Key Questions
What are domestic violence-related homicides?
Which groups experience domestic violence homicides the most?
What is a domestic violence fatality review?
Why conduct a fatality review?
Who might serve on the teams?
What philosophies have teams adopted and why?
How does a fatality review team operate?
Confidentiality: why is it so important?
How many and what kinds of cases might a team review?
What documents might a team review?
What are the practical steps in reviewing a death?
What protocols have teams adopted?
Funding direct services vs. fatality reviews?
The costs: what do you need and how are teams funded?
What about the emotional toll on reviewers?
Should teams consider working with family members or friends who lost loved ones?
How does the review fit with other prevention strategies like safety audits and court watch?
Is there a need for grassroots reviews?
What policy changes have been made because of fatality reviews?
What are the products of fatality reviews?
How do fatality reviews contribute to dangerousness or lethality assessments?
Working with the media: what are the issues?
How has domestic violence homicide changed over the years?
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What are domestic violence-related homicides? Many more Americans die from suicide than homicide. Most of these suicides involve male victims, some of whom kill their female intimate partners before taking their own lives. Research suggests that a significant number of the 6,000 or so women who commit suicide each year do so because of their violent victimization at the hands of an intimate male partner. Stark and Flitcraft note specifically, “in most cases we believe battered women are provoked to attempt suicide by the extent of control exercised over their lives.” According to these authors the proximity between woman battering and women’s suicide attempts in general, strongly suggests that battering may be one of the principal causes of the suicide attempts. Stark and Flitcraft point out that a number of studies identify abuse as a factor in as many as 44 percent of female suicide attempts. For these researchers it is very telling that over a third of the battered women in their sample, “visited the hospital with an abuse-related injury or complaint on the same day as their suicide attempt.” As the proportion of the elderly in the U.S. in the population increases, researchers have become increasingly aware of domestic violence among their ranks. Old stereotypes die hard, and social service providers and law enforcement agencies sometimes assume that because people are elderly they are not capable of committing or being victimized by domestic violence. This attitude sometimes translates into an assumption that homicide-suicides among the elderly usually take the form of “mercy killings.” Police officers or others who investigate the homicide-suicide and find a note telling authorities that the couple could not live on with ailing health might hastily label the death a “mercy killing.” Upon further investigation we find it is nearly always men who commit these killings and that in a significant number of cases their female victims had expressed to other family members a desire to live not die. Indeed, Donna Cohen found that homicide-suicides involving elderly women in West Central Florida accounted for 20 percent of the total homicides of people aged over fifty-five. Cohen also notes that while 50 percent of the women’s health had deteriorated, two-thirds had expressed “no desire to die.” Evidence that women killed in so-called mercy killings or suicide pacts had previously expressed “no desire to die” may suggest they were being battered before their demise. Deaths traceable to domestic violence and therefore subject to fatality review, increase considerably if we include women who die as prostitutes, HIV victims, or from causes related to homelessness. For example, one might argue that because battered women appear more vulnerable to HIV infections than non-battered women, some deaths of women attributed to HIV or some complication thereof, might be traceable to the women’s compromised status as battered. The same could be said of homeless women dying on the streets since roughly half of homeless women report “fleeing abuse” as the reason for their homelessness. Likewise, prostitutes have experienced enormous amounts of interpersonal abuse at the hands of male intimates, family members, and their clients Which groups experience domestic violence homicides the most? The following research is based on Websdale, N. 1999. Understanding Domestic Homicide. Northeastern University Press. Boston, MA. Gender
Notably no females killed intimate female partners, and no females killed other women in a love triangle dispute over a man or woman. Only two women killed other women in family disputes. One can presume that these gendered killings demonstrate men’s “intent” to exert their power/control over women. The percentage of female murder victims killed by intimate partners has remained at about 30% since 1976.
