Costs of Intimate Partner Violence in the United States

 
Understanding the economic costs of intimate partner violence (IPV) can aid policymakers in allocating resources more effectively and efficiently. This chapter provides the estimated annual costs of medical care, mental health care, lost productivity, and present value of lifetime earnings associated with IPV against U.S. adult women. The data presented reflect costs associated with IPV victimizations that occurred in 1995; these data are the most appropriate, reliable data currently available. It should be noted, however, that costs related to victimization in a given year are not always incurred in that year. For instance, mental health care visits related to IPV could continue for years after victimization. Therefore, estimated costs for victimization in a given year may underestimate the total costs of an incident of IPV victimization.

 
Calculating the Costs of Intimate Partner Violence

The economic costs of IPV are divided into two components—direct and indirect costs.

• Direct costs are the actual dollar expenditures related to IPV. They include spending for health care–related services such as emergency department (ED) visits; hospitalizations; outpatient clinic visits; services of physicians, dentists, physical therapists, and mental health professionals; ambulance transport; and paramedic assistance. To calculate the total costs of each medical and mental health care service, the unit cost of a particular service was multiplied by the number of times that service was used (Bardwell 2001).

• Indirect costs of IPV represent the value of lost productivity from both paid work and household chores for injured victims and the present value of lifetime earnings for victims of fatal IPV. Lost productivity was measured by the number of days victims were unable to perform paid work and/or household chores (including household chores and childcare for women not employed outside the home) because of illness, injury, or disability related to IPV victimization. The value of lost productivity was calculated using the mean daily values of work and household production, which are based on data from the U.S. Bureau of Labor Statistics (1996; 1999), Miller (1997), and the U.S. Bureau of the Census (1996). The present value of lifetime earnings was calculated by multiplying the number of IPV homicides for each age group by the average present value of the anticipated future earnings of women in those age groups. These calculations account for differential life expectancy by age group, labor force earning patterns and participation rates at successive ages, and imputed household production values for women in the labor force and women not in the labor force (Rice, Max, Golding and Pinderhughes 1997).

To yield more reliable estimates for service use and lost productivity, all most-recent IPV victimizations reported in the NVAWS—including those that occurred more than 12 months before the interview—were used to establish patterns of service use and lost productivity.
 

Data Sources Used to Calculate Costs of Intimate Partner Violence

As discussed previously, the National Violence Against Women Survey (NVAWS) and Uniform Crime Reports Supplementary Homicide Report were used to measure the incidence of fatal and nonfatal IPV, incidence of IPV-related health care service use among survivors, and lost productivity. Additionally, the following sources were used to calculate the health care costs of IPV:

• Medical Expenditure Panel Survey (MEPS), 1996. This survey by the Agency for Healthcare Research and Quality lists expenditures for medical care in the U.S. The MEPS is the main data source for unit costs of health care presented in this report. These unit costs were deflated to 1995 dollars using the appropriate health care components of the Consumer Price Index.
  

• Medicare 5% Sample Beneficiary Standard Analytic Files. This data source, which reflects physician/supplier claims, was used to calculate expenditures for ambulance and paramedic services, which are not available in MEPS.

In this report, service use estimates were restricted to services required as a result of the most recent victimizations by intimate partners, as derived from the NVAWS. In the NVAWS, only women who were injured as a result of IPV were asked about their use of medical care services. In contrast, all women who were victimized, regardless of injury, were asked about their use of mental health care services. Unit costs of medical and mental health care services for rape and physical assault victims were derived from the MEPS using medical and mental health visits related to injuries for women ages 18 and older. The unit costs of mental health care services for stalking victims were based on MEPS using mental health visits for women ages 18 and older who did not also sustain physical injuries.

 
Medical Care Costs

Medical care costs include ambulance transport and paramedic care; ED care; physician, physical therapy, and dental visits; inpatient hospitalizations; and outpatient clinic visits. Victims seeking medical care often received more than one service. We estimated the medical care costs of rape and physical assault separately. Rapes that involved physical assault were classified as rape only to avoid counting victimizations twice. No medical care costs were associated with stalking.

Rape. According to estimates from the NVAWS, 322,230 IPV rapes occur among women each year. Slightly more than one-third of these rapes (36.2%) result in physical injuries, 31.0% of which require medical care. In all, 36,161 IPV rapes result in women receiving medical care for injuries. Table 8 presents the number of times IPV rape victims use each medical care service, along with the unit costs of those services.

