three major religions of the world, their ideologies were explored in relation to the acceptance and prevalence of domestic violence.

• Africa: Domestic Violence and the Law
• Africa: The Criminal Justice System and the Problem of Domestic Violence in West Africa
• Asian Americans and Domestic Violence: Cultural Dimensions
• Child Abuse: A Global Perspective
• Christianity and Domestic Violence
• Cross-Cultural Examination of Domestic Violence in China and Pakistan
• Cross-Cultural Examination of Domestic Violence in Latin America
• Cross-Cultural Perspectives on Domestic Violence
• Cross-Cultural Perspectives on How to Deal with Batterers
• Dating Violence among African American Couples
• Domestic Violence among Native Americans
• Domestic Violence in African American Community
• Domestic Violence in Greece
• Domestic Violence in Rural Communities
• Domestic Violence in South Africa
• Domestic Violence in Spain
• Domestic Violence in Trinidad and Tobago
• Domestic Violence within the Jewish Community
• Human Rights, Refugee Laws, and Asylum Protection for People Fleeing Domestic Violence
• Introduction to Minorities and Families in America
• Medical Neglect Related to Religion and Culture
• Multicultural Programs for Domestic Batterers
• Qur’anic Perspectives on Wife Abuse
• Religious Attitudes toward Corporal Punishment
• Rule of Thumb
• Same-Sex Domestic Violence: Comparing Venezuela and the United States
• Worldwide Sociolegal Precedents Supporting Domestic Violence from Ancient to Modern Times

Part 4: Research Paper Topics on

Understudied Areas within Domestic Violence Research

Domestic violence has typically examined traditional relationships, such as husband–wife, boyfriend–girlfriend, and parent–child. Consequently, scholars have historically ignored non-traditional relationships. In fact, certain entries have limited cross-references based on the fact that there were limited, if any, scholarly publications on that topic. Only since the 1990s have scholars admitted that violence exists among lesbians and gay males. There are other ignored populations that are addressed within this encyclopedia including violence within military and police families, violence within pseudo-family environments, and violence against women and children with disabilities.

• Caregiver Violence against People with Disabilities
• Community Response to Gay and Lesbian Domestic Violence
• Compassionate Homicide and Spousal Violence
• Domestic Violence against Women with Disabilities
• Domestic Violence by Law Enforcement Officers
• Domestic Violence within Military Families
• Factors Influencing Reporting Behavior by Male Domestic Violence Victims
• Gay and Bisexual Male Domestic Violence
• Gender Socialization and Gay Male Domestic Violence
• Inmate Mothers: Treatment and Policy Implications
• Intimate Partner Violence and Mental Retardation
• Intimate Partner Violence in Queer, Transgender, and Bisexual Communities
• Lesbian Battering
• Male Victims of Domestic Violence and Reasons They Stay with Their Abusers
• Medicalization of Domestic Violence
• Police Attitudes and Behaviors toward Gay Domestic Violence
• Pseudo-Family Abuse
• Sexual Aggression Perpetrated by Females
• Sexual Orientation and Gender Identity: The Need for Education in Servicing Victims of Trauma

Part 5: Research Paper Topics on

Domestic Violence and the Law

The Violence against Women Act (VAWA) of 1994 helped pave domestic violence concerns into legislative matters. Historically, family violence was handled through informal measures often resulting in mishandling of cases. Through VAWA, victims were given the opportunity to have their cases legally remedied. This legitimized the separation of specialized domestic and family violence courts from criminal courts. The law has recognized that victims of domestic violence deserve recognition and resolution. Law enforcement agencies may be held civilly accountable for their actions in domestic violence incidents. Mandatory arrest policies have been initiated helping reduce discretionary power of police officers. Courts have also begun to focus on the offenders of domestic violence. Currently, there are batterer intervention programs and mediation programs available for offenders within certain jurisdictions. Its goals are to reduce the rate of recidivism among batterers.

• Battered Woman Syndrome as a Legal Defense in Cases of Spousal Homicide
• Batterer Intervention Programs
• Clemency for Battered Women
• Divorce, Child Custody, and Domestic Violence
• Domestic Violence Courts
• Electronic Monitoring of Abusers
• Expert Testimony in Domestic Violence Cases
• Judicial Perspectives on Domestic Violence
• Lautenberg Law
• Legal Issues for Battered Women
• Mandatory Arrest Policies
• Mediation in Domestic Violence
• Police Civil Liability in Domestic Violence Incidents
• Police Decision-Making Factors in Domestic Violence Cases
• Police Response to Domestic Violence Incidents
• Prosecution of Child Abuse and Neglect
• Protective and Restraining Orders
• Shelter Movement
• Training Practices for Law Enforcement in Domestic Violence Cases
• Violence against Women Act

Read more about Domestic Violence Law .

Part 6: Research Paper Topics on

Child Abuse and Elder Abuse

Scholars began to address child abuse over the last third of the twentieth century. It is now recognized that child abuse falls within a wide spectrum. In the past, it was based on visible bruises and scars. Today, researchers have acknowledged that psychological abuse, where there are no visible injuries, is just as damaging as its counterpart. One of the greatest controversies in child abuse literature is that of Munchausen by Proxy. Some scholars have recognized that it is a syndrome while others would deny a syndrome exists. Regardless of the term ‘‘syndrome,’’ Munchausen by Proxy does exist and needs to be further examined. Another form of violence that needs to be further examined is elder abuse. Elder abuse literature typically focused on abuse perpetrated by children and caregivers. With increased life expectancies, it is now understood that there is greater probability for violence among elderly intimate couples. Shelters and hospitals need to better understand this unique population in order to better serve its victims.

• Assessing the Risks of Elder Abuse
• Child Abuse and Juvenile Delinquency
• Child Abuse and Neglect in the United States: An Overview
• Child Maltreatment, Interviewing Suspected Victims of
• Child Neglect
• Child Sexual Abuse
• Children Witnessing Parental Violence
• Consequences of Elder Abuse
• Elder Abuse and Neglect: Training Issues for Professionals
• Elder Abuse by Intimate Partners
• Elder Abuse Perpetrated by Adult Children
• Filicide and Children with Disabilities
• Mothers Who Kill
• Munchausen by Proxy Syndrome
• Parental Abduction
• Postpartum Depression, Psychosis, and Infanticide
• Ritual Abuse–Torture in Families
• Shaken Baby Syndrome
• Sibling Abuse

Part 7: Research Paper Topics on

Special Topics  in Domestic Violence

Within this list, there are topics that may not fit clearly into one of the aforementioned categories. Therefore, they are be listed in a separate special topics designation. Analyzing Incidents of Domestic Violence: The National Incident-Based Reporting System

• Community Response to Domestic Violence
• Conflict Tactics Scales
• Dissociation in Domestic Violence, The Role of
• Domestic Homicide in Urban Centers: New York City
• Fatality Reviews in Cases of Adult Domestic Homicide and Suicide
• Female Suicide and Domestic Violence
• Healthcare Professionals’ Roles in Identifying and Responding to Domestic Violence
• Measuring Domestic Violence
• Neurological and Physiological Impact of Abuse
• Social, Economic, and Psychological Costs of Violence
• Stages of Leaving Abusive Relationships
• The Physical and Psychological Impact of Spousal Abuse

Domestic violence remains a relatively new field of study among social scientists but it is already a popular research paper subject within college and university students. Only within the past 4 decades have scholars recognized domestic violence as a social problem. Initially, domestic violence research focused on child abuse. Thereafter, researchers focused on wife abuse and used this concept interchangeably with domestic violence. Within the past 20 years, researchers have acknowledged that other forms of violent relationships exist, including dating violence, battered males, and gay domestic violence. Moreover, academicians have recognized a subcategory within the field of criminal justice: victimology (the scientific study of victims). Throughout the United States, colleges and universities have been creating victimology courses, and even more specifically, family violence and interpersonal violence courses.

The media have informed us that domestic violence is so commonplace that the public has unfortunately grown accustomed to reading and hearing about husbands killing their wives, mothers killing their children, or parents neglecting their children. While it is understood that these offenses take place, the explanations as to what factors contributed to them remain unclear. In order to prevent future violence, it is imperative to understand its roots. There is no one causal explanation for domestic violence; however, there are numerous factors which may help explain these unjustified acts of violence. Highly publicized cases such as the O.J. Simpson and Scott Peterson trials have shown the world that alleged murderers may not resemble the deranged sociopath depicted in horror films. Rather, they can be handsome, charming, and well-liked by society. In addition, court-centered programming on television continuously publicizes cases of violence within the home informing the public that we are potentially at risk by our caregivers and other loved ones. There is the case of the au pair Elizabeth Woodward convicted of shaking and killing Matthew Eappen, the child entrusted to her care. Some of the most highly publicized cases have also focused on mothers who kill. America was stunned as it heard the cases of Susan Smith and Andrea Yates. Both women were convicted of brutally killing their own children. Many asked how loving mothers could turn into cold-blooded killers.

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Research & Evidence

NRCDV works to strengthen researcher/practitioner collaborations that advance the field’s knowledge of, access to, and input in research that informs policy and practice at all levels. We also identify and develop guidance and tools to help domestic violence programs and coalitions better evaluate their work, including by using participatory action research approaches that directly tap the diverse expertise of a community to frame and guide evaluation efforts.

Safety & Privacy in a Digital World

Immigrant Survivors of Domestic Violence  

Teen Dating Violence

Housing and Domestic Violence

Domestic Violence in LGBTQ Communities

Trans and Non-Binary Survivors

The Difference Between Surviving & Not Surviving

Earned Income Tax Credit & Other Tax Credits

For an extensive list of research & evidence materials check out the research & statistics section on VAWnet

The Domestic Violence Evidence Project (DVEP) is a multi-faceted, multi-year and highly collaborative effort designed to assist state coalitions, local domestic violence programs, researchers, and other allied individuals and organizations better respond to the growing emphasis on identifying and integrating evidence-based practice into their work. DVEP brings together research, evaluation, practice and theory to inform critical thinking and enhance the field's knowledge to better serve survivors and their families.

The Community Based Participatory Research Toolkit  (CBPR) is for researchers and practitioners across disciplines and social locations who are working in academic, policy, community, or practice-based settings. In particular, the toolkit provides support to emerging researchers as they consider whether and how to take a CBPR approach and what it might mean in the context of their professional roles and settings. Domestic violence advocates will also find useful information on the CBPR approach and how it can help answer important questions about your work.

For over two decades, the National Resource Center on Domestic Violence has operated  VAWnet , an online library focused on violence against women and other forms of gender-based violence.  VAWnet.org  has long been identified as an unparalleled, comprehensive, go-to source of information and resources for anti-violence advocates, human service professionals, educators, faith leaders, and others interested in ending domestic and sexual violence.

Safe Housing Partnerships , the website of the Domestic Violence and Housing Technical Assistance Consortium , includes the latest research and evidence on the intersection of domestic and sexual violence, housing, and homelessness. You can also find new research exploring different aspects of efforts to expand housing options for domestic and sexual violence survivors, including the use of flexible funding approaches, DV Housing First and rapid rehousing, DV Transitional Housing, and mobile advocacy.

• Open access
• Published: 20 June 2023

A qualitative quantitative mixed methods study of domestic violence against women

• Mina Shayestefar 1 ,
• Mohadese Saffari 1 ,
• Razieh Gholamhosseinzadeh 2 ,
• Monir Nobahar 3 , 4 ,
• Majid Mirmohammadkhani 4 ,
• Seyed Hossein Shahcheragh 5 &
• Zahra Khosravi 6  

BMC Women's Health volume  23 , Article number:  322 ( 2023 ) Cite this article

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Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi’s 7-step method.

In qualitative study, seven themes were found including “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems”. In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions

Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Peer Review reports

Violence against women by husbands (physical, sexual and psychological violence) is one of the basic problems of public health and violation of women’s human rights. It is estimated that 35% of women and almost one out of every three women aged 15–49 experience physical or sexual violence by their spouse or non-spouse sexual violence in their lifetime [ 1 ]. This is a nationwide public health issue, and nearly every healthcare worker will encounter a patient who has suffered from some type of domestic or family violence. Unfortunately, different forms of family violence are often interconnected. The “cycle of abuse” frequently persists from children who witness it to their adult relationships, and ultimately to the care of the elderly [ 2 ]. This violence includes a range of physical, sexual and psychological actions, control, threats, aggression, abuse, and rape [ 3 ].

Violence against women is one of the most widespread, persistent, and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication [ 3 ]. In the United States of America, more than one in three women (35.6%) experience rape, physical violence, and intimate partner violence (IPV) during their lifetime. Compared to men, women are nearly twice as likely (13.8% vs. 24.3%) to experience severe physical violence such as choking, burns, and threats with knives or guns [ 4 ]. The higher prevalence of violence against women can be due to the situational deprivation of women in patriarchal societies [ 5 ]. The prevalence of domestic violence in Iran reported 22.9%. The maximum of prevalence estimated in Tehran and Zahedan, respectively [ 6 ]. Currently, Iran has high levels of violence against women, and the provinces with the highest rates of unemployment and poverty also have the highest levels of violence against women [ 7 ].

Domestic violence against women harms individuals, families, and society [ 8 ]. Violence against women leads to physical, sexual, psychological harm or suffering, including threats, coercion and arbitrary deprivation of their freedom in public and private life. Also, such violence is associated with harmful effects on women’s sexual reproductive health, including sexually transmitted infection such as Human Immunodeficiency Virus (HIV), abortion, unsafe childbirth, and risky sexual behaviors [ 9 ]. There are high levels of psychological, sexual and physical domestic abuse among pregnant women [ 10 ]. Also, women with postpartum depression are significantly more likely to experience domestic violence during pregnancy [ 11 ].

Prompt attention to women’s health and rights at all levels is necessary, which reduces this problem and its risk factors [ 12 ]. Because women prefer to remain silent about domestic violence and there is a need to introduce immediate prevention programs to end domestic violence [ 13 ]. violence against women, which is an important public health problem, and concerns about human rights require careful study and the application of appropriate policies [ 14 ]. Also, the efforts to change the circumstances in which women face domestic violence remain significantly insufficient [ 15 ]. Given that few clear studies on violence against women and at the same time interviews with these people regarding their life experiences are available, the authors attempted to planning this research aims to investigate the prevalence and experiences of domestic violence against women in Semnan with the research question of “What is the prevalence of domestic violence against women in Semnan, and what are their experiences of such violence?”, so that their results can be used in part of the future planning in the health system of the society.

This study is a combination of cross-sectional and phenomenology studies in order to investigate the amount of domestic violence against women and some related factors (quantitative) and their experience of this violence (qualitative) simultaneously in the Semnan city. This study has been approved by the ethics committee of Semnan University of Medical Sciences with ethic code of IR.SEMUMS.REC.1397.182. The researcher introduced herself to the research participants, explained the purpose of the study, and then obtained informed written consent. It was assured to the research units that the collected information will be anonymous and kept confidential. The participants were informed that participation in the study was entirely voluntary, so they can withdraw from the study at any time with confidence. The participants were notified that more than one interview session may be necessary. To increase the trustworthiness of the study, Guba and Lincoln’s criteria for rigor, including credibility, transferability, dependability, and confirmability [ 16 ], were applied throughout the research process. The COREQ checklist was used to assess the present study quality. The researchers used observational notes for reflexivity and it preserved in all phases of this qualitative research process.

Qualitative method

Based on the phenomenological approach and with the purposeful sampling method, nine women who had referred to the counseling units of healthcare centers in Semnan city due to domestic violence in February 2021 to March 2022 were participated in the present study. The inclusion criteria for the study included marriage, a history of visiting a health center consultant due to domestic violence, and consent to participate in the study and unwillingness to participate in the study was the exclusion criteria. Each participant invited to the study by a telephone conversation about study aims and researcher information. The interviews place selected through agreement of the participant and the researcher and a place with the least environmental disturbance. Before starting each interview, the informed consent and all of the ethical considerations, including the purpose of the research, voluntary participation, confidentiality of the information were completely explained and they were asked to sign the written consent form. The participants were interviewed by depth, semi-structured and face-to-face interviews based on the main research question. Interviews were conducted by a female health services researcher with a background in nursing (M.Sh.). Data collection was continued until the data saturation and no new data appeared. Only the participants and the researcher were present during the interviews. All interviews were recorded by a MP3 Player by permission of the participants before starting. Interviews were not repeated. No additional field notes were taken during or after the interview.

