Intimate partner violence and witnessing domestic violence: a comparison of Italian and international evidence

Intimate partner violence and witnessing domestic violence:
a comparison of Italian and international evidence

JACOPO SANTAMBROGIO1, TIZIANA R. FRATERRIGO2, GIUSEPPINA MURATORE3, ALICE DEL CORNO4, EMMA FRANCIA5, FRANCESCA MOSCA5, JESSICA MAISSEN5, ESTER DI GIACOMO6,7, FABRIZIA COLMEGNA6, ELENA ANDREINI8, SERGIO TERREVAZZI1, ANTONIO AMATULLI9, MICHELE SOFIA10, ANTONINO ZAGARI11, CARLO ALBERTO TERSALVI12, EMMA HOWARTH13, MASSIMO CLERICI6,7

1Disability Unit, Mental Health and Addiction Department, ASST Brianza, Limbiate; 2Medical Management Direction, ASST Brianza, Vimercate; 3ISTAT, Roma; 4“Pietre Vive”, Inverigo; 5Private Practice; 6Mental Health Department, IRCSS San Gerardo dei Tintori, Monza; 7Department of Medicine and Surgery, University of Milano-Bicocca, Monza; 8CPS Seregno, Mental Health and Addiction Department, ASST Brianza; 9Mental Health and Addiction Department Management, ASST Brianza, Vimercate; 10Healthcare Management ASST Brianza, Vimercate; 11Social-Health Management, ASST Brianza, Vimercate; 12General Management, ASST Brianza, Vimercate; 13School of Psychology, University of Sussex.

Summary. The objective of this review is to examine the recent literature on intimate partner violence (IPV) and witnessing domestic violence (WDV) with a view to providing definitions, prevalence data for Italy and other countries, and for special populations (such as patients with severe mental illness), investigations into risk factors (alcohol, substances, child abuse) and the consequences for general and mental health. In addition to a free search with Google, Medline was interrogated, using PubMed and PsycInfo for both topics. A total of 757 publications were extracted from PubMed and 338 from PsycInfo for IPV and mental disorders, while 334 publications were found in PubMed and 205 in PsycInfo for WDV; updated epidemiological data was obtained from Italian websites (e.g. ISTAT, Office for National Statistics). We concluded that given the increasing incidence of domestic violence, health and academic institutions should frame the phenomenon in epidemiological and clinical terms, providing updated research data to the stakeholders in order to improve treatment and prevention practices.

Key words. Intimate partner violence, witnessing domestic violence.

Violenza tra partner intimi e violenza domestica assistita: un confronto tra evidenze italiane e internazionali.

Riassunto. L’obiettivo di questa rassegna è esaminare la letteratura recente sulla violenza tra partner intimi (intimate partner violence - IPV) e sulla violenza domestica assistita (witnessing domestic violence - WDV), al fine di fornire definizioni, dati di prevalenza relativi all’Italia e ad altri Paesi, nonché a popolazioni specifiche (per es., pazienti con gravi disturbi mentali), approfondimenti sui fattori di rischio (alcol, sostanze, abuso infantile) e sulle conseguenze per la salute fisica e mentale. Oltre a una ricerca libera tramite Google, è stata effettuata un’indagine sistematica delle banche dati Medline (attraverso PubMed) e PsycInfo per entrambi gli argomenti. Sono state individuate complessivamente 757 pubblicazioni su PubMed e 338 su PsycInfo per l’IPV e i disturbi mentali, mentre per la WDV sono state trovate 334 pubblicazioni su PubMed e 205 su PsycInfo. Dati epidemiologici aggiornati sono stati inoltre ricavati da siti italiani istituzionali (per es., ISTAT). Si conclude che, considerato l’aumento dell’incidenza della violenza domestica, le istituzioni sanitarie e accademiche dovrebbero inquadrare il fenomeno in termini epidemiologici e clinici, fornendo dati di ricerca aggiornati agli stakeholder per migliorare le pratiche di trattamento e prevenzione.

Parole chiave. Violenza domestica assistita, violenza tra partner intimi.

Introduction

The home is commonly perceived as a place of safety and protection, yet this assumption does not always reflect reality. A substantial body of evidence shows that various forms of violence occur within the domestic sphere, generally referred to as domestic violence – a broad concept encompassing multiple forms of abuse perpetrated within familial or cohabiting relationships1,2. According to the UK Home Office (2016), domestic violence and abuse include «any incident of controlling, coercive, threatening, violent or abusive behaviour between people aged 16 and over who are, or have been, intimate partners or family members, regardless of gender or sexual orientation». Abuse may take psychological, physical, sexual, financial, or emotional forms.

Within this framework, specific categories have been identified. Intimate partner violence (IPV) refers to physical, sexual, or psychological abuse and controlling behaviours perpetrated by a current or former partner3,4. Child maltreatment includes direct physical, sexual, or emotional abuse, as well as neglect, by caregivers1,5. Children’s exposure to domestic violence can occur indirectly, when children are aware of violence through contextual cues6,7, or directly, when they witness or overhear violent acts between caregivers7,8. Other forms include sibling abuse9,10 economic abuse1,3, and psychological or emotional abuse, encompassing coercion, manipulation, humiliation, gaslighting, stalking, and coercive control – often in the context of IPV11,2. Finally, child neglect is defined as the failure to meet a child’s basic physical, emotional, and health-related needs1,4.

This review focuses on IPV and witnessing domestic violence (WDV), the latter often arising as a consequence of IPV. Both represent major global public health problems, with severe repercussions for physical and mental health and significant economic implications. Media reports in Italy and internationally document daily cases of domestic and gender-based violence, while large-scale surveys in many countries seek to quantify their prevalence. However, most scientific studies – particularly those exploring correlations between IPV, mental disorders, and associated risk factors – have been conducted in the United Kingdom and the United States. In 2011, the WHO also issued guidelines for health professionals on responding to IPV and sexual violence against women.

The aim of this review is to provide an updated overview of IPV and WDV by examining scientific definitions, international epidemiological data (including psychiatric populations), associated risk factors, and consequences for general and mental health. To this end, we conducted free web searches as well as systematic searches in PubMed and PsycInfo. Up-to-date epidemiological data were also retrieved from national statistical websites, including the Italian Statistics Institute (ISTAT) and the UK Home Office. Separate searches were carried out for information on WDV.

Materials and methods

Intimate partner violence and domestic violence

Searching MEDLINE via PubMed using the string below, we found 757 publications on IPV and mental disorders published over the past 17 years: ((“Mental Disorders”[Majr]) AND “Crime Victims”[Majr]) AND ((“Domestic Violence”[Majr]) OR “Intimate Partner Violence”[Majr]); and we found 338 papers in PsycInfo using this search string: MAINSUBJECT.EXACT.EXPLODE (“Victimization”) AND MAINSUBJECT.EXACT.EXPLODE (“Mental Disorders”) AND (MAINSUBJECT.EXACT.EXPLODE (“Intimate Partner Violence”) OR MAINSUBJECT.EXACT.EXPLODE (“Domestic Violence”)).

We interrogated Google and national websites such as ISTAT and the UK Home Office to obtain up-to-date epidemiological data on domestic violence.

Witnessing domestic violence

We also conducted a search on Medline via PubMed for Witnessing Domestic Violence, keeping in mind that it derives directly from IPV. We used the string below and found 334 publications published over the last 17 years: (“Mental Disorders”[Majr]) AND (Witnessing Domestic Violence OR children witnessing violence); we searched PsycInfo with the string below and found 205 papers: MAINSUBJECT.EXACT.EXPLODE (“Victimization”) AND (Witnessing Domestic Violence OR children witnessing violence).

