Review Article
Intimate Partner Violence among Women and Trauma-Informed Care: An International Perspective
Professor at Troy University School of Nursing, Alabama, Phenix City Campus, USA
*Corresponding author: Eula W Pines, Professor, Troy University School of Nursing, Troy, Alabama, Phenix City Campus, USA, E-mail: epines@troy.edu
Received: July 31, 2017 Accepted: August 18, 2017 Published: August 24, 2017
Citation: Pines EW. Intimate Partner Violence among Women and Trauma-Informed Care: An International Perspective. Madridge J Womens Health Emancipation. 2017; 1(1): 11-15. doi: 10.18689/mjwh-1000104
Copyright: © 2017 The Author(s). This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Purpose: The purpose of this review was to summarize the prevalence of intimate
partner violence and resultant consequences on womenʼs health and to describe an
evidence-based trauma-informed care model and a gender-trauma–specific group
intervention.
Method: An integrative literature review of publications was identified through a
comprehensive search of relevant databases (Cochrane Systematic Review, Agency for
Healthcare Research and Quality, National Guidelines Clearinghouse, PubMed, CINAHL,
EMbase) and other relevant databases. Articles were limited to primary clinical research,
systematic reviews, and meta-analyses of clinical studies published in English from 2010
to 2017.
Findings: Worldwide, women are disproportionately burdened by intimate partner
violence and significant preventable public health issues. Intimate violence is associated
with myriad adverse health outcomes for women, including chronic pain, disability,
psychological trauma, neurological injuries, physical and psychological sequelae, and
infectious diseases. The World Health Organization estimated that, globally, 35% of
women living in industrialized and developed countries have experienced exposure to
physical and/or sexual intimate partner violence. Nurses and other health providers are
in key positions to respond to womenʼs trauma associated with intimate partner violence.
Evidence suggests that trauma-informed care and trauma-specific interventions such as
the trauma recovery empowerment model are effective strategies to strengthen
womenʼs healing and recovery.
Conclusion: Intimate partner violence is a worldwide pervasive public health problem.
The prevalence rates and myriad adverse consequences on womenʼs health require
nurses and other health care providers to employ trauma-informed care and traumaspecific
interventions. Additionally, policy making and future research are paramount.
Keywords: Women and trauma; women intimate partner violence and women and
coping; intimate partner violence and trauma-informed care and interventions
Introduction
Worldwide, women are disproportionately burdened by intimate partner violence
(IPV) and significant preventable public health problems [1-4]. IPV is associated with
myriad adverse health outcomes for women, including chronic pain [5], disability [6],
psychological trauma, neurological injuries, physical and psychological sequelae [7-15],
and infectious diseases [16]. The World Health Organization (WHO)[2] estimated that,
globally, 35% of women living in industrialized and developed countries have experienced
exposure to physical and/or sexual IPV. The percentage of women assaulted by intimate partners varies; however, in 48 population-based surveys from
around the world, the WHO noted that 10% to 69% of women
have reported exposure to violent assaults by an intimate
partner [3] and 38% of female homicides were committed by
intimate partners [3]. The Centers for Disease Control and
Prevention (CDC) [1,para 1], defines intimate partner violence
as “individualsʼ exposure to physical and sexual violence,
stalking, and psychological aggression (including coercive
acts) by a current or former intimate partner.”Intimate partners
are individuals with whom a person has a close personal
relationship [2]. The CDC elaborated that relationships may be
characterized by emotional connectiveness, regular contact,
ongoing physical and/or sexual behaviors, identification as a
couple, and familiarity with and knowledge of each otherʼs
lives [2]. Despite the enormous influence of IPV borne by
women, this problem is often unrecognized by health care
providers and increases womenʼs risk for HIV infections and
myriad chronic physical and mental health sequelae [16, 1-4].
