Appendix B
Health Effects of IPV on Individuals Experiencing IPV Across the Lifespan
Health Effects of IPV on Individuals Experiencing IPV Across the Lifespan Lisa Fedina, PhD
INTRODUCTION
Intimate partner violence (IPV) has been linked to numerous acute and long-term health consequences among women of all backgrounds. Reviews of research on physical health outcomes associated with IPV document common health problems including chronic pain (e.g., back pain, neck pain), cardiovascular conditions (e.g., hypertension), gastrointestinal disorders (e.g., digestive problems, stomach ulcers), neurological problems (e.g., fainting, seizures, traumatic brain injury), gynecological and reproductive health issues (e.g., pelvic pain, urinary tract infections, sexually transmitted disease), and respiratory conditions (e.g., asthma) (Campbell, 2002; Dillon et al., 2013; Stockman et al., 2015; Stubbs and Szoeke, 2022; Wang et al., 2022). Additionally, the mental health outcomes of IPV are well documented and include anxiety, depression, suicidal ideation and behavior, post-traumatic stress disorder (PTSD), and sleep disorders as well as behavioral health challenges such as alcohol and substance misuse (Dillon et al., 2013; Lagdon et al., 2014; Mason and O’Rinn, 2014; Oram et al., 2022). The physical, mental, and behavioral health outcomes and subsequent health care needs among individuals experiencing IPV are often interrelated and highly comorbid (Mason et al., 2014; Mehr et al., 2022).
Individuals experiencing IPV at various points across the lifespan may be at greater risk for specific health conditions. Understanding age-specific
effects of IPV at various points in development can guide immediate health care responses to support health care needs of survivors in various age groups. Relatedly, understanding age-related differences in health outcomes can help tailor health care responses during public health emergencies. This paper addresses two aims: (1) identifies and describes the long-term health effects of IPV among women, including its additive effects on health throughout the lifespan; and (2) discusses the health effects of acute IPV in different age groups including age-related differences in those health effects. Studies on racial/ethnic minority, sexual minority, and transgender women as well as other populations of women (e.g., women with disabilities, pregnant women) are also highlighted to identify health effects and needs within populations of women, and to elucidate potential health inequities associated with IPV at various points across the life course.
LONG-TERM HEALTH EFFECTS OF IPV
Overview
Systematic review and meta-analysis studies on chronic health conditions and health behaviors (e.g., substance use) associated with IPV among adult women identify several key considerations when assessing the knowledge base on long-term health effects of IPV (Banjar et al., 2022; Dillon et al., 2013; Pate and Simonic, 2022; Stubbs and Szoeke, 2022; Stockman et al., 2015; Wang et al., 2022). First, many studies on IPV and health outcomes primarily assess only physical forms of IPV, with fewer studies including measures of sexual violence and psychological abuse (Stubbs and Szoeke, 2022). Psychological forms of IPV are often overlooked in screening and intervention, yet studies that include assessments of psychological IPV link psychological IPV to many of the same chronic health problems associated with physical IPV, including hypertension, diabetes, gynecological symptoms, and HIV (Al-Modallal, 2016; Campbell et al., 2018; Jewkes et al., 2015). Second, studies consistently show a dose–response relationship between IPV and health outcomes. More frequent or severe exposure to IPV as well as exposure to multiple types of IPV (e.g., physical, sexual, psychological, coercive control, stalking) result in compounded and more serious health problems over time (Dillon et al., 2013; Pate and Simonic, 2022; Stubbs and Szoeke, 2022). Finally, early studies on health outcomes associated with IPV have primarily used cross-sectional study designs, which has presented challenges in disentangling health effects of IPV and establishing temporality between victimization and subsequent health outcomes. However, a considerable number of longitudinal studies now exist that are consistent with findings in cross-sectional studies and establish temporal pathways between IPV and health outcomes, particularly for the health outcomes of somatic
symptoms, sleep disorders, HIV, and aspects of mental health including depression, anxiety, PTSD, and substance use disorders (Dillon et al., 2013; Mehr et al., 2022).
