Intimate Partner Violence and Its Health Impact on Disproportionately Affected Populations, Including Minorities and Impoverished Groups

Abstract

In the United States, intimate partner violence (IPV) against women disproportionately affects ethnic minorities. Further, disparities related to socioeconomic and foreign-born status impact the adverse physical and mental health outcomes as a result of IPV, further exacerbating these health consequences. This article reviews 36 U.S. studies on the physical (e.g., multiple injuries, disordered eating patterns), mental (e.g., depression, post-traumatic stress disorder), and sexual and reproductive health conditions (e.g., HIV/STIs, unintended pregnancy) resulting from IPV victimization among ethnic minority (i.e., Black/African American, Hispanic/Latina, Native American/Alaska Native, Asian American) women, some of whom are immigrants. Most studies either did not have a sufficient sample size of ethnic minority women or did not use adequate statistical techniques to examine differences among different racial/ethnic groups. Few studies focused on Native American/Alaska Native and immigrant ethnic minority women and many of the intra-ethnic group studies have confounded race/ethnicity with income and other social determinants of health. Nonetheless, of the available data, there is evidence of health inequities associated with both minority ethnicity and IPV. To appropriately respond to the health needs of these groups of women, it is necessary to consider social, cultural, structural, and political barriers (e.g., medical mistrust, historical racism and trauma, perceived discrimination, immigration status) to patient–provider communication and help-seeking behaviors related to IPV, which can influence health outcomes. This comprehensive approach will mitigate the racial/ethnic and socioeconomic disparities related to IPV and associated health outcomes and behaviors.

Introduction

Intimate partner violence (IPV) against women remains a significant public health issue resulting in adverse health consequences for women in the United States (U.S.).^1,2 Approximately 42.4 million (35.6%) women in the U.S. experience rape, physical violence, and/or stalking by an intimate partner at some point in their lifetime.¹ Ethnic minority women are disproportionately affected by IPV. According to the 2010 National Intimate Partner and Sexual Violence Survey, non-Hispanic Black and Native American/Alaska Native women reported higher prevalence rates of lifetime IPV (43.7% and 46%, respectively) compared to non-Hispanic White women (34.6%); the rate for Hispanic women was slightly higher (37.1%).¹ These disproportionate rates have also been consistently documented in multiple U.S. studies.^3–5

Marginalized populations such as women who are foreign born are also more likely to experience IPV than those born in the U.S. Physically abused Latinas residing in the U.S. but born in Mexico, Central America, South America, and the Caribbean are more likely to experience sexual IPV compared to their counterparts born in the U.S.^5,6 Moreover, 48% of Latinas in another study reported that their partners' violence had increased after they immigrated to the U.S.⁷ Asian immigrant women also experience high rates of IPV, with community-based studies based on nonrepresentative samples documenting rates between 24% and 60%.^8–10 Additionally, Asian immigrant women have been found to be at increased risk for intimate partner homicide when compared with U.S.-born Asians.^11,12 Many immigrant women experience IPV in the context of language difficulties, confusion over their legal rights, and the overall stress of adaptation to new cultural and social structures.¹² Immigrant women are especially vulnerable because of poverty, social isolation, disparities in economic and social resources (between the woman and her partner), and immigration status.¹²

IPV has been associated with multiple adverse physical and mental health conditions and health risk behaviors among women of all backgrounds.^2,13 Comprehensive reviews of physical health consequences of IPV report multiple health outcomes including chronic pain (e.g., fibromyalgia, joint disorders, facial and back pain); cardiovascular problems (e.g., hypertension); gastrointestinal disorders (e.g., stomach ulcers, appetite loss, abdominal pain, digestive problems); and neurological problems (e.g., severe headaches, vision and hearing problems, memory loss, traumatic brain injury).^13–17 The psychological impact of IPV on ethnic minority women includes higher rates of depression, posttraumatic stress disorder (PTSD), low self-esteem, and suicidality as compared to their counterparts who have not experienced IPV,¹⁸ and in some instances, as compared to White women with IPV experiences.¹⁸ In addition to the known adverse physical and mental health consequences, IPV can affect sexual and reproductive health outcomes. In particular, forced sex by an intimate partner can result in acute and chronic problems including vaginal and anal tearing, sexual dysfunction and pelvic pain, dysmenorrhea, pelvic inflammatory disease, cervical neoplasia, and sexually transmitted infections, including human immunodeficiency virus (HIV).^19–24 HIV disproportionately affects Black/African American and Hispanic/Latina women compared to other race/ethnicities.²⁵ IPV intersects with HIV through multiple mechanisms including forced sex with an infected partner, limited or compromised negotiation of safer sex practices, increased sexual risk-taking behaviors, an increase in other sexually transmitted infections (STIs) that accompany abuse and facilitate HIV transmission, and abuse-related immunocompromised states.^23,26–28 IPV also contributes to unintended pregnancy, miscarriage, abortion, and decreased contraceptive use.^19,29

An estimated $5.8 billion is spent annually as a result of medical and mental health costs and loss of productivity associated with IPV.³⁰ However, in the context of IPV, disparities related to race/ethnicity, socioeconomic, and foreign-born status are more paramount for these health outcomes and behaviors (e.g., cardiovascular disease, depression, HIV/STIs). Specifically, ethnic minority and immigrant women are more likely to have lower levels of education, live in poverty, and have less access to healthcare and other resources, further exacerbating the health consequences of IPV.³¹ Moreover, ethnic minority women are overrepresented in emergency departments.^24,32 Previous reviews have examined IPV and aggregated health outcomes (e.g., physical health, mental health, sexual health, HIV) among women in the U.S. and support overall positive significant associations. However, there is no published review that focuses solely on IPV among ethnic minority women in the U.S. and associated physical, mental and sexual and reproductive health outcomes. In this paper, we provide an overview of selected physical, mental, sexual and reproductive health conditions in the context of IPV among ethnic minority women in the U.S., some of whom are immigrant women.

Methods

A systematic approach was used to identify original research examining IPV and associated health outcomes among ethnic minority women in the U.S. Our review included peer-reviewed articles retrieved from the following databases: Pubmed, PsychInfo, Ovid Medline, and Science Direct, and also via handsearching. Literature searches were conducted from the titles, subject, abstract, and as keywords or subject-word headings of all articles in the databases. Searches were conducted by two authors.

