Original article

Medicine, Science and the Law

2021, Vol. 61(1S) 113–124
Violence against women in heterosexual ! The Author(s) 2020
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couples: A review of psychological and sagepub.com/journals-permissions
DOI: 10.1177/0025802420936081
medico-legal considerations journals.sagepub.com/home/msl

Valeria Tullio1,2 , Antonietta Lanzarone2, Edoardo Scalici2,

Marco Vella3, Antonina Argo2 and Stefania Zerbo2

Abstract
Intimate partner violence against women (IPVAW) is the most pervasive violation of women’s rights worldwide, causing
devastating lifelong damage. Victims can suffer physical, emotional or mental health problems, and experience detri-
mental effects in social, psychological and relational health with their families, especially children. Due to the complexity
regarding violence against women in heterosexual couples, it is important to make a clear distinction between psycho-
logical and physical mistreatment, which also includes psychological violence. This differentiation is important in deter-
mining different emotional and psychological aspects of mistreatment in order to understand the reasons why some
women stay in such relationships and to explain the personality profiles of victims and perpetrators. In this short
narrative review, we have combined perspectives of depth psychology and attachment theory from studies on
trauma, traumatic bonds and the perpetrator/victim complex in gender violence. We have also considered the growing
literature on IPVAW as it relates to the medico-legal field. Our search strategy included intimate partner violence,
attachment styles, risk factors and the victim/perpetrator relationship. Distinguishing the different types of IPVAW is a
necessary step in understanding the complexity, causes, correlations and consequences of this issue. Above all, it enables
the implementation of effective prevention and intervention strategies.

Keywords
Intimate partner violence, physical-psychological violence, victim–perpetrator relationship, medico-legal and psycholog-
ical issues

of all murders of women are committed by intimate

Introduction partners.
Intimate partner violence (IPV) against women According to the latest data published by the Office
(IPVAW) is the most common form of violence against for National Statistics,3 in Italy, 6.788 million women
women within relationships worldwide. The World
Health Organization1 (WHO) reports that 35% of
women worldwide have experienced physical and/or 1
Department of Psychology, Educational Science and Human Movement,
sexual violence by an intimate partner or non-partner University of Palermo, Italy
2
sexual violence; 30% of all women who have been in a Department of Health Promotion, Mother and Child Care, Internal
Medicine and Medical Specialties – Medico Legal Section, University of
relationship have experienced physical and/or sexual Palermo, Italy
violence by their intimate partner. The prevalence 3
Department of Surgical, Oncological and Stomatological Disciplines,
estimates for IPVAW range from 23.2% in high- University of Palermo, Italy
income countries and 24.6% in the WHO Western All authors contributed equally to this work.
Pacific region to 37% in the WHO Eastern
Mediterranean region and 37.7% in the WHO South- Corresponding author:
Valeria Tullio, University of Palermo, Department of Psychology,
East Asia region. The European Union Fundamental Educational Science and Human Movement, Viale delle Scienze,
Rights Association reports that the prevalence of psy- building n. 15, 90128, Palermo, Italy.
chological IPVAW in the EU is 43%.2 Globally, 38% Email: valeria.tullio@unipa.it
114 Medicine, Science and the Law 61(1S)