The age range of the participants was from 38 to 55 years and their average age was 40 years. The sociodemographic characteristics of the participants are summarized in table below (Table  1 ).

Five interviews in the courtyards of healthcare centers, 2 interviews in the park, and 2 interviews at the participants’ homes were conducted. The duration of the interviews varied from 45 min to one hour. The main research question was “What is your experience about domestic violence?“. According to the research progress some other questions were asked in line with the main question of the research.

The conducted interviews were analyzed by using the 7 steps Colizzi’s method [ 17 ]. In order to empathize with the participants, each interview was read several times and transcribed. Then two researchers (M.Sh. and M.N.) extracted the phrases that were directly related to the phenomenon of domestic violence against women independently and distinguished from other sentences by underlining them. Then these codes were organized into thematic clusters and the formulated concepts were sorted into specific thematic categories.

In the final stage, in order to make the data reliable, the researcher again referred to 2 participants and checked their agreement with their perceptions of the content. Also, possible important contents were discussed and clarified, and in this way, agreement and approval of the samples was obtained.

Quantitative method

The cross-sectional study was implemented from February 2021 to March 2022 with cluster sampling of married women in areas of 3 healthcare centers in Semnan city. Those participants who were married and agreed with the written and verbal informed consent about the ethical considerations were included to the study. The questionnaire was completed by the participants in paper and online form.

The instrument was the standard questionnaire of domestic violence against women by Mohseni Tabrizi et al. [ 18 ]. In the questionnaire, questions 1–10, 11–36, 37–65 and 66–71 related to sociodemographic information, types of spousal abuse (psychological, economical, physical and sexual violence), patriarchal beliefs and traditions and family upbringing and learning violence, respectively. In total, this questionnaire has 71 items.

The scoring of the questionnaire has two parts and the answers to them are based on the Likert scale. Questions 11–36 and 66–71 are answered with always [ 4 ] to never (0) and questions 37–65 with completely agree [ 4 ] to completely disagree (0). The minimum and maximum score is 0 and 300, respectively. The total score of 0–60, 61–120 and higher than 121 demonstrates low, moderate and severe domestic violence against women, respectively [ 18 ].

In the study by Tabrizi et al., to evaluate the validity and reliability of this questionnaire, researchers tried to measure the face validity of the scale by the previous research. Those items and questions which their accuracies were confirmed by social science professors and experts used in the research, finally. The total Cronbach’s alpha coefficient was 0.183, which confirmed that the reliability of the questions and items of the questionnaire is sufficient [ 18 ].

Descriptive data were reported using mean, standard deviation, frequency and percentage. Then, to measure the relationship between the variables, χ2 and Pearson tests also variance and regression analysis were performed. All analysis were performed by using SPSS version 26 and the significance level was considered as p < 0.05.

Qualitative results

According to the third step of Colaizzi’s 7-step method, the researcher attempted to conceptualize and formulate the extracted meanings. In this step, the primary codes were extracted from the important sentences related to the phenomenon of violence against women, which were marked by underlining, which are shown below as examples of this stage and coding.

The primary code of indifference to the father’s role was extracted from the following sentences. This is indifference in the role of the father in front of the children.

“Some time ago, I told him that our daughter is single-sided deaf. She has a doctor’s appointment; I have to take her to the doctor. He said that I don’t have money to give you. He doesn’t force himself to make money anyway” (p 2, 33 yrs).

“He didn’t value his own children. He didn’t think about his older children” (p 4, 54 yrs).

The primary code extracted here included lack of commitment in the role of head of the household. This is irresponsibility towards the family and meeting their needs.

“My husband was fired from work after 10 years due to disorder and laziness. Since then, he has not found a suitable job. Every time he went to work, he was fired after a month because of laziness” (p 7, 55 yrs).

“In the evening, he used to get dressed and go out, and he didn’t come back until late. Some nights, I was so afraid of being alone that I put a knife under my pillow when I slept” (p 2, 33 yrs).

A total of 246 primary codes were extracted from the interviews in the third step. In the fourth step, the researchers put the formulated concepts (primary codes) into 85 specific sub-categories.

Twenty-three categories were extracted from 85 sub-categories. In the sixth step, the concepts of the fifth step were integrated and formed seven themes (Table  2 ).

These themes included “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems” (Fig.  1 ).

Themes of domestic violence against women

Some of the statements of the participants on the theme of “ Facilitators” are listed below:

Husband’s criminal record

“He got his death sentence for drugs. But, at last it was ended for 10 years” (p 4, 54 yrs).

Inappropriate age for marriage

“At the age of thirteen, I married a boy who was 25 years old” (p 8, 25 yrs).

“My first husband obeyed her parents. I was 12–13 years old” (p 3, 32 yrs).

“I couldn’t do anything. I was humiliated” (p 1, 38 yrs).

“A bridegroom came. The mother was against. She said, I am young. My older sister is not married yet, but I was eager to get married. I don’t know, maybe my father’s house was boring for me” (p 2, 33 yrs).

“My parents used to argue badly. They blamed each other and I always wanted to run away from these arguments. I didn’t have the patience to talk to mom or dad and calm them down” (p 5, 39 yrs).

Overdependence

“My husband’s parents don’t stop interfering, but my husband doesn’t say anything because he is a student of his father. My husband is self-employed and works with his father on a truck” (p 8, 25 yrs).

“Every time I argue with my husband because of lack of money, my mother-in-law supported her son and brought him up very spoiled and lazy” (p 7, 55 yrs).

Bitter memories

“After three years, my mother married her friend with my uncle’s insistence and went to Shiraz. But, his condition was that she did not have the right to bring his daughter with her. In fact, my mother also got married out of necessity” (p 8, 25 yrs).

Some of their other statements related to “ Role failure” are mentioned below:

Lack of commitment to different roles

“I got angry several times and went to my father’s house because of my husband’s bad financial status and the fact that he doesn’t feel responsible to work and always says that he cannot find a job” (p 6, 48 yrs).

“I saw that he does not want to change in any way” (p 4, 54 yrs).

“No matter how kind I am, it does not work” (p 1, 38 yrs).

Some of their other statements regarding “ Repressors” are listed below:

Fear and silence

“My mother always forced me to continue living with my husband. Finally, my father had been poor. She all said that you didn’t listen to me when you wanted to get married, so you don’t have the right to get angry and come to me, I’m miserable enough” (p 2, 33 yrs).

“Because I suffered a lot in my first marital life. I was very humiliated. I said I would be fine with that. To be kind” (p1, 38 yrs).

“Well, I tell myself that he gets angry sometimes” (p 3, 32 yrs).

Shame from society

“I don’t want my daughter-in-law to know. She is not a relative” (p 4, 54 yrs).

Some of the statements of the participants regarding the theme of “ Efforts to preserve the family” are listed below:

Hope and trust

“I always hope in God and I am patient” (p 2, 33 yrs).

Efforts for children

“My divorce took a month. We got a divorce. I forgave my dowry and took my children instead” (p 2, 33 yrs).

Some of their other statements regarding the “ Inappropriate solving of family conflicts” are listed below:

Child-bearing thoughts

“My husband wanted to take me to a doctor to treat me. But my father-in-law refused and said that instead of doing this and spending money, marry again. Marriage in the clans was much easier than any other work” (p 8, 25 yrs).

Lack of effective communication

“I was nervous about him, but I didn’t say anything” (p 5, 39 yrs).

“Now I am satisfied with my life and thank God it is better to listen to people’s words. Now there is someone above me so that people don’t talk behind me” (p 2, 33 yrs).

Some of their other statements regarding the “ Consequences” are listed below:

Harm to children

“My eldest daughter, who was about 7–8 years old, behaved differently. Oh, I was angry. My children are mentally depressed and argue” (p 5, 39 yrs).

After divorce

“Even though I got a divorce, my mother and I came to a remote area due to the fear of what my family would say” (p 2, 33 yrs).

Social harm

“I work at a retirement center for living expenses” (p 2, 33 yrs).

“I had to go to clean the houses” (p 5, 39 yrs).

Non-acceptance in the family

“The children’s relationship with their father became bad. Because every time they saw their father sitting at home smoking, they got angry” (p 7, 55 yrs).

Emotional harm

“When I look back, I regret why I was not careful in my choice” (p 7, 55 yrs).

“I felt very bad. For being married to a man who is not bound by the family and is capricious” (p 9, 36 yrs).

Some of their other statements regarding “ Inefficient supportive systems” are listed below:

Inappropriate family support

“We didn’t have children. I was at my father’s house for about a month. After a month, when I came home, I saw that my husband had married again. I cried a lot that day. He said, God, I had to. I love you. My heart is broken, I have no one to share my words” (p 8, 25 yrs).

“My brother-in-law was like himself. His parents had also died. His sister did not listen at all” (p 4, 54 yrs).

“I didn’t have anyone and I was alone” (p 1, 38 yrs).

Inefficiency of social systems

“That day he argued with me, picked me up and threw me down some stairs in the middle of the yard. He came closer, sat on my stomach, grabbed my neck with both of his hands and wanted to strangle me. Until a long time later, I had kidney problems and my neck was bruised by her hand. Given that my aunt and her family were with us in a building, but she had no desire to testify and was afraid” (p 3, 32 yrs).

Undesired training and advice

“I told my mother, you just said no, how old I was? You never insisted on me and you didn’t listen to me that this man is not good for you” (p 9, 36 yrs).

Quantitative results

In the present study, 376 married women living in Semnan city participated in this study. The mean age of participants was 38.52 ± 10.38 years. The youngest participant was 18 and the oldest was 73 years old. The maximum age difference was 16 years. The years of marriage varied from one year to 40 years. Also, the number of children varied from no children to 7. The majority of them had 2 children (109, 29%). The sociodemographic characteristics of the participants are summarized in the table below (Table  3 ).

The frequency distribution (number and percentage) of the participants in terms of the level of violence was as follows. 89 participants (23.7%) had experienced low violence, 59 participants (15.7%) had experienced moderate violence, and 228 participants (60.6%) had experienced severe violence.

Cronbach’s alpha for the reliability of the questionnaire was 0.988. The mean and standard deviation of the total score of the questionnaire was 143.60 ± 74.70 with a range of 3-244. The relationship between the total score of the questionnaire and its fields, and some demographic variables is summarized in the table below (Table  4 ).

As shown in the table above, the variables of age, age difference and number of years of marriage have a positive and significant relationship, and the variable of number of children has a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). However, the variable of education level difference showed no significant relationship with the total score and any of the fields. Also, the highest average score is related to patriarchal beliefs compared to other fields.

The comparison of the average total scores separately according to each variable showed the significant average difference in the variables of the previous marriage history of the woman, the result of the previous marriage of the woman, the education of the woman, the education of the man, the income of the woman, the income of the man, and the physical disease of the man (p < 0.05).

In the regression model, two variables remained in the final model, indicating the relationship between the variables and violence score and the importance of these two variables. An increase in women’s education and income level both independently show a significant relationship with an increase in violence score (Table  5 ).

The results of analysis of variance to compare the scores of each field of violence in the subgroups of the participants also showed that the experience and result of the woman’s previous marriage has a significant relationship with physical violence and tradition and family upbringing, the experience of the man’s previous marriage has a significant relationship with patriarchal belief, the education level of the woman has a significant relationship with all fields and the level of education of the man has a significant relationship with all fields except tradition and family upbringing (p < 0.05).

According to the results of both quantitative and qualitative studies, variables such as the young age of the woman and a large age difference are very important factors leading to an increase in violence. At a younger age, girls are afraid of the stigma of society and family, and being forced to remain silent can lead to an increase in domestic violence. As Gandhi et al. (2021) stated in their study in the same field, a lower marriage age leads to many vulnerabilities in women. Early marriage is a global problem associated with a wide range of health and social consequences, including violence for adolescent girls and women [ 12 ]. Also, Ahmadi et al. (2017) found similar findings, reporting a significant association among IPV and women age ≤ 40 years [ 19 ].

Two others categories of “Facilitators” in the present study were “Husband’s criminal record” and “Overdependence” which had a sub-category of “Forced cohabitation”. Ahmadi et al. (2017) reported in their population-based study in Iran that husband’s addiction and rented-householders have a significant association with IPV [ 19 ].

The patriarchal beliefs, which are rooted in the tradition and culture of society and family upbringing, scored the highest in relation to domestic violence in this study. On the other hand, in qualitative study, “Normalcy” of men’s anger and harassment of women in society is one of the “Repressors” of women to express violence. In the quantitative study, the increase in the women’s education and income level were predictors of the increase in violence. Although domestic violence is more common in some sections of society, women with a wide range of ages, different levels of education, and at different levels of society face this problem, most of which are not reported. Bukuluki et al. (2021) showed that women who agreed that it is good for a man to control his partner were more likely to experience physical violence [ 20 ].

Domestic violence leads to “Consequences” such as “Harm to children”, “Emotional harm”, “Social harm” to women and even “Non-acceptance in their own family”. Because divorce is a taboo in Iranian culture and the fear of humiliating women forces them to remain silent against domestic violence. Balsarkar (2021) stated that the fear of violence can prevent women from continuing their studies, working or exercising their political rights [ 8 ]. Also, Walker-Descarte et al. (2021) recognized domestic violence as a type of child maltreatment, and these abusive behaviors are associated with mental and physical health consequences [ 21 ].

On the other hand and based on the “Lack of effective communication” category, ignoring the role of the counselor in solving family conflicts and challenges in the life of couples in the present study was expressed by women with reasons such as lack of knowledge and family resistance to counseling. Several pathologies are needed to investigate increased domestic violence in situations such as during women’s pregnancy or infertility. Because the use of counseling for couples as a suitable solution should be considered along with their life challenges. Lin et al. (2022) stated that pregnant women were exposed to domestic violence for low birth weight in full term delivery. Spouse violence screening in the perinatal health care system should be considered important, especially for women who have had full-term low birth weight infants [ 22 ].

Also, lack of knowledge and low level of education have been found as other factors of violence in this study, which is very prominent in both qualitative and quantitative studies. Because the social systems and information about the existing laws should be followed properly in society to act as a deterrent. Psychological training and especially anger control and resilience skills during education at a younger age for girls and boys should be included in educational materials to determine the positive results in society in the long term. Manouchehri et al. (2022) stated that it seems necessary to train men about the negative impact of domestic violence on the current and future status of the family [ 23 ]. Balsarkar (2021) also stated that men and women who have not had the opportunity to question gender roles, attitudes and beliefs cannot change such things. Women who are unaware of their rights cannot claim. Governments and organizations cannot adequately address these issues without access to standards, guidelines and tools [ 8 ]. Machado et al. (2021) also stated that gender socialization reinforces gender inequalities and affects the behavior of men and women. So, highlighting this problem in different fields, especially in primary health care services, is a way to prevent IPV against women [ 24 ].

There was a sub-category of “Inefficiency of social systems” in the participants experiences. Perhaps the reason for this is due to insufficient education and knowledge, or fear of seeking help. Holmes et al. (2022) suggested the importance of ascertaining strategies to improve victims’ experiences with the court, especially when victims’ requests are not met, to increase future engagement with the system [ 25 ]. Sigurdsson (2019) revealed that despite high prevalence numbers, IPV is still a hidden and underdiagnosed problem and neither general practitioner nor our communities are as well prepared as they should be [ 26 ]. Moreira and Pinto da Costa (2021) found that while victims of domestic violence often agree with mandatory reporting, various concerns are still expressed by both victims and healthcare professionals that require further attention and resolution [ 27 ]. It appears that legal and ethical issues in this regard require comprehensive evaluation from the perspectives of victims, their families, healthcare workers, and legal experts. By doing so, better practical solutions can be found to address domestic violence, leading to a downward trend in its occurrence.

Some of the variables of violence against women have been identified and emphasized in many studies, highlighting the necessity of policymaking and social pathology in society to prevent and use operational plans to take action before their occurrence. Breaking the taboo of domestic violence and promoting divorce as a viable solution after counseling to receive objective results should be implemented seriously to minimize harm to women, children, and their families.

Limitations

Domestic violence against women is an important issue in Iranian society that women resist showing and expressing, making researchers take a long-term process of sampling in both qualitative and quantitative studies. The location of the interview and the women’s fear of their husbands finding out about their participation in this study have been other challenges of the researchers, which, of course, they attempted to minimize by fully respecting ethical considerations. Despite the researchers’ efforts, their personal and professional experiences, as well as the studies reviewed in the literature review section, may have influenced the study results.

Data Availability

Data and materials will be available upon email to the corresponding author.