Researchers have acknowledged that some women are
violent in relationships with men and that violence is also
found in same-gender relationships; however, evidence shows
that the strongest risk factor for being a victim of IPV is being
female [1-5]. Furthermore, many women seek treatment in
adulthood for enduring physical and mental health conditions
related to childhood traumatic events [6-11]. The CDC [17,
para.1] described a traumatic event as “an event or series of
events that causes moderate to severe stress reactions.”
Traumatic events such as IPV have no end point and may
represent a single experience or an enduring or repeating
event that overwhelms the individualʼs ability to cope or to
integrate the ideas and emotions involved with that experience
[17]. These traumatic events often influence women to seek
support from health-care providers, but trauma related to IPV
is frequently not identified because of barriers such as healthcare
providersʼ insensitivity and womenʼs lack of disclosure
[18-21].
Because health-care providers are often the first point of
contact when women disclose personal exposure to IPV,
nurses and other health-care providers play an important role
in assessing, treating, and evaluating womenʼs health
outcomes related to this traumatic experience [18-21]. If
trauma and IPV are not addressed, many women may
inadvertently suffer from mental illness and chronic or
infectious diseases, including HIV [5]. Thus, the need to
address trauma in this vulnerable population is increasingly
viewed as an important component of effective behavioral
health care [8]. Despite this need, researchers have found that
many health-care providers are unprepared to address trauma
linked to IPV in women [4, 5, 7, 8]. Consequently, if a trauma
is unaddressed, traumatic events such as IPV can contribute to
life-long adverse health outcomes in womenʼs lives [2, 20].
The purpose of this review is to summarize the prevalence
of IPV and the effects of IPV on womenʼs health. Additionally,
the author will present an evidenced-based trauma-informed
care (TIC) model for adaptation in organizational and healthcare
practice settings.
Methods
Findings from relevant peer-reviewed articles from
relevant databases such as Cochranane, CINAHL, PubMed,
Psycho Review, and other databases were reviewed. Key words
included the following: women and trauma; IPV; IPV and
coping; traumatic stress; coping; and trauma-informed care.
The term trauma in this article depicts series of events or sets
of circumstances that are experienced and perceived by an
individual as physically or emotionally harmful or life-threatening
and that have lasting adverse effects on the
individualʼs functioning and mental, physical, social, emotional,
or spiritual well-being [22]. Articles are limited to primary
clinical research, systematic reviews, and meta-analyses of
clinical studies published in English between 2010 and 2017.
This author is sensitive to trauma experienced by menʼs
exposure to IPV, but this paper focuses on highlighting the
myriad adverse consequences to women who have faced IPV.
Articles were excluded if trauma focused primarily on men and
children, except when the articles linked adverse childhood
experiences (ACEs) to IPV and adult chronic diseases.
Violence against Women and Womenʼs
Health
Violence against women within partner relationships takes
many forms: physical, sexual, psychological, and economic.
However, IPV is the most common form [3]. These forms of
violence are interrelated and affect women from before birth to
old age [2-5]. In 2017, the CDC published the National Intimate
Partner and Sexual Violence Survey (NISVS): 2010–2012 State
Report [23]. Key findings revealed that, in the United States,
approximately 1 in 3 women and 1 in 6 men have experienced
some form of contact violence during their lifetime. The report
underscored the impact of violence on women. A closer look at
the report showed that 23 million women compared to 1.7
million men have been victims of completed or attempted rape
[22]. Additionally, more than 27% of women compared with
11% of men have experienced contact sexual violence, physical
violence, and/or stalking by partners and intimate partner
violence; and 1 in 6 women and 1 in 19 men experienced
stalking during their lifetime, respectively [23]. Negative health
responses to IPV include the following: gastrointestinal
disorders, substance abuse, sexually transmitted diseases, HIV,
and gynecological or pregnancy complications requiring
hospitalizations [23]. Survivors also experienced maladaptive
psychological responses such as anxiety, depression, substance
abuse, suicidal behaviors, and low self-esteem [5, 20].