Results

The present narrative review has shown the following results in terms of IPV and WDV definitions, prevalence data (both international and national), health consequences (both physical and psychological), possibilities of treatment of IPV and WDV survivors. The results are presented in two main sections: one focusing on IPV and the other on WDV, each comprising subsections corresponding to the specific aspects examined.

Intimate partner violence

IPV definitions

Terminologically speaking, IPV lies within the broader spectrum of “possible violence” that occurs within the household. This violence not only involves spouses or partners but can also include violent acts perpetrated by a parent toward a child or by other relatives toward family members. The definition of domestic violence provided by the UK Home Office in its 2016 report on domestic violence and abuse12 is «any incident of controlling, coercive, threatening, violent or abusive behaviour between people aged 16 and over who are, or have been, intimate partners or family members, regardless of gender or sexual orientation». Abuse can be «psychological, physical, sexual, financial, emotional». IPV specifically includes physical, sexual, emotional violence, and controlling behaviours (e.g., stalking) by a current or past partner, excluding other forms of family violence that do not manifest in a partner relationship. An “intimate partner” is defined as a person with whom one has a close personal relationship characterized by emotional connection, regular contact, physical and sexual contact, identity as a couple, and familiarity with each other’s lives.
The clinical-legal issue of IPV can be examined from three angles: physical violence, sexual violence, and emotional (or psychological) violence. Physical violence is defined as the intentional use of physical force that can cause death, disability, injury or pain, including behaviours such as scratching, pushing, choking, slapping, hitting, and the use of weapons. Sexual assault is defined as a sexual act committed or attempted without free consent or against a person incapable of giving consent, including forced or substance-facilitated penetration, unwanted touching, and compulsion to engage in sexual acts with a third party. Emotional (or psychological) violence consists of the use of verbal and nonverbal communications with the intent to mentally or emotionally harm a person and/or exert control over them. This form of violence can be expressive (e.g., name calling, humiliating), coercive (limiting access to transportation, money, friends), excessive monitoring, threats of physical or sexual harm, and control of reproductive or sexual health. Emotional violence often coexists with other forms of IPV, may precede physical and sexual violence, and has a significant impact on overall IPV.
Controlling behaviours also include stalking, which involves repeated and unwanted attention and contact that causes fear or concern for one’s own safety or that of others13.

International prevalence data

«Violence against women is nowadays widely recognized as a serious human rights abuse and, increasingly, as a major public health problem with substantial consequences for women’s physical, mental, sexual and reproductive health»14. This «awareness was reinforced by agreements at international conferences in the 1990s that identified the paucity of adequate information on the prevalence, nature, causes and consequences of violence around the world as a serious obstacle to a broader recognition of the scope and seriousness of the problem and the development of effective intervention strategies. Since that time, international research has produced more evidence of the prevalence of violence against women, particularly physical violence perpetrated by male intimate partners»14. A review of more than 50 population-based studies in 35 countries conducted before 1999 showed that «between 10 and 52 percent of women worldwide report having been physically abused by an intimate partner in their lifetime»15 and «between 10 and 30 percent have experienced sexual violence by an intimate partner»16. Due to differences in the research designs and methods of these studies, however, data comparison was impossible.

In an attempt to find a solution to this problem, a WHO multi-country study on women’s health and domestic violence against women was developed, with the objectives of: (a) estimating the prevalence of different forms of violence against women, with particular emphasis on physical, sexual, and emotional violence by intimate partners; (b) establishing the association between intimate partner violence and a range of health outcomes; (c) identifying factors that can both protect and put women at risk of intimate partner violence; and (d) documenting strategies and services that women can use to cope with this type of violence14. In this regard, population surveys on women’s health and experiences of different forms of violence were conducted between 2000 and 2003 in 15 sites located in 10 countries. 24,097 women responded to a standardized structured questionnaire that investigated physical violence, sexual violence, and controlling behaviour by a partner over a lifetime and in the previous 12 months. Between 15% and 71% of women with partners reported physical or sexual violence, or both, by a partner, over their lifetime. Between 4% and 54% of women reported physical or sexual violence, or both, by a partner in the previous 12 months.

The lowest prevalence rates of partner violence over a lifetime and in the previous 12 months were found in metropolitan Japan and Serbia-Montenegro: this finding suggests that abuse rates only partly reflect the country’s degree of economic development. The US National Violence Against Women (NVAW) Survey, sponsored by the US National Institute of Justice and the Centres for Disease Control and Prevention (CDC), found that intimate partner violence is very prevalent in the US population: about 25% of women surveyed and 7.6% of men surveyed said they had been sexually assaulted or physically assaulted by a current or former spouse, cohabitant, or partner in their lifetime; 1.5% of women surveyed and 0.9% of men surveyed said they had been sexually or physically assaulted by a partner in the past 12 months17. The most recent data – again from a survey conducted in America in 2011, the National Intimate Partner and Sexual Violence Survey (NISVS) – indicate that more than 10 million women and men in the United States experience physical violence each year from a current or past intimate partner.

The UK Government bulletin on crime in England and Wales for the year ending December 2023 estimated that 5.1% of people aged 16 to 59 years had experienced domestic abuse in the last year. It recorded a 5% decrease in domestic abuse-related offences compared with the year ending December 2022. In the year to December 2023, stalking and harassment accounted for nearly a third (32%) of all police recorded violence; this is a 6% decrease from the year ending December 2022. Most recently, conduct crimes such as stalking and harassment, which until May 2023 were recorded in addition to other crimes, are now recorded as the sole offence if it is deemed to be the more serious offence. As a result, offences that often occur alongside a conduct crime will no longer be recorded.

Stöckl et al.18 published an authoritative reference on intimate partner homicide prevalence data; the authors ran a systematic search of 5 databases (Medline, Global Health, Embase, Social Policy, and Web of Science) which provided 2167 abstracts. The authors selected 118 articles with 1,122 prevalence estimates of partner homicides. The data were obtained from 66 countries. 13.5% (IQR 9.2-18.2) of homicides were committed by an intimate partner, and this proportion was 6 times higher for female homicides than for male homicides (38.6%, 30.8-45.3 vs. 6.3%, 3.1-6.3). The average rates of partner homicide, overall (men and women) and women-only, were higher in high-income countries (overall, 14.9%, 9.2-18.2; homicides towards women, 41.2%, 30.8-44.5) and Southeast Asia (18.8%, 11.3-18.8; 58.8%, 58.8-58.8). At least one in seven murders, globally, and more than one-third of murders of women, are perpetrated by an intimate partner19. Such violence usually represents the culmination of a long history of abuse.

South Africa has high rates of IPV, with epidemiological research suggesting that up to half of South African women will be a victim of violence in an intimate relationship in their lifetimes. A significantly higher proportion of women compared to men reported being a victim of physical IPV in their lifetime (54% vs. 40%) or in the past 3 months (47% vs. 31%)20-26.

The Canadian Center for Justice Statistics (GSS) provides data on victimization from 2014 show how estimates of domestic violence declined over the course of the decade27. In 2014 there were about 19.2 million Canadians in the provinces with a former or current spouse or partner; of these, about 760,000 (4%) reported being physically or sexually abused by their partner in the previous 5 years. This figure was significantly lower than the prevalence of domestic violence reported in 2004 (7%) and 2009 (6%) (table 1).

