April 2008

Section 16

10.2310/7900.2008.S16C20

Domestic violence describes relationships characterized by intentional controlling or violent behavior by someone who is in an intimate relationship with the victim. The abuser’s controlling behavior may take many forms, including psychological abuse, physical abuse, sexual abuse, economic control, and social isolation. Abuse may ultimately lead to the death of the victim from homicide or suicide. Typically, an abusive relationship goes through cycles of violence. There are periods of calm, followed by increasing tension in the abuser, outbursts of violence, and return to periods of calm. These cycles often spiral toward increasing violence over time. The victims of domestic violence are usually women, but domestic violence is a significant problem for the disabled and elderly of both sexes.

Reports on the frequency of domestic violence differ depending on the setting studied. These reports usually use physical abuse or sexual assault as their definition of domestic violence, because these are objective findings that are easier to document. In 2000, the National Violence Against Women Survey researchers conducted telephone interviews with a nationally representative sample of 8,000 women and 8,000 men in the United States about their experiences with domestic violence.¹ Nearly 25% of the women and 7.5% of the men surveyed reported having been raped, physically assaulted, or both by a spouse, partner, or date at some time in their lifetime; 1.5% of surveyed women and 0.9% of surveyed men said they were raped, physically assaulted, or both by a partner in the past year. By extrapolation, in the United States each year approximately 1.5 million women and 834,732 men are raped or physically assaulted by an intimate partner.

The National Violence Against Women Survey found that women living with female intimate partners experienced less physical abuse than women living with male intimate partners. Eleven percent of women living with a woman in an intimate relationship reported having been raped, physically assaulted, or stalked by a female partner. In contrast, men living with a male intimate partner experienced more intimate partner violence than did men living with women. Approximately 23% of the men who had lived with a man reported having been raped, physically assaulted, or stalked by his partner, whereas only 7.4% of the men living with a woman reported having experienced violence by his female partner. Moreover, on average, women who were physically assaulted experienced more assaults and suffered more injuries than did the men who were victims. These findings indicate that women are the main victims of domestic violence.

Studies of women treated in emergency departments and primary care practices have found similar high rates of domestic violence against women. In a 1998 report of women treated in community-hospital emergency departments, 2% reported acute trauma from abuse by an intimate partner, 14% reported physical or sexual abuse in the past year, and 37% reported emotional or physical abuse during their lifetime.² In a study of primary care practices that defined domestic violence as physical or sexual abuse, 5% of the women patients were currently in an abusive relationship and 20% revealed a history of past abuse.³ However, the prevalence of domestic violence may be underreported. In a 2004 study, a sample of 1,268 women seeking health care at urban, suburban, or rural emergency departments and primary care clinics in Wisconsin, 50% to 57% reported having experienced physical abuse, emotional abuse, or both during their lifetime; of the surveyed women, 28% reported experiencing emotional abuse, 12% physical abuse, 6% severe physical abuse, and 4% sexual abuse in the previous year.⁴

There are limited data regarding the prevalence of domestic violence in women seen by medical specialists. Studies of women patients in two gastroenterology clinics reported that 40% to 50% had a history of childhood or adult sexual or physical abuse. The prevalence of abuse was 31% in patients with functional complaints such as nonulcer dyspepsia, chronic abdominal pain, and irritable bowel syndrome, and it was 18% in patients with organic problems such as peptic ulcer disease, liver disease, and inflammatory bowel disease.⁵ In a study of women patients in a neurology clinic, 66% of those with chronic headaches had a history of physical abuse, sexual abuse, or both.⁶ In a survey of 3,429 women selected from a large health care plan, it was found that women who had experienced domestic violence had higher numbers of physical symptoms and lower mental functioning scores as compared to women who had never experienced domestic violence.⁷ Women who reported recent physical or sexual abuse were 2.8 times as likely to report fair or poor health.⁷ Another study indicated that women who had experienced sexual abuse had worse adverse health effects than women who had experienced physical abuse.⁸

