ABSTRACT: Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician–gynecologists and other women’s health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

In this paper, we review the basis of the U.S. Preventive Services Task Force's recommendations related to routine screening for intimate partner violence (IPV), focus on two of the arguments of those who have rejected these recommendations, and based on these, suggest that this controversy has occurred, in part, as a result of different interpretations of the meaning of "screening." We differentiate screening from situations in which asking about IPV is essential for differential diagnosis, that is, exploring exposure to IPV when there are signs and symptoms that might result from this exposure. Finally, we describe the randomized, controlled trial CDC is conducting to contribute to the evidence the U.S. Preventive Services Task Force requries to make its recommendations.

This article provides the most recent U.S. prevalence estimates of forced sex and unwanted sexual activity. Results of a national telephone survey conducted in 2001-2003 indicate that 1 in 59 U.S. adults (2.7 million women and 978,000 men) experienced unwanted sexual activity in the 12 months preceding the survey and that 1 in 15 U.S. adults (11.7 million women and 2.1 million men) have been forced to have sex during their lifetime. There were 60.4% of females and 69.2% of males who were 17 years old or younger at the time the first forced sex occurred. This study provides an update to the National Violence Against Women Survey with more recent national data. Findings suggest that victimization rates have remained consistent since the 1990s. These findings suggest that a continued effort toward primary prevention of sexual violence, particularly rape of children and adolescents, is needed.

BACKGROUND:Stalking is a major public health concern, primarily for women, and is associated with many adverse health outcomes, including death. However, the prevalence of stalking among adults in the United States has not been assessed since 1995-1996. The objective of this analysis is to provide more recent national estimates on lifetime stalking and demographic characteristics of stalking victims.METHODS:A sample of adults aged 18 years and older living in the United States (n = 9684) participated in the second Injury Control and Risk Survey (ICARIS-2), a cross-sectional, random-digit-dial telephone survey conducted from 2001 to 2003. Analyses conducted in 2005 focused on the respondents' reports of having ever been stalked in a way that was somewhat dangerous or life-threatening.RESULTS:In the United States, 4.5% of adults reported having ever been stalked. Women had significantly higher prevalence (7%) of stalking victimization than did men (2%) (odds ratio [OR] = 3.68, 95% confidence interval [CI] = 2.77-4.90). People who were never married (OR = 1.43, 95%CI = 1.03-1.99) or who were separated, widowed, or divorced (OR = 1.68, 95% CI = 1.28-2.21) had significantly higher odds of being stalked than those who were married or had a partner. People aged 55 years or older and those who were retired were least likely to report stalking victimization.CONCLUSIONS:Comparable to previous national estimates, this study shows that stalking affects many adults. Nearly 1 in 22 adults (almost 10 million, approximately 80% of whom were women) in the United States were stalked at some time in their lives.

Purpose To expand the understanding of the association between recent health-risk behaviors and a history of forced sexual intercourse, using a nationally representative sample of female and male high school students. Methods Data were from the 2003 National Youth Risk Behavior Survey, a nationally representative biennial survey of U.S. high school students. Lifetime history of forced sex, recent physical dating violence, and health-risk behaviors (substance use, diet-related behaviors, violence-related behaviors, and health promoting behaviors) were assessed. Analyses were stratified by gender and controlled for grade and race/ethnicity. Results Of students surveyed, 8.9% reported ever being forced to have sex. One in eight females and one in 16 males experienced forced sex in their lifetime. For females and males, a history of forced sex was associated with experiencing physical dating violence and suicidal ideation in the 12 months preceding the survey and with substance use in the previous 30 days. Female victims were not as likely as female nonvictims to have participated in team sports during the previous 12 months. Male victims were more likely than male nonvictims to have fasted for more than 24 hours to lose weight during the previous 30 days. Conclusions A lifetime history of forced sex is associated with recent dating violence and participation in unhealthy behaviors. Services and intervention programs for victimized youth should address health concerns that have been linked to sexual assault. Such programs would provide opportunities for early intervention with lasting implications for improved health.

Objective: To learn about U. S. medical students' attitudes, experiences, and practices regarding intimate partner violence (IPV).Methods: In a sample reflective of all U. S. medical schools, we surveyed the class of 2003 in 16 U. S. medical schools at three different times in their training.Results: A total of 2316 medical students responded, for a response rate of 80%. By senior year, although 91% of medical students reported receiving at least some training in discussing IPV, only one fifth reported extensive training. Although 73% of students entering wards thought IPV was highly important for physicians to discuss with patients, only 55% of students entering wards, decreasing to 35% of seniors, thought IPV would be highly relevant to their own practice. Only 55% of seniors reported talking with general medicine patients at least sometimes about IPV. Greater frequency of discussing IPV for seniors was associated with being a woman (60% vs. 50% for men, p = 0.006), self-designating as politically moderate or liberal (p = 0.0008), and thinking (on entering wards) that it was highly important for physicians to talk to patients about IPV (p = 0.0002). Perceived relevance of discussing domestic violence to intended practice was substantially higher among women, underrepresented minorities, those having a personal or family history of domestic violence, and those categorizing themselves as politically liberal or very liberal. Among seniors, the prevalence of reporting a personal history of IPV was 3% for women and 1% for men; 12% of women and 7% of men reported a family or personal IPV history.Conclusions: Despite national interest in IPV issues, efforts in U. S. medical schools to increase IPV screening and prevention have not achieved saturation. These gaps in IPV instruction in medical schools are a concern because studies have reported that physicians who receive IPV education training are significantly more likely to screen for it.

STUDY OBJECTIVE:There is little information about sexual violence cases treated in emergency departments (EDs). This study describes ED visits associated with sexual violence and considers the associated health care burden.METHODS:A descriptive analysis was conducted using nationally representative data on nonfatal injury-related ED visits identified in the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) as sexual violence. To better understand these NEISS-AIP data, additional information about ED management of cases was collected, and additional information was collected from NEISS-AIP coders to determine the percentage of hospitals serving as designated examination facilities for sexual assault.RESULTS:Of all assault visits to the ED, 4.2% were sexual assault related, which represents an estimated 143,647 ED visits for sexual assault in 2001 to 2002. The majority of sexual assault-related visits involved female and young patients. Nearly half of ED visits for sexual violence had missing perpetrator data. Additional data from hospitals revealed that in 77.8% of the 54 sexual assault cases, someone with specific training completed the examination, and the majority of the hospitals in this study serve as designated examination facilities for sexual assault.CONCLUSION:Given the dearth of national data on sexual violence cases presented at US EDs, the data presented in this article are useful to understand the impact of sexual violence on the health care system at a national level. More complete documentation of sexual assault-related cases in EDs is needed to get a better estimate of the problem in future studies.

