Adverse Childhood Experiences and Women in Domestic Violence Shelters

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

Most forms of behavior used to maintain power and control in a relationship that disproportionately affects women’s reproductive health; however, some forms of reproductive and sexual coercion are included in the definitions below that males experience. Reproductive coercion is associated with behaviors that interfere with the use and/or pregnancy of contraception. Heterosexual relationships are limited to reproductive coercion. Below are two types of reproductive coercion, sabotage of birth control and pressure and coercion of pregnancy. In addition to traditional definitions of sexual assault and rape, sexual coercion expands our understanding. Sexual coercion includes a range of behaviors that a partner may use to pressure a person to have sex without using physical force in connection with sexual decision-making. Examples of sexual coercion that can occur in relationships of heterosexual or same sex.

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Adolescent and adult males may also experience sexual and reproductive coercion. A recent national survey on intimate partner and sexual violence in the United States provided 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 reproductive health of men. This research is essential for informing males experiencing reproductive and sexual coercion to develop and evaluate evidence-based interventions. IPV and sexual and reproductive coercion are health problems that affect women disproportionately. Women have a significantly higher risk of IPV experience, sustaining severe injuries, and being killed by an intimate partner than men. As noted earlier, reproductive coercion is limited to heterosexual couples whereas in heterosexual or same-sex couples sexual coercion may occur.

Recent research provides some insight into the sexual coercion experiences of gay and bisexual males. 18.5 percent reported unwanted sexual activity in a survey of gay and bisexual men. Qualitative data from interviews with gay and bisexual men suggest that many of the factors underlying sexual coercion are more related to male sexuality versus gay sexuality, and that the response of society to same-sex relationships leads to circumstances like marginalization that increase vulnerability to sexual violence. These guidelines address partnership violence as a health disparity problem for women and girls, with an emphasis on how men interfere with and limit their women’s partners ‘ ability to make choices in reproductive health. The guidelines offer an overview of recent study 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 is 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 on 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 causes sometimes physical injury, trauma and death (Kernic, Wolf & Holt, 2000). The impact of IPV can last for life. Abused women have more physical health problems, more depression, abuse of drugs and alcohol, and attempted suicide than non-abused women (Golding 1996). They also use health services more often (Miller, Cohen and Rossman 1993).

An increasing number of evidence shows the health impacts of intimate partners ‘ violence against women. But IPV’s economic costs 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 underestimated (Institute for Women’s Policy Research, 1995). Researchers recommended the development of national cost estimates for IPV-related medical care, mental health care, police, 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 deriving 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 — of 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 unstable cost estimates based on the small number of male IPV-related injuries, this report focuses solely on IPV costs for females aged 18 and older.

Although Congress only called for IPV-related injuries costs, it was important to include the costs of IPV-related loss of productivity and to determine the economic costs of IPV homicide-related lives. These costs significantly contribute to IPV’s economic burden. 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 negative health implications of domestic violence and the long-term toll on victims and society as a whole are among the non-monetary costs in particular. Several studies have shown that domestic abuse causes short-term and long-term physical and mental health problems including physical injuries, depression, stress and substance abuse. The World Health Organization sited women have been abused as being twice as likely to suffer poor health and physical and mental health problems as non-abused women. In addition, victims of domestic violence also suffer from premature death or suicide by the abuser. Women with domestic violence are significantly more likely to attempt suicide than non-abused women.

While victims suffer multiple types of abuse with varying severity levels, the overwhelming constant is that abusers will use whatever means at their disposal to control the independence of a victim. The abuser is able to manipulate the victim into remaining compliant by keeping the victim in a state of entrenched and reinforced powerlessness. It is 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 boy / 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 leaves the victim. Most victims, however, emphasize that their current abuse is the result of a gradual process of domination interspersed with good times and fearful events (LaViolette and Barnett, 2000).

This cycle keeps the victim hoping things are going to change, but fearing the consequences of a decision to leave. The Walker Cycle Theory of Violence stated in 1979 that the battering cycle involved 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 shells of eggs, is doing whatever it takes to keep the abuser quiet. Because the victim feels more scared, he / she often leaves the abuser waiting for the inevitable explosion. For survivors of intimate partner violence or sexual assault, a health care provider is likely to be the first professional contact.

Evidence suggests that women who have been subjected to violence seek health care more often than women who have not been abused, even if the associated violence is not revealed. They also identify health care providers as the most trusted professionals in disclosing abuse. The U.S. Task Force on Preventive Services Recommends IPV screening for all patients with childbirth. Several short screening tools proved efficient in the detection of IPV and can be used in the office environment. Identifying IPV enables a better care for the doctor and improves the health outcomes of the survivor. The offices of family doctors should provide patients with local and national resources. Comprehensive documentation of injuries associated with abuse is critical.

When it may be difficult for a doctor to care for patients who are unwilling to leave abusive relationships, ongoing supporting treatment improves patient results. Continuous relationship with the same doctor improves the opening of the patient to talk about IPV. Knowing about the experiences of a patient with IPV enables the doctor to gain insight into the medical and emotional problems of the patient and should prompt the doctor to show extra sensitivity with physical examinations (explaining each next step in the examination and getting the patient’s approval to move forward is a way to give the patient back 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 placed 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 domes should be provided.

A study carried out in 1998 by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente leads 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 make 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 experiences of childhood 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 trauma do not dictate the child’s future. Despite the trauma in their lives, children survive and even thrive. Adverse experiences with protective factors are counterbalanced for these children. Together experienced adverse events and protective factors have the potential to promote resilience. Knowledge of what constitutes resilience in children is evolving, but we know that several factors relate positively to such protection, including cognitive capacity, healthy relationships of attachment (especially with parents and caregivers), motivation and ability to learn and engage with the environment, ability to regulate emotions and behavior, and supporting 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 that call on children who have experienced trauma and adversity to intervene, 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 have an incredible promise for the prevention or mitigation of parent-and environment-mediated 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, abuse of substances, and abusive / violent behavior. Probably affecting one another are adult IPV and psychosocial characteristics. However, adult IPV is associated with childhood experiences, and there are significant indirect pathways through psychosocial characteristics. Future research investigating the (probably bidirectional) relationship between depression / anxiety and IPV would start to break down these complicated relationships. In addition, building a model capable of statistically differentiating competing models would help to determine associations ‘ directionality. These results differ from the few studies that also examined pathways between ACEs and IPV, as we use couple data and test 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 depression and anxiety treatment is critical to reducing adult partner violence and potentially weakening adult relationships between ACEs and 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 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 the exposure of children 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 one-time intervention that may include safety planning, shelter referrals, empowerment counseling, hazard assessment and other resources, as well as access to exposed children’s mental and behavioral health services.

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Adverse Childhood Experiences and Women in Domestic Violence Shelters. (2019, Sep 16). Retrieved from