Intimate partner violence (IPV) describes physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner (CDC, 2016). It can occur among heterosexual or same-sex couples and does not require sexual intimacy. IPV is a serious, preventable public health problem that affects millions of people in the United States and throughout the world. In many societies this type of violence is considered “normal.” It varies in frequency and severity and occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering (CDC, 2016; WHO, 2016).

There are four main types of IPV:

• Physical violence, the intentional use of physical force with the potential for causing death, disability, injury, or harm
• Sexual violence (has five categories)
  • Rape or penetration of victim
  • Victim was made to penetrate someone else
  • Non-physically pressured unwanted penetration
  • Unwanted sexual contact
  • Non-contact unwanted sexual experiences
• Stalking, a pattern of repeated, unwanted, attention and contact that causes fear or concern for one’s own safety or the safety of someone else (eg, family member or friend).
• Psychological aggression, the use of verbal and non-verbal communication with the intent to harm another person mentally or emotionally, and/or to exert control over another person (CDC, 2016, 2015, 2014b).

The CDC advocates use of a consistent definition of IPV (as above) to facilitate systematic data collection and meaningful comparisons and analysis of trends (CDC, 2016, 2015).

Just as intimate partner violence can be thought of as a continuum, domestic violence may also encompass child abuse when children are physically and psychologically harmed when IPV occurs, and elder abuse when the perpetrator is an intimate partner.

Although women can be violent to men, the vast majority of intimate partner violence is perpetrated by men against women. From 1994 to 2010, U.S. Department of Justice statistics showed that IPV declined by more than 60% for both males and females (Catalano, 2012), but a study of nonfatal domestic violence for 2003–2012 shows that females (76%) still experienced more domestic violence victimizations than did males (24%) (Morgan & Truman, 2014; CDC, 2014).

The rate of fatal incidents of intimate partner violence—sometimes referred to as “intimate homicide”—fluctuated during the period from 1980 to 2008 in the United States. The rate for both black and white males remained about 5% after 2002, while for females it rose from all-time lows in 1995 to 43% for black females and 45% for white females in 2008 (Cooper & Smith, 2011).

Violent crime statistics gathered in 2013 and 2014 reflect a continuing decrease since 2005 in violent crime overall, including domestic violence and intimate partner violence (Truman & Langton, 2015). However, while the overall rate of homicide has declined, women continue to be 64% of the victims of intimate partner homicide, and, considering all murder victims, “women are 6 times more likely than men to be killed by a current or former partner” (Zweig, 2014).

Statistics gathered in the first Centers for Disease Control and Prevention (CDC) National Intimate Partner and Sexual Violence Survey (NISVS) in 2010 showed that 35.6% of women and 28.5% of men in the United States have experienced rape, physical violence, and/or stalking by an intimate partner at some point in their lifetime. In Kentucky it is 37.5% of women and 31% of men, while percentages in other states range from 26% to 48% for women and 17% to 40% for men (CDC, 2011). The NISVS is being administered annually and will be used to track trends in IPV as well as sexual violence and stalking (CDC, 2014).

Broad national survey data can be more telling than law enforcement statistics because of the reluctance of both women and men to report intimate partner violence. In the National Violence Against Women Survey (NVAWS) completed in 1996, most women and men who were physically assaulted failed to file a complaint, although women were more likely than men to report their victimization to the police (26.7% and 13.5%, respectively) (Tjaden & Thoennes, 2000). However, a later review of studies found that reluctance to report can have many reasons, varies with the type of violence and the details of a given situation, and is not always correlated in the way people expect (Felson & Paré, 2005).

This reluctance to report intimate partner violence to authorities is also a problem internationally. According to a World Health Organization (WHO) survey of more than 24,000 women in ten countries, over half of the physically abused women surveyed reported that they had never sought help from a health service, shelter, legal service, or anyone in any position of authority such as religious leaders, police, or other government organizations (WHO, 2005).

Types of Intimate Partner Violence

According to Florida law 741.28, domestic violence means

. . . any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.

“Family or household member” means spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who are parents of a child in common regardless of whether they have been married. With the exception of persons who have a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit. (Florida Legislature, 2016)

CDC identifies four types of intimate partner violence—physical violence, sexual violence, stalking, and psychological aggression. Information about the important revisions in definition can be found in the CDC’s Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0, which was published in 2015. The CDC strongly advocates for coherent and uniform definitions to improve the collection and analysis of data.

Physical Violence

Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to:

• Scratching, pushing, or shoving
• Throwing, grabbing, or biting
• Choking, shaking, aggressive hair pulling, slapping, punching, hitting or burning
• Use of a weapon
• Use of restraints or one’s body, size, or strength against another person

Physical violence also includes coercing other people to commit any of the above acts (CDC, 2016).

