chapter 4
THE EFFECTS OF ABUSE—WHY DOES SHE STAY?

Why don't battered women leave? This question does not have a single answer but, rather, many answers. Even the question has many connotations. For battered women, the question is not uniformly, "How can I leave him?" but "How can I get the violence to stop?" or "How can I get my relationship to be happy and fulfilling?" For women who want to leave, the question may become "Can I support myself and the children by myself?" "How can I escape?" "Will he kill me if I try?" or "How will my children fare without a father?" For clinicians working with battered women, the question might be "How can she make any decisions when she is so emotionally traumatized?"

—Ola W. Barnett, "Why Battered Women Do Not Leave, Part 1, " Trauma, Violence, and Abuse, vol. 1, no. 4, October 2000

One of the most frequently asked questions about abused women is: Why do they stay? Some authors and advocates argue that the relevant questions for battered women themselves are very different. They believe that the very question implies there is something wrong with the woman for staying, rather than placing the blame where it belongs—on the batterer. Better questions, Barnett argues, might be: "Why does he beat her?" or "Why does society let him get away with it?" or "What can be done to stop him?"

But not all women stay in abusive relationships. Many leave abusive relationships and situations without turning to the police or support organizations. While their number is unknown, most who leave without asking for help usually have strong personal support systems of friends and family or employment and earnings that enable them to live economically independent of their abusive partners. Yet, there can be little question that a large percentage of women remain with their abusers. There are as many reasons why women stay as there are consequences and outcomes of abusive relationships.

REASONS TO STAY

Women stay in abusive relationships for a variety of reasons. A major reason women stay is their economic dependency on their batterers. Many women feel they are better off with a violent husband than facing the challenge of raising children on their own. Some harbor deep feelings for their abusive partners and believe that over time they can change their partners' behavior. Others mistakenly interpret their abusers' efforts to control their life as expressions of love. Other frequently reported considerations include:

• Most women have at least one dependent child who must be cared for.
• Many are unemployed.
• Their parents are either distant, unable, or unwilling to help.
• The women may fear losing mutual friends and the support of family, especially in-laws.
• Many have no property that is solely their own.
• Some lack access to cash, credit, or any financial resources.
• If the woman leaves, then she risks being charged with desertion and losing her children and joint assets.
• She may face a decline in living standards for herself and her children, and the children, especially older ones, may resent this reduced living standard.
• The woman and/or children may be in poor health.
• The abuser may have threatened or harmed her pets, as noted by Catherine A. Faver and Elizabeth B. Strand in "To Leave or To Stay? Battered Women's Concern for Vulnerable Pets" (Journal of Interpersonal Violence, vol. 18, no. 12, December 2003).

Some battered women hold values and beliefs that experts term "traditional ideology." These patriarchal beliefs, often reinforced by clergy, mental health profesionals, and physicians, tend to normalize violence against women. This ideology may include:

• a belief that divorce is not a viable alternative and that marriage is a permanent commitment
• a belief that having both a mother and father is crucial for children
• an emotional dependence on her husband, and a feeling she needs someone to take care of her
• feelings of helplessness and a belief that she is dependent on a man and unable to take the initiative to escape her situation
• a belief that a "successful marriage" depends on her, leading her to assume responsibility or to blame herself for the abuse
• feelings of low self-esteem and self-worth
• the rationalization that her situation is caused by heavy stress, alcohol, problems at work, or unemployment
• a cycle of abuse that includes periods when her husband is exceedingly romantic, leading her to believe that she still loves him or that he is basically good
• a feeling of isolation from friends and family that may have been forced on her by a jealous and possessive husband who did not allow her any freedom

Some social isolation may be self-imposed by a woman who is ashamed and neither wishes to admit that the person she loves is an abuser, nor wants visible signs of beating to be seen by friends or family.

Leaving an abusive partner is a process some therapists and counselors have termed an "evolution of separation," because many victimized women have to make several attempts before they depart from and remain parted from their abusive husbands. In order to separate from their abusers, women must first acknowledge that their relationship is unhealthy and will not get better, experience a catalyst for leaving (for example, a particularly severe beating), give up their dreams for the relationship, and accept that some aspects of the relationship will continue (for example, child-visitation arrangements). On average, women leave and return five times before separating for a final time (see Barnett citation at the head of this chapter).

Whether a separated woman will permanently leave her battering spouse largely depends on whether she has the economic resources to survive without him. Women who are economically dependent on their husbands are more likely to be battered, and also less likely to leave. Leaving will expose these women to the hazards of poverty: crime, violence, lack of health care, lack of affordable housing and quality child care. Batterers also often interfere with their partners' ability to find and keep employment, according to Ola W. Barnett in "Why Battered Women Do Not Leave, Part I" (Trauma, Violence, & Abuse, vol. 1, October 2000).

