Unsafe at home: The misery of intimate partner violence

The statistics are staggering — and so is the toll on society. Throughout the world, roughly 27 percent of women ages 15 to 49 experience violence by intimate male partners at least once during their lifetimes. The scourge costs society trillions of dollars and seriously harms children’s mental health.

“Each case of violence in a woman’s life is a tragedy for herself and for those around her, affecting not only the woman and her health and well-being, but also her family and community,” write two public health researchers in the 2024 Annual Review of Public Health. In their article, Susan B. Sorenson of the University of Pennsylvania and Heidi Stöckl of the Ludwig Maximilian University of Munich detail the scope of this urgent public health issue and how it might be more vigorously addressed.

In 1986, Sorenson began teaching the first violence-prevention course in a US school of public health. She has authored more than 150 publications, many of them focused on the epidemiology and prevention of violence against women and, since retiring from her university position, has written a guide for parents of college students who have suffered a sexual assault.

Stöckl’s research focuses on the epidemiology of intimate partner violence and human trafficking, the global prevalence of intimate partner homicide and the perpetrators of child homicide, and trafficking for sexual exploitation and forced marriage. She conducted the first prevalence study on intimate partner violence during pregnancy in Germany and is currently investigating violence during pregnancy in Bangladesh.

Knowable Magazine recently interviewed Sorenson and Stöckl. This conversation has been edited for length and clarity.

You have devoted much of your careers to studying violence against women. What led you to this topic?

Susan B. Sorenson: I grew up in a safe and loving environment, but at some point, I realized that wasn’t the case for everyone. At first, my focus was on individuals, but as I learned more, I came to recognize there is a bigger, more systemic picture that I wanted to explore.

Heidi Stöckl: I came to the topic from a human rights angle. I was always interested in human rights activism, and during an internship I had at Amnesty International, they launched the women’s rights campaign — I guess I was sold by then. Women make up 50 percent of the population, but their issues do not get the same attention.

Intimate partner violence is an age-old problem. Why was it a timely topic for this recent review?

Stöckl: It may be age-old, but not much has been done to address it. In many places of the world, it’s always been considered an issue to be dealt with behind closed doors. But the availability of data today shows just how serious the issue is. The other point is that we now know what works to prevent it; we have interventions and programs that work.

Sorenson: Many global organizations and researchers around the world have collaborated to get us to a point where we have some very strong data. The Violence Prevention Information System at the World Health Organization has done an excellent job, compiling a database of nearly 2,000 studies. Their website identifies 12 prevention strategies, including school programs about dating violence, bystander intervention training, and microfinance — and nine “response strategies,” meaning programs for after violence occurs, such as shelters, home visiting and psychological therapy for survivors and children.

Additionally, the United Nations has a database of more than 10,000 measures that nearly 200 countries have taken to address violence against women.

The phrase “intimate partner violence” has come to replace terms such as wife-beating, spousal abuse and domestic violence. How should the problem best be defined?

Sorenson: “Intimate partner violence” is a way to be more specific about what we’re trying to measure. Domestic violence can have multiple meanings. Spouse abuse is another term that isn’t used much these days, given that such violence isn’t limited to marriages.

As we write in our review, intimate partner violence refers to “any behavior by a current or former male intimate partner, within the context of marriage, cohabitation, or any other formal or informal union, that causes physical, sexual, or psychological harm.” The World Health Organization says such behavior includes physical aggression, such as slapping, hitting, kicking and beating; sexual aggression, such as forced intercourse; and psychological abuse, such as intimidation, monitoring movements and other controlling behaviors.

I notice that in your definition of intimate partner violence, you specify violence by males. Yet one major US survey found that about two in five men have reported experiencing “contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime.” Aren’t females also violent sometimes?

Sorenson: That’s correct: There can be female-on-female violence, as well as male-on-male and female-on-male violence, in an intimate relationship. But it’s a smaller part of the overall issue and, at this point, we have far less systematic data about it.

Why do you describe violence against women — and, more specifically, intimate partner violence — as a global public health issue?

Sorenson: Decades of research document a wide range of negative health outcomes. Being berated, threatened, assaulted or otherwise harmed is simply not health-enhancing. It’s a major cause of disability in and of itself while also contributing to conditions such as depression, HIV and traumatic brain injury.

There are huge financial costs, every year, which communities must pay. In 2012, in the US alone the costs of medical care, lost productivity, criminal justice and more due to intimate partner violence were estimated at $3.6 trillion over the victims’ lifetimes.

What does it mean to consider intimate partner violence as a global public health issue? How does that change the way it is treated?

Stöckl: It means it’s a problem that exists in every country, is highly prevalent and affects the lives of many women and children, with multiple other health consequences. Over the past two decades, we’ve shown the devastating effect it has on women’s mental and physical health and the impact it has on children. For instance, when women experience violence during pregnancy, their children can have long-term effects in terms of attention deficits and attachment issues.

Sorenson: Women are at risk of violence by a male intimate regardless of where they live in the world. In that way, intimate partner violence is like environmental concerns, infectious diseases and other problems that don’t stay within geographic or national boundaries. Acknowledging the reality that the risk goes beyond a specific locale can help lead to international collaboration to protect health through prevention and intervention.

Intimate partner violence is obviously a complex problem with a complex range of potential solutions. Which strategies have you found to be most effective?