Published studies were located in the databases using the following definitions: (1) IPV as physical and/or sexual violence with or without psychological abuse, perpetrated by a current or former male intimate partner, and (2) health outcomes as physical, mental, including substance use, and sexual and reproductive health issues affecting women. The following search terms were used for IPV: “battered women,” “spouse abuse,” “domestic violence,” “partner violence,” and “intimate partner violence.” The following search terms were used for physical health outcomes: “physical injury,” “physical health,” “cardiovascular or hypertension,” “gastrointestinal or stomach ulcers or appetite loss or abdominal pain or digestive problems,” “eating disorders or obesity or anorexia,” “broken bones,” “facial injuries or eye injuries,” “chronic pain or fibromyalgia,” and “neurological or memory loss or traumatic brain injury or vision or hearing problems.” The following search terms were used for mental health outcomes: “mental health,” “depression,” “post-traumatic stress disorder,” “anxiety,” “mood disorder,” “(attempted) suicide,” “suicide ideation/attempts,” “low self-esteem,” and, “substance use (abuse) or alcohol (use) or drug (use).” The following search terms were used for sexual and reproductive health outcomes: “sexual dysfunction,” “pelvic pain,” “vaginal tearing,” “dysmenorrhea,” “menstrual irregularity,” “pelvic inflammatory disease,” “cervical neosplasia,” “sexually transmitted infections or chlamydia or gonorrhea or human immunodeficiency virus,” “urinary tract infections,” “unintended pregnancy,” “miscarriage,” “abortion,” and “contraceptive use or contraception or contraception behavior.” Additional studies were included as per expert recommendation on an ad hoc basis.

Our review is limited to quantitative and qualitative peer-reviewed journal articles published in English conducted on the relationship between IPV victimization and health outcomes that (a) focused on ethnic minority women (i.e., Black/African American, Hispanic/Latina, American Indian/Alaska Native, Asian/Pacific Islander) born in the U.S. or born elsewhere and immigrated to the U.S., (b) were conducted in the U.S., and (c) included analyses (quantitative and/or qualitative) on the relationship between IPV victimization and any physical, mental, and sexual and reproductive health outcomes. Because there is not a wealth of findings devoted to the association between IPV and health outcomes among ethnic minorities in the U.S., we did not impose a timeframe on the literature review. Due to the complex risks presented by abuse during pregnancy on both the mother and child, and given previous reviews focused on this topic, we excluded studies that examined the relationship between IPV during pregnancy and pregnancy outcomes.

Initial searches yielded a total of 310 studies for potential inclusion in this review. After screening of abstracts, 102 articles were retained for full-text review. Of the 102 full-text articles reviewed, 36 were retained for final inclusion in the current review.

Results

Physical health

We identified 6 studies that examined associations between IPV and physical health outcomes for ethnic minority women in the U.S. (Table 1). Two studies were case-control in design and four were cross-sectional; two of the cross-sectional studies employed a mixed methods approach. Both case-control studies focused on African American women in the U.S. and African Caribbean women in the U.S. Virgin Islands. In the first analysis, those reporting a history of IPV experienced a significantly higher likelihood of having past year disordered eating patterns (i.e., irregularities in eating patterns by overeating or undereating) than nonabused women (adjusted odds ratio [AOR] 3.85; 95% confidence interval [CI]: 1.12–13.32). Among women with a history of IPV, those who experienced physical and sexual abuse were more likely to report past year disordered eating patterns than those who experienced emotional abuse alone (AOR 4.20; 95% CI: 1.22–14.44). Interestingly the relationship between IPV and disordered eating was partially mediated by depression.³⁴ In the same sample of women (i.e., African American and African Caribbean), multiple injuries (e.g., broken bones, facial injuries, eye injuries, head injuries, broken or dislocated jaw) were nearly three times more likely to be reported among those who experienced past year IPV (AOR 2.75; 95% CI: 1.98–3.81) compared to those without a history of IPV.³⁵ In a cross-sectional analysis, ethnic variation across various subgroups in the health outcomes of abused women was examined.³³ Poor perceived general health was associated with psychological and any abuse for Hispanic women but not for Black and White women; physical abuse was also associated with this outcome for Black women but not women of other race/ethnicities.³³

Table 1.

Studies on the Relationship Between Intimate Partner Violence and Physical Health Outcomes Among Ethnic Minority Women in the United States

