1 table omitted
Approximately 1.5 million women in the United States are physically
or sexually assaulted by an intimate partner (IP) each year.1
The Woman Abuse Tracking in Clinics and Hospitals (WATCH) Project at the Massachusetts
Department of Public Health analyzed data from the 1996 and 1997 Behavioral
Risk Factor Surveillance System (BRFSS) in Massachusetts to (1) estimate the
percentage of women aged 18-59 years experiencing intimate partner violence
(IPV) who used medical care, police assistance, and restraining orders during
the preceding 5 years, (2) determine where women experiencing IPV went for
medical care, and (3) examine the overlap in use of these three services.
This report describes the results of these analyses, which indicate that a
higher percentage of women aged 18-59 years use police assistance rather than
obtain a restraining order or seek medical care.
BRFSS is an ongoing, state-based, random-digit-dialed telephone survey
of the U.S. civilian, noninstitutionalized population aged ≥18 years. Questions
on IPV developed by the WATCH Project were added to the Massachusetts BRFSS
in 1996 and 1997. During the 2 years, 2940 women aged 18-59 years responded
to the survey (response rate: 64.5%). Of these, 129 (5.5%) were excluded from
analysis because they either refused or responded "don't know/not sure" to
the initial questions about whether they had ever been physically or sexually
hurt, and if so, if this was by an IP.* Women aged ≥60 years also were
excluded from the analyses because of low levels of reporting recent IPV.
Data were aggregated across the 2 years and weighted to reflect the probability
of selection and the demographic distribution of the Massachusetts adult population.
Estimated proportions and standard errors were calculated using SUDAAN.2
Survey respondents were asked whether they had ever been physically
or sexually hurt† by an IP and when this violence last occurred. Respondents
who reported IPV during the preceding 5 years also were asked the following
questions about service use: (1) "Did you see a doctor or nurse as a result
of being hurt by any of these people in the past five years?"; (2) "In the
past five years, were the police called about any of these incidents?"; and
(3) "In the past five years, have you gotten a restraining order at a court
against a current or ex-(husband/wife), partner, boyfriend, girlfriend, or
date?"‡ Respondents who reported having seen a doctor or nurse were
asked where they sought care most recently, and those who reported police
assistance were asked how many times the police had come for incidents of
IPV during the preceding 5 years.
Among women aged 18-59 years, 18.0% reported ever having experienced
IPV, 6.6% reported IPV during the preceding 5 years, and 2.1% reported IPV
during the preceding 12 months. Among women reporting IPV during the preceding
5 years, 39.0% received police assistance, 33.8% obtained a restraining order,
and 28.7% sought medical care as a result of IPV. Most women who received
police assistance also reported obtaining a restraining order: 69.7%§
of women who received police assistance for IPV also obtained a restraining
order against an IP. Among women reporting IPV, 11.1% sought medical care
as a result of IPV but did not obtain police assistance or a restraining order.
Approximately half (55.9%) of women reporting IPV received one or more of
the three services.
Most women reporting IPV during the preceding 5 years were aged 18-29
years (64.0%), employed (69.8%), had some college education (60.3%), and had
children in the household (52.5%). Half (50.1%) of the women had never been
married, 28.6% were divorced or separated, and 21.3% were married or cohabitating.
J Hathaway, MD, J Silverman, PhD, G Aynalem, MD, Woman Abuse Tracking
in Clinics and Hospitals Project, Bur of Family and Community Health; L Mucci,
MPH, D Brooks, MPH, Chronic Disease Surveillance, Bur of Health Statistics,
Research and Evaluation, Massachusetts Dept of Public Health. Family and Intimate
Violence Prevention Team, Div of Violence Prevention, National Center for
Injury Prevention and Control, CDC.
Federal, state, and local efforts are under way to establish surveillance
systems for IPV. The WATCH Project, along with projects in Michigan and Rhode
Island, have been funded by CDC to establish statewide tracking systems for
IPV against women. IPV surveillance systems are frequently based on service
provider data; however, these data represent only persons accessing that particular
service. Service provider data are unable to provide estimates of the total
number of women experiencing IPV in a population or the extent to which the
same women may be represented in different service provider data sets. Surveillance
data from the WATCH Project provide state-based estimates of the percentage
of women experiencing IPV using three key types of services and the degree
of overlap in service use.