Italian prevalence data

The data for Italy are sourced from the Women’s Safety Survey conducted by the Istituto Nazionale di Statistica (ISTAT) in 2014 which covers the five-year period before 2014 comparing the previous 2006 survey covering the five-year period before 200628. Violence against women is a widespread phenomenon. According to this survey, 6,788,000 women have experienced some form of physical or sexual violence in their lifetime: 20.2% have experienced physical violence, 21% sexual violence, and 5.4% more serious forms of sexual violence such as rape and attempted rape, with 652,000 women having experienced rape and 746,000 being victims of attempted rape. 3,466,000 women (16.1% of the female population) have experienced stalking in their lifetime; in 1,524,000 cases the offender was an ex-partner, in 2,229,000 persons other than an ex-partner28.

Current or former partners commit the most serious violence with 62.7% of rapes being committed by a current or former partner. In contrast, perpetrators of sexual harassment are strangers in most cases (76.8%). There are important signs of improvement from the previous survey: physical or sexual violence has decreased from 13.3% to 11.3% in the last 5 years (2010-2014), compared to the 5 years prior to 2006. This is due to more information, field work, but above all, a greater ability of women to prevent and combat the phenomenon and a social climate that increasingly condemns violence. Both physical and sexual violence have diminished, both by partners and ex-partners (physical from 5.1% to 4%, sexual from 2.8% to 2%) and non-partners (from 9% to 7.7%). Psychological violence by current partners is also in sharp decline (from 42.3% to 26.4%), especially when not accompanied by physical and sexual violence. Women are increasingly able to leave violent relationships or prevent them, and they are also more aware of the problem. They consider violence in the relationship as a crime more often than previously (from 14.3 % to 29.6 % for partner violence) and report it more frequently to law enforcement agencies (from 6.7 % to 11.8 %). They tend to confide more about their concerns regarding violent situations (from 67.8% to 75.9%) and seek help from specialized services, anti-violence centres and counters (from 2.4% to 4.9%). The trend for violence by non-partners is the same.

However, negative elements are also reported: there is no change in the hard core of violence, rapes and attempted rapes. The violence is more serious with increases in the number of cases that caused injuries (26.3% to 40.2% by partners) and the number of women who feared for their lives (18.8% in 2006 to 34.5% in 2014).

In 2025 ISTAT carried out a new survey, from March to August, were interviewed the Italian women aged 16-72 years old, while the foreign women living in Italy are yet undder the survey. The preliminary results showa stable framework for the Italian women. Nevertheless can be noted an important reduction of physical, sexual, psychological and economic violence from currente partner, and an increase of women awareness. Victims seeking for help in Anti-violence Centers and specialized services are doubled, higher are also victims that considered a crime what they suffered29.

The Covid-19 pandemic and the measures taken to contain its spread (e.g. confinement at home), as well as the unfolding socio-economic consequences of the crisis triggered by the health emergency, have accentuated the risk of violent behaviour. In Italy in 2020, more than 15,000 women started a personalized path-out-of-violence in the anti-violence centres and in more than 70% of the cases the violence did not originate with the pandemic. The data show that the mobility-restrictive measures taken to contain the pandemic have amplified women’s fear for their own safety. Indeed, in the first nine months of 2020 there was an increase in reports of violence in which the victim felt her life and/or that of her children or close family was in danger (3,583 compared to 2,663 in 2019). In contrast, the easing of the constraints in the same period of 2021 led to a decrease in reports of violence in which the victim perceived imminent danger (2,457 in 2021). The awareness campaign to help victims of violence feel less alone during the pandemic also led to less severe violence reported to the toll-free anti-stalking and anti-violence number in 2021 compared to 2020. Finally, in terms of homicide rates, of the women killed in 2020, 57.7 % were in a relationship and were murdered by their partner (table 2)30.

Prevalence data of IPV in special populations: psychiatric diagnoses and patients with severe mental illness

The studies conducted by King’s Women’s Mental Health (KWMH) of King’s College London, formed by Prof. Louise Howard in 2008 and now led by Siam Oran, achieved considerable impact, with its research on perinatal mental health, domestic abuse, and modern slavery being recognized in the Research Excellence Framework (REF) 2014 and 2021. A study conducted by the group31 analysed 42 studies on the prevalence of IPV in mental disorder patient populations in a systematic review and meta-analysis, reported the following findings:

• In the sample affected by depressive disorder (7 studies), the median value of lifetime IPV is 45.8%, with pooled odds ratio of 2.77 (95% CI 1.96-3.92); on the other hand, the median value of prevalence in the last year (7 studies) is 35.3% with pooled odds ratio of 3.31 (95% CI 2.35-4.68).

• In the sample with anxiety disorder (5 studies), the median value of lifetime IPV stands at 27.6% with pooled odds ratio of 4.08 (95% CI 2.39-6.97), while that in the last year (4 studies) is 28.4% with pooled odds ratio of 2.29 (95% CI 1.31-4.02). In women with post-traumatic stress disorders (PTSD) (4 studies) the median value of lifetime prevalence of IPV is 61.0% with pooled odds ratio 7.34 (95% CI 4.50-11.98), while it is known from a single study that the prevalence of physical IPV in the last year in women with PTSD is 27.0% with OR 3.62 (95% CI 2.32-5.67) compared with the group of women without PTSD.

• Special mention should be made of the group of patients with common mental disorders (CMD), i.e., depressive and/or anxiety disorders identified but not disaggregated, a diagnostic set in which the diagnoses of adjustment disorder with anxiety, adjustment disorder with depressed mood, adjustment disorder with mixed anxiety and depressed mood could be included. In that sample, traceable to 3 studies, the median value of lifetime prevalence of IPV is 48.0% with a higher likelihood in the CMD group to experience lifetime IPV than women without mental disorder. A UK national survey of 7047 people reported increased odds of IPV in the past year in women with CMD (OR: 4.4 95% CI: 3.32-5.82) compared with women without CMD with a prevalence estimate of 15.2%32-34.

Following Trevillion et al.’s systematic review32 of 42 studies (without control groups) showing a lifetime prevalence of IPV of 33% among women with psychiatric pathology followed by community-based outpatient clinics, Oram et al.31 explored the UK national territory with respect to the IPV phenomenon in the SMI population, starting with a comparison with a control group. In particular, they referred to two specific papers on the topic:

1. In the first paper, Khalifeh et al.35, the aim was to compare prevalence and impact of IPV in the population of patients with SMI versus the general population. The authors interviewed 303 randomly recruited psychiatric patients in contact with community services for more than 1 year using the British Crime Survey domestic/sexual violence questionnaire. Prevalence and correlates of violence in this sample were compared with data from 22,606 general population controls concurrently participating in the 2011-2012 National Crime Survey. Lifetime domestic violence was 69% in women with SMI vs. 33% in female controls. 49% in men with SMI compared with 17% in male controls. Domestic violence in the past year was found to be 27% in women with SMI vs. 9% in female controls. 13% in men with SMI compared with 5% in control men. Lifetime sexual violence was found to be 61% in women with SMI compared to 21% in female controls, while 23% in men with SMI compared to 3% in male controls. Sexual violence in the past year was found to be 10% in women with SMI compared to 2% in female controls. Family (non-partner) violence included a larger proportion of all domestic violence in the SMI group than in the control victims (63% vs. 35% p<0.01). Compared with non-SMI women, women with SMI were more likely to report adverse psychological/social consequences (91% vs. 64% p<0.001) and attempted suicides (53% vs. 3% p<0.001) as a result of serious sexual assaults suffered in adulthood, but an equal likelihood of reporting illness or physical injury (49% vs. 40% p=0.35) as a result of serious sexual assaults. Finally, women with SMI who had experienced IPV were more likely than controls to be able to disclose their experiences of violence to health professionals (43% vs. 15% p<0.001) and the police (37% vs. 16% p<0.001); while an equal proportion between the two groups were able to confide in informal networks. In summary, this study shows that people diagnosed as SMI who are followed by psychiatric services have odds 2 to 4 times higher for all subtypes of violence (emotional, physical, sexual) than the general population and odds 6 to 8 times higher for sexual assaults; 50% of women who experience severe sexual assaults attempt suicide. These data suggest that clinicians should investigate, in their practice, not only the experiences of physical violence, but also those of emotional and sexual violence; all the more so on the basis of the studies, found in the literature, which show that emotional abuse has a greater impact on health than physical abuse36.