		Measures
Author (year)	Study sample/setting and design	Intimate partner violence (IPV)	Physical health outcome	Confounders	Study findings
Lacey et al. (2013)33	Probability-based sample of U.S. adult women of all racial/ethnic groups (n=8000) Cross-sectional	Modified version of the Conflict Tactics scale (CTS)	Perceived general health, derived from the following question: “In general, would you say your health is … excellent, very good, good, fair, or poor.”	• Age, race/ethnicity, marital status, education, household income, employment	Bivariate analysis (comparing nonabused vs. abused women) • Hispanic women: significant association between poor perceived health and   ○ Psychologically abused (OR 3.09; p<0.05)   ○ Any abuse (OR 2.71; p<0.05) • Black women: significant association between poor perceived health and physical abuse (OR 2.89; p<0.05)
Lucea et al. (2012)34	Women (18–55 yrs) of African descent in Baltimore, MD, and U.S. Virgin Islands (n=781) Case-control	Past two year intimate partner abuse: Abuse Assessment Screen (AAS) and Women's Experiences of Battering (WEB)	Disordered eating: “How often have you had an eating disorder (overeating/ under-eating) in the past year?”	• Age, race/ethnicity, marital status, education, employment, insurance status, annual income • Children ≤18 years living at home • Study site	• Those reporting a history of IPV experienced a significantly higher risk for disordered eating patterns in past year than nonabused women (AOR 3.85; 95% CI:1.12–13.32) • Women with sexual and physical abuse experiences were more likely to experience disordered eating patterns than those with emotional abuse experiences alone (AOR 4.20; 95% CI:1.22–14.44)
Anderson et al. (2014)35	Women (18–55 yrs) of African descent in Baltimore, MD, and U.S. Virgin Islands (n=738) Case-control	Past two year intimate partner abuse: AAS, WEB, Danger Assessment, and Severity of Violence Against Women Scales (SVAWS)	Injury in the past year: Miller Abuse Physical Symptom and Injury Scale	• Age, education, marital status, employment, insurance • Children • Pregnancy status	• Multiple injuries (e.g., broken bones, facial injuries, eye injuries, head injuries, broken or dislocated jaw) were nearly 3 times more likely to be reported in those who experienced past year IPV compared with women who were never abused (AOR 2.75; 95% CI:1.98–3.81)
Kelly (2010)36	Latino women (19–74 yrs) at a DV agency in urban New England (n=33) Cross-sectional mixed-methods	Physical, sexual and psychological abuse: SVAWS (alpha coefficient=0.92)	Physical health: modified version of the National Health Interview Survey	• Childhood and adulthood sexual abuse • Immigration legal status • Health-related quality of life	• Physical abuse and bodily pain: r=0.343 • Physical abuse and severe or frequent headaches: r=0.375 • Sexual abuse and repeated neck/back pain: r=0.524
Lown and Vega (2001)37	Mexican American adult women (18–59 yrs) in Fresno County, CA (n=1155) Cross-sectional	Past year physical or sexual IPV: Questions adapted from the AAS and the National Comorbidity Survey	Three sets of health indicators: (1) self-assessed health status, (2) chronic health conditions, and (3) somatic symptoms	• Age, education • Health insurance (public or private)	Past year IPV was significantly associated with • Fair/poor overall health (AOR 1.9; 95% CI:1.0–3.7) • Fair/poor physical health (AOR 2.1; 95% CI:1.2–3.9) • Fair/poor mental health (AOR 3.4; 95% CI:1.9–6.1) • Worse health compared to non-abused women their age (AOR 4.4; 95% CI:2.3–8.3) • Heart attack (AOR 17.0; 95% CI:4.3–66.7)
Hurwitz et al. (2006)38	South Asian adult immigrant women from Boston area communities (quantitative n=210; qualitative n=23) Cross-sectional mixed methods	Physical abuse, sexual abuse, or injury from abuse in current relationship. Four items adapted from the Massachusetts Behavioral Risk Factor Surveillance System (BRFSS)	Single-item measures adapted from the Massachusetts BRFSS (e.g., “number of days in the month experiencing physical health concerns”)	• Age, education, income • Immigrant status • Recency of immigration	• Abused women were more likely than those with no history of abuse to report poor physical health (AOR 4.0; 95% CI:1.3–12.0) • Qualitative findings: In addition to the pain and injury as a direct result of the abuse, women no longer in an abusive relationship experienced chronic/intermittent pain (e.g., headaches, gastrointestinal concerns)

AOR, adjusted odds ratio; CI, confidence interval; DV, domestic violence; IPV, intimate partner violence; OR, odds ratio.

The remaining three cross-sectional studies occurred among Latina women and South Asian women. In an exploratory study of 33 Latina women, pain and sleeping difficulty were consistently and highly correlated with various forms of IPV.³⁶ Among Mexican American women, those reporting past year IPV were more likely to report fair or poor overall health, a history of heart problems, and persistent health problems than those without a past year IPV experience.³⁷ And among immigrant South Asian women, abused women were more likely than those with no history of IPV in their current relationship to report poor physical health (AOR: 4.0; 95% CI:1.3–12.0). Further qualitative inquiry revealed that in addition to the pain and injury as a direct result of the abuse, women no longer in an abusive relationship experienced chronic and intermittent pain, particularly headaches, backaches, and gastrointestinal concerns resulting from the stress and trauma from past abuse.³⁸

Mental health

We identified 18 studies that examined associations between IPV and mental health outcomes for ethnic minority women in the United States. (Table 2). Most studies were based on cross-sectional analyses (n=15). Two studies were case-control and only one study was a prospective cohort study. Black women with experiences of IPV have been found to suffer from adverse mental health outcomes, as documented by cross-sectional studies and the only prospective cohort study.^18,31,50,55 In the recent prospective study, psychological, sexual, and physical IPV were independently associated with depression, suicidality, and PTSD among African American female emergency department patients.⁴⁹ Mental health symptoms also increased significantly with the amount of abuse experienced.⁴⁹ Among low-income African American women, in addition to IPV being associated with severity of PTSD symptoms, those who reported a recent history of both IPV and suicidal behavior experienced strikingly high levels of PTSD symptoms.⁴⁰ Only one study has examined IPV and co-occurring mental health problems (i.e., PTSD and depression) among three ethnic subgroups of Black women in the U.S. and U.S. Virgin Islands.⁵⁴ This study showed that only among African American women, severe psychological (AOR 1.06; 95% CI: 1.03–1.09) and physical IPV (AOR 1.04; 95% CI:1.00–1.08) were associated with co-occurring mental health problems. No associations were found for African Caribbean women or Black women mixed with other racial/ethnic groups.⁵⁴ In the same study population but based on a different analysis, the relationship between comorbid PTSD and depression, and risk for intimate partner femicide, the most severe outcome of IPV, was significant among the overall sample (i.e., African American and African Caribbean women) and African Caribbean women only.⁵³

Table 2.

Studies on the Relationship Between IPV and Mental Health Outcomes Among Ethnic Minority Women in the United States