Victims of domestic violence are found among women of all ages, socioeconomic classes, and ethnicities. A study of 7,443 women receiving care at urban, primary health care clinics in Texas reported that white women disclosed abuse at a rate of 8.9%, African American women at a rate of 6.0%, and Hispanic women at a rate of 5.3%.⁹ One study found that physicians and medical students were as likely to experience domestic violence as members of the general population.¹⁰ Adolescents can also be victims of intimate partner violence.¹¹ Domestic violence is a significant problem in the elderly population. Community surveys estimate that 3% to 4% of persons older than 65 years are victims of neglect, verbal abuse, or physical abuse. Two percent of the elderly population report sexual abuse.¹² In a random sampling of 370 women 65 years of age and older, 3.5% experienced violence from an intimate partner within the past 5 years; the past-year prevalence of violence was 2.2%.¹³ Elder abuse is associated with higher mortality and with increased chronic pain and depression. The abuser is most commonly a relative, usually the spouse.

In women, risk factors for domestic violence include the following: having experienced childhood physical or sexual abuse; being younger than 35 years; being single, divorced, or separated; and being of low socioeconomic status. Substance abuse is also a significant risk factor. In a 2005 survey of 2,386 women in Boston medical office waiting rooms, cigarette smoking and problem drinking (four or more drinks on one occasion in the past 30 days) identified women who were at significantly high risk for domestic violence.¹⁴ The probability of being a victim of domestic violence in the preceding year was 27% in women who both smoked and were problem drinkers and 10% in women who did neither.

Pregnancy is also a significant risk factor. A review of the obstetric literature found that physical abuse occurred in 7% to 20% of pregnancies.¹⁵ This rate is higher than the prevalence of gestational diabetes and preeclampsia, conditions for which pregnant women are routinely screened. One study found that homicide was the leading cause of pregnancy-associated death in Maryland women between 1993 and 1998.¹⁶

Women with physical disabilities are as likely to be physically or sexually abused as women without physical disabilities. According to one national mail survey, women with physical disabilities were more likely to have been sexually abused by health care providers and physically or sexually abused by attendants. In addition, women with physical disabilities reported having experienced abuse for a significantly longer period of time than women without physical disabilities (7.4 years versus 5.6 years).¹⁷

In the elderly, increasing physical and mental frailty correlate with increased risk.¹⁸ Elderly persons who are unable to care for themselves are at higher risk than those who are somewhat able to care for themselves. The elderly who are confused are also at increased risk.

There are no overt characteristics that make it easy to identify an abuser. The abuser can be any age or ethnicity or from any socioeconomic background. Abusers tend to maintain different public and private images: being violent at home but behaving normally at work. They typically deny or minimize their abusive actions.

Risk factors for becoming an abuser include childhood exposure to violence and abuse, violent behavior in other settings, substance abuse, and unemployment. In addition, psychological characteristics that are common in abusers include antisocial personality, borderline personality, low self-esteem, and poor impulse control.

Domestic violence affects a victim’s life in many ways. She gradually becomes increasingly dependent on her abuser as he controls her economic well-being and isolates her from her family and friends. Victims of abuse suffer profound psychological harm. They frequently develop anxiety, depression, or somatization. Many turn to alcohol and drug abuse as a maladaptive way of numbing their pain. The profoundly abused woman may develop posttraumatic stress disorder with dissociation, flashbacks, and even multiple-personality disorder.

Physical abuse can lead to repeated injuries, including soft tissue trauma, lacerations, and fractures. Attempts at strangulation can lead to stroke.

