Introduction

Intimate partner violence—also called domestic violence, battering, or spouse abuse—is violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. It can occur among heterosexual or same-sex couples.

 
Introduction

Violence against women is a substantial public health problem in the United States. According to data from the criminal justice system, hospital and medical records, mental health records, social services, and surveys, thousands of women are injured or killed each year as a result of violence, many by someone they are involved with or were involved with intimately. Nearly one-third of female homicide victims reported in police records are killed by an intimate partner (Federal Bureau of Investigation 2001).

Intimate partner violence—or IPV— is violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. It occurs among both heterosexual and same-sex couples and is often a repeated offense. Both men and women are victims of IPV, but the literature indicates that women are much more likely than men to suffer physical, and probably psychological, injuries from IPV (Brush 1990; Gelles 1997; Rand and Strom 1997; Rennison and Welchans 2000).

IPV results in physical injury, psychological trauma, and sometimes death (Gelles 1997; Kernic, Wolf and Holt 2000; Rennison and Welchans 2000; Sorenson and Saftlas 1994). The consequences of IPV can last a lifetime. Abused women experience more physical health problems and have a higher occurrence of depression, drug and alcohol abuse, and suicide attempts than do women who are not abused (Golding 1996; Campbell, Sullivan and Davidson 1995; Kessler et al. 1994; Kaslow et al. 1998; Moscicki 1989). They also use health care services more often (Miller, Cohen and Rossman 1993).

A growing body of evidence demonstrates the health consequences of intimate partner violence against women (Coker, Smith, Bethea, King and McKeown 2000; Kernic, Wolf and Holt 2000). However, the economic costs of IPV remain largely unknown Previous cost estimates range from $1.7 billion to $10 billion annually (Straus 1986; Gelles and Straus 1990; Meyer 1992), but they are believed to underestimate the true economic impact of this type of violence (Institute for Women’s Policy Research 1995). Researchers have recommended developing national cost estimates for IPV-related medical care, mental health care, police services, social services, and legal services (Gelles and Straus 1990; Straus 1986; Straus and Gelles 1987). However, a recent literature review (Finlayson, Saltzman, Sheridan and Taylor 1999) found only one U.S. study that derived national cost estimates for violence among intimate partners (Miller, Cohen and Wiersema 1996).

Recognizing the need to better measure the magnitude of IPV and resulting economic costs—in particular, those related to health care—the U.S. Congress funded the Centers for Disease Control and Prevention (CDC) to conduct a study to obtain national estimates of the incidence of injuries resulting from IPV, to estimate the costs of injuries to health care facilities, and to recommend strategies to reduce IPV-related injuries and associated costs. Language related to this funding was included in the Violence Against Women Act provisions of the Violent Crime Control and Law Enforcement Act of 1994 (P.L. 103–322).

Given the greater number of IPV-related injuries that occur among women and the instability of cost estimates based on the small numbers of IPV-related injuries among men, this report focuses only on the costs of IPV against women ages 18 and older. Although Congress called only for costs of IPV-related injuries, it was important to include the costs of lost productivity resulting from IPV and to determine the economic costs of lives lost to IPV homicide. These costs contribute significantly to the economic burden of IPV.

This report describes the development of the requested study; presents findings for the estimated incidence, prevalence, and costs of IPV among U.S. adult women; identifies future research needs; and highlights some of CDC’s activities related to IPV prevention.

 
The Need to Estimate the Costs of Intimate Partner Violence 

Cost estimates can serve important purposes. For example, they help demonstrate the impact a problem has on society and can shape the attitudes of people who develop public policy and allocate limited funds (Miller, Cohen and Wiersema 1996; Phillips 1987; Snively 1994). They can also help assess the benefit or effectiveness of violence intervention strategies or programs (Haddix, Teutsch, Shaffer and Dunet 1996; Teutsch 1992), which may, in turn, lead to resource allocation to specific programs (Mercy and O’Carroll 1988).

 
The Need for National Estimates of Intimate Partner Violence

To estimate the costs of IPV, one must first estimate its incidence. While most people acknowledge IPV as a substantial public health problem, few seem to agree on its magnitude (Crowell and Burgess 1996). Several surveys (e.g., Bachman and Saltzman 1995; Rennison and Welchans 2000; Straus and Gelles 1990) have attempted to determine the extent of violence against women, but methods and findings vary considerably,arousing some debate. Many people contend that the magnitude of violence against women—including violence by intimate partners—is underestimated, while others believe it is exaggerated. Why has the scope of intimate partner violence been so difficult to measure?

Lack of consensus about terminology. Researchers have been unable to agree on a definition of intimate partner violence. In some studies, IPV includes only acts that may cause pain or injury, while ignoring behaviors designed to control or intimidate, such as stalking, humiliation, verbal abuse, imprisonment, and denial of access to money, shelter, or services. Much of the debate about the number of women affected by intimate partner violence results from this lack of consensus. For example, a researcher who defines IPV more broadly—including stalking and other forms of psychological abuse, as well as physical and sexual violence—will produce a larger estimate than a researcher who uses a more narrow definition that includes physical and sexual violence only (DeKeseredy 2000). A definition that separately measures component types of violence—physical, sexual, and emotional—will also likely produce different measurements than one that combines all types of violence (Gordon 2000).

