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With its daunting complexities, the path to change takes courage and support.

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Domestic abuse. Battering. Intimate partner violence. These are terms that make us wince. And they should: The phenomenon is widespread in the United States, and its effects can be long-lasting and life-threatening. Breaking the pattern of domestic violence can be extremely difficult and may take a long time. It requires courage, planning, and a support network.

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The U.S. Department of Health and Human Services defines domestic violence as "a pattern of assaultive and/or coercive behaviors...that adults use against their intimate partners to gain power and control in that relationship." It includes not only physical and sexual abuse but also emotional abuse. All can have serious health consequences.

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Domestic violence affects people of all ethnic backgrounds; it occurs among the poor and the rich and among the well educated and the poorly educated. Men are usually (though not always) the abusers, and women are usually on the receiving end. In the United States, a woman's lifetime risk of being a victim of such violence is 25%. Women who were abused as children are at an increased risk for being in an abusive relationship as an adult.

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First signs

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Women don't consciously choose to have an abusive partner. In fact, the abuser may be charming and well liked by most of the people who know him, but at home he shows a different side. Friends, family, and colleagues are often shocked when his abusive behavior becomes known. In the beginning, it may also be a shock to the abused woman. She may have regarded her relationship with this man as the most wonderful, romantic, fairy tale–like experience imaginable, says Susan Neis, executive director of Cornerstone, a shelter that serves five suburbs of Minneapolis.

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Changes in the relationship can be difficult to see at first. The abuser's need for control often begins to show itself in little things he says and does. He may criticize the way his partner acts or looks. He may say deeply hurtful things, such as accusing her of being a bad mother. "When somebody says this to you, somebody you're in love with, it's devastating," says Neis, who is herself a survivor of domestic abuse.

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Over time, the abuser's words can chip away at a woman's sense of herself. She starts to doubt her perceptions and may even come to believe the horrible things he says about her. She feels isolated, ashamed, and helpless, but at the same time may feel an obligation to keep herself convinced of the fairy tale because "there's nothing else to hold onto," says one 35-year-old woman who received help from Cornerstone.

 

Control and power

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At the center of domestic violence is the issue of control. The abuser is intent on gaining and maintaining power over his partner through fear and intimidation. Abuse doesn't necessarily involve physical harm. Threats can also be highly effective and should not be minimized, suggests Dr. Judith Herman, clinical professor of psychiatry at Harvard Medical School and training director of the Victims of Violence Program at Cambridge Health Alliance in Cambridge, Mass. A man who says "If you leave me, I'll track you down and kill you and anyone who helps you" can instill as much (or more) fear as one who strikes his partner.

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The abusive partner uses various tactics to achieve control. He may intimidate and demean his partner by constantly criticizing her, monopolizing household finances, or telling her what she can wear, where she can go, and whom she can see. He may play "mind games," such as suggesting that she's hypersensitive, hysterical, or mentally unbalanced. Often he isolates the woman from family, friends, and colleagues, either by removing her from them physically or by limiting her employment options and social contacts. Abuse may also take the form of pathological jealousy, such as false accusations of adultery. Soon, the woman may find that she's cut off from all outside connections, no longer in touch with the people and services that could help her.

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Isolation may also disconnect her from a sense of what's normal. She may not even think of herself as a victim of domestic violence, says Dr. Megan Gerber, an internist at Cambridge Health Alliance who specializes in women's health and an instructor of medicine at Harvard Medical School. After an incident, the abuser often apologizes and tries to placate his victim. There may be periods of relative calm. It may take a victim a long time to recognize that her partner's behaviors aren't random but form a pattern of abuse.

Intimate partner abuse is a health issue

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Intimate partner abuse can have profound effects on a woman's health, both physical and mental. Physical harm, including fractures, lacerations, and soft tissue trauma, is one obvious effect. Intimate partner abuse is also linked to chronic health problems and even death — from either suicide because of depression or murder (or manslaughter) by the partner.

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The intense, ongoing stress may result in chronic pain or gastrointestinal symptoms. Victims of domestic abuse are more likely to have arthritis, neck pain, pelvic pain, and migraine headaches. They also have an increased risk of menstrual problems and difficulties during pregnancy, including bleeding, low birth weight, and anemia.