		Measures
Author (Year)	Study sample/setting and design	IPV	Mental health outcome	Confounders	Study findings
Bonomi et al. (2009)39	Latina and non-Latina women (18–64 years) in the Pacific Northwest (n=3429) Cross-sectional	Physical, sexual, and psychological IPV since age 18 years: WEB, Behavioral Risk Factor Surveillance System	• Depressive Symptoms: Center for Epidemiological Studies-Depression (CES-D) scale (five items). • Physical, social, and psychological well-being: Short Form-36 Health Survey, subscales (i.e., vitality, mental health, emotional functioning, social functioning in past month, and overall mental component (MCS).	• Age, education, household income, employment • Number in household • Children in home for whom respondent is guardian • Childhood abuse	Abused versus non-abused Latinas: • Lower mental health, MCS, and vitality scores • MCS score was 7.52 points lower • >2× higher depression prevalence (prevalence ratio=1.84) • Latina women suffered significantly more adverse IPV-related mental health issues, both in their overall MCS (p<0.02) and in the specific areas of vitality (p<0.01) and emotional functioning (p<0.01)
Bradley et al. (2005)40	African American women (18–64 years) recruited from a public university-affiliated hospital serving a primarily low income and urban population (n=134) Cross-sectional	Physical violence and nonphysical violence in the past 6 months: Index of Spouse Abuse (ISA)	Frequency and severity of posttraumatic stress disorder (PTSD) symptoms: Davidson Trauma Scale that used items listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Sample (αs=0.79).	• Education, marital/relationship status, employment, sources of income • Number of children	• IPV was associated with and predicted PTSD symptoms (intercorrelation=0.28, p<0.001; β=0.37, p<0.001) • Those who reported a recent history of both IPV and suicidal behavior experienced high levels of PTSD symptoms
Caetano and Cunradi (2003)41	White, black, and Hispanic married or cohabitating couples aged 18+ years in 48 contiguous states (n=1635 couples) Cross-sectional	IPV in the past year: CTS, Short form R	Depression: CES-D	• Age, ethnic identification, education, household income, employment • Neighborhood unemployment, education level, poverty *Analyses stratified by race/ethnicity	• Among Hispanic women, those who were abused had a significant difference in prevalence of depressive symptoms compared to those who were nonabused women (48% vs. 15%; p<0.05)
Duran at al. (2009)42	American Indian/Alaska Native primary care female patients (18–45 years) at the Indian Health Service hospital in Albuquerque, NM (n=234) Cross-sectional	IPV in the past year: CTS2	University of Michigan Composite International Diagnostic Interview version that used items based on the DSM-IV to determine past year alcohol, drug, and mental health outcomes (anxiety, PTSD, substance abuse/dependence, mood disorders).	• Age, employment, debt, education • Family history of alcohol abuse	• Severe physical or sexual IPV was associated with any mood disorder (adjusted prevalence ratio 2.53; 95% CI:1.05–6.09)
El-Bassel et al. (2003)43	Ethnic minorities (i.e., Latina, African American, and other) (18–55 years) recruited from emergency department waiting rooms in New York (n=143) Cross-sectional	Physical or sexual IPV in the past year: Individual items to assess experiences of physical and/or sexual IPV	Drinking problems in the past year: Alcohol Use Disorders Identification Test (AUDIT) Drug-related problems in the past year: Drug Abuse Severity Test (DAST)	• Age, years of education, ethnicity, marital status, employment • Children under 18 years • Living with someone with a drug/alcohol problem • Received public support • Homelessness past year • Childhood victimization	• Physical IPV victims were more likely than non-abused women to report higher scores on AUDIT (4.9 vs. 2.4; p<0.01), and on the DAST (3.0 vs. 1.3; p<0.01) • Sexually abused women were more likely than non-sexually abused women to have significantly higher AUDIT scores (6.4 vs. 2.5; p<0.01)
Fedovskiy et al. (2008)44	Latina, predominantly low income (18–64 years) recruited from primary care clinic in urban, public hospital (n=105) Cross-sectional	Lifetime IPV: ISA	PTSD: Posttraumatic Stress Diagnostic Scale Major Depressive Disorder (MDD): CES-D	• Age, educational attainment, marital status, employment • Health insurance status • Type of residence • Number of children, children living at home • Relationship status	Bivariate analysis: Women with a history of IPV vs. those with no history of IPV had: • 1.68×odds of MDD but only marginally sig (p=0.22) • ∼3×odds of meeting criteria for PTSD (OR 2.97; 95% CI:0.98–0.11)
Hankin et al. (2010)45	African American (21–55 years) recruited from an emergency department of a Level One trauma hospital in a southeastern city (n=425) Cross-sectional	IPV in the past year: ISA	Depression: Beck Depression Inventory Alcohol abuse: Tolerance, Worried, Eye openers, Amnesia, K/Cut-down (TWEAK) survey Drug abuse: DAST, Hooked on Nicotine Checklist	• Age, education, marital status • Chief medical complaint	• IPV+ women more likely to be depressed vs. IPV−women • IPV+ women more likely to screen positive for alcohol abuse (47.1% vs. 23.2%; p<0.0001) and drug abuse (44.7% vs. 9.5%; p<0.001)
Hazen et al. (2008)46	Latinas (18–45 years) who received services in a community healthcare system in San Diego, CA (n=282) Cross-sectional	Past yr IPV: CTS2 Past 6 months Psychological abuse: Psychological Maltreatment of Women Inventory	Depression: Brief Symptom Inventory	• Age, education • Immigrant/migrant status (U.S. born, immigrant migrant/seasonal) • Recent life events • Childhood maltreatment • (physical abuse, neglect, sexual abuse)	• Depression significantly associated with physical assault (β=0.156; p<0.05) • Depression significantly associated with psychological maltreatment through dominance-isolation (β=0.158; p<0.05)
Holden et al. (2012)47	African American, Hispanic, White, Asian American, American Indian/Alaskan Native, Native Hawaiian/Pacific Islander (11–45 years) pregnant or post-pregnant women in Augusta-Richmond County, GA (n=602) Cross-sectional	Emotional and physical abuse in the previous 12 months: Women Abuse Screening Tool	Depression: Edinburgh Postnatal Depression Scale Alcohol Drug use/abuse: DAST	• Age, education • Substance (alcohol/drug) abuse	• Depression significantly associated with IPV during pregnancy (r=0.26; p<0.001) and after delivery of baby (r=0.25; p<0.001) • Depression significantly associated with substance abuse during pregnancy (r=0.16; p<0.001) and after delivery of baby (r=0.I7; p<0.001)
