Intimate partner violence: A loop of abuse, depression and victimization

Abstract

Intimate partner violence has been recognized as a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence, a loop that imprisons victims and perpetuates the abuse. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. In this narrative review, factors associated with intimate partner violence and consequences of exposure of children to parental domestic violence are discussed, along with possible intensification of violence against women with the spread of coronavirus disease 2019 pandemic and subsequent lockdown. Intervention programs with a multicomponent approach involving many health care settings and research have a pivotal role in developing additional strategies for addressing violence and to provide tailored interventions to victims. Prevention policy with a particular attention on healthy child and adolescent development is mandatory in the struggle against all forms of violence.

Key Words: Intimate partner violence, Women, Depression, Abuse, COVID-19, Personalized medicine

Core Tip: Intimate partner violence represents a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. Coronavirus disease 2019 pandemic is causing a tremendous impact on women's possible exposure to violence. Possible interventions against violence are discussed.

INTRODUCTION

Intimate partner violence is described as physical violence, sexual violence, stalking, or psychological aggression by a current or former intimate partner. It represents a serious public health issue. It has been estimated that more than 30% of women in the United States have experienced intimate partner violence, and it represents the leading cause of homicide death for women. Prevalence is higher among young women (18 to 24 years of age), among racial and ethnic minority groups, and among people with mental and physical disabilities[1]. Psychological violence is estimated to be the most common subtype of intimate partner violence (compared to physical and sexual violence) in the United States and Europe[2].

In women of reproductive age, intimate partner violence has been linked with poor reproductive health and poor sexual health (unintended pregnancy and sexually transmitted infections) and heightened risks of obstetrical and gynecologic complications (pregnancy-associated death, preterm birth, low birth weight) and represents a risk factor for peripartum depression and substance abuse[1]. There are specific physical injuries in women that can be considered as indicators of intimate partner violence: Contusions, lacerations, and fractures (especially in the head, neck and face) and are frequently reported by patients as domestic accidents. Partner violence has been associated with many mental health consequences: Depression, anxiety, post-traumatic stress disorder, eating disorders, suicidal behavior, alcohol or drug abuse, sexual problems, problems with concentration, somatization, social, educational, or occupational difficulties, as well as feelings of blame and guilt or reproach. It is also linked to several and often disabling physical health problems (chronic pain, gastrointestinal problems, sexually transmitted infections, traumatic brain injury, cardiovascular diseases).

Exposure to violence can contribute on one side to the genesis of psychopathological conditions or can exacerbate mental health conditions, but on the other side existing mental health problems can increase vulnerability and predisposition to partner violence.

It has been estimated that emotional violence is the most common form of intimate partner violence across all continents worldwide[3]. Factors associated with intimate partner violence originate from multiple levels: Individual, relationship, community, and societal level[4]. Subjects who are at greater risk of experiencing intimate partner violence more likely come from a lower education background and poorer socio-economic status (with difficulty of access to resources and greater acceptance towards violence), have a history or a current substance abuse, and have been exposed to prior abuse or violence (with a history of abuse reinforcing the normative nature of violence and developing violence-condoning attitude). For example, many immigrant women have to cope with issues regarding their cultural integration into another society while at the same time concurrently feeling related and profoundly bounded by cultures and traditions from their countries of origin. Dependence on one’s partner, difficulties in language proficiency, financial problems, lack of social support, and uncertain legal status can leave these subjects feeling fragile and socially isolated and can prevent them from seeking assistance; besides, women linked to particular cultural backgrounds may refuse to acknowledge certain acts and behaviors as abusive due to beliefs and traditions regarding familial obligations and culturally prescribed gender roles[5].

People with mental illness may have a heightened risk of becoming victims of domestic violence and can be reluctant to disclose abuse. On the other hand, mental ill-health can also be a consequence of victimization and can involve post-traumatic stress disorder, depression, suicidality, and alcohol or substance misuse: Physical sequalae of abuse are added to psychological morbidity[6].

