RESEARCH AND PRACTICE
Risk Factors for Femicide in Abusive Relationships:
Results From a Multisite Case Control Study
Jacquelyn C. Campbell, PhD, RN. Daniel Webster. ScD. MPH, Jane Koziol-McLain, PhD. RN. Carolyn Block. PhD. Doris Campbell, PhD. RN. Mary Ann
Curry. PhD. RN, Faye Gary, PhD, RN, Nancy Glass. PhD, MPH, RN. Judith McFariane, PhD. RN, Carolyn Sachs, MD, MPH, Phyllis Sharps. PhD. RN,
Yvonne Ulrich, PhD, RN. Susan A. Wilt. DrPH. Jennifer Manganello, PhD. MPH, Xiao Xu. PhD. RN, Janet Schollenberger. MHS, Victoria Frye. MPH.
and Kathryn Laughon. MPH
Femicide. the homicide of women, is the lead-
ing cause of deatli in the United States among
young African American women aged 15 to
45 years and the seventh leatling cause of
premature death among women overall.'
American women are killed hy intimate part-
ners (husbands, lovers, ex-husbands, nr ex-
lovers) more often than by any other type of
perpetrator,^^ Intimate partner homicide ac-
counts for approximately 40*'/(i to 50"/i) of US
femicides but a relatively small proportion of
male homicides (5.9%).''^"'*' The percentage
of intimate partner homicides involving male
victims decreased between 1976 and 1996.
whereas the percentage of female victims in-
creased, from 54"/() to 72%"'
The majority (67%-80%) of intimate pait-
ner homiddas involve physical abuse of the
female by the male before tlie murder, no
matter which partner is killed.'''^'^'""'^ There-
fore, one of the major ways to decrease inti-
mate partner homicide is to identify and in-
tervene willi battered women at risk, Tlie
objective of this study was to specify the risk
factors for intimate partner femicide among
women in violent relationships with tlic aim
of preventing this form of mortality.
METHODS
An ll-dty case-control design was used;
fpmicide victims wore cases {n = 220), and
randomly identified abused women residing
in the same metropolitan area were control
women (n=343). Co-investigators at each site
collaboi-ated with domestic violence advo-
cac)-, law enforcement, and medical examiner
offices in implementing the study. Sampling
quotas for cases and control women in eadi
cily were proportionately calculated so that
the dties with the liighest annual femidde
rates included the largest number of cases
and contrx)! women.
July 2003, Vol 93, No. 7 | American Journal of Public Health
Objectives. This 11-city study sought to Identify risk factors for femicide in abusive
relationships.
Methods. Proxies of 220 intimate partner femicide victims identified from police or
medical examiner records were interviewed, along with 343 abused control women.
Results. Preincident risk factors associated in multivariate analyses with increased
risk of intimate partner femicide included perpetrator's access to a gun and previous
threat with a weapon, perpetrator's stepchild in the home, and estrangement, espe-
cially from a controlling partner. Never living together and prior domestic violence ar-
rest were associated with lowered risks. Significant incident factors included the vic-
tim having left for another partner and the perpetrator's use of a gun. Other significant
bivariate-levei risks included stalking, forced sex. and abuse during pregnancy.
Conc/tisions. There are identifiable risk factors for intimate partner femicides. {Am J
Public Health. 2003:93:1089-1097)
FemJcide Cases dde cases abstracted, a knowledgeable proxy
All consecutive femicide police or med- was identified and located. In 82"/o (307/
ical examiner records from 1994 through 373) of these cases, proxies agreed to partici-
2000 at each site were examined to assess pate. Two exdusion criteria, age (18-50
victim-perpetrator relationships. Cases were years) and no previous abuse by the femidde
eligible if the perpetiator was a current or perpetrator, resulted iji the elimination of 87
former intimate partner and the case was additional cases (28.3% of 307 cases), with
designated as "closed" by the police {suicide 59 {19.2^/11 of 307 cases) eliminated solely as
by the perpetrator, arrest, or adjudication, a result of the latter criterion.
depending on the jurisdiction). Records were Researchers and doctoral students experi-
abstracted for data specific to the homicide. enced in working with victinvs of domestic vi-
At least 2 potential proxy informants, indi- olence conducted telephone or in-person in-
viduals knowledgeable about the victim's re- terviews in English or Spanish; interviews
lationship with the perpetrator, were identi- were 60 to 90 minutes in duration. Both
fied from the records. The proxy who. in the proxies and abused control women were ex-
investigator's judgment was the most knowl- duded if they could speak neither English
edgeable source was then sent a letter ex- nor Spanish,
plaining the study and including researcher
contact information. If no communication was Abused Control Women
initiated hy the proxy, study personnel at- Stratified random-digit dialing (up to 6 at-
temjjted telephone or (in the few cases in tempts per number) was used to select
which no telephone contact was possible) per- women aged 18 to 50 years who had been
sonal contact involved "romantically or sexually" in a rela-
If the first proxy was not knowledgeable tionship at some time in the past 2 years in
about details of the relationship, she or he the same dties in which Uie femicides oc-
was asked to identify another willing potential curred. A woman was considered "abused" if
proxy infomiant. When a knowledgeable she had been physically assaulted or threat-
proxy was found, informed consent was ob- ened with a weapon by a current or fonner
tained. In 373 of the 545 (68%) total femi- intimate partner during the past 2 yetu-s; we
Campbell et at. \ Peer Reviewed | Research anfl Practice | 1089