This paper asserts that although there is considerable agreement in the U.S. and internationally about the importance of uniform terminology and measurement related to violence against women, we need a strategy for choosing standardized definitions and measures. Responding to Kilpatrick’s comments at the October 2003 national research conference on violence against women, the author stresses the importance of developing and using uniform terminology related to violence against women, and discusses the lack of a formal mechanism to achieve uniformity of definitions and measurement. Uncertainty about the impact of context on survey findings and the lack of agreement about the optimal scope of measurement are discussed. The author also comments on some difficulties associated with implementing Kilpatrick’s proposed modifications to existing measures of rape and sexual assault.

Objectives: From self-reports we describe and compare the levels and patterns of physical abuse before and during pregnancy while also describing the demographic and pregnancy-related characteristics of physically abused women, the stressful experiences of abused women prior to delivery, and the relationship of the abused woman to the perpetrator(s). Methods: We used population-based estimates from the Pregnancy Risk Assessment Monitoring System (1996–98) to calculate a multiyear 16-state prevalence with 95% confidence intervals (CIs) and unadjusted risk ratios for demographic, pregnancy-related, and stressful experiences variables. Results: We found the prevalence of abuse across the 16 states to be 7.2% (95% CI, 6.9-7.6) during the 12 months before pregnancy, 5.3% (95% CI, 5.0–5.6) during pregnancy, and 8.7% (95% CI, 8.3–9.1) around the time of pregnancy (abuse before or during pregnancy). The prevalence of physical abuse during pregnancy across the 16 states was consistently lower than that before pregnancy. For time periods both before and during pregnancy, higher prevalence was found for women who were young, not White, unmarried, had less than 12 years of education, received Medicaid benefits, or had unintended pregnancies, and for women with stressful experiences during pregnancy, particularly being involved in a fight or increased arguing with a husband or partner. For each of these risk groups, the prevalence was lower during pregnancy than before. Abuse was ongoing before pregnancy for three quarters of the women experiencing abuse by a husband or partner during pregnancy. Conclusions: Women are not necessarily at greater risk of physical abuse when they are pregnant than before pregnancy. Both the preconception period and the period during pregnancy are periods of risk, which suggests that prevention activities are appropriate during routine health care visits before pregnancy as well as during family planning and prenatal care.

Homicide is among the six leading causes of death for those between the ages of 1 and 44, and accounts for approximately 18,000 deaths annually in the United States.1 The majority of homicides are committed by persons known to the victim.2 Approximately one in three homicides of females is committed by current or former spouses or boyfriends, a group collectively referred to as intimate partners.3 Among male homicide victims, five percent are killed by intimate partners. Unlike other causes of death, intimate partner homicides cannot be described by using death certificate information because death certificates do not record the victim's relationship to the perpetrator. This report summarizes information regarding intimate partner homicides that occurred in the United States during the period from 1981 through 1998, and is based on supplemental homicide reports collected by the Federal Bureau of Investigation as part of their Uniform Crime Reporting System. Supplemental homicide reports are filed voluntarily by police departments for homicides occurring within their jurisdiction, and include demographic variables regarding victims and perpetrators, their relationship, and any weapon used. Intimate partner homicide rates among white females decreased 23%, and rates among white males decreased 62% The database contains reports completed by police departments throughout the United States. Submission of crime data to the FBI is voluntary, and the system does not capture all homicides. The true number of homicides can be estimated by comparing FBI homicide counts with homicide counts from CDC's National Center for Health Statistics. This report uses FBI supplemental homicide report data, adjusted by comparison with NCHS data, to describe the risk for intimate partner homicide by demographic variables from 1981 through 1998. Homicide Reporting Supplemental homicide reporting began in the 1960s. The data collection form did not change during 1981–1998. Participating police departments complete the forms for every homicide that occurs within their jurisdictions and submit the forms monthly to the FBI as part of the Uniform Crime Reporting Program.4 All homicides that occur in the United States are included, and these homicides include U.S. and non U.S. residents. Deaths of U.S. residents abroad are not included. Data are not updated to reflect the results of subsequent investigation after they are submitted.5 Throughout this report, homicide rates refer to rates of victims rather than rates of perpetrators. This study excluded negligent homicides; homicides termed justifiable, which is defined by the FBI as the killing of a person committing a felony; and homicides resulting from legal intervention. The reports also include the relation of the victim to the offender if known when the reports are submitted. This study included homicides in which the victim was age 10 or older and the perpetrator was an intimate partner. The relationship categories are classified as intimate partner relationships are spouse, ex-spouse, common-law spouse, boyfriend, girlfriend, and homosexual relationships. There is no separate category for ex-boyfriend or ex-girlfriend, although such persons also are regarded as intimate partners by Centers for Disease Control and Prevention.6 Such persons would probably have been categorized as acquaintances by the FBI and therefore would not have been included in this study. Initial comparison of the total number of homicides in supplemental homicide reports with the total number of homicides not caused by legal intervention7 and reported by NCHS indicated that the database had included 85 to 90 percent of homicides recorded on death certificates from 1981 through 1998. Analyzing the Data From 1981 through 1998, 346,258 homicides were recorded in the supplemental homicide report database, and 381,408 homicides were recorded in the vital records database. Among the homicides, 16,809 were dropped from the analysis because they were classified as negligent manslaughter or justifiable homicide or were associated with legal intervention. An additional 28,927 homicides were dropped from the analysis because they involved multiple victims or because the age, race, or sex of the victim was missing. Consequently, 300,522 homicides were available for analysis. The average weight applied to the intimate partner homicide counts to generate the estimated number of intimate partner homicides was the ratio of vital records homicides (381,408) to 300,522 or 1.28. Of 300,522 records, supplemental homicide reports recorded 35,601 (11.8%) After weighting, an estimated 45,513 (11.9%) intimate partner homicides occurred from 1981 to 1998. Of these 45,513, approximately 28,991 (63.7%) of homicides were perpetrated against females, 93.8 percent of males were victimized by females, and 99.5 percent of females were victimized by males. Overall, male intimate partner homicide rates were 62.2 percent of female rates. Rates among females exceeded rates among males for all races except blacks, where intimate partner homicide rates among males were greater than rates among females. The highest overall and sex-specific rates were reported among blacks, followed by American Indian/Alaska Natives, whites, and Asian or Pacific Islanders, in that order. Ethnicity data were collected only from 1980 to 1987, and were not analyzed for this