Research has shown that physical violence is often accompanied by psychological abuse and in one-third to one-half of cases, by sexual abuse (Heise & Garcia-Moreno, 2002). The violence is usually not limited to one instance. The National Violence Against Women Survey (NVAWS) found that women who were physically assaulted by an intimate partner averaged 6.9 physical assaults by the same partner, while men who were assaulted averaged 4.4 assaults.

Women experience more chronic and injurious physical assaults at the hands of intimate partners than do men. The NVAWS found that more than 40% of women who were physically assaulted by an intimate partner were injured during their most recent assault, compared with about 20% of the men. Most injuries, such as scratches, bruises, and welts, were minor. More severe physical injuries may occur depending on severity and frequency of abuse. Physical violence can lead to death (Tjaden & Thoennes, 2000).

Sexual Violence

Sexual violence is divided into five categories, any of which constitute sexual violence, whether attempted or completed. Additionally, all of these acts occur without the victim’s consent, including cases in which the victim is unable to consent due to being too intoxicated (eg, incapacitation, lack of consciousness, or lack of awareness) through their voluntary or involuntary use of alcohol or drugs (CDC, 2016).

• Rape or penetration of victim. This includes completed or attempted, forced or alcohol/drug-facilitated unwanted vaginal, oral, or anal insertion. Forced penetration occurs through the perpetrator’s use of physical force against the victim or threats to physically harm the victim.
• Victim was made to penetrate someone else. This includes completed or attempted, forced or alcohol/drug-facilitated incidents when the victim was made to sexually penetrate a perpetrator or someone else without the victim’s consent.
• Non-physically pressured unwanted penetration. This includes incidents in which the victim was pressured verbally or through intimidation or misuse of authority to consent or acquiesce to being penetrated.
• Unwanted sexual contact. This includes intentional touching of the victim or making the victim touch the perpetrator, either directly or through the clothing, on the genitalia, anus, groin, breast, inner thigh, or buttocks without the victim’s consent
• Non-contact unwanted sexual experiences. This includes unwanted sexual events that are not of a physical nature that occur without the victim’s consent. Examples include unwanted exposure to sexual situations (eg, pornography); verbal or behavioral sexual harassment; threats of sexual violence to accomplish some other end; and/or unwanted filming, taking or disseminating photographs of a sexual nature of another person (CDC, 2016).

Sexual and physical abuse is often accompanied by controlling behaviors. In a World Health Organization (WHO) survey of more than 24,000 women in ten countries, the percentage of those who had experienced one or more of the following controlling behaviors ranged from 20% in Japan to 90% in urban United Republic of Tanzania:

• Keeping her from seeing friends
• Restricting contact with her family of birth
• Insisting on knowing where she is at all times
• Ignoring or treating her indifferently
• Getting angry if she speaks with other men
• Often accusing her of being unfaithful
• Controlling her access to healthcare (WHO, 2005)

Stalking

Stalking is a pattern of repeated, unwanted, attention and contact that causes fear or concern for one’s own safety or the safety of someone else (eg, family member or friend). Some examples include repeated unwanted phone calls, emails, or texts; leaving cards, letters, flowers, or other items when the victim does not want them; watching or following from a distance; spying; approaching or showing up in places when the victim does not want to see them; sneaking into the victim’s home or car; damaging the victim’s personal property; harming or threatening the victim’s pet; and making threats to physically harm the victim (CDC, 2016).

In the United States 7.5 million people are stalked in one year, with 85% of the victims being stalked by someone they know. Sixty-one percent of female victims and 44% of male victims are stalked by an intimate partner. Among women who have been murdered, 76% were stalked by their intimate partner and 67% had been abused by them. Stalking victims may become fearful and anxious, and their physical and mental health can suffer as a result (National Center for Victims of Crimes, 2012).

Today, stalkers have at their fingertips a wide array of computers and equipment including the Internet, global positioning systems (GPS), cell phones, and tiny digital cameras. In many states, general stalking statues have not kept up with these new technologies for cyberstalking.

Florida law (784.048) defines cyberstalking as “engag[ing] in a course of conduct to communicate, or to cause to be communicated, words, images, or language by or through the use of electronic mail or electronic communication, directed at a specific person, causing substantial emotional distress to that person and serving no legitimate purpose” (Florida Legislature, 2016).

Psychological Aggression

Psychological aggression is the use of verbal and non-verbal communication with the intent to harm another person mentally or emotionally, and/or to exert control over another person. Psychological aggression can include expressive aggression (eg, name-calling, humiliating); coercive control (eg, limiting access to transportation, money, friends, and family; excessive monitoring of whereabouts); threats of physical or sexual violence; control of reproductive or sexual health (eg, refusal to use birth control; coerced pregnancy termination); exploitation of victim’s vulnerability (eg, immigration status, disability); exploitation of perpetrator’s vulnerability; and presenting false information to the victim with the intent of making them doubt their own memory or perception (eg, mind games) (CDC, 2016).