identified episodes of abuse with a tnodified
vei-sion of the Conflict Tactics Scale with
stalking items added."'"*
English- and Spanish-speaking teleplione
interviewers employed by an experienced
telephone survey firm completed sensitivity
and safety protocol training.'^ A total of 4746
women met the age and relationship criteria
anti wrre read the consent statement. Among
these women, 3637 (76.6%) agreed to partic-
ipate, 356 (9,8%) of whom had been physi-
cally abused or threatened with a weapon by
a current or recent intimate partner. Thirteen
abused control women were exduded from
the ajialysis because they reported tliat tlie
injuries from their most severe incident of
abuse were so severe that they thought they
could have died.
Risk Factor Survey Instrument
Tbe Interview induded previously tested
instruments, such as the Danger Asst^ss-
ment,"^''' and gathered information on demo-
graphic and relationship characteristics, in-
cluding type, frequency, and severity of
violence, psychological abuse, and harass-
ment; alcohol and drug use; and weapon
availability. The Danger Assessment had
been ti-ansiated to and \'a!idated in Spanish in
earlier research; the remainder of the survey
was translated and back-translated by our
Spanish-speaking intm-viL-wers and by project
staff in Houston. Los Angeles, and New York.
A factor analysis of the risk items was used in
con.structing scales measuring |)ailners' con-
trolling and stalking behaviors, Each scale
was internally consistent (a=.83 and .75,
re.spectively).
Data Analysis
Logistic regression was used to estimate
the independent associations between each
of the hypothe,sized risk factors and the risk
of intimate partner femidde. Because the im-
portance of certain risk faetors may not be
detecteil when tlioir effects ari^ mediated by
more pi-oximal risk factors, we sequentially
added blocks of conceptually similar e.xplana-
toiy variable,s along a risk factor continuum
TTinging from most distal (demographic char-
acteri.stics of perpetrators and victims) to
most proximal (e.g., weapon used in tJie femi-
cide or mast serious abuse incident). Vari-
ables not significantly associated with femi-
1090 I Research ana Practice | Peer Reviewed | Campbell et al.
RESEARCH AND PRACTICE
cide risk were dropped from subsequent
models. Model coefficients were exponenti-
ated so that they could be interpreted as ad-
justed odds ratios (ORs),
RESULTS
Demographic, background, and relation-
ship variables that diflerentiated case women
from control women in bivariate analyses are
presented in Tables 1 and 2. Table 3 displays
findings from the series of logistic regression
models. The strongest sociodemographic risk
factor (model 1) for intimate partner femicide
was tlie abuser's lack of employment (ad-
justed OR=5.09; 95% confidence interval
[Cn=2,74, 9.45). Instances in which the
abuser had a college education (vs a high
school education) were protective against
femidde (adjtisted OR=0.31: 95% CI=0.12.
0.80), as were instances in which the abuser
had a college degree and was unemployed
but looking for work. Race/ethnicity of"
abusers and victims was not independently
assodated with intimate partner femidde risk
after contrfil for other demographic factors.
When additional individual-level risk fac-
tors for homidde were added to the mode!
(model 2), both abuser's access to a firearm
(adjusted OR = 759: 95% CI = 3.85. 14.99)
and abuser's use of illidt drugs (adjusted
OR=4.76; 95%CI=2.I9. 10.34) were
strongly assodated with intimate partner
femidde. although the abuser's excrasive use
of alcohol was not. Although the abuser's ac-
cess to a firearm increased femidde risk, vic-
tims* risk of being killed by their intimate
partner was lower when they lived apart from
the abuser and had sole access to a firearm
(adjusted 0R=0.22), Neither alcohol abuse
nor drug u.se by the victim was independently
assodated with her risk of being killed.
Relationship variables were added in
model 3. Never having lived with tlie abusive
partner significantly lowered women's risk of
femidde (OR=0.39; 95% CI=0.16, 0.97).
Having been separated from an abusive part-
ner after living togetlier was associated witli a
liigher risk of femicide (adjusted OR=3.64;
95<>/() Cl= 1.71, 778). as was having ever left
or having asked the partner to leave (adjusted
OR=3.I9: 95% CI= 1.70, 6.02). Having a
child living in tlie bome who was not the abu-
Amerlcart Journal of Public Health | July 2003. Vol 93, No. 7
sive partner's biological child more than dou-
bled the risk of femidde (adjusted OR=2.23;
95%CI=1.13, 4.39), AddiUon of the rela-
tionship variables resulted in victims' sole ac-
cess to a fiR'arm no longer being staU.stically
significant and substantially reduced the ef-
fects of abuser's drug use.
Variables related to ahusive partners' con-
trolling behaviors and verbal aggression were
added in model 4. The effects of a highly
controlling abuser were modified by whether
the abuser and victim sepai-att^d alter livirig
together The risk of intimate partner femi-
dde was increased 9-fold by the romhination
of a highly controlling ahuser and tlie cou-
ple's separation after living together (adjusted
OR=8.98; 95%CI=3.25, 24.83). f-emidde
risk was increased to a lesser degree when
the abuser was highly controlling but the cou-
ple had not separated (adjusted OR=2.90;
95% CI= 1.41, 5.97) and when the couple
had separated after living together but the
abuser was not liighly contrtilling (adjusted
0R = 3.10; 95% Cl= 1.20, 8.05).
Threatening behaviors and stalking were
added in model 5. Abusers' previous thn;ats
with a weapon (adjusted 0R=4,08; 95"Ai
CI= 1,91. 8.72) and tJircats to kill (adjusted
OR=2.60;95%CI=1.24, 5.42) were assod-
ated with substantially higher risks for femi-
dde. After control for threatening behaviors,
there were no significant independent elfccts
of abusers' drug use (0R= i.64; 95"/i) Cl=
0.88, 3.04). The effects of high control with
separation (adjusted OR=4.07; 95"/o CI=
1.33, 12.4) and access to guns (adjusted
OR=5.44; 95%CI=2.89, 10.22), altliough
substantially reduced, remained strong
Stalking and threats to harm cliildren and
other family members were not indepen-
dently associated with intimate partner femi-
cide risk after variables had been entered in
the first models. When variables related to
previous physical abase weif included in
model 6, previous arrest of the abuser for do-
mestic violence was awodated with a de-
creased risk of intimate partJier femidde (ad-
justed OR = 0.34; 95% Cl = O.lfi, 0.7.3). 'Vhe
assodation between abusers' use of forced
sex on victim,*; and increased intimate partner
femicide risks approached statistical signifi-
cance (adjusted 0 R = 1.87; 95% CI=0.97,
3.63: P<.07).
 RESEARCH AND PRACTICE