report. Risk for intimate partner homicide was greater for those 20 to 29 than for those 10 to 19. Intimate partner homicide risk peaked for black females 20 to 29, white females and black males 30 to 39, and white males 40 to 49. For all groups except black females, rates for those 80 or older exceeded those for persons 10 to 19. Rates among blacks exceeded rates among whites for females and males in all age groups. Rates among white females exceeded rates among white males for every age group, whereas rates among black males surpassed rates among black females in the 30–39 age group, and remained greater through successive age groups. Homicide against Children Overall, 113 homicides occurred among children 10 to 14, 0.3 percent of the total. Intimate partner homicides occurred at ages as young as 12 years. A total of 1,845 homicides occurred among those 15 to 19, which is 4.1 percent of the total. The 2,666 homicides among those 65 or older accounted for 5.9 percent of the total. Persons 20 to 64 accounted for approximately 90 percent of intimate partner homicide. From 1981 to 1998, intimate partner homicides decreased by 47.2 percent in the United States. Rates decreased among both whites and blacks. In that period, rates among white females decreased 23 percent, and rates among white males decreased 61.9 percent. Rates among black females decreased 47.6 percent, and rates among black males decreased 76.4 percent. As a result of the greater decrease in rates among black males versus black females, black females as of 1998 had the highest rates among black and white males and females. Overall, rates among males decreased 67.8 percent, and rates among females decreased 30.1 percent. The risks for intimate partner homicide among white and black females varied across states, but were highest in southern states. Rates among males are not indicated by state because of the unstable intimate partner homicide rates for both races. Rates among white females were higher in southern states and Rocky Mountain states. Rates were lowest among white females in New England and the upper Midwest. Among black females, the highest rates were clustered in southern states, but rates were unstable in many western and New England states. The highest rate among white females was in South Carolina; the highest rate among black females was in Arkansas. The risk for intimate partner homicide consistently decreased with decreasing city size for both males and females. Cities with more than 250,000 residents had rates two to three times the rates of cities of fewer than 10,000 residents. However, rural counties indicated rates comparable with those of cities of 50,000 to 99,999 residents. Approximately 50 percent of all intimate partner homicide victims of either sex were killed by their legal spouses. Approximately 33 percent were killed by boyfriends or girlfriends. The proportion of intimate partner homicides committed by same-sex partners was much greater for males than females. Among black victims of both sexes and female American Indian/Alaska Natives victims, a greater percentage was killed by boyfriends or girlfriends than by current spouses. Among male American Indian/Alaska Natives victims, an equal percentage was killed by girlfriends as by current spouses. Among white and Asian victims of both sexes, a greater percentage was killed by current spouses than by boyfriends or girlfriends. Firearms were the major weapon type used in intimate partner homicides among both sexes. Males were more likely to be killed by knives than females, while females were more likely to be killed by blunt objects or blows delivered by the hands or feet. Boyfriends and girlfriends and common-law spouses were much less likely to be killed by firearms than spouses and ex-spouses. Male victims killed by girlfriends or common-law spouses were equally likely to be killed by firearms and knives. In the analysis of the distribution of deaths by month, observed numbers exceeded expected numbers (i.e., the observed-to-expected ratio exceeded one) during the summer months among both white and black males. This pattern was less noticeable for females. For all race-sex groups, January, October, and November were below expectations, although the deficit was least noticeable among white females. The difference between the peak and nadir months was greatest among white males, for whom the risk for intimate partner homicide was 30 percent greater in July than in October. Women at Greater Risk From 1981 to 1998, substantial variation occurred in the risk for intimate partner homicide by race, sex, age group, time, state, and community size. Populations identified with the highest estimated rates were the same as those identified in previous studies using the supplemental homicide reports.8 Data from this analysis indicated that females have an overall greater risk for intimate partner homicide victimization than males. This was consistent with studies of sex-specific rates of nonfatal intimate partner assaults from emergency department data.9,10 Surveys that focused on more serious assaults (e.g., those accompanied by injuries) also reported a greater rate of assaults on females11,12 while surveys that included a substantial share of assaults without physical injuries between partners report equal victimization rates.13,14 The general interpretation of the data was that males have a size and strength advantage that reduces their risk for injury in any physical confrontation with a woman.15 Rates among black females decreased 48%, and rates among black males decreased 76% Why intimate partner homicide rates among black males were greater than rates among black females is unclear. Also unclear is why white males were at approximately the same risk as white females for intimate partner homicide in the early 1980s. One possible explanation is that females used lethal weapons more often in altercations with male intimate partners to compensate for their size and strength disadvantage. Intimate partner altercations involving firearms and knives are substantially more likely to result in death than other types of altercations.16 From 1981 to 1998, blacks had the highest intimate partner homicide rates for both sexes. Rates among whites and Asian or Pacific Islanders were lowest, with rates among American Indians/Alaskan Natives in between those among blacks and whites. Higher rates for nonfatal intimate partner altercations have been reported among nonwhites.11,12 One study reported a greater rate of intimate partner homicides among American Indians/Alaskan Natives.17 These rate differences among racial groups could partially or fully be explained by socioeconomic differences. Females with low education and income levels have a greater risk for intimate partner violence.11,18–23 Risk Begins at Puberty The risk for intimate partner homicide begins at puberty, and increases substantially when adolescents reach ages 20 to 29. Younger females have a greater risk for intimate partner violence as well as intimate partner homicide.11,19,20,22,24 This risk could be evident because females tend to move away from the protection of home in their 20s. However, the highest risk for intimate partner homicide, at least for a white female, does not occur until her 30s. Intimate partner homicide risk for black and white females decreases substantially thereafter. For males, the highest risk for intimate partner homicide occurs approximately 10 years after the peak periods for females of the same race and decreases more slowly with age. Previous studies reported that the mean age of male perpetrators of intimate partner homicide is three to four years greater than that of their victims2 and that risk increases with the age difference.24 Rates of nonfatal intimate partner violoence also have decreased.25 The identification of domestic violence as a national problem, subsequent legal and social measures (e.g., legal advocacy services, hotlines, shelters) to remedy domestic violence, as well as rising divorce rates, have led to greater percentages of abused females ending cohabitation with abusers.26,27 These measures might be expected to equally reduce rates among males and females in parallel. However, data