Variations in survey methodology. Sampling strategies and how the purpose of a survey is explained may affect how participants answer survey questions. For example, a respondent on the National Crime Victimization Survey may not acknowledge being the victim of IPV if he or she does not believe IPV is a crime. However, the same respondent might disclose IPV victimization on a survey about family conflict.

Gaps in data collection. Because no national system exists for ongoing collection of data about IPV against women, estimates are often drawn from data gathered for other purposes. For example, hospitals collect information about victims to provide patient care and for billing purposes; they may record few details about the violence itself or about the perpetrator and his or her relationship to the victim. In contrast, police collect data that will aid in apprehending the perpetrator, and thus may collect little information about the victim.

Different time frames. Studies of IPV have used different time frames to study victimization. Some measure lifetime victimization, while others measure annual victimization. These differences are not always well understood and have sometimes resulted in inappropriate comparisons being drawn between studies that are not in fact comparable.

Reluctance to report victimization. Many victims do not want to report IPV because they may fear, love, depend on, or wish to protect the perpetrator. When medical care is required, women may attribute their injuries to other causes.

Repetitive nature of IPV. Often, IPV involves repetitive behavior, rather than a single incident. However, reports about IPV do not always clearly indicate whether data refer to the number of IPV incidents or the number of victims.

Limited populations. Previous studies have focused either on married or cohabiting couples or on dating relationships. Although a few studies have looked at violence among same-sex couples, most research has examined only heterosexual relationships. Few studies have examined IPV among the population overall.

Survey limitations. Many data about IPV have been collected through surveys, which rely on self-reports by victims. These self-reports may not accurately reflect the magnitude of the problem, if respondents do not answer questions truthfully or do not accurately recall events. Additionally, despite carefully worded questions and efforts to ensure that participants understand what is being asked, respondents may interpret terms differently.

Because methodological differences such as those described here can affect the findings of a survey or study, researchers must explain the choice of a particular methodology, define terms used, and clearly explain how information was gathered (CDC 2000). This information allows others to examine findings in the context in which data were collected and can help readers understand how the findings compare with those of other surveys or studies. In keeping with this practice, this report specifies the methodology employed and the definitions used.

 
The National Violence Against Women Survey

When Congress requested a study about the costs of IPV, no existing survey or study had a large enough sample to reliably estimate the occurrence of IPV-related injuries in the U.S. population. Nor did any existing survey or study include enough information about the nature and extent of injuries and their treatment to make the national projections Congress had requested. A new study was needed to fill gaps in knowledge about the magnitude of IPV.

Developing and Implementing the National Violence Against Women Survey
CDC learned that the National Institute of Justice (NIJ), the research arm of the U.S. Department of Justice, had funded Patricia Tjaden and Nancy Thoennes of the Center for Policy Research in Denver to develop the National Violence Against Women Survey—or NVAWS. The NVAWS was to generate information about the incidence, prevalence, characteristics, and consequences of physical assault, rape, and stalking perpetrated against U.S. women ages 18 and older by all types of perpetrators, including intimate partners.

Rather than duplicating efforts, CDC approached NIJ about supplementing its grant to Tjaden and Thoennes to broaden the size and scope of the survey by increasing the sample size, conducting a companion survey of male respondents, and adding questions about violence in same-sex intimate relationships. The broader survey could then be used as the basis for calculating more reliable cost estimates of IPV and other forms of violence. Both NIJ and the Center for Policy Research agreed to delay the survey to accommodate a supplemental award and make CDC’s proposed changes.

The supplemental funds expanded the survey population to a number large enough to provide reliable national estimates of the incidence and prevalence of forcible rapes, physical assault, and stalking; related injuries and health care costs, including those for mental health care services; and indirect costs due to lost productivity of paid work and household chores. 

CDC and the office of the Assistant Secretary for Planning and Evaluation, another component of HHS, contracted with Wendy Max, Dorothy Rice, Jacqueline Golding, and Howard Pinderhughes at the University of California, San Francisco, to use the methodology they had developed earlier (Rice et al. 1996) to review draft survey questions and to recommend changes that would enable cost data to be collected with the NVAWS. The survey questions sought to detail the type of violence; the circumstances surrounding the violence; the relationship between victim and perpetrator; and consequences to the victim, including injuries sustained, use of medical and mental health care services, contact with the criminal justice system, and time lost from usual activities. 

From November 1995 to May 1996, a national probability sample of 8,000 women and 8,000 men ages 18 and older were surveyed via telephone using a computer-assisted interviewing system. Female interviewers surveyed female respondents. A Spanishlanguage version of the survey was used with Spanish-speaking respondents.