Abbreviations

Intimate Partner Violence

Human Immunodeficiency Virus

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Acknowledgements

The authors of this study appreciate the Deputy for Research and Technology of Semnan University of Medical Sciences, Social Determinants of Health Research Center of Semnan University of Medical Sciences and all the participants in this study.

Research deputy of Semnan University of Medical Sciences financially supported this project.

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M.Sh. contributed to the first conception and design of this research; M.Sh., Z.Kh., M.S., R.Gh. and S.H.Sh. contributed to collect data; M.N. and M.Sh. contributed to the analysis of the qualitative data; M.M. and M.Sh. contributed to the analysis of the quantitative data; M.SH., M.N. and M.M. contributed to the interpretation of the data; M.Sh., M.S. and S.H.Sh. wrote the manuscript. M.Sh. prepared the final version of manuscript for submission. All authors reviewed the manuscript meticulously and approved it. All names of the authors were listed in the title page.

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This article is resulted from a research approved by the Vice Chancellor for Research of Semnan University of Medical Sciences with ethics code of IR.SEMUMS.REC.1397.182 in the Social Determinants of Health Research Center. The authors confirmed that all methods were performed in accordance with the relevant guidelines and regulations. All participants accepted the participation in the present study. The researchers introduced themselves to the research units, explained the purpose of the research to them and then all participants signed the written informed consent. The research units were assured that the collected information was anonymous. The participant was informed that participating in the study was completely voluntary so that they can safely withdraw from the study at any time and also the availability of results upon their request.

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Shayestefar, M., Saffari, M., Gholamhosseinzadeh, R. et al. A qualitative quantitative mixed methods study of domestic violence against women. BMC Women's Health 23 , 322 (2023). https://doi.org/10.1186/s12905-023-02483-0

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Domestic violence and abusive relationships: Research review

Research review of data and studies relating to intimate partner violence and abusive relationships.

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by John Wihbey, The Journalist's Resource August 17, 2015

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The controversy over NFL star Ray Rice and the instance of domestic violence he perpetrated, which was caught on video camera, stirred wide discussion about sports culture, domestic violence and even the psychology of victims and their complex responses to abuse . In 2015, domestic violence drew a national spotlight again when the South Carolina newspaper, the Post and Courier , won a Pulitzer Prize for its investigation of women who were abused by men and had been dying at a rate of one every 12 days.

The research on domestic violence, referred to more precisely in academic literature as “intimate partner violence” (IPV), has grown substantially over the past few decades. Although knowledge of the problem and its scope have deepened, the issue remains a major health and social problem afflicting women. In November 2014 the World Health Organization estimated that 35% of all women have experienced either intimate partner violence or sexual violence by a non-partner during their lifetimes. This figure is supported by the findings of a 2013 peer-reviewed metastudy — the most rigorous form of research analysis — published in the leading academic journal Science . That metastudy found that “in 2010, 30.0% [95% confidence interval (CI) 27.8 to 32.2%] of women aged 15 and over have experienced, during their lifetime, physical and/or sexual intimate partner violence.” The prevalence found among high-income regions in North America was 21.3%. Of course, under-reporting remains a substantial problem in this research area.

In 2010, the National Intimate Partner and Sexual Violence Survey, conducted by the U.S. Centers for Disease Control and Prevention, found that “more than 1 in 3 women (35.6%) … in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime.” That survey was subsequently updated in September 2014. The findings, based on telephone surveys with more than 12,000 people in 2011, include:

The lifetime prevalence of physical violence by an intimate partner was an estimated 31.5% among women and in the 12 months before taking the survey, an estimated 4.0% of women experienced some form of physical violence by an intimate partner. An estimated 22.3% of women experienced at least one act of severe physical violence by an intimate partner during their lifetimes. With respect to individual severe physical violence behaviors, being slammed against something was experienced by an estimated 15.4% of women, and being hit with a fist or something hard was experienced by 13.2% of women. In the 12 months before taking the survey, an estimated 2.3% of women experienced at least one form of severe physical violence by an intimate partner.

Still, the overall rates of IPV in the United States have been generally falling over the past two decades, and in 2013 the federal government reauthorized an enhanced Violence Against Women Act , adding further legal protections and broadening the groups covered to include LGBT persons and Native American women. (For research on the relatively higher violence rates among gay men, see the 2012 study “Intimate Partner Violence and Social Pressure among Gay Men in Six Countries.” )

A 2013 study published in the Journal of Marriage and Family , “Women’s Education, Marital Violence, and Divorce: A Social Exchange Perspective,” analyzes a nationally representative sample of more than 900 young U.S. women to look at factors that make females more likely to leave abusive relationships. The researchers, Derek A. Kreager, Richard B. Felson, Cody Warner and Marin R. Wenger, are all at Pennsylvania State University. They note that traditional “social exchange theory” would suggest that as women have more resources, they become less dependent on men and have more opportunities outside relationships, and therefore have more ability to divorce. The study sets out to “determine whether the relationship between a woman’s education and divorce is different in violent marriages.” The researchers also hypothesize that women who have higher levels of education are less likely to get divorced in general — prior academic work they cite supports this — but they aim to see how the introduction of intimate partner violence changes this dynamic.

The study’s findings include:

• The data provide “support for our primary hypotheses that women’s education typically protects against divorce but that this association weakens in abusive marriages. In addition, we found a similar pattern for wives’ proportional income, net of education. Together, these patterns suggest that educational and financial resources benefit women by increasing marital stability in nonabusive marriages and promoting divorce in abusive marriages.”
• Further, the “greater tendency for educated women to leave abusive marriages was substantial. For example, in highly violent marriages, women with a college degree had over a 10% greater probability of divorce in the observed time period than women without a college degree.”
• The study also finds that “women with economic resources were likely to leave unhappy marriages, regardless of whether they involve abuse. Similarly, degree-earning women were more likely than less educated women to leave violent marriages, regardless of their feelings of dissatisfaction.”

The researchers note that, across the U.S. population, more women are attaining college degrees, and given the study’s findings, this suggests “increases in women’s education should reduce rates of domestic violence. In a population with many educated women, violent marriages are likely to break up.” They caution that it is also possible “that our observed patterns reflect husbands’ perceptions and decisions. Perhaps abusive men feel threatened by successful wives, which then increases divorce risk. Nonabusive men may not feel threatened and thus stay with successful women.” On this point, more research is required.

Related research: A 2015 study titled “When War Comes Home: The Effect of Combat Service on Domestic Violence” suggests that multiple deployments and longer deployment lengths may increase the chance of family violence. A June 2014 study published in the  Journal of Interpersonal Violence , “Intimate Partner Violence Before and During Pregnancy: Related Demographic and Psychosocial Factors and Postpartum Depressive Symptoms Among Mexican American Women,”  provides a snapshot of domestic violence in a community sample of low-income Hispanic women. A March 2013 report from the U.S. Department of Justice’s Bureau of Justice Statistics, “Female Victims of Sexual Violence, 1994-2010,” provides a broad picture of such crimes across American society, examining the demographics of both victims and offenders. Regarding the issue of IPV prevention, a 2003 metastudy published in the Journal of the American Medical Association (JAMA) , “Interventions for Violence Against Women: Scientific Review,” found that “information about evidence-based approaches in the primary care setting for preventing IPV is seriously lacking…. Specifically, the effectiveness of routine primary care screening remains unclear, since screening studies have not evaluated outcomes beyond the ability of the screening test to identify abused women. Similarly, specific treatment interventions for women exposed to violence, including women’s shelters, have not been adequately evaluated.” Subsequent research continues to find problems with current techniques for screening and detection.

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This article has a correction. Please see:

• Correction: Qualitative study to explore the health and well-being impacts on adults providing informal support to female domestic violence survivors - May 01, 2019

• http://orcid.org/0000-0002-4768-1574 Alison Gregory 1 ,
• Gene Feder 1 ,
• Ann Taket 2 ,
• Emma Williamson 3
• 1 Centre for Academic Primary Care, University of Bristol , Bristol , UK
• 2 School of Health and Social Development, Deakin University , Burwood, Victoria , Australia
• 3 Centre for Gender and Violence Research, University of Bristol, Social Science Complex , Bristol , UK
• Correspondence to Dr Alison Gregory; alison.gregory{at}bristol.ac.uk

Objectives Domestic violence (DV) is hazardous to survivors' health, from injuries sustained and from resultant chronic physical and mental health problems. Support from friends and relatives is significant in the lives of DV survivors; research shows associations between positive support and the health, well-being and safety of survivors. Little is known about how people close to survivors are impacted. The aim of this study was exploratory, with the following research question: what are the health and well-being impacts on adults who provide informal support to female DV survivors?

Design A qualitative study using semistructured interviews conducted face to face, by telephone or using Skype. A thematic analysis of the narratives was carried out.

Setting Community-based, across the UK.

Participants People were eligible to take part if they had had a close relationship (either as friend, colleague or family member) with a woman who had experienced DV, and were aged 16 or over during the time they knew the survivor. Participants were recruited via posters in community venues, social media and radio advertisement. 23 participants were recruited and interviewed; the majority were women, most were white and ages ranged from mid-20s to 80.

Results Generated themes included: negative impacts on psychological and emotional well-being of informal supporters, and related physical health impacts. Some psychological impacts were over a limited period; others were chronic and had the potential to be severe and enduring. The impacts described suggested that those providing informal support to survivors may be experiencing secondary traumatic stress as they journey alongside the survivor.

Conclusions Friends and relatives of DV survivors experience substantial impact on their own health and well-being. There are no direct services to support this group. These findings have practical and policy implications, so that the needs of informal supporters are legitimised and met.

• TRAUMA MANAGEMENT
• MENTAL HEALTH
• PRIMARY CARE
• PUBLIC HEALTH

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2016-014511

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Strengths and limitations of this study

This study provides an indepth exploration of the health and well-being impacts experienced by friends and family members supporting a woman who is experiencing domestic violence (DV).

A key strength of this research is the novelty of perspective, because it accessed the experiences of friends and relatives directly, which is vital if we are to understand the wider context and implications of DV.

The data came from face-to-face interviews, but the main researcher (AG) also kept a reflective diary and fieldnotes. AG also carried out a member-checking process during the interviews to increase rigour and validity of results.

This study shows that friends, colleagues and relatives of survivors experience substantial impact on health and well-being and may, in some cases, be experiencing secondary traumatic stress.

One of the limitations of this research was that the sample lacked breadth, particularly in terms of ethnicity. It will be important to try to address this in future research.

Introduction

Domestic violence (DV) is a global issue to which no age group, culture or socioeconomic group is insusceptible. 1 The United Nations Development Fund for Women estimates that, throughout the world, one in three women will experience violence in their lifetime, and in most cases, the abuser will be a family member. 2

The Council of Europe, the WHO and the United Nations have all identified violence against women as a major public health issue. 2–4 The most obvious health consequence is physical injury, with 70% of DV incidents resulting in injury. 5 Less apparent are chronic health problems which result; research demonstrates links between DV and gynaecological problems, 6 chronic pain, 7 gastrointestinal disorders 8 , 9 and cardiovascular conditions. 10 There is also substantial evidence for the harmful consequences on mental health, with depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse and suicidal ideation commonly experienced by survivors. 11 , 12

Research suggests that the majority of female DV survivors choose to access support (practical and emotional) from adults around them. 13–16 In a study by Parker and Lee, 14 89% of DV survivors disclosed the abuse they were experiencing to friends and relatives. While many survivors rely on informal support alongside professional and specialist services, there are a large number who rely initially, predominantly or exclusively on friends, relatives and colleagues. 13 , 16 , 17 Research has demonstrated that positive social support buffers against effects of abuse on survivors' physical health, mental health and quality of life, and that it can be preventive against them experiencing further abuse. 18–21

Exposure to violence can be traumatic in its own right. 22–24 Indeed, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 25 recognises the experiences of people who have witnessed traumatic events, and those who have learnt about events that have happened to close relatives and friends. Historically, this idea of secondary traumatic stress (STS)—sometimes referred to as indirect trauma, compassion fatigue or vicarious trauma—has only been applied to people working as professionals with traumatised patients or clients. More recently, however, researchers have begun to direct attention towards those providing support in an informal capacity, noting the overlap with impacts that professionals in caring roles experience. 26

In summary, there is substantial evidence that women experiencing DV draw support from people in their social network and that, when this is positive, there are important benefits. However, because the direct study of people in DV survivors' social networks is rare, little is known about the possible diffusion of impacts, including the possibility of STS. 17 , 27 , 28

This qualitative study was conducted in the UK. The aim of the research was exploratory, with the following research question: what are the health and well-being impacts on adults who provide informal support to female DV survivors? Owing to the emotive nature of the topic, individual interviews were considered the most appropriate mode of data collection.

Participants

Maximum variation sampling was used to recruit participants with a range of experiences, attitudes and beliefs. It is an approach which aims to capture and describe themes that cut across a great deal of participant variation, so that common patterns that do emerge are of value and interest. In order to access a diverse range of people, advertisement of the study included: posters in local healthcare and community settings, social media and web-advertisement, and promotion on local radio. Particular emphasis was placed on attempting to recruit participants with an ethnic background other than White British, in recognition of the general under-representation of individuals from minority ethnic backgrounds in health research. 29 For this reason, the study was also advertised by agencies in Bristol working with black and minority ethnic groups.

Participants were eligible if they had had a close relationship with a female survivor of DV, and were aged 16 or over during the time they knew the survivor.

DV was defined according to the UK Home Office definition: Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological, physical, sexual, financial & emotional. 30

Owing to the gender asymmetry around DV, particularly in terms of impact, 31–33 and because much less is known about the ways men experiencing DV interact with their social networks, 34 , 35 it was decided to focus this work on the friends and relatives of female survivors, though the perpetrator could be of either gender.

Twenty-three participants were recruited and interviewed. A further 63 people expressed an interest in the study: 33 were ineligible (27 were survivors rather than informal supporters, 5 had been exposed to DV during childhood rather than adulthood, and 1 was not based in the UK), 28 made no further response after initial contact and 2 were recruited but failed to attend the arranged interview. The relationships that participants had to a survivor were: mother (4), father (2), sister (2), niece (1), daughter-in-law (1), current partner (3), friend (15) and work colleague (2). There were more than 23 different relationships described, because some participants had known multiple survivors. The majority of participants were women (18), most were white (including ‘White British’, ‘White European’ and ‘White Other’ ethnicities) and their ages ranged from mid-20s to 80.

Procedures and data collection

People who were interested in taking part, having seen the posters or online advertisements for the study, contacted the first author (AG) by telephone or email. They were given a study information leaflet and a copy of the consent form (via email or mail) at least 48 hours prior to participating in an interview. Written consent was obtained from each participant. For safety, face-to-face interviews took place in university buildings or community premises (eg, private rooms in local council offices). Participants also had the option to be interviewed over the telephone or using Skype. Only AG and each participant were present during the interviews, and participants were only interviewed once. Sociodemographic data were collected to inform the analysis, contextualise participants and guide recruitment strategies. Participant confidentiality and anonymity were of paramount importance, thus only AG knew who had participated in the study. Transcripts of the data were cleaned to remove identifying information prior to sharing with the team for analysis, and all data were held securely in accordance with University of Bristol regulations. The limits of confidentiality, particularly reporting requirements for safeguarding issues, were explained to participants. To reduce the likelihood of distress, the voluntary nature of the research was emphasised throughout, and the researcher was attentive to participants' emotional state.

The interviews were conducted between August 2012 and April 2013 by the first author. A topic guide (which had been pilot tested) was used, with questions and prompts to elicit information pertinent to the research question. In addition, a form of member-checking was undertaken by AG throughout the interviews, by restating and summarising information to check accuracy of understanding with participants. Interviews were audio-recorded, transcribed verbatim and imported into NVivo10 software. The interviews ranged in length from 35 to 90 min, and saturation of themes was reached after 23 interviews. Following the interviews, an information sheet detailing local and national DV services and counselling services was shared with participants.

Researcher reflexivity

Part of ensuring the rigour of qualitative research is for investigators to recognise that they themselves necessarily form part of the context for interactions with participants, and that they bring their traditions, values and personal qualities to each aspect of the study. 36 For this reason, it is also important for the reader to have an understanding of who conducted the research: the first author (AG) is a woman, white and was in her late 30s when she carried out the interviews as part of her PhD. She had been a senior research associate for 4 years prior to her PhD studentship, and continued to work as a counsellor alongside her research (participants were informed that AG was a PhD student, but not that she had an additional counselling role). AG had had no prior contact with participants. Reflexivity also involves an active noticing by the researcher as she journeys through the research process, which for this study included keeping a reflective diary and detailed fieldnotes to capture reflections on: context, interview process, thoughts about participants, and about the relationships created during the interviews. At the interview stage, the recording of these reflections helped AG to consider what had gone well and what could have been performed differently, in order to hone interview skills and use of the topic guide. At the analysis stage, the noted descriptions of key messages from the interviews were revisited, in order to check that the developed themes reflected these.