Similarly, in Spain, legal institutions have documented
increased IPV recidivism rates against women. Lopez-Ossorio
et al., [24] found that in 2015, 129,193 IPV complaints were
documented, representing 1.98% higher IPV reporting rates
than in 2014 [6]. Other survey data revealed that 10.3% of
women 16 years or older have suffered physical violence
perpetrated by current or former partners, 81.1% experienced
sexual violence, and 25.4% have endured psychological
violence sometimes in their lives [24].
Australian researchers Loston et al., [5] conducted a 16-
year longitudal randomized cohort study to determine the
impact of IPV on womenʼs mental and physical health across
three generations. The participants comprised 40,395 women
representing three cohorts. The findings showed all cohorts
living with intimate partners were more likely to report poorer
mental health, physical decline in general health and function,
and overall higher levels of somatic pain compared to the
general population [25].
Machisa et al., [26] surveyed 511 women from Gauteng,
South Africa. They found that 50% experienced IPV in their
lifetime and 18% experienced IPV 12 months before the
survey. Overall, 23% were depressed, 14% engaged in binge
drinking, and 11.6% experienced post-traumatic stress
disorder symptoms. Moreover, 86% of the women had
experienced child abuse. They concluded that mental illness
plays a mediating role in the relationship between child abuse
and recent IPV. However, IPV negatively affected womenʼs
mental health [26]. The researchers asserted that effective
integration of mental health services in primary care, detection
of IPV symptoms, brief intervention, and broad referral
mechanisms for community-based care are necessary to meet
the needs of victims of IPV. The researchers elaborated that
programs designed to assist abused children need to take
similar approaches to reduce the long-term mental effects
associated with violence exposure [26].
Traumatic events such as IPV affect a womanʼs inner and
outer self [27]. When trauma affects the inner self, it impacts
womenʼs thoughts, feelings, beliefs, and values, resulting in
the, and disability in adulthood after controlling for important
confounders [30].
Additionally, many researchers have asserted that
exposure to trauma predisposes a woman to alcohol and
substance abuse [31]. According to Gilbert et al., [32]
approximately 80% of women who seek treatment for
substance use disorders have high lifetime prevalence rates of
physical or sexual trauma.
Many women may feel that the world is unsafe and that
others should not be trusted. Trauma can also affect a
womanʼs outer self, which includes relationships and behaviors.
Many women who have experienced trauma struggle with
interpersonal relationships with family, friends, and sexual
partners. Their parenting skills are challenged, particularly
when a woman has experienced childhood trauma [27].
A landmark ACEs [28] study has linked childhood
traumatic experiences to domestic violence and IPV, resulting
in long-term chronic physical and mental health outcomes in
men and women. The findings also indicated that, compared
with men, women were more vulnerable to childhood sexual
abuse and revictimization. Similarly, Brown et al., [29] collected
baseline survey data on health behaviors, health status, and
exposure to ACEs, from 17,337 adults aged greater than 18
years and found a positive correlation between ACEs and risk
of premature death.
Campbell et al., [30] analyzed 49,526, US adults from 5
states in the 2011 using the Behavioral Risk Factor Surveillance System. Exposures included psychological, physical, and
sexual forms of abuse, including substance abuse, violence,
mental illness, and incarceration. The researchers concluded
that, in addition to having a cumulative effect, individual ACE
components had complex relationships with risky behaviors, a
period.
Overall, cumulative data underscores the burden of IPV
on girls and women. Consequently, these adverse effects of
IPV on womenʼs physical and mental health provide
compelling evidence for health-care providers to provide TIC
[33-36] a period.
Trauma-Informed Care
The Substance Abuse and Mental Health Services
Administration (SAMSHA) [22] establishes a TIC framework as
an approach to engaging people with histories of trauma; this
framework enables people (health care providers and others)
to recognize these symptoms and acknowledges the role that
trauma has played in individualsʼ lives [22].
TIC is an organizational change process that focuses on principles
to promote healing and reduce the risk for re-traumatization
for vulnerable people [34-37]. SAMSHA approached this
framework by integrating trauma research findings, practice-generated
-
knowledge related to trauma interventions, and
lessons learned from survivors of trauma, including IPV
survivors. Bowen and Muurshid argued that many health and
social problems are linked to trauma, suggesting TIC is
relevant to a broad range of local, state, federal, and
international policies [37].
