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Domestic violence against women: definitions, epidemiology, risk factors and consequences

Background: Domestic violence is considered one of the most common forms of gender-related violence, and various studies estimate that between 10 and 35% of women experience domestic violence at some point in their lives. Nevertheless, it is a frequently neglected problem in crisis intervention centres, emergency wards, and obstetrics and gynaecological emergency rooms. This paper contributes to clarifying the definition, epidemiology, risk factors and consequences of domestic violence against women as well as the psychopathological profile of victims with a focus on Central European countries. Although different studies on domestic violence report different risk factors, such as younger age, being unmarried, lower education, violence experienced during childhood and alcohol/drug abuse of the partner or the victim herself, the results show no overall consistency. There seems to be neither a definite risk profile nor a specific association with a psychopathological profile. Women who have been victimised find it hard to share their experiences and seek help. It is often difficult for medical personnel who encounter these women to recognise violence and discuss this problem with them, just as it is difficult to offer adequate help. Medical personnel should be alerted to this subject and prepare guidelines for the further management and treatment of abused women. Infor-mation and support for medical staff can help to identify domestic violence, and encourage communication about this problem, thereby leading to a better and more efficient use of available services and resources.


Introduction
Domestic violence is a social problem that, although wellrecognised, is still associated with uncertainty and taboos. Many women, in their intimate relationships or immediate social environment, experience psychological and/or physical violence, which becomes a serious health problem for them.
Surveys investigating violence in Switzerland have shown that approximately every fifth woman, at some time during her life, will become a victim of either psychological or physical violence [1]. However, the actual extent of violence can only be assumed, as it is not easy for the affected women to speak about their experiences or to ask for help. The reasons for this may be feelings of shame or guilt, fear, or perceptions based on traditional ideas of marriage and family. Since the police are rarely notified in cases of domestic violence, the estimated number of unknown cases is high (most cases remain unrecorded) and reliable epidemiological data are scarce.
A WHO study on women's health and domestic violence in 10 different countries representing diverse cultural, geographical and urban/rural settings (Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand and Tanzania) [2] documents the horrifying extent of violence against women by their intimate partners. It also shows clearly that violence against women demands a public health response, because the impact of such violence goes far beyond the immediate harm and also affects many aspects of the women's future health.
For medical personnel who encounter victims of violence, it is usually not easy to recognise the problem or to voice the suspicion that a woman might have suffered domestic violence; accordingly, it is difficult to offer adequate help and support. Data concerning the prevalence of violence in someone's immediate social environment are not routinely collected.
Risk factors as well as the association between experienced violence and physical, emotional and psychosomatic sequelae are not well investigated.

Definition
Domestic violence is defined as the threat or exercise of physical, psychological, and/or emotional violence; i.e., any type of force against another person with the intent of inflicting harm or exercising power and control over them. The perpetrator belongs to the victim's "domestic environment": an intimate partner, husband, former intimate partner, family member, friend or acquaintance. Included among friends or acquaintances of the family, are those who maintain a friendly relationship to the victim and encounter her in a domestic setting. Whether or not the victim actually lives in the same household as the perpetrator is not crucial for the definition of domestic violence; the term is defined by the closeness of the relationship between perpetrator and abused victim.
The two terms "domestic violence" and "violence in the immediate social environment" are used synonymously and focus on violence between adults. Violence by parents or parent-proxies against children (child abuse) is treated, both legally as well as in social science research, as an independent problem and is not included in the definition of "domestic violence".
As a rule, domestic violence does not describe a single violent event, but rather a complex system of abuse that can include physical, psychological and sexual violence. Despite the neutral definition of domestic violence, it mostly involves gender-specific violence based on inequality between the sexes. This is elucidated by the term "gender violence" as coined by C. Hagemann-White [3], which includes all forms of injury inflicted against the physical and emotional integrity of another that are associated with power and gender, and the exploitation of a physical or other form of power.
It is known that the forms of violence differ between men and women. Men are more often affected by violence carried out in public places, whereas women experience violence more often within close social relationships. This also lends support to two studies published in 2004 in Germany. In a representative study investigating "life situation, safety and health of women in Germany" [4], it was shown that in 99% of the cases, violence against women is carried out by men. A pilot study investigating violence against men [5] showed that men are especially prone to be victims of violence in public settings; however, men were also found to experience violence in intimate relationships.