Data analysis

A thematic analysis of the data was carried out and was undertaken in parallel with the interviews. In thematic analysis, transcripts are read multiple times in conjunction with fieldnotes, and key concepts noted. 37 These concepts form a list of initial codes which are applied line-by-line to the transcripts (for this study, using NVivo10 software). Initial descriptive codes are grouped into themes which were refined using constant comparison : a process throughout the analysis of comparing units of data with the entire data set and emerging theories, to modify constructs and relationships between them. 38 For this study, AG analysed all of the transcripts, and EW and GF each analysed a subset. The researchers familiarised themselves with the data, identifying text that was relevant to the research question. AG generated initial descriptive codes, a vast index to encompass everything that might be of interest. AG then collated linked codes in tentative groupings at the broader level of themes. The themes were honed, through discussion, until consensus between the authors was reached, and any relationships between the coded data were noted—this was an iterative process which distilled and refined in a cyclical fashion. 39

In the end stages, fieldnotes were revisited to check whether the honed themes reflected the key messages recorded immediately postinterview.

In the presentation of findings, illustrative quotes from participants' narratives are used. The parentheses after each quote contain the participant's pseudonym and their relationship to the survivor.

The generated themes described a variety of different types of impact on health and well-being experienced by informal supporters of survivors. For clarity, the impacts on psychological and emotional well-being have been split into two sections. The first describes the impacts people experienced following the witnessing (either visually or by description) of incidents, such as shock, fear and panic. The second relates to impacts that were connected with the overall strain and pressure of the situation, including: anger, frustration, anxiety, distress, sadness, confusion and guilt. In the final section of the findings, the impacts on physical health are described; where the stress of the situation had begun to take a toll on people's functioning and physiology.

Psychological and emotional impacts

A large theme that emerged from the interviews was the impact on psychological and emotional well-being, which one participant described as the emotional burden. People talked about the recurrence or persistence of these impacts, with several suffering ill-effects long after abusive relationships had ended. Many of the impacts were experienced concurrently or in succession; thus, there was a cumulative effect on people's well-being.

Impacts following the witnessing of incidents

Shock and horror.

Several participants spoke of their shock when they first heard about the abuse, witnessed it first-hand or witnessed the aftermath. For a few participants, this shock was particularly triggered by seeing survivors' injuries following physical violence, or by unfolding revelations about the extent of the violence.

Fear and panic

This shock, at what the perpetrator was capable of, could lead to fear and panic, in response to a sense of threat that participants felt for their own safety: Suzie (a mother to a survivor) spoke about how frightened she was when the perpetrator was threatening to kill her . For Vicky, it was a growing sense that the perpetrator was a very dangerous man: I thought, ‘If he's worked out that I'm interfering and trying to pull her away from him, trying to help her to escape, he may well do anything irrational to me to stop me from interfering.’…I had to really train myself to remember that the bogey man wasn't there, [the perpetrator] wasn't there, I'd parked my car, there was nobody around, walk with purpose, be confident, he's not gonna attack you. (Vicky, Work colleague)

For other people, fear was linked with situations they recognised as highly dangerous for the survivor. These fears were proportional and realistic about potential outcomes, including: the abduction or harming of children and the death or serious injury of the woman. Emily described how panic could ensue during periods when the survivor's future was in doubt: I was kind of living on adrenalin, I was sort of just walking from room to room. I couldn't sit down, I couldn't concentrate. My mind was just racing, I was just in a state of panic. (Emily, Mother)

Impacts resulting from the overall strain of the situation

Anger and frustration.

Most participants talked about feelings of anger and frustration. For people who felt these emotions, the predominant cause was the perpetrators' behaviour towards survivors and children: I felt this anger welling up inside of me, and I just felt that I needed to sort of move away from him. … It's building up, and I can feel it. I just feel that, I mean I want to go round there and give him a good hiding, and I'm 70. (Eric, Father)

Several people also mentioned anger towards professionals or relatives, who they felt had responded insufficiently. Often tied with these feelings was a strong sense of injustice; that what was right had not prevailed: I feel very angry that no one helped her. And now I know that it was Social Services' responsibility to help the child and to help her. It was their responsibility… I still feel angry, because I think the way they did it, the baby could have died, they were putting the baby at risk. (Zakia, Friend)

For many, there was nothing short-lived about their anger, particularly where the perpetrator continued to be abusive towards the survivor via his contact with their children. In addition to anger, people often mentioned a level of frustration they felt towards the survivor, largely when they believed she was not using her capacity to act.

Anxiety and worry

All of the participants described feeling anxious or worried about the situation, and for many people, these feelings, and the associated thoughts, pervaded their lives for a period of weeks, months or even years. Some people described worry in the initial stages of the relationship, before they knew about the abuse, which manifested as nagging concern: It was when we were on holiday and I saw how he was towards my granddaughter that I was very worried, and when we came home I said to my husband that I was very concerned… (Eve, Mother)

Others described anxiety about their interactions with the survivor, or the perpetrator, wanting to guard against making the situation worse. People also mentioned ongoing concerns they had for the survivor after the abusive relationship ended, particularly the continuing potential for harm: I still worry now that he'll hurt her, I don't ever feel 100% that something bad isn't gonna happen. (Gwen, Sister)

Fear, following exposure to abuse, could manifest as anxiety longer term, as people began to imagine all the possible outcomes of the situation. This was true for Emily, who had feared that her daughter would re-enter the abusive relationship: I was just pacing the floor, just crying, just hysterical, I was like close to the edge. I couldn't go to work, I had to take weeks off work, ‘cos I couldn't focus, I couldn't go to work; I was just beside myself, absolutely beside myself. I really thought that there was a possibility my daughter would end up dead, if she went back, to that relationship. (Emily, Mother)

For many participants, anxious thoughts had persisted, particularly where the survivor was viewed as vulnerable, for example: by being young, by living far from their support network or by having recently exited the relationship.

Distress and upset

The feelings of distress and upset that people described were sometimes connected with changes in their relationship with the survivor, and sometimes with thoughts about the abuse the survivor had suffered. For Stacey, it was her friend Hannah's decision to remain in the relationship that was incredibly upsetting: I haven't been able to contact her, because it's just too upsetting to me… ‘He's now hurting you. How's it gone from there to there?’ And then I've told her, and then that's all I can do. I can't do anymore ‘cos I'm just so upset. (Stacey, Friend)

In describing what her team of colleagues had been exposed to, Vicky spoke metaphorically of a little container of terrible distress , an awfulness that was not easy to shake, due to the nature and frequency of abuse their colleague suffered.

Several participants talked about the longevity of distress. Suzie, for example, spoke of continued pain evoked by memories of harrowing times while supporting her daughter. People who had been in an abusive relationship themselves, or who had been exposed to DV during childhood, spoke of their distress as memories of their own past resurfaced: To watch it happening to somebody else I found very distressing…I was very frightened of my father at that age. (Lily, Friend)

Overwhelm and saturation

Some participants spoke about having reached a point where they felt overwhelmed or saturated, using words like, breaking point , exhausted and drained to convey the all-consuming nature of the situation. Others described peaks and troughs of intensity, and the need to take time out on occasion, to protect their own sense of well-being.

Tension and turmoil

Linked with feelings of shock, that some people experienced when they first heard about the situation, several participants also described the longer term challenges to their core beliefs about: humanity, justice and safety in the world. The way people described these impacts intimated the unsettling nature of having foundational assumptions called into question. Josie discovered that three women she knew had been abused by partners, which challenged her ideas about DV not happening to women who were professional or strong . Lily also struggled with the idea that her intelligent and dynamic friend chose to remain in an abusive relationship, and Emily was unsettled by the idea that DV could happen to people who were like her. For others, it was the fact that the survivor was prepared to remain with a violent man that led to their bewilderment : I didn't know how people could live like that, how you could treat someone like that, or even how you could go back to someone after they'd treated you like that. (Anne, Friend)

Many participants also described inner dissonance; conflicting pressures within themselves, leaving them ill-at-ease. Before they had understood the situation, Sally and Eric experienced tension between their love for their daughter, and frustration at the way Amanda was behaving towards them. A few participants also spoke of the tension between the desire to intervene and the need to respect the survivor's wishes: She had her plan and we wanted to respect that. But the stress that came with not hiring a van, going there, dealing with him … the stress of that was monumental at times. (Louise, Friend)

Sense of responsibility

Some participants found themselves in a position of feeling a burden, a duty or a weight of responsibility because of the nature of the situation. These people spoke of putting their own priorities on hold, of substantially altering life-plans and of the all-consuming nature of supporting a survivor through intense periods. Where there was complexity in the situation, the sense of responsibility was compounded; for example, where the survivor had an addiction, had children with the perpetrator, had a mental health condition or where she lacked additional social support.

Feeling disempowered

Another description which appeared in people's narratives was disempowerment. Participants spoke about feeling impotent to intervene during the relationship, and to protect and support sufficiently in the aftermath: I felt really helpless that she was going back to situations where we knew she was gonna be hurt, but by then understanding domestic violence, knowing that for her safety that's what she wanted to do. And we only had to go with what she wanted … (Gwen, Sister)

Several people spoke about the persistence of this sense of powerlessness; that months or years after the end of abusive relationship, they still felt unable to stop the perpetrator impacting on the lives of their loved ones: I just feel as if I want to protect my daughter and my grandchildren … it's very, very painful, very painful. But I don't seem to be able to do anything about it. My hands are tied and I need to get her out of this mess. (Eric, Father)

There was also a sense that some people lacked voice; that their experiences and their viewpoints were often disregarded, seen as unimportant or invalidated. Silencing came in many forms; sometimes it was professionals or employers not acting on information, and sometimes the survivor herself, either intentionally or unwittingly, prevented expression. Occasionally, participants silenced themselves by questioning the legitimacy of their feelings: I do [get opportunity to voice those thoughts] a bit, but I guess to some extent I feel that I should be supportive of Judy, because she is the victim and I kind of think I should just be able to be a bit more detached, not feel that way myself, and just be there to support her. (Richard, Partner)

Sadness and depression

Many participants spoke of having felt low at some point; most of these people described a dip in mood that indicated despondency or a temporary sense of hopelessness, but some had been diagnosed with depression, taken antidepressants or had had suicidal thoughts. Suzie mentioned taking antidepressants at a point where she had started to feel numb: I just I remember sitting in an armchair in my living room, literally with the duvet over me and I just couldn't move or I just lost it, I didn't really feel anything and then depression … (Suzie, Mother)

During this time, Suzie considered ending her life, because the circumstances felt so desperate. Likewise, Sally hit a similar point where she could not see a way forward: I decided I'd kill myself (crying) … I felt just done with everything; I was just going to jump in the sea … I remember going, choosing the place. (Sally, Mother)

Confusion and uncertainty

All participants described periods of confusion, not only about the situation itself, and what the trajectory might be, but also about how to best support the survivor and protect themselves. At the point where people knew very little, they described feeling in the dark and trying to work it out ; a piece-meal process to draw their own conclusions about the relationship, which they often discovered were inaccurate or partial: I thought perhaps I'd upset them in some way and I wasn't sure what or how … my assumption was that they had financial troubles, and I was trying to probe to see what it was … I was worried about her. But I didn't know what I was worried about. (Barry, Father)

Stacey made the point that with health conditions, it was possible to have some sense of trajectory and outcome, unlike DV: I think if you have a friend who's got cancer or diabetes or something like, you kinda know what's happening next…But when you're supporting someone who's in a violent relationship, you don't really know when it's gonna end, how long they're gonna need you to support them, or how much worse it's gonna get. (Stacey, Friend)

Guilt and self-blame

The most frequent causes of guilt described by informal supporters were not having known sooner about the DV, and not having understood what the behaviours they had witnessed meant: I'm sad, that we couldn't help her sooner, or that we didn't prevent it from happening, it makes me sort of sad with myself really, I think, and angry at myself and, for not being supportive sooner, and doubting her. (Gwen, Sister)

Several people also described guilt they felt in relation to offering support that felt inferior. This was especially the case where their relationship with the survivor had become strained, or was lost completely. For Kate, a sense of guilt, which had persisted for many years, was her over-riding emotion: I felt really guilty about that … I didn't feel like I could be honest with her anymore… I felt bad about it. Which was horrible of me, I still feel I've been horrible to her, because I didn't, well I don't know if I did the right thing, I still don't know if I did the right thing. (Kate, Friend)

For others, there were feelings of guilt when positive things happened in their own lives, for example, Anne described feelings akin to survivor guilt because she had fled an abusive relationship, started a new relationship, and become a mother, while her friend Sarah remained with her partner, and had been coerced into having an abortion.

Physical health impacts

In addition to psychological and emotional impacts, many people talked about the stress of the situation; a summary term, which they used to describe some of the physical health impacts they experienced.

Physical symptoms and ailments

Mostly, the health repercussions participants mentioned were those which had resulted from heightened states of panic, anxiety, fear, powerlessness and anger, describing feeling sick, shaky and physically unsettled: For me that comes with a physical feeling of almost not being able to breathe and feeling churned up inside… (Suzie, Mother)

A few people mentioned less transient physical ailments that they felt had resulted from the stress of supporting a survivor: back and neck tension, migraines, shortness of breath and tight-chestedness. Eric, in particular, felt his symptoms (similar to those of a heart attack) were connected with the anger and powerlessness he felt.

Sleep difficulties

Friends and relatives of survivors described broken sleep for a period of time, linked with relentless concerns for the survivor, or worries regarding their role. Relatives and partners, in particular, reported loss of sleep at critical times: I was close to breaking point, I didn't sleep. … And I thought, this means she'll go back to him, and I remember I didn't sleep at all that week, I was just pacing the floor. (Emily, Mother)

People who mentioned sleep difficulties talked about the impact of late evening communication with the survivor, or with others involved. Some proposed an association between reduction in quality of sleep and the intense emotions experienced.

Appetite and weight loss

Mark and Emily mentioned loss of appetite and weight loss when discussing their health, describing it as their bodies' default response to stressful events. For Mark, it was triggered when he tried to relieve the pressure on his wife by dealing with reams of solicitor correspondence. For Emily, it happened during a time of huge anxiety, while trying to persuade her daughter from returning to the perpetrator.

The interviews highlighted that impacts on health and well-being of informal supporters of DV survivors were many and varied. There was a spectrum of experience in terms of severity and longevity of impact, with informal supporters describing different impacts from one another, and also changes in impact at different stages in their individual journeys. The identification of subgroups of participants with differing experiences was complex, for example, while the relationship between the informal supporter and the survivor was important, it was not whether they were relatives, friends or colleagues, but rather the quality of the relationship which mattered. The gender of the informal supporter, whether or not the survivor had children, and the level of abuse the informal supporter knew about were additional mediators of impact. Further research is needed for a greater understanding of how variance in the DV situation and in the characteristics of informal supporters influence impact.

Many of these impacts, such as anger, fear, sadness, helplessness and disruptions to sleep and to core beliefs, are sequelae of trauma; the same symptoms as those known to be experienced by people following direct exposure to traumatic events. 40 , 41

One of the suggested mechanisms through which traumatic experiences have health implications is the stress-process framework. 42 , 43 Within this framework, external stressors provoke physiological and psychological responses, 43 , 44 which impact on health and well-being, particularly if the stressors are over a long period. Given that the average length of an abusive relationship is 5 years, 45 those involved are certainly at risk of chronic stress and its sequelae. More than 20 years ago, Figley 46 , 47 suggested that these effects were not limited to the person experiencing traumatic events; that emergency responders and therapists could also be affected, particularly when repeatedly exposed to incidents or disclosures over time. More recently, changes to the DSM-5 have drawn attention to those providing informal support as well as those providing professional support. 25 The findings from this study add weight to the idea of risk of STS for people providing informal support in the particular scenario of DV. In addition, research suggests differential experiences of traumatic stress dependent on factors such as personal characteristics, sociodemography, social support and aggregate life events. 42 , 43 , 46 , 48 The variation in reported impacts (in terms of type, severity and longevity) by participants in this study lends support to this idea.