The mean medical care cost per IPV rape is about $516. The mean medical care cost per rape among victims who actually receive treatment is $2,084 per victimization. Not all victims who reported receiving medical care used all types of medical services. Therefore, the average cost of medical care for victims receiving treatment reflects variations in service use; it does not equal the total of each of the individual service costs per rape.

Nearly half of the medical care costs associated with IPV rape are paid by private or group insurance; victims pay more than one-quarter of the costs (Table 9).

Physical Assault. Based on NVAWS estimates, 4,450,807 IPV physical assaults occur against women annually; 41.5% of these assaults cause injuries. Medical care for injuries is required in 519,031 incidents (28.1% of those injured). Table 10 presents the number of times physical assault victims use medical care services and the unit costs of those services.

The mean medical care cost per incident of IPV physical assault is $548. The mean medical care cost per physical assault among victims who actually receive treatment is $2,665. Not all victims who reported receiving medical care used all types of medical services. Therefore, the average cost of medical care for victims receiving treatment reflects variations in service use; it does not equal the total of each of the individual service costs per physical assault.

As with IPV rape, private or group insurance pays for nearly half of medical care costs for IPV physical assaults; victims pay more than one-quarter of the costs (Table 9).

 
Mental Health Care Costs

All women in the NVAWS who reported IPV were asked if they used mental health care services. Because mental health care often requires multiple visits over a long period of time, the cost of these services is substantial.

Rape. According to NVAWS estimates, one-third (33.0%) of IPV rapes result in the victim’s speaking with a psychologist, psychiatrist, or other mental health professional about the incident. On average, each incident requires 12.4 mental health care visits, for a total of 1.3 million mental health visits per year, at a mean cost of $78.86 per visit. The mean mental health care cost per incident of IPV rape is $323; the mean cost per IPV rape among victims who actually receive treatment is $978. Victims pay for more than one-third of mental health care services; private health insurers pay only slightly more than victims (Table 11).

Physical Assault. More than one-quarter (26.4%) of IPV physical assaults result in the victim’s speaking with a psychologist, psychiatrist, or other mental health professional, according to NVAWS estimates. On average, each incident requires 12.9 visits, for a total of 15.2 million visits annually, at a mean cost of $78.86 per visit. The mean mental health care cost per incident of IPV physical assault, is $269; among victims who actually receive treatment, the mean cost per incident is $1,017. Victims pay for approximately one-third of the costs (Table 11).

Stalking. NVAWS estimates indicate than more than half a million women are stalked by intimate partners each year. Forty-three percent of these victims seek mental health care services, at an average of 9.6 visits per person. That’s a total of nearly 2.1 million mental health care visits related to IPV stalking annually at a mean cost of $71.87 per visit. The mean mental health care cost per stalking incident by an intimate partner is $294; the mean cost per stalking incident among victims who actually receive treatment is $690. Private insurance pays for 34.7% of this mental health care; victims pay for 32.0% (Table 11).

Total Health Care Costs
The estimated total health care costs of IPV each year, including medical and mental health care services, is nearly $4.1 billion (Table 12). Of these costs, 89.7% are attributable to intimate partner physical assaults due to the large number of victimizations: 4,450,807 physical assaults compared with 322,230 rapes (6.7% of costs) and 503,485 stalking victimizations (3.7% of costs). The total medical and mental health care cost per victimization by an intimate partner was $838 per rape, $816 per physical assault, and $294 per stalking (Table 13).

 
Lost Productivity

Victims of IPV lose time from their regular activities due to injury and mental health issues. They may also be at greater risk for other health problems, such as chronic pain and sleep disturbances, which can interfere with or limit daily functioning (McCauley et al. 1995).

Rape. Among IPV rape victims, mean daily earnings lost are $69, and the mean daily value of household chores lost is $19.1 According to NVAWS estimates, more than one-fifth (21.5%) of the women raped by an intimate partner report losing time from paid work, and 13.5% lose time from household chores (Table 14). Rape victims lose an estimated 1.1 million days of activity each year, which is equivalent to 3,872 personyears.