Houry et al. (2005)48	African American (18–64 years) women in public hospital in urban setting (n=200) Case-control; cases were those who attempted suicide	IPV in past year: modified version of George Washington Univ. (GWU) Universal Violence Prevention Screening Protocol (UVPSP)	Depressive symptoms: Beck Depression Inventory-II (BDI-II) Suicide attempt: yes/no	• Age, education, income, employment status • Living with partner	• No significant differences between attempters and non-attempters for:  ○ Physical IPV (70% vs. 66%; p=0.57)  ○ Nonphysical IPV (77% vs. 68%; p=0.20)
Houry et al. (2006)49	African American emergency department patients in southeastern city (18–55 years) (n=461) Prospective cohort	Physical violence, threats, sexual violence, and emotional abuse in past year: GWU UVPSP	Depression: BDI-II. PTSD: Part 3 of the Posttraumatic Stress Diagnostic Scale Suicidal Ideation: The Beck Scale for Suicide Ideation	• Education • Socioeconomic status • Smoking status • Recent drug use • Alcohol problems	• Physical, emotional, and sexual IPV each significantly associated with depressive symptoms, suicidality, and PTSD symptoms • Mental health symptoms increased with amount of abuse: depression (OR 5.9 for 3 types of abuse); PTSD (OR 9.4 for 3); and suicidality (OR 17.5 for 3)
Kaslow et al. (2000)50	African American, low-income (18–64 years) from university affiliated public healthcare system (n=285) Case-control study	Physical and nonphysical partner abuse in the last year: ISA	Presented to the hospital following a suicide attempt: yes/no	• Education • Employment status • Number of children	Compared to nonattempters, those who attempted suicide more likely to report: • physical partner abuse (OR 2.51; 95% CI:1.40–4.50) • nonphysical partner abuse (OR 2.82; 95% CI:1.57–5.08)
Kelly (2010)36	Latina women (19–74 years) receiving domestic violence services in the northeastern United States (n=33) Cross-sectional	Severity of Violence Against Women Scale (SVAWS) Women's perceptions of abuse severity: revised version of three-item Appraisal of Violent Situations	PTSD in the past month: The PTSD Checklist-Civilian version (PCL-C) Current MDD: DSM-IV criteria for major depressive episode	• Age, years education, employment status • Country of origin, primary language, years living in United States, immigration status • Number of children • Involvement with children's protective services • Childhood assault	Psychological abuse and MDD Diagnosis: r=0.477; p<0.01 Psychological abuse and MDD symptoms: r=0.378; p<0.05 Psychological abuse and comorbid PTSD and MDD: r=0.387; p<0.05 Psychological abuse and MDD Diagnosis: r=0.388; p<0.05
Paranjape et al. (2007)51	African American women (18–64 years) seeking care from a university-affiliated public hospital in the southeastern United States (n=361) Cross-sectional	Physical and nonphysical abuse: ISA	Depression: Brief Symptom Index-Depression Subscale Alcohol problems (AP): Alcohol Alcoholism Screening Test	• Age, education, marital status, employment	Compared to women reporting low or no IPV and no AP: • Women reporting high IPV levels were 4.3×more likely to report moderate to severe depressive symptoms • Women reporting both high IPV levels and AP were 8×more likely to endorse elevated levels of depressive symptoms
Rodriguez et al. (2008)52	Latina women (18–42 years) at prenatal clinic in Los Angeles, CA (n=210) Cross-sectional	Psychological, physical, and sexual IPV in the past year: Abuse Assessment Screen	PTSD in the past month: PTSD Checklist, civilian (PCL-C) Current depressive symptoms: Beck Depression Inventory Fast Screen (BDI-FS) for Medical Patients	• Age • Language of interview • Type of recruitment clinic (i.e., private, nonprofit, healthcare organization)	• Significantly more women who experienced IPV in past year were depressed and had PTSD (depression: 41.3% vs. 18.6%; p<0.001; PTSD: 16.3% vs. 7.6%; p<0.001)
Sabri et al. (2013)53	Women (18–55 years) of African descent in Baltimore, MD, and U.S. Virgin Islands recruited from women's health clinics; (n=431; 79% low-income) Cross-sectional analysis derived from case-control study	Past year physical/sexual: SVAWS Psychological: WEB	• Past month PTSD: Primary Care-PTSD Screen • Past week depression: CES-D 10 Women classified as: co-occurring PTSD and depression, PTSD-only, depression-only, or neither PTSD nor depression	• Age, race/ethnicity, education, marital status, income, employment • Injuries *Analysis stratified by ethnic subgroup	• African American women: psychological (AOR 1.06; 95% CI:1.03–1.09) and physical IPV (AOR 1.04; 95% CI:1.00–1.08) associated with co-occurring mental health problems • No associations found for African Caribbean women or Black women mixed with other race/ethnicity
Sabri et al. (2013)54	Women (18–55 years) of African descent in Baltimore, MD, and U.S. Virgin Islands recruited from women's health clinics (n=543) Cross-sectional analysis derived from case-control study	Past year physical/sexual: SVAWS Psychological: WEB Risk for intimate partner femicide: Danger Assessment	Past month PTSD: Primary Care-PTSD Screen Past week depression: CES-D 10	• Age, ethnicity • Severity of injuries • Relationship with the abusive partner • Cohabitation with the abuser • Study site *Analysis stratified by ethnic subgroup	• The relationship between comorbid PTSD and depression, and risk for intimate partner femicide, the most severe outcome of IPV, was significant among the entire sample of Black women and when stratified, only among African Caribbean women
Williams and Grimly (2008)55	African American women (18–40 years) attending an STD clinic in Birmingham, AL (n=455) Cross-sectional	Past year physical IPV: “Did boyfriend, girlfriend or spouse hit, slap or physically hurt you?” Past year sexual IPV: “Forced to have sex when you did not want to?”	Past week depression: Modified CES-D Past week depressive symptoms: loneliness, crying, sadness	• Age, education, marital status • General healthcare visits in the last 12 months • Reason for STD clinic visit	Physical IPV+ women vs. IPV− more likely to have higher level of: • Depression (OR 1.40; 95% CI:1.08–1.83) • Loneliness (OR 1.63; 95% CI:1.25–2.14) • Crying (OR 1.63; 95% CI:1.23–2.17) • Sadness (OR 1.50; 95% CI:1.15–1.98) Sexual IPV+ women vs. IPV− more likely to have higher level of: • Depression (OR 1.75; 95% CI:1.38–2.22) • Loneliness (OR 2.18; 95% CI:1.72–2.78) • Crying (OR 1.82; 95% CI:1.41–2.36) • Sadness (OR 2.10; 95% CI:1.64–2.68)

