Terri L. Weaver, Ph.D.
Center for Trauma Recovery, University
of Missouri-St. Louis St. Louis, MO
Copyright
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Practitioners within the health arenas may knowingly (or unknowingly) see victims of partner violence everyday. These victims may be presenting with acute injuries, stress-related physical problems, or for routine health visits. Increasingly, health care providers are recognizing that they can play an important role in the intervention/prevention of partner violence. Therefore, visits to the health care provider are a window of opportunity for violence to be assessed, detected, and for appropriate referrals to be made. In order for health care providers to make the most of this opportunity, they need to have information about the physical impact of partner violence. This chapter reviews findings from a meta-analytic review of the partner violence literature, examining physical impact and post-traumatic stress disorder (PTSD) associated with partner violence. This chapter will focus on the clinical implications of these findings for practitioners and will conclude with a comprehensive set of recommendations for designing model programs for medical assessment and intervention in partner violence.
How Many Patients in Health Care Settings Have Experienced Partner Violence?
Generally, patients do not come into their health care provider's office saying that they are being pushed, slapped, or beaten by their partners. Even if patients are repeatedly coming into the office with stress-related health problems, such as frequent headaches, cold sweats, general anxiety, and sleeplessness, it is very unlikely that they will report that the stress that they are experiencing is from the conflict or violence within their relationship. Patients may fail to report these symptoms because they are embarrassed or stigmatized by these experiences or they may not even make the connection between these symptoms and their physical distress. The incidence and prevalence of partner violence has been assessed within hospital emergency departments (Abbott, Johnson, Koziol-McLain, & Lowenstein, 1995; Berrios & Grady, 1991; Elliot & Johnson, 1995; Goldberg & Tomlanovich, 1984; McLeer & Anwar, 1989; Pakieser, Muelleman, & Lenaghan, 1996), primary care settings (Hamberger, Saunders, & Hovey, 1992), general hospital settings (Bergman, Brismar, & Nordin, 1992) and obstetrical and gynecological settings (Amaro, Fried, Cabral, & Zuckerman, 1990; McFarlane, Parker, Soeken, & Bullock, 1992).
Within medical settings, one way that studies have assessed for partner violence is by examining hospital charts and looking for notations which would indicate that the patient reported partner violence. Chart review yields relatively low numbers of individuals stating that they are experiencing partner violence (5.6%)(McLeer & Anwar, 1989). Interestingly, this number is very similar to the number of victims of partner violence (6%) identified by the practice standard, in which health care providers ask individuals who they subjectively determine to be at risk for partner violence (Hamberger, Saunders, & Hovey, 1992). Given that hospital charts reflect the quality of the assessment done by the particular health care professional and that many health care professionals use subjective (and as we will see often inaccurate) means of making this determination, it is not surprising that these estimates are so similar.
In contrast, estimates of partner violence rise when health care providers use standardized assessment measures. Standardized assessment means that the health care providers use specific and detailed questions to assess every individual who presents to the health care setting, regardless of whether the individual seems like a victim of partner violence. Pakieser, Muelleman, and Lenaghan (1996) systematically assessed history of violence within a large sample of women (N = 9057) reporting to 10 emergency departments in two cities and found that 10% of the women stated that they were currently in an abusive relationship. Similarly, Abbott, Johnson, Koziol-McLain, and Lowenstein (1995) found that 12% of a sample of 418 women, reporting to the emergency department, stated on a survey that their current male partners were physically abusive. Within obstetrical settings, systematic assessments of violence history have found between 4%-7% of women reporting current physical abuse while pregnant (Amaro, Fried, Cabral, & Zuckerman, 1990; Hillard, 1985).
Estimates of current partner violence within primary care settings are even higher. Assessment of a consecutive sample of women within community practices revealed that 12%-23% of respondents have been physically assaulted by their partners within the past year (Elliott & Johnson, 1995; Hamberger, Saunders, & Hovey, 1992). When individuals are assessed for their lifetime history of experienced partner violence, estimates across settings rise even more dramatically. Between 36-54% of clients within emergency departments and primary care settings state that they have experienced partner violence at some point within their lifetimes (Elliott & Johnson, 1995; Abbott et al., 1995).
Taken together, these findings suggest that health care professionals will see many victims of partner violence, including roughly 10-23% of the patient population who are currently experiencing partner violence and 40-54% who have experienced partner violence in the past. These individuals will most often be hidden victims. That is, they will not be presenting with the violence as their primary complaint. Rather, they may be presenting for treatment of stress-related complaints, preventive health care, or (less often) treatment of violence-related injuries. While these prevalence rates inform us about the number of individuals who have experienced partner violence, they say nothing about the impact of the experiences of partner violence on an individual's health and physical functioning. In order to examine and review the magnitude of this impact, a meta-analytic study was conducted. Findings from this study will be summarized within this chapter. Before discussing these findings, I will briefly describe the meta-analytic method and provide a rationale for why this is the most powerful approach to examining the relationship between partner violence, physical health, and PTSD.
How Common is Partner Violence in Health Care Settings?
Standardized and detailed assessments of partner violence within health care settings yield more accurate estimates of the prevalence of partner violence when compared with chart reviews. Across all health care settings, primary care settings have the greatest number of current victims of partner violence (12-23% of all patients). Estimates of lifetime experiences of partner violence are even higher than estimates of current partner violence across all settings (40-54% of all patients).
What is a Meta-Analysis?
When literature is reviewed and synthesized, the reviewer has a number of different choices of how to approach the review. Narrative reviews focus on a particular question of interest and discuss research findings from studies which examined issues associated with that topic. Often, when the reviewer examines findings within these studies, there are groups of findings which conflict with one another. The reviewer is then forced to reconcile these differences by logically balancing the magnitude of the findings with the relative strengths and weaknesses of the vast number of variables within each study's methodology. A meta-analysis takes a quantitative (numbers) approach to reviewing the literature (Glass, McGaw, & Smith, 1981; Rosenthal, 1983; Rosenthal, 1995). That is, meta-analytic statistics are used to combine, summarize, and integrate findings from multiple studies. This combination can take place because the meta- analytic strategies statistically convert all findings from each different study into a common metric or common number which can be used for comparison across studies. Thus, these techniques are equipped for summarizing the results of a number of studies, in spite of the fact that the studies may have used very different methodologies and very different outcome measures. For example, if one study's findings are considered to be apples and oranges and another study's findings are considered to be bananas and pears, the common metric would be a fruit salad, which is both qualitatively different from the individual ingredients, but as a whole, able to be made by each set of ingredients. This fruit salad can then be used as the unit of analysis, regardless of the individual ingredients making up the salad. One advantage of doing a meta-analysis (as opposed to a narrative review) is that the reviewer does not have to rely on the limitations of memory or subjective interpretation when evaluating the relative strengths and weaknesses of different study findings. Rather, conflicting findings can be evaluated using statistical tests which systematically examine which variables may be determining the differences between the studies.
