SCIENTIFIC REVIEW AND CLINICAL APPLICATIONS

CLINICIANS CORNER

Interventions for Intimate Partner Violence Against Women

Clinical Applications
Karin V. Rhodes, MD Wendy Levinson, MD

N THIS ISSUE, WATHEN AND MACMillan1 present an evidence-based review of interventions for violence against women. Interventions that have been evaluated include screening, referral programs for battered women, court-mandated programs for men who perpetrate partner violence, social programs, and educational interventions. None of the studies have evaluated, in a comparative or a controlled design, the effectiveness of screening for violence in the primary care setting in terms of outcomes for abused women, that is, none of the screening studies met all inclusion criteria for the review conducted by Wathen and MacMillan. Studies of other interventions, including counseling for abused women, effectiveness of shelter stays, and advocacy and counseling following shelter stays, have demonstrated fair, insufficient, or unclear evidence for their effectiveness. Given the lack of sufficient evidence about effective interventions by primary care clinicians, what should physicians do to address intimate partner violence (IPV) in patients? One of the most important questions is whether primary care physicians should screen all women for IPV. Theoretically, screening is a low-risk, low-cost procedure with reliable screen-

Sufficient evidence regarding the effectiveness of physician screening, counseling, and referral for intimate partner violence is lacking. However, even in the absence of sufficient evidence, many medical organizations recommend that physicians make efforts to identify and refer patients who have experienced abuse. This article presents 3 cases that illustrate the interaction between patients experiencing violence in intimate relationships and physicians and other members of the health care team. Suggestions for care are based on guidelines and evidence where available. Resources to assist physicians with referral to appropriate services also are provided.
JAMA. 2003;289:601-605 www.jama.com

ing tools.2 If physicians ask about abuse, women often will disclose the problem,3 and exploratory qualitative research indicates that inquiry about abuse may be of benefit to abused women.4 However, because physician time is valuable, time spent on screening or counseling for nonevidence-based conditions can take time away from other physician tasks of proven benefit. To date, no rigorous studies demonstrate an improvement in outcomes from screening for domestic violence in the primary care setting.5 CASE SCENARIOS
Case Scenario 1

cian did not routinely screen women for abuse but when the clinical diagnosis was confusing, she would ask more detailed questions about the womans social history, including a standard question about potential abuse. In this case, she uncovered years of previously undisclosed emotional and physical abuse by the spouse. The patient was not willing to contact domestic violence supAuthor Affiliations: Health Service Research Group, Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Ill (Dr Rhodes) and the University of Toronto, St. Michaels Hospital, Toronto, Ontario (Dr Levinson). Corresponding Author: Karin V. Rhodes, MD, Section of Emergency Medicine, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, MC 5068, Chicago, IL 60637 (e-mail: krhodes @medicine.bsd.uchicago.edu). Disclaimer: Dr Levinson, who edits the Scientific Review and Clinical Applications column, was not involved in the final review or editorial decision to accept this work for publication. Scientific Review and Clinical Applications Section Editor: Wendy Levinson, MD, Contributing Editor. We encourage authors to submit papers to Scientific Review and Clinical Applications. Please contact Wendy Levinson, MD, Contributing Editor, JAMA; phone: 312-464-5204; fax: 312-464-5824; e-mail: wendy.levinson@utoronto.ca. 601

See also p 589.

A 60-year-old white woman from an affluent upper middle-class suburb came to the emergency department (ED) complaining of chest pain. Her medical record revealed multiple hospitalizations to rule out myocardial infarction and several series of cardiac investigations including a recent cardiac catheterization. The ED physi-