Among Latina women, literature has documented those with experiences of IPV as having increased prevalence of depressive symptoms (41%–48%)^39,41,46,52 and PTSD (16.3%).^44,52 In the only study to examine the association between lifetime IPV exposure and multiple mental health indicators, depression prevalence for abused Latina women was more than twice that of nonabused Latina women. In addition, Latina women with a lifetime history of IPV suffered significantly more adverse IPV-related mental health issues compared to nonabused Latina women in their overall mental health functioning, specific areas of vitality, and role of emotional functioning.³⁹ Among a small sample of immigrant Latinas, IPV was associated with PTSD but not major depressive disorder,⁴⁴ and in another sample of U.S.-born abused Latinas, PTSD and major depressive disorder were highly correlated with poor health–related quality of life.⁵⁶ In the limited data for American Indian/Alaska Native on IPV and associated mental health outcomes, severe physical or sexual IPV was associated with any mood disorder.⁴² South Asian immigrant women who have experienced IPV have an increased risk of depression, suicide attempts, and suicide ideation compared with those without such experiences.³⁸

The relationship between IPV and mental health problems is further complicated by substance abuse, as highlighted in previous studies among women from all ethnic backgrounds.^47,57 These co-occurring issues have not been extensively examined in separate racial/ethnic groups. In one cross-sectional study of African American women, those reporting high IPV levels and alcohol problems endorsed moderate to severe depressive symptoms eight times more often than women reporting neither.⁵¹ Other studies among African American and/or Latina women have identified positive associations between IPV and alcohol- and drug-related problems.^43,45

Sexual and reproductive health

We identified 11 studies that examined associations between IPV and sexual and reproductive health outcomes for ethnic minority women in the U.S. (Table 3). Seven studies were based on cross-sectional analyses; one of which was mixed methods (i.e., quantitative and qualitative). Three studies were qualitative in nature, with two based on in-depth interviews and one based on focus groups. Only one was a prospective cohort study. With the exception of HIV/STIs, most of the studies documenting associations between IPV and sexual and reproductive health outcomes have not been specifically conducted among ethnic minority and immigrant women. Among the few studies, South Asian immigrant women reporting IPV were more likely to report discolored vaginal discharge in the past year (AOR 2.64; 95% CI: 1.27–6.50), burning during urination in the past year (AOR 3.10; 95% CI: 1.52–6.31), and unwanted pregnancy in the current relationship (AOR 3.39; 95% CI: 1.33–8.66) compared to South Asian immigrant women reporting no history of IPV.⁶³ In a qualitative study, limited access to reproductive healthcare compounded by male partner sexual and pregnancy coercion, as well as physical and sexual violence, emerged from in-depth interviews with gang-affiliated Latina women.⁶¹ Mexican immigrant women described IPV experiences as pregnancy coercion, control over the use of contraception, insults and intimidation to leave if she did not become pregnant, and threats to abandon her if she did not deliver a baby of a particular sex.⁶² In a quantitative study, when an unintended pregnancy occurred among less acculturated Latinas, it was associated with greater risk of physical IPV during pregnancy (unadjusted OR 2.57; 95% CI: 1.06–6.23).⁶⁰ Associations with unexplained menstrual irregularity were strongest among African American women when compared to other groups (i.e., European American, Latina, and other ethnic groups).⁵⁹

Table 3.

Studies on the Relationship Between IPV and Sexual/Reproductive Health Outcomes Among Ethnic Minority Women in the United States