Cardiovascular Risk/Disease
Several cardiovascular risk factors have been associated with IPV victimization, including obesity, low high-density lipoprotein levels and high triglyceride levels, and hyperlipidemia (Al-Modallal et al., 2016; Bosch et al., 2017; Mason et al., 2021, 2017; Stene et al., 2013). Halpern and colleagues (2017) assessed inflammatory cardiovascular disease biomarkers in a small sample (N = 37) of African American (n = 19) women and non-African American women (n = 18) and found significant correlations between IPV and multiple risk markers. In this same study, researchers found significant disparities by race/ethnicity in women exposed to IPV, including increased expression of inflammatory mediators CRP, IL-1β, IL-6, and MMP9 among African American women (Halpern et al., 2017). One study examined differences in health outcomes among sexual minority women (Anderson et al., 2014). In this study, researchers examined differences in cardiovascular health risks among heterosexual (n = 484) and lesbian women (n = 394) experiencing IPV and found that although lesbian women reported higher rates of adult physical and sexual assault than heterosexual women, no significant differences were found in physical health (i.e., a combined report of hypertension, thyroid conditions, heart disease, and/or diabetes) between lesbian and heterosexual women (Anderson et al., 2014).
In one large data mining study of electronic health records, researchers found significant associations between IPV and cardiovascular disease (Karakurt et al., 2017). Another study by Wright and colleagues (2018, 2019) found that IPV increased 30-year cardiovascular disease by 1 percent; however, these effects were mitigated after controlling for race/ ethnicity, health insurance status, and other social and economic factors. Using data from the Nurses’ Health Study II (N = 51,431), Mason et al. (2012) found that women reporting severe emotional abuse had a 24 percent increased rate of hypertension compared to women without emotional abuse; however, no significant relationship was found between physical and sexual IPV and hypertension after controlling for confounding variables. Stubbs and Szoeke (2022) note that the relationship between IPV and cardiovascular health is likely a pathophysiological connection, and that psychological IPV, in particular, can affect blood pressure and lead to subsequent health risks.
Endocrine System
Endocrine-related health outcomes assessed in studies of IPV include diabetes, stress and cortisol, and menopause symptoms (Al-Modallal et al., 2016; Basu et al., 2013; Dillon et al., 2013; Gibson et al., 2019; Kim et al., 2015; Mason et al., 2012). In a sample of 238 Palestinian refugee women, Al-Modallal et al. (2016) found that women exposed to psychological IPV were significantly more likely to be diagnosed with diabetes than women without IPV exposure (21 percent vs. 13 percent, respectively). Similar patterns were found in Mason et al.’s (2012) study of 51,431 women from the Nurses’ Health Study II, such that women exposed to IPV had significantly higher rates of diabetes even after controlling for other variables and that severe psychological abuse was most strongly associated with diabetes.
Research with smaller samples of women suggest that cortisol-related indicators including lowered cortisol awakening response, dissociative symptoms, flattened diurnal cortisol patterns, and higher midday cortisol have all been positively correlated with IPV (Basu et al., 2013; Kim et al., 2015). In a cross-sectional analysis of women 2,016 women ranging from 40 to 80 years old, Gibson et al. (2019) found that physical and emotional IPV were each associated with increased risk for night sweats and dyspareunia and that sexual IPV was associated with other vaginal symptoms (e.g., dryness, irritation). More research is needed on the effects of IPV on cortisol and mechanisms between IPV and endocrine health, including mediating roles of hormonal changes particularly during menopause (Stubbs and Szoeke, 2022).
