Discussion

 
This report presents estimates of the incidence, prevalence, and costs of intimate partner violence against U.S. women ages 18 and older. In addition to data about IPV fatalities obtained from existing FBI sources, it uses data from the first large-scale survey to collect information about injuries IPV victims sustained, the medical and mental health care services victims used, and the time victims lost from paid work and household chores. The report reflects the most appropriate, reliable data currently available about the costs associated with IPV. Standard public health methods were applied to recent data on IPV-related injuries to estimate their incidence, estimate resulting health care costs and lost productivity, and to review strategies for reducing the incidence of IPV.

As reported in previous chapters, nearly 5.3 million intimate partner victimizations occur each year among U.S. women ages 18 and older, and nearly 1,300 women lose their lives as a result of IPV. Based on these estimates, such violence costs our nation more than an estimated $5.8 billion dollars annually—nearly $4.1 billion for medical and mental health care, $0.9 billion in lost productivity, and $0.9 billion in homicide lost earnings. These figures are believed to underestimate the problem of IPV for many reasons, and additional efforts are needed to better determine the costs of IPV against women in the U.S.
 

Using the Cost Figures in this Report

The cost estimates presented in this report can be used to—

• Calculate the economic cost savings from reducing a given number of injuries resulting from IPV;
  

• Demonstrate the economic magnitude of IPV in the U.S.;
  

• Evaluate the impact of IPV on a specific sub-sector of the economy, such as  consumption of medical resources or effects on employers.

However, because of some limitations in the data—the discussion of which follows— these estimates are not comprehensive. Therefore, the estimates in this report should not be used in direct comparisons with the costs of reducing IPV, namely to produce benefitcost ratios in analyses of interventions to prevent IPV.

 
Data Limitations

The cost estimates presented in this report have several limitations, the most obvious of which is the fact that 1995 incidence data were used to generate annual estimates. CDC recognizes that direct costs, value of lost productivity, and present value of lifetime earnings resulting from IPV today may differ from that of IPV that occurred in 1995. However, this report reflects the most appropriate, reliable data available to date about the costs associated with IPV. Other limitations involve the exclusion of certain costs potentially associated with IPV and the use of average rather than actual medical care costs.

Excluded Costs
Several cost components were excluded from this report because data were unavailable or insufficient. Perhaps the largest omission is criminal justice costs. NVAWS data indicate that an estimated 1.5 million intimate partner rape, physical assault, or stalking victimizations result in police reports each year; nearly 79,000 of these victimizations result in a jail or prison sentence. While IPV-related criminal justice service use is significant, current data about unit costs do not allow for reliable, nationally representative cost estimates associated with these services.

Some medical care costs, including home care visits, treatment for sexually transmitted diseases (STDs), and terminated pregnancies were excluded because there were too few victimizations resulting in these outcomes reported in the NVAWS to generate reliable cost estimates. Also excluded were cost components for which either no data were available or only incidence data were available: social services such as women’s shelters and counseling clinics; shelter, moral support, and financial assistance from IPV victims’ friends and family; medical or mental health costs of treating children who witness IPV; foster care for children as a result of IPV; and the value of time lost from volunteer work, school, and social and recreational activities.

Although the mental health care costs associated with IPV were calculated, it was not possible to estimate the intangible costs of pain and suffering associated with IPV that did not result in a mental health care visit, or that did not result in a visit where IPV was identified as associated with the suffering. Because costs of this type may be quite high, this report should be viewed as presenting very conservative estimates, or as the lower limit of the costs related to IPV.

Because the NVAWS reports on the survivors of IPV, data about victims’ use of medical and mental health services were collected only for victims of nonfatal IPV. No data were collected about the health care costs associated with treating victims who ultimately die as a result of IPV.

Limitations of the Medical Care Data
Health care service use resulting from IPV is not always readily reported. Therefore, the health care costs in this report are underestimates and should be viewed as lower limits of the magnitude of the problem.