2. The second paper, also by Khalifeh et al.37, analysed data from 23,222 adults participating in the British Crime Survey 2010-2011. After an initial anamnestic information-gathering interview conducted by a trained interviewer, each respondent was asked to fill out a self-administered form pertaining to experiences of emotional, physical, and sexual violence experienced by a partner or ex-partner or family members in the previous year. The main inclusion criterion was the presence of a chronic mental illness, defined as «any enduring mental illness condition such as depression that has lasted at least 12 months or longer and limits daily activities». The presence of emotional, physical, sexual violence was defined by positivity to at least one item in the respective group of questions. Further investigations in terms of secondary outcomes, such as physical or psychological consequences of IPV and seeking help from specific representatives, were requested in case of positivity to IPV. Among women, the prevalence of IPV in the previous year was 20% (89/442) and 5.3% (789/12309) for women with chronic mental illness and no mental illness, respectively. Among men with chronic mental illness, the prevalence of IPV was 6.9% (21/271) compared with 3.1% (356/10221). Comparing the group with mental illness and the group without, the former – if a victim of IPV – was found to have greater negative consequences in terms of emotional/psychological health (53% vs. 30%; OR adjusted for socio-demographic variables: 2.2 CI: 1.3-3.8) with particularly high odds in regard to attempted suicide as a result of IPV (13% vs. 2%, aOR: 5.4 CI: 2.3-12.9). The two groups equally experienced the physical consequences of IPV intended as illness or physical injury (24%, p=0.97). Victims with and without chronic mental illness equally sought help from any source, but victims with mental illness were less likely - compared to victims without mental illness - to seek help from informal networks (OR adjusted for socio-demographic variables and health problems: 0.47 CI: 0.27-0.83) and more likely to seek help from health professionals (aOR: 2.7 CI: 1.3-5.1).

These results are confirmed by a study in Italy38 conducted on a sample of women participating in a service for the treatment of anxiety disorders and depressive disorders: 36 (24%) were victims of IPV; 35 with emotional abuse, 23 with physical abuse, and 7 with sexual abuse. In the “abused” group, 80% had psychic and physical health consequences, and 53% requested help from relatives/friends and/or healthcare staff (tables 3a-3c).

Risk factors related to IPV: alcohol and substances

Although WHO no longer recommends “universal screening” for IPV, it still advocates the importance of asking about conditions that may contribute to or be worsened by IPV39. Common mental disorders, including the use of alcohol and illicit substances, may increase the risk of IPV victimization and thus deserve thorough clinical attention. According to Schumacher et al.40, the main risk factors for the perpetration of physical IPV include verbal abuse, stress, marital dissatisfaction, anger, and depression; for victimization, on the other hand, child abuse, depression, low education, and violent behaviour toward a partner. A common risk factor for both roles is substance use.

Alcohol is a key factor in aggressive behaviour between intimate partners. Research shows that IPV episodes are more frequent and severe when the perpetrator has consumed alcohol41-43. The pharmacological effects of alcohol, such as reduced cognitive and problem-solving skills, increase the likelihood of aggressive behaviour44.

A study by Cunradi et al.44 on blue-collar couples found that the husband’s problematic alcohol use is associated with unidirectional male-to-female and bidirectional violence, but not with unidirectional female-to-male violence. In contrast, other studies indicate that both husband’s and wife’s problematic alcohol use are associated with two-way violence46,47.

Two systematic reviews were found showing that opioid use among women is strongly associated with IPV victimization48,49. Cannabis use has been correlated with increased victimization and perpetration of both physical and psychological IPV49. In addition, methamphetamine use has been associated with an increased likelihood of physical IPV victimization and perpetration.

A study by Kraanen et al.51 examined the relationships between substance use disorders and IPV in a sample of individuals in substance abuse treatment. Results indicate that personality-related factors, as well as PTSD, may contribute to the high prevalence of IPV among substance users.

In summary, alcohol and illicit substances play a significant role in perpetuating and experiencing IPV, with complex effects affecting both the severity and frequency of violent episodes.

Risk factors related to IPV: childhood abuse

The literature shows that being abused in childhood increases the risk of being abused in adulthood52-54. For example, an Australian study (IVAWS) shows that the risk of experiencing intimate partner violence (IPV) is one and a half times higher for those who were abused as children (78%) than for those who were not (49%)55.

Female survivors of IPV are more likely than non-abused women to report physical abuse, sexual abuse, neglect, and witnessing violence (exposure to violence between parents) during childhood56-58. These maltreatment experiences tend to co-occur and have lasting effects on mental health, including increased symptoms of PTSD in both childhood and adulthood59. In addition, experiencing IPV can cause or exacerbate PTSD symptoms60-64.

Women who experienced childhood abuse and physical or sexual violence in adulthood report more severe PTSD symptoms than those who experienced only some form of victimization in adulthood65. Gobin et al.66 investigated the possible mediation of IPV in the relationship between childhood abuse and PTSD symptoms in adulthood. Contrary to expectations, IPV did not mediate this association. Wuest et al.67, Becker et al.68 and Trickett et al.69 examined the impact of stress and sexual abuse in survivors of IPV70-72. Childhood maltreatment experiences have a direct and lasting effect on PTSD symptoms in adulthood, outweighing the effects of recent IPV experiences. This can be explained by a theoretical framework of personality development, where childhood maltreatment, especially “polyvictimization” (experience of multiple forms of child maltreatment and family violence) is associated with dysregulations in interpersonal functioning and emotional regulation. This pattern of chronic dysregulation in affective arousal may explain how childhood maltreatment is directly related to posttraumatic symptoms in adulthood.

General health consequences

IPV is not limited to acts of violence but has numerous clinical consequences that affect both physical (illness or injuries) and mental health (anxiety, depression, PTSD). The most extreme consequence of IPV is the death of the victim.

According to Campbell73, the health effects of IPV lead to increased demand for health care and high costs. Population and clinical studies show that abused women have worse mental and physical health, more injuries and higher utilization of medical services than non-abused women. A Canadian study74 on abused wives showed that this category sought emergency room care and consulted specialists about three times more often than non-abused women. In addition, the use of medical services increased with the severity of the physical abuse. Abused women generate 92% higher annual healthcare costs than their non-abused counterparts, with mental health services being the largest cost item. IPV can cause chronic health problems such as chronic pain, gastrointestinal symptoms, heart disease and hypertension. The effects of abuse during pregnancy, such as preterm delivery and other complications, are still being studied75.

Gynaecological problems, such as pelvic inflammatory diseases, sexually transmitted diseases, vaginal bleeding and chronic pelvic pain, are common among IPV victims. Michele C. Black of the Atlanta CDC highlighted that millions of women in the United States suffer IPV injuries each year, with more than 2 million injuries and 1,300 deaths annually76. The United States has the highest intimate partner homicide rate among the world’s 25 wealthiest countries, with about 1,500 homicides each year. Between 42% and 66% of women killed by their partners had sought medical care in the previous 12 months77,78.

Black also showed the biological effects of IPV, including neural, neuroendocrine, and immune responses to acute and chronic stress, according to McEwen’s model of homeostasis, allostasis, and allostatic load79. Chronic and acute stress resulting from IPV can increase secretion of stress hormones and cause prolonged physiological responses, with lasting effects even after the abuse ends.