Coercive control and intimidation by the abusive partner is considered an underlying component of all of these types of violence. The abusive partner’s ability to control relies on the abused person’s belief that if she or he does not comply with the abusive partner’s demands, the victim, the victim’s children, or other persons or things the victim cares about will be harmed. Often, threats are alternated with acts of kindness from the perpetrator, making it difficult for the victim to break free of the cycle of violence.

The ten-country WHO survey and other research have consistently shown that emotional abuse can have a more profound and negative effect than physical violence. Between 20% and 75% of women across all the countries surveyed reported being the recipient of emotional abuse within the previous 12 months (WHO, 2005).

Violence Against Women

Violence against women has been the focus of international attention for more than twenty years. In 1993 the World Conference on Human Rights published the Declaration on the Elimination of Violence Against Women. It established that, according to international human rights law, “states have a duty to exercise due diligence to prevent, prosecute, and punish violence against women” (WHO, 2005).

Recognizing the need for research in the area of intimate partner violence, in 2005 the WHO completed a ten-country population-based survey (cited earlier) of 24,000 women called the WHO Multi-country Study on Women’s Health and Domestic Violence Against Women. The WHO researchers asked participants a series of questions about physical and sexual violence, emotional abuse, and controlling behaviors.

Overall, the proportion of women who had ever suffered physical violence by a male partner ranged from 13% in Japan to 61% in provincial Peru. Japan had the lowest level of sexual violence at 6%, while Ethiopia had the highest figure of 59%. The majority of settings were between 10% and 50% (WHO, 2005). A review study published by WHO in 2013 found substantially similar data. It shows the global average of prevalence of intimate partner violence of ever-partnered women to be 26.4%, and ranging from a low of 8.9% in some areas of East Asia to a high of 77.7% in central Sub-Saharan Africa (WHO, 2013).

It is well known that violence perpetrated against women by an intimate partner is often accompanied by emotionally abusive and controlling behavior. The National Violence Against Women survey found that women whose partners were jealous, controlling, or verbally abusive were significantly more likely to report being raped, physically assaulted, or stalked by their partners, even when other socio-demographic and relationship characteristics were controlled.

Having a verbally abusive partner was the variable most likely to predict that a woman would be victimized by an intimate partner. These findings support the theory that violence perpetrated against women by an intimate partner is often part of a systematic pattern of dominance and control (Tjaden & Thoennes, 2000). The victims are often emotionally involved and economically dependent upon the person victimizing them. In contrast, men are more likely to be victimized by someone outside their close circle of relationships (Heise & Garcia-Moreno, 2002).

Intimate Partner Violence During Pregnancy

Approximately 324,000 women are abused during pregnancy every year in the United States. Worldwide the prevalence of IPV during pregnancy in one study ranged from a low of 1% in urban Japan to 28% in Peru Province (WHO, 2005). Other studies have found even higher percentages (WHO, 2011).

More research is critical to understand the details of IPV during pregnancy but what is known so far indicates many negative effects for both mother and unborn child. Effects can be seen in negative health behaviors such as tobacco, alcohol, and drug use or delayed prenatal care. Reproductive health may be affected by many things including poor pregnancy weight gain, low birth weight, or obstetric complications. Physical and mental effects can include injury of all kinds—up to and including death; depression; poor attachment of mother to child; and others (ACOG, 2012; WHO, 2011).

Research has demonstrated that being pregnant does not protect women from IPV, but the evidence is conflicting as to whether or not violence increases or decreases during pregnancy. All of the usual triggers for IPV will be in play but the additional stresses that surround unplanned or unwanted pregnancies appear to be an additional risk factor for violence during pregnancy (WHO, 2011).

Pregnancy (at all stages) can present opportunities for health care professionals to inform and advise women regarding IPV and offer choices for assistance if a woman is being abused (ACOG, 2012). These professionals can become knowledgeable on the recognition and documentation of abuse, applicable laws in their locale, and the variety of resources available for victims of IPV.

Child Abuse

Intimate partner violence is often associated with the abuse of children. This is an important public health issue because witnessing violence in the home as a child is a strong risk factor for involvement in abusive relationships as an adult. In addition, experiencing abuse as a child has been associated with other risk factors such as depression, substance abuse, poor school performance, and high-risk sexual activity (CDC, 2016a, 2014a).

The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as, at minimum:

• Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation
  or
• An act or failure to act which presents an imminent risk of serious harm (Child Welfare Information Gateway, 2013, n.d.)

This definition of child abuse and neglect refers specifically to parents and other caregivers. A child under this definition generally means a person who is under the age of 18 or who is not an emancipated minor (Child Welfare Information Gateway, 2013, n.d.).