Forms of domestic violence
The following categorisation is based on current guidelines [6]:

Physical violence
Physical abuse is defined as any behaviour in which the body of the perpetrator intentionally affects the body of another person, so that there is the risk for the latter to be physically harmed, even if in the actual case no injuries occur. Examples of this are kicking, biting, threatening with knives or other weapons, etc.

Sexual violence as a subtype of physical violence
Sexual abuse has been defined in a variety of ways; although it is categorised as physical abuse, it makes sense to differentiate sexual abuse from other types of physical abuse. From a clinical standpoint, it refers to any unwanted sexual activity. The legal definition of a sex crime against adults varies from country to country. According to the Swiss Criminal Code, it especially includes sexual acts against minors, attacks on another's sexual freedom and honor, rape, etc.
In addition to those criminal acts that are punishable by law, Russel [7] also included forced oral, anal or digital penetration in the definition. Brownmiller [8] extended the definition of sexual abuse to include any type of sexual intimacy that is forced upon another person, even without the necessity of physical contact (for example, forced nakedness).

Psychological and emotional violence
This term is the least clearly defined among the various types of abuse. Psychological abuse is not simply negative verbal communication as found in many couples: the former essentially and significantly differs from the latter both with respect to its intensity and to how it takes place. The currently acknowledged definition is based on that of psychological torture by Amnesty International [9]. It also includes isolation of the victim, induced disability due to exhaustion, weakening or incapacitation, humiliation, outrage and offenses, etc.
Other authors additionally include "social violence" in the various forms of domestic violence (when contacts are forbidden, social isolation, etc.) and "economic violence" (confiscation of money, forbidding or forcing another to work, etc.). In the above-mentioned definition, both of these forms should be understood as a subgroup of psychological violence. Characteristic for these types of behavior is that they aim to control the victim and limit her free will [10].

Epidemiology
Worldwide, domestic violence is considered as one of the most frequent forms of gender-based violence [11]. In various European countries the lifetime prevalence of violence in intimate partnerships is reported to be between 10% and 36% [4].

Representative surveys among the general population
Regarding Germany, in 2004, on behalf of the German Federal Ministry for Family Affairs, Senior Citizens and Women, a study was published in which, based on a representative sample of a mixed rural/urban population, 10 264 women aged between 16 and 85 years, were questioned about physical, sexual and psychological violence.
The results indicate that violence against women predominantly occurs within their own home. In more than 75% of the cases of physical and sexual violence, the women knew the perpetrator [4]. Thirty-seven percent of the women had experienced at least one episode of physical violence after the age of 16 years, with two thirds of the attacks involving moderate to severe acts in which the vic-tims were harmed, felt considerable fear or were threatened with weapons. Every fourth woman indicated that she had experienced physical and/or sexual violence in an intimate partnership by a current or previous partner; indeed, in some cases, even up to 40 violent situations were reported. Thirteen percent of the women were victims of sexual violence such as rape or attempted rape, or were coerced to perform sexual acts.
The first representative survey investigating domestic violence in Switzerland in a random sample of 1500 women currently living or having lived until recently in an intimate partnership, yielded the following results [1]: The lifetime prevalence of physical and sexual violence was shown to be 21%, while that for psychological violence was 40%. The twelve-month prevalence (i.e., within the past 12 months before the survey on domestic violence was conducted) was 7%.
However, Gillioz [1] assumes that the actual numbers are even higher, since comparable studies in the Netherlands, Canada and the USA showed up to twice as high prevalence rates.
An expert report [12] estimates, based on studies from the Netherlands and Sweden, that at some point in their lives, about 22% of women suffer from gender-related violence with ensuing negative consequences to their health, and approximately 10% of all adult women are forced to perform sexual acts, half of them by their intimate partners.
The above-mentioned multi-country WHO study [2] found that across the study sites between 15% and 71% of the women reported physical and/or sexual violence by an intimate partner at some point in their lives. In most countries between 15% and 30% (total range 4-54%) of the women reported physical or sexual violence or both by a partner within the 12 months prior to the study. These results add to the existing body of research, primarily from industrialised countries, on the extent of physical and sexual violence against women and confirm that violence by an intimate partner is a common experience for a large number of women in the world.
A study from rural Maharashtra in Central India reported that 38% of the interviewed 500 women had repeatedly been exposed to physical violence: 44% had been kicked during pregnancy; 12% had been threatened by their husbands; 30% of the physically assaulted victims had required medical care [13].