Sexual and Reproductive Health
Gynecological symptoms (e.g., pain or burning during urination, pain during intercourse), sexually transmitted disease and infections (STDs/STIs), and HIV/AIDS are all well-established health outcomes of IPV in samples of women from developed and developing countries (Dillon et al., 2013; Stubbs and Szoeke, 2022). An early systematic review of studies (N = 51) published from 1996 to 2006 assessing physical IPV and sexual health found that across numerous studies, IPV was consistently associated with sexual risk behaviors (e.g., inconsistent condom use), risk of STIs, unplanned pregnancy or induced abortion, and gynecological symptoms primarily in the form of chronic pelvic pain (Coker et al., 2007).
Stockman et al.’s (2015) systematic review of studies (N = 36) on racial/ethnic minority women found that IPV was associated with multiple symptoms, including discolored vaginal discharge, burning during urination, unwanted pregnancy, irregularity in menstruation, sexual risk-taking
behaviors (e.g., having multiple sex partners, inconsistent condom use), and increased risks for HIV among African American, Latina, and South Asian immigrant women. Further, the research on IPV and HIV status among women suggests that women experiencing IPV are not only at greater risk for contracting HIV, but also for suffering worse outcomes and reduced immune states (e.g., lower CD4+, CD8+, T cells among HIV positive samples of women) (Jewkes et al., 2015; Stubbs and Szoeke, 2022). Researchers have attributed HIV as well as STIs/STDs to reduced sexual decision making and free choice victims have in violent and coercive relationships (Decker et al., 2014; Josephs and Abel, 2009; Stockman et al., 2015).
Neurological Symptoms
Compared with other health outcomes, fewer studies have assessed neurological health outcomes associated with IPV, and among extant studies the findings are mixed. In Dillon et al.’s (2013) review of qualitative and quantitative studies (N = 75), headaches, migraines, and dizziness were commonly reported in studies and documented as long-term chronic problems in some samples. Karakurt and colleagues’ (2017) study of electronic health records found that commonly reported symptoms among patients with histories of IPV included loss of consciousness, dizziness, disorientation, and memory problems. Headache symptoms have also been documented in samples of women exposed to both physical and psychological IPV, suggesting that psychological abuse may have similar effects on neurological health as physical violence resulting in injury (Stubbs and Szoeke, 2022).
Although research is limited, neurological symptoms associated with IPV may be associated with traumatic brain injury (TBI). In a study of 901 women of African descent, Campbell et al. (2018) found that abused women with a probable TBI were more likely to report increased central nervous system symptoms than abused women without TBI, even after controlling for mental health symptoms (e.g., depression, PTSD). Additional symptoms associated with IPV in Campbell et al. (2018) included blackouts, vision and hearing problems, memory loss, and difficulty concentrating.
Other studies have found similar patterns in smaller samples of service-seeking women and general population convenience samples of women (Maldonado-Rodriguez et al., 2021; Raskin et al., 2023; Valera and Kucyi, 2017). Maldonado-Rodriguez et al. (2021) found that in a sample of 40 women with histories of IPV, brain injury load significantly affected some cognitive functions (i.e., number of targets hit, average hand speed); however, mental health symptoms including PTSD, anxiety, and depression also contributed to these and other cognitive functioning measures. Similarly, Valera and Kucyi (2017) conducted clinical interviews, functional
magnetic resonance imagings, and neuropsychological measures with 20 women experiencing TBI resulting from IPV and found that greater TBI severity was associated with resting-state functional connectivity and poor performance on memory and learning-related cognitive tasks. In another recent study, Raskin et al. (2023) recruited survivors of IPV (n = 50) and sexual assault (n = 35) seeking formal services and a comparison group of women without victimization histories recruited from online advertisements (n = 50). In this study, researchers found survivors of IPV with potential TBI scored lower on memory and executive functioning than survivors of sexual assault and women without victimization histories and that cognitive changes were greatest for women experiencing non-fatal strangulation (Raskin et al., 2023).