The common metric used within a meta-analysis is called an effect size. There are a number of different types of effect sizes which the meta-analytic reviewer can use, including Rosenthal's r, Cohen's d, or Hedges' g (Mullen, 1989). Cohen's effect size (1988) d was the common metric used within this review of the literature. This effect size was calculated for each study from the t, F, chi-square, r, or d statistic, or from raw means and standard deviations, utilizing procedures by Rosenthal (1991). In addition, each effect size was weighted by the study's sample size with the rationale that larger samples produce more reliable estimates (Rosenthal, 1991). Essentially, Cohen's d is a score which consists of the difference between the average score of the group of interest (for example, victims of partner violence) and the comparison group (for example, victims who are experiencing marital distress but no violence) divided by the sum of the standard deviations of the two groups. As effect sizes get larger, the researcher is more confident of the differences between the group of interest and the comparison group. That is, larger numbers indicate more of a relationship. Using words to describe the magnitude of the effect size, Cohen (1988) designated that small effect sizes are in the range of .2, a medium effect size is within the range of .5, and a large effect size is within the range of .8. Effect sizes falling between these anchors were evaluated accordingly. An effect size of 0 (or approaching zero) means that there was no difference between the experimental and comparison groups. Findings from the meta-analysis will be summarized in each section by using these terms (small, medium, or large) to refer to the magnitude of the effect size or strength of the relationship between the variables of interest.
After the effect sizes have been calculated, statistical tests can be conducted to determine if two effect sizes are significantly different from one another (for example, to answer the question of whether the magnitude of the impact from partner violence is greater if one is examining physical injuries or chronic health problems). Finally, statistical tests can be conducted to determine if the effect sizes appear to hang together for each individual construct (for example, is the magnitude of the effect sizes for sleep problems similar across studies or is there significant variability from one study to another) (Rosenthal, 1991). This quality of hanging together is referred to as effect size homogeneity, and when effect sizes are homogeneous the reviewer is more confident that the finding is strong and not better explained by another variable.
What is a Meta-Analysis?
A meta-analysis takes a quantitative approach to reviewing the literature. All research findings are converted to a common number called an effect size. The effect size used in this chapter is called Cohen's d.
A Cohen s d of :
How Were Studies Chosen For Inclusion in this Review?
The literature was reviewed looking for studies which examined the relationship between partner violence and physical health, including physical injuries, chronic health problems, and medical utilization. Studies which examined the relationship between partner violence and PTSD were also included. Sources for the search included electronic literature searches (PSYCHINFO and MEDLINE), scans of the reference lists from review articles (e.g. Fagan & Browne, 1994; Campbell, Harris, & Lee, 1995), and scans of the reference lists of selected studies. In order to be used in the meta-analytic portion of the literature review, studies had to use a quantitative (numbers) form of measurement and had to examine the relationship between partner violence and physical health/PTSD.
Thirty-three studies met this criteria and each of studies are listed and described in Appendix A. Studies typically failed to meet this criteria because they were not research studies (but were commentaries or opinion pieces) or they were descriptive studies, which examined the prevalence of partner violence in health care settings but did not examine the impact of such experiences. Even though these studies could not be included in the meta-analysis they were frequently still used in this review in the discussion of the meta-analytic findings. Findings within the literature will now be reviewed with an emphasis on relevant findings for the detection of partner violence within health care settings.
How Much Does Partner Violence Impact Upon Victim's Physical Health and Symptoms of PTSD?
The literature review to this point has established that there are a number of victims of partner violence who present to health care settings and whose underlying problem (the violence within the relationship) goes undetected. The meta-analytic review of the literature was able place a number on just how much partner violence negatively impacts a victim's physical health and PTSD symptoms by calculating an overall effect size. Overall, there was a small to medium impact of partner violence on physical health and PTSD symptoms. Even though a small to medium effect sounds like the impact is not very serious, further testing revealed that the size of the effect was both significant in a statistical sense and in a practical sense (Rosenthal, 1991; 1995). In addition, the size of the impact of partner violence on physical health and PTSD varied significantly across the studies, depending on such things as whether health problems and PTSD was measured in populations of shelter victims (e.g. Jaffe, Wolfe, Wilson, & Zak, 1986) or was measured in general/community samples (Sorenson, Upchurch, & Shen, 1996).
As a general rule, victims of partner violence who go to shelters tend to have histories of very chronic and severe types of violence. Therefore, the impact of these experiences on the victim's health and PTSD is typically the most serious. For example, the Jaffe et al. shelter study (1986) found a very large impact of partner violence on women's chronic physical problems and sleep problems. On the other hand, when researchers assess individuals in the community for their experiences of partner violence, they typically find very few members within the community studies who are experiencing the same serious level of violence as victims within shelter studies. Therefore, Sorenson, Upchurch, and Shen (1996) found an extremely small effect size for the relationship between partner violence and men and women's physical injuries within their community sample.
In summary, averaging across all studies within the meta-analytic portion of the literature review, partner violence had a small to medium, but very important, impact upon victims' health and PTSD. The amount of impact varied widely, in part, depending on the amount of violence which the individual has experienced. Victims who experience the most serious types of violence will have some of the most serious types of health problems and PTSD, while victims who experience less severe forms of violence will have less of an impact. Given that partner violence does impact victims' health and PTSD symptoms, how can health care providers begin to use the clinical presentation of the victim to help in the identification of victims of partner violence within health care settings? The meta-analysis addressed this question by looking at types of health or PTSD impact which may be distinctive or unique to the victim of partner violence.