Evidence has shown that victims of IPV manifest a wide range of physical symptoms that are not directly related to abuse. These can include headaches, reproductive health problems, chronic pain, digestive problems, and sleep disturbances (McCauley et al.1995). To the extent that medical care service use associated with indirect physical symptoms of IPV was not reported by victims, related costs are excluded from the health care estimates in this report.

Limitations of the Mental Health Care Data
Data about mental health–related costs of IPV are limited for several reasons. First, incidence estimates derived from the NVAWS are based on the response to a question about whether or not the victim spoke to a mental health professional. As no definition of mental health professional was given, this question was subject to the interpretation of the respondent. Furthermore, mental health professionals are not the only individuals from whom victims may seek mental health care.

Second, respondents were asked only about mental health care providers with whom they discussed their experience of IPV victimization. Some women may have sought care for mental health problems but not identified that it was related to past experiences of IPV.

Finally, the cost of unmet mental health needs is not estimated. This is a critical gap in IPV research because the violence itself may limit women’s use of needed services. That is, men who physically abuse their partners are also likely to control and coerce them (Wilson, Johnson and Daly 1995), including restricting their access to mental health care (Walker 1984).

Underestimate of a Particular Type of Victimization
Although some incidents involved more than one type of victimization (e.g., a woman whose former husband stalks and then rapes her), the NVAWS counted each incident only once and classified it according to the severity of abuse. Rape was considered more severe than physical assault, and physical assault more severe than stalking. Women who sustained injuries during incidents involving more than one type of victimization were asked to report services used as a result of these injuries for the most severe type of victimization involved in these incidents. They were asked not to report service use for the same injuries when asked about the less severe type(s) of victimization involved in the particular incident. These procedures prevented double-counting of both service use and associated costs resulting from these incidents. However, these procedures likely resulted in an underestimate of health care costs resulting from physical assault, because some costs are included under rape. Likewise, some stalking costs are likely included under physical assault and rape.

 
Conservative Cost Estimation

The cost estimates of IPV in this report are generally conservative for several reasons. First, the NVAWS estimates of IPV victimization among women are lower than estimates in other studies. Second, the estimates presented in this report are based on services that victims of IPV reported using. Some NVAWS respondents may not have reported IPV due to embarrassment or shame. Consequently, any services used as a result of these victimizations also went unreported.

Finally, the estimate of present value of lifetime earnings relies on criminal homicide data that include the relationship between victim and perpetrator and the victim’s age. The relationship between victim and perpetrator was not known for all homicide cases, which likely results in an undercounting of IPV homicides. Additionally, about 1% of homicide cases determined to be the result of IPV did not report victim’s age. The present value of lifetime earnings could not be calculated for those cases, thus resulting in a conservative estimate.
 

A Need for More Data

This report is an important step in understanding the current knowledge about intimate partner violence in the U.S. However, it highlights a need for more data to fully appreciate the economic and human costs of this problem. Obtaining these data will involve creating standard definitions of IPV, expanding quantitative data collection efforts, and employing methods to gather qualitative data.

Standardizing the Definition of Intimate Partner Violence
Definitions of intimate partner violence vary among agencies collecting data. For example, some definitions include same sex partners, and some do not. Some consider IPV among both current and former intimate partners, some do not. Because of these variations, survey data also vary, making it difficult to firmly state the magnitude of IPV. 

To address problems posed by varying definitions, CDC recently facilitated a national process to develop standard definitions of IPV (Saltzman et al. 1999). At the same time, CDC funded several states to develop IPV surveillance systems that use these definitions to gather data from the health care, social service, and criminal justice systems. This project serves as a pilot test of the IPV definitions and the feasibility of developing statewide public health surveillance to estimate the magnitude of the problem.