Some research has explored the long-term effects of non-fatal strangulation on neurological symptoms and cognitive functioning. Monahan et al. (2022) conducted a review of 55 studies addressing short- and long-term effects of IPV-related non-fatal strangulation and found that survivors of non-fatal strangulation report post-concussive symptoms including fatigue, headaches, vision problems, mood disturbances, and sleep problems. In this same review, one study found that survivors of chronic non-fatal strangulation reported more severe symptoms (e.g., lightheadedness, memory loss) than survivors who did not experience chronic non-fatal strangulation. Overall, Monahan and colleagues (2022) note significant challenges in characterizing cognitive consequences resulting from IPV non-fatal strangulation and that few studies on IPV include non-fatal strangulation when discussing IPV-related TBIs, and among existing studies most do not separately report impacts for both strangulation and TBIs.
Chronic Disease
Chronic diseases associated with IPV include gastrointestinal disorders, respiratory diseases, chronic pain, fibromyalgia, and liver and urinary health problems (Al-Modallal, 2016; Banjar et al., 2022; Dillon et al., 2013; Stubbs and Szoeke, 2022; Wang et al., 2022). Banjar et al. (2022) conducted a systematic review of studies (N = 15) on IPV and functional gastrointestinal (FGID) symptoms and found increased risks for FGID symptoms for physical, sexual, and psychological IPV when assessed as singular and combined exposures. In Wang and colleagues’ (2022) review of studies (N = 37) on IPV and asthma, findings suggest evidence for increased rates of asthma among women exposed to IPV, including increased asthma exacerbations and worsened asthma control. In smaller studies, some evidence suggests that women exposed to IPV report increased risks for temporomandibular joint disorder and premature telomere shortening indicative of cellular aging and neoplasms (Chandan et al., 2019; Karakurt et al., 2017; Whiting
et al., 2017). A review by Cook et al. (2011) on IPV among older adults found evidence for long-term impacts of trauma exposure in older adult women samples including pre-mature aging, premature mortality, cognitive functioning, and dementia. In a sample of women (average age 76) with probable Alzheimer’s disease, researchers found that 17.5 percent of women had reported spousal abuse with head trauma (i.e., being struck in the head five or more times and losing consciousness on two or more occasions), with the majority of women experiencing abuse nearly 30 years earlier (Leung et al., 2006).
Mental and Behavioral Health
While there is variation in prevalence of IPV across demographic and cultural contexts, IPV is consistently associated with a range of mental health issues. Dillon et al.’s (2013) review of studies (N = 75) on mental health outcomes associated with IPV found consistent associations between victimization and increased depression, PTSD, anxiety, self-harm, and sleep disorders. A more recent review of studies (N = 29) demonstrates worsened mental health symptoms associated with lifetime IPV, with depression, anxiety, PTSD, and substance misuse most frequently assessed in the research (Pate and Simonic, 2022). Physical, sexual, and psychological IPV have all been independently associated with worsened mental health symptoms (Nur, 2012). However, some research shows that women experiencing stalking (accompanied with fear and threat) is specifically associated with worsened post-traumatic stress severity even after accounting for other forms of IPV and that women with stalking histories experience twice the rate of hyperarousal symptoms (Fleming et al., 2012).
Additionally, certain populations of women may experience compounded mental and behavioral health problems associated with IPV victimization. A review of studies (N = 13) on mental health outcomes associated with IPV among women in the military suggests stronger evidence for an association between IPV and depression and alcohol problems than between IPV and PTSD in this population of women (Sparrow et al., 2017). This same study found differences between active-duty service members and veterans, such that IPV and alcohol misuse were more consistently found among active-duty samples whereas IPV and mental health problems were found more frequently among veterans. Additionally, psychological IPV was more commonly associated with depression and alcohol problems than physical/sexual IPV among active-duty personnel (Sparrow et al., 2017). In another study, Coston (2019) analyzed data from the National Intimate Partner and Sexual Violence Survey and found that women survivors of IPV who had a disability were more likely to report their mental health as
poor, difficulty sleeping, difficulty attending school or work, and PTSD than victimized women without disabilities.