According to SAMSHA, a TIC program, organization, or
system realizes the widespread impact of trauma and
understands potential pathways for recovery; recognizes the
signs and symptoms of trauma in clients, families, staff, and
others involved in the system; responds by fully integrating
knowledge about trauma into policies, procedures, and
practices; and seeks to actively resist re-traumatization [22].
TIC approaches can be implemented in any type of service
organization, but clear distinctions are made between TIC and
trauma-informed interventions or treatment. Overall, the
overall aim of TIC is to promote healing by addressing the
consequences of trauma, in this case IPV.
SAMSHAʼs TIC approach is grounded by six key principles [37]:
1. Safety. TIC embraces program efforts to ensure service
usersʼ physical and emotional safety, including freedom
from harm or danger, and to prevent further trauma from
occurring. For example, during assessment, if women feel
safe, they are more likely to report violence [22, 37].
2. Trustworthiness and transparency include the extent to
which an organization maintains transparency in its
policies and procedures, with the objective of building
trust among stakeholders such as women who experience
IPV, staff, and community members [22, 37].
3. Peer support is needed to support female survivors in
shared decision-making and in establishing safety and
hope, building trust, enhancing collaboration [22, 37].
4. Collaboration and mutuality in TIC means that agency
staff view service users as active partners and experts in
their lives with peer mentorsʼ interprofessional teams [22,
37].
5. Empowerment, voice, and choice include efforts to share
in decision-making at individual and agency levels.
Having meaningful choices and options gives female
survivors a level of control and is associated with positive
health outcomes [22, 37].
6. Cultural, historical, and gender issues or intersectionality
references awareness of identity characteristics such as
race, gender, sexual orientation, and the privileges or
oppression these characteristics can incur [22, 37].
Trauma-Specific Interventions
Trauma-specific interventions are based on the following
psychosocial educational empowerment principles [38]:
1. The survivorsʼ need to be respected, informed, connected,
and hopeful regarding their recovery.
2. The interrelation between trauma and symptoms of
trauma such as substance abuse, eating disorders,
depression, and anxiety.
3. The need to work in a collaborative way with survivors,
family, friends of survivors, and other human services
agencies in a manner that will empower survivors and
consumers.
For example, the trauma recovery and empowerment
model (TREM) is an evidence-based gender-specific group
intervention appropriate for women with exposure to IPV. The
model is listed on the CDCʼs website with the compendium of
evidence-based specific trauma interventions.
Fallot et al., [39] designed a quasi-experimental study to
test the effectiveness of TREM, a group intervention for female
trauma survivors, compared with usual care. The study
included 250 women with histories of physical and/or sexual
abuse and simultaneously occurring serious mental illnesses
and substance use disorders. Comprehensive assessments
were completed at 6 and 12 months. The researchers found
that the TREM participants showed reductions in alcohol
intake, drug abuse severity, anxiety symptoms, and current
stressful events. Moreover, the participants demonstrated
greater increases in perceived safety [39]. Thus, this traumaspecific
group intervention was appropriate for women
survivors of IPV.
Similarly, in a recent study, researchers found that TREM
group psychotherapy may be beneficial for some participants
particularly for female trauma survivors with symptoms of
dissociation and self-esteem [40].
Conclusion
IPV is a worldwide pervasive public health problem. The prevalence rates and myriad adverse consequences for womenʼs health require nurses and other health-care providers to demonstrate sensitivity to the needs of this vulnerable population. These evidence-based approaches enable nurses and other health-care providers to empower female survivors of IPV. Additionally, trauma-specific interventions provide the tools for womenʼs empowerment and recovery, thus enabling women to regain a sense of self and, ultimately, self-empowerment.
Conflict of interest
The authors confirm that there is no conflict of interest regarding this manuscript.