What is a domestic violence fatality review? Why conduct a fatality review? Domestic violence fatality review provides a systematic way of reviewing domestic homicides through a lens of prevention and accountability. While it is important that each review team determine their specific purpose for conducting reviews, most review teams share the following underlying objectives:
Fatality review can also enhance a community’s coordinated response. Fatality Review provides an opportunity for a diverse, multi-disciplinary group of professionals and community members to meet on a regular basis and discuss issues of system response and social change. Many teams have reported that the relationships developed as a result of fatality review have been invaluable and have enhanced coordination among individuals, agencies, and the community as a whole. Usually adult fatality review teams are inclusive rather than exclusive, often being open to incorporating new members and agencies. Stone recommends including a member of the public to guard against members engaging in cover-ups. Anyone remotely involved with or affected by a domestic violence fatality might serve on a team. Two observations are helpful: teams ought be inclusive rather than exclusive, creatively constituted with an eye on learning more about how the deaths might have been prevented. Also, teams might consider having a core group or executive committee work on administrative and process issues, as well as a larger group. Finally, membership can be local or statewide, depending on the jurisdiction where the team is being established. Here are some membership suggestions:
Some states legislate membership. For example, according to the Florida fatality review legislation (Section 741.316, Florida Statutes), “local domestic violence fatality review team” should include representatives the following offices, agencies and organizations:
What philosophies have teams adopted and why? Although the perpetrator of domestic homicide bears the ultimate responsibility for the killing, many agencies that work with victims of domestic violence might have become more involved, perhaps saving a life. The failure to prevent deaths through inaction, negligence, malfeasance, corruption, the inability to better coordinate service delivery, and so on, is common in many walks of life where the safety and security of the public are at stake. It is essential that review teams gather information to make informed decisions about how to introduce changes to prevent domestic violence. In other words, the review team works with a philosophy of kindness and concern, a philosophy that respects the rights of surviving family members, but with a philosophy that recognizes that better agency coordination can save lives. The “no blame and shame” philosophy does not remove the need for agency accountability. How does a fatality review team operate? Teams operate in a variety of ways, depending on available resources, participation, legal or legislative direction and local preferences. For example, some Florida teams (e.g. Miami and Orlando) have a two-tiered organization structure. The actual review team contains those agency players who bring information to the table in order to discuss domestic violence related deaths. Usually one or two of the members of these review bodies assume responsibility for leading the team, coordinating meetings, and a variety of other duties. These chairs / co-chairs are usually actively involved in domestic violence cases and are well placed to orchestrate the activities of a wide range of professionals. Rotating leadership is desirable in order to avoid burnout, inject new ideas into team deliberations, and insure that as many reviewers as possible learn about chairing team activities. Other teams (New Hampshire’s statewide team) has a single tier for review, and a small group that carries out administrative and organizational tasks. Washington State’s review teams are both regional and statewide. The regional teams meet and provide information to the statewide team, which reviews regional findings and produces a statewide report. Teams are also located in a variety of ways, all of which impact their mode of operation. Some are domestic violence coalition or advocate based (Washington state, Denver, CO, Berks County, PA). Some are located as a subcommittee of an existing domestic violence coordinating effort (Palm Beach County, FL, Santa Clara County, CA, New Hampshire). Still others are system-based and are an adjunct to a governmental office (Philadelphia, PA). Confidentiality: why is it so important? How effective can a fatality review be if some of the information is confidential and the team cannot have complete access to it? When does the team cross the line into discovering or discussing information that is private and should be kept out of the public eye? What impact will the disclosure of information to a fatality review team have on a domestic violence victim?s desire to access a shelter, to call law enforcement or to hire a lawyer? Laws regarding an individual?s right to privacy and the public?s right to know attempt to balance these interests. Often positioned between these two interests is the work of the domestic violence fatality review team. When teams meet, they process all levels of information ‘? some public, some private and some in between. It is essential that the fatality review teams respect both the privacy of the persons whose lives, and deaths, it studies… How many and what kinds of cases might a team review? The simple answer to this question is, ?Resources permitting, as many cases as the team feels it is able to review in order to better understand, intervene in, and prevent domestic violence and domestic homicide. Cases for review can include:
The Philadelphia Death Review Team reviews hundreds of women?s deaths per year, taking perhaps 30 minutes per review. The idea in Philadelphia is to identify as many cases as possible where women died as a direct or indirect result of domestic violence. Conversely, reviews like the Charan Investigation (a homicide-suicide case in San Francisco in 1990) seek to identify system failures through an extremely detailed analysis of one case. Some jurisdictions review a large number of cases in summary fashion, others delve into individual cases in great depth. Both approaches have the potential to improve the delivery of multiple services to victims of domestic violence. What documents might a team review?