Populations in women's clinics
In 2003, at the Maternité Inselhof Triemli, Clinic for Obstetrics and Gynaecology, Zurich, 1772 women (both inpatients and out-patients) older than 15 years were surveyed [14]. In the interview, the health situation of the women, psychological and physical assaults, threats and unwanted sexual solicitations carried out by those close to them were comprehensively questioned.
Ten percent of the women had experienced physical violence within the previous 12 months and 2% reported current sexual violence.
With respect to lifetime prevalence, more than ¾ of the women (76.8%) were found to have experienced at least one episode of emotional violence and controlling behaviour by a person close to them; indeed, 43.6% reported physical violence and threats. Furthermore, 12.9% had experienced sexual violence, either from an intimate partner or from a relative.
Analyses of the extent of violence indicate that, frequently, the longer the attacks continue, the more violent they become.
Investigations from the US carried out among pregnant women within a preventive medicine framework showed prevalence rates of physical and/or sexual violence between 4% and 20%, increasing with the progression of the pregnancy [15][16][17]. "Violence by partners or husbands frequently begins or escalates during pregnancy or shortly after birth, especially when the pregnancy was unwanted [18]." In the USA, an estimated 12-15% of pregnant women are abused. This percentage is higher than that in women suffering from complications of pregnancy, such as pre-eclampsia, gestational diabetes or placenta praevia.
An Iranian study was performed at three obstetric and gynaecological clinics in Teheran. The study population consisted of 1000 married women aged between 15 and 64 years. Data were collected in a period of 12 months. The lifetime prevalence domestic violence was 59% [19].

Out-patient emergency room populations
One US study shows that among 3455 patients from 11 different emergency medicine providers, 37% have experienced physical and/or sexual violence from a current or former intimate partner at some point in their lives. Of these, 14.4% reported abuse within 12 months prior to the survey, and 2.2% were seeking medical care due to a current act of violence [20].
The portion of women with physical injuries who seek emergency medical care appears to be smaller than those seeking emergency help for complaints such as anxiety attacks, pain syndromes, depression and attempted suicide [21].
One survey carried out in a German first-aid/emergency ward setting questioned the prevalence of domestic violence among 806 female patients and reported the following statistics [22]: The life-time prevalence (from 16 years of age) for at least one of the three forms of domestic violence was 36.6%. Three point five percent of the patients who had experienced violence were abused by their intimate partners during their pregnancy.
In a Jordanian study on 365 women attending public health centres in the Balkan region, 87% had been victims of domestic violence in the last 12 months. The most common type of reported violence was emotional abuse (47.5%) followed by wife beating (19.6%) [23].

Risk factors
"Experiences from shelters for battered women and counselling centres show that domestic violence can happen to any woman, regardless of her level of education, nationality, income, religion, age or ethnicity. Victims and abusers are found among all social classes" [24].
The representative investigation "Circumstances, Safety and Health of Women in Germany" from 2002-2004, carried out by the Centre for Interdisciplinary Research on Women and Gender (IFF) [4], determined the risk factors for the origin of violence and/or for a higher incidence of experiencing violence as "separation and divorce from a relationship" and "previously experienced violence in childhood and adolescence". Women who had experienced interparental violence in their childhood or adolescence later in life experienced violence from their (ex-)intimate partners more than twice as often as those with non-pugilistic parents (47% versus 21%). Those women who, as a child, had experienced violence from a parent or parent-proxy, either frequently or occasionally, were three times as likely as other women to be affected by violence in their intimate relationships. In this study the educational level or social status had no influence on violence in a partnership.
As part of the previously mentioned study at the Maternité Clinic in Zurich, the results were analysed taking the different sociodemographic aspects into account. Patients who were divorced, separated, or widowed experienced violence in their immediate social environment more frequently than the average of those interviewed.
Women with children older than four years of age also experienced domestic violence significantly more often. For the other sociodemographic variables considered in the analysis (nationality, age, education and income), no significant differences were found between those affected and those not affected by domestic violence.
Some other studies also show an increased risk of physical violence for unmarried [25] or unemployed [26] women as well as for those of low socioeconomic status, but the latter is contradicted by other studies.
In Maffli and Zumbrunn's study investigating domestic violence and alcohol based on calls to the telephone helpline "Die Dargebotene Hand", having an alcohol-dependent partner was clearly associated with domestic violence [27]. Frequently, there is a direct connection between the perpetrator of domestic violence and the influence of alcohol. However, alcohol and drug abuse by the women themselves was also found to be a risk factor for experiencing abuse [28].
Furthermore, pregnancy has been found to be a risk factor for domestic violence (cf. above). In one large study carried out in the USA in 1992, 691 black, white and South American pregnant women were questioned about violence in their immediate social environment. The evaluation of the three-item screening questionnaire yielded a prevalence of 17% for physical and/or sexual violence during pregnancy, and 60% of these affected pregnant women reported several episodes of violence [17].
The WHO study [2] showed that in almost all parts of the world partner violence occurs in younger women, especially those aged 15 to 19 years. This pattern may reflect in part that younger women on average have younger partners and these tend to be more violent than older men. There was also more partner violence among women who were just living with a man than among married women. Furthermore, in most parts of the world women who have been separated or divorced reported much more partner violence during their lifetime than currently married women. And not unimportantly, lower education was associated with significantly more partner violence in many countries. In other words, education seems to have a protective effect.
In conclusion, only few risk factors for domestic violence have been unequivocally identified. These are violence experienced in childhood, current alcohol/drug abuse in the women themselves or their partners, younger age, lower education and being unmarried. However, risk factors seem to differ in different parts of the world and in principle domestic violence can affect women of any age, education or marital status. Unfortunately, a meta-analysis on this topic is lacking so far.

