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Risk Factors for Death or Life-Threatening Injury 
for Abused Women in Chicago* 

By Carolyn Rebecca Block 

NCJ 199732 

Carolyn Rebecca Block, Ph.D., is with the Illinois Criminal Justice Information Authority. 

Findings and conclusions of the research reported here are those of the author and do not reflect 
the official position or policies of the U.S. Department of Justice. 

The Chicago Women’s Health Risk Study was supported by award 96—IJ-CX—0020 from the 
National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. 

Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 


The Chicago Women’s Health Risk Study (Block, Devitt, Fugate et al., 2000) was designed to 
give nurses, patrol officers, and other primary support people the information they need to help 
women who are experiencing violence at the hands of an intimate partner lower their risk of life- 
threatening injury or death. Previous research did not provide this practical information. The 
purpose of the study was to identify risk factors for life-threatening injury or death in situations 
in which an intimate partner is physically abusing a woman. 

Although previous research focused on who in the general population was most likely to be 
abused, it did not tell practitioners about risk patterns for women who were experiencing 
violence. Previous research also tended to measure only one or two factors and did not consider 
the interaction of events and circumstances as they change over time. Practitioners need to know 
how changing factors, such as attempting to leave, pregnancy, having children at home, or 
firearm availability, may affect the risk of a lethal outcome. 

Field practitioners also need to know whether risk patterns differ for different racial or ethnic 
groups, for women in same-sex relationships, or for pregnant women, and they need to be able to 
respond to women who may be in high-risk situations but have not sought help from helping 
agencies or support networks. Prior to the study, information about the needs and best 
interventions for these groups was very limited. 

The Study Methodology 

The Chicago Women’s Health Risk Study compared longitudinal data on abused women with 
similar data on women who had been killed by or who killed their intimate partners. The study 
design had a “homicide sample” of all intimate partner homicides involving a woman that 
occurred in Chicago over a 2-year period, and a “‘clinic/hospital sample” of detailed, longitudinal 
interviews with women sampled as they came into hospitals and clinics in Chicago 
neighborhoods where the risk for intimate partner violence was high. 

Clinic/Hospital Sample 

The study conducted domestic violence screening for 2,616 women as they came into a hospital 
or health care clinic for any kind of treatment. The screening, given as part of the clinic or 
hospital routine, included three short questions regarding current violence, current sexual abuse, 
and whether the woman was afraid to go home. Women aged 18 or older who were in a 
relationship and who answered “yes” to at least one question screened positive and those who 
answered “no” to all questions screened negative. An attempt was made to interview all women 
who screened positive and about 30 percent of the women who screened negative. In addition, 
about 66 percent of the abused women who were interviewed were reinterviewed at least once 
during the following 12 months. 

The staff of each study site (two health clinics and a public hospital) worked hand in hand with 

the interviewers and project staff to ensure that safety and privacy standards were upheld. To 
ensure that high-risk but understudied groups, such as women who were at high risk but who 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 

were not known to be at risk by any helping agency, would not be excluded from the sample, 
instruments and procedures were designed to minimize selection bias. 

Homicide Sample 

The homicide sample included all of the 87 intimate partner homicides in 1995 or 1996 that had 
a woman victim or offender age 18 or older. Up to three people who knew about the relationship 
(friends, family, the woman herself) were interviewed (Block, McFarlane et al., 1999), using the 
same questionnaires as for the clinic/hospital sample (to the extent possible). Information was 
also gathered from the Chicago Homicide Dataset, medical examiner’s office records, court 
records, newspapers, and other sources. 


Members of the collaborating team developed study instruments over many months of intense 
work. Advocates, activists, community members, academics, and researchers all took an active 
role in finding, evaluating, and devising scales for the various dimensions researchers hoped to 
capture, including household composition, mental and physical health, substance use, firearm 
availability, social support network, power and control, harassment or stalking, and help-seeking. 
Women who had experienced violence in the past year developed a “calendar history” of every 
violent incident and other important events that had happened in the year. The followup 
interview included a calendar history for the period from the first interview. 