have suffered some form of physical or sexual violence for a better understanding of complex phenomena,
during their life, that is, 31.5% of women aged between such as violence against women. Moreover, this study
16 and 70 years, of whom 20.2% suffered physical vio- adopted an interdisciplinary approach to examine
lence, 21% sexual violence and 5.4% more serious IPVAW by including the medico-legal perspective on
forms of sexual violence, such as rape and attempted IPVAW. We conducted a comprehensive search of
rape. Violence by a partner or former partner is the PubMed database for published articles, focusing
normally more serious than that caused by outsiders. on two main aspects of IPVAW and attachment
A total of 3.466 million women have been stalked styles: victim–perpetrator relationship, and related risk
during their lifetime (16.1% of women). Of these, factors. Our search yielded 15 relevant articles or sys-
1.523 million were stalked by a former partner. tematic reviews.
Separated or divorced women are particularly at risk
of violence by their former partner. Approximately
36.6% of victims suffered physical or sexual violence Violence against women in heterosexual
by a spouse or partner from whom they were separat- couples: definitions and main features
ed.4 According to the Italian National Police,5 of the The WHO defines IPV as behaviour within an intimate
total murders committed from January 2019 to August relationship that causes physical, sexual or psycholog-
2019, 34% of victims were women, and in 63% of ical harm.11 This definition includes physical aggres-
cases, the perpetrator was the partner or former part- sion; sexual coercion, including marital rape; forced
ner of the victim. Comparable data emerged from impregnation; forced marriage or cohabitation; psy-
our Specialized Service at the University Hospital of chological abuse; and controlling behaviours (e.g.
Palermo.6,7 verbal violence and all actions aimed at making the
It is not only the individual victims and their families victim feel inadequate, threats and intimidation, depri-
who pay a high price because of violence. Due to the
vation of essential emotional needs, isolation of the
psychophysical consequences of abuse, female victims
woman by deprivation of personal liberty, violation
of IPV need more frequent medical care, prescriptions
of privacy and the use of psychological manipulation
and hospitalisations (about three times more than non-
techniques such as brainwashing and gaslighting).
abused women), generating about 92% more costs for
Sexual violence is defined as any sexual act or attempt
health care per year than non-abused women.8
to engage in a sexual act by coercion, or any act direct-
Violence against women also has serious negative
ed against a person’s sexuality, regardless of the rela-
effects on the economic and productive system in
tionship to the victim. It includes rape, defined as
terms of human capital, job losses, low productivity
and increased accidents at work, and on the socio- physically forced or otherwise coerced penetration of
educational and cultural system.9 An Italian study, the vulva or anus with a penis, other body parts or
conducted by a non-governmental organisation in objects.1 Stalking is conservatively defined as ‘a
2013,10 quantified the economic damage caused by vio- course of conduct directed at a specific person that
lence against women, considering not only the physical involves repeated (two or more occasions) visual or
damage suffered by the victims, but also the moral and physical proximity, nonconsensual communication, or
psychological damage, the vulnerability with which verbal, written, or implied threats, or a combination
families live and the impact on relationships until the there of, that would cause a person reasonable fear’.
transmission of violence from one generation to anoth- Further, stalking behaviours may include:
er. According to this study, the ‘human and suffering’
costs of violence against women may amount to more . . . persistent patterns of leaving or sending the victim
than e14 billion per year. unwanted items or presents that may range from seem-
This short narrative review addresses the issue of vio- ingly romantic to bizarre, following or laying in wait
lence against women with specific reference to heterosex- for the victim, damaging or threatening to damage the
ual couples. Further, it combines the perspectives of victim’s property, defaming the victim’s character,
depth psychology and attachment theory from studies or harassing the victim via the Internet by posting
on trauma, traumatic bonds and the perpetrator–victim personal information or spreading rumours about the
complex in gender violence. In this review, recent studies victim.12
and reviews on the relationship between IPVAW and
attachment systems have been linked to the main psy- Moreover, many of these forms of violence, particu-
choanalytic and non-psychoanalytic studies concerning larly physical violence, may arise or intensify during
the victim–perpetrator relationship. This choice is con- pregnancy, causing serious damage to the foetus or
sistent with the recent orientations in psychology regard- complications that can lead to the death of the
ing the integration of different theoretical approaches woman and/or the unborn child.13
Tullio et al. 115