Ultimately, abuse may lead to the death of the victim, either from suicide or from murder by her abuser. It is estimated that approximately 1,200 women in the United States die annually as a result of domestic violence.¹⁹

Clinical Clues

There are clinical features that can lead the physician to suspect that a patient is in an abusive relationship. An inconsistent explanation of injuries or a delay in seeking treatment is characteristic of patients presenting because of abuse-related trauma. The presence of psychological conditions that are more common in victims of abuse can be a clue. Such conditions include somatization, anxiety and depression, and posttraumatic stress disorder. Substance abuse is also more common in victims of abuse. Likewise, there are many gynecologic conditions that are seen more frequently in abused women. These include chronic pelvic pain, pain on intercourse, and sexually transmitted diseases. Obstetric clues are unwanted pregnancies and starting prenatal care late in the pregnancy.

The patient’s pattern of care seeking can also be helpful. Abused patients often make frequent emergency room visits rather than seeking care from one primary care physician. This may be because their abuser is controlling their comings and goings, making them unable to keep scheduled appointments and preventing them from forming a stable relationship with a physician.

Apparent noncompliance can be a powerful clue. Often, abused patients are unable to complete medical evaluations because their abusers prevent them from doing so, and they may be unable to take their medications because their abusers refuse to let them fill their prescriptions or throw their medicines out.

The physical examination can also yield clues to the diagnosis of abuse. The patient’s demeanor may be revealing. The abused patient may appear to be evasive or unable to make eye contact. This behavior occurs because she does not wish to discuss her abuse. The patient who is suffering from posttraumatic stress disorder will have the flat affect that is characteristics of this illness.

Injuries that fit the typical pattern of physical abuse provide powerful clues. Most often, victims sustain blows on the trunk and abdomen. They may also have bruises on the neck from attempts at strangulation. There may be injuries on the forearms that were sustained when the abused patient tried to defend herself. Multiple bruises of different ages are also characteristic of physical abuse.

The partner’s behavior may yield valuable clues. The physician should be suspicious if the partner is overly solicitous. His controlling behavior may manifest itself in his answering questions for the patient. A partner’s refusal to leave the exam room is a powerful clue. If the partner refuses to leave, an appropriate strategy is to tell the partner that it is the policy of the physician’s practice to examine each patient privately and that the partner must leave the room.

In the elderly female population, neglect is the most common form of abuse; therefore, the physician may suspect abuse if the patient is unkempt, malnourished, or dehydrated or has bedsores. As with younger patients, abuse in the elderly should be suspected if the patient presents with unexplained injuries, implausible explanations of injuries, or multiple injuries in various stages of evolution. The patient’s behavior in relation to her caregiver can also be a clue; if the patient appears fearful of the caretaker, the physician should consider the possibility of abuse.

Screening

Patients are more apt to disclose abuse in interviews than on questionnaires. To be successful, screening needs to occur in an appropriate setting. The appropriate setting is one that is private and appears safe. In the Brigham and Women’s Hospital emergency department, detection of lifetime abuse increased from 4% to 16% of all women patients evaluated in the emergency department when the site of screening was moved from the public triage area to private curtained cubicles.²⁰ It is essential that the patient be interviewed alone. Certain communication behaviors on the part of the interviewer can facilitate patient disclosure of experiences of abuse. A recent study found that patients were more likely to disclose experiences of abuse when interviewers used open-ended questions and probed for abuse by using one follow-up question.²¹ Another successful strategy was the use of empathy and the creation of windows of opportunity during the interview to allow the patient to share highly charged or emotionally laden information.²¹ The sex of the interviewer is not crucial; women will disclose abuse to male interviewers as well as to female interviewers. What is essential is that the victim feels that she can trust the interviewer.

It is recommended that the interviewer normalize questions about domestic violence before asking them. One common approach is to say, “Because abuse happens so frequently in relationships, I ask all of my patients about this.” This approach makes the patient feel that she is not being singled out for screening.

There are many domestic-violence screening tools available. An efficient and effective screen is the single question developed by the Massachusetts Medical Society Committee on Violence: “At any time, has a partner hit, kicked, or otherwise hurt or threatened you?” This question, which can be adapted as needed, has been shown to increase the detection rate of partner violence.

The SAFE screen has been proposed as a useful tool. It consists of the following four questions:

• Stress/safety - "Do you feel safe in your relationship?"