References
- Centers for Disease Prevention and Control. Intimate Partner Violence: Definitions, 2016.
- World Health Organization. Responding to intimate partner violence, 2013.
- World Health Organization. Violence by intimate partners.
- United Nations. Violence against women. United Nations Secretary- General Campaign to End Violence against Women, 2017.
- Taft C, Schwartz S, Liebschutz JM. Intimate partner aggression in primary care chronic pain patients. Violence. Vict. 2010; 25(5): 649-641.
- Curry MA, Renker P, Robinson-Whelen S, Hughes RB, Swank P. et al., Facilitators and barriers to disclosing abuse among women with disabilities. Violence. Vict. 2011; 26(4): 430-444. doi: 10.1891/0886- 6708.26.4.430
- Wong JYH, Fong DYT, Lai V, Tiwari A. Bridging intimate partner violence and the human brain: A Literature Review. Trauma. Violence. Abuse. 2014: 22-33.
- Wheeler, K. Neurophysiology of trauma. In K. Wheeler. Psychotherapy for the Advanced Practice Psychiatric Nurse. 2nd ed. St. Louis, MO: Springer Publishing Company; 2014: 51-93.
- Perese, EF. Stress-related responses: adaptive behaviors, bereavement, and adjustment disorder, In EF Perese. Psychiatric Advanced Practice Nursing: A Biopsychosocial Foundation for Practice. Philadelphia, PA: FA Davis Company; 2012: 245-267.
- McEwen BS. Protection and damage from acute and chronic stress: allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. Ann. N. Y. Acad. Sci. 2004; 1032: 1-7. doi: 10.1196/ annals.1314.001
- McEwen BS. Allostasis and Epigenetics of Brain and Body Health Over the Life Course: The Brain on Stress. JAMA. Psychiatry. 2017; 74(6): 551-552. doi: 10.1001/jamapsychiatry.2017.0270
- McEwen BS. Protective and damaging effects of stress mediators: central role of the brain. Dialogues. Clin. Neurosci. 2006; 8(4): 367-381.
- Aupperle RL, Stillman, AN, Simmons AN, et al. Intimate Partner Violence PTSD And Neural Correlates of Inhibition. J. Trauma. Stress. 2016; 29(1): 33-40. doi: 10.1002/jts22068
- Aupperle RL, Melrose AJ, Stein MB, Paulus MP. Executive function and PTSD:disengaging from trauma. Neuropharmacology. 2012; 62(2): 686- 694. doi: 10.1016/j.neuropharm.2011.02.008.
- Griffing S, Lewis CS, Chu M, Sage RE, Madry L, Primm BJ. Exposure to interpersonal violence as a predictor of PTSD Symptomatology Domestic Violence Survivors. J. Interpers. Violence. 2006.
- Hunnicutt G, Lindgreen K, Murray C, Olsen L. The Intersection of Intimate Partner Violence and Traumatic Brain Injury: A Call for Interdisciplinary Research. J. Fam. Violence. 2017; 32(5): 411-480. doi: 10.1007/s10896-016- 9854-7
- Brezing C, Ferrara M, Freudenreich O. The syndemic illness of HIV and trauma: implication for a trauma-informed model of care. Psychosomatics. 2015; 56(2): 107-118. doi: 10.1016/j.psym.2014.10.006
- Centers for Disease Control and Prevention. Coping with atraumatic event. 2017.
- Hall A, McKenna B, Dearie V, Maquire T, Charleston R, Furness T. Educating emergency department nurses about trauma-informed care for people presenting with mental health crisis: a pilot study. BMC. Nursing. 2016; 15(21): 1-8. doi:10.1186/s12912-016-0141-y
- Hegarty K, Tarzial L, Taft A. Interventions to support recovery after domestic and sexual violence in primary care. Int. Rev. Psychiatry. 2016; 28(5): 519-532. doi: 10.1080/09540261.2016.1210103
- Kalra N, Tarzia L, Taft A. Training healthcare providers to respond to intimate partner violence against women. Cochrane. Library. 2017. doi: 10.1002/14651858.CD012423
- Substance Abuse and Mental Health Services Administration. SAMHSAʼs concept of trauma and guidance for a trauma-informed approach. 2017.