In the literature, a fundamental criterion for distin- and, above all, to implement effective prevention and
guishing between IPVAW and couple conflicts is coer- intervention strategies.19–22
cive behavioural patterns, which tend to increase in The complex view of violence against women in het-
frequency and severity over the years, are implemented erosexual relationships manifests itself along a contin-
in the context of an affective relationship characterised uous line of increasing severity, with psychological
by imbalances in physical, psychological, economic or violence that manifests itself through the maintenance
social power between partners, and are aimed at deter- of control over the partner on one extreme, and phys-
mining and maintaining control over the victim, using ically and sexually violent behaviours that put the
aggression.14–18 woman’s life in danger on the other. However, there
IPVAW is repeated over time, often following a cir- are many reasons that make it useful to distinguish
cular process that is defined as ‘cycle of abuse’. This exclusively between psychological and physical abuse
cycle generally consists of three phases, characterised (which inevitably includes psychological violence).23
These reasons include: (a) diversity in the forms of
by an increase in tension, breaking down of tension and
the violent act manifested and their subsequent legal
increase in violence and a ‘honeymoon phase’ post vio-
considerations (e.g. in Italy, the criminal code identifies
lence. During this third phase, it is common for the
crimes related to physical and gender violence, with
abuser to appear calm, to admit to having a problem
reference to the family but not specifically to psycho-
and to promise change in behaviour. These assurances logical violence, except for the crime of stalking and,
are intended to persuade the survivor to stay in the since July 2019, revenge porn); (b) the peculiar emo-
relationship. The repetitiveness of this cycle of abuse tional and psychological aspects characterising the dif-
and the sudden change in the behaviour of the abusing ferent forms of mistreatment; (c) the fact that different
partner are two factors that make it difficult for women types of abuse seem to correspond, although unclearly,
to leave abusive relationships. The victims, psychically to varying profiles and traits of the victim’s personality;
imprisoned in these perverse relationships, often ratio- (d) identifying different profiles and personality traits
nalise the violence, forgive the partner and blame them- of abusers; (e) and the inability of the victims and pro-
selves for having provoked the anger in which the fessionals to ‘recognise’ two different forms of violence:
violence is rooted.13 physical and psychological violence.
Moreover, the construct of coercive control has been Past studies report a very strong circular connection
at the centre of many IPVAW conceptualisations. between IPVAW and trauma. Female victims of IPV
Three aspects of coercive control have been identified: often develop symptoms of post-traumatic stress disor-
(a) intentionality or orientation of objectives in the der (PTSD) and depression which, in turn, are risk
abuser, with respect to motivation; (b) victim’s lack factors for re-victimisation of IPV.24-26
of perception of the control behaviour; and (c) the In the case of physical violence, the perpetrator
abuser’s ability to gain control through the use of a often manages to re-victimise their victim, in cases
credible threat.18,19 where the victim has already suffered abuse or ill treat-
ment during childhood and therefore has already been
deeply ‘damaged’.8,23,27 Using the Jungian conception
Physical and psychological violence: of the ‘psyche’ as a complex system capable of self-
victims, perpetrators and traumatic regulation, in studies based on trauma and the modal-
bonding ity of functioning archaic defences, Kalsched believes
that the victim’s inclination to relive traumatic experi-
In addition to identifying the elements that help
ences can be explained by activation of the ‘self-healing
researchers, health professionals, lawyers and other
system of the psyche’.28,29 This system is activated by
professionals to distinguish IPV from, albeit violent, the victim’s psyche during trauma in order to defend
couple conflicts, numerous studies have focused on the self from the risk of suffering further attacks.
the reasons that prevent female victims from leaving Although this system is incredibly effective in the
abusive partners; the basis of factors that combine short term, in the long term, this self-care system
and/or differentiate the experience of female victims ends up ‘screening’ all relations with the outer world.
of physical violence from those of psychological vio- What was originally intended to be a defence against
lence; and the definition of possible personality profiles further trauma instead becomes a resistance to
of victims and perpetrators. all spontaneous expressions of the self in the world.
Distinguishing the different types of IPV, depending The trauma does not end with the cessation of external
on patterns of violence, form of violence and type of violation, but rather continues unabated in the internal
perpetrators, is necessary to understand the complexi- world of the trauma victim, whose dreams are often
ty, causes, correlations and consequences of this issue haunted by predatory inner figures. Therefore, the
116 Medicine, Science and the Law 61(1S)