indicated that greater decreases occurred in intimate partner homicide rates among males from 1981 to 1998. In 1981, rates among males were only slightly less than rates among females, whereas in 1998, rates among males had decreased to less than half the rates among females. The reason for the more substantial decreases in rates among males compared with females is not known. Firearm-related homicide rates among males might have been reduced by simplifying the process by which females can leave their abusers. Theoretically, a female who does not live with her attacker could be less likely to kill him with his own firearm. In addition, overall rates among females might not have decreased as much as rates among males because of social and legal changes that have brought about an increase in intimate partner homicide rates among females in less formal noncohabiting relationships with males. From 1976 through 1995, the only type of intimate partner homicide to increase was that of white females by their boyfriends, where the rate increased 29 percent.3,28 A comparison of trends in intimate partner homicide with trends in total homicides demonstrates that other nonspecific factors might be involved. The most appropriate comparison is with total homicides among adults because teenage intimate partner homicides account for less than five percent of all intimate partner homicides, whereas teenage homicides account for a majority of the variation in overall homicide rates from 1981 to 1998.8 The comparison documents that intimate partner homicide decreases occurred at the same time as decreases in total homicides. Demographic DataTable: Intimate Partner Homicides 1981-1998From 1981 to 1998, total homicide rates among persons those 20 and older decreased 30.9 percent among females and 43.1 percent among males. Therefore, the decrease in female intimate partner homicide (30.1%) is essentially the same as the decrease in total adult female homicides while the decrease in male intimate partner homicide (67.8%) is more substantial than the corresponding decrease in total adult male homicides. Possibly, the nonspecific demographic, social, and economic changes also contributed to the decrease in IPH among both sexes.29 From 1981 to 1998, intimate partner homicides decreased by 47.2 percent in the United States Comparison of rates by state for white and black females indicates a pattern similar to that of all homicides, with greater rates in the southern and western states when stratified by race.30 This regional variation might be attributable to differences in cultural and social norms. For example, southerners might be more likely to endorse violence in response to insults.31,32 The steady increase in risk for intimate partner homicide with urbanization is consistent with the pattern for homicide8 and nonfatal violence among intimate partners.11,21 However, the relation might be confounded by an association between black race and urban residence.33 An increased risk from residence in rural counties compared with cities has not been reported for all homicides. The distribution of intimate partner homicides by relationship indicates differences by sex and race. However, these differences cannot be interpreted as risk differences without translating them into rates. Such analysis has been conducted previously for whites and blacks3 but not for other races. Previous analysis indicates that intimate partner homicide victimization rates are greater for wives than girlfriends and for husbands than boyfriends. However, these differences have been decreasing perhaps because laws and services addressing intimate partner violence historically have been directed toward married persons.27 The weapon type used also varies by the victim's sex and relationship to the perpetrator. The percentage of male intimate partner homicide victims killed with firearms (59.1%) is less than the percentage of all male homicide victims killed with firearms during the same time period (69.1%). Knives were used to kill 35.1 percent of male intimate partner homicide victims and 16.1 percent of all male homicide victims during the same period. In contrast, the percentage of female victims killed with firearms (64.1%) was greater than the percent of all female homicide victims killed with firearms (47.5%). Knives account for 17.4 percent of all female homicides and 16.1 percent of female intimate partner homicide. Therefore, female victims are more likely to be killed with a gun than are all female homicide victims, whereas male victims are more likely to be killed with a knife than are all male homicide victims. Overall, the figures demonstrate the importance of reducing access to firearms in households affected by intimate partner violence.16,34 Firearms are more likely to be used by spouses than by girlfriends in the killing of male intimate partners. This finding might be a result of the association noted previously between intimate partner homicides among unmarried partners and black race. Firearms are less likely to be present in nonwhite households in the United States.35 Finally, the lower observed-to-expected ratios for intimate partner homicides during January, October, and November have not been reported previously. However, a summer increase and autumn decrease in police dispatches for domestic violence disputes have been described in California.36 This seasonal pattern is distinct from that noted among all homicides, where increased rates are observed in the summer, but the winter is the period of lowest rates.37,38 In Brief Amiodarone Compared with Lidocaine for VF Lidocaine has been the initial antiarrhythmic drug treatment recommended for patients with ventricular fibrillation that is resistant to conversion by defibrillator shocks, and research published in the New England Journal of Medicine (2002;346[12]:884) compared intravenous lidocaine with intravenous amiodarone as an adjunct to defibrillation in victims of out-of-hospital cardiac arrest. Patients were enrolled if they had out-of-hospital ventricular fibrillation resistant to three shocks, intravenous epinephrine, and a further shock; or if they had recurrent ventricular fibrillation after initially successful defibrillation. They were randomly assigned in a double-blind manner to receive intravenous amiodarone plus lidocaine placebo or intravenous lidocaine plus amiodarone placebo. The primary end-point was the proportion of patients who survived to be admitted to the hospital. In total, 347 patients (mean [±SD] age, 67±14 years) were enrolled. The mean interval between the time at which paramedics were dispatched to the scene of the cardiac arrest and the time of their arrival was 7±3 minutes, and the mean interval from dispatch to drug administration was 25±8 minutes. After treatment with amiodarone, 22.8 percent of 180 patients survived to hospital admission, as compared with 12 percent of 167 patients treated with lidocaine (P=0.009; odds ratio, 2.17; 95 percent confidence interval, 1.21 to 3.83). Among patients for whom the time from dispatch to the administration of the drug was equal to or less than the median time (24 minutes), 27.7 percent of those given amiodarone and 15.3 percent of those given lidocaine survived to hospital admission (P=0.05). As compared with lidocaine, amiodarone leads to substantially higher rates of survival to hospital admission in patients with shock-resistant out-of-hospital ventricular fibrillation. AAEM Elects New Members The American Academy of Emergency Medicine elected new officers and members of its board of directors at its Eighth Annual Scientific Assembly in March. The new officers who will serve until 2004 are Joseph P. Wood, MD, of Scottsdale, AZ, president; A. Antoine Kazzi, MD, of Orange, CA, vice president; and Tom Scaletta, MD, of La Grange, IL, as secretary-treasurer. Kevin J. Rodgers, MD, was elected to serve as an board member-at-large while Howard Blumstein, MD, and Raymond Roberge, MD, were re-elected to second terms on the board. All three will serve until 2005. Anthony DeMond, MD, James Li, MD, and Paul Sierzenski, MD, were appointed to one-year terms on the board to fill vacancies left by Drs. Kazzi and Scaletta and Margaret O'Leary, MD.