CAPTA provides definitions for sexual abuse and the special cases related to withholding or failing to provide medically indicated treatment but does not provide specific definitions for other types of maltreatment such as physical abuse, neglect, or emotional abuse. While federal legislation sets minimum standards, each state is responsible for providing its own definition of maltreatment within its civil and criminal laws (Child Welfare Information Gateway, 2013, n.d.).

Florida statute [39.01(2) and 39.01(30)] defines child abuse as

any willful act or threatened act that results in any physical, mental, or sexual abuse, injury, or harm that causes or is likely to cause the child’s physical, mental, or emotional health to be significantly impaired. Abuse of a child includes acts or omissions.

“Harm to a child’s health or welfare can occur when any person inflicts or allows to be inflicted upon the child physical, mental, or emotional injury,” which can include:

• Willful acts that produce certain specific injuries
• Purposely giving a child poison, alcohol, drugs, or other substances that substantially affect the child’s behavior, motor coordination, or judgment or that result in sickness or internal injury
• Leaving a child without adult supervision or arrangement appropriate for the child’s age or mental or physical condition.
• Inappropriate or excessively harsh discipline
• Exposure to a controlled substance or alcohol (Florida Legislature, 2016)

Domestic Violence with Child Maltreatment

Children exposed to domestic violence may be the victims of co-occurring maltreatment. In particular, domestic violence is a significant risk factor for verbal abuse, physical punishment, and physical abuse of children. Although high rates have been noted in the general population, this co-occurrence has most commonly been investigated in clinical samples of abused women and of physically abused children, with the majority of studies indicating rates of co-occurrence ranging from 30% to 60% (Kelleher, 2006).

There is evidence that children who are exposed to domestic violence and also experience maltreatment are at risk for poor development. There also is a growing concern that children’s exposure to domestic violence constitutes a type of psychological or emotional abuse in and of itself (Kelleher, 2006).

Although domestic violence and child maltreatment commonly occur together, policymakers and planners of services lack a nationally representative study that examines the prevalence of this co-occurrence. Equally important is the need for information on state and local policies and practices around services for families with co-occurring domestic violence and child maltreatment (Kelleher, 2006; NIJ, 2011).

Domestic Violence and the Child Welfare System

Domestic violence is a significant problem for 30% to 40% of families in the child welfare system. Because co-occurring domestic violence and child maltreatment are so prevalent, many communities have implemented policies and practices to protect women and children from domestic violence, and to provide services, especially as they relate to interactions with the child welfare system.

Many of these initiatives have arisen out of local advocacy through domestic violence centers and services, while others come from national movements promulgated by the National Council of Juvenile and Family Court Judges, such as its Model Code or its more recent policy and practice recommendations, sometimes referred to as the Greenbook (Kelleher, 2006; NIJ, 2011).

Elder Abuse and Abuse of Vulnerable Adults

Florida’s future is linked to the financial health and physical security of its elder population.

DOEA, 2016

Abuse of a vulnerable adult is defined in Florida law (415.102) as “any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment” to a vulnerable adult’s physical, mental, or emotional health.”

A vulnerable adult is a “person 18 years of age or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to a mental, emotional, sensory, long-term physical, or developmental disability or dysfunction, or brain damage, or the infirmities of aging” Abuse includes acts and omissions (Florida Legislature, 2016).

Exploitation of a vulnerable adult includes breaches of fiduciary relationships, unauthorized taking of personal assets, misappropriation of money, and intentional or negligent failure to use the vulnerable adult’s assets for their support and maintenance.

Neglect of a vulnerable adult includes the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult. Neglect also means the failure of a caregiver to make reasonable efforts to protect a vulnerable adult from abuse, neglect, or exploitation by others (Florida Legislature, 2016).

While much more research is needed, what we have so far suggests that there are more than 41 million Americans age 65 and older and they are a growing proportion of the population. One in 10 Americans 60 and older experienced abuse over one year, and some experienced more than one form of abuse. Almost 50% of people with dementia experience some form of abuse (NCEA, 2013).

A recent elder abuse prevalence study conducted in New York State found that for every known case of elder abuse there were 23.5 unknown cases, and in the case of financial exploitation it was 44 unknown cases for each known one (NCEA, 2013).

Elder abuse results in financial losses for victims, and often in increased rates of hospitalization, risks of dying sooner, and significantly higher rates of psychological distress (NCEA, 2013).

Florida has approximately 4.9 million residents age 60 and older. That is a greater number of elders as a percentage of population than in any other state and it is expected to grow—from 23% in 2010 to 35% in 2030. With a large, growing, and physically and culturally diverse elder population, the state faces many challenges (DOEA, 2016).