2003 American Medical Association. All rights reserved.

(Reprinted) JAMA, February 5, 2003Vol 289, No. 5

Downloaded from www.jama.com on February 14, 2008

INTERVENTIONS FOR INTIMATE PARTNER VIOLENCE AGAINST WOMEN

port services but gave permission to discuss the abuse with her primary care physician. The patient wanted her primary care physician to know about the violence but she had been too ashamed to volunteer the information. Her primary care physician expressed surprise when the ED physician told him about the abuse history. According to a random representative survey of approximately 2500 women conducted for the Commonwealth Fund in 1993, only 8.4% of women who reported experiencing abuse had ever told a physician, and less than 50% had told anyone.6 According to several studies, the majority of women experiencing IPV present to both EDs and primary care settings with noninjury-related complaints.7,8 In these settings, a history of IPV is rarely identified.9,10 Case scenario 1 is an example of a case finding in which the physician asked direct questions about violence because of a confusing clinical picture. The case finding approach requires the physician to have a low threshold for asking questions about IPV.11 Many medical organizations suggest use of a case finding or use of aggressive case finding with appropriate referrals when domestic violence is detected.12-14 However, some organizations recommend routine screening for IPV based on the prevalence and health burden of IPV and the feasibility of detection with routine screening.15,16 In addition, the identification of an abuse history may influence the assessment and treatment of presenting health concerns. 17,18 Indeed, evidence suggests that failing to detect a patients abuse history may be associated with the use of unnecessary investigations and interventions.19,20 A variety of direct, gender-neutral questions can be useful for addressing the issue of IPV. Some examples are, Has your partner ever hit you, shoved you, or otherwise physically hurt you? or Are you in a relationship with anyone who has hurt or threatened you? If the initial question is answered affirmatively, the physician can follow up with questions regarding the nature of any injuries. In addition, questions re-

garding issues of power and control are helpful to elucidate the nature of the abuse. Example questions include Is your partner very jealous or controlling?; Does your partner keep you away from family and friends?; Can you come and go as you please?; and Has your partner ever made you have sex when you didnt want to? Common sense regarding safety and confidentiality dictates that these questions be asked in a private setting.
Case Scenario 2

A 41-year-old Hispanic woman was seen by her family physician in a large multispecialty clinic. She had been evaluated multiple times in the previous 6 months for asthma and symptoms diagnosed as anxiety or panic disorder. Her physician had twice referred her to a psychiatrist but she had failed to follow-up. On this visit, the physician had a medical student in the office. The student learned that a marital fight had triggered the womans asthma. On questioning by the family physician, the patient admitted to emotional abuse but denied physical abuse. The physician did not have enough time to adequately assess her situation or counsel her but asked the clinics parttime social worker to see her. The social worker reported there was significant physical abuse as well but said the woman was not willing to go into a domestic violence shelter. She had children at home and no independent financial support. The social worker encouraged the woman to talk to her extended family and referred her to a community-based IPV support group. When clinicians discover IPV, what should they do? Qualitative evidence from interviews and focus groups with abuse survivors suggests that even brief discussions with a physician, conducted in a concerned and nonjudgmental fashion, can help to change the way abused women view their situations, even if they do not disclose the abuse.21,22 Women have reported that a discussion with a physician who acknowledged the abuse and validated their self-worth was a turning point in

the process of extrication from an abusive relationship.23 However, the process of changing any health behavior takes time and may happen gradually or not at all.24 The primary care physician may help initiate thoughts of change by discussing the abuse, but patients may take weeks, months, or years before they contact community resources or initiate changes in their lives; and they may never take any such action. In the end, physicians may never know whether they were able to help the patient. While primary care physicians frequently provide brief advice for other health risks, such as alcohol use,25 many do not feel comfortable counseling women about abuse and some may wonder if their efforts are worthwhile.26 Intensive screening programs with onsite advocacy and counseling have been shown to help identify abused women and link them to resources.27 Wathen and MacMillan1 identified a study in which domestic violence advocacy and counseling following a shelter stay were effective in improving abused womens quality of life.28 In addition, civil orders of protection have been found to be effective in decreasing incidents of violence.29 However, abused women will present in various stages of denial or readiness to change their situation.30 Like the woman in case scenario 2, many women may understand their situation and yet choose to remain in the relationship for complex reasons, not the least of which is an increased risk of becoming a homicide victim in the 6 months following a separation from a violent relationship.31 Physicians who try to encourage women to make changes may find this frustrating.32 Ideally, they could rely on trained social workers or domestic violence advocates for help with assessment, counseling, and referral to supportive legal or counseling resources,33 but such trained personnel often are not available. If physicians learn about abuse, they should be prepared to acknowledge it and make appropriate referrals. In addition, physicians should be aware of state reporting or other requirements.