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Domestic abuse is closely linked with mental illness and substance abuse. A study found that 47.6% of battered women were depressed and 63.8% had post-traumatic stress disorder; 18.5% used alcohol excessively; 8.9% used drugs; and 7.9% committed suicide.

Because women in abusive relationships often need emergency room and primary care services, physicians, nurses, and other clinicians are often the first outsiders to learn about the emotional or physical abuse. Women are often reluctant to mention the subject on a patient history form, but if asked by a clinician, they may be relieved to acknowledge it.

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Getting out

Walking away from an abusive relationship is a process more than a single action. Women usually make several attempts — five, on average — before they leave the partner for good. Isolation and fear may prevent a woman from leaving, even when she knows it is probably for the best. She may still love her partner or worry about what will happen to her children if she leaves. She may be unsure how to escape or how to survive financially and care for her children.

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Community support can be crucial (see "Selected resources"), although a woman in an abusive relationship often has difficulty taking advantage of that support. The abuser may track her computer use, looking for visits to Web sites and evidence of keyword searches. If that's a concern, says Rita Smith, executive director of the National Coalition Against Domestic Violence in Boulder, Colo., she should use a computer outside the home — for example at a library or a friend's home or work place. As a safeguard, the coalition's own site (www.ncadv.org) features a red "Escape" button that immediately switches the user to an Internet search engine.

Selected resources

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National Domestic Violence Hotline800-799-7233 (toll free)800-787-3224 (for the hearing impaired; toll free)

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National Sexual Assault Hotline800-656-4673 (toll free)

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National Women's Health Information Center, "Violence against Women" womenshealth.gov/violence/domestic/800-994-9662 (toll free)

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United Way First Call for Help800-231-4377 (toll free)

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Care for the children

Each year, up to 10 million children witness the abuse of a parent or caregiver. Many women stay in an abusive relationship because they think it's best not to disrupt the children's lives so long as they're not being abused themselves. But children who live with domestic violence are at serious risk for behavioral and cognitive problems. In later life, they may suffer depression and trauma symptoms, and they may tolerate or use violence in their own relationships.

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Experts say that women leaving an abusive relationship should take their children with them. Otherwise, it can be difficult to get the children later, because police may not want to remove them from the home if the abusive partner is their biological father. Also, the abuser may later try to get custody by arguing that the woman abandoned her children.

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What can I do to help?

You suspect that your friend is in an abusive relationship. For example, she seems anxious and fearful when she recounts arguments with her husband. Or she may mention having to ask him each time she needs money. (While by itself not a sign of abuse, controlling finances can be part of a pattern of abuse.)

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Part of you wants to rescue her and take her to a safe place where her husband can't find her. Yet you worry that any action you take could make things worse, increasing the danger she's already in. You know the decision is hers to make, not yours. But you can do a lot to help. Here are some things to consider:

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• Think about your relationship with your friend. When and where might you talk with her safely, and what could you say? Does she trust you? Does she feel that she can confide in you without fearing that you'd judge her harshly or dismiss her concerns?

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• Ask questions that let her know of your suspicions and concern. One question might be: Are you afraid of your husband? Understand that she might be hesitant to talk about this directly — or might deny or minimize what's happening. Assure her that you'll keep what she says strictly confidential.

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• When she talks about the situation, believe what she says and validate her concerns. Let her know you don't think she's crazy or it's all in her head. And let her know that she's not to blame, despite what her partner may have told her.

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• Help your friend make use of local resources — public health services, a hospital or clinic, a women's shelter, or a legal assistance program. If she thinks the abuser is monitoring her phone calls, offer her the use of your home phone or cell phone to make these contacts.

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• Work with your friend to develop a personal safety plan. One resource for this step is the National Coalition Against Domestic Violence, www.ncadv.org/protectyourself/MyPersonalSafetyPlan_131.html.

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• Help her prepare to leave if the danger and abuse escalate. Your friend should have coins with her at all times for phone calls, or a phone card. She should prepare a small bag with clothes, cash, and copies of important documents (birth certificate and passport, for example) and keep it in a safe place. Would you be willing to keep the bag for her in case of need?

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Knowing that someone believes her and is ready to help can be crucial to your friend's safety and eventual escape from the abusive relationship. Be patient, listen, and offer her hope. Recognize that it may take a long time, and often several attempts at leaving, for the relationship to end.