Moreover, there is overlap between the findings from this study, and research with people providing informal support to relatives or friends who have experienced other forms of trauma. For example, one in three spouses of Holocaust survivors were found to be suffering from psychological distress and STS symptoms, 49 and Christiansen et al 24 reported that relatives, friends and partners of men and women who had been raped showed ‘significant levels of traumatization’ , with 25% suffering from PTSD.

Implications for policy, practice and research

The findings from this research indicate that the health and well-being of informal supporters are affected in situations of DV. In terms of policy, the social context of survivors is rarely visible, which needs to be addressed, so that the needs of informal supporters are considered. In addition, there is need for professionals who work in positions where they routinely come into contact with survivors to attend to other people within the situation; reflecting on who might be experiencing impact, and providing opportunities for disclosure, and for legitimisation of concerns. Healthcare providers, in particular, are well placed to respond to all parties affected by DV, which is why training around this issue for doctors, nurses and allied health professionals is vital. 50–52

Research about informal supporters is crucial for understanding the context of survivors' lives. 53 Specifically, with the intention of improving outcomes for informal supporters and for survivors, research is needed to develop and test interventions directly targeting those in the social networks of survivors.

Strengths and limitations

One of the limitations of this research is that the sample lacked breadth for certain sociodemographic characteristics, ethnicity in particular. People from minority ethnic backgrounds are frequently under-represented in research 29 and, while substantial effort was made to recruit people from a variety of ethnic backgrounds, this was not especially successful. Moreover, though a wide definition of DV was used (to include perpetrators who were other family members), the experiences captured were almost exclusively those of informal supporters of survivors of intimate partner violence. The reported findings relate specifically to this sample, so it is possible that the experiences of other people providing informal support to a survivor would differ.

A key strength of this study is the novelty of perspective because it accessed the experiences of informal supporters of survivors directly, which is vital in order to understand the wider context and implications of DV.

Research has drawn attention to the extent to which women experiencing violence seek support from their friends, colleagues and family members, and the advantages this can have for their well-being and safety. The impact that this has on the health and well-being of people providing informal support has previously been unexplored. Findings from this study indicate the physical, psychological and emotional impacts on people providing informal support, suggesting that this is a group of people who may be at risk of STS. In order to prevent and reduce these impacts, informal supporters of survivors would benefit from recognition of their predicament, and provision of support, so that their own well-being, quality of life, capacity and coping are not diminished. These findings have practical and policy implications, so that the experiences and needs of the full range of people in DV scenarios are legitimised and met.

Acknowledgments

The authors would like to acknowledge and sincerely thank all the participants who took part in this research.

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Contributors As part of her PhD, AG secured the funding, designed the reported study and carried out the data collection. AG analysed the data in collaboration with EW, AT and GF. AG wrote the first draft of the manuscript. All authors critically revised the manuscript and approved the final version.

Funding This research was conducted as part of PhD study which was funded by the National Institute for Health Research (NIHR) School for Primary Care Research and was hosted by the University of Bristol.

Competing interests None declared.

Ethics approval Research Ethics Committee in the School for Policy Studies at the University of Bristol.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

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• Correction Correction: Qualitative study to explore the health and well-being impacts on adults providing informal support to female domestic violence survivors British Medical Journal Publishing Group BMJ Open 2019; 9 - Published Online First: 30 May 2019. doi: 10.1136/bmjopen-2016-014511corr1

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Asking the Right Questions? A Critical Overview of Longitudinal Survey Data on Intimate Partner Violence and Abuse Among Adults and Young People in the UK

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• Published: 07 March 2023
• Volume 38 , pages 1095–1109, ( 2023 )

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• Valeria Skafida   ORCID: orcid.org/0000-0001-9053-7001 1 ,
• Gene Feder 2 &
• Christine Barter 3  

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A Correction to this article was published on 01 April 2023

This article has been updated

We undertake a critical analysis of UK longitudinal and repeated cross-sectional population surveys which ask about experiences of intimate partner violence and abuse (IPVA).

Seven relevant UK representative population-based surveys which ask about IPVA among adults and/or young people (16–17 years old) were identified. We critically engage with the questionnaires to analyse the strengths and limitations of existing UK data on IPVA.

Several limitations in UK surveys are identified. Many questions still show a bias, partly historical, towards collecting more data about physical abuse. Few surveys ask about financial abuse, abuse post-separation or through child contact, or through technologies, though improvements are under way. Surveys still seek to count incidents of abuse, instead of enquiring about the impact of abusive behaviours on victims. Ethnicity and other demographic variables are not always adequately captured (or accessible to data users), making it difficult to explore aspects of inequality. Potentially useful comparisons within the UK are difficult to undertake given the increasingly divergent questionnaires used in different UK nations.

Conclusions

We discuss how future iterations of existing surveys or new surveys can improve with regards to how questions about IPVA are asked. Given that surveys across geographical contexts often suffer similar weaknesses, our findings will be relevant for IPVA survey methodology beyond the UK context.

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Introduction

Longitudinal population surveys in the UK have sought to collect data on intimate partner violence and abuse (IPVA). These include cross-sectional crime surveys as well as longitudinal cohort studies of children and families. Together, these surveys provide us with the means to address a range of research questions about IPVA, including prevalence rates, risk factors, impact and changes over time (Campbell & Rice, 2017 ; Herbert et al., 2021 ; Murray et al., 2016 ; Office for National Statistics, 2019b ; Skafida et al., 2021 ; Yakubovich et al., 2020 ).

Since domestic abuse is significantly under-reported in police records (Campbell & Rice, 2017 ; Office for National Statistics, 2020 ), research using representative community and national surveys is important in determining the extent and nature of IPVA in the general population. Though such surveys are fraught with methodological challenges they do provide higher prevalence rates than police reports (Campbell & Rice, 2017 ; Office for National Statistics, 2020 ). Population surveys also allow for exploration of social stratification and inequalities in IPVA experiences, a challenging area to examine using convenience samples.

Longitudinal surveys of IPVA offer additional advantages and can help us better understand trajectories of abuse experiences, critical stages or events for abuse onset, long term impacts of abuse (Devries et al., 2013 ), and can enable causal inference (Herbert et al., 2022 ). As the legal landscape around IPVA is constantly shifting, longitudinal surveys provide the potential to monitor if and how changes in IPVA prevalence and experiences vary or not over time. Across the four legislatures in the UK, new legislation has recently been introduced which extends the criminalisation of domestic abuse to include coercive control. This is reflected in the new Domestic Abuse Act 2021 (England and Wales), the Domestic Abuse and Civil Proceedings Act (Northern Ireland) 2021, the Domestic Abuse (Scotland) Act 2018, and the Violence against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015.

A comprehensive overview of all recent and relevant UK longitudinal and repeated cross-sectional population surveys asking about IPVA, and a critical reflection regarding their strengths and weaknesses, and their similarities and differences, has not yet been undertaken in the current UK survey landscape. It is this gap we wish to address. There have been important contributions from scholars which we review further below.

Our first aim is to provide a comprehensive overview of the existing relevant data regarding IPVA among adults and young people (aged 16–17) which are being collected in recent large scale longitudinal UK surveys. We use the term longitudinal to cover both repeated cross-sectional surveys as well as cohort studies. Our second aim is to understand how these questionnaires represent the experiences of IPVA among adults and young people, given the nature and wording of the questions being asked, the context within which such questions are being asked, such as other variables of interest, different survey structures and sampling frames utilised. Our third aim is to examine the strengths and limitations of the different questionnaires. We discuss whether current surveys are asking the right questions and whether there are evidence gaps in measuring IPVA. We do not assess the development methods and psychometric properties of the surveys and we have not included questions about child abuse.

This paper seeks to present a frame of reference for how existing data collected on IPVA can be improved. We reflect on what areas are being ignored in existing surveys and on how questionnaires can be improved to collect more meaningful information. We aim to make a significant contribution to how IPVA is measured both in the UK and internationally.

Key debates around IPVA measurement and conceptualisation

Methodologically, measuring IPVA poses several challenges. For example, IPVA victims often fail to recognise their experiences as abuse, or may not recall details of abusive behaviour often spanning long periods of exposure. Victims can also hesitate to disclose such experiences to researchers. Additionally, it is difficult to create survey appropriate questions which accurately capture the lived experiences of abuse and the complex dynamics of abusive relationships. Some of the key literature on IPVA measurement is summarised below.

Gendered dimension of IPVA

Scholars have debated whether gendered dimensions of violence are appropriately captured or potentially overlooked in population surveys (Myhill, 2015 , 2017 ; Walby & Towers, 2017 ; Walby et al., 2017 ). Walby and Towers ( 2017 , 2018 ) note that surveys which focus on the victim rather than the crime as the unit of measurement obscure the gender asymmetry of domestic abuse, and that counting frequency of physical assaults is crucial in revealing such gender disparities. In line with Myhill ( 2015 , 2017 ) we argue that surveys should measure non-violent coercion previously not captured in traditional crime codes, since failure to do so means that the highly gendered nature of IPVA remains hidden. For a gendered understanding of IPVA, contextual information about the dynamics of abusive relationships is important in differentiating between IPVA perpetration and ‘violent resistance’ (Boxall et al., 2020 ). Finally, gender-blind reporting of IPVA often arises from how data are analysed and presented, rather than from what data is collected (MacQueen, 2016 ; Walby et al., 2017 ).

Measurement of non-physical IPVA

Earlier evaluations of IPVA survey questions called for questionnaires which looked beyond just counting incidents of physical violence (Lindhorst & Tajima, 2008 ; Waltermaurer, 2005 ), something surveys are increasingly trying to address. Scholars have asked for questionnaires which are better able to capture daily micro-aggressions and relationship power dynamics as well as the perceived emotional impact reported by victims (Lindhorst & Tajima, 2008 ). Bender’s ( 2017 ) review of different US national surveys identifies weaknesses which include: narrow definitions of rape; IPV questions framed as criminal acts which may discourage disclosure; questions which do not contextualise violence (i.e. differentiating between self-defence versus intent to injure); and interviewers not specifically trained to ask about IPV. Higher rates of sensitive behaviours were reported in self-administered surveys compared to surveys that were administered by interviewers (Mirrlees-Black, 1999 ). To date no review has determined which longitudinal UK surveys have included questions on controlling behaviours and what aspects of coercive control are currently being measured.

In the academic community, there have been differing theoretical perspectives on non-physical forms of IPVA and how these can be measured. For example, Walby and Towers ( 2017 , 2018 ) argue against the concept of coercive control and in favour of what they label domestic violence crime as a lens through which to develop IPVA measures. According to their approach, existing crime codes and legislation allow us to capture domestic abuse and IPVA, and counting discrete incidents of physical violence is of paramount importance when exploring the gendered nature of IPVA. While Walby and Towers propose that crime codes are adequate tools to capture harm, Myhill and Kelly ( 2021 ) disagree and argue in defence of coercive control as a conceptual framework. Like Myhill and Kelly, we contend that coercive control as a framework is better able to account for the various ways in which perpetrators can abuse their victims in ways which reflect more accurately the lived experiences of victims of abuse. However, there is little consistency in how coercive control has been conceptualised and measured thus far, and there are challenges in developing measures to appropriately capture dimensions of coercive control which include notions such as ‘intentionality’, especially in a survey setting (Hamberger et al., 2017 ).

From incidents to patterns of behaviour.

Early iterations of IPVA modules in relevant surveys (e.g. the crime surveys, and surveys which borrowed their questionnaires) predominantly focused on enumerating incidents of abuse; mostly of physical violence. Though public discourse and legislation around IPVA has evolved (Myhill, 2017 ) even recent surveys quantify abuse experience by enquiring either about the number or frequency of abuse incidents (Maguire & McVie, 2017 ). We recognise that data on incidence is of value and can be part of understanding broader patterns of abuse, but there are limitations to a reliance on this approach in isolation. Counting incidents, in isolation from other factors, risks not recognising the nature of abusive relationships and the ongoing impact of these lived experiences for victims (Crossman et al., 2016 ; Kelly, 1999 ; Myhill & Hohl, 2019 ). Yet, if we want to quantitatively measure patterns of abusive behaviour it may prove difficult to define a ‘pattern’ without any discussion of incidents or frequency (Walby & Towers, 2018 ). We argue that questionnaires should try to better capture the fact that living in fear of abuse – even in the absence of measurable incidents—is often an inherent part of being a victim of abuse, as is altering one’s behaviour to avoid triggering the perpetrator.

Measuring Victim Impacts

While Walby et al. ( 2017 ) argue that crime surveys where IPVA questions align with crime codes are adequate tools for capturing IPVA exposure, other scholars have called for measures which better capture IPVA impact and harm not adequately captured by traditional crime categories (Myhill & Kelly, 2021 ; Stark & Hester, 2019 ). Though UK crime surveys have improved and are improving their IPVA questionnaires in recent years, they are still limited by their exclusive focus on criminal acts as legally defined at each relevant time point. While this is perhaps expected given the aims of these surveys, it is worth questioning whether crime surveys should also measure the impact and context around IPVA related crimes.

Research with survivors of abuse has noted that victims often develop coping strategies which can involve extensive modification of their behaviour or lifestyle to try and avoid abuse (Kelly, 1999 ; Pain & Scottish Women’s Aid, 2012 ), leading victims to ‘doublethink’ their every move (Pain & Scottish Women’s Aid, 2012 , p. 15). We therefore agree with Myhill ( 2015 ) that future survey questions could seek to address the consequences of ongoing abuse such as “generalized fear; degradation; objectification; loss of confidence, self-esteem, and the will and ability to resist; self-blaming; and the distortion of a victims’ subjective reality” as well as questions about financial dependency and social isolation (Myhill, 2015 , p. 370).

For survey measures to reflect an experiential understanding of IPVA, questions need to address how victims may change their behaviour due to the perpetrator’s actions or threats; the extent to which respondents fear their perpetrator (even in the absence of ‘incidents’); and the measures victims take to avoid a perpetrator, including post-separation. Research by Troisi ( 2018 ) shows how a screening tool for IPVA trauma could focus on questions about ‘fear, a state of alarm elicited by the avoidance of the danger; terror, a paralyzing state that hinders an active process of reaction; shame as a strong exposure to the other that disarms the individual and the guilt as a defensive dimension aiming at the restoring of the link with the abusive partner’ ( 2018 , p. 1). However, the practical implications of measuring victim impacts are numerous and complex, and include the difficulty in distinguishing between measurement of generalised versus specific fear (Hardyns & Pauwels, 2010 ) as well as difficulties in capturing lived experiences of abusive relationships through closed survey questions.

Children’s exposure to IPVA

Some of the large UK child cohort studies ask study parents to report on their IPVA experiences, and this enables us to estimate how many children have experienced domestic abuse. For example, a Scottish birth cohort estimates that 14% of mothers had experienced IPVA in the 6-year period since the study child was born and mothers from more disadvantaged backgrounds were far more likely to report IPVA (Skafida et al., 2021 ). The same data shows that children living in homes where domestic abuse is reported are more likely to themselves experience parental aggression (Skafida et al., 2022b ) and to experience detrimental impacts on their social and emotional wellbeing (Skafida & Devaney  2023 ). The ALSPAC birth cohort was one of the first globally to measure exposure to IPVA antenatally, (albeit with only two questions) showing its deleterious effect on subsequent maternal mental health and child behaviour (Flach et al., 2011 ). Measurement of IPVA in the 1 st generation of the cohort at 21 years showed a high incidence in young adults (Yakubovich et al., 2019 ), and has been the basis of further research on the relationship between IPVA and depression (Herbert et al., 2022 ).

We sought to identify UK longitudinal and repeated cross-sectional population surveys with measures on IPVA among adults and young people. We searched the UK Data Service ( https://ukdataservice.ac.uk/ ) where large UK surveys are deposited using search terms ‘domestic abuse’, ‘domestic violence’ and ‘intimate partner violence and abuse’ and variants of these. Search results returned some of the surveys which we knew a priori existed. Additional surveys were identified via the UK Data Service’s ‘variable and question bank’ search function where we searched using question wording extracts from other already identified questionnaires (UK surveys often borrow modules from other surveys). This included terms such as: ‘controlling’; ‘threatened’; ‘unwanted letter’; ‘belittled’; ‘used a weapon against you’. Finally, we also searched Google Scholar for literature using combinations of the above search terms along with terms: national; representative; UK surveys; population surveys; prevalence; and variations of these. It is possible – though we believe unlikely—that a relevant survey has been missed. There is no established protocol for reviewing surveys and our methodology resembles that of similar survey reviews in the field (Wood et al., 2017 ), though future research could explore and implement a systematic protocol to reviewing survey measures.