Physical assault. Among IPV physical assault victims, mean daily earnings lost are $93, and the mean daily value of household chores lost is $24. Approximately one in six (17.5%) victims report time lost from paid work, and 10.3% report lost time from household chores (Table 14). Victims of IPV physical assault lose an estimated 9.5 million days of activity each year; that equals 33,163 person-years of lost productivity.

Stalking. Among IPV stalking victims, mean daily earnings lost are $93, and the mean daily value of household chores lost is $24. More than one-third (35.3%) of stalking victims report time lost from paid work, according to NVAWS estimates; 17.5% report time lost from household chores (Table 14). Stalking victims lose an estimated 2.9 million days of productivity—or 10,304 person-years—annually.

As shown in Table 12, the estimated total value of days lost from employment and household chores is $858.6 million. The value of lost productivity from employment is $727.8 million, representing 84.8% of the total; the value of lost productivity from household chores is $130.8 million. More than 13.5 million total days are lost from job and housework productivity, which is equivalent to 47,339 person-years. Nearly three-quarters (71.6%) of lost productivity is due to physical assault; 22.6% of lost productivity is due to stalking.
 

Present Value of Lifetime Earnings

The present value of lifetime earnings (PVLE) measures the expected value of lost earnings that IPV homicide victims would have otherwise contributed to society had they been able to live out their full life expectancies. An estimated 1,252 women are killed by an intimate partner each year. The PVLE for these victims is an estimated $892.7 million—an average of more than $713,000 per fatality. (See Appendix B for PVLE by age group.)

¹See Appendix A for calculations of lost productivity and related values as illustrated for rape estimates.

Summary: Total Costs of Intimate Partner Violence

The costs of IPV against women exceed an estimated $5.8 billion (Table 12). These costs include nearly $4.1 billion in the direct costs of medical care and mental health care and nearly $1.8 billion in the indirect costs of lost productivity and PVLE. Statistically, the overall total cost estimate of $5.8 billion varies from more than $3.9 billion to more than $7.6 billion, as indicated by the 95% confidence interval for the total costs (Table 12).

The largest proportion of the costs is derived from physical assault victimizations because that type of IPV is the most prevalent (Figure 3). The largest component of IPV costs is health care, accounting for nearly $4.1 billion—more than two-thirds of the total costs (Figure 4).

Bardwell Consulting, Ltd. Final Report on Methodology for Computation of Confidence Intervals for Summary-Level Estimates in the Cost Study of Intimate Partner Violence Against Women; July 2001. Final report for task order 0621-15, funded by the Centers for Disease Control and Prevention.

Bardwell Consulting, Ltd. Unpublished data for task order 0621-15, funded by the Centers for Disease Control and Prevention; 2001.

Max W, Rice DP, Golding J, Pinderhughes H. Cost of Intimate Partner Violence Against  Women in the United States, 1995; 1999. Report for contract 282-92-0048, funded by the Office of the Assistant Secretary for Planning and Evaluation and the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

McCauley J, Kern DK, Kolodner K, Dill L, Schroeder AF, DeChant HK, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Annals of Internal Medicine 1995;123:737–46.

Miller T. Unpublished data on the value of household production. Landover (MD): National Public Services Research Institute; 1997.

Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Collapsed total cost summary estimates of intimate partner violence. Unpublished data; 2002.

Research Triangle Institute International. Methodology Used to Produce Select Unit Cost Estimates, Variance Estimates, and Confidence Intervals; 2001. Report for task order 0621-15, funded by the Centers for Disease Control and Prevention.

Rice D, Max W, Golding J, Pinderhughes H. The Cost of Domestic Violence to the Health Care System. Final Report. Report prepared for the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 1997.

Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Intimate Partner Violence Against Women: Findings from the National Violence Against Women Survey; 1999. Unpublished report for grant 93-IJ-CX-0012, funded by the U.S. Department of Justice, National Institute of Justice; and the Centers for Disease Control and Prevention.

Tjaden P, Thoennes N. Extent, Nature, and Consequences of Intimate Partner Violence: Findings from the National Violence Against Women Survey, Research Report; 2000. Report for grant 93-IJ-CX-0012, funded by the U.S. Department of Justice, National Institute of Justice; and the Centers for Disease Control and Prevention. NCJ 181867.

U.S. Bureau of the Census, U.S. Department of Commerce. Money Income in the United States: 1995. Current Population Reports, P60-193. Washington (DC): U.S. Government Printing Office; 1996.