602 JAMA, February 5, 2003Vol 289, No. 5 (Reprinted)

2003 American Medical Association. All rights reserved.

Downloaded from www.jama.com on February 14, 2008

INTERVENTIONS FOR INTIMATE PARTNER VIOLENCE AGAINST WOMEN

A link to these resources is provided in BOX 1 along with other Web-based domestic violence resources to assist physicians in identifying resources in their community.
Case Scenario 3

A 26-year-old black man presented to an urgent care clinic for the third time with back and neck pain. At this visit, he was screened for possible IPV and depression as part of a computer selfadministered health risk assessment, which ideally could be given to all clinic patients. 34 The treating physician received an alert on the risk summary sheet generated by the computer indicating that the patient was possibly involved in partner abuse and that he had symptoms of depression. A chart review showed that, in addition to evaluating the patient for chronic sciatica, another physician had previously documented the patients depression and difficulty controlling his temper. The treating physician prescribed a nonsteroid medication and referred the patient to a specialist to further evaluate his back and neck pain. The physician also documented a difficult home situation and a strained relationship with his current wife and referred the patient to a community mental health program, which included a batterers treatment program. Several studies that have reported that men screened for IPV had similar rates of partner violence as women.35,36 Others have concluded that many of the men disclosing being abused were abusers as well.37,38 Given the cyclic nature of battering and that the majority of partner abuse will never be reported to police,39 primary care physicians need to know what to do if a male patient either directly or indirectly discloses conflict with his partner. These disclosures may occur when asking about a source of stress. In addition, some patients may recognize they have a problem with controlling their anger.40 Typically, perpetrators of violence may portray themselves as the recipients of abuse or present the situation as one of mutual combat.41 These pa-

Box 1. Domestic Violence Internet Resources Centers for Disease Control and Prevention (domestic violence information): http://www.cdc.gov/ncipc/dvp/fivpt/spotlite/home.htm Domestic Violence: A Practical Approach for Clinicians: http://www.sfms.org /domestic.html Family Violence Prevention Fund: http://www.fvpf.org American Academy of Family Physicians: http://www.aafp.org American Academy of Pediatrics: http://www.aap.org American College of Emergency Physicians: http://www.acep.org American College of Obstetricians and Gynecologists: http://www.acog.org US Department of Justice: http://www.ojp.usdoj.gov/vawo/ Same-Sex Domestic Violence: http://www.xq.com/cuav/domviol.htm Stop Abuse for Everyone (SAFE): http://www.safe4all.org/ State Reporting Requirements: http://endabuse.org/statereport/list.php3

tients, or their partners, may ask physicians about programs for marital problems or anger management. Wathen and MacMillan1 identified an important intervention study for men who assaulted their wives, the San Diego Navy Experiment,42 that did not find any difference between treatment and control groups for prevalence of reabuse but did find that on-going surveillance by a commanding officer resulted in low rates of recidivism. A randomized clinical trial by OFarrell and Fals-Stewart has shown a reduction of IPV as a result of couples behavioral therapy for alcoholism.43 However, primary care counseling and referral of men who experience and perpetrate IPV has not been evaluated for either safety or effectiveness, and there are no current recommendations about screening male patients for partner abuse.44 If violent conflict is voluntarily disclosed, the physician should treat the violent behavior in a concerned but matter-of-fact manner, similar to other unhealthy behaviors. This includes assessing the pattern of abuse, risk of lethality, and patient willingness to change. It is important that the physician does not collude in blaming the spouse or partner but holds the perpetrator responsible for their own behavior.40 The physician can focus patient education on the adverse conse-

quences of family violence, for everyone involved, and make appropriate referrals to community resources. THE ROLE OF EXISTING GUIDELINES The 3 cases presented highlight the inevitability that physicians will be caring for patients who may be experiencing violence in their relationships. What are the clinical implications when evidence is lacking? Many medical organizations offer clinical guidelines that are based on both a review of the evidence and the consensus of expert opinion.45 Consensus opinions can take into account both clinical context and professional experience and may be useful when research is lacking.46 Guidelines on domestic violence have been published by the American Academy of Family Physicians (1996),16 the American Academy of Pediatrics (1998),13 the American College of Emergency Physicians (1990-1991),47 the American College of Obstetricians and Gynecologists (1995),12 the American Medical Association (1992),15 and Joint Commission on Accreditation of Healthcare Organizations (1993).48 Most of these recommend a concerted effort at casefinding and a structured approach to documentation and referral. BOX 2 contains a list of most of these medical organizations and their current practice
603