Sorenson: There are so many ways you can intervene, with many of them backed up by credible studies. We describe some of these in the review.

Changing a woman’s financial situation can help quite a lot. We’ve long known that there are strong links between poverty and all kinds of violence. So, microfinance programs, in which low-income women can get access to small amounts of capital to start small businesses, have been very promising. For example, in the early 2000s, in villages in the rural Limpopo province of South Africa, researchers carried out a randomized controlled study, known as IMAGE (Intervention with Microfinance for AIDS and Gender Equity). They recruited 6,576 low-income women and men who were divided into three groups. One of the groups received microfinance loans and attended twice-a-month trainings that addressed gender roles, community mobilization and much more. In that group, intimate partner violence was reduced by 55 percent, according to a report in the Lancet in 2006.

Since then, many more well-designed studies have linked microfinance programs with less intimate partner violence. A 2023 review of 10 randomized clinical trials, with a total of 16,136 participants, published in JAMA Network Open, concluded that microfinance interventions can reduce psychological and emotional abuse as well as controlling behaviors.

In the United States, we’ve seen increasing evidence about the effectiveness of bystander intervention education for college and high school students. One popular evidence-based program known as “Green Dot” uses workshops and social marketing to train students in the skills they need to intervene when they see signs of violence.

Stöckl: The kinds of prevention efforts that work will obviously depend on where they take place. In low- and middle-income countries, where a lot of the work I’m doing takes place, I’d argue strongly in favor of couples’ interventions and tying empowerment programs like cash transfers to gender training to prevent violence from happening as a backlash.

What are really important are community interventions that tackle both women and men and norms in society, as a holistic approach. In the review, we write about the SASA! Study in eight communities in Kampala, Uganda. SASA means “now” in Kiswahili and is also an acronym for the phases of the approach: Start, Awareness, Support and Action. From 2007 to 2012, the program trained a cadre of activists who raised awareness among their friends, families and colleagues. This approach has helped reduce intimate violence and has since been replicated in 15 countries.

We definitely also need more investment in preventing violence by working with men, particularly with the most at-risk groups, such as men who abuse alcohol.

Let’s talk about a specific kind of intimate partner violence, namely homicide. The UN Office on Drugs and Crime reported that 51,000 women and girls were killed by an intimate partner or family member in 2023. But apparently, homicides connected with intimate partner violence have dropped a lot in the United States since the 1970s. What’s that about?

Stöckl: The drop in the US is really impressive and also very telling about the gendered patterns of intimate partner homicide. It’s driven mainly by fewer men being murdered by their partner. We’ve also seen a drop in homicides of women, but it’s, by far, not as steep. So what’s going on?

Criminologists have identified several key changes at the societal level that help explain this. Women mainly kill their partners while in a relationship with them, while men often do so during separation or afterwards. So that means a lot of the societal changes have been important. For example, marrying later in life reduces the risk of this type of homicide, which mainly occurs early in life. Other factors include women’s employment, less stigma about separation and, of course, the greater availability of domestic violence shelters, hotlines and other prevention measures. These have all worked in favor of men in terms of homicide risk, as marriages that weren’t working could be dissolved.

Sorenson: Although all that is true, it’s obvious that empowering women isn’t enough. We need to work more on interventions addressing men who kill their partners.

Can you think of some ways in which this problem could actually get worse?

Sorenson: Oh, yes, and I’ll tell you two ways this could happen. As global migration increases, women who are fleeing war and civil unrest, famine, and environmental disasters are at heightened risk. The community in which they were embedded has been torn apart and their previous support systems no longer exist.

Women are also at risk in refugee camps, where sexual coercion and assault can sometimes be the price for obtaining food and shelter.

Also, consider the increased use of electronic technology. Abusers can increasingly track movements and online activities, harass and shame their intimate partners on social media, and film sexual activity without consent and then post it online. With rare exceptions, tech companies and legislators have avoided regulating these activities.

What might be some of the biggest differences you see between how the US and Europe confront intimate partner violence?

Stöckl: A huge difference is the availability of guns in the US, which makes this violence so much more lethal. It’s just so much easier to kill someone, threaten to kill someone, and make the stakes of leaving an abusive relationship so much higher. Apart from that, I find it hard to make sweeping statements about the US, given how different many states are, both in their culture, their acceptance of violence, and the laws they have. Europe is similarly huge, with big differences between Nordic and southeastern European countries, which have many differences in culture and laws.

Last year, a particularly terrible case of intimate partner violence made the news, in which dozens of men were found guilty of raping Gisèle Pelicot, in assaults arranged by her husband while she was drugged and unconscious. The crimes prompted street demonstrations in France and outrage throughout the world. What did you make of it?

Sorenson: On the positive side, the trial raised a lot of awareness, including about changes we still need to see in laws and in cultural attitudes. Her husband admitted to the crimes, but then a lot of the men said, “I didn’t rape her because he had said it was OK” — as if he had authority over her body. I found it striking that this has happened against the backdrop of a rising manosphere where aggrieved men promote slogans like “Your body, my choice.”

We’ve made such important progress in defining and measuring the scope of intimate partner violence. And we know there are ways to prevent it. Yet this case illustrates how much still needs to be done. Governments really need to move faster to take some of the most promising programs to scale.