U.S. Bureau of Labor Statistics, U.S. Department of Labor. Employment and Earnings. January 1994. Washington (DC): U.S. Government Printing Office; 1996.

U.S. Bureau of Labor Statistics, U.S. Department of Labor. National Compensation Survey: Occupational Wages in the United States, 1997. Washington (DC): U.S. Government Printing Office; 1999.

Table 8. Estimated Medical Care Service Use and Unit Costs for Nonfatal Intimate Partner Rape Against U.S. Adult Women, 1995

^a To determine the cost per rape across all rapes, the total cost associated with each medical care service is divided by the estimated total number of intimate partner rapes (322,230), whether or not the victim was injured. 
^b The unit cost estimates of hospital overnights and dental visits are unstable and are used only as part of intermediate calculations.

Sources: Max, Rice, Golding and Pinderhughes 1999; Research Triangle Institute International 2001; Bardwell Consulting, Ltd. (unpublished data) 2001; Tjaden and Thoennes 2000.

Table 9. Distribution of Primary Source of Payment for Medical Care Resulting from Nonfatal Intimate Partner Rape and Physical Assault Against U.S. Adult Women, 1995

^aAmong the reported rape cases in the NVAWS that resulted in injury and medical care, no payments were made by Medicare or "some other source." However, analysts assume that among the total rapes resulting in injury and treatment in the U.S., these payment categories are not actually 0%. Therefore, the estimates are considered unavailable. To determine the percentage distribution of the remaining payment categories, the categories with unavailable estimates were ignored.

Source: Tjaden and Thoennes (unpublished data) 1999.

Table 10. Estimated Medical Care Service Use and Unit Costs for Nonfatal Intimate Partner Physical Assault Against U.S. Adult Women, 1995

					Cost Per Physical Assault
Type of Service	No. of Physical Assaults Requiring Medical Care	Average No.  of Uses Per Assault	No. of Uses	Unit Cost  for Service	All Physical Assaultsa	Physical Assaults Requiring Medical Care
ED visits	241,103	1.9	458,096	$ 346.73	$ 35.69	$ 658.79
Outpatient visits	98,726	3.1	306,051	347.59	23.90	1,077.53
Hospital overnights	132,994	5.7	758,066	2,519.90	429.19	14,363.43
Physician visits	268,858	3.2	860,346	112.21	21.69	359.07
Dental visits	49,308	4.4	216,955	308.90	15.06	1,359.16
Ambulance/paramedic services	77,336	1.1	85,070	121.13	2.32	133.24
Physical therapy visits	46,194	21.1	974,693	89.74	19.65	1,893.51

^aTo determine the cost per physical assault across all physical assaults, the total cost associated with each medical care service is divided by the estimated total number of intimate partner physical assault victimizations (4,450,807), whether or not the victim was injured.

Sources: Max, Rice, Golding and Pinderhughes 1999; Research Triangle Institute International 2001; Bardwell Consulting, Ltd. (unpublished data) 2001; Tjaden and Thoennes 2000.

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Table 11. Distribution of Primary Source of Payment for Mental Health Care Resulting from Intimate Partner Rape, Physical Assault, and Stalking Against U.S. Adult Women, 1995

Payer	Rape Victims  (Percent Paid)	Physical Assault Victims  (Percent Paid)	Stalking Victims (Percent Paid)
Medicare	2.1	1.9	2.8
Medicaid	10.5	6.9	11.1
Private or group insurance	37.1	43.1	34.7
Out-of-Pocket	33.6	32.0	32.0
Free or low-income clinics	10.5	11.6	15.3
Some other source	2.8	1.6	N/Aa
Other public sources	3.5	2.9	4.2
TOTALb	100.0	100.0	100.0

^a Among the victimizations of stalking in the NVAWS that resulted in mental health care, no payments were made by "some other source." However, analysts assume that among the total stalking victimizations resulting in mental health care in the U.S., this payment categoryis not actually 0%. Therefore, the estimate is considered unavailable. To determine the percentage distribution of the remaining payment categories, the "some other source" category estimate was ignored.
^b Columns may not sum due to rounding.

Source: Tjaden and Thoennes (unpublished data) 1999.