Health consequences
Violence affects a woman's health in many ways. The consequences of violence can be short-term, medium-term or even long-term; these effects can be direct or indirect, and range from physical injuries, (psycho-)somatic complaints and psychological (mental and emotional) disturbances to fatal outcomes. It also affects how a woman deals with her health and her chances for health.
Most insight into the broad spectrum of health consequences of violence is currently to be gained from studies originating in Anglo-American countries. Among the typical direct physical consequences are stab wounds and battering injuries as well as fractures, head injuries and damage to the spinal cord [29].
Frequent psychosomatic complaints involve pain in the head, back, breast, and abdomen [30] as well as gastrointestinal disorders [31] and disturbances in menstruation and reproductive health [21,32].
The psychological consequences of domestic violence are numerous. In particular, depression, anxiety and panic attacks, nervousness, insomnia, concentration problems, disturbances in sexual feelings and perceptions, fear of intimacy, loss of self-esteem and self-respect have been described [32,33]. Studies show that 37% of the women who have experienced violence suffer from depression [34,35], 46% from anxiety and panic attacks, and 45% have posttraumatic stress disorder [35].
Violence in a relationship can also lead to substance abuse. Substances such as alcohol, drugs or calming medication are often used to forget [36].

Conclusions
Domestic violence is a frequent problem which can affect any woman, regardless of her age, socioeconomic or sociocultural status. No clear risk profile exists; the health consequences of those affected by violence are serious. It is still unknown how many percent of women seek medical attention due to violence-related complaints. Initial studies, especially from the USA, indicate that a considerable number of women do seek first aid because of a current act of violence.
Physicians are often the first contact persons in industrialised countries in case of domestic violence. In particular local general practitioners and gynaecologists are often confronted with that problem [37].
It is important that medical personnel is alerted to this problem and trained in its recognition. Easy-to-use screening instruments, such as the English "Partner Violence Screen" [39] questionnaire or the German "Screening Partnergewalt" [38], should be available in all medical institutions. Furthermore, staff should have guidelines and skills for the management and care of women affected by violence. Information and education of the staff of medical institutions can reduce insecurity and contribute to improving the situation of women who have experienced violence. Another important factor is the training of medical students [37].
The FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) Committee for the Study of Ethical Aspects of Human Reproduction has released statements on this issue [40]. Physicians are ethically obliged to inform themselves about the manifestations of violence and how to recognize cases, to treat the physical and psychological results of violence, to affirm to their patients that violent acts are not acceptable and to advocate for social infrastructure to provide women the choice of seeking secure refuge and ongoing counseling [40].
In the WHO statement by Dr. Margaret Chan, issued on the occasion of the International Women's Day 2009, we can read: "Preventing violence against women requires a multi-sector approach, and in this context the health sector has a central role to play. This role includes helping to identify abuse early, providing victims with the necessary treatment, and referring women to appropriate and informed care. Promising public health strategies include changing attitudes that foster violence and gender inequality, helping women to become financially independent, strengthening the self-esteem of women and girls, and reducing excessive alcohol consumption" [41].

Funding / potential competing interests
No funding; no conflict of interest.