Adverse Childhood Experiences and Women in Domestic Violence Shelters

Intimate partner violence is a widespread problem, involving physical, sexual, verbal, or psychological violence, or stalking by an existing or former intimate partner. It is a pattern of aggressive and coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive isolation, stalking, intimidation, and threats. These behaviors are perpetrated by someone who is, has been, or wishes to be in an intimate or dating relationship with an adult or adolescent, and are intended to establish control by one partner.

Reproductive and sexual coercion involves behaviors in which someone, who is, was, or wants to be involved in an intimate or dating relationship with an adult or adolescent, can maintain power and control related to reproductive health.

Most forms of behavior used to maintain power and control in a relationship disproportionately affect women's reproductive health. However, some forms of reproductive and sexual coercion that males experience are included in the definitions below. Reproductive coercion is associated with behaviors that interfere with contraceptive use and/or pregnancy. Reproductive coercion is limited to heterosexual relationships and includes two types: sabotage of birth control, and pressure or coercion of pregnancy. Aside from the traditional definitions of sexual assault and rape, sexual coercion expands our understanding. It comprises a range of behaviors that a partner may use to pressure a person into having sex, without using physical force, in connection with sexual decision-making. Examples of sexual coercion can occur in both heterosexual and same-sex relationships.

Adolescent and adult males also experience sexual and reproductive coercion. A recent national survey on intimate partner and sexual violence in the United States yielded the first population-based data on male reproductive and sexual coercion experiences. There is an urgent need for research into the impact of reproductive and sexual coercion on men's reproductive health. This research is crucial for informing strategies to develop and evaluate evidence-based interventions for males experiencing reproductive and sexual coercion. Both intimate partner violence (IPV) and sexual and reproductive coercion are health problems that disproportionately affect women. Women have a significantly higher risk of experiencing IPV, sustaining severe injuries, and being killed by an intimate partner than men. As mentioned earlier, reproductive coercion is limited to heterosexual couples, but sexual coercion may occur in both heterosexual and same-sex couples.

Recent research provides some insight into the sexual coercion experiences of gay and bisexual males. In a survey of gay and bisexual men, 18.5 percent reported unwanted sexual activity. Qualitative interviews with gay and bisexual men suggest that many factors underlying sexual coercion are related more to male sexuality than gay sexuality, and societal responses to same-sex relationships can lead to marginalization that increases vulnerability to sexual violence. These guidelines address intimate partner violence as a health disparity issue for women and girls, with a focus on how men interfere with and limit their female partners' ability to make reproductive health decisions. The guidelines provide an overview of recent research on family planning, abortion services, and the impact of relationship violence on sexually transmitted infections/HIV. Because the relationship between IPV and poor pregnancy outcomes are well documented elsewhere, this paper does not address the impact of IPV on maternal, fetal, and child health.

Health care providers play an essential role in prevention through discussions with all patients about healthy, consensual, and safe relationships. It is possible to adapt some of the screening and intervention strategies outlined in the guidelines for male patients. Future research is expected to provide more information on how to better serve men, same-sex couples, and other populations at risk. Although the literature shows that both men and women are victims of IPV, it is much more likely that women will suffer physical or possibly psychological injuries than men. IPV sometimes causes physical injury, trauma, and death (Kernic, Wolf & Holt, 2000). The impact of IPV can last for life. Abused women are likely to suffer more from physical health problems, depression, drug and alcohol abuse, and attempted suicide than non-abused women (Golding 1996). They also use health services more often (Miller, Cohen, and Rossman 1993).

An increasing body of evidence shows the health impacts of intimate partners' violence against women. However, the economic costs of IPV still remain largely unknown. Previous cost estimates range from $1.7 billion to $10 billion annually, but the true economic impact of this type of violence is believed to be vastly underestimated (Institute for Women's Policy Research, 1995). Researchers recommended the development of national cost estimates for IPV-related medical care, mental health care, policing, social services, and legal services (Gelles and Straus 1990). However, a recent literature review (Finlayson, Saltzman, Sheridan, and Taylor 1999) found only one U.S. study that provided national cost estimates for intimate partnership violence.

Recognizing the need to better measure the magnitude of IPV and the resulting economic costs—especially those associated with health care—the United States Congress funded the Centers for Disease Control and Prevention (CDC) to conduct a study to obtain national estimates of the incidence of IPV-related injuries, to estimate the cost of health care injuries, and to recommend strategies to reduce IPV-related injuries and associated costs. The language associated with this funding was included in the provisions of the Violence Against Women Act 1994 (P.L. 103–322) Violent Crime Control and Law Enforcement Act. Given the increased number of female IPV-related injuries and the less stable cost estimates based on the smaller number of male IPV-related injuries, this report focuses solely on IPV costs for females aged 18 and older.