		Measures
Author (Year)	Study sample/setting and design	IPV	Sexual/reproductive health outcome	Confounders	Study findings
Campbell et al. (1999)20	Primarily African American (77%) and relatively poor from a large Midwestern city. Other ethnics groups included Anglo-American, European American, Mexican American, Asian American, Arab American and other/mixed race. (n=159) Cross-sectional	Physical, sexual and emotional abuse in the last year: ISA	Sexual health in past year: The Health Responses Scale was (HRS) was used to assess functional health. Items in the HRS related to gynecological issues included lower abdominal cramping/pain and decreased sexual activity.	• Age • Race • Tangible resources • Stress	Women who experienced sexual IPV compared to those who did not report sexual IPV: • Had a higher prevalence of abdominal cramping or pain (56% vs. 42%; p=0.08). • Significant difference in number of gynecological problems (p=0.013). • Controlling for confounders, sexual assault significantly associated with gynecological problems (AOR 2.65; 95% CI:1.11–6.32)
Davila (2002)58	Mexican American abused women (18–46 years) in an urban south-central Texas city (n=20) Qualitative	Emergent themes: included physical, sexual, verbal, and psychological abuse	Condom use negotiation, partners' perceptions, and behaviors toward sexual encounters and practices (e.g., condom use)	N/A	• Initiation of condom negotiation may be in direct conflict with sociocultural and gender norms
Golding (1996)59	White, Latina, African American women (18–96 years), Epidemiologic Catchment Area Study (Los Angeles, CA, and North Carolina (n=3,419) Cross-sectional	Sexual assault: single item referring to pressured or forced sexual contact, including items on context of abuse/perpetrator	Reproductive and sexual health problems: Symptom items from the Somatization section of the Diagnostic Interview Schedule	• Age, ethnicity, income, education • Study site • Missing data	• Associations with unexplained menstrual irregularity were significant among African American women (AOR 5.82; p<0.001) and Latina women (AOR 2.44; p<0.01)
Martin and Garcia (2011)60	Latina women (30% <21 yrs, 70% ≥21 years) recruited from 5 OB/GYN clinics in Los Angeles, CA; 87% low income, earning ≤$1500 per month (n=313) Cross-sectional	Physical, sexual, and emotional IPV 12 months before and during pregnancy: 12-item screening instrument validated among Latina populations	Pregnancy intent, single item: “Before you got pregnant, were you thinking of having a baby?”	• Age, education • Level of acculturation	• Significant association between women who had an unintended pregnancy and physical IPV during pregnancy compared to women who had an intended pregnancy (AOR 2.80; 95% CI:1.01–7.73) • Bivariate only: Unintended pregnancy among less acculturated Latinas associated with physical IPV during pregnancy (OR 2.57; 95% CI: 1.06–6.23)
Miller et al. (2012)61	Latinas with known gang involvement (18–34 years) in Los Angeles, CA (n=20) Qualitative	Participants probed on dating/sexual relationships, and violence or sexual assault within such relationships	Pregnancy experiences, male partner pregnancy intentions, and sexual coercion	N/A	Emergent themes: • Limited access to reproductive healthcare compounded by male partner sexual and pregnancy coercion, as well as physical and sexual violence
Quelopana and Alcalde (2014)62	Primarily Mexican immigrant women (≥18 years) from an urban center in Kentucky (n=24) Qualitative	Experiences of psychological, physical and sexual abuse by their partner	Fertility/knowledge: contraception and unintended pregnancy	N/A	• Mexican immigrant women described IPV experiences as pregnancy coercion, control over the use of contraception, insults and intimidation to leave if she did not become pregnant, and threats to abandon her if she did not deliver a baby of a particular sex
Raj et al. (2005)63	South Asian women in Boston, MA [quantitative [18–68 years], n=208; qualitative [25–53 years] n=23] Cross-sectional mixed methods	Physical, sexual abuse and injurious IPV by current male partner: Massachusetts Behavioral Risk Factor Surveillance System	Sexual and reproductive health: single items to assess sexual and reproductive health in the past year	• Age, marital status, income * Analyses only controlled for significant demographic characteristics	Women reporting IPV vs. those without IPV experiences were more likely to report: • Discolored vaginal discharge in the past year (OR 2.64; 95% CI: 1.27–6.50) • Burning during urination in the past year (OR 3.10; 95% CI:1.52–6.31) • Unwanted pregnancy (AOR 3.39; 95% CI:1.33–8.66) (Adjusted for age)
Seth et al. (2010)64	African American (18–29 years) from Kaiser Permanente hospitals in Atlanta, GA (n=848) Cross-sectional	Past 6 months physical: “partner punched, kicked, slapped, pushed, yanked hair, or physically hurt you” Past 6 months sexual: “male partner made them have vaginal sex when they did not want to”	Risky sexual partner in the past 6 months (i.e., partner with a sexually transmitted infection (STI), injection drug user, had multiple partners) Poor condom use in past month Positive test for an STI	• Age, education, income • Living situation	Women reporting IPV vs. those not reporting IPV were more likely to report: • Risky sexual partners (AOR 2.00; 95% CI:1.5–2.8) • Inconsistent condom use (AOR 1.60; 95% CI:1.1–2.3) • Test positive for an STI (AOR 1.46; 95% CI:0.99–2.1)
Sormanti et al. (2004)65	African American and Latina women (50–83 years), predominantly low income, receiving care in urban outpatient clinics in New York City (n=139) Cross-sectional	Past 6 months and lifetime physical and/or sexual IPV: CTS-2	Sexual Risk Behavior Questionnaire: No. of sexual partners in the past year, history of being diagnosed with an STD, and consistent condom use in the past 3 months Additional questions on partner sex- and drug-related risk in past 90 days	• Age, race/ethnicity, employment • Current relationship status • Length of relationship with primary partner	• Women with multiple sexual partners more likely to report lifetime IPV (OR 4.8; 95% CI:1.6–14.4) and recent IPV (OR 8.2; 95% CI: 2.3–29.3) vs. those without multiple sex partners • Women who had primary partner with known HIV risk were more likely to report lifetime IPV (OR 3.9; 95% CI:1.3–11.9) and recent IPV (OR 8.6; 95% CI:2.4–31.3) vs. those whose partners did not have known HIV risks • Accounting for sociodemographics, significant associations remained
Stockman et al. (2013)66	African American (AA) women in Baltimore, MD, and African Caribbean (AC) women in US Virgin Islands (18–55 years) recruited from women's health clinics (n=668) Cross-sectional analysis derived from case-control study	Physical and sexual IPV in past 2 years: AAS and the Severity of Violence Against Women Scale	Sexual risk behaviors: Multiple sex partners in the past year, concurrent sex partners during the relationship, having a partner that had concurrent sex partners during the relationship, lifetime history of casual or exchange sex STI diagnosis the past year Condom use/negotiation	• Age, education • Having a current partner • Having children ≤18 years living in household	Baltimore and USVI (AA and AC women) • Having a partner with concurrent sex partners associated with recent IPV (Baltimore, AOR 3.91; 95% CI: 1.79–8.55 and USVI, AOR 2.25; 95% CI:1.11–4.56). • In Baltimore only, recent IPV associated with lifetime casual sex partners (AOR 1.99; 95% CI: 1.11–3.57); exchange sex partners (AOR 5.26; 95% CI:1.92–14.42); infrequent condom use for vaginal sex (AOR 0.24; 95% CI:0.08–0.72); and infrequent condom use for anal sex (AOR 0.29 95% CI:0.09–0.93) • In USVI only, recent IPV associated with having a concurrent sex partner (AOR 3.33; 95% CI:1.46–7.60), frequent condom use for vaginal sex (AOR 1.97; 95% CI:1.06–3.65); frequent condom use for anal sex (AOR 6.29; 95% CI:1.57–25.23); drug use (AOR 3.16; 95% CI:1.00–10.06); and a past-year STI (AOR 2.68; 95% CI:1.25–5.72)
Williams et al. (2008)67	African American low income women (≥18 years) recruited from HIV and other service agencies in Los Angeles, CA (n=155) Longitudinal study	IPV in the past 6 months: CTS items that assessed physical abuse, threats with a knife or gun and abuse during pregnancy	HIV: Determined by enzyme linked immunoabsorbent assay, confirmed by Western blot	• Age, marital status, education, employment, income • No. of sexual partners in past 6 months	• HIV+ women more likely to report at least one incident of IPV at three time points (i.e., baseline, p=0.01; 6-month, p=0.02; 12-month, p=0.07) vs. HIV−women • At baseline, abused HIV+ women reported greater depressive symptoms than nonabused HIV+ women: t(71.8)=−1.89; p=0.06.

Related to the association between IPV and HIV risk, multiple studies have found that African American and Latina women with lifetime and recent experiences of IPV are more likely to report multiple sex partners, partner-related risk (i.e., having a partner who has multiple or concurrent sex partners, is HIV-infected, injects drugs, and/or has an STI), inconsistent condom use, and an STI or STI-related symptoms when compared to African American and Latina women with no experiences of IPV.^27,64,65,68 In the only study to examine potential differences in HIV risk correlates of IPV among African American and African Caribbean women, divergent findings were observed.⁶⁶ Among African American women in the U.S., factors independently associated with recent IPV were lifetime casual and exchange sex partners, and inconsistent condom use during vaginal and anal sex; whereas, among African Caribbean women in the U.S. Virgin Islands, having a concurrent sex partner, frequent condom use during vaginal and anal sex, drug use, and a past year STI were associated with recent IPV.⁶⁶ Within Hispanic subgroups, unexpectedly, comparisons between Puerto Rican women born in the U.S. compared to those born in the Commonwealth of Puerto Rico revealed that birth in the U.S. was an indicator of greater risk for IPV, risky sexual practices, and risky partners.⁶⁹ Qualitative inquiry among Mexican American women in abusive relationships found that initiation of condom negotiation may be in direct conflict with sociocultural and gender norms.⁵⁸ Further, additional conflict may result from condom negotiation that is initiated by these women, who have less power, culturally defined by personal assets (e.g., socioeconomic status, male gender) on which an individual's authority or control over another is based.⁵⁸ Finally, specifically related to HIV status, a prospective study examined patterns in relationship violence among African American women.⁶⁷ Those who were HIV-positive were more likely to report at least one incident of IPV at three time points (i.e., baseline, 6-month and 12-month) compared to those who were HIV-negative.⁶⁷