Other population-based studies report similar findings regarding the
frequency at which women experiencing IPV use services. Police assistance
for IPV is received by 35%-56% of women reporting IPV.3- 5
Of women physically abused by their partners, 22% seek restraining orders
against an IP.4 Among women reporting IPV,
10%-21% receive medical care as a result of IPV, and approximately 70% of
these women seek care at an emergency department.3,4,6
Finally, 16% of persons who experience family violence or IPV identified through
police incident reports have violence-related contact with a regional hospital.7
The findings in this report are subject to at least three limitations.
First, BRFSS is a retrospective self-report survey and may be subject to recall
bias. Second, women experiencing IPV who were not eligible to be included
in the phone survey, declined participation, or did not disclose IPV may have
a different pattern of service use than respondents. Persons who were ineligible
to participate included those who were homeless, lived in group housing, did
not have a phone, or did not speak English, Spanish, or Portuguese. Finally,
IPV may not have been reported because of mistrust, fear of reprisals, and
feelings of shame and/or denial.
These findings have implications for both IPV surveillance and medical
practice. For surveillance, these results suggest that police data may capture
a larger portion of women aged 18-59 years experiencing IPV than a medical
care-based surveillance system. In Massachusetts, where police are directed
to inform women reporting IPV about the availability of restraining orders,
police and restraining order data appear to capture a similar demographic
group. However, a medical care-based tracking system may capture a sizeable
portion of women experiencing IPV who do not receive police or restraining
order assistance. Emergency departments appear to provide the most efficient
location within the medical system for tracking IPV-related injuries because
most women who seek medical care following incidents of IPV are seen in emergency
departments. However, a surveillance system designed to include police, restraining
order, and medical care data may miss nearly half of women experiencing IPV.
Medical practitioners, particularly those in emergency departments,
need to be prepared to identify and provide support, safety planning, and
resources to those experiencing IPV.8 Because
many women experiencing IPV do not disclose partner violence unless directly
asked, some groups believe women patients whose conditions may be injury-related
should be screened systematically for IPV.9,10
Because 38.7% of women who received medical care for IPV had not received
police or restraining order assistance, medical practitioners may be a critical
source of support and intervention to many women.
*Same or opposite sex, current or ex-husband/wife, partner, boyfriend,
girlfriend, or date.
†Being physically or sexually hurt included being shoved, slapped,
hit with an object, or forced into any sexual activity.
‡Questions on medical care and restraining orders were revised
during 1996-1997 for clarification. The question on medical care was reworded
from "after being hurt" to "as a result of being hurt" and the question on
restraining orders was reworded from "have you been to court to get a restraining
order" to "have you gotten a restraining order at a court." Response frequencies
for women aged 18-59 years did not vary significantly for each version of
§Calculated as the percentage of women who used police and restraining
order and the percentage who used police, restraining order, and medical care
divided by the percentage who used police with or without other services.
2 tables omitted
Approximately 20% of emergency department visits for trauma and 25%
of homicides of women involve intimate partner violence (IPV).1,2
To assess IPV prevalence in Washington, the Washington State Department of
Health added questions from the Conflict Tactics Scale3
and the Revised Conflict Tactics Scale4
to its 1998 Behavioral Risk Factor Surveillance System (BRFSS) survey. This
report describes an analysis of responses to the questions, which indicated
that women were more likely than men to experience IPV in their lifetime,
and more than three times more likely than men to experience injuries from
BRFSS is an ongoing, state-based, random-digit-dialed telephone survey
of the U.S. civilian, noninstitutionalized population aged ≥ 18 years that
collects information about modifiable risk factors for chronic diseases and
leading causes of death. In 1998, 3604 persons responded to the Washington
BRFSS. Because the questions were considered sensitive, permission was asked
before beginning the IPV section, and 3381 (93.5%) gave permission. Only English-speaking
persons were respondents. The survey response rate was 61.4%.
Respondents were asked whether they had experienced IPV during their
lifetime (i.e., kicked, bit, or hit with fist; hit or tried to hit with something;
beat up; threatened with gun or knife; or used gun or knife) and whether they
had sustained physical injury (sprain, bruise, or small cut; physical pain
the next day; passed out from being hit on head; went to doctor; needed to
see doctor but didn't; or broken bone) resulting from IPV. An intimate partner
was defined as a current or former spouse, live-in partner, boyfriend, girlfriend,
or date. Some respondents might have referred to a same-sex partner; the sex
of the partner was not asked. Responses were weighted for selection probability
by the number of adults and telephone numbers in the household, and whether
the number was drawn from a block of 100 numbers containing at least one or
no listed number. Responses also were weighted to approximate the Washington
population on the basis of the respondents' age and sex.