The study covered highly sensitive topics, and there was a possibility that women from different 
cultural backgrounds could have different perceptions of these sensitive issues. The collaborators 
invested a great deal of effort to word questions carefully and to provide a context that would 
encourage women to disclose their sensitive experiences. They tried to keep the questionnaire 
short enough so that the women would not be fatigued, and to build in enough flexibility to 
encourage a natural flow of talk. The study design and the dedication of the collaborators who 
made the design a reality produced a rich dataset with the necessary detail and accuracy to 
answer the questions practitioners ask. 


Findings revealed the combinations of factors that indicate that a woman in an abusive situation 
is at high risk for serious injury or death. Although practitioners working with women will not be 
surprised by most of the study’s results, the data provide measurable confirmation of knowledge 
gained in the field. Other results, however, may challenge commonly held beliefs. 

Past Violence as a Risk Factor for Homicide 

The conventional wisdom that violence in the past predicts violence in the future was borne out 
by the Chicago Women’s Health Risk Study. The majority of women who were killed or who 
killed their partners had experienced violence at the hands of their partners in the previous year 
(85 percent of homicide victims and 80 percent of offenders). Of the abused clinic/hospital 
women who were reinterviewed, 29 percent experienced an incident in the followup period that 
the study defined as “severe or life threatening” (permanent injury; being completely “beaten 
up,” being choked or burned; or suffering an internal injury, a head injury, broken bones, or a 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 

threat or attack with a weapon), and another 25 percent experienced other physical violence. 

However, the study results go beyond conventional wisdom to reveal three specific aspects of 
past violence that make some women’s situations more risky than others: 

@ Type of past violence (threat or use of a weapon, having been choked or strangled). 
@ Recency (number of days since the last incident). 
@ Frequency or an increase in frequency. 

In addition to weapon use, attempted strangulation or choking were also important risk factors. 
In 20 percent of the homicides committed against a woman intimate partner, the man strangled 
his partner, and in an additional 4 percent, he smothered her. Of all the women killed by a male 
partner, those who had been choked or grabbed around the neck in the previous year were more 
likely to have been strangled or smothered in the fatal incident than those who had not (40 
percent compared to 20 percent). In addition, when a partner had tried to choke or strangle 
clinic/hospital women, followup incidents were more likely to be severe or life threatening (63 
percent compared to 40 percent). 

Regardless of the severity of the last incident, the more recently it had happened, the higher the 
woman’s risk. Half of the women homicide victims and 75 percent of the women offenders had 
experienced violence within 30 days of the homicide, some within a day or two beforehand. 
Frequency was important for all women, but especially for abused women who killed their 
partners. For 71 percent of women offenders, the violence had been increasing in frequency, 
compared to 44 percent of abused women homicide victims and 38 percent of abused 
clinic/hospital women. 

The First Incident Can Be Fatal 

For a substantial minority of study participants, a fatal or life-threatening incident was the first 
physical violence they had experienced from their partners. For 27 percent of the 143 
clinic/hospital women who experienced only one incident in the previous year, that incident was 
life threatening. In 15 percent of the 74 homicides for which the study had good information, the 
fatal incident was the first incident. The important risk factors for these women were— 

¢ Their partner’s controlling behavior (especially jealousy). 
¢ Their partner’s drug use. 
¢ Their partner’s violence outside the home. 

In 40 percent of female homicides by a man where there was no prior violence, the fatal incident 
was sparked by his extreme jealousy (compared to 28 percent with prior violence). Almost a 
quarter (24 percent) of clinic/hospital women with one incident that was very severe answered 
“yes” to all five “power and control” questions, but only 9 percent of other women with one 
incident did so. 

More than half (56 percent) of clinic/hospital women who had experienced one incident that was 

very severe said their abusers used drugs, compared to 20 percent of other women; 41 percent 
compared to 21 percent said that the abuser was violent outside the home. 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 

Leaving or Trying to End the Relationship 

The connection between serious violence and the woman leaving or trying to end the relationship 
will be familiar to field-level workers. The potential gain from leaving is substantial, because a 
woman’s risk of being seriously injured or killed by an intimate partner declines if the partner 
has no more contact with her. The potential risk is also substantial because the partner may use 
increased violence to keep her from leaving. 