• Afraid/abused - "Have you ever been in a relationship where you were threatened, hurt, or afraid?"

• Friends/family - "Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?"

• Emergency plan - "Do you have a safe place to go and the resources you need in an emergency?"

In pregnant women, the three-question Abuse Assessment Screen has been shown to be as sensitive as more extensive research questionnaires in identifying physical or sexual abuse. The questions are the following:

• "Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?"

• "Since you’ve become pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?"

• "Within the past year, has anyone forced you to have sexual activities?”

For sexual assault, one recommended screening question is the following: “Has anyone forced you to have sexual relations against your will?” There are no published data on the sensitivity or specificity of this question or similar versions of the sexual-assault question.

Figure 1.

An abuse screening tool specifically intended for women with disabilities, the Abuse Assessment Screen–Disability (AAS-D), has been developed [see Figure 1]. This four-question screen was tested in five specialty clinics serving women with physical disabilities. It was administered orally in a private setting to 511 women and offered in English and Spanish. When interviewers used the full AAS-D, 9.8% of the women (50 of 511) reported abuse. When interviewers asked only questions 1 and 2 from the AAS-D, only 7.8% of the women (40 of 511) reported abuse. The implications of this study are that adding questions about abuse that address issues specific to disabled women increases case-finding in this group.²²

The American Medical Association has proposed a series of screening questions for elder abuse [see Table 1].²³ The sensitivity and specificity of these questions is unknown.

There can be many reasons why patients deny abuse. The patient may not think of herself as being abused. She may not yet have enough trust in her physician, or she may be too fearful to disclose the abuse. The physician who suspects abuse despite patient denials should let the patient know that support is available and should ask again at a later visit.

Screening all patients who have an intermediate or high probability of abuse, on the basis of the history, physical examination, and observed relationship with the partner, leads to increased detection of abuse. In an emergency department study, the percentage of female trauma victims identified as abused rose from 6% to 30% when the department instituted a protocol of routine inquiry.²⁴

Screening of patients with an intermediate to high probability of abuse is endorsed by many national groups. The United States Department of Health and Human Services²⁵ and the American Academy of Family Physicians²⁶ recommend that physicians consider the possibility of domestic violence as a cause of illness and injury. The American College of Obstetricians and Gynecologists²⁷ and the American Medical Association²⁸ recommend routine screening of all pregnant women; they also recommend that clinicians be aware of markers and characteristics of abuse, such as bruising, improbable injury, depression, late prenatal care, missed prenatal visits, and appointments cancelled on short notice.

Routine screening of patients who appear to be at low probability for abuse also leads to increased detection and is endorsed by three national groups: the American College of Emergency Physicians (ACEP),²⁹ the Joint Commission on Accreditation of Healthcare Organizations (JCAHO),³⁰ and the United States Department of Justice Office on Violence Against Women.³¹ The ACEP encourages emergency personnel to screen patients for domestic violence. The JCAHO recommends that all emergency departments use protocols to increase the diagnosis of domestic violence. The Office of Violence Against Women urges that all adult and teenage women be routinely screened for intimate partner violence.

Other groups do not currently endorse universal screening. The United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for domestic violence or elder abuse in women.³² In addition to finding no direct evidence that screening leads to decreases in disability or premature death, the USPSTF found no evidence of harm from screening, including false positive results that could compromise the clinician-patient relationship, loss of contact with established support systems, psychological distress, or escalation of abuse. The Canadian Task Force of Preventive Health Care similarly found insufficient evidence to recommend for or against routine universal screening for violence against either pregnant or nonpregnant women, but the task force does recommend that clinicians be alert to the signs and symptoms of abuse.

I recommend that all women be screened for domestic violence. Women with an intermediate to high probability of abuse, including those who present to emergency departments with symptoms or signs of abuse or who are pregnant, should be asked directly about domestic violence. In addition, I recommend routine screening of women with a low probability of abuse at the time of their initial visit with a primary care clinician and periodically thereafter.