2003 American Medical Association. All rights reserved.

(Reprinted) JAMA, February 5, 2003Vol 289, No. 5

Downloaded from www.jama.com on February 14, 2008

INTERVENTIONS FOR INTIMATE PARTNER VIOLENCE AGAINST WOMEN

Funding/Support: This work was funded by the Agency for Healthcare Research and Quality, grant No. HS11096-02

Box 2. Existing Clinical Practice Guidelines American Academy of Family Physicians Position Statement (2002)16 The guidelines include routine screening, counseling, and advocacy for all patients experiencing family violence. American Academy of Pediatrics (AAP) (1998)13 Advocates a high degree of clinical suspicion and outlines key physical and psychological presenting symptoms. While not directly encouraging routine screening, they provide a brief set of screening questions to be used as part of historytaking. American College of Emergency Physicians (1999)47 Recommends screening and referral for patients who indicate domestic violence may be a problem in their lives. American College of Obstetricians and Gynecologists (1995)12 Similar guidelines to AAP (ie, case finding approach). American Medical Associations Council on Scientific Affairs (1992)15 Guidelines include routine screening in primary care settings and a structured approach to documentation and referral to appropriate community resources. Canadian Task Force on Preventive Health Care (2001)49 Insufficient evidence is available to recommend for or against routine screening for violence against either women who are pregnant or who are not pregnant, or of men. This is distinct from the need for clinicians to include questions about exposure to domestic violence as part of their diagnostic assessment of women. This information is important in caring for the patient and may influence assessment and treatment of other health problems. US Preventive Services Task Force (1996)14 Insufficient evidence is available to recommend for or against using specific screening tools to detect domestic violence, although clinicians should be alert to signs of abuse and may use selective screening questions if indicated.

REFERENCES 1. Wathen CN, MacMillan HL. Interventions for violence against women: scientific review. JAMA. 2003; 289:589-600. 2. Koziol-McLain J, Coates CJ, Lowenstein SR. Predictive validity of a screen for partner violence against women. Am J Prev Med. 2001;21:93-100. 3. Titus K. When physicians ask, women tell about domestic abuse and violence. JAMA. 1996;275:18631865. 4. Gerbert B, Abercrombie P, Caspers N, Love C, Bronstone A. How health care providers help battered women: the survivors perspective. Women Health. 1999; 29:115-135. 5. Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? systematic review. BMJ. 2002; 325:314-318. 6. Columbia University Louis Harris and Associates. The Health of American Women. Prepared for The Commonwealth Fund. New York, NY: Columbia University; 1993. 7. Elliot BA, Johnson MP. Domestic violence in a primary care setting: patterns and prevalence. Arch Fam Med. 1995;4:113-119. 8. Muelleman RL, Lenaghan PA, Pakieser RA. Nonbattering presentations to the ED of women in physically abusive relationships. Am J Emerg Med. 1998; 16:128-131. 9. Campbell JC, Coben JH, McLoughlin E, et al. An evaluation of a system-change training model to improve emergency department response to battered women. Acad Emerg Med. 2001;8:131-138. 10. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women: incidence and prevalence in an emergency department population. JAMA. 1995;273:1763-1767. 11. Elliott L, Nerney M, Jones T, Friedmann PD. Barriers to screening for domestic violence. J Gen Intern Med. 2002;17:112-116. 12. American College of Obstetricians and Gynecologists. ACOG issues technical bulletin on domestic violence. Am Fam Physician. 1995;52:2387-2388, 2391. 13. American Academy of Pediatrics Committee on Child Abuse and Neglect. The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics. 1998;101:1091-1092. 14. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996. 15. American Medical Association, Council on Scientific Affairs. Violence against women: relevance for medical practitioners. JAMA. 1992;267:3184-3189. 16. American Academy of Family Physicians. Violence position paper: AAFP policy and advocacy statement. Available at: http://www.aafp.org /x7132.xml. Accessed January 3, 2003. 17. Drossman DA, Li Z, Leserman J, Toomey TC, Hu YJ. Health status by gastrointestinal diagnosis and abuse history. Gastroenterology. 1996;110:999-1007. 18. Roberts SJ. The sequelae of childhood sexual abuse: a primary care focus for adult female survivors. Nurse Pract. 1996;21(12 pt 1):42, 45, 49-52. 19. Rosenberg HJ, Rosenberg SD, Wolford GL 2nd, Manganiello PD, Brunette MF, Boynton RA. The relationship between trauma, PTSD, and medical utilization in three high risk medical populations. Int J Psychiatry Med. 2000;30:247-259. 20. Zink T. Domestic violence: reality for some of your toughest patients. Minn Med. 1997;80:26-27, 2932. 21. Gerbert B, Abercrombie P, Caspers N, Love C, Bronstone A. How health care providers help bat-