The Most Prevalent Reasons Women Stay in Abusive Relationships

A 1999 research project in Maricopa County, Arizona, considered intimate partner violence and asked women who participated why they remained in emotionally and physically abusive situations. Although nearly half of the study participants said they fought weekly or even daily with their abusive partners, 62% felt they would be unlikely to leave their current partners. The reasons they offered for remaining in dangerous and destructive relationships included:

• Income—Sixty percent of participants said they earned less than $20,000 per year and 32% said they had no money of their own.
• Hope—Fifty-five percent felt they would be able to repair the relationship.
• Fear—Forty-five percent worried that they could not take their children with them if they left their abusers.
• Opportunity—Forty-four percent could not see any way they could earn enough money to support themselves and their children.
• Education—Forty percent reported no education beyond high school.
• Lack of information—Thirty-six percent of respondents said they did not know where to go to escape an abusive relationship.

More than 30% of the participants said they had been abused as children and more than half had grown up watching their parents in abusive relationships. Analyzing these data, Jude Miller-Burke concluded that along with the stated economic reasons and practical logistical considerations involved in ending abusive relationships, many women remain because they mistakenly believe they either cause or deserve the abuse.

How Will Abusive Men Respond When Women Try to Leave?

A battered woman's fear of reprisal is very real and well founded. As Lenore Walker explained in Terrifying Love: Why Battered Women Kill and How Society Responds (New York: Harper and Row, 1989), batterers often panic when they think women are going to end the relationship. In the personal stories women told Walker, they repeatedly related that after calling the police or asking for a divorce, their partners' violence escalated.

Walker observed that in an abusive relationship it is often the man who is desperately dependent on the relationship. Battered women are likely to feel that the batterers' sanity and emotional stability is their responsibility—that they are their men's only link to the normal world. Walker alleged that almost 10% of abandoned batterers committed suicide when their women left them.

It appears, however, that more batterers become homicidal than suicidal. Angela Browne, the author of When Battered Women Kill, and Kirk Williams, of the Family Research Laboratory, in "Resource Availability for Women at Risk and Partner Homicide" (both published in Law and Society [Durham, NH: University of New Hampshire, 1989]), found that more than 50% of all female homicide victims were murdered by former abusive male partners. Ola W. Barnett emphasized that evidence consistently demonstrates that after women leave abusive partners they often continue to be assaulted, stalked, and threatened, and that leaving provokes some batterers to kill their partners (see citation at the head of this chapter). Carolyn Rebecca Block concurred that an attempt to leave can escalate domestic violence; she found that 45% of homicides of a woman by a man were in response to women trying to leave abusive partners ("How Can Practitioners Help an Abused Woman Lower Her Risk of Death?" National Institute of Justice Journal, no. 250, November 2003).

MULTIPLE VICTIMIZATION ARGUMENTS

In order to mobilize an effective and widespread protest against intimate partner violence, the battered women's movement that emerged in the 1970s had to satisfactorily answer the question, "Why do women stay in abusive relationships?" In response, a variety of theorists emerged who explained that women were victimized and coerced into staying in violent relationships by a variety of factors. Among these theorists is Bess Rothenberg who listed several factors in "'We Don't Have Time for Social Change': Cultural Compromise and the Battered Woman Syndrome" (Gender & Society, vol. 17, October 2003). According to Rothenberg, women were victimized first and foremost by violent abusers; second, by a society that sanctioned the right of men to hit women and socialized women into staying in abusive relationships; third, by representatives of institutions who were in a position to help but who instead ignored the plight of battered women (for example, doctors, police, the criminal justice system, clergy, and therapists); and finally, by the everyday realities of being a woman in a patriarchal system that expects women to raise children and denies them access to education, job skills, and good employment.

Do Women Learn to Be Helpless from Their Life Experience?

Among the best known of the multiple victimization arguments is Lenore Walker's concept of "battered woman syndrome," based in part on the research of Martin Seligman.

Seligman, in Helplessness: On Depression, Development and Death (1975), describes how he came to discover the phenomenon he calls learned helplessness. Seligman conducted an experiment in which he attempted to teach dogs to fear the sound of a bell. He did so by restraining a dog, ringing the bell, and then subjecting the dog to a painful (but not dangerous) shock. This process was repeated many times.

Next, to test the effectiveness of the training, Seligman placed the dog in a cage with a floor that could be electrified. One wall of the cage was low enough that the dog could jump over it if it wished. Seligman then rang the bell. He expected that the dog would jump out of the cage. But most of the dogs did not. Their earlier experience, where they had been shocked with no possibility of escape, had taught them that they were helpless. And so even though they were clearly afraid of the bell and found the shocks painful, they made no attempt to escape. On closer observation Seligman found that some dogs developed coping skills, such as using their own excrement to insulate themselves from the floor.

Seligman and other psychologists have theorized that learned helplessness also occurs in humans, with similar effects. Lenore Walker, the author of several well-regarded books about intimate partner violence, theorized that victimized people tend to stop trusting their instinctive responses that protect them after they have experienced inescapable pain in apparently random and variable circumstances. When a person no longer controls his or her own life and does not know what to expect, the individual becomes helpless and develops coping skills to try to minimize the pain. Walker contends that battered women have learned that they are helpless. Although outsiders may not understand why they do not leave their abusers, battered women become conditioned to believe that they cannot predict their safety and that nothing can be done to fundamentally change their situations.