In 1998, of approximately 2,113,000 women aged ≥ 18 who resided in
Washington,5 approximately 499,000 (23.6%)
(95% confidence interval [CI] = 453,000-545,000) experienced IPV during their
lives, and 456,000 (21.6%) women (95% CI = 410,000-502,000) had a physical
injury resulting from IPV. Of the 2,049,000 men,5
approximately 336,000 (16.4%) (95% CI = 289,000-383,000) experienced IPV and
approximately 154,000 (7.5%) (95% CI = 121,000-187,000) experienced injury
from IPV. Multivariate logistic regressions were conducted to identify the
levels of lifetime risk associated with sex, education, income, and marital
status. Odds ratios (ORs) for education, income, and marital status were similar
for men and women; therefore, data for both sexes were combined.
Compared with never married status, divorced/separated status was associated
with an almost three-fold increase in the risk for reported IPV (OR = 2.7;
95% CI = 1.9-4.0) and a four-fold increase in the risk for injury from IPV
(OR = 4.0; 95% CI = 2.7-6.1); 45.3% of divorced/separated women reported an
injury from an intimate partner. Low education level also was associated with
increased risk for IPV (OR = 1.4; 95% CI = 1.1-1.8) and injury from IPV (OR
= 1.4; 95% CI = 1.04-1.8). Low income level was associated with increased
risk for IPV (OR = 1.6; 95% CI = 1.2-2.2); however, the association between
low income and injury from IPV was not significant (OR = 1.3; 95% CI = 0.9-1.9).
L Bensley, PhD,'s Macdonald, PhD, J Van Eenwyk, PhD, Acting State Epidemiologist,
Office of Epidemiology; K Wynkoop Simmons, PhD, D Ruggles, MBA, Washington
State Dept of Health. Family and Intimate Violence Prevention Team, Div of
Violence Prevention, National Center for Injury Prevention and Control, CDC.
This report indicates that IPV in Washington is more prevalent among
women than men. Other studies have found that women have similar or higher
IPV rates than men but that women are more likely to sustain injury.3,6- 8
Although low education and income levels are risk factors for reported IPV,
17.6% of women with incomes of ≥ $50,000 per year and 20.2% of women with
at least some college education reported injuries as a result of IPV. In addition,
divorced/separated respondents were more likely to report violence than married,
widowed, or never married respondents.
The findings in this report are subject to at least three limitations.
First, the study was limited by its dependence on self-reports, which might
be inaccurate because of recall bias or unwillingness to report. Second, this
study did not include persons without telephones or persons who did not speak
English. Third, because of their cross-sectional nature, the results do not
provide evidence of causal relations (e.g., IPV may have been the cause of
divorce or may have occurred during the divorce process).
Identification of IPV is difficult because of its private and sensitive
nature. Interventions may include strategies to increase IPV recognition,
and should occur in varied settings (e.g., health-care, criminal justice,
and school systems) and with varied approaches, including IPV screening protocols
by health-care providers,9 school programs
teaching conflict resolution, public education campaigns regarding the unacceptability
of IPV, and information about community resources such as shelters and counseling
for battered women. Other interventions may include treatment of offenders10; interventions for children who witness IPV; and
efforts to make the criminal justice system more responsive to victims by
reforming laws, providing victim advocates, and training police, prosecutorial,
and court personnel. Although most of these approaches have shown some success,
rigorous evaluations of these interventions are needed to determine their
This report underscores the usefulness of BRFSS for collecting data
about IPV, although IPV questions are not asked routinely on BRFSS. State
and national efforts to plan and evaluate programs to lower IPV rates would
benefit from more widespread use of IPV items on BRFSS surveys. Standardizing
questions would facilitate comparisons between geographic regions. Questions
assessing IPV have been developed by CDC for potential use in BRFSS and soon
will be pilot tested in several states. IPV is a new area of public health
but one that affects many persons. Continued surveillance and well-evaluated
and effective programs are needed to prevent IPV.
Use of Medical Care, Police Assistance, and Restraining Orders by Women Reporting Intimate Partner Violence—Massachusetts, 1996-1997. JAMA. 2000;284(5):558-559. doi:10.1001/jama.284.5.558