Women do try to escape abusive relationships. When people hear about a severely abused 
woman, many ask, “Why doesn’t she leave?” Women do try to leave abusive partners. Most 
clinic/hospital women in this study (85 percent) who had experienced severe violence in the 
previous year had left or tried to end the relationship in the previous year, and most women 
homicide victims (75 percent) had left or tried to end the relationship in the previous year. In 
contrast, 66 percent of clinic/hospital women who had experienced less severe incidents and only 
25 percent who had not experienced violence in the previous year had left or tried to leave. 

Leaving can be related to a lower chance of future violence. In reinterviews over a period of 1 
year, only 47 percent of women who had experienced less severe violent incidents and had tried 
to leave in the previous year told of any additional violent incident, compared with 67 percent of 
women who also had experienced less serious violence but had not tried to leave. 

Leaving can be fatal. In 45 percent of the homicides in which a man killed a woman, an 
immediate precipitating factor of the fatal incident was the woman leaving or trying to end the 
relationship. For clinic/hospital women who were abused on followup, 69 percent of those who 
had left or tried to leave an abuser in the previous year but whose abuse continued despite their 
attempted departure experienced severe incidents compared to 44 percent of women who had not 
left or tried to leave. 

Risk Factors for the Fatal Incident 

Many study participants were in high-risk situations but did not experience a fatal or life- 
threatening incident. Sometimes the only difference between women who were killed and 
women who were not lay in aspects of the specific incident. Someone was more likely to die 
when one of the following factors was present in the violent situation: 

¢ The partner threatened to use or used a knife or gun. 
@ The woman was being choked, grabbed around the neck, or strangled. 
@ The woman, the partner, or both were drunk. 

Risk Factors for Abused Women Becoming Homicide Offenders 

Abused women who killed their partners differed from abused women who were killed and from 
abused clinic/hospital women in the following ways (Block, Devitt, Donoghue et al., 2000): 

@ Abused women who killed their partners had experienced more severe and increasing 
violence in the previous year. 

@ They had fewer resources, such as employment or high school education. 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 

@ They had a more traditional relationship (e.g., they were married, had children, or were in a 
long-term relationship). 

Seeking Help 

Even when they had experienced severe violence, clinic/hospital women were less likely to 
consult a counselor or agency (24 percent) than to seek medical help (41 percent) or to contact 
the police (53 percent). However, 34 percent of severely abused Latina/Hispanic women had 
consulted a counselor or agency in the past year, while 29 percent had sought medical help and 
43 percent had contacted the police. In contrast, none of the 11 women who were severely 
abused by a woman had contacted the police, although 45 percent sought medical care, and 18 
percent talked to a counselor. 

More than 30 percent of the clinic/hospital women who had experienced severe or life- 
threatening violence in the previous year had not sought any kind of formal help (medical, 
counseling, or contacting the police). Ten percent of severely abused clinic/hospital women and 
abused homicide women had sought neither formal nor informal help (talking to someone) in the 
previous year. 

Implications for Researchers 
Study researchers offer three suggestions: 

1. Recognize the complexity of women’s lives. The study asked women to discuss the real 
circumstances of their lives, provided many opportunities for them to describe their 
relationships, and avoided constraining language and predetermined categories. This 
interview style was comfortable and appropriate for women from a wide variety of cultural 
and racial/ethnic backgrounds and for women in nontraditional intimate relationships. 

2. Add a separate category for strangulation as a method of attack or cause of death to law 
enforcement and public health datasets to improve preventive policies and interventions for 
intimate partner homicides. Currently, these cases are scattered under various weapon 
categories (e.g., belt or scarf) or as “hands, fists, and feet.” 

3. Develop a collaborative culture. A collaborative culture is a climate characterized by shared 
standards for research and practice, equalized power, permeable roles, group decisionmaking, 
and the assumption of good will (Block, Engel et al., 1999a; 1999b). This was the foundation 
of the high quality of study data. 

Implications for Practitioners 

Clinic/hospital women who had experienced severe violence were more likely to have sought 
help than other abused women. Women who were killed or who killed their partners were even 
more likely to have sought help. Seeking help, by itself, indicates that a woman’s situation may 
be serious. 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 

Study researchers found the following questions to be important to ask a woman to assess her 
risk for lethal or life-threatening violence. (Most of these questions are part of the Campbell 
[1986; 1995] Danger Assessment.) 