Inddent-Ievel variables were added in

TABLE 1-Soclodemo^phic Characteristics of Victims and Perpetrators and General Risk
model 7. Abuser's use of a gun in the worst
Factors for Homicide, by Group
incident of abuse was associated with a 41-
Victims Perpetrators fold increase in risk of femidde after control
Nonfatal Nonfatal
for other risk factors, this effect apparently
Ptiysicat Abuse Homicide Physical Abuse Homicide mediating the effects of abuser's access to a
|n-343) (n-220) P (n-343) (n-220) P gun, which was no longer significant How-
evei", previous threats with a weapon contin-
Soclodemographic variables
ued to be associated with increased femidde
l ^ , y , meaniSD 30.118.6 31,41 7,7 .081 31.2 ± 9.2 34.2 ± 8,7 <.OO1
risks {OR=4,41; 95% a = 1.76. 11.06).
Don't ktiow/refused/missing 0 0 4 22
When the worst incident of abuse was
Race/ethnicity, Ho. (%) <,001 <.OO1
triggered by the victim's having left the
Black/African American 70 (20,6) 104 (47,3) 83 (24.3) 107 (48,9)
abuser for another partner or by the abuser's
White 157 (46.3) 53 (24.1) 153(44.7) 49 (22,4)
jealousy, there was a nearly 5-fold increase
Latino/Hispanic 82 (24,2) 53 (24.1) 80 (23.4) 58 (26,5)
in femicide risk (adjusted OR = 4.91; 95%
Other 30 (8.9) 10 (4.5) 26 (7.6) 5(2.3)
Cl=2.42, 9.96). When the incident was trig-
Don't know/retused/fflissing 4 0 1 1
gered by the victim's having left the abuser
Education, No. (%) <,001 <,001
for any other reason, femicide risks were
Less tlian high school 61 (17.9) 71 (33.2) 92 (28,0) 70 (48.9)
also significantly increased (adjusted OR =
High sctiooi 73 (21.5) 59 (27.5) 91 (27,7) 47 (32.9)
4,04; 95% CI= 1.80. 9,06), These incident-
Some college/trade school 109 (32.1) 68 (31.8) 58 (17.7) 17(11.9)
level effects appear to mediate those i-elated
College/trade school 97 (28.5) 16 (7.5) 87 (26,5) 9(6.3)
to highly controlling abusers and separation
Oon't know/refused/missing 3 6 15 77 after cohabitation.
&nployment, No. (%) <,001 <.O01
Each of the models induded in Table 3
Fuii-time 179(52,2) 114 (51,8) 229 (68,2) 84 (39,6)
demonstrated an adequate fit according to
Part-time 70 (20.4) 31 (14.1) 39 (11.6) 20 (9.5)
Hosmer-Lemeshow'^ goodness-of-fit tests.
Unempioyed, seeking job 40 (11.7) 12(5.5) 25(7.4) 13 (6.1)
Model 6 correctly predicted the case status of
Unempioyed, not seekingjob 54 (15,7) 63 (28.6) 43 (12.8) 95 (44,8)
73% of the cases and 93% of the control
Don't know/refused/mlssing 0 0 7 8 women. Model 7 correctly predicted the case
income (anntiai household). $, .005 stattis of 81 % of the cases and 95"/o of the
No. (%) control women.
Less than 10000 67 (21,7) 25 (18,8)