victim’s psychological trauma continuously seeps into levels compared with the family-only category, while
life situations such that he or she is ultimately re- the ‘generally violent-antisocial batterers’ exhibit very
traumatised, since the unconscious self-healing severe marital violence, the highest level of general vio-
system, which is more powerful than the ego, sabotages lence and the highest psychopathology.36
any attempt to change. Despite the possibility of identifying profiles and
In psychological violence, however, it seems that the personalities of those who have been physically violent
perpetrator appropriates the self-esteem or self- instead of psychologically abusive, research on the
confidence of their victim to increase his own value. attachment theory has highlighted that such abusive
The victims often are vital, generous and capable of behaviours could be connected to disorganisation of
establishing relationships. In cases of psychological the attachment system in childhood.37–39
abuse, victims are often ‘realised’ women who Victims of child abuse with ‘disorganised attach-
become dependent on the relationship with ‘that’ com- ment’ are likely to inhibit their capacity of ‘mentalisa-
panion. The abuser, day after day, like a vampire, con- tion’ (i.e. the ability to attribute mental states
tinues to suck their vital energy away, while victims are adequately to others and themselves) to defend them-
unable to realise it.23 Specific types of symptoms asso- selves from the unpredictability of the caregiver’s
ciated with psychological violence (i.e. depression, anx- behaviour. This attachment style is termed ‘disorgan-
iety, confusion and low self-esteem) and the absence of ised’ because the child desperately seeks physical close-
physical injuries often make it difficult for these women ness while simultaneously trying to create mental
to understand that they are experiencing abuse rather distance.40,41 A child living in a dysfunctional family
than simply a couple’s conflict.30 system with an abuser or a frightened or frightening
According to Filippini, both physical and psycho- caregiver internalises both the caregiver’s feelings of
logical maltreatment behaviours arise from a combina- rage, hatred or fear and a frightening or unmanageable
tion of particularly non-empathic relational styles self-image. This terrifying self-image, internalised by
typical of certain personality types (mainly, but not the child, constitutes a sort of ‘alien self’ or a ‘persecu-
exclusively, of the narcissistic disorder) and with per- tory object’ that the child must externalise to ‘survive
version understood as a character trait.23,31–33 psychically’ and to achieve a bearable and coherent
Maltreatment behaviours can be assessed by referring self-representation. These mechanisms have serious
to psychopathologies that range from high-level narcis- consequences on the ability to form interpersonal rela-
sistic disorder through borderline disorder to the most tionships in adulthood. Therefore, the insecure attach-
severe forms of antisocial personality disorder. ment system experienced by ‘violent men’ in childhood,
Filippini23 thus affirms that perversion, along with bor- with consequent disorganisation of the representation
derline pathology, malignant narcissism (that of the self, leads them to experience intense anger
Kernberg, in his peculiar classification, situates close linked to the fear (real or imagined) of losing a loved
to his concept of antisocial personality disorder) and one. This anger culminates into violence in those who
antisocial personality disorder,31,32,34 configure the are unable to ‘mentalise’ their emotional states.
clinical picture that mainly characterises the perpetra- Research on attachment theory focusing on adult
tor of ‘physical mistreatment’. When perversion affects attachment relationships has highlighted that the
the ‘covert’ narcissistic disturbance, the clinical picture ‘avoidance’ and ‘anxiety’ dimensions best describe
mainly characterises the perpetrator of ‘psychological adult attachment.40–43
mistreatment’.23,35 Abusers who exhibit moderate levels of violence
Some researchers have hypothesised a classification report higher scores on the ‘anxiety’ dimension of
of perpetrators of IPVAW into four categories: attachment, while abusers that exhibit high levels of
family-only batterers, borderline-dysphoric batterers, violence report high scores on the dimensions of both
low-level antisocial batterers and generally violent- anxiety and avoidance. People with an insecure-
antisocial batterers. These categories are based on the anxious attachment tend to be ambivalent, show a
severity of marital violence, generality of violence and strong need for intimacy and fear being rejected by
psychopathology or personality disorders. The ‘family- their partners; they want to have control of the rela-
only batterers’ exhibit less severe marital violence, the tionship but fear to obtain it. This form of attachment
lowest level of general violence and the lowest psycho- has been associated with every form of IPVAW. People
pathology, while the ‘borderline-dysphoric batterers’ with an insecure-avoidant attachment tend towards
exhibit moderate to high severity of marital violence, autonomy and distance, show emotional detachment
a moderate level of general violence and moderate-high and self-sufficiency, and perceive others as objects to
psychopathology. The ‘low-level antisocial batterer’ be used instrumentally for the satisfaction of their
exhibits more severity in marital violence, a higher needs. Perpetrators of IPVAW who are antisocial and
level of general violence and the same psychopathology highly violent exhibit an insecure-avoidant attachment.
Tullio et al. 117