Using data from the National Crime Victimization Survey, this paper attempts to disentangle the effects of self-protective behaviors on the risk of injury in assaults against women. Unlike previous research, in this study we address simultaneously three important conceptual and methodological issues: (1) type of self-protective behavior, (2) temporal sequencing of self-protective behavior in relation to injury, and (3) the victim/offender relationship. Results indicate that even after controlling for other contextual characteristics of an assault, the probability of a woman being injured was lowest when she employed non-physical resistance strategies such as arguing or reasoning with the offender. This was true for all types of offenders. However, for assaults involving intimates, the probability of injury was increased for women who physically resisted their attackers.

PROBLEM/CONDITION:A substantial percentage of all homicides in the United States are committed by intimate partners of the victims. Among females, approximately 1 in 3 homicides are intimate partner homicides (IPHs). Intimate partner homicides cannot be tracked by using death certificates because death certificates do not record the victim's relationship to the perpetrator.REPORTING PERIOD COVERED:This report summarizes information regarding IPHs that occurred in the United States during 1981-1998.DESCRIPTION OF THE SYSTEM:This report is based on Supplemental Homicide Reports (SHRs) collected by the Federal Bureau of Investigation (FBI) as part of their Uniform Crime Reporting System. SHRs are filed voluntarily by police departments for homicides occurring within their jurisdiction. SHRs include demographic variables regarding victims and perpetrators, their relationship, and weapon(s) used. Data from the SHR file were weighted by comparison with homicide data from death certificates to compensate for underreporting. IPHs were restricted to victims aged > or = 10 years.RESULTS:The risk for death from IPH among males was 0.62 times the risk among females. However, the rate among black males was 1.16 times the rate among black females. Among racial groups, rates among blacks were highest, and the rates among Asian or Pacific Islanders were lowest. Rates were highest among females aged 20-49 years and among males aged 30-59 years. During the study period, rates among white females decreased 23%, and rates among white males decreased 61.9%. Rates among black females decreased 47.6%, and rates among black males decreased 76.4%. Highest rates occurred in the southern and western states among both white and black females. A graded increase in IPH risk occurred with community population size. Approximately 50% of IPHs were committed by legal spouses and 33% by boyfriends or girlfriends for both male and female victims. IPH rates were less than expected during the months of January, October, and November.INTERPRETATION:Although total homicide rates have fluctuated during 1981-1998, IPH rates have decreased steadily during this period, and among certain subpopulations, the decrease has been substantial. Decreases are temporally associated with the introduction of social programs and legal measures to curb intimate partner violence, but a causal relationship has not been established. Likewise, no confirmed explanation exists for the greater decrease in rates among males compared with rates among females. The differences in IPH rates by race indicate that economic, social, and cultural factors are involved. The analysis by community population size and state demonstrates that regional sociocultural differences might be involved also. Access to firearms might be a key factor in both male and female IPHs.PUBLIC HEALTH ACTIONS:The descriptive epidemiology of IPH is changing rapidly and should continue to be monitored. Understanding the reasons forthe recent decreases in IPHs might help identify methods for primary and secondary prevention and further reduce IPH rates.

Despite the recognition that violence may be associated with serious consequences for women's reproductive health, the understanding of the relationship between the two remains limited, as does our understanding of the most effective role for reproductive health care providers and services. This paper briefly summarizes the history of the nexus of public health, health care, and violence against women in the United States. In addition, we present some considerations for future directions for research, health care practice, and policy that will advance the understanding of the complex relationship between violence and reproductive health.

Objective: This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors. Methods: In 1996–1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2–6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy. Results: Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics; the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester. Conclusions: Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Since the early 1980s, the Centers for Disease Control and Prevention (CDC) has focused on preventing violence using a public health approach. In 1994, the CDC's National Center for Injury Prevention and Control (NCIPC), Division of Violence Prevention, was funded to strengthen efforts to prevent family and intimate partner violence and to develop a national prevention program for violence against women (VAW).1Saltzman L.E. Johnson D. CDC's Family and Intimate Violence Prevention Team basing programs on science.J Am Med Womens Assoc. 1996; 51: 83-86PubMed Google Scholar This work continues today, not only within the NCIPC, but also in collaboration with other CDC programs and federal agencies. We use the term VAW to include intimate partner violence (IPV), sexual violence by any perpetrator, and other forms of violence against women (e.g., physical violence committed by acquaintances or strangers). In this commentary, we describe the public health approach to prevention; give examples of some current CDC activities focused on VAW, including those conducted in partnership with agencies both within and outside the federal government; and suggest future directions for the field. The overriding emphasis for public health efforts is prevention.2U.S. Public Health Service. Healthy People 2000: national health promotion and disease prevention objectives. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Disease Prevention and Health Promotion. Washington, DC: U.S. Government Printing Office, 1990 (DHHS Publication No. [PHS] 91-50212).Google Scholar, 3Rosenberg M.L. O'Carroll P.W. Powell K.E. Let's be clear violence is a public health problem.JAMA. 1992; 267: 3071-3072Crossref PubMed Scopus (144) Google Scholar More specifically, we focus on primary prevention: keeping adverse health outcomes from happening in the first place. To prevent interpersonal violence and its consequences—injuries, disabilities, and deaths—we must include strategies that focus both on the violent behavior of the perpetrator and on the risk factors related to victimization. A public health perspective emphasizes making changes in social, behavioral, and environmental factors that lead to violence.4Mercy J.A. Hammond W.R. Preventing homicide a public health perspective.in: Smith M.D. Zahn M.A. Studying and preventing homicide issues and challenges. Sage, Thousand Oaks, CA1999: 274-294Google Scholar Such a prevention-oriented approach complements the efforts of those in the criminal justice system, where strategies typically focus on apprehending, sentencing, incarcerating, and rehabilitating violent offenders. It also complements the patient care efforts of those in the medical care system. The public health approach has resulted in dramatic successes in other areas, from smallpox eradication to the prevention of injuries caused by motor vehicle crashes. We believe that it can have an equally impressive impact when applied to VAW.1Saltzman L.E. Johnson D. CDC's Family and Intimate Violence Prevention Team basing programs on science.J Am Med Womens Assoc. 