10000-19999 49 (15,9) 32 (24,1) DISCUSSION

20000-29999 «(13,9) 20 (15,0)

30000-39999 41 (13.3) 29 (21.8) Seventy-nine percent (220/279) of the

40000 Of more 109 (35,3) 27 (20.3) femidde victims aged 18 to 50 years and
Don't know/refused/missing 34 87 70% of the 307 total femicide cases were
Geaend vtotence/tiomlcide risk variables physically abused before their deaths by the
Threatened/attempted suicide .091 ,149 same intimate partner who killed them, in
Ves 33 (9,6) 12 (5.6) 68 (20.1) 45 (25.0) comparison with lO"/o of the pool of eligible
Don't know/rehjsed/missing 0 6 i 40 control women. Thus, our first premise, that
Problem alcohol drinker. No. {%) <.OO1 <^1 physical violence against the victim is the pri-
Yes 27 (7,9) 36(19.1) 106 (30,9) 105 (52,0) mary risk factor for intimate partner femicide,
Don't know/refused/missing 0 32 0 18 was upheld. The purpose of this study, how-
Illicit drug use. No. (%) -002 <,001 ever, was to determine the risk factors that,
Yes 49 (14,3) 48 (25.3) 101 (30,4) 123 (65.4) over and above previous intimate partner vio-
Don't know/retused/missing 1 30 11 32 lence, are assodated with femidde within a
Access to a firearm,' No, (%) ,996 <.0Ol sample of battered women. Our analysis
Yes 17 (6.0) 10 (5.0) 82 (23.9) 143(65.0) demonstrated that a combination of the most
Don't know/refused/missing 2 19 0 0 commonly identified risk factors for homicide,
in conjunction with characteristics specific to
Sontrntffid
violent intimate relationships, predicted inti-
/// mate partner femidde risks.

July 2003, Vol 93, No. 7 { American Journal of Public Heattii Peer Reviewed | Research and Practice | 1091