AGE-SPECIFIC ACUTE HEALTH EFFECTS
Adolescents and Young/Emerging Adults (18–29)
Research on the acute health effects of IPV at adolescent and young/ emerging adult developmental stages largely include sexual/reproductive health symptoms and behavioral health/mental health symptoms (Exner-Cortens et al., 2013; Glass et al., 2003; Hanson et al., 2010; Reuter et al., 2017). Sexual and reproductive health outcomes associated with IPV at this developmental stage include increased risk for STIs, self-reported HIV status, pregnancy, and sexual risk-taking behaviors such as inconsistent condom use and having multiple sexual partners (Bonomi et al., 2013; Brennan et al., 2012; Fedina et al., 2016; Glass et al., 2003; Hanson et al., 2010; Hill et al., 2019).
Co-occurring forms of IPV likely contribute to poor sexual and reproductive health outcomes, including sexual risk-taking behaviors. For example, Hill et al.’s (2019) study with a clinical health care sample of 550 girls ages 14 to 19 found that respondents who reported both reproductive coercion and relationship abuse were more likely to have had multiple sexual partners, using fewer birth control methods, and to have a partner at least 5 years older. Notably, Glass’s review (2003) of studies on adolescent dating violence revealed that several studies found low birthweight in adolescent pregnancies associated with IPV, which researchers note may be due to abusive partners pressuring girls not to gain weight during their pregnancy.
Although limited, some research has documented physical injuries associated with IPV in studies of adolescents and young adults. Tharp and colleagues’ (2017) analyzed data from a randomized control trial with adolescents in 8th through 12th grade enrolled in the Safe Dates prevention program. Researchers found that risks for physical injury associated with IPV were elevated for girls and for victims who experienced all three forms of IPV (physical, sexual, psychological). Researchers also found that girls in 8th grade were at highest risk for injury, and that injury risk declined at higher grade levels (Tharp et al., 2017).
Mental and behavioral health outcomes associated with IPV include substance use, depression, suicidal ideation, suicide attempts, smoking and heavy drinking, and eating disorders (Bonomi et al., 2013; Exner-Cortens et al., 2013; Glass et al., 2003; Hanson et al., 2010). In Hanson’s (2010) analysis of the Youth Risk Behavior Survey (YRBS), researchers found that female adolescents exposed to IPV victimization were more likely
to engage in risky sexual behavior and substance abuse, to contemplate suicide, and to engage in violent behavior at school than girls without IPV victimization. Similarly, Exner-Cortens et al. (2013) analyzed three waves of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) and found that female participants who reported emotional and/or physical IPV had increased rates of depression, suicidal ideation, smoking, and heavy drinking at adolescent and young adult time periods. Another study of women ages 18–19 (N = 726) found that past psychological IPV was associated with increased psychological distress, whereas physical IPV was associated with depression, loneliness, and stress (Shen and Kusunoki, 2019). Mental and behavioral health effects of IPV have also been documented in sexual and gender minority populations within this age group. A study by Whitton et al. (2019) found that IPV victimization was associated with increased psychological distress among lesbian, gay, bisexual, transgender, queer, and other (+) sexual and/ or gender minority identity (LGBTQ+) youth ages 16–20 across 5 years of data. In this same study, experiencing physical IPV was also associated with marijuana use sustained across several waves of data, with sexual risk behaviors associated with both physical and sexual IPV in the past six months (Whitton et al., 2019).
Midlife (30–64)
Acute health effects of IPV in midlife include physical injuries primarily to the head and neck, anxiety and depression, post-partum depression, substance misuse, somatic symptoms including headaches, and sexual/ reproductive health issues including pregnancy-related diagnoses and STIs (Bachhus et al., 2018; Eaton et al., 2016; Kishton et al., 2022; Wu et al., 2010).