Although Congress only called for estimates of IPV-related injury costs, it was important to include the costs of IPV-related loss of productivity and determine the economic costs of IPV-related homicides. These costs significantly contribute to the economic burden of IPV. Researchers also noted that domestic violence imposes substantial non-monetary costs, many of which have an economic impact. However, quantifying the economic impact of these costs in concrete figures can be challenging. As a result, many of the overall cost estimates discussed above do not include these non-monetary costs, thus underestimating the true cost of domestic violence.

The serious health implications of domestic violence and the long-term toll on victims and society as a whole are among the non-monetary costs, particularly. Several studies have shown that domestic abuse leads to short-term and long-term physical and mental health problems including physical injuries, depression, stress, and substance abuse. The World Health Organization has cited that abused women are twice as likely to suffer poor health and physical and mental issues than non-abused women. In addition, victims of domestic violence also face premature death or suicide by the abuser. Women experiencing domestic violence are significantly more likely to attempt suicide than non-abused women.

While victims endure multiple types of abuse with varying severity levels, the overwhelming constant is that abusers will use whatever means at their disposal to control the victim's independence. The abuser manipulates the victim into remaining compliant by keeping them in a state of entrenched and reinforced powerlessness. It's important for those who question why victims stay in abusive situations to understand that victims often feel as if they have no choice. We've all heard comments like "if my boyfriend/girlfriend or husband/wife ever treated me like that, I'd be gone." However, this statement assumes the violent behavior is a one-time event that immediately drives the victim away. Most victims, however, emphasize that their current abuse is the result of a gradual process of domination interspersed with moments of happiness and fearful events (LaViolette and Barnett, 2000).

This cycle keeps the victim hoping things will change, while fearing the consequences of a decision to leave. The Walker Cycle Theory of Violence stated in 1979 that the battering cycle involves three distinct phases (Walker, 2000). The first phase is a building tension characterized by the abuser beginning to get angry. The victim—feeling like walking on eggshells—does whatever it takes to keep the abuser quiet. As the victim feels more scared, they often leave, with the abuser waiting for the inevitable explosion. For survivors of intimate partner violence or sexual assault, a healthcare provider is likely their first professional contact.

Evidence suggests that women subjected to violence seek healthcare more often than women who've not been abused, even if the associated violence is not revealed. They also identify healthcare providers as the most trusted professionals to disclose abuse. The U.S. Task Force on Preventive Services recommends IPV screening for all patients during childbirth. Several short screening tools have proven to be efficient in the detection of IPV and can be used in the office setting. Identifying IPV provides better care for the patient and improves their health outcomes. The offices of family physicians should offer patients local and national resources. Comprehensive documenting of injuries related to the abuse is crucial.

Although it might be difficult for physicians to care for patients unwilling to leave abusive relationships, ongoing support improves patient outcomes. A continuous relationship with the same doctor enhances the patient's willingness to discuss IPV. Understanding a patient's experiences with IPV gives insight into their medical and emotional problems, prompting the doctor to demonstrate extra sensitivity during physical examinations. This involves explaining each step of the examination and obtaining the patient's consent to proceed, thereby giving the patient a sense of control over their body.

Documenting any injuries thoroughly and providing a detailed record of what happened, including direct quotes from the patient when appropriate, is critical for the doctor. If charges are pressed, this can help the patient. The patient should be provided with information on safety planning. A safety plan helps prepare the patient to leave if the situation worsens dramatically and they are at immediate risk. It may include copying personal documents, making key copies, securing money, and packing a bag with essential items.

The patient should identify a safe place (e.g., family home, domestic violence shelter). Code words should be shared with trustworthy friends or family so they can call and warn of imminent danger in the presence of the abuser. A list of national and local resources, including local refuges and the hotline number of national domestic violence shelters, should be provided.

A study carried out in 1998 by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente led to a paradigm shift in the approach to disease of the medical community. This study of more than 17,000 middle-class Americans clearly documented that adverse childhood experiences (ACEs) can significantly contribute to negative physical and mental health outcomes for adults and affect over 60 percent of adults. More recent studies continue to reaffirm this. There are known predictive factors, along with the original 1998 ACE Study, which makes sense to include in the list of adverse experiences. These can be events that are single, acute, or sustained over time. Examples include a parent's death and, among others, the harmful effect of community violence and poverty.