Table 1 provides an overview of the relevant surveys included in this study. We read the questionnaires and extracted all IPVA related questions into Online Appendix A . Details of surveys not included are provided in Online Appendix B . We noted the broader survey methodology, sampling strategy, demographic variables collected, and the positioning of IPVA questions in the larger survey. To engage critically with the questionnaires we use a qualitative methodology for survey quality assessment which can be best described as an ‘experts review’ (Biemer & Lyberg, 2003 ; Italian Institute of Statistics, 2017 ). The process of identifying strengths, weaknesses and limitations of the reviewed surveys, which we subsequently discuss, drew on both deductive and inductive reasoning. Some weaknesses have been previously discussed in relevant literature on IPVA measurement methodology and we were able to compare known pitfalls with the reviewed surveys. Other limitations emerged by reflecting on whether qualitative accounts of lived experiences of IPVA are appropriately captured in the survey questions at hand. Finally, further insights came from the process of comparing and contrasting the seven identified questionnaires, and reflecting on what IPVA data they provide as a whole. Expert reviews typically take place prior to a survey being issued and they aim to aid questionnaire development. In our study we employ the same principles and reflect on how selected questionnaires meet the intended analytic objectives of surveys measuring IPVA.

Overview of Relevant Surveys

In this section we summarise, in survey name alphabetical order, which surveys enquire about IPVA among adults and young people, and we provide details regarding the broader context and aims of the survey and the methodology around collecting the data. The range of survey topics within which IPVA questions feature is fairly broad, and includes surveys focusing on criminal behaviour, as well as surveys of families focusing on children’s development. Table 1 provides a brief overview of some general survey characteristics.

Adult Psychiatric Morbidity Survey (APMS)

The APMS, also known as the Mental Health and Wellbeing Survey, is a repeated cross-sectional survey (every 7 years) of psychiatric morbidity in adults living in private households in England (McManus et al., 2020 ). This survey first ran in 1993, and the latest data is from 2014. IPVA questions are part of a module on factors associated with mental health problems. In 2014, 57% of those approached agreed to take part in the survey (N:7528). Data was collected via Computer Assisted Personal Interviewing (CAPI), and IPVA questions featured in a self-completion module (McManus et al., 2016 ). Most of the questions in this survey were borrowed verbatim from the Crime Survey for England and Wales described further below. IPVA questions are asked in relation to a partner or ex-partner, for abuse taking place since age 16. A consultation on APMS modules which ran in 2021 resulted in a number of recommendation to improve domestic abuse questions which are being redeveloped for the forthcoming iteration of the survey (Gill et al., 2022 ).

Avon Longitudinal Study of Parents and Children (ALSPAC)

ALSPAC is an ongoing prospective-longitudinal study based in the south west of England. All pregnant women resident in one of three health districts in the former county of Avon in the UK due between April 1, 1991, and December 31, 1992, were eligible to participate ( http://www.bristol.ac.uk/alspac/ ). Initially, 14,541 pregnant women (and their eventual babies) were enrolled. When the oldest children were approximately 7 years of age, an attempt was made to bolster the initial sample with eligible cases who had failed to join the study originally, resulting in an additional 913 children being enrolled. This resulted in a total sample of 15,454 mothers (76% of all eligible) with 14,901 babies alive at age 1. The ALSPAC Ethics and Law Committee and Local Research Ethics Committees provided ethical approval. Information has been regularly collected since enrolment until present. Questionnaire data in ALSPAC was collected by postal questionnaires until 2014 (when the study children were aged 22 years) when data collection moved to online self-completion.

IPVA was reported by parents of child participants when the child was 8 months, 2, 3, 4, 5, 6, 8, 9, 11, 12 and 18 years old, and by participants themselves at aged 21. IPVA measures were reported by participants (retrospectively) at 21 and 23 years old. At age 21, women responded to a validated 8-item scale on physical, psychological, and sexual IPV experiences before and/or after age 18 (Table 1 , α = 0.95; Yakubovich et al., 2019 ). The measure was developed by a team of IPV researchers based on questionnaires used with young people (Barter et al., 2009 ) and a clinical sample in Bristol (Hester et al., 2015 ) and piloted for acceptability with the ALSPAC participant advisory group. Items were conceptually similar to those from existing IPV scales but with the benefit of not limiting measurement to conflicts or disagreements or overburdening participants with a large inventory of items (Yakubovich et al., 2019 ). Moreover, unlike most short-form IPV measures, the current measure captured physical, psychological, and sexual IPVA.

Crime Survey for England and Wales (CSEW)

The CSEW is the current version of what originally started as the British Crime Survey in 1982. The most recent iterations of the survey contain some of the most detailed questions on IPVA in the UK survey landscape. The survey first collected data on IPVA in 1996 and has since 2001 collected IPVA data regularly, seeking to run the relevant module on alternate years. Respondents are interviewed on a rolling basis during the course of a year, and the CSEW reports average crime data over a moving reference period which allows the data to be more comparable to police recorded crime figures (Office for National Statistics, 2021 ). The Office for National Statistics, the official UK body responsible for producing national statistics on a vast range of topics, regularly reports on CSEW data including but not limited to IPVA. Since 2019, reporting on IPVA has improved and now includes reporting on a range of relevant sub-topics, such as IPVA prevalence, and victim characteristic, detailed data on partner abuse, interactions with the criminal justice system and victim services and more (Office for National Statistics, 2019b ).

Though most of the survey is run using CAPI, the IPVA module is a self-complete module which respondents complete using the interviewer’s tablet by themselves. Respondents’ answers are hidden from the interviewer during and after the self-completion. The self-completion modules feature at the end of the face-to-face interviews (Office for National Statistics, 2021 ). From 2017 onwards, the self-completion module of the CSEW questionnaire is given to all respondents aged 16 to 74 years (the upper age limit was previously 59 year). In 2009, the survey featured a sub-sample of respondents aged 10–15 years old which enquired about their experiences of crime, including hate crime and cyber security.

Growing Up in Scotland Survey (GUS)

GUS is a longitudinal nationally representative prospective study of children and their families in Scotland. The main birth cohort included 5,217 babies in the first survey, born between 06/2004–05/2005 (Bradshaw et al., n.d. ). Babies were 10 months old at the first sweep. Interviews were carried out in participants’ homes usually with the child’s mother, and mothers and partners (if present) were asked a range of questions about themselves and their children’s development in one-to-one interviews via CAPI. The survey used a stratified random sample. Attrition rates are relatively low (87% response rate of surveys issued).

Maternal experiences of IPVA were recorded when children approached their 6 th birthday (3646 mother–child pairs were still part of the survey) (Skafida et al., 2021 ). Though the survey was interviewer led, the IPVA module was a self-complete feature. Mothers reported whether they had experienced a range of different types of violence covering coercive control, physical and sexual violence. Questions were based on the Scottish Crime and Justice Survey (described below) at the time of the GUS questionnaire design, but GUS asks about experiences of such abuse in a 6-year period from the birth of the study child to the present day, whereas the Scottish Crime and Justice Survey asks respondents to report on violence occurring in the last 12 months. Table E in the Online Appendix A shows the original question wording.

Northern Ireland Safe Community Survey (NISCS)

Devolved nations Scotland and Northern Ireland run their own national crime surveys for their nations. The NISCS, previously known as the Northern Ireland Crime Survey which launched in 1994/95, has been running regularly since 2005. Survey results are published by the Northern Irish Department of Justice. It includes a self-complete module entitled ‘Experience of Domestic Violence and Abuse’ module which runs biannually. The most recently collected data are from 2015/16 (Campbell & Rice, 2017 ). The 2020/21 version of the survey would have originally featured the IPVA module again, but due to the Covid pandemic and the survey being carried out by telephone the relevant self-complete module could not be included (Department of Justice et al., 2022 ).

The latest available domestic abuse data from the NISCS dating back to 2015/16 was based on self-completion modules that featured in face-to-face interviews with respondents aged 16 to 64. Since 2008/09 the module has changed in multiple ways, making comparability difficult in terms of comparing to earlier data. The changes included extending the upper age limit to 64 (previously 59), and including an additional domestic violence question hoping to capture a more psychological aspect of abuse (i.e. a question about being ‘repeatedly belittled so that you felt worthless’). Additional questions were also introduced to capture experiences of abuse in the wider family, beyond intimate partner violence.

Millennium Cohort Study (MCS)

MCS is a longitudinal survey of just under 19,000 children born in the UK in 2000–2001. The survey is broad in its focus and aims to capture various aspects of interest with regards to children’s development, their family and immediate environment. Children were 9 months old at the first survey sweep, and subsequent sweeps took place at regular intervals tracking children into adulthood. In the surveys where children were 9 months, 3, 5, 7, 11 and 14 years old, a question about domestic violence was included in the questionnaire, and only mothers and fathers with a full-time resident spouse or partner were asked to respond (via a self-complete module) (Bunting & Galloway, 2012 ). The survey features one single question about IPVA which focused on physical abuse (see Table F in Online Appendix A ) (Jofre-Bonet et al., 2016 ). The question was identical in wording across all sweeps. Cohort children are now adults, and recent data collection with the study-children themselves sought to measure experiences of serious violence among the participants (both as victims and perpetrators) (Smith & Wynne-McHardy, 2019 ). Children were 14 years old when this data was collected, and specific questions about IPVA were not part of the questionnaire.

Scottish Crime and Justice Survey (SCJS)

As discussed above, devolved nations Northern Ireland and Scotland have their own crime surveys. The SCJS is a national survey about crime and victimisation. It draws on a representative sample of adults aged 16 and over. Unlike the English/Welsh and Northern Irish counterparts the SCJS does not have an upper age limit. As with the other crime surveys, questions about IPVA are asked through a self-complete questionnaire at the end of the face-to-face survey. Questions cover a range of different types of abuse, including stalking, harassment, physical violence and sexual abuse, as well as threats of violence and questions about coercive control (MacQueen, 2016 ). The most recent iteration of the survey (2019–20) also contains questions about physical and psychological impacts of abuse and questions about children’s experiences and involvement in abuse incidents.

Limitations of Current Surveys

Overemphasis on physical abuse.

We note that there is still a bias, in the existing survey milieu, towards data on physical abuse (Devries et al., 2013 ). This is in large part due to the fact that some of the reviewed questionnaires were developed and issued before public discourse and UK legislation across jurisdictions changed to recognise coercive control as a crime. Earlier versions of different crime surveys contain several questions about physical abuse and fewer questions about emotional abuse, a pattern that is subsequently also reproduced in non-crime surveys such as GUS and APMS which borrowed these modules.

MCS only measures physical violence using one question repeated over six sweeps: ‘ People often use force in a relationship—grabbing, pushing, shaking, hitting, kicking etc. Has your husband/wife/partner ever used force on you for any reason? ’ ALSPAC first included physical abuse questions when children were 8 years old, and only four years later (children aged 12 years old) were detailed questions about coercive control introduced. ALSPAC features repeated measures of physical and psychological abuse starting during pregnancy with the study child. Both questions however rely on a single item which requires respondents to identify a specific experience, in this case ‘cruelty’ (i.e. Your partner was physically cruel to you; Your partner was emotionally cruel to you). Previous commenters (Barter, 2014 ; Devries et al., 2013 ) have recognised that these limitations can ‘open the possibility of substantial misclassification of total violence exposure’ (Devries et al., 2013 , p. 4).

Evolving Non-Violent IPVA Measures

Except for MCS, all reviewed surveys continue to try to better capture non-physical aspects of IPVA. Relevant questions seek to identify which respondents have experienced specific types of controlling behaviours. Though the inclusion of survey items measuring non-physical abuse is welcome, such questions are often under-represented compared to questions about physical violence, even in some of the most recent survey sweeps. For example, in the 2019–20 CSEW, there were three questions about coercive control (i.e. questions about being belittled; being frightened or threatened; being stopped from seeing friends and relatives), and eight questions about physical or attempted physical violence (though we note that there are also specific questions about stalking and abuse through technologies which would be categorised as psychological abuse).

The CSEW and APMS are both seeking to develop better measures of controlling or coercive behaviour for future surveys (Gill et al., 2022 ; Office for National Statistics, 2019a ). The SCJS has five questions about controlling behaviours, seven questions about threats of physical abuse, and seven questions about physical and sexual abuse. The SCJS also has a detailed module on stalking and harassment, which asks whether or not partners or ex-partners were the perpetrators. It is worth noting that some elements of coercive control are more likely than others to feature in surveys. For example, in the SJCS, threats of physical violence make up seven of the total 12 items capturing non-violent IPVA. It could be argued that this shows a persistence for questionnaires to still focus on physical IPVA.

Counting Incidents

All of the reviewed surveys included questions structured around the aim of counting incidents or ‘events’. Questions typically sought to establish the incidence of specific types of IPVA in a certain time frame (e.g. since age 16; in the last 12 months; since the birth of the study child), and in some cases follow-up questions were asked about ‘how many times’ the abuse took place (SCJS, GUS). It was not always possible to make inferences about ‘patterns’ of abusive behaviour from questions about incidents, though the APMS did ask about frequency within the last year for each form of abuse. Only one question, versions of which featured in CSEW, SCJS, GUS, NISCS, and APMS, was phrased from the onset to reflect the systemic nature of abuse, and this asked if a perpetrator ‘repeatedly put you down so you felt worthless’ (SCJS, GUS) or ‘repeatedly belittled you’ (CSEW).

The surveys we reviewed lacked questions about how victims were affected by IPVA and how the abuse shaped their lives and behaviours. The APMS only asks one question about IPVA impacts, which is about physical injuries. Questions on impacts feature in ALSPAC which asks the survey children at age 21 to record the impact of their IPVA experiences, including asking if their partner’s behaviour had made them feel: scared or frightened; upset or unhappy; sad; anxious; annoyed or angry; and/or depressed.

Some promising developments can be found in the latest SCJS questionnaire, which asks IPVA victims to report how they were physically and psychologically affected. Potential responses for physical impacts following the ‘most recent’ incident include: minor and/or severe bruising; minor and/or severe cuts; severe concussion or loss of consciousness; internal injuries; pregnancy. Psychological impacts include: Difficulty sleeping / nightmares; Depression; Low self-esteem; Fear; Anxiety / panic attacks; Isolation from family or friends; Isolation from children in your household. For a complete list of all effects see Table D in Online Appendix A . While the question about physical impacts is asked following any reported incident of abuse in the last year, the question about psychological impact is only asked once in relation to the ‘most recent’ incident. It is unclear why this would be the case and presumes impact relates to a single incident. In the SCJS, and other surveys, it would be preferable for psychological impact questions to be asked in a way which recognises that the impact of the abuse is often a result of a continuous and accumulative process of harm (Stark, 2007 ) rather than a single identifiable event.

Sexual Violence

Sexual violence, as a form of IPVA is often overlooked in research (Bagwell-Gray et al., 2015 ). All surveys we reviewed, except for MCS, had at least one question about sexual violence. However, GUS, NIJSC only ask one and two questions respectively about being forced to have sexual intercourse or another sexual activity. However, ALSPAC child respondents at age 21 years were asked four questions about sexual IPVA which included being pressured or physically forced into a range of sexual activities. The most recent versions of the CSEW and the SCJS have the most extensive questionnaires on sexual violence (some of which also feature in the APMS), including initial screening questions about sexual violence and attempted sexual violence, and survey routing to a follow-up module with a comprehensive list of items about different types of sexual violence experienced, the context surrounding these experiences, and for the SCJS survey only, also about physical impacts on the victim and whether the police was notified (see Table D, Online Appendix A ).

Economic Violence

There are several dimensions of IPVA which are largely overlooked or not adequately explored in the existing surveys. For example, there is a case for treating economic violence as a separate category of IPVA (Bender, 2017 ). This includes excluding victims from financial decision making, or limiting their access to funds (Fawole, 2008 ). In the reviewed surveys, there is usually an item, albeit only one, which attempts to capture this dimension. The SCJS and GUS ask whether a partner ‘stopped you having a fair share of the household money or taken money from you’. The NISCS, CSEW and APMS ask a similar question about ‘having a fair share of the household money’.