In a study by Eaton et al. (2016), researchers analyzed electronic medical records in two age cohort samples of adult women in midlife (i.e., ages 45–53 vs. ages 54–64). Among both age groups, anxiety symptoms, psychiatric problems other than anxiety and depression, headaches, and injury to the head/neck/jaw were all significantly associated with an IPV ICD-9 diagnosis. Notable differences were found specifically for women of childbearing age, such that reproductive health concerns were significantly associated with a IPV diagnosis. Mental health symptoms were most strongly associated with an ICD-9 IPV in women ages 45–53 compared with women ages 54–64 (Eaton et al., 2016).
Similar patterns were found by Kishton and colleagues (2022), who analyzed administrative claims from the United Health Clinical Research Database to compare health outcomes among privately insured women with histories of IPV and those without histories. In this study, over twice
as many women with histories of IPV had a mental health diagnosis claim, and they also had increased rates of substance use disorder diagnoses, pregnancy-related diagnoses, and STIs (Kishton et al., 2022). Similar to the findings in Eaton et al. (2016), there was a slightly higher percentage of pregnancy-related claims in age-bearing populations (age 30–39). Additionally, women with histories of IPV had comorbidity scores nearly three times greater than women without IPV histories.
As previously discussed, mental and behavioral health symptoms associated with IPV victimization can persist over the life course as long-term health consequences of IPV. However, research also demonstrates acute effects on mental and behavioral health in studies of women in midlife. Bacchus et al.’s (2018) systematic review and meta-analysis of cohort studies (N = 35) examined past-year IPV exposure and mental and behavioral health outcomes among adult women (Bacchus et al., 2018). In this review, eight studies found a positive association between recent IPV and subsequent depressive symptoms, five studies found positive associations between depressive symptoms and subsequent IPV, and five studies found associations between IPV and subsequent postpartum depression. In some studies IPV was found to have a bidirectional relationship between recent IPV and substance use (i.e., hard drug use, marijuana use). However, there was no evidence of an association between recent IPV and alcohol use or STIs. Notably, very few studies measuring recent IPV exposure included measures of substance use, alcohol use, and STIs (Bacchus et al., 2018).
Older Adulthood (65+)
While older adult women experiencing IPV have many of the same mental health outcomes as younger women, they also face additional challenges that compound health outcomes, including decreased physical health and physical mobility, decreased financial stability, loss of independence, and challenges in facing the end of their life (Cook et al., 2011; Roberto et al., 2013). Systematic reviews of research on IPV among older adult women identified strong associations between IPV exposure and mental health symptoms including depression, loneliness, and isolation (Cook et al., 2011; Knight and Hester, 2016). Some evidence also suggests associations between IPV victimization and cognitive challenges, functional impairment, dementia, and greater likelihood of premature death (Cook et al., 2011; Knight and Hester, 2016). Roberto et al. (2013) conducted an integrated review of studies (N = 57) on IPV in late life and found that older women experiencing IPV report increased risks for chronic pain, digestive issues, heart problems, bone and joint concerns, and physical injuries in samples of women 60 and older and increased risk for HIV in samples of women 50 and older (Roberto et al., 2013).
Notably, Knight and Hester (2016) found that much of the research on elder abuse does not differentiate between intimate and non-intimate partner abuse. This presents challenges to distinguishing acute health effects of IPV from other forms of abuse (e.g., non-intimate physical, sexual, psychological, and financial abuse) experienced in late life. Despite these limitations, data suggests that many older adults experience abuse from intimate partners. For example, a nationally representative study of older adults ages 70 and older (N = 2,185) found that among those reporting physical and/or psychological abuse in the past year, 23 percent were abused by intimate partners only, 20.8 percent were abused by both intimate and non-intimate partners, and 56.2 percent were abused by non-intimate partners only. In this study, older adults reporting past-year abuse were more likely to have been currently romantically involved, have current activity limitations, and to experience health care insecurity (i.e., needed to see a doctor in the past year but could not afford it) (Rosay and Mulford, 2017).