These men manipulate their partners using behaviours seems to indicate that the death of their partner is
aimed at generating fear in the victim, and they engage equivalent to the loss of self-regulation and the irreme-
not only in physical violence but also psychological and diable loss of one’s self.
sexual abuse.40,42–45 What female victims of physical violence have in
According to Fonagy: common with those of psychological violence is the
difficulty they face in leaving their abusers.50
. . . in adulthood, disorganized self-representation still The most important scientific contribution in this
manifests as an overwhelming need to control the regard concerns the examination of the particular
other. Violent men have to establish a relationship in type of bond that victims establish with their abuser.
which their partner acts as a vehicle for intolerable self The idea of the ‘traumatic bond’ describes, in general,
states. They manipulate the relationship to engender the strong emotional bonds that are established
the self-image in the other that they feel desperate to between victims and their oppressors in different
disown. They resort to violence at times when the inde- forms/relationships of abuse.15,51,52 Therefore, an abu-
pendent mental existence of the other threatens this sive relationship from this perspective is characterised
process of externalization. At these times, dramatic by two specific factors: the perceived imbalance of
action is taken, because of a fear that the coherence power between abuser and victim, and the cycle of
of the self may be destroyed by the return of what good/bad treatment. Moreover, the alternating adverse
has been externalized.39 and pleasant conditions represent a form of reinforce-
ment that is very efficient in creating persistent patterns
These men perceive the partner as ‘regulator of the Self of behaviour that are difficult to extinguish or termi-
states’. Even a simple expression of psychological inde- nate, and which develop strong emotional bonds. Since
pendence by the woman could constitute a threat to the traumatic link is enhanced by relational dynamics,
their fragile mental integrity and trigger destructive the process of detachment from an abusive relationship
violence.46 The outburst of violence is usually preceded becomes more difficult. Intermittent abuse therefore
by an intensification of the fear of abandonment (real enables the development of an emotional bond between
or symbolic), manifesting as controlling behaviour. A the abuser and victim that disrupts the victim’s ability
sign of psychological independence of women, even to leave the abusive relationship. When the umpteenth
insignificant, usually constitutes the stimulus that abuse occurs, the woman, trapped in this bond, reacts
causes the explosion of male violence. Moreover, in with disorientation and confusion, and cannot under-
the case of physical violence, acts of contrition by the stand the situation created. Due to the manipulation by
perpetrator post abuse paradoxically end up reinforc- her partner, she tends to feel guilty, and believes that
ing the affective bond with the female victim, who lacks modifying her own behaviour will solve the problems
the knowledge not only that the abuse will be repeated, within the relationship. However, she does not achieve
but also that it will become worse and unavoidable. the desired results due to the cycle of abuse. This trau-
The tragic aspect of this situation is that the more matic bond explains the reason why intermittent
the woman is reassured by the apparent remorse abuse, both in anxious and avoidant attachment,
expressed by her partner and by her manifestations of plays a relevant role in maintaining the victim–
repentance, the more she relaxes and allows her indi- perpetrator relationship.
viduality to emerge and the closer she is to the next In relation to attachment theory, victims with
episode of violence. anxious attachment are characterised by fear of
A study conducted by Buck et al. reported a secure abandonment, high levels of separation anxiety and
attachment style among some abusers (i.e. low attach- low self-esteem. These women have difficulty leaving
ment anxiety and avoidance) and no difference in the abusive relationships, since losing a partner is experi-
scores on insecure attachment between perpetrators enced as catastrophic and consequently highly anxio-
and a control group consisting of non-abusers. genic. Due to a negative self-image, these victims tend
Therefore, some authors suppose that attachment to attribute the responsibility of IPV to themselves, and
acts as a mediator between an underlying personality tend to deceive themselves about the change in their
disorder and IPVAW.47,48 partner’s behaviour.42,53 Conversely, victims with avoi-
Moreover, physical violence often leads to femicide. dant attachment generally exhibit dysfunctional beliefs
In these cases, the guilty often confess and claim to that are increased by isolation and lack of social sup-
have killed as a result of a ‘burst’, when in reality femi- port due to IPV, thereby making it difficult for them to
cide is the culmination of a crescendo of violence, leave violent partners. These women are often con-
which may also involve those who try to defend/help vinced that their request for help would be rejected
the victim and even their children. However, the perpe- by others, and also tend to underestimate the psycho-
trators sometimes commit suicide.49 This extreme act logical costs of IPV.40,54
118 Medicine, Science and the Law 61(1S)