Based on her research, much of which focused on severely abused women who killed their husbands, Walker identifies five factors in childhood and seven factors in adulthood that contribute to learned helplessness. The childhood factors include physical or sexual abuse, the learning of traditional sex roles, health problems, and episodes during childhood when a child loses control of events, such as in frequent moves or the death of a family member. Adult factors include patterns of physical and sexual abuse, jealousy and threats of death from a batterer, psychological torture, seeing other abuse committed by the batterer, and drug or alcohol abuse by either partner.

Battered Woman Syndrome

In The Battered Woman (New York: Harper & Row, 1979) Walker argues that abused women suffer from a constellation of symptoms—"the battered woman syndrome"—that keeps them from leaving abusive partners. Walker argues that learned helplessness and a cycle of violence make it extremely difficult for women to leave abusive partners. When women fail to escape from violence, she argues, they become passive, submissive, depressed, overwhelmingly fearful, and psychologically paralyzed. While Walker recognizes, as did other multiple victimization theorists, that women were victims of a patriarchal society and institutions that failed to advocate for abused women, she emphasizes the psychological problems women develop in response to abuse.

In Walker's article "The Battered Woman Syndrome Is a Psychological Consequence of Abuse" (Current Controversies on Family Violence [Thousand Oaks, CA: Sage, 1994]), Walker claims that battered woman syndrome is common among severely abused women and that it is part of the recognized pattern of psychological symptoms called post–traumatic stress disorder (PTSD). Women suffering from battered woman syndrome learn that they cannot predict the outcomes of their actions because they cannot reliably determine if a particular response will bring them safety. Walker emphasizes that although they do not respond with total helplessness, they narrow their choices, choosing the ones that seem to have the greatest likelihood of success.

Normally, fear and the responses to fear abate once the feared object or circumstance is removed. People who have suffered a traumatic event, however, often continue to respond to the fear with flashbacks and violent thoughts long after the event has passed. Symptoms of PTSD can afflict individuals regardless of whether they suffer from other psychological problems. Otherwise mentally healthy, and emotionally stable people can develop these symptoms as an adaptive mechanism—a coping strategy to survive abnormal or unusually frightening experiences.

Symptoms of PTSD involve cognitive, psychological, and emotional changes that occur in response to severe trauma. Symptoms may include difficulty in thinking clearly and a pessimistic outlook. The disorder can also produce two distinct forms of memory distortions:

• Unwanted, intrusive memories of the trauma may magnify the terror.
• Partial amnesia may cause an affected individual to suppress and forget many of the painful experiences.

Other symptoms of PTSD include sleep and eating disorders and medical problems associated with persistent high levels of stress. Symptoms described under the PTSD diagnosis cover nearly every possible—and seemingly contradictory—response to battering, including chronic alertness, flashbacks, floods of emotion, detached calm, anger, inability to concentrate, sleep disturbances, indifference, profound passivity, and depression. Over time, the more aggressive symptoms diminish and are replaced by more passive, constrictive symptoms, making the affected women appear helpless. The abused woman's outlook often improves, however, when she regains some degree of power and control in her life.

Women Are Not Helpless

Beginning in the 1980s, a number of critics emerged who argued that the emphasis on psychological problems of abuse victims was an inadequate explanation of domestic violence. Lee Bowker argued in "A Battered Woman's Problems Are Social, Not Psychological" (Current Controversies on Family Violence [Thousand Oaks, CA: Sage, 1994]) that women remain trapped in violent marriages because of conditions in the social system rather than because they suffer from psychological problems. According to the author, battered women are not as passive as they are portrayed in abuse literature and routinely take steps to make their lives safer or to escape abuse. Bowker viewed husbands' unwillingness to stop being dominant and a lack of support from traditional social institutions as the factors that delay battered women in escaping from abuse.

To support these findings, Bowker analyzed survey questionnaires completed by one thousand women and found that women used several major strategies to end abuse. They tried to extract promises from their partners that the battering would stop, threatened to call police or file for divorce, avoided their partners or certain topics of conversations, hid or ran away, tried to talk the men out of violent behavior, covered their bodies to deflect the blows, and, in some cases, tried to hit back. Of these strategies, extracting a promise to change helped most often (54% of the time), while self-defense proved the least effective strategy.

Because the effectiveness of these strategies was limited, most women turned to outside sources for help. First, they contacted family or friends. However, for most women, family and friends did not help stop the violence. Generally, these women then turned to organized or institutional sources of aid, such as police, physicians, clergy, lawyers, counselors, women's groups, and shelters. Calling a lawyer or prosecutor proved the most effective way to end the battering, followed by seeking assistance from women's groups and social service agencies offering referral to shelters or counselors.

Bowker did not find that loss of self-esteem inevitably paralyzes women, leading them to remain in abusive relationships. While battered women do lose self-esteem for a time, many still escape from their abusers. This suggests that when all seems hopeless, an innate need to save themselves propels abused women to escape from their situations. Bowker theorized that the reason women's groups and shelters are effective is that they counter the effects of abuse by supporting personal growth and nurturing the women's strength.