Age-Related Differences in Acute Health Effects
Overall, few studies have specifically assessed age-related differences in acute health outcomes associated with IPV. In Bacchus et al.’s (2018) review of studies on past-year IPV and physical health, studies included age primarily as a control variable but did not examine group differences or test interaction effects by age in health outcomes associated with IPV. Some systematic reviews, however, have noted differences in mental health outcomes associated with IPV by age group within studies. Cook et al.’s (2011) review found that psychological symptoms were lower among older adult women reporting IPV than among women in young adulthood and midlife. Similarly, an updated review by Knight and Hester (2016) found that most studies reported lower levels of psychological distress among older adult women experiencing IPV in comparison to younger victims. Knight and Hester (2016) also noted that very little research has compared the impact of IPV on health across age cohorts, but that some evidence suggests that the physical health of older adult victims may be more severely affected than younger victims.
In an older study by Wilke and Vinton (2005), researchers analyzed data from the 1995–1996 National Violence Against Women Survey data examining health outcomes among cohorts of women ages 18–29, 30–44, and 45 and older. In this study, younger women were more likely to report drug use than older women, and women ages 45 and older were more likely to report chronic health conditions and the use of sedatives, antidepressants, and tranquilizers in the past month than women in younger cohorts. Although the health consequences were similar overall for all age
groups, the authors found that older women faced more prolonged abuse, and many reported injuries resulting from recent violence.
Using data mining methods, Yilmaz et al. (2023) analyzed data from a private electronic health record database of ambulatory visits to compare health outcomes among women ages 18–65 and older adult women ages 65 and older. Researchers found that poisoning and substance abuse were significantly comorbid with IPV in older women, in addition to numerous mental health diagnoses (i.e., major depression, mood disorder, anxiety, chronic PTSD), alcohol intoxication, and continuous opioid dependence. In particular, older victims of IPV suffered from major depression at four times the rate of younger IPV victims. Additionally, limb deformity and other musculoskeletal conditions were more common among older adult women—an outcome that may be due to IPV injuries, including IPV-related fall injuries. Neoplasm of the stomach was also found to be a significant differential comorbidity among older adult women (Yilmaz et al., 2023).
In a retrospective analysis of data from the 2005–2015 National Electronic Injury Surveillance System (NEISS) All Injury Program (AIP), Khurana and Loder (2022) compared the demographics and injuries of older (60 years or older) and younger (under age 60) IPV patients reporting to emergency departments. Older adults were significantly more likely to sustain trunk fractures, trunk strain/sprains, lacerations, and upper extremity injuries compared with younger patients, and they also had greater hospital admission rates. The younger age cohort of adults were more likely to experience contusion/abrasions, upper extremity strains/ sprains, and fractures of both the upper and lower extremities. Overall, the authors suggest that younger victims may be more likely to sustain upper extremity fractures due to being able to physically fight back or resist abusers instead of protecting their trunk or face and may be less likely to have lower extremity fractures due to their physical ability to flee from abusers (Khurana and Loder, 2022).
SUMMARY AND CONCLUSIONS
Systematic review and meta-analysis studies have established multiple long-term health outcomes associated with physical, sexual, and psychological IPV among adult women. These include cardiovascular risks, endocrine disorders, gastrointestinal disorders, gynecological and reproductive health issues, and a range of mental and behavioral health-related consequences (e.g., anxiety, depression, PTSD, substance misuse). Additionally, some evidence has linked IPV to long-term neurological health symptoms, which may be connected to TBIs and non-fatal strangulation. However, research in this area has relied primarily on small convenience samples and
does not differentiate between neurological effects of TBIs versus non-fatal strangulation.