Stalking and Harassment

Stalking as a form of intimidation and abuse which can be difficult to measure in surveys (Fox et al., 2011 ). Among the reviewed surveys, the CSEW and SCJS ask relevant questions in relation to the perpetrator being a partner or ex-partner. These surveys ask two different questions about being followed, (e.g. CSEW asks if ‘ever followed you around and watched you on more than one occasion in a manner which caused you fear, alarm or distress’) and both surveys also ask about a perpetrator waiting or loitering outside participant homes or workplaces. The SCJS has a separate section about stalking and harassment (including questions about unwanted phone calls and letters) which asks about unwanted attention both from people whom participants know (like partners and ex-partners) as well as strangers. The follow-up question to every reported stalking or harassment incident asks respondents to specify if the perpetrator was, among other options: a partner, ex-partner, a date, someone from a casual sexual relationship, a family member.

Abuse via Technologies

Surveys need to better capture how technologies continue to change the ways in which perpetrators can abuse victims (Barter & Koulu, 2021 ). The CSEW and SCJS ask about unwanted messages or posts via email, social networks or social media sites. The SCJS asks whether ‘a perpetrator has shared intimate images of you without our consent for example by text, on a website, or on a social media site like Facebook or Twitter’ and the CSEW asks about a perpetrator sharing personal or threatening information about a victim on the internet. ALSPAC respondents (at age 21) were asked if their partners had ‘regularly checked what they were doing and where they were (by phone or text)’. There are analogous questions in GUS regarding bullying by peers, but not in the context of IPVA. An interesting follow-up question in the SCJS harassment and stalking module, where questions about technologies also feature, is whether the police was notified, and if not, why not.

Other Dimensions of IPVA

Other dimensions of IPVA rarely feature in survey questionnaires. For example, we find no questions on female genital mutilation (FGM), and there is little robust data on FGM prevalence generally (Walby et al., 2017 ). One of the complications of enquiring about FGM is the possibility of victims themselves not knowing if FGM has happened to them (Walby et al., 2017 ). There is also relatively little data about ‘reproductive coercion’ (Grace & Anderson, 2018 ) which can include pregnancy coercion, or controlling the outcome of a pregnancy, or interfering with a woman’s birth control decisions. Only the SCJS asks if the ‘most recent’ incident of abuse or any prior incident led to pregnancy or if the ‘most recent’ incident left the victim ‘feel[ing] forced to terminate a pregnancy’.

Questions about the Perpetrator

MacQueen argues that what is needed is ‘a more nuanced understanding of how and why abuse, and violence more broadly, is perpetrated, how it is understood by perpetrators and victims and what its impact is’ (MacQueen, 2016 , p. 486). Most surveys seek to learn more about the perpetrator via victims themselves, and ask, for example, if the perpetrator is a partner or ex-partner. The CSEW and the NISCS ask whether respondents experienced IPVA from someone other than a partner (e.g. another family member). The SCJS asks similar questions but only in relation to stalking and harassment, and in the sexual abuse module, but the rest of the ‘core’ IPVA questions only ask about intimate partners and ex-partners. The SCJS also asks if perpetrators were living with respondents at the time of the abuse and whether respondents are still living with perpetrators at the time of the interview. The NISCS asks if the perpetrator consumed alcohol prior to the abuse, and the SCJS asks if perpetrators of sexual abuse were under the influence of alcohol or drugs during the incident, recognising the alcohol and drugs may be a compounding factor, but not a cause of IPVA. Of the surveys reviewed, only APMS and ALSPAC asked about perpetration . In the core module of the APMS there are four perpetrator questions, of which three about physical and sexual violence, and these questions have been criticised for underreporting prevalence (Gill et al., 2022 ). In ALSPAC when cohort children were 18–21 years old, they were asked four questions about coercive control and psychological abuse, physical violence and sexual abuse.

Better Individual Demographic Variables

Socio-economic and neighbourhood variables are collected across all reviewed surveys, and were more granular in the child cohort studies (MCS, GUS, ALSPAC). Crime surveys collected fewer demographic details on respondents, but age, social class, household income, religion, gender, and disability status are collected in some form in all reviewed surveys, though variable quality differs. For example, questions on disability are more detailed in GUS than in SCJS. Research is increasingly showing associations between IPVA risk and neighbourhood and community level factors, suggesting important drivers behind violence which go beyond the individual, relationship or household level (Benson et al., 2003 ; Lauritsen & Schaum, 2004 ; Yakubovich et al., 2020 ).

There are other less frequently explored characteristics, such as sexual orientation, gender identification, religious affiliation and disability; and existing survey data does not always allow for meaningful analysis of how these dimensions affect IPVA exposure and experiences (MacQueen, 2016 ). The CSEW and SCJS both ask whether respondents experienced a range of crimes (e.g. harassment) which respondents believe were motivated by factors such as: “ethnic origin/race; religion; sectarianism; gender/gender identity or perception of this; disability/condition they have; sexual orientation; age; and pregnancy/maternity or perception of this” (Scottish Government, UK Statistics Authority, et al., 2021 ).

Nixon and Humphries call for better measurement of how gender, race, class and disability interact and overlap with each other in affecting women’s experiences and risk of domestic violence (Nixon & Humphreys, 2010 ). Ethnicity variables are not always adequately captured in existing surveys, or datasets released to researchers do not always allow for meaningful analysis of how the risk of experiencing IPVA may be heightened for some ethnic minority groups (Skafida et al., 2022b ). An added complexity is that since prevalence of abuse in surveys which ask about recent incidents (e.g. the 12 month reference period in the reviewed crime surveys) is relatively low, it is often difficult to undertake meaningful analysis in relation to sub-samples of interest, such as ethnic minorities (MacQueen & Norris, 2016 ). We believe that depending on the survey context, boosted samples should be considered to address some of these challenges, as has been done for example in the UK Understanding Society survey with ethnic minority boosts (Platt et al., 2021 ). Commissioned qualitative work for these and other minorities would also be important in addressing evidence gaps.

Lack of Longitudinal Data

Though we review seven longitudinal and repeated cross-sectional studies in this paper, the type of longitudinal data they offer is limited in two ways. Firstly, there are few high quality variables within surveys providing insight regarding individual IPVA experiences over time and duration of such experiences. Even within cohort studies, several of the questions provide limited temporal insight. Crime survey questions tell us little about the length of time victims spent living with IPVA, or whether the onset of abuse was triggered by key life transitions. SCJS asks respondents to specify if reported incidents took place in the last year or before this, but the rest of the survey (also applies to CSEW and NISCS) focuses on recording incidents within the 12 months prior to interview, and the only added granularity beyond prevalence in the last year is life-time prevalence. Secondly, among the repeated cross-sectional crime surveys, some of the potential which such studies can offer, such as tracking changes in prevalence over time, is limited by the fact that IPVA questions have changed from sweep to sweep over the years – though often this has been for good reason.

ALSPAC has regularly collected data about IPVA over the years, starting with maternal IPVA reports at 18 weeks gestation of the study child, though to IPVA questions answered by the mother and father when study children were 18 and 12 years old respectively. In the most recent sweep, children aged 21 years old are themselves asked about controlling partners, and about their recall of experiences of parental IPVA when they were younger. ALSPAC is potentially the best source to analyse IPVA from a life-course perspective, though it is worth noting that even in this survey, detailed indicators of (mostly) physical violence were only collected once from the mother when children were 8 years old, and four questions about coercive control were asked once when children were 12 years old. In GUS questions about IPVA have only featured once when children were 6 years old. MCS does collect repeated identical measures over six sweeps but it only asks one question about physical abuse.

IPVA onset can vary over the life-course following a curvilinear pattern (MacQueen, 2016 ). Data on teenagers suggests higher rates of victimisation than the general population (Barter et al., 2009 ). Other transitions, such as pregnancy (Bailey, 2010 ), childbirth, onset of menopause, and older age have also been associated with increased risk of experiencing IPVA, yet surveys rarely allows for analysis of these phenomena at a population level.

More Data on Sources of Support

Other than in the most recent SCJS, there were few questions about sources of support victims turn to, who—if anyone—they have spoken to about the abuse, and whether they used any of the different support services which they would have access to. The recent SCJS, asks about a range of people or organisations which victims may have discussed domestic abuse issues with, ranging from friends and relatives to health professionals, and different support helplines. The CSEW features some questions about sources of support in a rotating survey module, but they are difficult to interpret as they cannot be analytically associated with a perpetrator or type of abuse experienced.

Children’s Experiences Poorly Measured

A systematic review by Latzman et al. ( 2017 ) found that few measures capture children’s direct involvement in IPVA and few assess exposure to coercive control, sexual violence or stalking. In the surveys we review, though GUS and MCS are both child cohort studies, no specific questions address this. ALSPAC does retrospectively ask the study children at age 21 to report on their childhood experiences of parental domestic abuse. The most recent SCJS questionnaire is the most promising source of data on this topic. It asks if children were present, if they saw or heard, if they got involved, if they got hurt or injured as a result of an incident, if they experienced different psychological problems as a result; and if they had called the police. Though the qualitative literature has highlighted the ways in which child contact opens up opportunities for perpetrators to continue to abuse victims (Morrison, 2015 ), there are no questions which specifically address this.

Questions Tailored to Survey Contexts

Though there is a logic to borrowing validated survey modules across different survey settings our review finds that borrowing is not always the optimal choice. This applies most strongly to cases where crime survey modules developed to reflect crime codes and measure crime incidents have been widely borrowed in completely different survey contexts, such as GUS and APMS. These latter surveys could have developed their own questions, or borrowed non-crime survey questions to, for example, ask about children’s IPVA exposure and impacts in the GUS survey, or ask about psychological (instead of only physical) impacts of abuse in the APMS – a survey about psychiatric morbidity.

Within UK Comparability

With devolution, UK nations produced their own versions of what was originally the British Crime Survey. We have discussed in this paper the three different surveys that now run in Scotland, Northern Ireland, and in England and Wales. Although earlier iterations of these surveys had significant overlap in question wording, with the passing of time, each nation has modified their IPVA questionnaires substantially, at times to reflect different changes in legislation between nations. The IPVA module changes have often improved the questionnaires compared to their predecessors. But as changes have not been homogenous across nations, it is increasingly more difficult to compare survey data across the devolved nations. It is important to work towards consistency in IPV measures which would enable comparisons across time and populations (Walby et al., 2017 ; Waltermaurer, 2005 ), though this should be balanced with improving IPV measurements as our understanding of the phenomenon evolves (Waltermaurer, 2005 ). To return to the point argued in the previous section, this is a scenario where at least some question homogeneity would be beneficial.

Concerns about Survey Structure

The most common way to collect information about IPVA in the three different crime surveys we have reviewed (CSEW, SCJS, NISCS) is via a self-complete module often positioned at the end of a long ‘main’ face-to-face survey. Thus, response rates for the self-completion part tend to be lower than for the main survey. For example, the SCJS technical report noted that ‘ran out of time’ was the main reason why the self-complete module was not completed, with 34% of the non-response group stating this (Scottish Government, ScotCen Social Research, et al., 2021 ). Also, in the SCJS, the IPVA module follows the questionnaire about respondents’ drug use. The Scottish Women’s Aid consultation on SCJS data notes that ‘having the gender-based violence questions immediately after questions on behaviour and illicit drug use may be perceived as suggesting a link between them, or potentially, as victim-blaming.’ (Scottish Women’s Aid, 2021 , p. 3). Finally, since crime surveys tend to underestimate prevalence of relevant abuse (Brunton-Smith et al., 2022 ), perhaps IPVA survey modules would be better placed within public health surveys.

Sampling Strategies, Survey Response and Non-Random Attrition

Some population groups are routinely left out of sampling frames for most national surveys. These include populations living in sheltered accommodation, those changing addresses very frequently, those living temporarily with friends or family, homeless people, students, and prison populations (Scottish Women’s Aid, 2021 ; Walby et al., 2017 ). This means that key parts of the population most at risk of experiencing IPVA are also those who are left out of most prevalence surveys. For example, IPVA is a key cause behind women’s homelessness (Bimpson et al., 2021 ). Frequently changing homes is associated with higher attrition (Watson, 2003 ), meaning that disadvantaged populations in unstable accommodation are also most likely to be underrepresented in such surveys.

Despite these weaknesses, little work has been done to explore non-random non-response, aside from overall survey attrition, in IPVA questionnaires and what the implications of this are for making population inferences. According to an ONS report (ONS, 2021 ), analysis of CSEW non-response was commissioned, though little detail is provided regarding findings. Research into item-non response in the GUS IPVA questionnaire notes that non-response in IPVA questions is highly socially stratified, and likely to be masking unreported experiences of abuse (Skafida et al., 2022a ). This suggests that the social gradient in experiences of IPVA is likely to be substantially underestimated through population surveys.

Questionnaires Versus Their Reporting

On a final note, we wish to draw attention to the fact that most of the existing questionnaires offer potential for detailed analysis which is usually not fully exploited in the standard reporting of such data. This is especially the case where such reporting is carried out by organisations tasked with producing overall summaries of entire surveys – and not merely IPVA modules (for example reports produced by the Office for National Statistics, Scottish Government, Northern Ireland Department of Justice). This is something that Walby and Towers ( 2017 ) raise with regards to ONS publications using CSEW data, as does MacQueen ( 2016 ) reflecting upon the potential of the SCJS dataset. It is worth considering to what extent the increasingly stringent data access requirements for many of these datasets are dissuading a larger pool of scholars from using the data in more creative ways.

In this paper we review seven UK longitudinal and repeated cross-sectional population surveys which include questions about IPVA. We have critically engaged with the questionnaires and reflected upon the strengths and limitations of the surveys both individually and collectively in terms of the quality of IPVA data that they have to offer. In doing so we have drawn extensively on literature of methodological discussions around measurement of IPVA in surveys. We conclude by outlining a range of recommendations, summarised in Box 1, to aid both in the development of future iterations of the same surveys as well as in the creation of new surveys focusing on IPVA. Though our geographical context is the UK, most of the limitations we identify are of relevance for IPVA population survey methodology beyond the UK context.

Box 1 . Recommendations for future IPVA survey questionnaires and data collection

Change history

01 april 2023.

A Correction to this paper has been published: https://doi.org/10.1007/s10896-023-00538-2

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The project has been funded by the Nuffield Foundation grant number WEL/43875, but the views expressed are those of the authors and not necessarily the Foundation. GF's salary was supported by the UK Prevention Research Partnership (Violence, Health and Society; MR-VO49879/1), an initiative funded by UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities.

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Valeria Skafida

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The original online version of this article was revised: The Millennium Cohort Study asks both mothers and fathers (where possible) about domestic abuse experiences across six sweeps of the survey: at child ages 9-months and 3, 5, 7, 11 and 14 years. Survey data users should be aware that there are discrepancies between the official survey user guides and the actual data collected.

The Adult Psychiatric Morbidity Survey asks further questions about abuse perpetration as part of an antisocial behavior disorder screen, but these are not reviewed in our survey.

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Skafida, V., Feder, G. & Barter, C. Asking the Right Questions? A Critical Overview of Longitudinal Survey Data on Intimate Partner Violence and Abuse Among Adults and Young People in the UK. J Fam Viol 38 , 1095–1109 (2023). https://doi.org/10.1007/s10896-023-00501-1

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Domestic violence against women: a qualitative study in a rural community

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• 1 Department of Community Medicine, Maulana Azad MedicalCollege, New Delhi, India. [email protected]
• PMID: 19703815
• DOI: 10.1177/1010539509343949

Domestic violence is a major contributor to physical and mental ill health of women and is evident, to some degree, in every society in the world. The World Health Organization reports that globally 29% to 62% of women have experienced physical or sexual violence by an intimate partner. Ending gender discrimination and all forms of violence against women requires an understanding of the prevailing culture of bias and violence. The present study was conducted in a rural area in India. Focus group discussions (FGDs) were conducted among married women in the age group of 18 to 35 years. Physical violence was a major cause of concern among these women. Some women had to suffer even during pregnancy. An alcoholic husband emerged as the main cause for domestic violence. Husbands' relatives instigating wife beating was also common. Majority of the women preferred to remain silent despite being victimized. The women feared to resort to law because of implications such as social isolation. To address this, all sectors including education, health, legal, and judicial must work in liaison. Gender inequality must be eliminated and equal participation of women in the decision-making and development processes must be ensured.

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Domestic Violence

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Domestic violence describes abuse perpetrated by one partner against another in the context of an interpersonal relationship. Domestic violence can be committed by current or former partners. The alternate term intimate partner violence has gained favor in the twenty-first century, as it expands the definition to include relationships between couples who are not married or cohabiting. Family violence further extends the scope of the issue to consider cases in which other immediate family members are victimized by violent or abusive behavior.