Therefore, it is essential to distinguish the depen- IPV against women: risk factors and
dence generated within an abusive relationship from a consequences on victims’ health
more stigmatised ‘diagnosis’ of dependent personality
Research has found that physical IPV against women is
structure among victims. There is a possibility for
associated with unemployment, lower levels of educa-
detecting dependent personality structures among
tion, low family income, marital discord, partner’s
female victims of abuse, especially physical abuse,
lower level of occupation, jealousy and a lack of asser-
and there is also a possibility for dependence inevitably
tiveness with the spouse.8,63–68 Drug and alcohol abuse
to become a habitual response of defence in highly
are relevant risk factors for both the perpetration of
traumatic situations involving being controlled by
IPV and for suffering IPV. An abuser may engage
others. Moreover, victims tend to renounce essential in more severe aggressive behaviour towards a
components of their individuality, including opinions, female partner, and an injury is more likely when the
interests and beliefs, and adapt to those of the abuser as man is drunk.69–71
a means to survive and avoid violence. Severe mental illness, PTSD as well as common
This condition appears particularly evident the first mental disorders can be outcomes of IPV and, at the
time these victims finally manage to talk about the suf- same time, risk factors for intimate partner victimisa-
fered abuse. They talk about themselves from the point tion.24–26,72 Moreover, anger, hostility and mental
of view of the abuser, as if there is no difference health problems may increase both the risk of violent
between the woman’s psyche and the abuser’s behaviours among offenders and the risk of victimisa-
psyche.49,55 However, what starts as a coping strategy tion of women.73–75
becomes dysfunctional in the long run, and the woman Individuals who have been abused as children or
unconsciously finally surrenders to her abuser and who have witnessed violence between their parents
accepts a condition that her past self could never fore- are at a greater risk of being abused in adulthood.
see, imagine or accept. Krystal highlights how surren- Moreover, a high number of female victims of IPV
dering to a ‘real’ external enemy can generate two report stories of abuse in childhood. In addition,
patterns of behaviour.56 On the conscious level, there female victims of IPV with a history of child abuse
may be problems with shame, either directly experi- exhibit more severe symptoms of PTSD than those
enced or defended against in any number of ways. who suffer IPV in adulthood. A history of maltreat-
Simultaneously, there may be an inability to be asser- ment and abuse during childhood represents a risk
tive, which actually represents a continuation of sur- factor for perpetrating violence in adulthood.38–41,76–78
render behaviour. The conscious recognition of the With regard to risk factors for psychological
tendency to submit to phallic, sadistic or narcissistic aggression, researches do not report correlations capa-
objects may be strongly warded off and replaced by ble of unequivocally associating demographic and psy-
intense shame, which follows every episode where the chological variables usually related with psychological
victim was unable to resist and viewed submission as IPVAW.63
Most female victims of physical and psychological
necessary for survival.
violence experience severe physical and psychopatho-
In addition to the feelings of guilt stemming from
logical repercussions that compromise their social-
the conviction of having somehow ‘provoked’ the
relational and family functioning. Numerous studies
abuse, for never having talked before or for finally
conducted on female victims of violence have reported
deciding to talk, these women experience intense feel-
a correlation between a history of repeated abuse/IPV
ings of shame. These feelings of shame may be associ-
and pathologies of medical interest and psychological/
ated with feeling exposed to the power of the other, in psychiatric interest.8,11,40 The former include gynaeco-
their fragility; to not being seen or heard by their part- logical/urinary disorders, sexually transmitted diseases,
ner, family, friends and health-care professionals; and abortions, insomnia, poisoning, physical injury, respi-
being watched and judged when instead they would ratory disorders (asthma, emphysema), musculoskele-
prefer to hide. Past findings suggest that guilt, self- tal disorders, pain, circulatory system disorders,
blame and shame are predictors of PTSD, depressive cardiac disorders, neurological disorders, diabetes and
symptoms and suicidal ideation.57–59 Women often do disorders of the digestive system. The latter include
not take adequate measures to protect themselves, even psychosocial disorders, trauma, PTSD, depression,
after reporting abuse, due to a lack of awareness anxiety, suicidal ideation, eating disorders, sexual
regarding the severity of the problem and feelings of disorders, drug/alcohol addiction, self-harm and
impotence. They may continue to believe that their somatisation.8,11,13,26,60,66,79–87
partner did not intend to harm them, or that the pro- IPV victims often exhibit alexithymic traits that
tective measures would not guarantee their safety.60–62 could be linked to the traumatic experience of suffering
Tullio et al. 119