How Much Does Partner Violence Impact Victim's Physical Health and PTSD Symptoms
Overall, partner violence has a small to medium, but important, impact on victims physical health and PTSD symptoms.
Individuals who experience the most serious types of partner violence (for example, women in shelters) experience the most impact of the violence on their health and PTSD symptoms. Individuals who experience the least serious types of partner violence (for example, victims in the community who have not reported for treatment) experience the least impact.
How Can the Health Care Clinician Better Identify the Victim of Partner Violence?
Are Individuals' Personal Characteristics Related to the Severity of Physical Health or PTSD Impact?
The review to this point has found that clinicians, who are left to their own devices to determine which patient may or may not be a victim of partner violence, do a very poor job of identifying these patients. What types of clues are these clinicians using to decide who to assess? Often clinicians say that they are more likely to assess for partner violence in their patients who are minorities or from lower socioeconomic levels (Sugg & Inui, 1992). In essence, they are using the individual's personal characteristics as a clue to determine whether to ask if the individual's injuries, health problems, or PTSD symptoms were caused by partner violence. In addition, one study, using college students (but not medical students), found that knowing the race of the perpetrator may subtly influence how severe the student viewed the victim's injuries (Pierce & Harris, 1993). In this study, a white assailant was perceived by white subjects as causing more severe bleeding and internal injuries than a black assailant (whose victim's injuries were described in exactly the same way). While it is a leap to draw conclusions about the medical community based on studies within college (non-medically trained) populations, the possibility does exist that health care providers may even judge the severity of victim's injuries differently, depending on their own race and the race of the perpetrator.
The meta-analytic review of the literature found that there was not a significant impact of the victim's age, race, education, minority representation, and income on the magnitude of the physical health/PTSD effect size. That is, the impact of partner violence on the victim's physical health and PTSD did not differ, regardless of the victim's personal characteristics. These findings also suggest that these personal characteristics are not helpful markers when deciding to assess whether a physical health problem or PTSD symptoms are related to partner violence. One personal characteristic, whether the victim of partner violence was a man or a woman, did influence the severity of the impact of partner violence. There was a high medium to large effect size for women's physical injuries (such as bruises, cuts, abrasions, etc.) (Cantos, Neidig, & O' Leary, 1994) and women's serious injuries (Cascardi, Langhinrichsen, & Vivian, 1992) compared with men's injuries or serious injuries.
Taken together, a victim's personal characteristics do not influence the physical health or PTSD symptoms associated with partner violence. However, women appear to be more likely than men to be physically injured as a result of the partner violence.
Do Partner Violence-Related Symptoms Differ Based on the Individual's Personal Characteristics?
The impact of partner violence on the victim's physical health and PTSD did not differ, regardless of the victim's personal characteristics of age, race, education, minority representation, and income.
Women, compared to men, victims of partner violence were more likely to be physically injured and seriously physically injured.
Clinicians should not continue to use a patient's personal characteristics to determine whether to ask about partner violence as a cause of their physical health complaints or PTSD symptoms.
What Types of Injuries and Physical Health Problems are Reported by Military Samples?
Three studies within the meta-analytic review focused on military couples (Cantos, Neidig, & O' Leary, 1994; Langhinrichsen-Rohling, Neidig, & Thorn, 1995) and women veterans of the military (Murdoch & Nichol, 1995). Overall, military status did not influence the partner violence and physical health/PTSD relationship when compared with other types of populations, such as shelter samples, prenatal clinics, or community samples.
Cantos, Neidig, and O' Leary (1994) studied 180 couples who had been referred to a treatment program for partner violence being conducted at three military bases. The most common route of referral was through military police in response to domestic disturbance calls. This study primarily examined the types of injuries reported by each individual, including no injuries, minor injuries, moderate injuries (treatment needed), serious injuries (hospitalization), and permanent disability. In 65% of the couples, the husband or the wife reported having experienced injuries as result of the violence. The majority of these injuries did not require medical attention (76%) and none of the injuries resulted in permanent disability. The wife reported receiving injuries when the husband did not in significantly more of the couples (38%) compared with the number cases in which the husband reported being the only person who was injured (5%). This study found that there was a range of medium to large effect sizes for wives' injuries compared with husbands' injuries. In cases in which the women did inflict injuries on their male partners, they were more likely to have used weapons or objects. In contrast, men did not need to resort to using weapons to cause injury and were more likely to push, grab, shove, choke, strangle, and beat up their spouses than were women.
Langhinrichsen- Rohling, Neidig, and Thorn (1995) assessed 199 military couples who were mandated for treatment. Ten percent of the sample self-referred to the treatment program and the remaining number were referred after military police were called to their house for a domestic disturbance. Like the previous study, significantly more women reported experiencing injuries (61%) compared with the men (30%), with the women also reporting more serious injuries. Murdoch and Nichol (1995) surveyed 191 women veterans of the military. Twenty-four percent of the respondents under 50 years old reported domestic violence in the past year. Among older respondents, 7% stated that they had experienced domestic violence within the past year. Thirty percent of the women experiencing physical assault from their partners also reported rape by their partners. A history of partner violence was associated with significantly more lifetime surgical procedures, although the size of the effect was very small.
Taken together, military samples, as a whole, did not show stronger relationships between partner violence and physical health/ PTSD symptoms compared with nonmilitary samples. Specific studies supported the larger impact of physical injuries for women compared with men and one study found higher rates of surgical procedures for women veterans who experienced partner violence compared with nonvictims. However, none of these three studies specifically compared military with non-military groups, so it is not possible to say if any of these findings are particularly distinctive for military samples or if they are just characteristic of partner violence.
What Types of Injuries and Physical Health Problems are Reported By Military Samples?
Overall, military samples do not appear to be distinctive for their reported types of physical health problems or PTSD symptoms.
Findings within specific studies supported previous conclusions that women victims of partner violence were more apt to experience physical injuries compared with men.
What Types of Physical Injuries Would the Clinician See with a Victim of Partner Violence?