Mental health consequences (PTSD, anxiety, depression)

We found only one Italian research group80 that investigated the outcomes of IPV. A cross-sectional study of women attending six general practice clinics in the province of Belluno showed that episodes of violence were strongly associated with psychological distress, psychoactive substance use, and poor health. Psychological abuse, without physical or sexual violence, was also associated with impaired health status. Women who had been victims of violence in the past year were six times more likely to be depressed and four times more likely to use psychotropic drugs than nonvictims. Comparing these findings with those of a meta-analysis by Golding81, who found the average prevalence of depression among abused women to be 47.6%, Romito and colleagues found 53.3% of abused women had elevated GHQ (psychological distress indicator) scores. Although physical and sexual violence is more prominent, psychological violence has a significant impact on health; 38% of women experiencing psychological abuse only had elevated GHQ scores, compared to 13% of non-abused women. A similar study in France showed similar trends82.

In the United States, it was shown that PTSD symptoms were predicted by both the intensity of physical aggression and partner dominance/isolation tactics83. Victims often report that psychological violence can be worse than physical aggression84. An Italian researcher collected similar experiences in her book on surviving sexual violence85.

A study by Pico-Alfonso et al.86 examined the impact of physical, psychological and sexual violence on women’s mental health. Abused women showed a higher incidence and greater severity of anxiety-depressive symptoms, PTSD and suicidal thoughts than non-abused women. The concomitance of sexual violence was associated with a greater severity of depressive symptoms and a higher incidence of suicide attempts. In conclusion, psychological violence is as destructive to mental health as physical violence, with independent effects on anxiety-depressive symptoms and contributing to PTSD and PTSD/depression comorbidity87-90. Therefore, psychological IPV should be considered by professionals as a significant form of violence.

Domestic violence is also associated with suicidal behaviour, sleep and eating disorders, social dysfunction, exacerbation of psychotic symptoms, and alcohol and substance abuse91,92. Female victims of IPV are up to six times more likely than non-abused women to develop alcohol and substance dependence. The nature of PTSD in these women is often classified as “complex traumatic stress syndrome”, which includes changes in attitudes about themselves, the perpetrator, relationships, and their beliefs. In addition, studies have shown a correlation between PTSD and difficulties in positive emotion regulation. There is evidence to support a bidirectional causal link between domestic violence and psychiatric disorders: psychiatric disorders can make a woman more vulnerable to domestic violence, and domestic violence can cause mental health damage93-97.

Treatment of IPV survivors

IPV is highly prevalent and is associated with a range of mental health problems and a multifaceted approach to healing and recovery is needed. Interventions span medical, psychological, legal and social support systems.

Psychiatric care can target mental health conditions such PTSD, depression, anxiety, substance use disorders and suicidality, involving a comprehensive assessment to identify trauma-related conditions and risk assessment for self-harm, suicidality or further abuse. Psychotropic medications could be a good option, involving antidepressants, anxiolytics, sleep aids, mood stabilizers or antipsychotics. Individual psychotherapies are focused on trauma and the most evidenced based approaches are Trauma-Focused Cognitive Behavioral Therapy, EMDR, Narrative Exposure Therapy, and Dialectical Behavior Therapy. Urgent interventions comprehend shelters and safe housing when women access to Emergency Room in General Hospitals after being battered, for example, and specific protocols of action are started. Associations and network to prevent IPV can offer legal advocacy programs, short psychotherapies, safety planning, support with accessing healthcare, childcare, education, IPV hotlines to provide immediate emotional support and referrals.

Although focused on secondary and tertiary prevention programmes, treating models of IPV are further supported by frameworks for primary prevention and by models developed with different populations and settings.

As described, a broad range of psychosocial interventions have been developed to support the recovery of women survivors of IPV98, but their mechanisms of action remain unclear. In a recent review by Paphitis et al.99, mechanisms of action were categorised as either associated with intervention design and delivery or with specific intervention components (access to resources and services; safety, control and support; increased knowledge; alterations to affective states and cognitions; improved self-management; improved family and social relations). Findings suggest that psychosocial interventions to improve the mental health of women survivors of IPV have the greatest impact when they take a holistic view of the problem and provide individualised and trauma-informed support.

Moreover, as Sullivan’s100 social and emotional well-being conceptual framework of domestic violence interventions shows, the “intrapersonal changes” are an important target in the therapy of traumatized women, with a group approach. The support groups101,102 are interventions, led by knowledgeable and trained facilitators, designed to provide emotional, psychological, educational, and sometimes practical support to groups of individuals who share a problem or situation. It is theorized that the practice of sharing experiences and feelings with people going through similar situations is central to the success of such groups. Furthermore, the act of helping others within the group provides members with an opportunity to be an “expert”, which can feel empowering and affirming. Support groups are generally expected to increase participants’ feelings of support and overall well-being, and to reduce stress. Some research has examined the extent to which support groups can alleviate depression or increase members’ sense of self-efficacy or self-esteem as well.

The underlying theory behind these groups is that abuse often results in women having distorted and overly negative perceptions of themselves (including shame, self-blame, sense of powerlessness)103. Abusers also often intentionally isolate women, and support groups break this isolation through the act of bringing survivors together. Hearing each other’s stories, providing mutual help and support, and encouraging each other’s strengths is expected to lead to increased self-esteem and self-efficacy; Paphitis et al.99 model’s descriptions of the mechanisms through which interventions affect change (the how and the why) is supported by existing work detailing the common components of domestic violence programmes and models of trauma recovery. For example, key features of domestic violence programmes identified by the Domestic Violence Evidence Project100 align with the mechanisms in this model, suggesting that they are core features of programmes that aim to improve survivors’ mental health. Herman’s three-stage model of trauma-recovery 92, widely cited in the IPV literature, closely reflects the model’s mechanisms of action contributing to cognitive, behavioural, and emotional changes.

Witnessing domestic violence

On a global scale, attention to intra-family violence began after it had been agreed that the rights of the child must be guaranteed, starting from the “Geneva Declaration on the Rights of the Child” of 1924 to the “Convention on the Rights of the Child” of 1989.

In Italy, where the Civil Code that came into force in 1942 still recognises paternal monocratic power, a definition of children’s rights was obtained only after a long legal, social, and psychological journey. Indeed, the concept of the family as an authoritarian institution was only abandoned in 1975 and the first definition of WDV was coined in 2005.

Gracia and Herrero104 found that the existence of legislation protecting children from violence, a low infant death rate and personal education is significantly linked to a low level of acceptance of violence.