TABLE 1-Contfnuetf
Arrest for violent crime. No. (%)
Ves
Don't know/terused/missing
Note. The referent time periods for all rish variables were the year previous to the most abusive event for abused control
women and the year previous to Itie temicrde for femicide victims.
'For abused women, gun access was defined as a woman's sole access to a firearm on the basis of her living apart from her
partner and reporling having s gun in the home; gun access for partner was based on reports of his personal ownership of a
firearm or living in a tiousefiold with a firearm.
TTie model-building strategy we used al-
lowed for consideration ol' dirferent levels of
|)a'vpntion and the degree to which intimate
partner femicides could be prevented hy strat-
egies directed al risk factors for homicide in
gtmerai. For example, our analysis and those
of others suggest that increasing emplc^ment
opportunities, preventing substance abuse,
ami restricting abusers' access to guns can po-
tentially reduce both overall rates of homicide
and rates of inliniate partner I'emicide.
In comparing our femidde perpetrators
with other abusive men, we found that unem-
ployment was tlie most important demo-
jiraphic risk factor for acts of intimate partner
feniicide. In fact abuser's lack of employtnent
was the only demographic risk factor that sig-
nificantly predicted femicide risk's after we
controlled for a comprehensive list of more
proximate risk factors, increasing risks 4-fold
relative to tlie case of employed abusers
(model 6), Unemployment appears to under-
lie increased nsks often attributed to race/
ethnicity, as has been found and reported in
other analyses related to violence.'^'^"^
'Hie prt'sent results revealed that traits of
perfieti"atoi"s thought to be chai^acteristic of vi-
olent criminals in general^' tended to be no
more characteiistic of femicide peqietrators
than of uther batterera. For instance, in con-
trast to results of previous research compar-
ing abusers fuid nonabusers,^^ our regression
analyses showed that arrests for other crimes
did not differentiate femicide perpetrators
from por[)etrators of intimate partner vio-
lence. .After controlling for other risk factors,
prior arrest for domestic violence actually de-
creased the risk for femicide. suggesting that
arrest of ahusers piT)tects against future inti-
mate partner femidde risks. I^rpetrator drug
abuse significantly increased the risk of inti-
1092 I Research and Practice | Peer Reviewed I Campbell et al.
RESEARCH AND PRACTICE
<.0Ol
38(11.5) 43 (21.8)
12 23
mate partner femidde, but only before the ef-
fects of previous threats and abuse wei"e
added. Drug abuse, therefore, was assodated
with patterns of intimate partner abuse that
increase femicide risks-
Our iterative model-building strategy also
allowed us to observe whether the effects of
more proximate risk factoi-s mediate the ef-
fects of more distal factors in a manner con-
sistent with theory. For example, the 8-fold in-
crease in intimate partner femicide risk
associated witli abusers' access tofirearmsat-
tenuated to a 5-fold increase when character-
istics of the abuse wei-e considered, including
previous thi-eats with a weapon on the part of
the abuser. This suggests that abusers who
possess guns tend to inflid the most severe
abuse.
However, consistent with other re-
seardi.'''^'^'^'^''''^ gun availability still had sub-
stantial independent effects that increased
homidde risks. As expected, these effects
were due to gun owning ahusere' much
greater likelihood of using a gun in the worst
incident of abuse, in some cases, the actual
femicide, Tbe substantial increase in lethality
assodated with using a firearm was consistent
with the findings of other research assessing
weapon lethality. A victim's access to a gun
could plausihly reduce her risk of being
killed, at least if she does not live vnth the
abuser. A small percentage (S^/o) of both case
and control women lived apart iram the
abuser and owned a gun, however, and there
was no clear evidence of protective effects.
Previous arrests for domestic violence was
protective f^ainst intimate partner femicide
in both of tbe final models. In most of the
cities where data were collected, there is a
coordinated community response to domes-
tic violence. Under optimal conditions, such
American Journal of Public Health | July 2003, Vol 93, No. 7
responses include adequate and swift adjudi-
cation, close supervision of parole outcomes
through periodic court reviews or spedalized
probation programs, ongoing risk manage-
ment for arrested perpetrators and ongoing
safety planning for victims, and close super-
vision involving sanctions for batterers who
drop out of mandated intervention pro-
grams.''' Under tliese kinds of conditions,
arrest can indeed be protective against do-
mestic violence escalating to lethality.
Two relationship vanahles remained signif-
icant throughout the models. Consistent with
earlier research,"^** instances in which a
cliild of the victim by a previous partner was
living in the home increased the risk of inti-
mate partner fnmicide. Situations in which
the victim and abuser had never lived to-
gether were protective, validating safety ad-
vice that battered women have offered to
oilier battered women in interview studies.^**
Women who separated from Uieir abusive
partners after cohabitation experienced in-
creased risk of femicide, particularly when
the abuser was highly controlling. Other stud-
ies have revealed the same risks posetl by es-
trangement,"'"" but ours further explicates
tlie findings by identifying bighly controlling
male partners as [irt'senting the most danger
in this situation. At tlie Lnddent level, we
found that batterers were significantly more
likely to perpetrate homicide if Iheir partner
was leaving them lor a dilTerent paitner.
TTie bivariate analysis supported earlier ev-
idence that certain characteristics nf intimate
partner \iolence are associated with intimate
partner femidde. induding stalking, strangula-
tion, forced sex. abuse during pn-gnancy. a
pattern of escalating severity and frequency
of physical violence, perpetrator suiddaiity,
perce|>tion of danger on the part of the vic-
tim, and child abuse.'^•"*^"'^^" However,
these risk fadors, with the exception of forced
sex. were not associated with inliniate partner
femicide risk in the multivariate analysis.
Many of these characteristics of abuse are as-
sotnated witli previous threats with a weapon
and previous tlireats to kill tlie victim, factors
that more closely predid intimate partner
femidde risks.
This investigation is one of the few studies
of intimate partner femidde to include a
control population and, to our knowledge.
 RESEARCH AND PRACTICE