It has been estimated that as many as 1 million women receive emergency medical services each year in the United States for injuries related to partner violence (National Committee for Injury Prevention and Control, 1989). Additionally, women make almost three times as many medical visits for injuries related to partner violence as they do for injuries related to motor vehicle crashes (National Committee for Injury Prevention and Control, 1989). There is no single type of injury which would help the clinician to identify that the injury was caused by partner violence. However, there do appear to be some patterns of physical injuries which may inform identification.
Health care providers note that injuries due to partner violence are more often found in central areas of the body, including the head, face, neck, breast, or abdomen compared with accidental injuries, which are more likely to involve more peripheral parts of the body, such as arms and legs (Alpert, 1995; Council on Scientific Affairs, American Medical Association, 1992). The types of injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to more permanent disability such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds (Council on Scientific Affairs, American Medical Association, 1992; Judd, 1991). It has been estimated that 75% of injuries incurred by women victims of partner violence are to the areas of the head, face, and neck (Appleton, 1980). One medical practice of 546 women with facial injuries found that men's violence was the third largest cause of facial injury with 8% (N=51) of these women stating that (typically) their husband or boyfriend caused the injury (Zachariades, Koumoura, & Konsolaki-Agouridaki, 1990). The most common type of facial injury within this study was fracture of the mandible (jaw). Although injuries to the more central parts of the body are the most common, another type of characteristic partner violence-related injury involve bruises of the ulnar (the long bone) portion of the forearm (Alpert, 1995). These injuries can result as women raise their arms to protect their faces from the blows during the assault.
In addition to the specific type of injury, the pattern of physical injuries and the clinical presentation of the client can also serve as clues that the injuries were caused by partner violence. Specific injury patterns include multiple injuries or injuries which are in various stages of healing. The clinician may also be suspect when there has been a delay between the time of the injury and arrival to the health care setting (Alpert, 1995). The coloration of bruises changes over time and the following guide to these changes can assist the clinician with diagnosis of previous injuries and with determining the length of time since the injury:
| Time | Color |
|---|---|
| 24 hours | Swollen, tender; reddish with some blue or purple discoloration |
| 1-5 days | Blue to bluish brown |
| 5-7 days | Greenish coloration |
| 7-10 days | Yellowish coloration |
| 10-14 days | Brown |
| 2-4 weeks | Clearn |
Finally, the clinical presentation or behavior of the patient can be another potential source of identification. For example, the patient may 1) make repeated visits to the office, emergency room, or clinic, 2) describe herself as being accident prone, and 3) describe the injuries in an implausible way or may offer a simplistic, vague explanation of the injuries. These behavioral/clinical signs in conjunction with the injury presentation can signal the clinician that partner violence was the cause of the injury.
The meta-analytic portion of the literature review was able to evaluate the magnitude or strength of the relationship between physical injuries and partner violence. Physical injuries were measured one of two ways: 1) the specific type of injury was measured (for example, fractures, bruises, or abrasions) or 2) the location of the injury was measured. Within the literature review, very few studies actually measured the type of injury which the victim experienced. Rather, the study focused on describing whether there had ever been any injury or the researchers asked the victim subjectively to determine whether there had ever been any severe injury. The effect size for the relationship between partner violence and physical injury was small to medium in magnitude and the size of this effect was significantly smaller than the effect size for the relationship between partner violence and chronic health problems and PTSD. These findings suggest that, while physical injuries are a very significant problem associated with partner violence, other types of chronic physical health problems and PTSD, may be an an even bigger problem. However, the magnitude of the partner violence/physical injury effect sizes varied significantly across studies. As discussed previously, the smallest effect sizes were found in studies in which the victims experienced very little violence (Brush, 1990; Sorrenson, Upshurch, & Shen, 1996) and medium to large effect sizes were found in studies which compared women's injuries with men's injuries in couples presenting for treatment for domestic violence (Cantos, Neidig, & O'Leary, 1994; Cascardi, Langhinrichsen, & Vivian, 1992).
What Types of Injuries Would the Clinician See with a Victim of Partner Violence?
Injuries from partner violence are more often found in central areas of the body, including the head, face, neck, breast, or abdomen compared with accidental injuries, which are more likely to involve the periphery of the body (for example, the arms or the legs).
Injury patterns, characteristic of partner violence, include multiple injuries, injuries which are in various stages of healing, and injuries for which there has been a delay in seeking medical attention.
Overall, the meta-analysis found a small to medium effect size for the relationship between partner violence and physical injuries. Studies with victims who experienced little violence had the smallest injury effect sizes and studies with victims who experienced the most violence had the largest injury effect sizes.
What Type of Chronic Health Problems Would the Clinician See with a Victim of Partner Violence?
Given that partner violence occurs within relationships in which there is lots of conflict, intense and negative emotions, and generally high levels of stress, partner violence may be even more likely to be associated with stress-related physical health problems than physical injuries (Koss & Heslet, 1992). Similarly, stress-related physical health problems may impact more people (than do physical injuries), even people who are experiencing relatively low levels of physical violence. It is also possible that people may misinterpret some of their stress-related psychological reactions to the partner violence as physical problems. For example, the symptoms of one stress-related psychological condition called panic disorder include symptoms of a racing heart, rapid breathing, choking sensations, and chest pain (APA, 1994). Patients with symptoms of panic will often go to their primary care physician or to the emergency department with these symptoms and think that they are having a heart attack. Other physical symptoms, such as sleep problems and difficulty with concentration, are part of the symptoms of two psychological conditions which are commonly associated with partner violence: depression and post-traumatic stress disorder (PTSD) (APA, 1994).
Clinicians in primary care settings need to be particularly alert for the types of chronic physical health problems which may signal that a patient is experiencing partner violence. Like the physical injuries, there is no single type of chronic physical health problem which is indicative of partner violence. However, there may be a pattern of symptoms which can alert the clinician to inquire about other stressful experiences in the patient's life.