Definitions and clarification of terms

A recurring issue in the literature on children affected by domestic violence is the lack of terminological clarity. Scholars frequently use terms like witnessing domestic violence and exposure to domestic violence interchangeably, despite referring to conceptually distinct phenomena. As Holden6 noted, “the problem has been impeded by a lack of common terminology and definitions,” which complicates research comparability and policy formulation. Similarly, Dodaj105 emphasized that definitions of witnessing range from direct observation of violence to broader forms of awareness, including hearing or sensing violent episodes. Rasmussen106 further confirms this ambiguity, stating that many studies fail to distinguish between witnessing and exposure, despite their different implications in terms of psychological impact. According to Devaney107, the term exposure may in fact be more appropriate to describe the breadth of children’s experiences in violent households. This conceptual overlap has contributed to widely varying prevalence estimates across studies105, indicating a need for clearer operational distinctions. To bring conceptual clarity, it is useful to distinguish three primary forms through which children may be involved in domestic violence: exposure, witnessing, and experiencing. Exposure to domestic violence refers to any situation in which a child becomes aware of violent acts within the home, even without directly observing them. This includes hearing arguments or assaults, noticing injuries or damage, or experiencing disruptions in daily routines due to violence. As Holden6 and Edleson7 argue, exposure encompasses a spectrum of experiences that extend beyond the act of observation. Witnessing domestic violence is a more specific category within exposure. It involves a child directly seeing or hearing incidents of violence between caregivers or other household members. Edleson7 defines witnessing as including not only visual observation but also hearing violent episodes or being emotionally involved in the aftermath. Carnevale et al.8 also describe it as a form of psychological victimization with serious consequences for child development. Experiencing domestic violence describes situations in which the child is a direct victim of abuse – physical, emotional, sexual, or psychological. This is often referred to as child abuse. According to Moylan et al.5, children who experience direct abuse tend to show more severe outcomes than those who only witness or are exposed to domestic violence, including greater risk for PTSD, behavioral dysregulation, and mental health disorders. Other authors have argued that distinguishing between witnessing and exposure may be detrimental, as while it acknowledges the impact of domestic violence on children, at the same time could deny them direct victim status. Consistent with policy and criminal law, this framing constructs children as collateral to the abusive dyad, rendering them secondary within support services where the primary focus remains on the couple’s violence108. In the present article, the focus is primarily on the first two situations, as the boundary between them is also blurred in the research literature, whereas the analysis of cases in which the child is a direct victim of abuse falls outside the scope of this work. In summary, while these three concepts are interconnected and often co-occur, distinguishing them analytically allows for a more precise understanding of how domestic violence affects children at different levels of proximity and involvement. This clarity is crucial for both effective intervention and the development of tailored prevention strategies.

Children and IPV: international prevalence data

Estimates of children’s exposure to domestic violence vary widely across countries and methodologies (sampling procedures, data collection, and definitional challenges)109. Nevertheless, most studies emphasize that this is a phenomenon characterized by high prevalence rates. In the United States, national surveys indicate that more than one in fifteen children witness IPV each year110. The National Survey of Children’s Exposure to Violence (NatSCEV II) was the first to include questions specifically about witnessing partner assault, reporting that 17.3% of children had observed parental assaults during their lifetime, and 6.1% had witnessed such assaults in the past year111,112.

Findings from the WIDE Project (2016) further highlight the widespread nature of children’s exposure to domestic violence across Europe (Italy, Spain, Portugal, and Romania). In Italy, it is estimated that more than three million minors are affected each year. National social service records show that nearly one in five cases of child maltreatment involve children identified primarily as witnesses of domestic violence, with 17,676 cases reported and 11,236 (63.6%) confirmed as abuse. In Spain, research conducted in women’s shelters indicated that in 85% of cases children had witnessed violence against their mothers, and in approximately two-thirds (66.6%) they had also experienced direct abuse. Portuguese law enforcement data similarly documented children’s frequent presence in domestic violence incidents, with official reports recording their involvement in 42% of cases in 2012, 39% in 2013, and 38% in 2014. In Romania, the national child helpline received over 105,000 calls from minors in 2015, with 7,745 cases requiring specialized intervention and long-term monitoring, many linked to domestic violence exposure (WIDE, 2016).

In Finland, 12% of adolescents reported witnessing interparental violence, with additional exposure to sibling-directed violence113. In the United Kingdom, approximately 29.5% of children under 18 have been exposed to domestic violence, with an annual prevalence of 5.7%114. Kieselbach et al.115 examined differences between high-income countries and other regions. They reported that in high-income countries, between 8% and 25% of children are exposed to IPV at home, while a review including both high- and middle-income countries in the Asia-Pacific region estimated prevalence rates ranging from 10% to 39%. Their systematic review further indicated that 29% (95% CI= 26%-31%) of children in low- and lower-middle-income countries had been exposed to IPV, with a past-year prevalence of 35%. Lifetime prevalence estimates ranged from 2% to 78%, with an interquartile range of 16%-37% and a median of 26%.

Broader reviews corroborate the global scope of this issue, with studies reporting prevalence rates ranging from 20% to 40% in retrospective assessments and reaching as high as 59% to 80% when based on parental self-reports105.

Whitten et al.116 conducted the most comprehensive systematic review and meta-analysis on the global prevalence of childhood exposure to physical domestic and family violence, examining victimization and witnessing separately, based on studies published between 2010 and 2022. This study represents one of the first meta-analyses to also examine childhood witnessing of domestic violence, whereas previous research and meta-analyses had primarily focused on children as direct victims of violence, largely overlooking the phenomenon of witnessing domestic violence. The findings revealed that, worldwide, 17.3% of children had been victims of physical violence perpetrated by a family or household member, while 16.5% had witnessed such violence. Prevalence rates were highest in West Asia and Africa, where nearly half of the pooled population was affected. In contrast, exposure levels were considerably lower in other regions, with approximately one in eight children affected in North America, Europe, and East Asia, and only one in twenty in the Developed Asia Pacific region. Overall, the results indicate that exposure to physical domestic and family violence is a relatively common experience, impacting roughly one in six children worldwide by the age of 18, albeit with substantial regional variation. Given the wide range of serious adverse outcomes associated with such exposure, these findings underscore the urgent need for preventive and intervention strategies117-120.

Collectively, these findings demonstrate that witnessing domestic violence is a pervasive experience among children worldwide, irrespective of socioeconomic context, with significant implications for public health and child protection systems.

Children and IPV in Italy: background and data

Robust data on the prevalence of children’s exposure to IPV in Italy is limited. As mentioned above, WDV was first defined in 2005 and updated in 2017 as «the experience by the child and adolescent of any form of maltreatment carried out through acts of physical, verbal, psychological, sexual, economic violence and persecutory acts (so-called stalking) on reference figures or other emotionally significant figures, adults or minors»121.

However, the most tragic situations are those in which children directly witness violence and where they can also be involved indirectly122,123.

According to the survey carried out by CISMAI, Terre des Hommes for the Authority for Childhood and Adolescence (AGIA)124 in 2015, witnessed violence is the second most widespread form of maltreatment in Italy. It was estimated that between 2009-2014 as many as 427,000 children witnessed domestic violence and that only 7% of women who have suffered abuse have reported it. This survey shows that the majority of the minors in the care of Social Services for maltreatment are in Northern Italy and are predominantly female. Children are usually taken into care between the ages of 11 and 17, which reflects the complexity of detecting situations of fragility in the early years of a child’s life. The data collected indicate that usually a minor is taken into charge following only one case of obvious maltreatment; in Italy the most common form of maltreatment is neglect.

In a population survey in 2007 on women who had suffered physical or sexual violence carried out by Italy’s National Institute of Statistics, 62.4% stated that their children had witnessed abuse125. A more recent ISTAT survey (2015) shows a strong increase in IPV and WDV: the percentage of violent episodes to which children were exposed rose to 65.2% compared to 60.3% in 2007126.

Italian ISTAT data on WDV derived from emergency number 1522 calls (4th trimester 2024 report)127 are shown in table 4.

Difficulties in defining and measuring children’s exposure to IPV

The findings outlined above highlight a serious public health issue; the scale of the problem may be significantly underestimated given the emphasis on quantifying only those children who directly witness abuse.

This measure is problematic for a number of reasons: first, children may also be adversely affected by the effects the violence has on parental mental health, parenting, and on the stability of housing. This broader concept of exposure is not reflected in the way abuse is defined in prevalence studies.