The acute health effects of IPV among adolescents and young adults primarily include behavioral health symptoms (e.g., substance misuse), sexual risk-tasking behaviors (e.g., inconsistent condom use), and sexual/ reproductive outcomes including increased risks for STIs and unintended pregnancy. Among studies of women in midlife, the documented acute effects of IPV include physical injuries, sexual and reproductive health impacts (e.g., STIs, pregnancy-related diagnoses), somatic symptoms (e.g., headaches), and mental and behavioral health symptoms (e.g., substance misuse, anxiety, postpartum depression). Research on health outcomes among women in older adulthood finds poor mental and emotional health (e.g., loneliness, isolation, depression), cognitive challenges, functional impairment, dementia, chronic pain, digestive problems, and physical injuries.
Studies testing the age-specific effects of IPV are limited. However, existing research suggests some differences in acute health effects based on age primarily related to physical injuries, mental/behavioral health outcomes, and chronic health conditions. Physical injuries more commonly sustained among older adult women may include upper extremity and trunk-related injuries, whereas younger women may experience more upper extremity strains/sprains and fractures of both upper and lower extremities (Khurana and Loder, 2022). Significant age group differences and more severe impacts have been found in mental health diagnoses, alcohol use, substance dependence, and musculoskeletal conditions among older adult women victims ages 65 and older when compared with younger women victims under the age of 65 (Yilmaz et al., 2023). Although dated, one survey study using nationally representative data found significant differences in chronic health conditions and substance use among women aged 45 and older compared with women in younger age cohorts (Wilke and Vinton, 2005).
Notably, there is very little data on potential racial/ethnic differences in acute and long-term health outcomes associated with IPV among women. Stockman’s review (2015) on IPV among ethnic minority women noted that most studies did not have sufficient power or conduct data analyses to test group differences. Studies included in multiple systematic reviews (e.g., Bacchus et al., 2018; Pate and Simonic, 2022; Stubbs and Szoeke, 2022) primarily include race/ethnicity as a control variable, in addition to age (as previously noted), without exploring potential differences in health outcomes among women. Relatedly, few studies have examined the health effects of IPV among sexual minority women or have tested for potential differences in health outcomes based on sexual orientation in addition to other pertinent sociodemographic factors (e.g., disability status, socioeconomic indicators) that act as social determinants of health (Davis et al., 2020; Javed et al., 2022; Logie, 2012).
Communities of color, sexual and gender minority populations, and lower-income communities experience increased stressors and discrimination that ultimately lead to health inequities and that also likely exacerbate acute and long-term health effects of IPV among survivors from minoritized backgrounds (Adams and Campbell, 2012; Davis et al., 2020; Stockman et al., 2015; Waltermaurer et al., 2006). Indeed, the social and economic factors contributing to both poor health outcomes and IPV victimization represent a complex and interrelated set of relationships. Structural inequities related to access and discrimination in the areas of education, employment, and housing in particular have been well-researched in the general population and linked to many of the same poor health outcomes associated with IPV (Davis et al., 2020; HealthyPeople 2030, n.d.). Many women experiencing IPV face increased risks for homelessness, housing insecurity, and barriers to accessing health care, which in turn can increase risks for poor health outcomes among survivors (Fedina et al., 2022; Jagasia et al., 2022). Additionally, barriers to accessing affordable and culturally responsive health care affect the acute and long-term effects of IPV. Reviews of research indicate that many survivors report experiences of discrimination and stigma from health care providers (e.g., not being able to privately discuss abuse with health care professionals, being left out of decision-making processes, being dismissed) as well as a lack of availability of inclusive and affirming services, particularly for sexual and gender minorities (Papas et al., 2023; Robinson et al., 2021). Discriminatory experiences not only lead to increased stress, but also influence survivors’ decisions to seek needed health care in the future. Researchers highlight the need to attend to stigma and discrimination and broader social, political, cultural, and structural barriers influencing patient–provider communication and survivors’ decisions to seek health care in order to prevent adverse health outcomes, particularly for women disproportionately affected by both health inequities and IPV victimization (Pappas et al., 2023; Stockman et al., 2015).
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