1996; 51: 83-86PubMed Google Scholar The approach can be characterized by four steps (often occurring simultaneously). The first step is to define the problem and ask how big it is. Typically, public health activity begins by developing a public surveillance system with the capacity to collect, analyze, and disseminate data in a timely fashion for use in prevention and control activities.5Thacker S.B. Historical development.in: Teutsch S.M. Churchill R.E. Principles and practice of public health surveillance. Oxford University Press, New York1994: 3-17Google Scholar We gather information on the demographic characteristics of persons involved, the temporal and geographic characteristics of relevant incidents, the victim-perpetrator relationship, physical and psychological outcomes, and the severity of associated injuries. Without accurate surveillance data, program staff cannot determine whether people who need their services have been reached or whether prevention and intervention strategies are effective.6Galavotti C. Saltzman L.E. Sauter S.L. Sumartojo E. Behavioral science activities at the Centers for Disease Control and Prevention a selected overview of exemplary programs.Am Psychol. 1997; 52: 154-166Crossref PubMed Scopus (23) Google Scholar The second step of the public health approach involves asking about causes of the problem. We analyze risk factors that may be causative or protective. Priority is given to modifiable factors. Unmodifiable factors such as age, gender, or ethnicity are measured because risk often varies by them, and information about them can inform intervention selection. The third step of the public health approach focuses on identifying and evaluating interventions, using what has been learned about the underlying patterns and causes. The fourth step of the public health approach involves taking the promising prevention and intervention strategies and putting them in place at local, state, and national levels. It is important also to put in place mechanisms to evaluate the effectiveness of the strategies in those settings. This step of the public health approach awaits implementation until developmental prevention efforts are demonstrated to be effective, but without it, the first three steps can bear little fruit. Thus, it is a fundamental tenet of the public health approach to disseminate effective strategies widely to those in need. The following examples from several CDC activities illustrate how steps 1 through 3 contribute to the public health approach to VAW. Definitional and measurement issues provide several key challenges to the prevention of VAW. Until recently, there has been little consensus on the scope of the term "violence against women." It has been used to refer to a wide range of behaviors: murder, rape, sexual assault, physical assault, emotional abuse, battering, stalking, prostitution, genital mutilation, sexual harassment, and pornography.7National Research CouncilUnderstanding violence against women. National Academy Press, Washington, DC1996Google Scholar Researchers have used certain terms to mean different things and a variety of terms to describe the same behaviors.6Galavotti C. Saltzman L.E. Sauter S.L. Sumartojo E. Behavioral science activities at the Centers for Disease Control and Prevention a selected overview of exemplary programs.Am Psychol. 1997; 52: 154-166Crossref PubMed Scopus (23) Google Scholar Although CDC uses VAW to encompass IPV as well as sexual violence by any perpetrator, others use it to refer only to violence between intimate partners or to violence between family members. This inconsistent use of terminology confuses not only scientists but also practitioners and program staff engaged in prevention efforts. Programs are usually dependent on public funding, which in turn is usually linked to the relative rankings of many competing issues, so clarity about definitional and measurement issues is critical. In 1994, to improve the quality of data about VAW, CDC initiated an extensive consultative process with researchers, practitioners, and victim advocates.8Saltzman L.E. Fanslow J.L. McMahon P.M. Shelley G.A. Intimate partner violence surveillance. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA1999Google Scholar This project resulted in a set of recommendations designed to promote consistency in the use of terminology and data collection related to a particular subset of VAW: IPV. Intimate partners are identified in the uniform definitions as current or former spouses, boyfriends/girlfriends, or dating partners. Intimate partners may or may not be cohabiting and may be either opposite-sex or same-sex partners. IPV is defined to include physical violence, sexual violence, threats of physical or sexual violence, and psychological/emotional abuse. Using a similar process, CDC is developing a set of uniform definitions and recommended data elements for sexual violence that expands on the definitions of sexual violence from the IPV uniform definitions. Eventually, we hope to develop uniform definitions for all of VAW. Although available data suggest that VAW is a substantial public health problem in the United States,9Tjaden P. Thoennes N. Prevalence, incidence, and consequences of violence against women. U.S. Department of Justice, Washington, DC1998Google Scholar there is no established and ongoing mechanism for VAW surveillance. The field has to rely on multiple data sources such as police records, which are developed and maintained for reasons other than monitoring the scope of the VAW problem.8Saltzman L.E. Fanslow J.L. McMahon P.M. Shelley G.A. Intimate partner violence surveillance. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA1999Google Scholar Thus, it should not come as a surprise that varied conclusions have been drawn about the magnitude of VAW and its component parts (e.g., IPV or sexual violence). This has limited public health's ability to compare the magnitude of VAW to other problems, to identify at-risk groups for targeted intervention, and to monitor the effectiveness of intervention activities.8Saltzman L.E. Fanslow J.L. McMahon P.M. Shelley G.A. Intimate partner violence surveillance. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA1999Google Scholar Since 1994, the CDC has funded programs at the state health departments in Massachusetts, Michigan, and Rhode Island to develop and evaluate the feasibility of statewide surveillance for IPV. The states have implemented very different systems: an emergency department–based surveillance in Massachusetts; a system based on police reporting forms in Rhode Island; and a system linking information from a prosecutor database to emergency department records in Michigan. We intend to summarize what they have learned about implementing IPV surveillance and to develop guidelines to replicate the effective components of their systems. In 1999, CDC funded programs at the state health departments in Kentucky and Oklahoma to develop population-based IPV surveillance, conduct a representative survey of the same population, and compare findings from the surveillance system to the survey data. The three previously funded states (MA, MI, RI) are providing consultation to Kentucky and Oklahoma. The uniform definitions and recommended data elements for IPV surveillance are now being pilot tested as part of these five statewide surveillance systems. Another surveillance partnership is the Pregnancy Risk Assessment Monitoring