Adverse childhood experiences occur regularly in all races, economic classes, and geographic regions with children aged 0 to 18 years; however, there is a much higher prevalence of ACEs for those living in poverty. Adverse experiences of childhood (ACEs) include abuse, neglect, and household dysfunction experienced before age 18, and ACEs have well-established downstream health effects over the course of life. Higher ACE figures help us anticipate behavioral issues for children or adults, deteriorating mental health, adverse health behavior, chronic disease burden, and premature mortality. However, little evidence has been published about intergenerational relationships between ACE scores and behavioral health of parents.

Although specific adverse experiences of parents, such as childhood abuse, have been associated with the socio-emotional problems of children and the risk of maltreatment, intergenerational associations between more global counts of parent ACE and behavioral health problems of children remain largely unexamined. If, as is commonly hypothesized, different types of childhood adversity cause harm through a common set of stress pathways, then parent ACE count could better reflect the total "dose" across adversity types than any particular ACE count. In addition, intergenerational effects of ACEs could be transmitted through common pathways such as mental health of parents and unfavorable practices of parenting.

Adults who have experienced ACEs in their early years may have reduced parenting or ill-adapted responses to their children. Because of earlier trauma, the physiological changes that have occurred to the stress response system of the adult may result in decreased capacity to respond healthily to additional stressors. Adverse childhood experiences increase the likelihood of social risk factors, mental health problems, substance abuse, intimate partner violence, and risky adult behavior. All of these can negatively affect parenting and perpetuate ongoing exposure to ACEs through generations through the transmission of epigenetic genome changes.

Nevertheless, adverse experiences and other childhood traumas do not dictate a child's future. Despite the trauma in their lives, children survive and even thrive. The adverse experiences are counterbalanced by protective factors for these children. Adverse events and protective factors, experienced together, have the potential to promote resilience. Our understanding of what constitutes resilience in children is evolving, but we know that several factors relate positively to such protection, including cognitive capacity, healthy attachments in relationships, particularly with parents and caregivers, motivation and ability to learn and engage with the environment, ability to regulate emotions and behavior, and supportive environmental systems. More detail is provided by the framework of protective factors developed by Strengthening Families, as well as the CDC's Essentials for Childhood program.

There are other reasons for optimism. There are now several evidence-based, effective clinical treatments available for children who have experienced trauma and adversity, including trauma-focused cognitive-behavioral therapy and interactive parent-child therapy. Each of these programs includes parenting skills and works to develop behaviors that promote child and parent resilience. Although not widely disseminated, proactive initiatives such as home visitation programs for high-risk families hold incredible promise for the prevention or mitigation of parent and environment-mediated Adverse Childhood Experiences (ACEs), specifically because they focus on critical periods of human development — prenatal through the first 2 to 3 years of life. Regardless of the exact connection between the two, it is evident that the short-term and long-term effects of abuse and violence can be devastating, whether children experience child abuse, intimate partner violence, or both.

Victims of abuse may be at risk for physical, emotional, behavioral, and cognitive issues, including impaired brain development, emotional health issues, social problems, substance abuse, and abusive or violent behavior. Adult Intimate Partner Violence (IPV) and psychosocial characteristics are probably interrelated. However, adult IPV is associated with childhood experiences, and there are significant indirect pathways through psychosocial characteristics. Future research into the probable bidirectional relationship between depression or anxiety and IPV could elucidate these complicated relationships. Furthermore, constructing a model capable of statistically differentiating competing models could help determine the directionality of associations. These results differ from the few studies that also examined pathways between ACEs and IPV, as we used couple data and tested a different set of mediators.

These studies, taken together, are beginning to elucidate important mechanisms that link childhood exposure to adverse experiences and adult behaviors. Effective treatment of depression and anxiety is critical to reducing adult partner violence and potentially weakening the relationship between ACEs and adult IPV. Beyond the prevention of IPV, it is important to prevent ACEs and mental health disorders, but this analysis highlights the contribution of specific psychosocial pathways that link childhood circumstances to violence in adult partners. Important next steps in understanding how ACEs affect adult partner violence should include further exploration of other mediating pathways and why these pathways differ between men and women.

Meaningful changes in these policies have the potential to effectively identify children at potential risk and reduce or eliminate their exposure to domestic violence by providing services to adult caregivers. Any caregiver who identifies as a victim of violence can receive ongoing advice from the counselor. The counselor also provides a single-time intervention that may include safety planning, shelter referrals, empowerment counseling, hazard assessment, and other resources, as well as access to mental and behavioral health services for the children exposed.

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