Bowker concluded that because women recover from their feelings of helplessness as they gain strength, battered woman syndrome symptoms are fundamentally different from the long-lasting symptoms that characterize most psychiatric disorders. In Bowker's interpretation, battered woman syndrome refers to the social, economic, psychological, and physical circumstances that keep women in abusive relationships for long periods. The abusive relationship engenders feelings of learned helplessness that are difficult to escape. Conditioned by their batterers to feel helpless, such women have not yet learned how to resist this type of brainwashing and how to compel their abusers to retreat without having to leave or kill the batterer.

Exploration of External Barriers to Leaving

In "Why Battered Women Do Not Leave, Part 1" (see previous citation), Ola W. Barnett argued that battered women face many obstacles to leaving abusive relationships. She argued that many of these barriers are external—in other words, not due to an individual or psychological problem with the abused woman. Barnett outlined many external obstacles to an abused woman's quest to leave her partner, including:

• The patriarchal structure of society—When men control all of a family's resources, women may be economically powerless. In addition, the political and legal system of the United States—particularly in areas of income, employment, and child support—have codified sexist practices that sabotage women's attempts to become economically independent of their abusers.
• Problems with the criminal justice system—The criminal justice system in the United States is underfunded and tends not to enforce legislation prohibiting the abuse of women. The lack of adequate funding keeps battered women from getting legal assistance. Police decisions to arrest or not arrest batterers tend to be inconsistent; when police don't arrest, it impedes women's attempts to leave as well as leaving them vulnerable to further abuse. Only one quarter of batterers are arrested, about one-third of those arrested are prosecuted, and only 1% of those prosecuted serve jail time beyond the time served at arrest. Orders of protection are ineffective because most judges will not enforce them.
• Child custody and visitation—Women fear losing their children if they report intimate partner violence. A report of domestic violence can trigger an investigation by child protective services. When women do retain custody of their children, judges usually do not take intimate partner violence into account when writing visitation orders. Court-ordered visitation is often used by abusers as an opportunity for further battering.

Internal and Psychological Barriers to Leaving

Barnett also outlined several internalized socialization beliefs—normal, learned beliefs about how society and relationships work—as well as psychological factors induced by trauma that serve as obstacles to battered women leaving their abusers ("Why Battered Women Do Not Leave, Part 2," Trauma, Violence, & Abuse, vol. 2, no. 1, January 2001). Barnett emphasized that many of these beliefs are detrimental to all women—but battered women are particularly vulnerable. Among them are:

• Gender-role socialization—Society values male traits more than female traits and often devalues female gender roles. As girls age into adolescents, they begin to lose self-confidence as they turn to romantic relationships for a sense of self-worth. When an adult woman values her ability to form a relationship with a male partner over other characteristics, losing the relationship may seem worse than staying and enduring the abuse.
• Distorted beliefs and perceptions—Battered women tend to hold some distorted beliefs that keep them in abusive relationships. Common distorted thought patterns among battered women include a belief that violence is commonplace and not abusive, a belief that they caused the abuse, a lack of recognition that children are harmed more by witnessing intimate partner violence than by living with a single parent, and a belief that she can and should help the abuser to change.
• Post–traumatic stress disorder—PTSD is a prolonged psychological reaction to a traumatic event. Its symptoms include difficulty sleeping, reliving trauma in flashbacks, and numbing of emotional responses. The level of psychological distress abused women experience can keep them from being able to escape the violence.
• Impaired problem-solving abilities—Many factors can impede the problem-solving abilities of battered women, including post-concussion syndrome resulting from head injuries as well as the cognitive distortions of PTSD.
• Prior victimization effects—Women who have been abused during their childhoods have an increased risk of becoming involved with an abusive intimate partner in adulthood. This may be because these women have difficulty judging how trustworthy people are, or they hold a distorted belief that they cannot escape violence.

A LARGER CONTEXT

Evan Stark and Anne Flitcraft, best known for their research about battered women who seek help in medical emergency rooms, explored the question of traumatization in a larger context in their book Women at Risk (Thousand Oaks, CA: Sage, 1996). Stark and Flitcraft questioned whether the severe psychological symptoms caused by post–traumatic stress disorder are a result of violence. They believe that the damage is done by the coercive control exercised by the abuser and that the damage may be compounded when law enforcement, health, and social service institutions ignore a woman's attempts to get help; traditional mental health treatment contributes to the coercion by assigning mutual responsibility or defining the issue in terms of the victim's behavioral problems, including her apparent helplessness. Stark and Flitcraft point out that often women's attempts to leave are undervalued because of the pervasiveness of the "learned helplessness" theory. The view of an abused woman as a passive victim is often easier for therapists, doctors, police officers and others to sympathize with than the view of the abused woman as a sometimes aggressive woman with a history of persistent (but failed) attempts to seek help.

