Cavanagh gathered qualitative data from interviews with the female partners of violent men to illustrate that battered women try to end the violence in their relationships in many ways, even if they stay—complicating the notion of the battered woman as passive and helpless. She found that women worked to stop the violence by talking with their partners about the violence, developing strategies for avoiding the violence (for example, being affectionate or feigning agreement with the abuser), challenging the violence (for example, fighting back, verbally or physically), telling other people about the violence, and leaving (usually temporarily) the relationship. Cavanagh argued that abused women almost always actively fight the abuse: "At some points in time the struggle to change took second place to the struggle to survive but not even women subjected to the extremes of abuse totally 'gave up.'"
Richard Gelles and Murray Straus found that only 13% of the severely abused women in the 1985 National Family Violence Survey felt their situations were completely hopeless and out of their control. In Intimate Violence: The Definitive Study of the Causes and Consequences of Abuse in the American Family (New York: Simon and Schuster, 1988), Gelles and Straus argued that women who experienced more severe violence and grew up in more violent homes were more likely to stay. Predictably, women who were less educated, had fewer job skills, and thus were more likely to be unemployed were also more likely to stay, as were women with young children.
Gelles and Straus interviewed 192 women who suffered minor violence and 140 who suffered severe violence, and asked which long-range strategies they used to avoid violence. Fifty-three percent of the minor-violence victims and 69% of the severe-violence victims learned to avoid issues they thought would anger their partners. Others learned to read a change in their partners' facial expressions as one of the first signs of impending abuse. "I have learned what gets him mad. I also know just by looking at him, when he gets that kind of weird, screwed-up expression on his face, that he is getting ready to be mad. Most of the time I figure I just have to walk on eggshells," one woman said. Avoidance worked for about 68% of those women who suffered minor abuse, but for less than one-third of the more severely abused victims.
Some battered women do leave their husbands. Straus and Gelles found that 70% had left their spouses in the year preceding the interview. Only about half of those who left, however, reported that this was a "very effective" method of ending the abuse. In fact, for one out of eight women it only made things worse. Batterers put incredible pressure on their partners to return. Often, when the women returned they were abused more severely than before—as revenge or because the men learned that, once again, they could get away with this behavior. Women who returned also risked losing the aid of personal and public support systems, because these people perceived that their help or advice was useless or ignored.
Just Say "No"
Many researchers believe that there is real truth to the statement that men abuse because they can. A wife who will not permit herself to be beaten from the very first act of minor abuse, like a slap or push, is the most successful in stopping it. Straus and Gelles found that simply eliciting a promise to stop was by far the most effective strategy women could undertake—especially in cases of minor violence. Threatening to divorce or leave the home worked in about 40% of the minor abuse cases, but in less than 5% of the severe-abuse situations. Physically fighting back was the most unsuccessful method. It worked in fewer than 2% of the minor-abuse cases and in less than 1% of the severe-abuse cases.
Many battered women remain in abusive relationships out of fear, but it is not always fear of their husbands that causes them to stay. Some women fear they may lose custody of their children if they walk out on an abusive partner. Others fear they will lose their homes or their social status. For other women, religious or cultural pressures to hold the family together at all costs trap them in bad marriages, even as the abuse worsens.
Maria Eugenia Fernandez-Esquer and Laura Ann McCloskey studied a group of Mexican American and Anglo women to learn about the ethnic and social influences that pressured them to remain in or leave abusive relationships. In "Coping with Partner Abuse among Mexican American and Anglo Women: Ethnic and Socioeconomic Influences" (Violence and Victims, vol. 14, no. 3, Fall 1999), they recounted their interviews with fifty-one Mexican American and forty-one Anglo women, all of whom had violent confrontations with their spouses in the year prior to the interview. All the women had been victims of verbal abuse. About half the women reported being beaten for several minutes, choked, raped, or threatened with murder if they left. About 25% were threatened with a gun or knife or forced to engage in sex against their will.
At least 25% of respondents in both ethnic groups reported coping tactics that included verbally aggressive intervention, "thinking through" the situation, and physical separation. In addition, more than 25% of the Anglo women reported physically aggressive intervention and avoidance tactics.