EXPOSURE OF CHILDREN TO PARENTAL DOMESTIC VIOLENCE

It has been outlined by recent research that the presence of intimate partner violence often compromises a child’s attachment to primary caregivers, which results in an additional risk factor for social, emotional, and psychological impairment[7]. A child can be exposed to domestic violence also through the awareness that violence occurs between parents, regardless of whether the child directly witnesses it. Infancy is a critical period of developing a secure attachment, and infants spend most of the time with caregivers, in a relationship of close proximity to them and high and obliged dependence from them; in addition, younger children have not completely strengthened the cognitive ability to discern between intimate partner violence as a threat to caregiver or to the self. As a consequence, the situation of violence in the household can indirectly impact on the child because it compromises the caregiving system in the parent. The presence of intimate partner violence increases a child’s risk of developing a wide variety of negative outcomes (internalizing symptoms, externalizing behaviors, problems with perceptual and cognitive functioning, academic difficulties, interpersonal difficulties). Possible consequences can be affected by the child’s age, relationships with other caregivers, and period of exposure to violence.

Violence against young girls causes physical and psychological effects, which can manifest as mild anxiety symptoms, apprehension, flashbacks, or feeling ashamed or worried to more severe anxiety signs, including a variety of sleep or eating disorders, post-traumatic symptoms, and even thoughts of self-harm and suicide. The inaction of a valid support system may further worsen this complex situation[8].

Children exposed to parental domestic violence are predisposed to physical and mental health disorders and are subjected to an increased risk of become a victim or a perpetrator of intimate partner violence in adolescence and adulthood[9]. Besides, adverse childhood experiences, such as child abuse, maltreatment, substance abuse in the household, incarceration of household members, and emotional or physical neglect, have long-term consequences with poorer physical, mental, individual behavioral, and social/interactional outcomes: The larger the number of adverse childhood experiences, the higher the odds of worst physical and mental health outcomes, including heart disease, stroke, asthma, diabetes, and mental distress[10]. Adolescence is a critical developmental period characterized by puberty, progressive autonomy from parents and family, changes in social relationships, and often the beginning of romantic relationships. Child sexual abuse, child physical abuse, witnessing parental intimate partner violence, exposure to school-related violence (e.g., bullying), and community violence (e.g., racism or discrimination) during childhood are potentially related to future intimate partner violence. Recently, it has been demonstrated that adverse childhood experiences in adolescence are predictive of interpersonal violence 15 years later[10].

Teen dating violence

When male violence against females occurs within intimate relationships during youth, it is termed adolescent or teen dating violence, occurring in individuals aged 10-24 years, including early, middle, and late adolescence, and described as physical, sexual, or psychological/emotional abuse, comprising threats, towards a dating partner. Six forms of teen dating violence have been assessed: Threatening behaviors, verbal/emotional abuse, relational abuse, physical abuse, sexual abuse, and stalking.

The cultivation of emotional relationships during adolescence are pivotal to the progressive growth of interpersonal communication skills, autonomy, and self-perceived competence, but together with affective and behavioral vulnerability experienced during adolescence, a variety of individual, social, and community risk factors may favor the emergence of adolescent dating violence[11]. Victims of teen dating violence may develop adverse health outcomes such as increased sexual risk behaviors, suicidality, unhealthy behaviors (e.g., lack of physical activity and negative weight-controlling behaviors), inauspicious mental health outcomes, substance use, injuries, victimization, and death. Additionally, it is common for adolescents who experience dating violence to struggle with their academics, drop out of school, or skip school to avoid seeing their partner.

Risk factors for perpetration of adolescent dating violence seem to be a history of experiencing, witnessing, and/or initiating abuse within the home, school, and community; childhood trauma in the form of physical and emotional abuse or neglect (due to personality anxiety traits formed during childhood, so that the individual feels a lack of security in the relationship and worries about being left by the partner); sexism and gender roles present in society; bullying; developing and formulating ineffective interpersonal communication and conflict resolutions skills during adolescence; alcohol or substance use during adolescence; attachment insecurities (anxiety and avoidance) expressed as anger, hostility, aggression, and emotional dysregulation[12]. Recent research suggests that there are multiple form of adolescent dating violence and that males may be victimized at similar rates as females[13]. Increasingly high rates of technology usage, as well as diffusion of apps and social media platforms, has created more opportunities for cyber teen violence dating (typically people who are no longer with their dating partner perpetrate this form of violence against an ex-partner).