In "Affect, Verbal Content and Psychophysiology in the Arguments of Couples with a Violent Husband" (Journal of Consulting and Clinical Psychology, vol. 62, no. 5, 1994), Neil S. Jacobson, a pioneering researcher in the area of marital violence, also questioned the view of the abused woman as a helpless and submissive victim. He theorized that a woman's intense anger, combined with fear and sadness, may be a part of her apparent helplessness. According to him, these women are hostile to their husbands and are by no means beaten into submission, but because of the physical abuse they are also afraid. Jacobson believes there is an intense need for more services and public policies to meet the needs of battered women.

DIFFERENT PERCEPTIONS OF REALITY

Some researchers have found that battered women often hold distorted beliefs and perceptions that tend to keep them in an abusive relationship. Some women blame themselves for the violence; others see the abuse as normal and rationalize the violence as "not that bad."

Self-Blame

Researchers find that women who return to abusive relationships have higher levels of self-blame than women who permanently leave their abusers. Women who blame themselves believe that they cause the abuse, and they should be able to prevent it by changing their own behavior. In "The Relationship between Violence, Social Support and Self-Blame in Battered Women" (Journal of Interpersonal Violence, vol. 11, no. 2, June 1996), Ola W. Barnett et al. found that battered women have higher levels of self-blame and perceive less availability of social support than women who are not battered.

Escalating levels of violence in a relationship often lead to greater use of violence by the woman as a means of self-defense or retaliation. This can result in still more self-blame, since the woman feels she is at fault for the violence. It also may deter her from seeking help and prompt her to believe no help is available. External sources of support may be less inclined to help the woman who presents the problem as her fault; as a result, the self-blaming woman may receive less assistance from health and social service agencies and organizations. To break this vicious cycle requires counselors or advisors who can help the woman shift the blame to her abusive mate. In fact, some researchers suggest that while women may blame themselves when the abuse begins, as the frequency and severity of violence increases, they do eventually begin to assign the blame to the perpetrators (see Kate Cavanagh, "Understanding Women's Responses to Domestic Violence," Qualitative Social Work, vol. 2, no. 2, September 2003).

"It's Not That Bad"

In "Coping with an Abusive Relationship: How and Why Do Women Stay?" (Journal of Marriage and the Family, vol. 53, 1991), Tracy Herbert et al. compared the perceptual differences of women who leave abusive relationships and those who stay. They theorized that all relationships are a mixture of good and bad elements, but as long as a partner perceives that the good outweighs the bad, he or she will maintain the relationship.

The researchers interviewed 130 women to find out how they viewed their relationships. They suspected that the women who stayed would emphasize the positive aspects of their marriages and minimize the negative, because as long as they could maintain positive images, they would remain. Studies find that women are often finally driven to go to shelters when their husbands' abuse suddenly becomes more severe or when kindness after beatings diminishes, thereby forcing a change in the women's perceived reality.

The women reported that the frequency of abuse was, on average, once a month or less; 78% reported verbal and physical abuse. Of these, 77% felt the verbal abuse was as difficult, or more difficult, to deal with than the physical abuse. The more frequently the woman was verbally abused, the less capable she was of seeing her relationship as positive. One woman wrote, "Bruises, cuts, etc., heal within a short time. When you listen to someone tell you how rotten you are and how nobody wants you day after day, you begin to believe it. Verbal abuse takes years to heal but before that happens, it can ruin every part of your life."

Herbert et al. did not find evidence that the women were trapped by low self-esteem or the length of the relationship. The three variables they found most closely related to the decision to stay were:

• The women perceived more positive aspects to their relationship.
• They saw little or no change in the frequency or intensity of the battering or love that their husbands expressed.
• They felt their relationship was not as bad as it could be.

WHAT CAN A WOMAN DO?

Cavanagh gathered qualitative data from interviews with the female partners of violent men to illustrate that battered women try to end the violence in their relationships in many ways, even if they stay—complicating the notion of the battered woman as passive and helpless. She found that women worked to stop the violence by talking with their partners about the violence, developing strategies for avoiding the violence (for example, being affectionate or feigning agreement with the abuser), challenging the violence (for example, fighting back, verbally or physically), telling other people about the violence, and leaving (usually temporarily) the relationship. Cavanagh argued that abused women almost always actively fight the abuse: "At some points in time the struggle to change took second place to the struggle to survive but not even women subjected to the extremes of abuse totally 'gave up.'"

Richard Gelles and Murray Straus found that only 13% of the severely abused women in the 1985 National Family Violence Survey felt their situations were completely hopeless and out of their control. In Intimate Violence: The Definitive Study of the Causes and Consequences of Abuse in the American Family (New York: Simon and Schuster, 1988), Gelles and Straus argued that women who experienced more severe violence and grew up in more violent homes were more likely to stay. Predictably, women who were less educated, had fewer job skills, and thus were more likely to be unemployed were also more likely to stay, as were women with young children.