Fernandez-Esquer and McCloskey found that the socioeconomic status of battered women, as defined by education and employment, affected the way they coped. As socioeconomic levels rose, abuse victims tended to report more types of internal focus-coping tactics to deal with partner abuse. The researchers theorized that women who "think through" the situation might feel more self-reliant and capable of handling the violence without police intervention. However, internal coping also involved crying spells, angry outbursts, suicidal feelings, and self-blame.
Fernandez-Esquer and McCloskey did not find support for their hypothesis that ethnicity influences coping strategies of battered women. They concluded that the study illustrated similarities between ethnic groups, especially when faced with an abusive partner.
Injuries and Medical Care
There are often urgent and long-term physical and health consequences of domestic violence. Short-term physical consequences include mild to moderate injuries, such as broken bones, bruises, and cuts. More serious medical problems include sexually transmitted diseases, miscarriages, premature labor, and injury to unborn children, as well as damage to the central nervous system sustained as a result of blows to the head, including traumatic brain injuries, chronic headaches, and loss of vision and hearing. The medical consequences of abuse are often unreported or underreported because women are reluctant to disclose abuse as the cause of their injuries, and health professionals are uncomfortable inquiring about it.
A report titled "Violence against Women" found that while more than half of abused women are physically injured by their abusers, only four out of ten seek professional medical care (The Women's Health Data Book [Washington, DC: Jacobs Institute of Women's Health and the Henry J. Kaiser Family Foundation, 2001]).
Abused women also are at risk for health problems not directly caused by the abuse. In "Intimate Partner Violence and Physical Health Consequences" (Archives of Internal Medicine, vol. 162, no. 10, May 2002), investigators from several medical centers and schools of public health compared the physical health problems of abused women to a control group of women who had never suffered abuse. The investigators found that abused women suffered from 50% to 70% more gynecological, central nervous system, and stress-related problems. Examples of stress-related problems included chronic fear, headaches, back pain, gastrointestinal disorders, appetite loss, increased incidence of such viral infections as colds, and such cardiac problems as hypertension and chest pain. Although women who most recently suffered physical abuse reported the most health problems, the researchers found evidence that abused women remain less healthy over time.
SCREENING FOR DOMESTIC VIOLENCE. Although women have about a 30% to 44% chance of experiencing intimate partner violence at some point during their lives, health professionals detect as few as one out of twenty are victims of physical abuse. Lorrie Elliot et al. conducted a national survey of physicians to identify factors associated with the documented low screening rates for domestic violence. In "Barriers to Screening for Domestic Violence" (Journal of General Internal Medicine, vol. 17, no. 2, February 2002), researchers reported the responses of physicians in four medical specialties likely to encounter abused women—internal medicine, family practice, obstetrics-gynecology, and emergency medicine.
The vast majority of physician respondents (88%) said they knew patients in their practices who had experienced domestic violence, but physicians in all specialties except emergency medicine underestimated the prevalence of the problem in their states. The physicians were questioned about the percentage of their patients they screened, i.e., specifically asked about their experience with domestic violence. Overall, just 10% of respondents screened their female patients for domestic violence and of this group, just 6% screened all female patients. Of the specialties, obstetrician-gynecologists screened the highest proportion of their patients.
Although most respondents felt they should be screening for domestic violence in their practices, most did not fulfill this responsibility. Along with unrealistically low estimates of the prevalence of the problems in their communities, physicians also cited lack of training, lack of confidence in their abilities, fear of offending patients, and the mistaken belief that women will volunteer a history of abuse without being questioned. The researchers concluded that mandatory training on intimate partner violence, reminders in patients' medical charts, and physician interaction and involvement with victim service providers might all serve to increase physicians' confidence and competence to screen patients for intimate partner violence and abuse.
Hospitalization of Battered Women
The National Crime Victimization Surveys estimate that of the more than half of women battered by an intimate partner who are injured, 30% to 40% require medical treatment and 15% require hospitalization. The hospital emergency department is often the first contact the health care system has with battered women and offers the first opportunity to identify victims, refer them to support services and safe shelters, and otherwise intervene to improve their situations.