In addition to the 8,000 completed interviews, the women’s survey contacts included 4,829 ineligible households; 4,608 eligible households that refused to participate; and 351 interviews that were terminated before completion. The women’s response rate was 71.0%.

Analyzing NVAWS Data and Estimating the Costs of Intimate Partner Violence
Tjaden and Thoennes (1999) used the NVAWS data and U.S. Census figures for the population of women ages 18 and older to generate national estimates of the incidence and prevalence of IPV-related injuries among women.1 Cost estimates were to be derived from these estimates. Max and colleagues (1999) applied their previously developed methodology for estimating the costs of intimate partner violence to the NVAWS incidence data and data from other sources (Rice, Max, Golding and Pinderhughes 1996). 

¹This report used only the data about violence committed against women by intimate partners. However, NVAWS data have also provided insight into other areas of violence, including a comparison of women’s and men’s experiences as victims of rape, physical assault, and stalking by all types of perpetrators.

CDC funded Research Triangle Institute International (RTI) to derive measures of reliability for the incidence, prevalence, and cost estimates. Additionally, Max and colleagues and RTI developed estimates of the present value of lifetime earnings for fatal IPV by combining economic data with IPV homicide data from the Federal Bureau of Investigation.

The report that follows reflects CDC’s integration of the work by Tjaden and Thoennes, Max and colleagues, and RTI.

 
Definitions Used in the NVAWS and this Report

Throughout this report, one will read about intimate partner violence (IPV) and specific types of violent behaviors, as well as about incidence, prevalence, and victimization rates of IPV. As stated earlier, there is a lack of consensus about IPV-related terminology. Therefore, it is important to define those terms as they were used in the NVAWS to ensure that readers have a consistent understanding of what they mean and to allow readers to compare findings presented in this report with those of other studies.

Intimate partner violence (IPV) against women includes rape, physical assault, and stalking perpetrated by a current or former date, boyfriend, husband, or cohabiting partner, with cohabiting meaning living together as a couple. Both same-sex and opposite-sex cohabitants are included in the definition. This definition of IPV resembles the one developed by CDC (Saltzman et al. 1999); however, it also includes stalking because of the high level of fear that stalking generally provokes in women and the associated costs that may result.

Rape is the use of force, without the victim’s consent, or threat of force to penetrate the victim’s vagina or anus by penis, tongue, fingers, or object, or the victim’s mouth by penis. The definition includes both attempted and completed acts. This definition is similar to that used in the National Women’s Study (National Victim Center and Crime Victims Research and Treatment Center 1992) and is roughly equivalent to what the justice system refers to as rape or attempted rape.

Physical assault is any behavior that inflicts physical harm or threatens or attempts to do so. Specific behaviors include throwing something at the victim; pushing, grabbing, or shoving; pulling hair; slapping, hitting, kicking, or biting; choking or trying to drown; hitting with an object; beating up the victim; threatening with a gun or knife; and shooting or stabbing the victim. This definition is similar to that used in the National Family Violence Survey (Straus and Gelles 1986) and the Canadian Violence Against Women Survey (Johnson 1996), and it is roughly equivalent to what the justice system refers to as simple and aggravated assault.

Stalking is repeated visual or physical proximity, non-consensual communication, and/or verbal, written, or implied threats directed at a specific individual that would arouse fear in a reasonable person. The stalker need not make a credible threat of violence against the victim, but the victim must experience a high level of fear or feel that they or someone close to them will be harmed or killed by the stalker. This definition is similar to that used in the model anti-stalking legislation developed for states by NIJ (National Criminal Justice Association 1993).

Prevalence is the number of U.S. women ages 18 and older who have been victimized by an intimate partner at some point during their lifetimes (lifetime prevalence) or during the 12 months preceding the NVAWS (past 12 months prevalence). In this report, prevalence refers to past 12 months prevalence unless otherwise specified.

Incidence is the number of separate episodes of IPV that occurred among U.S. women ages 18 and older during the 12 months preceding the survey. For IPV, incidence frequently exceeds prevalence because IPV is often repeated. In other words, one victim (who is counted once under the prevalence definition) may experience several victimizations over the course of 12 months (each of which contributes to the incidence count).

Victimization rate is the number of IPV victimizations involving U.S. women ages 18 and older per 1,000 women in that population. The population estimate used in this report is the U.S. Census Bureau’s projection of 100,697,000 women ages 18 and older in 1995.

 
A Note About Annual Estimates

This report presents annual data about IPV and its costs, generalized from data about the incidence of intimate partner violence in a given year (1995) and the costs associated with those victimizations. CDC acknowledges that the health care costs, value of lost productivity, and present value of lifetime earnings among IPV murder victims may be different today than in 1995. However, this report reflects the most appropriate, reliable data currently available about the costs associated with IPV.

 
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This page last reviewed September 07, 2006.

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