- Smith SG, Chen J, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey (NISVS). 2017; 2010-2012. State Report. 2017 at the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: 2017.
- Lopez-Ossorio JJ, Alvarez JLG, Pascual SB, Garcia LF, Buela-Casal G. Risk factors related to intimate partner violence police recidivism in Spain. Int. J. Clinical. Health. Psychol. 2017; 17(2): 107-119. doi: 10.1016/j. ijchp.2016.12.001
- Loston D, Doija X, Andersen AE, Townsend N. Intimate partner violence adversely impacts health over 16 years and across generations: a longitudinal cohort study. PLoS. One. 2017; 12(6): e0178138. doi: 10.1371/ journal.pone.0178138
- Machisa MT, Christofides N, Jewkes R. Mental ill health in structural pathways to womenʼs experiences of intimate partner violence. PLoS. One. 2017; 12(4): e0175240. doi: 10.1371/journal.pone.0175240
- Covington, SS. Beyond Trauma: A Healing Journey for Women: Facilitatorʼs Guide. Center City, MN: Hazelton; 2003.
- Feli VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experience (ACE study). Am. J. Prev. Med. 1998; 14(4): 245-58.
- Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am. J. Prev. Med. 2009; 37(15): 389-396. doi: 10.1016/j.amepre.2009.06.021.
- Campbell JA, Walker RJ, Egede LE. Associations Between Adverse Childhood Experiences, High Risk Behaviors and Mordidity in Adulthood. Amer. J. Prev. Med. 2016; 50(3): 344-352. doi: 10.1016/j.amepre.2015.07.022
- Maniglio, R. The impact of child sexual abuse on health: a systematic review of reviews. Clin. Psychol. Rev. 2009; 29(7): 647-657. doi: 10.1016/j. cpr.2009.08.003
- Gilbert LK, Breiding MJ, Merrik MT et al. Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. Am. J. Prev. Med. 2015; 48(3): 345-349. doi: 10.1016/j. amepre.2014.09.00
- Devries KM, Mak JY, Child JC, et al. Childhood sexual abuse and suicidal behavior: a metal-analysis. Pediatrics. 2014; 133(5): e1331-44. doi: 10.1542/peds.2013-2166
- Cleary M, Hungerford C. Trauma-informed care and the Research Literature: How Can the Mental Health Nurse Take the Lead to Support Women Who Have Survived Sexual Assault? Issues. Ment. Health. Nurs. 2015; 36(5): 370-378. doi: 10.3109/01612840.2015.1009661
- Reeves E. A synthesis of the literature on trauma–informed care. Issues. Mental. Health. Nurs. 2015; 36(9): 698-709. doi: 10.3109/01612840.2015.1025319
- Milles KL. The importance of providing trauma-informed care in alcohol and other drug services. Drug. Alcohol. Rev. 2015; 34(3): 231-233. doi:.10.1111/dar.12273.
- Bowen EA, Murshid NS. Trauma-Informed Social Policy: A Conceptual Framework for Policy Analysis and Advocacy. AM. J. Public. Health. 2016; 106(2): 223-229. doi: 10.2105/AJPH.2015.302970
- Substance Abuse and Mental Health Services Administration. SAMHSAʼs trauma specific interventions 2015.
- Fallot RD, McHugo GJ, Harris M, Xie H. The Trauma Recovery and Empowerment Model: A Quasi- Experimental Effectiveness Study. J. Dual. Diagn. 2011; 7(1-2): 74-89. doi: 10.1080/15504263.2011.566056.
- Karatzias T, Ferguson S, Gullone A, Cosgrove K. Group psychotherapy for female adult survivors of interpersonal psychological trauma: a preliminary study in Scotland. J. Ment. Health. 2016; 25(6): 512-519. doi: 10.3109/09638237.2016.1139062