Avoidance

Gelles and Straus interviewed 192 women who suffered minor violence and 140 who suffered severe violence, and asked which long-range strategies they used to avoid violence. Fifty-three percent of the minor-violence victims and 69% of the severe-violence victims learned to avoid issues they thought would anger their partners. Others learned to read a change in their partners' facial expressions as one of the first signs of impending abuse. "I have learned what gets him mad. I also know just by looking at him, when he gets that kind of weird, screwed-up expression on his face, that he is getting ready to be mad. Most of the time I figure I just have to walk on eggshells," one woman said. Avoidance worked for about 68% of those women who suffered minor abuse, but for less than one-third of the more severely abused victims.

Leaving

Some battered women do leave their husbands. Straus and Gelles found that 70% had left their spouses in the year preceding the interview. Only about half of those who left, however, reported that this was a "very effective" method of ending the abuse. In fact, for one out of eight women it only made things worse. Batterers put incredible pressure on their partners to return. Often, when the women returned they were abused more severely than before—as revenge or because the men learned that, once again, they could get away with this behavior. Women who returned also risked losing the aid of personal and public support systems, because these people perceived that their help or advice was useless or ignored.

Just Say "No"

Many researchers believe that there is real truth to the statement that men abuse because they can. A wife who will not permit herself to be beaten from the very first act of minor abuse, like a slap or push, is the most successful in stopping it. Straus and Gelles found that simply eliciting a promise to stop was by far the most effective strategy women could undertake—especially in cases of minor violence. Threatening to divorce or leave the home worked in about 40% of the minor abuse cases, but in less than 5% of the severe-abuse situations. Physically fighting back was the most unsuccessful method. It worked in fewer than 2% of the minor-abuse cases and in less than 1% of the severe-abuse cases.

Coping Strategies

Many battered women remain in abusive relationships out of fear, but it is not always fear of their husbands that causes them to stay. Some women fear they may lose custody of their children if they walk out on an abusive partner. Others fear they will lose their homes or their social status. For other women, religious or cultural pressures to hold the family together at all costs trap them in bad marriages, even as the abuse worsens.

Maria Eugenia Fernandez-Esquer and Laura Ann McCloskey studied a group of Mexican American and Anglo women to learn about the ethnic and social influences that pressured them to remain in or leave abusive relationships. In "Coping with Partner Abuse among Mexican American and Anglo Women: Ethnic and Socioeconomic Influences" (Violence and Victims, vol. 14, no. 3, Fall 1999), they recounted their interviews with fifty-one Mexican American and forty-one Anglo women, all of whom had violent confrontations with their spouses in the year prior to the interview. All the women had been victims of verbal abuse. About half the women reported being beaten for several minutes, choked, raped, or threatened with murder if they left. About 25% were threatened with a gun or knife or forced to engage in sex against their will.

At least 25% of respondents in both ethnic groups reported coping tactics that included verbally aggressive intervention, "thinking through" the situation, and physical separation. In addition, more than 25% of the Anglo women reported physically aggressive intervention and avoidance tactics.

Fernandez-Esquer and McCloskey found that the socioeconomic status of battered women, as defined by education and employment, affected the way they coped. As socioeconomic levels rose, abuse victims tended to report more types of internal focus-coping tactics to deal with partner abuse. The researchers theorized that women who "think through" the situation might feel more self-reliant and capable of handling the violence without police intervention. However, internal coping also involved crying spells, angry outbursts, suicidal feelings, and self-blame.

Fernandez-Esquer and McCloskey did not find support for their hypothesis that ethnicity influences coping strategies of battered women. They concluded that the study illustrated similarities between ethnic groups, especially when faced with an abusive partner.

Injuries and Medical Care

There are often urgent and long-term physical and health consequences of domestic violence. Short-term physical consequences include mild to moderate injuries, such as broken bones, bruises, and cuts. More serious medical problems include sexually transmitted diseases, miscarriages, premature labor, and injury to unborn children, as well as damage to the central nervous system sustained as a result of blows to the head, including traumatic brain injuries, chronic headaches, and loss of vision and hearing. The medical consequences of abuse are often unreported or underreported because women are reluctant to disclose abuse as the cause of their injuries, and health professionals are uncomfortable inquiring about it.

A report titled "Violence against Women" found that while more than half of abused women are physically injured by their abusers, only four out of ten seek professional medical care (The Women's Health Data Book [Washington, DC: Jacobs Institute of Women's Health and the Henry J. Kaiser Family Foundation, 2001]).

Abused women also are at risk for health problems not directly caused by the abuse. In "Intimate Partner Violence and Physical Health Consequences" (Archives of Internal Medicine, vol. 162, no. 10, May 2002), investigators from several medical centers and schools of public health compared the physical health problems of abused women to a control group of women who had never suffered abuse. The investigators found that abused women suffered from 50% to 70% more gynecological, central nervous system, and stress-related problems. Examples of stress-related problems included chronic fear, headaches, back pain, gastrointestinal disorders, appetite loss, increased incidence of such viral infections as colds, and such cardiac problems as hypertension and chest pain. Although women who most recently suffered physical abuse reported the most health problems, the researchers found evidence that abused women remain less healthy over time.

screening for domestic violence. Although women have about a 30% to 44% chance of experiencing intimate partner violence at some point during their lives, health professionals detect as few as one out of twenty are victims of physical abuse. Lorrie Elliot et al. conducted a national survey of physicians to identify factors associated with the documented low screening rates for domestic violence. In "Barriers to Screening for Domestic Violence" (Journal of General Internal Medicine, vol. 17, no. 2, February 2002), researchers reported the responses of physicians in four medical specialties likely to encounter abused women—internal medicine, family practice, obstetrics-gynecology, and emergency medicine.