What are the practical steps in reviewing a death? Alana Bowman has identified a number of possible steps involved in creating review teams (Bowman, Alana. 1997. “Establishing Domestic Violence Review Teams.” Domestic Violence Report, August/September 1997, pp. 83, 93-94.) We paraphrase the following:
As a primary order of business, teams first need to develop protocols regarding the above points before conducting the first review. Teams also can do ?practice? reviews using hypothetical situations. (Contact the NDVFRI for training tools and hypotheticals.) Existing teams examine intimate partner homicides, for the most part, although many more deaths are linked with and traceable to domestic violence. Teams have paid less attention to sexual competitor killings, women?s suicides, family homicides, or mercy killings, but these types of case reviews are also important. Teams that form in areas with few or no intimate partner homicides might consider exploring cases such as women?s suicides. Here they might begin by exploring whether the person who killed herself had injuries consistent with prior domestic violence, or whether police had ever visited her home on a domestic disturbance call, or whether she ever was the recipient of a domestic violence injunction or restraining order. They might also examine perpetrator suicides. What protocols have teams adopted? Although a number of states have confidentiality legislation that protects the deliberations of domestic violence fatality review teams, it is a good idea to sign confidentiality documents at the start of each review. In this way, each participant understands his/her responsibilities. Each team should develop its own set of protocols about how to conduct reviews. New teams need not reinvent the wheel here; we can provide lists of working teams, many of whom will be happy to share their existing protocols. Otherwise new teams can visit the NDVFRI website to see sample protocols. Note that while it is helpful to see and draw upon the work of established teams it is important to go through the process of formulating protocols as part of team building. Funding direct services vs. fatality reviews? Some skeptics have suggested it is better to channel scarce resources into direct services for victims of domestic violence than to scrutinize the relatively small proportion of cases where victims die. We have a lot of sympathy with this perspective. It is indeed the case that fatality review is not a process that every community will want to embark on. Some communities will want to use their funds for direct service for battered women. Others will conduct safety and accountability audits. Neither is it possible to prove in any scientific manner that fatality reviews reduce the amount of domestic violence or the number of domestic violence related homicides. In defense of fatality reviews, it does appear that domestic homicide attracts widespread attention and can serve as a vehicle for improving service delivery. It is also a highly focused mechanism for bringing diverse agencies to the table to discuss major social problems. The costs: what do you need and how are teams funded? To date, most teams are resourced by volunteer efforts and many have done exemplary work without funding. Team members incorporate death review work into their regular and very busy work schedules. Some teams have sought and received funding. For example, one team in Florida receives funding from the county for a line item in the municipal budget to fund two persons to engage in death review work and at least one team has received funding from the state?s STOP grant program. Similarly, the Washington State death review team also received state STOP Grant funding. There are also a variety of funding opportunities through the various federal agencies that offer assistance to multi-agency teams working to prevent to domestic violence. These agencies include the Violence Against Women Office (including the STOP Grant Program and the Grants to Encourage Arrest Grant Program). The State Justice Institute has also funded state fatality review development in New Hampshire. When teams are formed as subcommittees to existing state or local domestic violence task forces, funding and resource support (such as administrative staff to set meetings, take minutes, prepare reports and monitor recommendations) can come from those umbrella efforts to support fatality reviews. It is also wise for teams to solicit the presence of local business people on their teams. Not only is domestic violence and domestic homicide an important workplace issue; these individuals may be able to offer support or sponsorship to assist with supplies, telephone costs, and other administrative expenses. What about the emotional toll on reviewers? Reviewing the life and deaths of other human beings can be a disturbing and emotionally taxing process. People react differently to the details that surface during death reviews and it is important for teams to anticipate this. Teams should establish a process of ?taking care? of each other and discuss the impact fatality reviews are likely to have on them emotionally. For instance, some reviewers are openly disturbed by evidence such as crime scene photographs. As such, members should be allowed to opt out of this portion of a review or teams should decide whether the emotional impact of viewing photographs outweighs factual value. Should teams consider working with family members or friends who lost loved ones? Working with family members or friends who have lost loved ones to domestic homicide is extremely difficult. It is important for teams to determine at the outset, what their position will be regarding interviewing victim or perpetrator contacts. In the course of our work we have met family members and friends who did not want to discuss the homicide. We have also met people who are traumatized by the insensitivity of service