Within a large national study (N=6002) of partner violence, Stets and Straus (1990) found that 77% of the women victims of minor or severe partner violence reported psychosomatic symptoms of headaches and cold sweats compared with 48% of male victims of minor or severe partner violence. While more women than men had these chronic types of physical complaints, the difference between the two rates was not statistically significant. Within another very large study (N = 3419) of women, only, Golding (1996) found that women victims of sexual assault by a spouse were at higher risk of difficulties with decreased interest in sex or decreased sexual pleasure compared with other sexual assault groups (sexual assault by a parent, acquaintance, or stranger). It is important to note that, even though these symptoms are labeled as psychological or psychosomatic in nature, it does not mean that the individual is not experiencing genuine physical distress. Rather, this means that these individuals are experiencing psychological and physical reactions with an environmental cause (e.g. the high levels of stress that they live with on a daily basis) rather than a biological cause (e.g. a bacterial or viral agent).
Aside from physical reactions to the stress and violence, victims of partner violence may also be more likely to contract other physical illnesses, since experiencing the stress associated with the physical violence may decrease the effectiveness of the individual's immune functioning. An individual's immune functioning helps their body to resist other contagious diseases. At least one study has found that individuals exposed to very chronic and traumatic stressful experiences experience a decrease in the effectiveness of their immune system (McKinnon, Weisse, Reynolds, Bowles, & Baum, 1989). However, to date, no researcher has ever examined the impact of partner violence on immune functioning, so these assumptions are speculative at this point.
The meta-analytic portion of the literature review was able to examine the magnitude or strength of the impact of partner violence on chronic physical health problems. Overall, the effect size for partner violence and chronic health problems was small to medium in size. The size of the effect was larger than the effect size for partner violence and physical injury but smaller than the effect size for partner violence and PTSD. However, in a statistical sense, the effect size was not significantly different from either outcome (injury or PTSD). Depending on the type of chronic health problem measured in a particular study, the strength of the relationship between partner violence and chronic health problems varied significantly. Chronic physical health problems were measured in five ways: 1) general physical complaints, 2) insomnia, 3) headaches, 4) chronic pain, and 5) sexual difficulties.
Most studies assessed chronic health problems using measures of general physical complaints (45%) with the other types of health problems measured less often. The relationship between general physical complaints and partner violence had a medium to large effect size. Within all of the studies which did use measures of general physical complaints, findings differed significantly across studies. A study which used a measure called the General Health Questionnaire (GHQ) (Goldberg & Hillier, 1979) had very large effect sizes compared with studies using a measure called the Symptom Checklist-90 (SCL-90). These findings suggest that the GHQ may be a particularly sensitive instrument for measuring chronic physical complaints within this population. Headaches had a very small effect size, while chronic pain and sexual difficulties had small to medium effect sizes. Insomnia had a very large effect size but these findings should be considered very cautiously since only one study examined the effects of partner violence on sleep problems.
Based on these findings, the clinician should be alert to the following. Victims of partner violence may be most likely to present with rather vague and general chronic physical health problems, such as not feeling well, general aches and pains, and feeling stressed out. As far as specific complaints go, chronic sleep problems may indicate that the individual is experiencing high levels of stress which may be associated with partner violence. Chronic pain and sexual complaints may also suggest that the clinician inquire further about the source of these problems. Complaints of persistent headaches are less likely to be specifically associated with partner violence, although an individual who is experiencing partner violence could be having problems with headaches.
What Types of Chronic Physical Health Problems Would the Clinician See with a Victim of Partner Violence?
Stress-related physical health problems (such as sleep problems, problems with concentration, or difficulties with sexual functioning) may even be more commonly seen in victims of partner violence than physical injuries.
Victims of partner violence may present to the clinician with vague and general physical health problems, such as not feeling well, general aches and pains, and feeling stressed out.
What are the Symptoms of PTSD which the Clinician may See in a Victim of Partner Violence?
PTSD is a psychological condition which individuals can develop after experiencing a traumatic event (APA, 1994). The traumatic quality of the event includes experiencing something which included intense fear, helplessness, or horror, and experiencing something that involved a threat to a person's life, to their physical integrity, or the threat of or receipt of injury. Clearly, many individuals who are experiencing violence within their relationship have had assaults or other threatening experiences which would meet this criteria. The actual symptoms of PTSD include a set of re-experiencing symptoms, a set of avoidance symptoms, and a set of arousal symptoms (APA, 1994). Samples of the warning signs of trauma-related stress include:
Adapted from the American Psychological Association, Warning Signs of Trauma-Related Stress
There is one large national study which has looked at the prevalence of PTSD in a community sample of women victims of partner violence (Weaver, Kilpatrick, Resnick, Saunders, & Best, 1995). This study found that 27% of women victims of partner violence met diagnostic criteria for PTSD. Studies examining rates of PTSD within shelter samples have typically found higher estimates of PTSD ranging from 45% - 84% (Astin, Ogland-Hand, Coleman, & Foy, 1995; Houskamp & Foy, 1991; Kemp, Rawlings, & Green, 1991). Rates of PTSD have not been examined within male victims of partner violence. These findings mirror the physical injury results in that victims of partner violence within treatment settings, such as shelters, exhibit higher rates of symptoms (physical injuries and PTSD) compared with victims of partner violence who are not in treatment settings. Researchers have found that experiences of PTSD are more likely when victims have experienced a threat to their life and/or threatened or actual physical injury (Resnick, et al., 1993). Given that victims of partner violence within shelter settings have typically experienced more chronic and severe levels of violence, these more serious experiences explain why they are having higher rates of PTSD.
The meta-analytic portion of the literature review was able to examine the magnitude or strength of the impact of partner violence on PTSD. Overall, the effect size for partner violence and PTSD was medium to large and was significantly larger than the effect sizes for the other types of impact (physical injuries and chronic physical complaints). The size of the PTSD impact varied significantly across studies. A study (Gleason, 1993) which used a diagnostic instrument called the Diagnostic Interview Schedule (DIS) had a very small effect size. Some researchers (see Resnick, Kilpatrick, Dansky, Saunders & Best, 1993) have suggested that this instrument may not be a very sensitive measure for detecting PTSD and this may account for the small effect size. Large to very large effect sizes were found within two studies of treatment-seeking (shelter residents and attendees of shelter groups) victims of partner violence (Astin, Ogland- Hand, Coleman, & Foy, 1995; Houskamp & Foy, 1991). As previously stated, given that women seeking treatment for partner violence typically experience severe and repeated physical assaults, the finding that PTSD has a stronger impact within this sample is not surprising.