violence.88,89 A deeper understanding of the mecha- defined as second or third level of care assistance serv-
nisms and risk factors of violence may help forensic ices, and they are the first point of contact for female
specialists uncover early signs of IPV in victims. victims of IPV. Recognising the signs of IPVAW is a
Professional teams are required to evaluate all physical priority, even in cases where the patient does not show
and psychological indicators of IPVAW to prevent apparent signs of violence or the signs of physical or
abuse and protect victims.20,22,90–92 sexual violence are minimal.22,100–103 According to the
Moreover, violence – namely, physical, sexual or directives of the Council of Europe Convention on pre-
psychological – has serious consequences on the venting and combating violence against women and
health of a pregnant woman, foetus and newborn and domestic violence,105 a deeper understanding of indica-
the psychological development of children.93,94 tors of psychological abuse may facilitate early detec-
Although the intergenerational transmission of vio- tion of IPV cases that require specialised support and
lence is unclear, a history of domestic violence in child- victim protection.
hood is associated with violence perpetrated in Italy was one of the first countries to ratify the
juveniles or adults. Moreover, the collected data high- Istanbul Convention of the Council of Europe on pre-
light not only a high risk for suicide in female victims of venting and combating violence against women and
violence, but also a high probability of being killed by domestic violence in 2011. Italy adopted Law No.
the abuser or committing murder.95–99 119,106 known as the law against femicide, on 15
Blame, shame, traumatic bond and feelings of impo- October 2013, which was before the convention entered
tence are factors that prevent the victim from reporting into force on 1 August 2014. This legislation intro-
the violence suffered, even in situations where they duced important changes, such as the obligation to
require first-aid services. Female victims of physical inform the victim of the pending case against the per-
abuse are more likely to be recognised and thus more petrator, the introduction of the crime of assisted vio-
likely to receive help, since they often have to use emer- lence and of special aggravating circumstances in case
gency or hospital services due to physical inju- of violence against pregnant women. However, the
ries.6,7,100–103 Alternately, victims of psychological number of femicides did not decrease, and support
maltreatment are less likely to be recognised as victims centres, deprived of resources, struggled to provide
and helped, since they mainly interact with private pro- basic assistance to victims.
fessionals, such as doctors or psychotherapists, for In response to the persisting high rates of violence
problems such as anxiety, depression, somatisation, against women in Italy, Parliament finally enacted Law
gastric disorders, headaches, menstrual irregularities, No. 69 on 19 July 2019, Amendments to the Penal Code,
pressure disorders, myalgias, osteo-articular pains, Code of Criminal Procedure and other Provisions on the
hypoacusis, olfactory disorders, alopecia and autoim- Protection of Victims of Domestic and Gender
mune disorders. Therefore, health-care practitioners Violence107 (also known as the ‘Red Code), providing
may not always be able to identify signs of psycholog- civil and criminal law remedies for victims of violence.
ical abuse. Moreover, many patients exhibit non- Law No. 69 introduces amendments to the Code of
physical symptoms and subclinical forms of depression Criminal Procedure concerning the sexual mistreat-
and anxiety due to IPV that are difficult to identify. ment of a family member or of minor children, sexual
According to Pico-Alfonso,26 suffering IPV, both phys- violence, aggravating circumstances concerning sexual
ical and psychological, constitutes a significant predic- violence, sexual acts with minors, corruption of minors
tive factor for depression and state anxiety, whereas and group sexual violence and threats. Under the new
psychological violence represents a primary factor in law, judicial police must immediately report the offence
determining PTSD and co-morbidity between PTSD to the public prosecutor verbally, taking immediate
and depression. Therefore, the damage due to emotion- action with no possibility to assess if there are grounds
al and psychological abuse is insidious, and its effects for urgency. The victim must be interviewed by the
are pervasive and resistant to treatment.40,50,104 prosecutor within 3 days. The new law also stipulates
that the victim may file a complaint within 12 months,
and the convicted is required to follow rehabilitation
Medico-legal issues programmes provided by agencies and associations
A growing body of literature in forensic science from dealing with prevention and assistance to victims of
the last decade has primarily focused on preventing domestic and gender-based violence, even in the case
IPVAW, with specialised medico-legal or forensic of a suspended sentence.
units collecting evidence and evaluating the negative It is imperative for health professionals to report
effects on the physical and emotional health of signs of violence to competent organisations or author-
women. In addition, emergency medical services are ities to prevent further severe and sometimes fatal con-
usually provided by forensic medicine experts, usually sequences for victims. Specialised health-care services
120 Medicine, Science and the Law 61(1S)

