SURVIVORS OF ABUSE

REPRINT OF: Physical and Mental Health Effects of Intimate Partner Violence for Men and Women

EDITOR'S NOTE

This article is a reprint of a previously published article. For citation purposes, please use the original publication details: Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 1985;1(6):1-8.

BACKGROUND

Few population-based studies have assessed the physical and mental health consequences of both psychological and physical intimate partner violence (IPV) among women or men victims. This study estimated IPV prevalence by type (physical, sexual, and psychological) and associated physical and mental health consequences among women and men.

METHODS

The study analyzed data from the National Violence Against Women Survey (NVAWS) of women and men aged 18 to 65. This random-digit-dial telephone survey included questions about violent victimization and health status indicators.

RESULTS

A total of 28.9% of 6790 women and 22.9% of 7122 men had experienced physical, sexual, or psychological IPV during their lifetime. Women were significantly more likely than men to experience physical or sexual IPV (relative risk [RR]=2.2, 95% confidence interval [CI]=2.1, 2.4) and abuse of power and control (RR=1.1, 95% CI=1.0, 1.2), but less likely than men to report verbal abuse alone (RR=0.8, 95% CI=0.7, 0.9). For both men and women, physical IPV victimization was associated with increased risk of current poor health; depressive symptoms; substance use; and developing a chronic disease, chronic mental illness, and injury. In general, abuse of power and control was more strongly associated with these health outcomes than was verbal abuse. When physical and psychological IPV scores were both included in logistic regression models, higher psychological IPV scores were more strongly associated with these health outcomes than were physical IPV scores.

CONCLUSIONS

Both physical and psychological IPV are associated with significant physical and mental health consequences for both male and female victims.

The Global Health Burden Of Rape

Women's rights to be free from male violence are now recognized by the United Nations as fundamental human rights. Two parallel transformations in the understanding of rape have been central to the international effort to achieve this declaration. The first is increased recognition of the extent to which rape typically involves intimates. The second is the shift from regarding rape as a criminal justice matter towards an appreciation of its implications for women's health. The focus of this paper is the health burden of rape, which is addressed from the global perspective and includes discussion of its prevalence and psychological, sociocultural, somatic, and reproductive health consequences. Quantitative efforts to capture the relative economic impact of rape compared to other threats to women's health are also discussed. The paper concludes with an agenda for future research on rape that could enrich activists' efforts on behalf of women's health and development.

The health care experiences of adult survivors of child sexual abuse: a systematic review of evidence on sensitive practice

This systematic review analyzes empirically based medical literature relevant to the experiences of adult survivors of sexual abuse in the health care setting and what is known about providing sensitive care to this population. Effects of this trauma may impact the adult survivor's experience of care, health behaviors, and outcomes. The 10 articles reviewed in this study provide patient-based information on the experience of child sexual abuse and its impact on health and health care for patients. Suggestions are made for health care providers in two main areas: facilitation of communication and disclosure issues, and improving the experience of the health care encounter for survivors. Specific strategies are offered to assist in providing nonthreatening care encounters for adults who have been affected by childhood sexual trauma. Implications for research, practice, and policy for patients, health care providers, and social workers in the health care setting are discussed.

Sexual violence among two populations of men at high risk of HIV infection

This study sought to compare the prevalence of, and relationship between, age at first experience of sexual violence and HIV and other health risk behaviors in two populations of men at high risk of HIV infection. Data were drawn from two cohorts: Vanguard, a prospective study of young men who have sex with men (MSM), and VIDUS, the Vancouver Injection Drug Users Study. Controlling for fixed sociodemographics, multivariate logistic regression was used to assess the relationship between age at first sexual violence (vs. never experiencing it) and several health risk behaviors. There were 140/498 (28%) MSM from Vanguard and 173/932 (19%) injection drug users (IDU) from VIDUS who reported having experienced sexual violence. Among VIDUS men, 130/852 (15%) IDU-only and 43/80 (54%) who were both IDU and MSM reported a history of sexual violence. The prevalence of child sexual abuse was 13% in Vanguard MSM, and 11% among VIDUS IDU-only, but 26% among VIDUS MSM/IDU. The median age of onset was significantly lower among VIDUS IDU-only compared to the two other groups. Experiencing sexual violence first in childhood was strongly related to ever being in the sex trade in both IDU and MSM. MSM in Vanguard who experienced sexual violence in childhood were more likely to have attempted suicide, and have a diagnosed mood disorder. Non-MSM IDU in VIDUS who experienced sexual violence in childhood were more likely to have a diagnosed mental illness, to binge on alcohol, and to have ever accidentally overdosed. In conclusion, men who have ever had sex with men appear to have a higher lifetime prevalence of sexual violence, compared to non-MSM injection drug users. Sexual violence is differentially associated with different health risk behaviors, depending on the age at first occurrence and the primary HIV risk factor (i.e. MSM vs. IDU).