Table 12. Estimated Total Costs of intimate Partner Violence Against U.S. Adult Women, 1995

	Estimated Total Cost	Total Cost 95% Confidence interval (in Thousands)
Type of Cost	(in Thousands)	Lower Limit	Upper Limit
Health carea	$ 4,050,211	$ 2,207,491	$ 5,892,931
Lost productivity	$ 858,618	$ 596,058	$ 1,121,178
Paid work	$ 727,831	$ 470,435	$ 985,227
Household choresb	$ 130,787	$ 78,969	$ 182,605
Present value of lifetime earnings	$ 892,733	$ 839,723	$ 945,743
TOTAL COSTS (Direct + Indirect)	$ 5,801,561	$ 3,939,475	$ 7,633,648

^a Health care costs include mental health and medical care costs. In turn, medical care costs include outpatient clinic visits; emergency department visits; ambulance transport or paramedic care; physician, physical therapy, and dental visits; and inpatient hospitalization.
^b The productivity value for household chores was discounted for victims who also worked at a job for pay. Due to the uncertain labor force status of victims who reported only lost productivity from household chores, one cannot assume that these victims were necessarily out of the labor force. Consequently, the value assigned to all lost productivity from household chores was discounted.

NOTE: The Estimated Total Cost column does not sum to Total Costs due to rounding.

Sources: CDC, NCIPC, Office of Statistics and Programming (unpublished data) 2002; Bardwell 2001; Bardwell Consulting, Ltd. (unpublished data) 2001; Max, Rice, Golding and Pinderhughes 1999; Research Triangle Institute International 2001.

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Table 13. Estimated Average Health Care Costs per Nonfatal Intimate Partner Rape, Physical Assault, and Stalking Victimization Against U.S. Adult Women, 1995

Health Care Costs	Rapea	Physical Assaulta	Stalkinga
Medical Care, Totalb	$ 515.51	$ 547.50	N/A
ED visits	30.19	35.69	N/A
Outpatient visits	15.30	23.90	N/A
Hospital overnights	382.76	429.19	N/A
Physician visits	38.76	21.69	N/A
Dental visits	14.67	15.06	N/A
Ambulance/paramedic services	3.60	2.32	N/A
Physical therapy visits	30.23	19.65	N/A
Mental Health Care, Total	$ 322.70	$ 268.57	$ 293.92
TOTAL	$ 838.21	$ 816.07	$ 293.92

^a Estimates are based on 322,230 rapes, 4,450,807 physical assaults, and 503,485 stalking incidents.
^b No medical care costs are associated with stalking.

Sources: Max, Rice, Golding and Pinderhughes 1999; Research Triangle Institute International 2001; Tjaden and Thoennes 2000.

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Table 14. Estimated Lost Productivity Due to Intimate Partner Rape, Physical Assault, and Stalking Against U.S. Adult Women by Victimization Type, 1995

Victimization Type	Paid Work	Household Chores	Total
Rape
Percentage of victims reporting days lost	21.5	13.5	N/A
Mean number of days  lost per rapea	8.1	13.5	N/A
Total Days Losta	561,000	587,000	1,148,000
Physical Assault
Percentage of victims reporting days lost	17.5	10.3	N/A
Mean number of days lost per physical assaulta	7.2	8.4	N/A
Total Days Losta	5,608,000	3,851,000	9,459,000
Stalking
Percentage of victims reporting days lost	35.3	17.5	N/A
Mean number of days lost per stalkinga	10.1	12.7	N/A
Total Days Losta	1,795,000	1,119,000	2,914,000

 

^a Among victims who returned to the reported activity.

NOTE: The estimated total number of victimizations for rape is 322,230; for physical assault, 4,450,807; and for stalking, 503,485.

NOTE: For each type of victimization, the percentage of victims reporting days lost and the mean number of days lost per victimization differ between those victims who lost time from paid work and those victims who lost time from household chores. Consequently, the number of days lost from paid work and household chores must be determined separately, then totaled to obtain the total of days lost for each vicitimization type. As a result, the total or overall percentage of victims reporting days lost and the overall mean number of days lost per vicitimization were not calculated.

NOTE: See Appendix A for illustrations of calculations of lost productivity and related values.

Sources: Max, Rice, Golding and Pinderhughes 1999; Research Triangle Institute International 2001; Tjaden and Thoennes (unpublished data) 1999.

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