Researchers at the University of Washington reported on hospitals and battered women in "Rates and Relative Risk of Hospital Admission among Women in Violent Intimate Partner Relationships" (American Journal of Public Health, vol. 90, no. 9, September 2000). They found that women who had filed for protection orders against male intimate partners had an overall increased risk for earlier hospitalization than women who had not been abused. Abused women had a 50% increase in hospitalization rates for any diagnosis, compared to nonabused women, and the risk of hospitalization was highest in the younger age groups of abused women. Abused women were hospitalized much more frequently for injuries resulting from assaults, suicide attempts, poisonings, and digestive system disorders than the nonabused women and were almost four times as likely to be hospitalized with a psychiatric diagnosis. The researchers reaffirmed the observation that intimate partner violence has a significant impact on women's health and their utilization of health care services.
Improving Health Professionals' Responses to Victims of Domestic Violence
In 2001, the National Academy of Sciences Institute of Medicine released the report Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (Washington, DC: National Academy Press, 2001), which was mandated by the Health Professions Education Partnerships Act of 1998 (PL 105-392) and sponsored by the Centers for Disease Control and Prevention. The study involved fifteen professionals from a variety of disciplines, including health sciences, mental health, law, and the study or aid of victims of child maltreatment, domestic violence, and elder abuse. They reviewed available research about the training of health professionals and others who come into contact with victims; the effectiveness of training and programs to screen, identify, and refer victims of family violence in health care settings; and the outcomes of available interventions.
The report described family violence as a serious public health problem and societal tragedy, cited inadequate training of health professionals as a major problem, and called for vigorous efforts to improve health professionals' abilities to screen, diagnose, treat, and refer victims of abuse. The Institute of Medicine report recommended:
- Family violence centers should conduct research on the impact of family violence on the health care system and to evaluate and test training and education programs for health professionals. The report suggested that centers be established by the Department of Health and Human Services and modeled after similar multi-disciplinary centers in fields such as injury control research, Alzheimer's disease, and geriatric education. To lay the foundation for the centers' coordinating role, the report suggested that the U.S. General Accounting Office analyze the level and adequacy of existing investments in family violence research and training.
- Health professional organizations and educators—including academic health-center faculty—should address core competency areas for health professional curricula on family violence, including effective teaching strategies, approaches to overcoming barriers to training, and approaches to promoting and sustaining behavior changes by health professionals in dealing with family violence.
- Health care delivery systems and training settings, particularly academic health care centers and federally qualified health clinics and community health centers, should assume greater responsibility for developing, testing, and evaluating innovative training models or programs.
- Federal agencies and other funders of education programs should create expectations and provide support and incentives for evaluating curricula on family violence for health professionals. Evaluations should focus on the impact of training on the practices of health professionals and the effects on family violence victims.
Empowerment of Battered Women
Researchers and advocates have found that one of the most effective ways to deal with partner violence is by giving the victim the power, encouragement, and support to stop it. In "Estrangement, Interventions and Male Violence Toward Female Partners" (Violence and Victims, vol. 12, no. 1, Spring 1997), Desmond Ellis and Lori Wight asserted that abused women want the violence to stop and most, if not all, attempt to do something to stop it. They found evidence showing that empowerment of abused women is related to a decrease in the likelihood of further violence. The interventions Ellis and Wight recommended to promote gender equality include:
- social service agencies such as counselors or shelters to provide information and support
- mediation to facilitate a woman's control over the process
- prosecution with an option to drop the charges, which also facilitates control by female victims
- separation, which indicates the woman's strength in decision making
Ellis and Wight found that separation or divorce is one of the most effective strategies for ending abuse. Levels of violence after separation, according to these researchers, varies with the type of legal separation or divorce proceedings. Women who participate in mediation prior to separation are less likely to be harmed, either physically or emotionally, than women whose separation is negotiated by lawyers. Ellis and Wight found that other legal proceedings, such as restraining orders and protection orders, were relatively ineffective in protecting female abuse victims.