Survivors of Childhood Sexual Abuse Diagnosed with Cancer

The incidence of survivors of childhood sexual abuse (CSA) diagnosed with cancer is unknown. It is estimated that one in three women and one in six men in the United States are survivors of CSA. Survivors of CSA diagnosed with cancer are presented with multiple and potentially accumulating traumas. The re-traumatizing nature of a cancer diagnosis and treatment affects all elements of the CSA survivor's care and may impede her/his treatment. To date, the impact of CSA on the medical treatment of people with cancer has been unexplored with the existing studies on female survivors of CSA with cancer focusing on the post-treatment experience and their higher incidence of sexual dysfunction. This article describes the impact of CSA on the cancer treatment of 18 survivors of CSA and the clinical interventions used to address the unique psychosocial needs of this population. Anecdotal information suggests that the survivors of CSA may find aspects of the cancer experience reminiscent of their history of abuse. All 18 survivors of CSA experienced distressing memories of their abuse during their cancer treatment. Fifteen CSA survivors presented traumatic memories that were inaccessible to conscious thought processes prior to their cancer diagnosis. Psychodynamic interventions address issues of disruption in the cancer treatment, non-adherence, and difficulties in relationships with the health care team. Containment of intense affect and distressing thoughts rather than exploration improved CSA survivors' adherence with cancer treatments. The acquisition of self-comforting skills helped CSA survivors feel less re-victimized by their cancer experience. The establishment of an environment of internal and external safety improved communication with the health care team. Health care/psychosocial clinicians' awareness and use of appropriate interventions can minimize the affects of re-traumatization and enhance the CSA survivor's treatment experience.

Sexual abuse in childhood and interpersonal violence in adulthood: a cumulative impact on depressive symptoms in women

This study investigates the cumulative impact of sexual abuse in childhood and adult interpersonal violence in the past year on depressive symptoms in a nonclinical sample of 265 primarily African American (74%) women. The frequency of depressive symptoms, measured by the Center for Epidemiologic Studies Depression Scale (CES-D), was highest for women who experienced both forms of victimization. Women who reported greater stress over life's daily hassles reported more depressive symptoms. Women with higher levels of family support and a sense of personal mastery reported fewer depressive symptoms. The final model explained 42% of the variance in CES-D scores. Implications for practitioners are discussed.

Social support reduces the impact of partner violence on health: application of structural equation models

BACKGROUND

Intimate partner violence (IPV) is associated with poorer health, yet pathways through which IPV affects either mental or physical health are not well characterized.

METHODS

Structural equation modeling was used to test a model in which physical-IPV and battering were considered as separate independent variables. The sample included 191 women currently experiencing either physical IPV or battering. Emotional support provided to women experiencing IPV was hypothesized to mediate the impact of IPV on current mental and physical health (dependent variables).

RESULTS

Higher scores on emotional support were associated with better physical (beta = -0.23, P < 0.01) and mental health (beta = -0.27, P < 0.001). Physical IPV was directly associated with poorer mental health (beta = 0.023, P < 0.01) and indirectly associated with poorer physical health (beta = 0.18, P < 0.001) and mental health (beta = -0.04, P < 0.05), primarily through battering. Higher battering scores were directly associated with less emotional support (beta = -0.33, P < 0.001) and indirectly associated with poorer physical (beta = 0.12, P < 0.01) and mental health (beta = 0.09, P < 0.01), primarily through emotional support. Model diagnostics indicated a good fit (chi(2) = 20.44, P = 0.37, GFI = 0.98, CFI = 0.99, RMSEA = 0.02).

CONCLUSIONS

Higher levels of emotional support may modify the effect of IPV on health. Interventions to increase social and emotional support to abused women may reduce mental and physical health consequences.

Identifying domestic violence within inpatient hospital admissions using medical records

This paper examines incidences of domestic violence among hospitalized patients identified as being victims of domestic violence. Specifically, we focus on defining the type and cost of domestic violence and identifying demographic characteristics of individuals at risk for domestic violence. Data for this paper were abstracted from the 1994 HCUP-3 data set. Findings from these data suggest that identifying incidences of domestic violence is very complex and difficult. The primary diagnosis of those who are victims of domestic violence range from broken bones and bruises to chronic and acute illness to mental illness. Finally, non-white populations are approximately two times more likely to be identified as victims of physical violence than whites and as age increases the likelihood of being identified as a victim of physical violence decreases.

A classification system of social problems: concepts and influence on GPs' registration of problems

OBJECTIVES

(1) To test lists of problems in the three axes of well-being (physical, mental, and social) with the GPs' collaboration (2) To place the resulting classification in the context of other ones aiming at collecting data about psycho-social aspects of life (assessment, index and classification systems). (3) To test if GPs would be induced to record psychological and social problems more often in their everyday practice, after having been trained to look more closely at them, inter allia with the use of classification and codes.