There are compelling reasons to do universal screening. Screening deepens the clinician-patient relationship. The patient who is in an abusive relationship feels understood and supported, and the clinician gains insight into what is often the most important issue in the patient’s life. Focus groups with abused women demonstrate the value they place on being asked about abuse. In addition, screening can serve as an educational tool, helping abused women to understand their situation, and as a catalyst to change their situation. Abused women in focus groups report that screening was the action that opened the door to their receiving help and support. In the words of one victim, “You asked me about domestic violence and I never said anything, but it was the start of my understanding of my situation. It’s like planting a seed for someone, that I could do something and try to get out.”³³ Women who have never been victims of abuse often express appreciation that their clinicians are doing this screening.

A Canadian study of more than 2,600 women presenting at various health care settings compared three methods of screening for intimate partner violence: a face-to-face interview with a health care provider, a written self-completed questionnaire, and a computer-based self-completed questionnaire.³⁴ The study found that women preferred self-completed approaches over face-to-face interviews.³⁴ A smaller New Jersey study that compared the use of a self-administered questionnaire with two forms of interview (medical-staff interview and physician interview) concluded that patient self-administered domestic violence screening is as effective as clinician interview in terms of disclosure, comfort, and time spent screening.³⁵ On the basis of these findings, it appears that written questionnaires may provide a viable option as a screening tool for intimate partner violence and may be a preferred method of screening in some settings.

Documentation

Specific, detailed documentation of screening and the information disclosed by the patient is essential. If she ever goes to court for issues related to domestic violence, her medical chart can be helpful evidence. It is important to quote her exact words and to include the specific details of abuse that she discloses. It is important to use nonjudgmental language, such as “patient states that” rather than “patient claims that.” If she denies abuse, documentation should leave the door open for possible future disclosures. Simple nonjudgmental statements, such as “domestic violence screen negative” or “patient stated that abuse is not an issue,” are sufficient.

If the patient has injuries, a sketch or photograph of the injuries should be placed in the chart. To establish beyond a doubt that the photograph is of the patient, it should include an identifying detail such as her face.

Treatment of abuse in women encompasses the acute response to a patient who has disclosed abuse and the long-term follow-up of such a patient. When a patient has disclosed abuse, the first step is to provide immediate emotional support, with statements such as, “I’m concerned for you,”“You deserve to be safe,” and “You are not alone.” The next step is to ask about her emotional state and her needs: “How do you feel about what happened?” and “What would you like to do?” The clinician needs to provide patient-centered care and to avoid creating a controlling relationship with the patient.

It is essential to assess the woman’s immediate safety. Some helpful questions to assess safety are “Do you feel safe to go home?”; “Has the violence at home been increasing over the past year?”; “Has he threatened to kill you, the children, or himself?”; and “Are there weapons in the house?” Positive answers to any of these questions correlate with an increased risk for serious injury within the year and it is important to make the patient aware of this.

After offering support and assessing safety, the next step is to review options for help with the patient. The clinician needs to be aware of the options in the practice environment and local community so as to be able to outline them to the patient and to refer the patient. In many practices, the best and most immediate option is referral to a social worker. Clinicians practicing in health centers, hospital-based practices, and emergency departments often have social workers affiliated with their practice site. Clinicians in private practice can often connect a patient with an emergency department social worker in the hospital that is most convenient for the patient. The social worker can then serve as the coordinator of the patient’s subsequent domestic violence care.

The next option is referral to a domestic-violence hotline. The patient can call the national domestic-violence hotline (1-800-799-SAFE), which offers immediate counseling in English and Spanish, as well as information on local resources. In many states, the physician or patient can call 911 and obtain information about local hotlines. The social worker can also provide the clinician in advance with information about local hotlines. Local hotlines typically offer immediate counseling and information on how to access local services.