System (PRAMS), administered by CDC's Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) for use by states.10Colley Gilbert B. Shulman H.B. Fischer L.A. Rogers M.M. The Pregnancy Risk Assessment Monitoring System (PRAMS) methods and 1996 response rates from 11 states.Matern Child Health J. 1999; 3: 199-209Crossref PubMed Scopus (97) Google Scholar PRAMS is a risk-factor surveillance system implemented in 1987 to provide ongoing, population-based, state-specific information on selected maternal behaviors and experiences that occur before and during pregnancy and during a child's early infancy. Currently, health departments in 22 states and New York City participate and work jointly with the CDC to analyze and use the data. The CDC Working Group on Violence and Reproductive Health developed a set of questions related to violence occurring around the time of pregnancy that was incorporated into PRAMS in 1996. As a result, we now have the first population-based data on this problem for surveillance, analytic, and programmatic purposes.11Colley Gilbert BJ, Johnson CH, Morrow B, Gaffield ME, Ahluwalia I, PRAMS Working Group. Prevalence of selected maternal and infant characteristics, Pregnancy Risk Assessment Monitoring System (PRAMS), 1997. MMWR CDC Surveill Summ 1999;48(SS-5):1–37.Google Scholar PRAMS data on violence have been incorporated into an educational curriculum targeting a variety of professionals, including health care workers, child protection and juvenile delinquency staff, state and local law enforcement staff, and victim advocates. PRAMS data have also been used in the development of guidelines and policies for assessment of violence during prenatal care visits. The Working Group on Violence and Reproductive Health, representing three CDC Centers, in collaboration with the CDC Office of Women's Health, other federal partners, and external funders, organized the National Conference on Violence and Reproductive Health: Science, Prevention and Action, held in Atlanta, Georgia, in June 1999.12Goodwin M.M. Petersen R. Kowal D. Koenig L.J. Saltzman L.E. Spitz A.M. Highlights of National Conference on Violence and Reproductive Health.Am J Prev Med. 2000; 18: 186-187Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Conference papers, including discussions of measurement issues, risk and protective factors for violence, and prevention and intervention strategies, along with some post-conference commentaries, were published in a special issue of the Maternal and Child Health Journal.13Spitz AM, Goodwin MM, Koenig L, Saltzman LE, Ramsey T, Marks JS, eds. Violence and Reproductive Health [special issue]. Matern Child Health J 2000;4(2).Google Scholar Another surveillance partnership is the Behavioral Risk Factor Surveillance System (BRFSS) in NCCDPHP. Established in 1984, BRFSS operates in all states and is the primary source of state-based information on adult health risk behaviors.14Centers for Disease Control and Prevention (CDC). Assessing health risks in America: the Behavioral Risk Factor Surveillance System (BRFSS) at-a-glance. Atlanta, GA: CDC, 1998.Google Scholar For potential inclusion in BRFSS, the Division of Violence Prevention is developing sets of questions that will provide state estimates for both women and men on IPV and sexual violence. In October 1998, the Department of Health and Human Services (DHHS) and the Department of Justice (DOJ) co-sponsored the Workshop on Building Data Systems for Monitoring and Responding to Violence Against Women. The impetus for the workshop was a 1998 briefing for DHHS Secretary Donna Shalala and Attorney General Janet Reno in which concerns were raised about differences among various published estimates of rape, sexual assault, and IPV, and about the difficulties this posed for developing and implementing effective programs and policies related to VAW.15Saltzman L.E. Guest editor's introduction, special issue on building data systems for monitoring and responding to violence against women, part 1.Violence Against Women. 2000; 6: 699-704Crossref Scopus (8) Google Scholar Background papers from the workshop, which focused on definitional and measurement issues, local and national data collection from criminal justice and health data sources, and on other research-related topics, have been published in Violence Against Women.16Saltzman LE, ed. Building data systems for monitoring and responding to violence against women, part I [special issue]. Violence Against Women 2000;6(7).Google Scholar, 17Saltzman LE, ed. Building data systems for monitoring and responding to violence against women, part II [special issue]. Violence Against Women 2000;6(8).Google Scholar Conference recommendations were published in the Recommendations and Reports series of the CDC's Morbidity and Mortality Weekly Report in 2000 (www2.cdc.gov/mmwr/). The CDC and the National Institute of Justice, DOJ, also collaborated on VAW measurement activities by co-sponsoring the National Violence Against Women Survey. The Survey was conducted in 1995–1996 by a private organization. Telephone interviews were completed with a nationally representative sample of 8000 women and 8000 men about their experiences as victims of various forms of violence.9Tjaden P. Thoennes N. Prevalence, incidence, and consequences of violence against women. U.S. Department of Justice, Washington, DC1998Google Scholar Results indicated that an estimated 2.1 million women are raped or physically assaulted annually, 1.5 million of them by an intimate partner; that VAW is primarily partner violence; and that women experience significantly more partner violence than men.9Tjaden P. Thoennes N. Prevalence, incidence, and consequences of violence against women. U.S. Department of Justice, Washington, DC1998Google Scholar The survey provides a wealth of information about incidence and prevalence of VAW, comparisons of VAW with violence against men, and information that can be used to estimate the costs of VAW. The survey has also assisted the CDC and DOJ in planning how best to develop and implement surveillance strategies for VAW. One example of efforts to identify the risk and protective factors involved focus groups conducted with African-American and Caucasian women who had experienced IPV, but who had been living violence-free for at least six months.18Short LM, McMahon PM, Chervin DD, et al. Survivors' identification of protective factors and early warning signs in intimate partner violence. Violence Against Women 2000;6:273–87.Google Scholar Qualitative data from this exploratory study identified early some warning signs for physical partner violence (e.g., whirlwind romances) and protective factors that helped women decide to end their relationships (e.g., having the logistical and emotional help of friends and relatives). A national random-digit-dial survey has been conducted by the CDC using a representative sample of African-American, Caucasian, and Hispanic women; data will be analyzed to test hypotheses generated in the initial exploratory research. Another example is a case–control study on suicide attempts conducted at a large urban hospital.19Kaslow N.J. Thompson M.P. Meadows I.A. et al.Factors that mediate and moderate the link between partner abuse and suicidal behavior in African American women.J Consult Clin Psychol. 