METHOD

The lists of problems have been initiated by the WHO Department of Mental Health and discussed at an international symposium; they were then tested on the field, first at an international level, then in Belgium. After discussion by 4 Belgian GPs' Teaching Units, they were then improved. In all surveys concerned, general practitioners were asked to collaborate in three ways: opening their usual medical records and collaborating to prospective phases, including one "test phase," i.e., a training session, recording problems with the use of coding lists, and looking for the proper code. Retrospective and prospective approaches were used both before and after this test phase.

RESULTS

(1) The original lists of problems have been improved on the basis of the findings in medical files and in the survey. (2) A conceptual framework is presented for recording social problems, either in everyday practice (i.e., in health records) or in research settings, e.g., for social surveys. It is biaxial: domains and types of problem. (3) Training GPs for using such a coding system drastically increases the number of psycho-social problems, but only during the prospective phases. In the long run older habits prevail again; only the overall number of contacts mentioning a reason increases, together with the number of "other" reasons for encounter (requests, ...).

CONTENTS

(1) Main concepts (section 1). (2) Various tools for measuring psychosocial problems and well-being (section 2). (3) New conceptual fanmework for a classification of psychosocial problems ( 2.2.3). (4) Using the lists: influence on MDs' recording propensity (section 3).

Alienation from self and others: the psychosocial problem of rural alcoholic women

The purpose of this study was to describe women's perspectives in becoming and being alcohol dependent. Using grounded theory techniques, 14 adult Black and White women receiving treatment for alcohol addiction at rural substance abuse centers participated in an intensive interview. Data analysis focused on the identification of the basic psychosocial problem and the process of becoming alcohol dependent. The results are presented in 2 parts. Part 1, "Alienation From Self and Others," focuses on the basic psychosocial problem faced by women in becoming alcohol dependent. Part 2, "Running Away to Nowhere," on page 142 of this issue of Archives, describes the process used by women to resolve this problem.

Conseqüências da violência familiar na saúde da criança e do adolescente: contribuições para a elaboração de propostas de ação

No Brasil, o conhecimento sobre a dimensão da violência familiar é ainda escasso. Todavia, existem evidências apontando para um cenário merecedor de enfrentamento imediato. Nesta perspectiva, o presente artigo destaca o campo das investigações sobre o tema, procurando explicitamente fazer uma ponte entre a apropriação do conhecimento gerado e efetivas propostas de ação. O artigo divide-se em cinco partes. Inicialmente, é discutida a importância da violência familiar no cenário de morbi-mortalidade de crianças e adolescentes A seguir, procura-se mapear as principais linhas de investigação sobre o tema, sugerindo uma tipologia de estudos da área. A terceira sessão explora com mais ênfase as investigações que avaliam as conseqüências do fenômeno na saúde de crianças e adolescentes. Na quarta seção, são discutidos os possíveis elos entre o conhecimento a ser gerado nesse âmbito e as propostas de ação para o enfrentando da violência familiar. Na última seção, são feitas algumas considerações sobre a importância do enfoque familiar em oposição ao individual; do multidisciplinar, em vez da abordagem compartimentalizada; e sobre a necessidade de integração das várias agências e serviços envolvidos com a violência familiar.

How multiple types of stressors impact on health

OBJECTIVE

Although many studies have focused on the relationship between stress and health, few have examined the impact of multiple types of stressors. The current study investigated the health impact of four stressors: sexual and physical abuse history, lifetime losses and traumas, turmoil in childhood family, and recent stressful life events.

METHOD

The sample included 239 female patients from a referral-based gastroenterology clinic.

RESULTS

We found that the four stressors (abuse history, lifetime traumas, turmoil in childhood family, and recent stressful life events) were related to poor health status (eg, more pain, symptoms, bed disability days, physician visits, functional disability, and psychological distress); together, these stressors accounted for 32% of the variance in overall current health. Furthermore, women who scored high on one type of stressor also tended to have experienced other types. Unlike many previous studies, we did not find that social support buffered the effects of stress.

CONCLUSIONS

This study provides evidence that many different types of stressors independently contribute to poor health outcome. Such findings suggest that health practitioners and researchers should question patients about histories of traumatic events, in addition to the examination of the biological aspects of illness, inasmuch as both may have notable effects on health status.

Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure

OBJECTIVE

Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about which dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure.

METHODS

Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68).

RESULTS

Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p = .0006), victimization by multiple perpetrators (p = .03), and being raped (p = .09). Among the physically abused, rape (in addition to life threat) (p = .0001), and multiple life-threatening incidents (p = .002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample.

CONCLUSIONS

Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.

Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status

OBJECTIVE

There is an increasing amount of literature pointing to a relationship between sexual and/or physical abuse history and poor health status, although few studies provide evidence concerning which aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse.

METHOD

The sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess sexual and physical abuse history.

RESULTS

We found the following: 1) 66.5% of patients experienced some type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first abuse in childhood did not appear to differ on health from those whose first abuse was as adults.

CONCLUSIONS

The authors conclude that asking about abuse should be integrated into history taking within referral-based gastroenterology practices.