A third option is for the patient to obtain a protection order against her abuser. This process can be initiated at a police station or in court. If the patient wants legal advice and is poor, she can be referred to community pro bono legal organizations such as the Legal Aid Society. Social workers and domestic-violence hotlines will have specific information available. The clinician’s responsibility is to introduce this as an option.

Finally, the patient may feel that she cannot return home and that she needs immediate safe shelter. Most communities have shelters available for abused women. Social workers and domestic-violence hotlines can provide specific information and help the woman find a place in a shelter. The abused woman can also go to her local emergency department for safety and can be admitted to the hospital as a social admission, if this is needed for her safety.

The Massachusetts Medical Society’s mnemonic RADAR summarizes the clinician’s role in the initial assessment and treatment of the abused patient:

R Routinely ask about domestic violenc

A Ask direct questions

D Document your findings

A Assess patient safety

R Review options

Reporting

All states require mandatory reporting of abuse in three situations. First, child abuse (i.e., involving a child younger than 18 years) must be reported to the Department of Social Services. In many states, witnessing physical abuse of the mother is considered to be child abuse and grounds for reporting. Second, abuse of disabled persons must be reported to the Disabled Persons Protection Commission. Third, elder abuse (i.e., involving a persons 60 years of age or older) must be reported to the physician’s local Elder Abuse Hotline.

Currently, three states—California, Colorado, and Kentucky—require that physicians report all injuries from domestic violence. New Hampshire requires reporting if the victim suffered from a gunshot wound and consents to the reporting. Rhode Island requires reporting for medical-data-collection purposes only and does not include identification information. A 1996 survey of 1,218 recently abused women presenting to emergency departments found that 44% did not support mandatory reporting of domestic violence to police.³⁶ A 1999 California survey found that despite the mandatory reporting law, 59% of physicians were choosing not to report injuries resulting from domestic violence.³⁷

Follow-up

Follow-up of the abused patient focuses on four responsibilities: support, safety, a safety plan, and ongoing assessment. The clinician needs to provide ongoing support and periodically reassess the patient’s safety. The patient should have a safety plan—a plan of what to do in an emergency. If a social worker is also following the patient, the social worker will usually take on this responsibility. If the patient is not being followed by a social worker, the primary clinician can help the patient develop her safety plan. The key elements in a safety plan include the following: a plan for what to do in an emergency, a place to go in an emergency, and organization of the resources that the patient will need if she has to leave home emergently. These resources include adequate money, essential documents (e.g., her social security card and the children’s immunization records), and keys to the house and car. Finally, an important part of follow-up is ongoing assessment of the patient’s desires and the options that are available to her.

It is important that the clinician have a realistic idea of the course followed by most women in abusive relationships. Only a minority of women take definitive action quickly and leave their abusers; most women remain in the relationship for long periods of time. Over time, the primary clinician can help these women by meeting their perceived needs, with the goal of enabling them to increase their self-esteem and safety.

There are limited data available on the outcomes of interventions to help the victims of domestic violence.³⁸ Most victims of abuse are not ready to leave their abusers. Their reasons for staying include the following: belief in the abuser’s promises of change, belief that the abuse is their fault, lack of money, lack of a place to go, fear of reprisal if they try to leave, and absence of intervention on their behalf.

Observational data demonstrate that with counseling, victims experience gradual increases in self-esteem, with the improvement taking place over months to years. Advocacy programs have been shown to decrease abuse. A randomized, controlled trial of women who had spent one or more nights in a shelter studied the intervention of a specific program of advocacy and counseling versus usual care. The intervention group was shown to have a decreased rate of abuse and an improved quality of life.³⁹

Several studies have shown that the act of seeking a protection order decreases intimate partner violence even if the order is not granted. A 2004 cohort study from Houston followed 149 women who applied for restraining orders. At baseline, levels and types of violence were similar among women who did and did not receive final protection orders. By 3 months, threats of assault, physical abuse, stalking, and work-site harassment had decreased to at least half the baseline levels in both groups. These decreases were maintained throughout the 18-month study period.⁴⁰ These findings suggest that clinicians should encourage abused women to pursue protection orders and should provide these women with assistance in making the necessary phone calls as a concrete, effective way of empowering them and increasing their safety.