Conclusions

This review of the literature revealed a number of prevailing themes supporting a positive and significant relationship between various form of IPV (i.e., physical and/or sexual) and physical, mental, and sexual health outcomes among ethnic minority women. Among African American, African Caribbean, Hispanic/Latina and South Asian women, IPV was associated with a variety of negative physical health outcomes including: disordered eating patterns, physical injuries (e.g., broken bones, facial injuries, head injuries), and poor perceived and overall general health. Among African American, Latina, American Indian/Alaska Native, and South Asian immigrant women, IPV was associated with various mental health disorders including: depression, suicidality, PTSD, poor mental health functioning and mood disorders. Lastly, among African American, Latina and South Asian immigrant women, IPV was associated with sexual and reproductive health outcomes including: discolored vaginal discharge, burning during urination, unwanted pregnancies, menstrual irregularity, as well as sexual risk taking (e.g., multiple sex partners, inconsistent condom use), and consequentially higher likelihood of HIV infection.

Unfortunately, most studies of IPV and health outcomes have either not had sufficient sample sizes of ethnic minority women or have not used sufficiently sophisticated statistical techniques to sort out the differences among different racial/ethnic groups. Many of the intra-ethnic group studies have confounded race/ethnicity with income and other social determinants of health by using samples of primarily poor ethnic minority women because of easier access to those populations in various clinic settings. One exception was a case-control study of 109 nonabused and 97 abused middle class, primarily employed African American women.⁷⁰ Similar to other studies, the abused African American women reported significantly more central nervous system problems, gastrointestinal problems, gynecological problems, and STDs compared with nonabused African American women within the previous year.⁷⁰ This highlights the need for future research that does not confound race/ethnicity with other social determinants to adequately capture the relationships between IPV and physical and mental health outcomes, to ultimately facilitate race- and context-specific interventions.

Implications for Prevention and Treatment

Given the disproportionate rates of IPV among ethnic minority women (i.e., Black, American Indian or Alaska Native, Hispanic/Latina) and those who are marginalized (i.e., immigrant women), as well as the health inequities associated with both minority ethnicity and IPV, there is a critical need to acknowledge the role of sociopolitical dynamics, including immigration, acculturation, and other social determinants of health in prevention and treatment efforts. In addition, there is an equally critical need to identify specific aspects of culture that are relevant to IPV in terms of seeking care, discussing abuse with healthcare providers, and responding to interventions. Abused Latina and Asian immigrant women face significant social, cultural, structural, and political barriers to patient–provider communication and help-seeking behaviors related to IPV.^71–73 U.S.-born ethnic minority women face similar barriers in addition to medical mistrust, perceived discrimination, and historical racism and trauma for both African Americans and indigenous Americans.³¹ To appropriately respond to the health needs of these women, it is essential that these multiple stressors be considered simultaneously.⁷⁴

In general, women with experiences of IPV need more healthcare than those who do not experience IPV. Those exposed to IPV are known to have higher rates of overall healthcare use (i.e., primary and preventive, urgent care, emergency care, and specialty care) and healthcare costs than women not exposed to IPV.^75,76 In one of the only population-based studies on IPV and specific preventive screening behaviors in women, those who had lifetime experiences of IPV were more likely to undergo HIV testing, cervical cytology, and breast examinations compared to those without IPV experiences.⁷⁷ However, women exposed to IPV tended to be less likely to obtain passive preventive screening tests such as mammography screening conducted in the context of routine physical care compared with women unexposed to IPV.⁷⁷ This discrepancy may be related to insurance coverage and socioeconomic status. Expanding upon these findings, a prospective longitudinal study of 1,420 women found that IPV exposure increased the odds of receiving counseling for safety and violence in the home (although the overall rate was only 20%) and screening tests for HIV/STIs; no associations were observed for IPV exposure and Pap testing, contraceptive counseling, alcohol and drug use counseling, and smoking counseling.⁷⁸ In addition, it is unknown how preventive screening behaviors may differ for abused women who are ethnic minority, impoverished, or foreign-born. What we do know is that Black and Latina women with experiences of IPV are less likely to utilize mental health services and medical attention for injuries resulting from IPV compared with White women.^79–81 Likewise, ethnic minority abused women often seek IPV-related help from informal support systems (e.g., friends, family) rather that formal support systems (e.g., health providers, mental health professionals) given experiences of medical mistrust and perceived discrimination.^72,81–83

The IPV-related health needs of Hispanics or Latinos are becoming increasingly salient with a population growth rate more than three times that of the general U.S. population⁸⁴ and continued evidence of health inequities for these groups in comparison to White women, especially middle class White women.²⁴ Similarly, there is increased recognition to account for the heterogeneity of Black women in addressing health outcomes and behaviors,⁸⁵ as there is the importance of contextualizing IPV across the different tribes among Native Americans, particularly because class and power relations differ across tribes.⁴ Further there is recognition that by preventing or alleviating IPV it is possible to prevent or alleviate some of the health problems that ethnic minority women face completely or delay their emergence and/or mitigate severity.⁸⁵ For IPV prevention programs targeting Hispanic and Black women, it is not only important to learn about the needs and preferences of these groups in general, but to tailor prevention and treatment strategies for different subgroups, accounting for possible confounding factors unique to these groups including immigration, acculturation levels, traditional gender roles, historical racism, and other socioeconomic and environmental factors that may influence health outcomes.^31,86

Acknowledgments

This work was supported by the National Institutes of Health (K01DA031593, R01HD077891, and L60MD003701).

Author Disclosure Statement

No competing financial interests exist.