These findings have a number of implications for the clinician. First, given the magnitude of the impact of PTSD, the clinician should be particularly alert to the symptoms of post-traumatic stress as indicators of extremely stressful or traumatic experiences in the patient's life, including the possibility of partner violence. The difficulty for the clinician lies in the fact that the patient will not come in to the clinician making the connection between their symptoms and the traumatic experience. Rather, they may come in with a number of individual symptoms of the PTSD response. In particular, patients frequently present with complaints of sleep problems. Sleep problems may include having difficulties with night-time awakening after having had a nightmare, having difficulty falling asleep, or having difficulty staying asleep. Patients will typically not volunteer the fact that they are experiencing nightmares. The clinician is advised to inquire thoroughly about the sleep problems and listen for clues that the sleep difficulty may include some more traumatic material (for example, the patient may report that they frequently awaken from sleep and find that they are screaming or are feeling extremely afraid upon awakening). Patients may also report individual symptoms of irritability (for example, saying that they are snapping at their children), difficulty with concentration (for example, saying that they can't keep their mind on what they are doing), or generally feeling stressed out. The clinician is encouraged to assess for the spectrum of PTSD symptoms if patients report any of these individual symptoms. Of course, each symptom could be associated with any number of different psychological or medical conditions (other than PTSD), but a thorough assessment will give the clinician much more information than relying on the client to report spontaneously all of their symptoms.
The other challenge facing the clinician lies in the fact that PTSD, by nature, involves avoidance of anything that reminds the patient of the traumatic event. This avoidance will include not wanting to talk about the partner violence. Clinicians frequently lament the fact that victims of partner violence do not want to talk about their experiences due to denial or wanting to minimize their experiences. However, victims of partner violence may also not want to talk about the partner violence because they experience the PTSD symptoms of extreme anxiety and fear when they talk about them. Therefore, it can be helpful for the clinician to talk with patients about the post-traumatic response so that they have a frame for understanding the reactions that they are having and for understanding why it is so hard to talk about their experiences.
What is the Relationship between Partner Violence and PTSD?
It is estimated that 27% of women victims of partner violence within community settings and 45%-84% of women victims of partner violence within shelter settings meet criteria for PTSD.
The effect for the relationship between partner violence and PTSD was medium to large in size.
PTSD is most likely following experiences of partner violence which include life-threat and/or threatened or received physical injury.
Clinicians need to be alert for individual symptoms which may signal PTSD, including difficulties with sleep, nightmares, irritability, and avoidance of reminders of the partner violence.
What Types of Violent Acts Have the Most Impact on Physical Health and PTSD?
Partner violence can include more minor experiences of violence, including pushing, shoving or slapping, or extremely serious experiences of violence, including threats with a weapon, being beat up, or being raped (See Chapter 1 for more details on different types of partner violence experiences). Certain types of partner violence experiences may have more of an impact on individual's physical health and PTSD symptoms. We have already seen that physical injuries and higher rates of PTSD are related to more severe experiences of partner violence.
The meta-analytic portion of the review was able to examine the magnitude or strength of the impact of specific types of partner violence on physical health and PTSD. Studies frequently did not ask the participants about which types of violence they have been experiencing. Rather, they tended to develop a single score to measure the overall severity of the violence. Studies using these types of measures were included in the "other" category. However, one study did specifically ask about the type of violence which was associated with the impact. From this study, three categories were created: 1) being beat up, 2) having a knife or gun used on you, and 3) being kicked or hit with a fist. Each of these acts of violence had a medium to high medium impact on physical health/PTSD. The other category, which was frequently a general severity measure of partner violence, had a high medium impact on physical health/PTSD.
These findings have a number of different implications for the clinician for guiding their assessment of the patient's relative risk, depending on the type of violence within their relationship. Reports of more serious forms of violence, including beatings, threats with weapons, and strikes with fists or kicks are associated with higher relative risk in terms of the impact on victim's physical health/ PTSD.
There are two omissions in these findings which also have implications for the clinician's assessment. Sexual violence within the relationship was seldom assessed in the reviewed studies. Sexual assault can have very serious impacts upon the victim's health, including increased risk of contracting sexually transmitted diseases, chronic difficulties with pelvic pain, urinary tract infections, and sexual assault is also strongly associated with PTSD. Therefore, it is recommended that the clinician assess for sexual assault within the relationship, whenever the clinician learns that there is partner violence of a physical nature. Also, some acts of violence with the greatest potential to cause death, such as threat with a gun, may result in fewer (non-fatal) physical injuries, because the victim is too intimidated to resist (Saltzman, Mercy, O'Carroll, Rosenber, & Rhodes, 1992). Therefore, it is important for clinicians not to assume that the partner violence is not of a serious nature when victims do not present with injuries. These victims may actually be experiencing the most serious types of partner violence.
What Types of Violence Have the Most Impact on Physical Health/PTSD
More serious types of partner violence, including threats with a weapon, being beat up, or being raped are associated with more severe impacts on physical health and PTSD.
Some of the most serious types of violence, such as threats with a weapon, may be least likely to result in physical injuries, because of the victim's fear of serious injury or death. Therefore, clinicians should not assume that victims who do not present with injuries are not in dangerous situations.
Sexual assault is frequently not assessed in victims of partner violence. Clinicians should be sure to assess for sexual assault in all female victims of partner violence.
Sexual assault increases the likelihood of specific types of physical health problems and PTSD.
What are the Financial Costs of Partner Violence in Health Care Settings?
Thus far, this chapter has focused on the human cost of partner violence to individuals' physical and psychological health. Partner violence also extracts a huge financial cost from health care settings. One hospital in Washington state studied the cost of medical services to victims of partner violence (Appleton, 1980). This study found that the average cost of treating a victim of partner violence within their emergency department was $111. This cost did not include the cost of prescriptions and this was an average cost, so there were clearly patients whose expenses were much more costly. It has been estimated that the yearly medical costs of partner violence are an astounding 1,800 million (1993) dollars (Miller, Cohen, & Wiersema, 1996). Based on these estimates, it is clear that partner violence has both a human and a financial cost.
What is the Financial Cost of Partner Violence?