1998; 66: 533-540Crossref PubMed Scopus (155) Google Scholar The CDC-supported study was designed to investigate the links between suicide attempts and IPV. The researchers found that the partner abuse–suicidal behavior link was mediated by psychological distress, hopelessness, and drug use, and was moderated by social support. Results are now being used to guide development of prevention programs for women at risk for both IPV and suicidal behavior. The information will also enable health care and mental health care professionals to develop more comprehensive assessment and intervention programs. A National Research Council report found a limited number of rigorous evaluation studies of family violence interventions. The report notes that findings from small-scale studies are often used as the basis for policies and practice, despite the lack of adequate replication or consideration of study limitations.20Chalk R. King P.A. Violence in families assessing prevention and treatment programs. National Academy Press, Washington, DC1998Google Scholar The CDC is taking steps to address this problem. For example, as part of its emphasis on evaluating interventions, the CDC funded a community-based primary prevention project from 1993 to 1997, addressing dating violence in a rural North Carolina county.21Foshee V.A. Linder G.F. Bauman K.E. et al.The Safe Dates project theoretical basis, evaluation design, and selected baseline findings.Am J Prev Med. 1996; 12: 39-47PubMed Google Scholar In this project, eighth- and ninth-grade students at seven randomly selected "treatment schools" received classroom instruction about gender stereotypes, conflict management skills, and social norms that contribute to dating violence. Classroom instruction was supplemented with student-conducted dramatic performances. Parents, police workers, and other key individuals in the community were also trained to be better resources for youth seeking assistance about teenage dating violence. Seven "control" schools were not provided this intervention. At follow-up, less psychological abuse, sexual violence, and violence perpetrated against the current dating partner were reported in the treatment schools. Most program effects were explained by changes in dating violence norms, gender stereotyping, and students' awareness of available services.22Foshee VA, Bauman KE, Arriaga XB, Helms RW, Koch GG, Linder GF. An evaluation of Safe Dates, an adolescent dating violence prevention program. Am J Public Health 88;45–50.Google Scholar From 1996 to 1999, a longitudinal follow-up was conducted, and data are now being analyzed to determine the magnitude of the program's continuing effectiveness. The CDC also supports extramural research evaluating intervention strategies. For example, a researcher funded in 1999 has been conducting a follow-up of batterers and their female partners, extending an earlier 15-month follow-up to 48 months. Hypothesis testing will allow examination of questions such as whether re-assault rates decrease over time following batterer intervention. Another project funded in 1999 is exploring the prevention of sexual assault in women who are previous sexual assault victims. The program includes training in identification of personal risk factors, problem-solving skills; and assertiveness in risky situations; it is expected to reduce women's risk of revictimization. We have made progress in establishing some definitional uniformity for VAW. Future efforts will need to expand on what has been done regarding IPV and on what is beginning to be done for sexual violence. Similarly, we have begun developing surveillance systems for IPV and need to expand these to incorporate other forms of VAW. We will then be better able to evaluate the effectiveness of prevention and intervention strategies. Activities of ten CDC-supported Injury Control Research Centers include identification and description of injury problems, identification of risk and protective factors, evaluation of current and new interventions for prevention and control of injuries, implementation of effective strategies in the public and private sector, and provision of technical assistance to injury prevention and control programs. Some Centers have included a focus on violence (including VAW) in their activities. Results from the studies being conducted at these research centers will give CDC information needed for charting a course in the future. The NCIPC web site (www.cdc.gov/ncipc/) provides a complete list of funded Centers and projects. We need continued risk factor research, with emphasis on all forms of VAW. A primary prevention focus requires targeting attitudes or behaviors that result in victimization of women. We must learn how best to teach children ways to handle conflict and anger without violence. We might emphasize developmental factors and study the impact of children's exposure to violence and abuse on their subsequent perpetration and victimization. Ways to influence social norms about violence (e.g., attitudes about the acceptability of men's violence against women) should also be explored. As our ability to identify risk factors improves, we can use the information to inform the development of prevention strategies. In tandem with the primary prevention focus, we must also assess the effectiveness of identifying and responding to violence after it occurs. Early interventions implemented before violence escalates in frequency or severity are probably more effective than interventions implemented later, when patterns of violence may be well established and difficult to change. Much research on health care providers has focused on how to increase providers' identification of women who are victims or who are at risk of IPV. Less has been done in terms of screening for sexual violence. Although screening women in clinical settings has been endorsed by a large number of professional associations and organizations, screening for violence often does not occur in those settings.23Rodriguez M.A. Bauer H.M. McLoughlin E. Grumbach K. Screening and intervention for intimate partner abuse practices and attitudes of primary care physicians.JAMA. 1999; 282: 468-474Crossref PubMed Scopus (398) Google Scholar The Guide to Clinical Preventive Services of the U.S. Preventive Services Task Force notes, "Although the benefit of routine screening has not been directly assessed, several factors support greater efforts by clinicians to detect domestic violence between spouses or sexual partners: the substantial prevalence of violent behavior among couples, the repetitive nature of domestic violence, and its high medical and social costs."24U.S. Preventive Services Task ForceGuide to clinical preventive services. 2nd ed. Williams & Wilkins, Baltimore, MD1996Google Scholar The Family Violence Prevention Fund similarly recommends screening for all female patients over age 14 regardless of the presence of symptoms or signs of abuse, and regardless of whether the provider suspects that abuse has occurred. The Fund cautions, however, that since there is little definitive research about the effectiveness of screening for all patients in all settings, research must focus on the efficacy of screening policies.25Family Violence Prevention FundPreventing domestic violence. Family Violence Prevention Fund, San Francisco1999Google Scholar Such research should determine whether there is a negative impact of screening and whether screening may threaten the safety of the women. We should also determine how a woman's history of abuse affects her answers to screening questions. Longitudinal research that allows us to assess the impact of family dynamics and specific developmental interventions on later behaviors and victimization experiences is needed. Similarly, we know little about the long-term impact on women of being screened in health care settings about violence. Current strategies wait until violence has occurred and then separate victims from perpetrators; we must move beyond those to strategies that prevent the initial development of violence. Applying the four steps of the public health approach will help accomplish this shift and bring us closer to preventing violence against women.