TABLE 2-Reiationshlp Dynamics, Threatening Behavior, and Abuse Characteristics the first to examine the connection between
relationship variables and specific demo-
Abused Control Homicide Victims grapliic diaracteristics of victims and perpe-
Women [n-343) (11-220) P
trators. Pferhaps the most important limita-
Relationship vsriatries tion of the study is its necciisary reiiance on
Age djflerence, y, mean ± SD 1.1 £ 5.7 2.9 ±6.4 .001 ptx>xy respondents for data rt-garding hy-
Length of relationship, No. (%) ,023 pothesized risk factors for intimate partner
1 morth or less 5(1.5) 0 femicide cases. Because we obtained data
1 month to 1 year 94 (27.5) 44(20,0) from controi women directly, rather than
1 or more years 243 (71.0) 176 (80.0) from a proxy, observed differences between
Don't know/refused/missing 1 0 case anc] conti'ol women may have been
Relationship partfter. No. (%) .005
whoily or partly attributable to tlilTerences in
Hiishand 101 (29.7) 85 (39.0)
accuracy of reporting between victims and
Boyfriend 86 (25.3) 65 (29-8)
their proxies. To examine tbis issue, we con-
Ex-husband 36(10.6) 20 (9.2)
ducted a small pilot study comparing re-
Ex-boyfriend 117(34.4) 48(22.0)
sponses of victims of attempted femidde and
Don't know/reftised/missing 3 2 respoiises of their proxy respondents and
Separated. No. (%) <,001
found good agi-eement between summed
Ves 117 (34.9) 101 (55.2)
Danger Assessment scores from the 2
Doi't hnow/tefused/missing 8 37
sources of information. Furthermore, tliere
Cohabitation, No. {%) <,001
was no cleat" tendency for proxies to tmder-
Yes 174(50.7)
rt'pfirt or overreport victims' exposure to
81 (45.0)
!n the past year, but not currently 39(n.4) 68(37.8)
specific risk factors relative to the self-
teports of victims themselves.^''
Previously, but not in the past year 11 (3.2) 11(6.1)
Never 118(34.7) 20(11.1)
li is also possible that some of the women
Don't know/refused/missing 1 40 who were excluded fmm this analysis be-
Biological child(fen) of victim and partner living in the
cause of no record of previous physical vio-
household, No. {%) ,034
lence were in fact being abused, unknown to
Ves 98 (28.6) 73(37.4)
the proxy. However, we found fairly good
Ooi't know/refused/missing 0 25
correspondence witli |K>lice records of previ-
Biological child(^n) of victim, and not of partner, living
ous domestic violence, and, if anything, we
in thehousetiold,No.(%) <.0Ol
found more loiowledge of previous physical
Yes 82 (38.7)
abuse among proxies tlian among police. A
60 (17.5)
related limitation is the relatively lai^ge pro-
Don't know/refused/missing 0 8
portion of "don't know" responses frotn prox-
Relationslilp abuse dynamics
ies regarding certain hypotliesizcd risk lac-
Partner controlling behaviors {score > 31, No. {%) <.0Ol
tors of a more personal nature (e,g.. forced
Ves 84 (24.5) 145(65.9)
sex). Our decision to treat these "don't know"
Partner called victim names to put her down. No. (%| <.OO1
responses as representing absence of the "ex-
Yes 164 (47.8) 151 (77.8)
posure" produced conservative biases in our
Don't know/refused/missing 0 26
estimates of relationships with intimate part-
Eienerai vioience/iiomiclde risk variabies
ner femicide risks. Therefore, we may have
Partner violent outside home, No. (%) <.oai
inappropriately failed to reject the null hy-
Yes 116(35.5) 102(55.7)
pothesis in the case of some of these vari-
Don't know/refused/missing 16 37
ables witli large amounts of missing data and
Partner threatened to kill woman. No. (%) <.0Ol
near-significant associations with intimate
Yes 50(14.6) 142 (73.6)
partner femiride risk.
Don't know/refused/missing 1
Another limitation was that we excluded
Partner threatened to kill family, tio. {%) <.0Ol
women who did not reside in large urban
Yes 26 (7.6) 72 (33.8)
areas (other than Wichita. Kan) and control
Don't know/refused/missing 0 7
group women who did not have telephones.
Continued We also failed to keep records of exactly
which proxy intei-views (estimated to be less

July 2003, Vol 93, No. 7 [ American Journal of Public Health Campbell et al. { Peer Reviewed I Researcn ana Practice | 1093
 RESEARCH AND PRACTICE

TABLE 2-Continued
than 10% of the total) were conducted in
person rather than by telephone, and thti.s
Partner threatened woman with a weapon, No. (%) <.OO1 we cannot evaluate the efiects of this source
Yes 16 (4.7) I I D (55,3) of bias. Finally, we have no way to compare
Don't know/refused/missing 0 21 the control women who participated with
Partner tfirealened to harm children, No. (%) <.0Ol those who did not. and womon living in the
Vfes 4(1.2) 36 (18.5) most dangerotis situations may have been
Don't know/refused/missing 7 25 less likely to participate as control women, [f
Stalking behavior (score >3}, No, (%) <.OO1 so, true exposure to the risk factors ol" inter-
YBs 21(6.1) 47 (21.4) est among women involved in abusive inti-
Don't know/refusetl/missing 0 0 mate relationships may be greater than our
Characteristics ot physical violence
control data suggest, thus inflating our esti-
Increase in frequency, No, (%) <.O01
mates of increased risks associated with
Yes 88 (25.7} 109 (59.9)
these exposures.
Don't know/refused/missing 5 38
Increase in severity. No. (%) <.0Ol CONCLUSIONS
Yes 70 (20,4) 105 (64.4)