Treating the physical health consequences of partner violence requires a lot of medical resources.
The yearly medical cost of partner violence is estimated to be 1,800 million dollars.
What Can Health Care Settings do to Intervene in and Prevent Under-Detection of Partner Violence?
Develop Standardized Assessments of Violence
Assessment should be conducted in emergency settings as well as in primary care settings. Assessments should be universal; that is, all patients should be asked about any possible experiences of partner violence. The acronym RADAR serves as a useful tool for the clinician to aid in the assessment of partner violence. This acronym is as follows:
Using RADAR
A = Ask Direct Questions
D = Document Your Findings
A = Assess Patient Safety
R = Review Options and Referrals
Adapted from the Massachusetts Medical Society
Assessment measures should not contain loaded terms, such as partner violence or rape, but rather should describe such experiences to the patient. The Abuse Assessment Screen was developed by the Nursing Research Consortium on Violence and Abuse. This screen has been used effectively in clinical and research settings to assist with the identification of victims of partner violence.
One limitation of this measure is that the terminology in the first question does use the loaded term of abuse. Many patients will not view themselves as abuse victims. However, the subsequent questions do clarify the behaviors with descriptions of hitting, slapping, or kicking, so patients may in fact deny partner violence in response to the first question but answer affirmatively in response to the second question.
Assess for Symptoms of PTSD
When the clinician is repeatedly hearing complaints of sleep problems, irritability, difficulty with concentration, nightmares, etc., the clinician should be alert for these symptoms as being part of a larger set of symptoms of PTSD. There is a 17 item self-report PTSD symptom checklist which can be used as a more standardized assessment of PTSD (PSS-SR: Resick, et al., 1991). This checklist was adapted from a self-report scale developed by Foa et al. (1993). This scale is included in Appendix B.
Couples Should be Assessed Separately, not Conjointly
If clinicians interview couples about their experiences with partner violence together, they run two risks: they may not get accurate information and they may be inadvertently putting the victim at much greater physical risk if she betrays her partner by talking about the violence.
Develop Standardized Procedures for Documenting Partner Violence-Related Injuries
Injury documentation includes having the victim receive a complete physical examination, documentation of the victim's statement of how the injury occurred, documentation of his/her relationship to the alleged perpetrator, and documentation of the injury on a body map and/or in photographs (Sheridan, & Taylor, 1993). Also, use the body map to document residual signs of old injuries. Regardless of whether the victim of partner violence wishes to pursue legal recourse for the partner's behavior, the physical injuries are evidence of a crime and should be documented as such.
Include The Patient's Exact Description of How the Injury Occurred
Documentation should also include the patient's exact description of how the injury occurred. Refrain from making disembodied documentation such as "blow to the head by a fist." Rather, identify how and who caused the injury, using the patient's words. For example, "Patient states that her boyfriend, John Smith, punched to the face five times with a closed fist. By naming the offender (rather than saying boyfriend), the victim is protected from a defense attorney who tries to allege that it was her other boyfriend who hit her. It is also important to note the victim's emotional presentation while she was reporting the crime. Increasingly, attorneys are trying to proceed with prosecution without the victim's testimony. Highly emotional statements about a crime can sometimes be used as evidence.
Develop a Standardized Protocol for Assessing the Safety of the Victim of Partner Violence
Risk factors for lethality may include presence of a gun, partner's violence outside of the home, violence to the children, or threats to the victim's life, use of illicit substances, abuse while the victim was pregnant, imminent plans to leave or divorce a partner (Sheridan & Taylor, 1993). Assist the victim with developing an individualized safety plan. Safety planning consists of identifying idiosyncratic risk factors for the escalation of violence and developing very specific strategies for responding at these times. See Chapter 7 for a more detailed description of a safety plan.
Develop a coordinated legal, psychological and medical response system:
Dutton, Haywood, and Mitchell (in press) have developed a coordinated legal, psychological, and medical response to partner violence within the emergency department. Within this response system, victims of partner violence are able to get legal advice on their options, referral and recommendations for psychological treatment programs, and medical treatment within the emergency room. Developing bridges with these other agencies goes a long way towards continuity, rather than fragmentation of treatment services, with victims of partner violence.
Train staff in helpful and non-helpful responses to victims of partner violence:
Women victims of partner violence report that being listened to, within an atmosphere of respect, and being believed were very helpful responses by individuals providing professional services (Hamilton & Coates, 1993). On the other hand, responses which consisted of persistent questioning of the victim's story, or denying or minimizing the seriousness of the situation were classified as not helpful responses. Statements which initially seem helpful, such as "You don't need the guy, just leave him. Why is a person like you staying with someone like that?" can also be unhelpful as they are subtle victim-blaming statements. Provide training to staff on issues related to the prevalence, dynamics, and impact of partner violence.
Vignettes can also be used in which victim and perpetrator characteristics are systematically changed in order to explore how particular individuals may be responding to stereotypes. These vignettes can also be used to objectively evaluate the effectiveness of the training programs. Individuals who appear to hold entrenched stereotypes about partner violence should not be placed in critical positions of intervening with victims. Have health care providers practice talking about stigmatizing experiences to decrease any personal discomfort that they may experience.
Put aside the quick fix:
Often clinicians may wish that their patients could simply get away from their batterers and be done with all of this. This is a simplified view of things, particularly considering the increased risk which victims experience when they are trying to leave. The goal in working with the victim of partner violence should be based on an empowerment model, assisting the victim to make her own decisions by informing her about available options.
Train staff in characteristic types of victim's injuries:
Train health care providers on injury characteristics and general physical health complaints which appear to be associated with partner violence. These characteristics may include: evidence that an individual has been beat up, soft-tissue injuries, vague or psychosomatic complaints, and central versus peripheral injuries (Judd, 1991). Train health care providers on the changes in the coloring of soft tissue injuries with the passage of time, to assist with injury identification.
Carefully consider some of the negative implications of mandatory reporting of partner violence:
State statutes differ in their mandates of whether partner violence has to be reported (Hyman & Chez, 1995). Victims of partner violence are adults who can make their own decisions (compared with children who are being abused by their caregivers who need to be protected by other adults). These adults are in the process of seeking medical care when it is discovered that they have experienced a crime. It is recommended that this be used as an opportunity to inform and refer rather than mandate individuals to report to legal or criminal justice authorities. If reporting is mandated, one possible backlash is that victims will avoid seeking medical care.