Improving Quantitative Data
The information about service use provided in this report includes medical and mental health care obtained from the traditional medical care system. Many survivors of IPV do not seek out these health care providers, especially for mental health care. Instead, they may go to support groups and rape crisis centers or contact crisis hotlines. Researchers should find ways to gather data from such service providers. Additionally, many women experience repeated IPV victimizations, yet little is known about the cumulative effects of such repeat abuse on service use.

One area for which costs of IPV may be substantial is criminal justice services. The NVAWS asked survivors about their involvement with the criminal justice system, but inadequate unit cost data exist to allow for generating unbiased estimates of the costs of those services. In fact, only one county at the time of the survey had unit cost data. Nationally representative data about the costs of individual criminal justice services—police reports, arrests and detainment, legal and judicial services, incarceration, probation—are needed.

While health system data about IPV, primarily derived from hospital discharge and emergency department records, have improved in recent years, future efforts will allow for even better data collection. The clinical modification of ICD-10 (ICD-10 CM) will provide information about abuse, neglect, abandonment, and the perpetrator’s relationship to the victim. This will enable better IPV data collection from health sources.

 
Collecting Qualitative Data

Perhaps more compelling than the economic costs are data about the human costs. But how do you quantify pain, suffering, and decreased quality of life associated with intimate partner violence, both on survivors and on children exposed to such violence? Data are needed to assess the long-term, psychosocial effects of IPV and to demonstrate more clearly the social burden of this problem. Researchers should explore methods for collecting data about indirect or intangible costs of IPV, such as using in-depth interviews with survivors and service providers.

 
A Need for Primary Prevention of Intimate Partner Violence

To reduce both the economic and human costs of intimate partner violence against women, we must focus on primary prevention—finding ways to stop such violence before it ever occurs—rather than only treating victims and rehabilitating perpetrators. To that end, CDC has identified several priorities to address IPV prevention. These priorities, set forth in CDC’s Injury Research Agenda, represent the research issues that warrant the greatest attention and extramural and intramural research from CDC for the next three to five years. (The agenda can be viewed online at: www.cdc.gov/ncipc/pub-res/research_agenda/agenda.htm.) 

One key area of CDC’s IPV research is social norms. Social norms—what a community views as acceptable behaviors for its citizens—can profoundly affect efforts to prevent public health problems. In October 2000, CDC began exploring how social norms affect intimate partner violence. Findings are guiding development of a campaign to change social norms that accept or promote IPV against women. The campaign will target boys in sixth through eighth grades, a population in which strong social norms are developing quickly and in which we can effect lasting changes. It will focus on the characteristics of healthy relationships, in which violence is unacceptable.

CDC is also working to find ways to intervene with individuals, families, and communities in ways that stop violence before it happens. Its research agenda calls for developing programs and policies that provide counseling for batterers and prevent dating violence as means of intervening with perpetrators and potential perpetrators. The agenda also sets a priority to better understand how violent behavior toward intimate partners develops, so that researchers can implement strategies to reduce factors that increase the risk of IPV perpetration.

Other areas of research about preventing intimate partner violence include developing and evaluating training programs about IPV detection and prevention for health professionals, evaluating the health consequences of IPV across the life span, developing and evaluating surveillance methods to better collect data about incidence and prevalence of IPV, and disseminating information about IPV prevention strategies that work.

 
Conclusion

With an estimated economic cost of $5.8 billion, and the untold intangible costs, intimate partner violence against women is a substantial public health problem that must be addressed. Significant resources for research are needed to better understand the magnitude, causes. and risk factors of IPV and to develop and disseminate effective primary prevention strategies. Until we reduce the incidence of IPV in the United States, we will not reduce the economic and social burden of this problem.
 

References

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.

Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate Partner Violence Surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 1999.

Walker LE. The Battered Woman Syndrome. New York: Springer; 1984. Wilson M, Johnson F, Daly M. Lethal and nonlethal violence against wives. Canadian Journal of Criminology 1995;37:331–61.

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