Don't know/refused/missing 5 57 In light of our flndings, it is important to

Partner tried to choke (strangle) woman, No, (%) <.OO1
consider the role medical professionals might
34(9.9) 84 (56.4)
play in identifying women at high risk of inti-
Don't know/refused/missing 1 71 mate partner femicide. The variables that re-
Forced sex, No. {%) <.OO1
mained significant in model 6 are those most
Yes 51 (14.9) 84 (57.1)
important for identifying abused women at
risk for femicide in the health care system
Don't know/refused/missing 1 73
and elsewhere, whereas those that were sig-
Abused during pregnancy (ever). No, (%) <.OO1
nificant in model 7 are partiailarly impoiiant
Yes 24 (7.0) 49 (25.8)
in prevention of the lethal incident itself.
No or never been pregnant 319 (93,D) 141 (74.2)
When women are identified as abused in
Don't know/refused/missing 0 30
medical settings, it is important to assess per-
Partr^er arrest previously for domestic violence. No, (*) .003
petrators' access to gun.s and to warn women
Yes 46 (13.9) 50 (25,6%)
of the risk guns present This is e^wcially
Don't know/refused/missing 12 25
true in the case of women who have been
Incident-level variables
threatened with a gtin or another weapon
Gun used. No. {%) <.0Ol
and in conditions of estrangement. Under fed-
Yes 3(0,9} 84 (38.2)
eral law. individuals who have been con-
Partner used alcohol or drugs. No, t%) <.OO1
victed of domestic violence or who are sub-
Yes 123(34.6) 133 (60,5)
ject to a restraining order are barred from
Victim used alcohol or drugs, No. (%] <.0Ol
owning firearms. Judges issuing orders of pro-
Yes 44(12.4) 53 (24,1)
tection in cases of intimate partner violence
Order of protection. No. (%) <.0Ol
should consider the heightened risk of lethal
Yes 16(4.7) 54 (24,5)
violence associated with abusers' access to
Trigger: jealousy. No. (%) <,001 firearms.
Yes 52(17,1) 85 (38.6)
Often, battered women like the idea of a
No or don't know 291 (82,9) 135 (61.4)
health care professional nodtying the police
Triger: woman leaving, No. {%) <.OD1
for them; however, with the exception of Cal-
Yes 32 (10,5) 72 (32.7)
ifornia, states do not require health care pro-
No or don't know 311 (89,5) 148(67.3)
fessionals to report to the criminal justice sys-
Trigger: woman has new relationship. No, {%] <.OO1
tem unless there is evidence of a felony
Yes 7(2.0) 26(11.8)
assault or an injury from an assault. '^""' In
No or don't know 336 (98,D} 194 (88,2) states other than California, the professional
Note. Unless otherwise noted, the referent time periods for risk variables were the year previous to the most abusive event for
can offer to call tlie police, but the woman
abused control women and the year previous to the femicide for femicide victims. should have the final say, in that she can
best assess any increased danger that might

1094 I Research and Practice | Peer Reviewed i Campbell et al. American Journal of Public Health I July 2003. Voi 93, No, 7
 RESEARCH AND PRACTICE