Use research and continued evaluation to insure that protocols are being implemented:
The only way to insure that protocols are used as directed is to continue to monitor their use with evaluation and research within health care settings.
Table 1. Characteristics of the Studies Used Within the Meta-Analysis
| Author | N | Mean Age | Source | Comparison |
|---|---|---|---|---|
| Astin, Lawrence, & Foy (1993) | 53 | 33 | Shelter plus Treatment-Seeking | Within-Subject Assault Severity and Recency of Assault |
| Astin, Ogland-Hand, Coleman & Foy (1995) | 87 | 36 | Shelter plus Treatment-Seeking | Victims of Partner Assault vs. Maritally Distressed, PTSD positive vs. PTSD Negative |
| Bergman, Larsson, Brismar, & Klang (1987) | 98 | 33 | Emergency Room | Assault-Related Injuries vs. Nonassault-Related Injuries |
| Brush (1990) | 5,474 | NR | Community | Male vs. Female Victims |
| Cantos, Neidig, & O'Leary, (1994) | 180 | 25 | Outpatient Treament | Male vs. Female Victims, Injured vs. Noninjured Victims, Minor vs. Serious Injuries |
| Cascardi, Langhinrichsen, & Vivian (1992) | 214 | 37 | Treatment-Seeking plus Community | Within-Subjects Assault Severity, Frequency of Assault, Mild Level of Aggression, and Severe Level of Aggression, Victims of Partner Assault vs. Nonvictims of Partner Assault |
| Cherpitel (1993) | 1,770 | NR | Emergency Room | Violence-Related vs. Nonviolence-Related Injuries |
| Drossman, Leserman, Nachman, Li, Gluck, Toomey, & Mitchell (1990) | 206 | 44 | Outpatient Medical | Victims vs. Nonvictims of Abuse |
| Eby, Campbell, Sullivan, & Davidson (1995) | 110 | 28 | Community Advocacy Program | Within-Subject Assault Severity, Sexual Assault plus Physical Assault vs. Physical Assault only |
| Follingstad, Brennan, Hause, Polek, & Rutledge (1991) | 234 | 37 | Mixed, Shelter plus other Supportive Services | Short-Term vs Long-Term Abuse, Severe Physical Force vs. Moderate Physical Force, More Frequent vs. Less Frequent Abuse |
| Fullilove & Fullilove (1993) | 105 | 32 | Drug Treatment Outpatient | PTSD positive vs. PTSD negative |
| Gelles & Harrop (1989) | 3,002 | NR | Community | Within-Subject Assault Severity, No Violence vs. Severe Violence |
| Gleason (1993) | 11,015 | NR | Shelter plus Community | Shelter vs. Community |
| Golding (1996) | 350 | 43 | Community | Victims of Partner Assault vs. Other Assault |
| Hillard (1985) | 328 | NR | Pre-natal Clinic | Abused vs. Non-Abused |
| Houskamp & Foy (1991) | 26 | NR | Outpatient Treatment Sample | Within-Subject Assault Severity |
| Jaffee, Wolfe, Wilson, & Zak (1986) | 145 | NR | Shelter | Victims vs. Nonvictims of Partner Assault, Victims with high levels of symptoms vs. Victims with low levels of symptoms |
| Kemp, Rawlings, & Green (1991) | 77 | 30 | Shelter | Within-Subject Assault Severity, Subjective Distress, Length of Relationship, and Frequency of Assault |
| Kerouac, Taggart, Lescop, & Fortin (1986) | 300 | 31 | Shelter | Abused vs. Non-Abused |
| Kilpatrick, Best, Saunders, & Veronen (1988) | 187 | 40 | Community | Husband vs. Stranger Rape, Date vs. Stranger Rape |
| Langhinrichsen-Rohling, Neidig, & Thorn (1995) | 398 | NR | Military Sample | Male vs. Female Victims of Partner Assault |
| Murdoch & Nichol (1995) | 333 | 55 | Military Sample | Victims of Partner Violence vs. Non-victims |
| Pakieser, Muelleman, & Lenaghan (1996) | 4,528 | NR | Emergency Room | Partner Assault vs. Accident Victims, Victims of Partner Assault vs. Nonvictims |
| Riggs, Kilpatrick, & Resnick (1992) | 143 | 43 | Community | Partner vs. Stranger Physical Assault, Partner vs. Stranger Sexual Assault, Husband Physical Assault vs. No Assault |
| Saunders, Hamberger, & Hovey (1993) | 374 | 37 | Family Practice | Victims vs. Nonvictims of Partner Assault, Victims with vs. Victims without Injuries |
| Saunders (1994) | 159 | 34 | Treatment-Seeking and Non Treatment-Seeking | Victims of Partner Violence who Seek Help vs. Victims of Partner Violence who do not Seek Help |
| Shields, Resick, & Hanneke (1990) | 142 | 31 | Mixed Shelter and Out-patient Treatment | Sexual Assault plus Physical Assault vs. Physical Assault Only, Sexual Assault plus Physical Assault vs. Nonvictims |
| Sorenson, Upchurch, & Shen (1996) | 6,779 | NR | Community | Male vs. Female Victims of Partner Assault |
| Stets & Straus (1990) | 600 | NR | Community | Male vs. Female Victims of Partner Assault, Victims vs. Nonvictims of Partner Assault |
| Vitanza, Vogel, & Marshall (1995) | 93 | NR | Community (recruited) | Within-Subjects Assault Severity |
| Vivian & Langhinrichsen-Rohling (1994) | 114 | 34 | Treatment-Seeking Outpatient | Male vs. Female Victims of Partner Assault |
| Weaver, Kilpatrick, Resnick, Best, & Saunders (in press) | 3,349 | 45 | Community | Partner vs. Stranger Physical Assault |
| West, Fernandez, Hillard, Schoof, & Parks (1990) | 30 | 30 | Shelter | Within-Subjects Assault Severity |
Note: NR means that this information was not reported.
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