The vast majority of physician respondents (88%) said they knew patients in their practices who had experienced domestic violence, but physicians in all specialties except emergency medicine underestimated the prevalence of the problem in their states. The physicians were questioned about the percentage of their patients they screened, i.e., specifically asked about their experience with domestic violence. Overall, just 10% of respondents screened their female patients for domestic violence and of this group, just 6% screened all female patients. Of the specialties, obstetrician-gynecologists screened the highest proportion of their patients.

Although most respondents felt they should be screening for domestic violence in their practices, most did not fulfill this responsibility. Along with unrealistically low estimates of the prevalence of the problems in their communities, physicians also cited lack of training, lack of confidence in their abilities, fear of offending patients, and the mistaken belief that women will volunteer a history of abuse without being questioned. The researchers concluded that mandatory training on intimate partner violence, reminders in patients' medical charts, and physician interaction and involvement with victim service providers might all serve to increase physicians' confidence and competence to screen patients for intimate partner violence and abuse.

Hospitalization of Battered Women

The National Crime Victimization Surveys estimate that of the more than half of women battered by an intimate partner who are injured, 30% to 40% require medical treatment and 15% require hospitalization. The hospital emergency department is often the first contact the health care system has with battered women and offers the first opportunity to identify victims, refer them to support services and safe shelters, and otherwise intervene to improve their situations.

Researchers at the University of Washington reported on hospitals and battered women in "Rates and Relative Risk of Hospital Admission among Women in Violent Intimate Partner Relationships" (American Journal of Public Health, vol. 90, no. 9, September 2000). They found that women who had filed for protection orders against male intimate partners had an overall increased risk for earlier hospitalization than women who had not been abused. Abused women had a 50% increase in hospitalization rates for any diagnosis, compared to nonabused women, and the risk of hospitalization was highest in the younger age groups of abused women. Abused women were hospitalized much more frequently for injuries resulting from assaults, suicide attempts, poisonings, and digestive system disorders than the nonabused women and were almost four times as likely to be hospitalized with a psychiatric diagnosis. The researchers reaffirmed the observation that intimate partner violence has a significant impact on women's health and their utilization of health care services.

Improving Health Professionals' Responses to Victims of Domestic Violence

In 2001, the National Academy of Sciences Institute of Medicine released the report Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (Washington, DC: National Academy Press, 2001), which was mandated by the Health Professions Education Partnerships Act of 1998 (PL 105-392) and sponsored by the Centers for Disease Control and Prevention. The study involved fifteen professionals from a variety of disciplines, including health sciences, mental health, law, and the study or aid of victims of child maltreatment, domestic violence, and elder abuse. They reviewed available research about the training of health professionals and others who come into contact with victims; the effectiveness of training and programs to screen, identify, and refer victims of family violence in health care settings; and the outcomes of available interventions.

The report described family violence as a serious public health problem and societal tragedy, cited inadequate training of health professionals as a major problem, and called for vigorous efforts to improve health professionals' abilities to screen, diagnose, treat, and refer victims of abuse. The Institute of Medicine report recommended:

• Family violence centers should conduct research on the impact of family violence on the health care system and to evaluate and test training and education programs for health professionals. The report suggested that centers be established by the Department of Health and Human Services and modeled after similar multi-disciplinary centers in fields such as injury control research, Alzheimer's disease, and geriatric education. To lay the foundation for the centers' coordinating role, the report suggested that the U.S. General Accounting Office analyze the level and adequacy of existing investments in family violence research and training.
• Health professional organizations and educators—including academic health-center faculty—should address core competency areas for health professional curricula on family violence, including effective teaching strategies, approaches to overcoming barriers to training, and approaches to promoting and sustaining behavior changes by health professionals in dealing with family violence.
• Health care delivery systems and training settings, particularly academic health care centers and federally qualified health clinics and community health centers, should assume greater responsibility for developing, testing, and evaluating innovative training models or programs.
• Federal agencies and other funders of education programs should create expectations and provide support and incentives for evaluating curricula on family violence for health professionals. Evaluations should focus on the impact of training on the practices of health professionals and the effects on family violence victims.