must balance the confidentiality rules imposed by law, interdisciplinary approach aimed at considering and
and understand that reporting to the competent organ- recognising all aspects of violence, both physical and
isations or authorities does not constitute an obstacle psychological. In its various forms, the abuse damages
to the victim’s protection. On the contrary, their the victim’s ability to maintain the healthy relation-
reporting, under appropriate conditions, could present ships already present in their lives, to create new ones
a rare opportunity to prevent further serious acts of and to establish deep emotional ties.
violence and provide effective protection of the Experiencing a consistently traumatic and threaten-
victim.100,108,109 ing situation, which is impossible to escape from, react
effectively to and obtain help for, generates a profound
IPV against women: prevention and sense of distrust in oneself and in others, resulting from
response policies impotence. Sense of distrust, feelings of helplessness,
guilt and shame are the most common and important
Ending IPVAW requires an integrated and holistic clinical elements in trauma-related disorders.
approach to connect the different services in the coun- Therefore, it is essential for health professionals in
try, local and national associations, initiatives and so
charge of reception, listening and helping abused
on. Violence against women is a complex phenomenon,
women to pay special attention to these experiences
since individuals, families, communities and societies
and to those aspects of the traumatic link that are
suffer the negative consequences of such violence, but
more difficult to recognise and understand, such as
also simultaneously create the conditions for such vio-
lence through an intricate and multidimensional inter- the feeling of affection and nostalgia felt by the
action. Therefore, effective prevention and response victim to the violent companion when the abusive rela-
policies must involve the entire society and not just tionship ends, and ‘why’ she suffered without reacting
individuals, since individual well-being can only be to the violence or running away immediately.30
attained by integrating relational, organisational and The inability to recognise these factors may lead
collective levels.110,111 health professionals to assume, more or less conscious-
The main strategies aimed at preventing conditions ly or defensively, an attitude towards victims that rein-
that promote violence against women include interven- forces the collusive dynamics of ‘guilt’ typical of abuse
tions concerning social norms, such as the implemen- relationships. Conversely, the possibility for these
tation of gender equality within institutions and women to experience a sense of security and accep-
working organisations, and the introduction/applica- tance, and to share their story without feeling judged,
tion of national laws; providing women access to may allow them to carry out a gradual process of self-
microfinance projects and entrepreneurship training; discovery (the ‘thrivership model’) from victim status,
reducing use and access to alcohol/drugs; providing through survivor stage, to thriver condition. A positive
communication/relationship skills training to health perspective of themselves and their future, an improve-
personnel, law professionals, teachers and others; train- ment in health and a new sense of well-being, self-
ing schools on the risks and outcomes of gender vio- esteem, self-efficacy and a new social network are the
lence; home visits; and clinical enquiry and referral.112 outcomes of the thriving process.104
Response strategies aim to reduce the immediate
and long-term consequences of violence on victims
and/or offer treatment to perpetrators of violence. Acknowledgements
The main response strategies include safety planning; We would like to thank Editage (www.editage.com) for
increasing the number of dedicated anti-violence English language editing.
centres and shelters; training for health-care professio-
nals aimed at recognising the ‘signs’ related to violence; Declaration of conflicting interests
advocacy/empowerment interventions; home visits;
The authors declared no conflicts of interest with respect to
support and guidance for nurses; psychological therapy
the authorship and/or publication of this article.
for victims, couples and children; career counselling for
victims and critical consciousness awareness; peer sup-
port groups; and IPV perpetrator care/rehabilitation Funding
programmes.63,112 The authors received no financial support for the research,
authorship and/or publication of this article.
Conclusions
To help female victims of violence, it is essential to ORCID iD
address this phenomenon globally through an Yasir Nawab https://orcid.org/0000-0002-6207-1993
Tullio et al. 121

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