guidelines as well as a information about the level of evidence for interventions from the Canadian Task Force on Preventative Health Care (2001)49 and the US Preventive Services Task Force (1996).14 These guidelines were developed as an acknowledgment that domestic violence is a highly prevalent condition50,51 with significant morbidity,52 mortality,53 and potential for the intergenerational transmission of violence.54,55 CONCLUSION The accompanying review points out that much work remains to be done to establish whether physician screening, counseling, and referral in the primary care setting results in a decrease in violence against women. Domestic violence services need to undergo rigorous evaluation to assess their effect on a variety of

short and long-term safety and quality of life outcomes for battered women and their children. For perpetrators of partner violence, research should focus on evaluating the effectivenss and safety of interventions not only for courtmandated batterers but also for those willing to disclose problems with violence to physicians and other members of the health care team. Nonetheless, physicians will continue to see both women and men who are abused by, or perpetrating, partner violence. Their identification may influence the evaluation of presenting complaints as well as the outcomes of care. Until there are more studies that meet evidence-based criteria, physicians should continue following clinical guidelines, increasing efforts to identify women in violent relationships, and linking them to appropriate community resources.

604 JAMA, February 5, 2003Vol 289, No. 5 (Reprinted)

2003 American Medical Association. All rights reserved.

Downloaded from www.jama.com on February 14, 2008

INTERVENTIONS FOR INTIMATE PARTNER VIOLENCE AGAINST WOMEN

tered women: the survivors perspective. Women Health. 1999;29:115-135. 22. Rodrigues MA, Szkupinski Quiroga S, Bauer HM. Breaking the silence: battered womens perspectives on medical care. Arch Fam Med. 1996;5:153-158. 23. Elaine Weiss. Surviving Domestic Violence: Voices of Women Who Broke Free. Salt Lake City, Utah: Dept of Family and Preventive Medicine, University of Utah, Agreka Books; 2000. 24. Prochaka JO, Velicer, WF, Rossi JS, Stage of change and decision balance for 12 problem behaviors. Health Psych. 1994;13:39-46. 25. Fleming MF, Mundt MP, French MT, et al. Benefitcost analysis of brief physician advice with problem drinkers in primary care settings. Med Care. 2000;38: 7-18. 26. Suggs NK, Inui T. Primary care physicians response to domestic violence: opening Pandoras box. JAMA. 1992;267:3157-3160. 27. Krasnoff M, Moscati R. Domestic violence screening and referral can be effective. Ann Emerg Med. 2002;40:485-492. 28. Sullivan CM, Bybee DI. Reducing violence using community-based advocacy for women with abusive partners. J Consult Clin Psychol. 1999;67:43-53. 29. Holt VL, Kernic MA, Lumley T, Wolf ME, Rivara FP. Civil protection orders and risk of subsequent policereported violence. JAMA. 2002;288:589-594. 30. Frasier PY, Slatt L, Kowlowitz V, Glowa PT. Using the stages of change model to counsel victims of intimate partner violence. Patient Educ Couns. 2001; 43:211-217. 31. Violence Against Women in the United States: A Comprehensive Background Paper. New York City, NY: The Commonwealth Fund Commission on Womens Health; November 1996. 32. Rittmayer J, Roux G. Relinquishing the need to fix it: medical intervention with domestic abuse. Qual Health Res. 1999;9:166-181. 33. Role of victims services in improving intimate partner violence screening by trained maternal and child healthcare providersBoston, Massachusetts, 19941995. MMMR Morb Mortal Wkly Rep. 2000;49:114117. 