Empowerment of Battered Women

Researchers and advocates have found that one of the most effective ways to deal with partner violence is by giving the victim the power, encouragement, and support to stop it. In "Estrangement, Interventions and Male Violence Toward Female Partners" (Violence and Victims, vol. 12, no. 1, Spring 1997), Desmond Ellis and Lori Wight asserted that abused women want the violence to stop and most, if not all, attempt to do something to stop it. They found evidence showing that empowerment of abused women is related to a decrease in the likelihood of further violence. The interventions Ellis and Wight recommended to promote gender equality include:

• social service agencies such as counselors or shelters to provide information and support
• mediation to facilitate a woman's control over the process
• prosecution with an option to drop the charges, which also facilitates control by female victims
• separation, which indicates the woman's strength in decision making

Ellis and Wight found that separation or divorce is one of the most effective strategies for ending abuse. Levels of violence after separation, according to these researchers, varies with the type of legal separation or divorce proceedings. Women who participate in mediation prior to separation are less likely to be harmed, either physically or emotionally, than women whose separation is negotiated by lawyers. Ellis and Wight found that other legal proceedings, such as restraining orders and protection orders, were relatively ineffective in protecting female abuse victims.

Interventions to Help Battered Women

Throughout the United States, voluntary health and social service agencies and institutions, such as hospitals, mental health centers, clinics, and shelters, have developed programs that aim to help abused women break free physically, economically, and emotionally from their violent partners. Still, many abused women do not seek help from these specialized programs and services as a result of fear, shame, or lack of knowledge about how to gain access to available services. Instead, many injured women seek medical care from physicians, nurses, and other health professionals. For this reason, medical professional organizations, such as the American Medical Association and the American College of Obstetricians and Gynecologists, exhort physicians to advocate on behalf of abused women. They offer guidelines to help professionals detect and intervene in cases of domestic violence.

Despite the ambitious objectives of professional societies and the widespread distribution of guidelines, many health professionals most likely to encounter victims of abuse remain untrained, fearful, and unable even to question patients about domestic violence. Barbara Gerbert et al. interviewed physicians to determine how they have overcome these and other barriers to help patients who are victims of domestic violence. Their findings were published in "Interventions That Help Victims of Domestic Violence: A Quantitative Analysis of Physicians' Experiences" (Journal of Family Practice, vol. 49, no. 10, October 2000).

Although physician respondents reported feeling overwhelmed, frustrated, and often ill-prepared to tackle these problems, they nonetheless felt it was their responsibility to help battered women improve their situations. The technique they believed most effective was validation—expressing concern by compassionately communicating to the woman that the abuse was undeserved. Other strategies they considered effective were:

• Overcome denial and plant seeds of change—Physicians helped the women to appreciate the seriousness of their situations and to understand that the abusers' actions were wrong and criminal. Some physicians used photographs of injuries to remind patients who denied the extent of their abuse about the severity of the injuries they had sustained.
• Nonjudgmental listening—To build trust, physicians listened without rushing to judgment or criticizing women for not fleeing their abusers.
• Document, refer, and help prepare a plan—Physicians documented abuse with photographs and detailed descriptions in the patients' medical records for use in medical and mental health treatment as well as in court proceedings. They offered ongoing, confidential referrals to hot lines, shelters, and other community resources; advised patients about when to call police; and assisted them to develop escape plans.
• Use a team approach—Physicians felt it was valuable to be able to immediately refer abused women to on-site professionals, such as counselors, nurses, social workers, or psychologists, who were able to take advantage of the medical visit as a "window of opportunity," that is, an occasion to detect and intervene to stop abuse.
• Make domestic violence a priority—Given time constraints of busy medical practices, many physicians advocated forgoing all but the most urgent medical treatment and instead used the appointment time to address the issue of abuse. They also encouraged colleagues and personnel in their practices to obtain continuing education about domestic violence, child, and elder abuse.

Carolyn Rebecca Block has made recommendations to nurses, doctors, and other service professionals likely to come in contact with battered women on what to look for as indications that the violence may soon escalate to deadly violence in "How Can Practitioners Help an Abused Woman Lower Her Risk of Death?" (NIJ Journal, no. 250). She found that practitioners should evaluate three aspects of the violence:

• The type of past violence—Women who had experienced at least one serious or life-threatening incident, for example, being choked, burned, or threatened with weapons in the past year were at the greatest risk of being killed by their partners. Being choked, burned, or threatened with weapons also indicated a higher risk.
• The number of days since the last incident—No matter how severe the incident of past abuse, women who have been abused within the past thirty days are at greatest risk for being killed.
• The frequency, or increasing frequency, of violence—If violent episodes are increasing, women are at high risk of deadly violence.

an innovative program to help battered women. Collaboration between law enforcement and hospital emergency department personnel produced a novel program to prevent and intervene in domestic violence. This program was developed in Richmond, Virginia, in response to a challenge issued by Mark Rosenberg, the director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. The program, called "Cops and Docs," involves participation of emergency and trauma nurses working "handcuff in glove" with law enforcement personnel. The program was described and praised in the Journal of Emergency Nursing (vol. 27, no. 6, December 2001).

Program personnel are trained together in a variety of techniques, including interviewing victims, collecting and preserving forensic evidence, and gathering and documenting information. In addition to helping to safeguard victims and apprehend and prosecute offenders, the program offers other health benefits to the community it serves. For example, shared emergency department data about substance abuse gives law enforcement personnel additional information to use in efforts to combat drug-related violence and crime.