professionals who initially notified them of the death of their loved one, or who subsequently became involved in the prosecution of the perpetrator. Most fatality review legislation does not permit fatality review teams to share information with family members or anyone else concerning the homicide, unless that information is part of the public record. If family members or friends approach review teams and state a willingness to provide information to the team, it is important for the team to spell out the limitations regarding what they can share about the case. It is important for survivors to feel they have access to the review team; at the same time it is important for the review team to adhere to its statutory duties regarding the disclosure of information. It might also be wise for a trained counselor who works on the team to assume the onerous responsibility of being the “point person” to work with families and others who were close to the deceased. This counselor might wish to inform them that digging more deeply into the death of their loved one, even by using available public record data, might uncover information or accusations about the decedent that the family members were not aware of prior to the death. Finally, remember that there are persons close to the perpetrator who may also wish to participate and from whom the team may wish to request information. Once more, it is imperative that teams consider all options regarding interviewing persons close to either the victim or perpetrator before beginning the review process. The NDVFRI can assist teams in providing some excellent resources to assist teams in making this determination and establishing protocols for communicating with persons who were close to a decedent. How does the review fit with other prevention strategies like safety audits and court watch? The federal government, some individual states, and many individual jurisdictions have begun to explore the reasons for domestic violence-related deaths in a systematic manner. Approximately 25 states have at least some form of domestic violence fatality review. In some regions these reviews dovetail with or naturally build upon existing coordinated community responses to domestic violence. The highly detailed examination of the relationships between service delivery systems in a fatality review also has much in common with the approach used by safety audits and court watch programs. Put differently, fatality reviews increasingly form part of an expanding array of multi-agency, interdisciplinary strategies for confronting domestic violence. Moreover, safety audits, court watch programs and fatality reviews can take place simultaneously and complement one another or they can occur independently. Underpinning each of these strategies is a concern with the experiences of women and other family members, a desire to improve the accountability of individual agencies and enhance interagency and system coordination. In fatality reviews, such processes, if conducted thoughtfully, are likely to yield much deeper and more detailed understandings of domestic homicide. Is there a need for grassroots reviews? Yes. Cookie cutter approaches to reviewing domestic violence homicides may be convenient, quick, and produce aggregate data that can be relevant to effecting social change. However, many fatality review teams have tried to avoid perpetuating the domineering styles of batterers by trying to create reviews that are local, democratic, operate at the level of grassroots community activity, and that access the subjective experiences of the parties involved. Such reviews are not necessarily amenable to the kind of convenient aggregate data gathering that some forms of legislation call for. However, these as exercises in local democracy, such reviews are invaluable. Members should consider an array of options used by other jurisdictions when piecing together the elements of their team processes. What policy changes have been made because of fatality reviews? While it is obviously too early to determine with any certainty what the effects these death review teams are having, early anecdotal information suggests that the process has revitalized coordinated community responses and provided a new focus for interagency liaison work and communication. This appears to be of vital community importance. Some examples illustrate the kinds of changing taking place as a result of fatality review work:
A number of statewide reviews recognize the urgent need for translation services in cases of domestic violence involving victims and perpetrators whose first language is not English. The Washington State report recommends that “Institutions such as law enforcement, hospitals, domestic violence programs, and Temporary Aid to Needy Families (TANF) offices should create collaborative relationships with grassroots organizations based in limited English-speaking communities.” The report continues, “consistent with our state law, law enforcement agencies should conduct investigations of domestic violence crimes with qualified interpreters.” In one domestic homicide case in Washington State, “a law enforcement officer asked a six-year-old child to translate for the family member on the scene who had discovered the bodies of the two victims.” In another case, “a hostage situation went for at least an hour, and because no translator was present, the young hostage had to provide translation while the murderer held a gun to her head.” In addition to the potentially traumatizing effects on on-scene unprofessional translators, the use of imprecise translators may also impede the subsequent case investigation in both domestic homicides and non-lethal domestics. What are the products of fatality reviews? There are formal and informal products of fatality review. Among the informal products are:
Among the formal products are:
How do fatality reviews contribute to dangerousness or lethality assessments? Most intimate violence against women does not escalate to homicide. Lethality assessment tools that purport to assess the risk of lethal violence often derive from research and practical understandings about domestic violence and domestic homicide. Given that the research shows little if any qualitative difference in the antecedents to lethal and non-lethal domestic violence, it might be more appropriate to use the term dangerousness assessment rather than lethality assessment. The dangerousness assessment recognizes a continuum of violence against women and seeks to place that victimization on that continuum. The research into domestic homicide is limited because it is impossible to know precisely the characteristics of domestic violence relationships that end in death. In the final analysis, our knowledge is limited by the information reported by the involved parties prior to the homicide, and subsequently inserted into the official record. It is also clear from other research that lethal outcomes may also depend upon the availability of emergency medical services, especially in the first hour after a shooting or stabbing. While rare, it is nevertheless the case that domestic homicides occur when none or very few of the antecedents are present. It is therefore incumbent upon us not give women a false sense of security if lethality or dangerousness assessment tools indicate an apparently low level of risk. At the same time the assessment tools are useful if used as part of an overall safety plan that takes women’s perceptions into account. Any thoughtful instrument has the potential to enlighten those who know little about the plight of battered women. They may also provide a touchstone for victims themselves as they seek to strategize about their futures and those of their children. Hart (1988) identifies attempts/threats/fantasies of homicide or suicide as key indicators of a risk of possible serious or lethal assaults. She notes that when these factors are present alongside a number of others (availability/access to/willingness to use or history of using weapons; obsessiveness; isolation of the batterer and his degree of dependence on the battered woman; rage; depression; drug and alcohol consumption; access to the battered woman) the risk is elevated. Websdale’s (1999) analysis of male perpetrated intimate partner killings in Florida, quantifies some of these above antecedents by examining documents from different agencies and conducting follow-up interviews with various system players. He distinguishes between the antecedents in multiple killings (47 cases, 104 victims, including children; essentially homicide-suicides and familicides) and single killings (67 adult female victims). In single killings, perpetrators are more likely to have a criminal history of violence, to have had prior contact with the police regarding domestic violence, and to be poorer. Essentially, the antecedents that emerge most prominently in both multiple and single killings were:
Important caveat: The research into domestic violence homicide is limited because it is impossible to know precisely the characteristics of domestic violence relationships that end in death, or indeed the characteristics of any domestic violence relationship. In addition, there is so much variation in the degree to which case files document details of domestic violence that any kind of standardized, so-called objective research must be viewed with great caution. In the final analysis, our knowledge is limited by the information reported by the involved parties before the homicide, and subsequently inserted into the official record. It is also clear from other research that lethal outcomes may also depend upon the availability of emergency medical services, especially in the first hour after a shooting or stabbing (Doerner, 1983; Mann, 1988; Websdale, 1999). The inaccessibility to emergency services may be particularly problematic in rural communities. Working with the media: what are the issues? The media is a powerful tool and teams have been both helped and hindered by media coverage of team reviews. The media can help in significant ways such as:
However, the media can be problematic in other ways, such as:
It is important to reassure the media that confidential fatality reviews will, in the long run, improve our understanding of domestic violence homicides, and system accountability. |
Intimate Homicide Victims by Race and Gender |
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|
Male
|
Female
|
Male
|
Female
|
Male
|
Female
|
||||
|
1976
|
493
|
849
|
846
|
714
|
18
|
37
|
|||
|
1977
|
479
|
831
|
804
|
570
|
11
|
34
|
|||
|
1978
|
490
|
868
|
703
|
583
|
7
|
30
|
|||
|
1979
|
535
|
883
|
712
|
594
|
16
|
29
|
|||
|
1980
|
493
|
913
|
718
|
588
|
5
|
34
|
|||
|
1981
|
554
|
952
|
703
|
591
|
18
|
27
|
|||
|
1982
|
510
|
946
|
619
|
504
|
10
|
29
|
|||
|
1983
|
508
|
910
|
594
|
513
|
10
|
37
|
|||
|
1984
|
443
|
938
|
530
|
467
|
15
|
34
|
|||
|
1985
|
427
|
1,005
|
518
|
492
|
12
|
48
|
|||
|
1986
|
448
|
1,000
|
529
|
532
|
5
|
52
|
|||
|
1987
|
424
|
968
|
498
|
486
|
8
|
35
|
|||
|
1988
|
376
|
1,007
|
459
|
527
|
15
|
36
|
|||
|
1989
|
371
|
883
|
512
|
474
|
11
|
42
|
|||
|
1990
|
393
|
952
|
441
|
490
|
18
|
45
|
|||
|
1991
|
359
|
931
|
413
|
520
|
7
|
55
|
|||
|
1992
|
337
|
890
|
369
|
509
|
10
|
48
|
|||
|
1993
|
330
|
989
|
362
|
542
|
12
|
43
|
|||
|
1994
|
318
|
900
|
359
|
463
|
11
|
35
|
|||
|
1995
|
255
|
874
|
282
|
387
|
9
|
50
|
|||
|
1996
|
259
|
862
|
248
|
422
|
8
|
28
|
|||
|
1997
|
239
|
761
|
202
|
401
|
9
|
40
|
|||
|
1998
|
275
|
881
|
225
|
394
|
12
|
38
|
|||
|
1999
|
223
|
814
|
190
|
338
|
11
|
61
|
|||
|
2000
|
229
|
851
|
192
|
333
|
18
|
49
|
|||
| * intimate relationships involve current or former spouses, boyfriends, or girlfriends. These individuals may be of the same gender. |
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