There are limited data available regarding the efficacy of interventions for batterers. Most programs for batterers combine group counseling and individual counseling for a period of 6 to 12 months. Batterers are often ordered to attend these programs by the courts and often fail to complete the programs. Observational data suggest that some men who voluntarily choose to attend these programs succeed in decreasing their abusive behavior. One randomized, controlled trial of interventions for batterers has been conducted: the San Diego Navy Experiment.⁴¹ In this trial, abusive naval officers were randomized to group sessions for men, group sessions for couples, individual counseling, or no treatment. The no-treatment group received one session of counseling. At the end of the experiment, the frequency of abuse and new arrests had declined to equally low levels in all four groups. The men were all career officers who may have felt that their abusive behavior was jeopardizing their career, and this may have led to the overall improvement of behavior in all groups.

Two studies have shown that abusers who complete a batterer intervention program are less likely to be charged with new crimes. One study assessed the efficacy of a program called EVOLVE, which addressed parenting issues, sexuality, and sexual violence and integrated substance-abuse education. The study compared the outcomes in batterers ordered by the courts to attend EVOLVE with the outcomes in batterers ordered to attend a more general 26-week program. The evaluation used a sample of 420 men who attended at least one session of EVOLVE and a sample of 124 men who attended at least one session at the comparison site. Completion rates were similar in the two groups: 63.5% for EVOLVE and 65.2% for the comparison group. Six months after leaving the program, 83.4% of those who successfully completed EVOLVE had no further arrests, compared with 58.3% who did not complete the program. A similar pattern was found for the comparison group. This study showed that successful completion of a batterer’s program correlated with a decrease in arrests.⁴²

Similarly, a Massachusetts study with a 6-year follow-up of offenders who attended batterer-intervention programs showed that those who completed a program were significantly less likely to be charged with new crimes. Supervision by a probation officer significantly increased the likelihood that the batterer would complete the program: 62% of offenders who were actively supervised by a probation officer completed a certified batterer-intervention program, versus 30% of offenders who were not under probation supervision.⁴³

It is not recommended that the primary clinician confront the abuser. Letting the abuser know that his victim has disclosed abuse can place her in increased danger. Marriage counseling is not recommended for couples in abusive relationships. Instead, clinicians should focus their efforts on helping the victim.

Efforts to prevent domestic violence are increasing. The Boston Dating Violence Intervention Project has focused on high-school students, offering school assemblies that educate students about the characteristics of abusive relationships and training for the school staff on how to identify students who may be in abusive relationships. Students felt that the sessions were helpful in teaching them how to identify and get out of abusive relationships. A study of female public-high-school students in Massachusetts found that about 20% had been physically or sexually abused by a dating partner.⁴⁴ In a larger study of Maryland public-high-school students, 10% of those surveyed reported experiencing physical violence from dating partners; a variety of risk factors were prevalent in adolescents who experienced dating violence, including depression, considerations of suicide, physical fighting, and unprotected sexual activity.¹¹ These findings suggest that prevention efforts must begin at an even earlier age.

The Centers for Disease Control and Prevention created the Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) program in 2002 to facilitate primary prevention of intimate partner violence at the community level. Nine states were initially funded, and five more were added in 2003. Through the DELTA program, the CDC funds state-level domestic-violence coalitions to provide prevention-focused training, technical assistance, and funding to local Coordinated Community Responses (CCRs).⁴⁵ For example, the Rhode Island Coalition Against Domestic Violence has funded four local CCRs that are focusing prevention efforts on youth and their parents, and it is partnering with an evaluator to assess the efficacy of these interventions. Data on the efficacy of these community-based primary prevention interventions will be helpful.

The author has no commercial relationships with manufacturers of products or providers of services discussed in this chapter.