34. Rhodes KV, Lauderdale, DS, Stocking CB, Howes DS, Roizen, MF, Levinson W. Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med. 2001;37:284291. 35. Mechem CC, Shofer FS, Reinhard SS, Horig S, Datner E, History of domestic violence among male patients presenting to an urban emergency department. Acad Emerg Med. 1999;6:786-791. 36. Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department: new findings. JAMA. 1984;251:3259-3264. 37. Muelleman RL, Burgess P. Male victims of domestic violence and their history of perpetrating violence. Acad Emerg Med. 1998;5:869-870. 38. Salber P, Taliaferro E. Men and domestic violence. Acad Emerg Med. 1998;5:849-850. 39. Kaufman Kantor, G, Straus MA. Response of victims and police to assaults on wives. In: Straus MA, Gelles RJ, eds. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. Washington, DC: Visage Press; 1990:151-559. 40. Ganley A. Health care responses to perpetrators of domestic violence. In: Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. In: Lee D, Durborow N, Salber PR, eds. 2nd ed. San Francisco, Calif: The Family Violence Prevention Fund; 1996:89-106. 41. Dutton DG, Hemphill KJ. Patterns of social desirability responding among perpetrators and victims of wife assault. Viol Vict. 1992;7:29-39. 42. Dunford FW. The San Diego Navy Experiment: an assessment of interventions for men who assault their wives. J Consult Clin Psychol. 2000;68:468-476. 43. OFarrell TJ, Fals-Stewart W. Behavioral couples therapy for alcoholism and drug abuse. J Subst Abuse Treat. 2000;18:51-54. 44. Ferris LE, Norton PG, Dunn EV, Gort EH Degani N, for the Delphi Panel and Consulting Group. Guidelines for managing domestic abuse when male and female partners are patients of the same physician. JAMA. 1997;278:851-857. 45. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiopulmonary care, part 3: adult basic life support. Circulation. 2000;102(8 suppl): I22-I59. 46. Kottke TE. Clinical prevention services: how should we define the indications? Mayo Clin Proc. 1990;65: 899-902. 47. American College of Emergency Physicians. Domestic Violence. Approved October 1999. Policy No. 400286. Available at: http://www.acep.org /1,2194,0.html. Accessed January 3, 2003. 48. Joint commission: tighter domestic abuse standards should improve assessment. AIDS Alert. October 1993;8:152-154. 49. MacMillan HL, Wathen CN, with the Canadian Task Force on Preventive Health Care. Prevention and Treatment of Violence Against Women. In: Systematic Review & Recommendations. London, Ontario: Canadian Task Force; Sept 2001. CTFPHC Technical Report No. 01-4. 50. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA. 1996;275:1915-1920. 51. Centers for Disease Control and Prevention. Physical violence during the 12 months preceding childbirthAlaska, Maine, Oklahoma and West Virginia, 1990-1991. MMWR Morb Mortal Wkly Rep. 1994; 43:132-137. 52. Kyriacou DN, Anglin D, Taliaferro E, et al. Risk factors for injury to women from domestic violence against women. N Engl J Med. 1999;341:1892-1898. 53. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence and Consequences of Violence Against Women: Research Report. Washington, DC: National Institute of Justice; 2000. NCJ 183781. 54. Herrera VM, McCloskey LA. Gender differences in the risk for delinquency among youth exposed to family violence. Child Abuse Negl. 2001;25:10371051. 55. Williams-Evans SA, Evans KR, Call-Schmidt T, Williams G. The lived experiences of adult female victims of child abuse. J Cult Divers. Summer 2000;7: 48-54.

2003 American Medical Association. All rights reserved.

(Reprinted) JAMA, February 5, 2003Vol 289, No. 5

605

Downloaded from www.jama.com on February 14, 2008