@ When a woman is being physically abused by an intimate partner, ask her— 

—When did the last incident happen? 
—Dzid your partner ever threaten you with a gun or knife or try to strangle or choke you? 
—Has the violence been increasing in frequency? 

@ When a woman is not experiencing physical violence, ask her— 

—Is your partner violent outside the home? 

—Does your partner use drugs? 

—Does your partner control all or most of your daily activities? 
—lIs your partner violently and constantly jealous of you? 

Abused women often consult medical staff or call the police before they go to a counselor or 
agency for help. Medical staff and the police should recognize their pivotal gatekeeping role. 
They may be able to refer abused women to counseling or other resources. 

When a woman is being physically abused, both partners are at risk for homicide. Women who 
kill a partner tend to be severely abused, to be in a marital or other long-term relationship, and to 
have few material resources. They are much more likely than women who are killed or than 
clinic/hospital women to contact the police after an incident. Law enforcement agencies need to 
develop a protocol for linking women in this situation to places where they can get help. 


* Although most of the collaborators of the Chicago Women’s Health Risk Study were silent 
partners in writing this report, they were equal partners in the project. They include Olga Becker, 
Nanette Benbow, Jacquelyn Campbell, Debra Clemons, James Coldren, Alicia Contreras, 
Eugene Craig, Roy J. Dames, Alice J. Dan, Christine Devitt, Edmund R. Donoghue, Barbara 
Engel, Dickelle Fonda, Charmaine Hamer, Kris Hamilton, Eva Hernandez, Tracy Irwin, Mary V. 
Jensen, Holly Johnson, Teresa Johnson, Candice Kane, Debra Kirby, Katherine Klimisch, 
Christine Kosmos, Leslie Landis, Susan Lloyd, Gloria Lewis, Christine Martin, Rosa Martinez, 
Judith McFarlane, Sara Naureckas, Iliana Oliveros, Angela Moore Parmley, Stephanie Riger, 
Kim Riordan, Roxanne Roberts, Martine Sagan, Daniel Sheridan, Wendy Taylor, Richard 
Tolman, Gail Walker, Carole Warshaw, and Steven Whitman. Collaborating agencies in the 
study were the Mayor’s Office on Domestic Violence; the Chicago Police Department Domestic 
Violence Unit; the Erie Family Health Center; the Chicago Department of Public Health; the 
Cook County Medical Examiner’s Office; the Cook County Hospital; the Chicago Abused 
Women Coalition; and the Illinois Criminal Justice Information Authority. 


Risk Factors for Death or Life-Threatening Injury for Abused Women in Chicago 


Block, C.R., with C.O. Devitt, M. Fugate, C. Martin, T. Pasold, D. Fonda, B. Engel, S.M. 
Naureckas, K.A. Riordan, J. McFarlane, and G.R. Walker (2000). “The Chicago Women’s 
Health Risk Study, Risk of Serious Injury or Death in Intimate Violence: A Collaborative 
Research Project.” Final Report to the National Institute of Justice, NCJ 184511. 

Block, C.R., Devitt, C.O., Donoghue, E.R., and Dames, R.J. (2000). “Who Becomes the Victim 
and Who the Offender in Chicago Intimate Partner Homicide?” Paper presented at the American 
Society of Criminology meeting, San Francisco, CA. 

Block, C.R., Engel, B., Naureckas, S.M., and Riordan, K.A. (1999a). “The Chicago Women’s 
Health Risk Study: Lessons in Collaboration.” Violence Against Women, 5, 1157-1176. 

. (1999b). Collaboration in the Chicago Women’s Health Risk Study. Research Brief: 
May 1999. Chicago: Illinois Criminal Justice Information Authority. 

Block, C.R., McFarlane, J.M., Walker, G.R., and Devitt, C.O. (1999). “Beyond Public Records 
Databases: Field Strategies for Locating and Interviewing Proxy Respondents in Homicide 
Research.” Homicide Studies, 3, 349-366. 

Campbell, J.C. (1995). “Prediction of Homicide of and by Battered Women.” In J.C. Campbell 
(ed.), Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers 
(pp. 96-113). Thousand Oaks, CA: Sage Publications. 

. (1986). “Nursing Assessment for Risk of Homicide With Battered Women.” Advances 
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