The prevalence of domestic and intimate partner violence is difficult to determine, as these forms of violence often remain unreported. For example, according to the US Department of Justice's Office for Victims of Crime, reports of intimate partner violence...  ( Opposing Viewpoints )

• Is domestic violence a sign that  America’s family values are in decline?
• Do female batterers differ from male batterers?
• How do drug abuse and alcoholism affect family violence?
• Are there signs that violence will escalate to murder?
• How have the O.J. Simpson, Chris Brown, or Ray Rice cases affected domestic violence awareness?
• Is the "conditioned helplessness" of abused women a factor?
• I s violence genetic or environmental?
• Does poverty affect spousal abuse?
• Why do some men still regard their wives as property?
• What affect does domestic violence have on the divorce rate?
• Is counseling effective for couples in violent relationships?
• Can abusers be rehabilitated?
• Has the economic downturn increased the number of battered spouses?
• Why do some women stay in an abusive relationship?
• Discuss particular issues in same-sex intimate partner violence.
• What are the signs of a battered person/partner?
• Why do women under-report being abused?
• Why are men less likely than women to report being abused?
• Is there adequate support for victims of same-sex partner violence?
• How do gender roles, stereotypes, and hetero-sexism shape domestic violence?
• What are the behavioral patterns of spousal abuse?
• What is the psychological make-up of an abuser?
• How does spousal abuse affect the family unit?
• Does spousal abuse impact the larger community, if so how?
• Is spousal abuse a crime?
• What are the statistics for spousal abuse in the U.S.?
• What types of treatment are available for abusive husbands and wives?
• How effective are these treatments in preventing future abuse?
• Do children who witness spousal abuse become abusers or abused as adults?
• What resources are available for abused spouses to get help?
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Domestic violence.

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• 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
• Review Questions
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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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• Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--national intimate partner and sexual violence survey, United States, 2011. [MMWR Surveill Summ. 2014] Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--national intimate partner and sexual violence survey, United States, 2011. Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. MMWR Surveill Summ. 2014 Sep 5; 63(8):1-18.
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Employing Research To Understand Violence Against Women

Fifty years ago, violence against women, and domestic violence in particular, was not considered a criminal justice concern in this country. It was largely viewed as a personal matter, best dealt with privately within families.

With a sweeping reinvestment in criminal justice reform in the 1960s, the women’s movement of the 1960s and 1970s, and efforts in the late 1980s and 1990s that led to passage of the Violence Against Women Act in 1994, violence against women entered the public consciousness in the United States. It began to be recognized as a serious public health and public safety problem that warranted criminal justice system intervention.

Over the past 50 years, NIJ has established and expanded a strong program that addresses violence against women. Its portfolio has funded more than $130 million in research on intimate partner violence, sexual violence, stalking, teen dating violence, and other related topics. NIJ-funded initiatives have also helped finance the testing of previously unsubmitted sexual assault kits and establish best practices in testing these kits.

Kristina Rose, a former NIJ acting director who worked on violence against women issues throughout her 19 years with the U.S. Department of Justice, summed up NIJ’s influence: “When it comes to violence against women, NIJ has been brave and pioneering across the spectrum of issues to help people understand what we know about violence against women, including what the criminal justice response should look like.”

Minneapolis Domestic Violence Experiment

In the wake of national attention surrounding violence against women in the 1970s and early 1980s, NIJ funded a randomized controlled trial experiment in Minneapolis that examined various law enforcement responses to domestic violence. [1] In 1984, the results of the Minneapolis Domestic Violence Experiment indicated that spending a night in jail significantly reduced the risk that a person would commit a future act of domestic violence. As a result, many police departments across the country implemented pro-arrest or mandatory arrest policies in domestic violence situations.

Given the findings and the implications for law enforcement, NIJ funded six replication studies, beginning in 1986. These studies showed contradictory results, which underscored the importance of replicating research studies. Replication ensures that results are valid, reliable, and generalizable.

Although replications found mixed results, the Minneapolis Domestic Violence Experiment marked a significant change in how law enforcement approached intimate partner violence.

“This was the first time there was a shift in how the criminal justice system thought about and responded to domestic violence,” says Angela Moore, senior science advisor and social scientist at NIJ.

Nearly 40 years later, the Minneapolis Domestic Violence Experiment is still frequently cited as a pivotal study.

The Violence Against Women Act

The Violence Against Women Act (VAWA) of 1994 was landmark legislation that created legal protections for victims of domestic and sexual violence and established funding streams for responding to these crimes. Filling critical resource gaps in every state, VAWA grant programs support law enforcement agencies, prosecutors’ offices, courts, domestic violence shelters, and rape crisis centers in serving victims and holding persons who commit violent acts against women accountable. VAWA also expanded the scope and scale of U.S. research on violence against women and led to a significant expansion of NIJ’s major research and evaluation efforts in the field.

“VAWA was an impetus,” says Moore. “We did some work on violence against women before the Act, but the funding NIJ received as a result of VAWA helped us spring forward and gave rise to the program we have today.”

VAWA was reauthorized in 2000, 2005, and 2013, and separate legislation in 2002 established the Office on Violence Against Women (OVW), a Department of Justice agency responsible for leading the implementation of VAWA grant programs.

“Thanks to funding administered by OVW, communities have developed coordinated responses to crimes of violence against women,” says OVW Acting Director Katharine Sullivan. “Justice system professionals, victim services providers, and other community partners have used these grants to work together to ensure that victims get the help they need and that dangerous persons are stopped from committing more crimes. These coordinated community responses have transformed how domestic violence is treated in the criminal and civil justice systems and sparked innovative prevention efforts like Maryland’s Lethality Assessment Program to reduce domestic violence homicides.”

In 1998, NIJ began receiving designated VAWA funds for research on violence against women. Funding allocations varied by year — ranging from $7 million in 1998 to $1.88 million in 2008 and 2009 — with a current allocation of $3 million to $5 million each fiscal year. This steady stream of funds from OVW has helped NIJ study the nature and scope of violence against women and the effectiveness of strategies for combatting these crimes. Knowledge generated through NIJ’s Violence Against Women program informs efforts within the Department of Justice and in communities across the nation to protect victims and bring those who commit violent acts against women to justice.

Collecting Representative Data

Despite the considerable number of studies on violence against women that were conducted in the 1980s and 1990s, there remained a critical need to understand the magnitude and nature of intimate partner violence, sexual violence, and stalking in a way that would provide accurate and reliable data. Surveys that frame questions within the context of crime do not necessarily provide representative data on respondents’ experiences with violence against women, in part because people do not always self-identify as victims of crime.

To address this research gap, in 2000 NIJ partnered with the Centers for Disease Control and Prevention (CDC) on the National Violence Against Women Survey (NVAWS). [2] The survey revealed that more than half of the surveyed women reported being physically assaulted at some point in their lives, and nearly two-thirds of women who reported being raped, physically assaulted, or stalked were victimized by intimate partners.

For two reasons, this survey has been consistently cited as a more reliable representation of rates of violence against women than surveys that frame victimization within the context of crime. First, the NVAWS did not rely solely on reported offenses because the vast majority of crimes go unreported. Second, the survey was designed to ask detailed, behavior-specific questions about respondents’ victimization experiences. By asking questions that avoid legal terms (for example, “rape”) and instead asking about a suspect’s specific behaviors (for example, “slapped,” “pushed,” and “shoved”), the survey avoided attributing blame or labeling respondents as victims.

The NVAWS was one of many NIJ-CDC collaborations to address violence against women. As a result, NIJ was able to bring a public health perspective to its work, alongside its inherent focus on public safety. NIJ again collaborated with CDC, as well as the U.S. Department of Defense Family Advocacy Program, to develop the National Intimate Partner and Sexual Violence Survey (NISVS); the first survey report was produced in 2011. [3] CDC continues to administer the NISVS to capture data about violence against women and men, and the survey has become one of the most frequently cited data sets in the National Archive of Criminal Justice Data.

Research After VAWA

VAWA mandated that the Department of Justice work in partnership with the National Academy of Sciences (NAS) to develop a research agenda for violence against women. The 1996 NAS report Understanding Violence Against Women was instrumental in shaping the direction of NIJ’s violence against women research portfolio. Subsequent NAS reports, along with strategic planning workshops and other input, have also informed program goals and direction.

Intimate Partner Violence

Through grants, cooperative agreements, and contracts supported by VAWA funding, NIJ has supported more than 200 studies on intimate partner violence — accounting for nearly half of the agency’s total funding allocations for violence against women research since 1993. Over this period, rates of intimate partner homicides have dropped nearly 30 percent as public awareness of intimate partner violence and policy responses have grown. [4] In 2016, NIJ hosted a meeting with prominent researchers and criminal justice practitioners to inform the Institute’s research agenda moving forward.

NIJ-funded studies on intimate partner violence have focused on definition and measurement, victims and those who commit the violent act, impacts on children, contexts and consequences, civil and criminal justice interventions, and processes used to respond to these crimes. This research has found links between intimate partner violence and early parenthood, severe poverty, and unemployment and has shown that understanding the demographic differences among victims and person who abuse their partner helps predict which interventions will be successful in specific groups.

Violence Against Women in Special Populations

Violence against women is a multifaceted issue that affects populations on many levels. NIJ’s broad name for its violence against women program — the Violence Against Women and Family Violence Research and Evaluation Program [5] — helped make it possible for NIJ to fund research on a wide range of topics related to violence against women, including trauma and the impact on children exposed to violence. This work also gave rise to a focus on teen dating violence and the maltreatment of elderly adults.

“There’s a lot of research that talks about the intergenerational aspects of violence against women,” says Moore. “It’s important to study these other facets of violence because they can have a tremendous impact within families, communities, and society as a whole.”

Building on a long history of research in the area of intimate partner violence, NIJ’s teen dating violence research portfolio grew out of a recognition that the field needed to explore how to prevent dating violence in populations younger than adults. NIJ has funded nearly three dozen studies on teen dating violence since the portfolio was established in 2005. NIJ also sponsored an interagency working group on teen dating violence in 2006. [6]

VAWA reauthorizations in 2005 and 2013 called for NIJ, in consultation with OVW, to conduct analyses and research on violence against American Indian and Alaska Native women in Indian Country. NIJ focused subsequent research on dating violence, domestic violence, sexual assault, sex trafficking, stalking, and murder in these communities. NIJ-funded research also evaluated the effectiveness of federal, state, tribal, and local responses to violence against American Indian and Alaska Native women. As part of the NIJ-CDC partnership, NIJ funded an oversampling of American Indian and Alaska Native women and men in 2010. The data revealed that four out of five American Indian and Alaska Native women in the United States have experienced violence in their lifetimes, and that these women find it much more difficult than other populations to access victim services. [7]

NIJ has funded dozens of additional studies to examine violence against women in specific populations, including disabled, elderly, and homeless persons; recipients of welfare; immigrants; incarcerated individuals; and various racial, cultural, and ethnic groups.

Sexual Violence

NIJ supported its first sexual violence research project in 1973, but the agency’s research on sexual violence dramatically expanded in the 1990s after the passage of VAWA. The first solicitation that focused exclusively on sexual violence was issued in 2002, when NIJ-funded research provided the first comprehensive national look at rape and sexual assault on college campuses.

NIJ has also done groundbreaking work to assist in the processing of sexual assault evidence nationally. In 2011, NIJ funded action-research projects in Houston, Texas, and Wayne County, Michigan, to help understand the nature and scope of untested sexual assault kits and to identify effective, sustainable, victim-centric responses to sexual assault. Additionally, through an NIJ-FBI partnership, the FBI laboratory in Quantico, Virginia, tested thousands of previously untested sexual assault kits from across the country, and NIJ convened the NIJ Sexual Assault Forensic Evidence Reporting (SAFER) working group. Information gleaned from these efforts contributed to the creation of the publication National Best Practices for Sexual Assault Kits: A Multidisciplinary Approach, which NIJ released in 2017. [8]

NIJ is also evaluating the Bureau of Justice Assistance’s Sexual Assault Kit Initiative (SAKI). The action-research projects in Houston, Wayne County, and other jurisdictions helped inform and establish the multidisciplinary nature of SAKI and underscored the need for collaboration between multiple components of the criminal justice system on sexual assault kit testing.

NIJ’s preliminary research in this area examined the stalking of members of Congress and celebrities in the 1980s. In 1993, NIJ was directed to develop a model anti-stalking code. NIJ has funded five projects on stalking, but this remains the least funded research topic in NIJ’s violence against women program, in part because of the difficulty of measuring and capturing reliable data on the subject.

Disseminating Results

NIJ-funded researchers have published scholarly articles related to violence against women in more than 50 different journals. The NIJ Journal has been an additional platform to disseminate research results, and a special issue of the Violence Against Women journal in 2013 highlighted NIJ’s programs. [9] NIJ’s Compendium of Research on Violence Against Women spans nearly 300 pages and includes summary information on all research related to violence against women from 1993 to the present, with links to study reports and manuscripts. [10]

NIJ releases an annual solicitation and has more than 50 active research projects on violence against women.

“All of NIJ’s work aims to respond to the needs and questions of the criminal justice field,” says Moore. “NIJ has funded work that has transformed the evidence base around what we know in regard to violence against women. We have come a long way since the Minneapolis Domestic Violence Experiment and the early days of our violence against women work. What hasn’t changed over the past 50 years is our commitment to funding research to better understand violence against women and how best to combat it moving forward.”

About This Article

This article was published as part of NIJ Journal issue number 281 , released May 2019.

[note 1] In this article, the terms “domestic violence” and “intimate partner violence” can be considered synonyms. NIJ now uses the more inclusive term “intimate partner violence,” which does not imply that this violence occurs exclusively within a domestic setting.

[note 2] National Institute of Justice, Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey , Washington, DC: U.S. Department of Justice, National Institute of Justice, November 2000, NCJ 183781.

[note 3] “ The National Intimate Partner and Sexual Violence Survey (NISVS) ,” Centers for Disease Control and Prevention, updated September 19, 2018.

[note 4] See Intimate Partner Violence: Interventions .

[note 5] See Violence Against Women and Family Violence Program .

[note 6] For more information on the NIJ teen dating violence research portfolio, see Teen Dating Violence .

[note 7] André B. Rosay, Violence Against American Indian and Alaska Native Women and Men: 2010 Findings From the National Intimate Partner and Sexual Violence Survey , Washington, DC: U.S. Department of Justice, National Institute of Justice, May 2016, NCJ 249736.

[note 8] National Institute of Justice, National Best Practices for Sexual Assault Kits: A Multidisciplinary Approach , Washington, DC: U.S. Department of Justice, National Institute of Justice, 2017, NCJ 250384.

[note 9] Bernard Auchter, ed., “The Violence Against Women Research and Evaluation Program at the National Institute of Justice,” special issue, Violence Against Women 19 no. 6 (2013).

[note 10] National Institute of Justice, Violence and Victimization Research Division's Compendium of Research on Violence Against Women, 1993-2016 , Washington, DC: U.S. Department of Justice, National Institute of Justice, August 2017, NCJ 223572.

About the author

Rianna P. Starheim is a writer and former contractor with Leidos.

Cite this Article

Read more about:, related publications.

• Violence and Victimization Research Division's Compendium of Research on Violence Against Women, 1993-2018
• NIJ Journal Issue No. 281

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• Religion, Disability, and Interpersonal Violence 2017 eBook "Religion, Disability, and Interpersonal Violence brings transformative insights to psychologists, social workers, and mental health professionals across disciplines providing guidance within religious and disabled communities in their clinical practice. It also provides valuable background for researchers seeking to examine the interface between religious culture and the abuse of persons with disabilities."

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• Dynamics of Domestic Violence "This Power & Control Wheel (on this page) shows the kinds of behavior perpetrators use to gain and maintain control over their victim. Domestic violence abuse is never an accident. It is an intentional act used to gain control over the other person. Physical abuse is only one part of a whole series of behaviors an abuser uses against his/her victim. Violence is never an isolated behavior. There are other forms of abuse, which are shown in the Power and Control Wheel."
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• Office for the Prevention of Domestic Violence: NY "The Office for the Prevention of Domestic Violence (OPDV), created in 1992, is the country’s only executive level state agency dedicated to the issue of domestic violence." Includes statistical data.
• Articles about Domestic Violence from 'The Conversation' "The Conversation is a nonprofit, independent news organization dedicated to unlocking the knowledge of experts for the public good. We publish trustworthy and informative articles written by academic experts for the general public and edited by our team of journalists."
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