Secondly, the term “witnessing” appears to intend only those acts of abuse that are “observable”108. Research and service delivery tend to treat exposure to domestic violence and abuse (DVA) as a “homogenous unitary”. This is not helped by a paucity of multi-dimensional measures of children’s exposure128. Finally, the focus on witnessing abuse conflates the type of abuse to which children are exposed with the means through which they become aware of its presence129.

Whilst the focus on witnessing, as opposed to experiencing, domestic violence is by no means a problem unique to Italian prevalence studies, it is nevertheless a hindrance to understanding the scale of the problem, and therefore in planning policies to address children’s needs.

What is needed to improve estimates of children’s exposure to IPV

Several measures could be adopted to improve estimates of the dimensions and nature of WDV:

1. recognizing children as direct victims of IPV may change the focus of policy makers and increase the push for robust data on WDV;

2. in line with the requirements of the Council of Europe Convention on preventing and combating violence against women and domestic violence, regular population-based surveys are needed to assess the prevalence of WDV;

3. multi-dimensional measures of exposure should be developed;

4. there should be efforts to collect information about the contexts in which children are exposed to IPV. Much of the current understanding relates to children who have experienced IPV between cis-gender parents with less focus in the context of gender-diverse caregiver relationships;

5. efforts should be made to harmonize measurements both within and across countries.

Psychological and developmental effects of WDV and exposure to domestic violence

Repeated exposure to domestic violence and intrafamilial conflict can significantly affect children’s behavioral, psychological, social, cognitive, and phy­si­cal development130,131. Callaghan et al.108 provide a com­prehensive synthesis of the consequences of witnessing domestic violence (WDV), highlighting that children raised in families affected by domestic violence are at increased risk of lifelong mental and physical health difficulties, educational underachievement and dropout, criminal involvement, and impaired interpersonal relationships. They are also more likely to be bullied, to perpetrate bullying, and to experience sexual abuse, exploitation, and violent relationships in adulthood. Emerging evidence further suggests potential long-term neurological effects, with witnessing domestic violence being at least as detrimental as direct physical abuse.

The severity of these consequences is influenced by multiple factors, including the child’s age, the type and intensity of the violence, the presence of protective elements, the family context, the existence of additional stressors, and access to effective support and treatment110,132-134. As a comprehensive examination of the wide-ranging impacts of witnessing domestic violence (WDV) on individual development falls beyond the scope of this article, we provide a brief overview of the relevant literature.

The literature has documented the diverse psychological consequences of exposure to intimate partner violence (IPV) and domestic violence across developmental stages, from the prenatal period through adolescence. Violence experienced by mothers during pregnancy can adversely affect fetal development by disrupting emotional regulation and arousal processes. In infancy, children exposed to violent environments may display sensory-motor disorganization, dysregulation of biological rhythms (e.g., prolonged crying, sleep disturbances, feeding problems), sphincter issues (e.g., constipation, diarrhea), and signs of emotional withdrawal. As they gain mobility, such children may exhibit hypervigilant behaviors, inhibition of exploratory activity, and premature self-care strategies. Later in childhood, self-blame, helplessness, and ambivalence toward caregivers (fear, anger, desire for closeness) become more pronounced, often manifesting as externalizing or internalizing behaviors135. Persistent patterns of this nature, combined with the attribution of abuse to internal, stable, and global personal causes, can further erode coping capacities and foster a pervasive sense of failure136. Some children, particularly adolescents, may adopt parentified roles within the family. School-aged children may experience severe separation anxiety, leading to absenteeism, behavioral problems, learning difficulties, and poor academic performance. Numerous studies have also documented impairments in social functioning as a consequence of witnessing domestic violence (WDV)137,138. Such children often experience difficulties in regulating their emotions and in engaging in socially appropriate behavior with others.

Physical health consequences are also common: children in violent households present higher rates of allergies, asthma, respiratory infections, gastrointestinal disorders, and headaches110,139. Furthermore, early and intense stress has been shown to induce permanent alterations in brain development. Neuroimaging studies have identified structural abnormalities in the cerebral cortex of children exposed to domestic violence, including changes in white matter tracts such as the inferior longitudinal fasciculus, which connects the occipital and temporal cortices and forms part of the visual-limbic pathway. These alterations have been linked to depression, anxiety, and dissociation140-143. The literature also suggests alterations in the limbic system and hypothalamic-pituitary-adrenal (HPA) axis, both of which are strongly associated with PTSD and emotion dysregulation. However, further research is needed to clarify the relationship between witnessing domestic violence (WDV) and limbic system dysregulation144,145.

WDV and exposure to high levels of expressed emotion during childhood have also been associated with cognitive and intellectual consequences. As noted in the review by Howell et al.110, preschool children (ages 3-6) exhibit lower IQ scores compared with same-age peers, whereas school-aged children (ages 6-12) and adolescents (ages 13-18) demonstrate deficits in executive functioning (e.g., difficulties in planning, sustaining attention, and completing tasks), poorer academic performance, and a higher incidence of learning difficulties or disabilities. Additional research is warranted to further elucidate these associations.

From a psychopathological standpoint, children exposed to chronic domestic violence from the earliest stages of life, including the prenatal period, are at heightened risk of experiencing acute, paralyzing trauma. Such exposure can lead to a complex array of psychological symptoms – often extending beyond the diagnostic boundaries of PTSD – including both externalizing (e.g., aggression) and internalizing (e.g., anxiety, depression) manifestations110,146. Exposure to parental violence is also associated with a number of adolescents’ background factors such as self-perceived health, satisfaction with life, family relationships, parenting practice, school bullying and sexual activity113.

From a developmental perspective, many psychologists and psychiatrists examining this phenomenon emphasize attachment-related issues as a framework for understanding the difficulties these children face. Witnessing domestic violence is strongly associated with disorganized attachment. Early relational trauma, as theorized by Schore147,148 arises from unconscious parental expressions of fear, which are internalized by the child and interfere with the formation of secure attachment. Consequently, these children are at elevated risk of developing disorganized attachment models149,150. Without timely protective interventions, they may carry post-traumatic symptoms into adulthood, including helplessness, guilt, shame, low self-esteem, emotional detachment, depression, anxiety, impulsivity, aggression, passivity, dependency, somatic complaints, dissociation, eating disorders, substance abuse, impaired parenting capacities, neglect, and an increased likelihood of perpetuating violence151.

Several studies have identified profiles of adjustment for children exposed to IPV and find that about 35% are in the clinical range on internalizing and externalizing adjustment problems, 45% are in the borderline range on adjustment problems and about 20% experience low or no adjustment problems, suggesting some resilience. Studies of long-term effects have shown that childhood exposure to IPV is associated with increased risk for delinquency, greater mental health problems, and the potential for intergenerational violence in dating and intimate partner relationships110.

Exposure to domestic violence is also a significant risk factor for adopting violent behavior patterns, both within and outside the family152. Victims may come to normalize violence in intimate relationships and associate emotional expression with danger153. Adolescents who witness such violence are more likely to engage in delinquent behavior, substance abuse, and violent romantic relationships130. Moreover, exposure to intrafamilial violence has been linked to running away from home, suicidal ideation, and bullying154: studies show that IPV exposure during infancy can lead to peer victimization in childhood and early adolescence138.

Treatment of WDV survivors

1. Interventions for Child Survivors of WDV. Evidence-based interventions for children exposed to domestic violence emphasize both individual and group approaches aimed at processing traumatic experiences, enhancing emotional regulation, and fostering a sense of safety and support134,155,156. Such programs typically include structured opportunities for children to develop communication and coping skills, either in group settings, which provide normalization and peer support, or in individualized therapy, which allows for tailored interventions107,15,158. Early interventions are particularly crucial, as IPV exposure has cascading developmental effects that may begin in utero and persist across the life course if unaddressed110. By targeting children’s psychosocial functioning at an early stage, clinicians can interrupt the intergenerational cycle of violence and promote resilience.