TABLE 3-Hypottiesfzed Risk Factors for Intimate Partner Femicide Among Women involved result from the police being notified. An ex-
in a Physicaiiy Abusive intimate Relationship Wltiiin the Past 2 Years: Adjusted Odds Ratios cellent resource for referral, shelttT, and in-
fonnatioii is Lhe NsUanal Domestic Violence
Modell Model 2 Model 3 Model 4 Models Model 6 Model 7
Hotline (1-800-799-SAFE).
Abuser age UO**' 1.08" • NS If a woman confides that she is planning to
Abuser race/ethnicJty NS leave her abuser. it Is critical to warn her not
Abuser ^ucation (reference group: to confront him personally with her decision.
high school graduates) Instead, she needs to leave when he is not
Less than high school 140 NS present and leave a note or call him later. It is
Some college 0.72 NS also dear that extremely controlling abusers
College 0,31* NS are particularly dangerous under conditions
Abuser job slalu5 (reference group: of estrangement A question such as "Does
employed lull lime) your partner try to control all of yotir daily
Employed parl time 1,61 m NS NS NS f^S NS activities?" (from the Danger Assessment'^)
Unemployed, seeking job 1,34 fJS NS NS NS NS NS can quickly assess lliis extienic need for con-
Unemployed, not seeking job 5,09* • ' 6.27'" 4,00" • 3.24* • • 4.28"* 4.42*" 4.35* trol. Health care professionals can also expe-
Victim age NS didously assess whether tlie perpeti-ator is un-
Victim cace/ethfiicity NS employed, whether stepchUdren ai-e present
Victim education (reference group: in the home, and whether tbe perpetrator has
high school graduates) threatened to kill the victim. Under these con-
Less than high scfino) 1.61 NS NS NS ditions of extreme danger, it is incumbent on
Some college 0.87 NS NS NS health care professionals to be extremely as-
College 0.31* • 0.15* 0,28* NS sertive with abused women about theii" risk of
Victim job status (feference group: homidde and their need for shelter." •
employed f j l l time)
Employed part time 0.95 NS NS
Unemployed, seekingjob 0.13*'* 0.25* NS About the Authors
Unemployed, not seekingjob 0.99 NS NS Jai'ijueli/n C. CumpbeU, Phi/llb Shai-ps. and Kathryu
iaughon are with the .'icliool of/Vumng.Jt'lnu' llopkms
General risk factors for homicide
University. Hallmtore, Md. Daniel Webster, /ennifer
Abuser problem drinker NS Manganello. and Janet Sclwllenherger are with Ike
Abuser used illicit drugs 4.76'" 2,19* 1.88' NS NS Bloomberg Schtjol of Ihihlir Ilealih.John'i llnpkin.t Vnh
I'ersiiif. Jane Koziol-McLain is wiih the School of Nursing.
Abuser mental health NS .Auckland Vniwrsiiy of Ti-chnology. Auckland. New
Abuser threatened suicide NS Zealan<l Carolipi Rebeaa BhKk is with the Illinois Crim-
inal Jxislice Informalxon Aiilliority. Chicagn Dons Camp-
Abuser hurt pet NS
bell IS with the Collide of Medicine. Umivrsitj/ of South
Abuser access to gun 7.59* *• 9,21"* 8,28'" 5,44*" 5,38"' NS f-lorida. Tatnpa Mury Ann Curry and Nancy Glasi ure
Abuser arrest for violent crime NS with the Schoitl ufNwsing, Oi-ef-on Health Scimces Vni-
versity. Portland. Fat/e Can/ it with the College of Nurs-
Victim problem drinker NS ing. Univeisity off-lnrida. Came.'sville. Judifh McFarlanr
Victim used illicit drugs NS IS with the School of .Wursing. Texw Wnmiti's Uniivrsjly.
Victim sole access to gun 0,22* N5 NS NS NS NS Houston Camlt/n Sarlvi is wilh the School of Mediiine.
Universitj/of California Los Angeles. YmniK Ulrich is
Relationship variables with the Scliool ofNiining, Vniveniti/ of Washington.
Married NS Seattle. Susan A. Wilt is with the \'ew York City Depart-
ment of Health Xiao Xu is with Covttnce Inc. Woihing-
Divorced NS
ton, DC. Victoria A. Fiye w wiHi St. Luke's Medicat Cen-
Time in relationship NS ter. New York Ci'fy,
Cohabitation (reference: living
He<piestsfor reprinLt sliouid IK smi tofavquelyn C.
together during entire past CampbeU, /•*/), RN. Johns Hopkins Vmvenitii. School of
year) Nursing. 525 N Wolfe St. *-i.W. Baltimore. MU 21205-
2110 (e-mail jmmphell@son.jhmiedul.
Living togetha less than 1 year NS
This article was accepted September 23. 2002.
Previously lived together, 3,64"
separated at time of
Contributors
incident J.C, Canipbiill tlcsignL'd the study and wrote most of
Never lived together 0J9" 0.30" 0.36' 0.34" 0.31" the introducLoty and Discussion sections, D. Webster
analyzed tlic data, wmtc most of the Ktsuils section,
Continued and contribnlpd lo tlie Mi-tliods and DLsaission sec-
tifKis, J. Koziiil-Mcl^n vimW Uie Mtilhods sectiun, con-

July 2003, Vol 93, No. 7 1 American Journal of Public Health Campbell et al. I Peer Reviewed 1 Research and Practice I 1095
 RESEARCH AND PRACTICE

TABLE 3-Continued References

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Updated edition with all-new
epilogue
I n this softcover edition, conttibutors
demonstmtc the devastating effects of
war. Tliey discuss nuclear weiipon.s, bio-
logical <ind cheniical weapons, conven-
tional arms -lnd services, the United
Nations, .ind the onomicnis costs im'olveti
in depri\ ing warring nations from t^txius-
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This b(Kik should be on the reading list
of not only health professionals but of all
those who are interested in international
studies, diplomacy or the military.

29. Campbell JC. Miller P. Cardwell MM. Bdknap RA, ISBN 0-87553-023-0
RelatifHLsliip status of battered women over time, / Fam 2000 1417 pages I softcover
Violence. 1994;9:99-m. S17.00APHA Members
$23.50 Nonmembers
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trangement. Violence Viet. 1993:8:3-15.
31. f)awsori R, Gartner R. Differences in Ihe charac- American Public Health Association
Publication Sales
teristics of mtimate femidde-s: the m\c of relationship
Web: www,apha.org
state and relationship status. Homicide Stiid !998;2:
E-tTiail: APHA@TASC01.com
378-399. Tel: (301) 893-1894
32. Campbell JC, Soekcn K. McFariane J. I ^ k e r B.
APHA FAX: (301) 843-0159
Risk factcH-s foi- feinidde among pregnant and nonpreg-
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SuTVinors of Abuse- Health Care for Battered Women and
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July 2003, Vol 93, No. 7 I American Jotjmal of Pueiic HealtJi Catnptell et al. , Peer Reviewed | Research and Practice | 1097