Abusive behavior in adolescent dating relationships is associated with a risk of intimate partner violence later in adulthood[14].

Violence during coronavirus disease 2019 pandemic

Coronavirus disease 2019 (COVID-19) has had a dreadful impact on the world’s economy, and women are forced to take on additional risks as they are already disadvantaged and vulnerable, especially in rural and remote settings[8]. Sexuality suffers because it has to deal with the arrogance of a death drive rekindled by the current pandemic condition. A life in which less libido is exchanged stably than one would like can become unbearable. But the libido, in the forms of stasis and engorgement, can turn, in the unconscious, into anguish and give rise to internal conflicts that inevitably end up resulting in the relationship with the other[15]. As the COVID-19 pandemic has intensified, its effects diversified by gender have begun to gain attention[16]. During the institutional lockdown, victims of domestic violence were required to remain closed with partners and without help or support: In such scenario there is a great chance that abusive situations can further aggravate, with a possible increase of domestic homicides or murder-suicides or deviant behaviors towards children. Increased concerns about domestic violence have been expressed in many countries. The reasons for this include social isolation, exposure to economic and psychological stressors, increase in negative coping mechanisms (such as alcohol or drugs misuse), and inability to access usual health and social services[6]. School closure due to lockdown can potentiate the risk for children to witness violence, exploitation, and abuse at home and away from help[8].

As the outbreak of COVID-19 has developed, referral rates to mental health and psychology services have declined, despite a likely increase in psychological distress, victimization, and mental illness. It is well-known that intimate partner violence has short-term and long-term effects on physical and mental-health of affected subjects and in particular might increase the risk of cardiovascular disease in women, by indirect (chronic inflammation or dysregulation of the hypothalamic pituitary axis as a consequence of chronic stress) and indirect pathways (coping strategies used by victims of abuse to deal with stress, such as smoking and overeating, and higher incidence of depressive disorders correlated to chronically elevated levels of cortisol, catecholamines, and inflammatory markers, all of which promote the development and progression of cardiovascular disease)[17].

Psychological distress linked with the pandemic itself, arising in response to fears about personal and familial infection as well as the sequelae of social distancing and quarantine measures, add worry about possible consequences of intimate partner violence during this global pandemic.

Particularly during the COVID-19 pandemic, programs are necessary to provide funding sources to guarantee telephone or remote counseling services or psychological assistance hotlines to manage and attempt to prevent crisis situations[18,19]. The use of mobile health and telemedicine to support safely subjects experiencing violence must be urgently improved, together with other strategies to reach women at risk in settings where access to mobile phones or the internet is limited or completely lacking. We must learn lessons from the past epidemics and also from the present about errors and defeats to recognize and address gender related effects of outbreaks[16].

Prevention and management of the violence against women of all ages should be expected and potentiated as a pivotal service in the COVID-19 response plan.

CONCLUSION

Possible interventions against violence

Lifetime and current intimate partner violence is common and unacceptably high. It has been outlined that approximately 1 in 4 women becomes a victim of violence at some point in their life regardless of their age, economic status, or ethnicity. Domestic violence against women is a well-recognized health concern and has serious negative impact on women’s lives. It is important to stress the fact that most of the factors associated with violence against women are preventable. Studies assessing screening and interventions practice in primary care services for women who experience intimate partner violence have demonstrated that clinical programs can mitigate the risk of subsequent violence[20]. In addition, interventional studies have stressed that gender-norms transformation through behavioral change and communication focused program can promote gender equality norm and avert domestic violence against women[21].