2. Interventions for Adult Survivors of WDV. Adults who have survived domestic violence often face overlapping challenges that include trauma symptoms, disrupted attachment patterns, economic dependence, and social isolation. Evidence-based interventions for this group emphasize trauma-informed care, empowerment, and restoration of autonomy. Therapeutic approaches such as cognitive-behavioral therapy (CBT), trauma-focused CBT, and Eye Movement Desensitization and Reprocessing (EMDR) have been shown to reduce post-traumatic stress symptoms and depression159,160. Group-based programs can provide mutual support, reduce stigma, and enhance coping skills, while advocacy and case management services address practical barriers to safety such as housing, employment, and legal protection161. Integrating mental health treatment with social and legal support is crucial, as survivors often require multidimensional assistance to rebuild their lives. Interventions that strengthen parental capacity are also central, given the dual role many survivors hold as caregivers of children who may themselves be exposed to IPV.

3. Interventions with families: victims and perpetrators.

• Victims. Parent-focused programs frequently address caregivers’ beliefs and attitudes toward violence, raise awareness of its negative consequences for children, and promote positive parenting practices that foster secure attachment and healthy development157,162,163. Therapeutic interventions also aim to strengthen caregivers’ mental health and enhance their capacity to provide consistent emotional support to their children. By addressing parental trauma alongside parenting skills, these interventions contribute to breaking cycles of violence and creating safer family environments.

• Perpetrators. Programs targeting perpetrators of domestic violence emphasize psychosocial treatment aimed at reducing violent behaviors, increasing accountability, and promoting healthier family dynamics. Many treatment models include mandatory group interventions, integrating psychoeducation on the detrimental impact of IPV on children with behavioral strategies to reduce aggression and coercive control157,164. A key challenge remains the conceptualization of children as “witnesses” rather than direct victims: this linguistic framing risks minimizing their experiences and hinders adequate service provision108. Shifting toward recognizing children’s agency and lived victimization is essential to ensure interventions address both the perpetrators’ responsibility and the children’s need for protection and validation.

4. Interventions in schools and educational settings. Schools and other educational contexts play a pivotal role in identifying and supporting children exposed to domestic violence. Evidence suggests that consistent discipline strategies and positive reinforcement can buffer the negative impact of violence exposure on children’s adjustment165,166. Teachers and school practitioners, when adequately trained, can collaborate with clinicians to promote psychological recovery, foster emotional regulation, and reduce behavioral difficulties. Educational interventions also provide a unique opportunity to address stigma, encourage resilience, and create safe environments where children can build adaptive coping strategies. Further research is needed to develop and evaluate school-based programs that effectively integrate prevention, early detection, and therapeutic support.

Discussion and conclusions

What can be done to prevent domestic violence? According to the Italian National Institute of Statistics, preventing violence means addressing its cultural roots and causes. Policy strategies should aim at education, awareness raising and the realization of equal opportunities in every sphere of public and private life167.

Adequate risk assessment is fundamental to violence prevention. Risk assessment is a decision-making process that determines the best course of action by estimating, identifying, qualifying, or quantifying risk, with the goal of reducing harm to victims of intimate partner violence and their children168. There are three main approaches to risk assessment:

1. unstructured clinical decision: an informal approach used by professionals (such as police, social workers and health care providers) that relies on the subjective judgment and experience of the professional;

2. actuarial approach: a method that predicts specific violent behaviours using evidence-based risk factors, providing an accurate estimate of the likelihood of a repeat attack;

3. structured professional judgment: the practitioner follows specific risk assessment guidelines that reflect current theoretical, professional, and empirical knowledge about violence, considering a minimum set of risk factors and recommendations for information gathering.

In Canada several tools are available for assessing the risk of partner violence, including the Canadian SARA (Spousal Assault Risk Assessment Guide) checklist, and actuarial scales such as ODARA (Ontario Domestic Assault Risk Assessment), DVI (Domestic Violence Inventory) and IRAD (Idaho Risk Assessment of Dangerousness Tool)169.
Prevention actions promoted by the Italian Department of Equal Opportunity include:

• increasing public awareness of the roots, causes and consequences of male violence against women;

• training public and private sector practitioners on the phenomenology, interception, emergence, intake, assessment and management of cases of violence, including those involving migrant, refugee and asylum-seeking women;

• strengthening preventive efforts against recidivism through re-education pathways for males;

• raising awareness in the private sector and the media about the influence of communication and advertising regarding gender stereotypes and sexism, and their impact on male violence against women.

Intimate partner violence, as presented according to national and international prevalence data, risk factors and the burden of secondary effects on physical and mental health, assumes an impact and a relevance that needs to be taken into account at multiple levels:

1. Health care. Gynaecology and psychiatry departments and outpatient clinics must be called upon to carry out prevention, interfacing as early as possible with women living in situations of risk who reach out for assistance. If violence has already been committed, these contexts must be prepared to take the victims in and provide shelter, and clinical and legal support, returning the possibility of a wide-ranging path of care, including both clinical and legal aspects, also through collaboration with anti-violence centres, that receive a demand for listening and psychological care from battered women. For broad-based prevention work, it may be useful to use validated screening tools. WHO has developed some guidelines and clinical guidelines on IPV for health workers170.

2. Political-institutional. Work must be done at the legislative level to ensure that the appropriate penalties for domestic violence are in place and applied; actions must be taken at institutional to ensure that the centres providing shelter, treatment and support for victims of domestic violence are adequately funded.

3. Epidemiological research. National statistics institutions and academic institutes should provide continuously updated data on the phenomenon to guide the thinking of all stakeholders. With regard to raising awareness on the issue, the Italian Society of Psychiatry’s “Women’s Mental Health” coordination in the document “Violence Against Women and Mental Health” recommends support programs to improve the training of psychiatrists to recognize and treat victims of violence171.

In conclusion, it can be said that the phenomenon of intimate partner violence, domestic violence and child witnessing violence is still widespread today and, often, still poorly recognized and intercepted. It is, therefore, essential for institutions and health professionals to act preventively and promptly, with networking based on an integrated approach aimed at fostering person-focused care and based on treatment guidelines for IPV172,173. This article integrates and expands on the finding of our previous search, published in Italian on the Rivista di Psichiatria in 201913.

Author contributions. Conceptualization: JS, EH and MC; methodology: JS, EH and MC; software: JS ADC and FM; validation: MC, TF, GM, FC, EdG, AA and ST; formal analysis: JS, ADC; investigation: JS, ADC; resources: JS, ADC, FM, EF, JM; data curation: JS, ADC, FM, EF, JM; writing – original draft preparation: JS, EA, FM, ADC; writing – review and editing: JS, EF; visualization: MC, TF, AA, ST, CAT, MS, AZ; supervision: MC, TF, GM, FC, EdG, AA and ST; project administration: JS, EH, MC, CAT, MS, AZ; funding acquisition: JS, CAT, MS, AZ.

All authors have read and agreed to the published version of the manuscript. Please refer to the CRediT taxonomy for explanations of the terms used.

Conflict of interests: the authors declare no conflicts of interest.

Funding: this research received no external funding.

Data availability statement: all the articles included in this review were sourced from the public databases PubMed and PsycInfo, accessed through the University of Milano-Bicocca; up-to-date epidemiological data on domestic violence were obtained through a free Google search of national websites, such as that of the Italian Institute of Statistics (ISTAT) and the UK Home Office.

Acknowledgments: the authors wish to express their thanks to Roberta Mazzoli and Frances Anderson for reviewing the English.

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