Interventions to Help Battered Women
Throughout the United States, voluntary health and social service agencies and institutions, such as hospitals, mental health centers, clinics, and shelters, have developed programs that aim to help abused women break free physically, economically, and emotionally from their violent partners. Still, many abused women do not seek help from these specialized programs and services as a result of fear, shame, or lack of knowledge about how to gain access to available services. Instead, many injured women seek medical care from physicians, nurses, and other health professionals. For this reason, medical professional organizations, such as the American Medical Association and the American College of Obstetricians and Gynecologists, exhort physicians to advocate on behalf of abused women. They offer guidelines to help professionals detect and intervene in cases of domestic violence.
Despite the ambitious objectives of professional societies and the widespread distribution of guidelines, many health professionals most likely to encounter victims of abuse remain untrained, fearful, and unable even to question patients about domestic violence. Barbara Gerbert et al. interviewed physicians to determine how they have overcome these and other barriers to help patients who are victims of domestic violence. Their findings were published in "Interventions That Help Victims of Domestic Violence: A Quantitative Analysis of Physicians' Experiences" (Journal of Family Practice, vol. 49, no. 10, October 2000).
Although physician respondents reported feeling overwhelmed, frustrated, and often ill-prepared to tackle these problems, they nonetheless felt it was their responsibility to help battered women improve their situations. The technique they believed most effective was validation—expressing concern by compassionately communicating to the woman that the abuse was undeserved. Other strategies they considered effective were:
- Overcome denial and plant seeds of change—Physicians helped the women to appreciate the seriousness of their situations and to understand that the abusers' actions were wrong and criminal. Some physicians used photographs of injuries to remind patients who denied the extent of their abuse about the severity of the injuries they had sustained.
- Nonjudgmental listening—To build trust, physicians listened without rushing to judgment or criticizing women for not fleeing their abusers.
- Document, refer, and help prepare a plan—Physicians documented abuse with photographs and detailed descriptions in the patients' medical records for use in medical and mental health treatment as well as in court proceedings. They offered ongoing, confidential referrals to hot lines, shelters, and other community resources; advised patients about when to call police; and assisted them to develop escape plans.
- Use a team approach—Physicians felt it was valuable to be able to immediately refer abused women to on-site professionals, such as counselors, nurses, social workers, or psychologists, who were able to take advantage of the medical visit as a "window of opportunity," that is, an occasion to detect and intervene to stop abuse.
- Make domestic violence a priority—Given time constraints of busy medical practices, many physicians advocated forgoing all but the most urgent medical treatment and instead used the appointment time to address the issue of abuse. They also encouraged colleagues and personnel in their practices to obtain continuing education about domestic violence, child, and elder abuse.
Carolyn Rebecca Block has made recommendations to nurses, doctors, and other service professionals likely to come in contact with battered women on what to look for as indications that the violence may soon escalate to deadly violence in "How Can Practitioners Help an Abused Woman Lower Her Risk of Death?" (NIJ Journal, no. 250). She found that practitioners should evaluate three aspects of the violence:
- The type of past violence—Women who had experienced at least one serious or life-threatening incident, for example, being choked, burned, or threatened with weapons in the past year were at the greatest risk of being killed by their partners. Being choked, burned, or threatened with weapons also indicated a higher risk.
- The number of days since the last incident—No matter how severe the incident of past abuse, women who have been abused within the past thirty days are at greatest risk for being killed.
- The frequency, or increasing frequency, of violence—If violent episodes are increasing, women are at high risk of deadly violence.
AN INNOVATIVE PROGRAM TO HELP BATTERED WOMEN. Collaboration between law enforcement and hospital emergency department personnel produced a novel program to prevent and intervene in domestic violence. This program was developed in Richmond, Virginia, in response to a challenge issued by Mark Rosenberg, the director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. The program, called "Cops and Docs," involves participation of emergency and trauma nurses working "handcuff in glove" with law enforcement personnel. The program was described and praised in the Journal of Emergency Nursing (vol. 27, no. 6, December 2001).
Program personnel are trained together in a variety of techniques, including interviewing victims, collecting and preserving forensic evidence, and gathering and documenting information. In addition to helping to safeguard victims and apprehend and prosecute offenders, the program offers other health benefits to the community it serves. For example, shared emergency department data about substance abuse gives law enforcement personnel additional information to use in efforts to combat drug-related violence and crime.