Intimate partner violence is often not obvious, and patients may present with nonspecific signs and symptoms. Clinicians must be aware of the red flags of domestic violence and incorporate the principles of trauma-informed care into their practice. This means asking about violence or risk of violence when it is safe and appropriate, in a private discussion and in a compassionate and nonjudgmental way, discussing needs, preferences, and immediate options. It is necessary to support the subject’s autonomy, provide emotional and practical support, and personalize responses and possible solutions to the individual patient[22].

For pregnant women suspected or known to be exposed to partner violence, it is mandatory to consider a pregnancy high-risk and to provide prenatal assessment and counseling for the mother and home-visitation programs in the child’s first years. Screening in primary care for mental health disorders such as depression or anxiety should reasonably include an inquiry about current and previous intimate partner violence. In parallel, current or past intimate partner violence should be appropriately included in the differential diagnosis of many medical and behavioral health conditions, particularly in women[1]. It should be taken into account the fact that violence victims may not disclose their experience immediately but in the context of multiple queries and a trusting relationship. It results important that a multicomponent approach involving many health care settings, training of staff, clinical specific tools of assessment (including multiple violence domains: Physical, sexual, emotional/psychological), established workflows, connection to follow-up social services, and legal services can be dedicated and promoted to improve the prevention and response and care to the problem of intimate partner violence and its serious consequences. It has been observed that women have the tendency to remain with violent partners due to a variety of reasons, including social norms, worry for children, and economic issues. Immigrant women require a specific culturally-tailored approach and may need specific advocacy and interventions that also focus on financial abuse and are finalized to economic empowerment, including individual mental health counseling (when the shame and stigma associated to intimate partner violence in many ethnic communities increase the reluctance to discuss in groups) and services provided in community member’s native language or in intervention delivery settings (shared community environments including churches, mosques, temples)[5].

Interventions integrating legal framework and programs that focus on transformation of traditional gender-norms are of great importance in order to prevent violence against women of all ages. There is an increasing need of intervention programs and techniques to reduce violence among offenders (group therapy or counseling aimed to work on impulsive and angry behavior or inability to control emotions) with a particular focus on trauma and substance abuse[23]. Since it has been observed that men with mental health problems (in particular depression, anxiety, alcohol or drug use disorder, attention deficit hyperactivity disorder, personality disorders) carry a higher probability to perpetrate domestic violence against women, treatment for any co-existing mental illness and in particular substance abuse or misuse should be prioritized to reduce risk[24].

Also, research has a pivotal role in developing additional strategies for addressing violence and to provide personalized interventions to victims. For example, qualitative studies exploring the emotional impacts of intimate partner sexual violence on women are scarce. Understanding should be deepened of the so-called invisible impacts of violence, described as the emotional repercussions (sense of powerlessness, helplessness, shame, ongoing fear of men) that are difficult to quantify and measure but may be a trigger for mental health outcomes, such as post-traumatic stress disorder, anxiety, and depression[25]. Research can guide attachment- and family-based interventions for families impacted by interpersonal violence. Besides, there is an urgent need for rigorous research to understand better which interventions are most effective and tailored for ethnic minority populations.

Last but not least, prevention is mandatory: Interventions focusing on community and domestic health and violence prevention and, focusing on high-risk and disadvantaged socio-economic groups (such as institutionalized children or adolescents), with a particular attention on healthy child and adolescent development, may greatly contribute to lower intimate partner violence victimization in adulthood by correcting attitudes on violence and improving help-seeking behavior (Table 1).

Table 1 Proposed interventions against intimate partner violence.

No.
1	Clinical routine screening for indicators of intimate partner violence
2	Prenatal assessment and counseling for pregnant women suspected or known to be exposed to violence and home-visitation programs
3	Culturally tailored specific approach for immigrant women victims of violence
4	Intervention tecniques to reduce violence among offenders
5	Implementation of research aimed to develop additional strategies for addressing interpersonal violence
6	During COVID-19 pandemic, enhancement of telephone or remote counseling services or psychological assistance hotlines to manage crisis situations
7	Specific programs for prevention of domestic violence with a particular attention on healthy child and adolescent development

COVID-19: Coronavirus disease 2019.