The Scottish Government

Violence against Women

A literature review commissioned by

the National Group to Address Violence Against Women

A. Lily Greenan

August 2004

Acknowledgements

Many people assisted with this review. In particular, I would like to thank the staff of the Women's Support Project, especially Janette de Haan, who provided invaluable information, support and assistance during the writing of this report. Thanks also to Jillian Gilchrist and Peter Jamieson at the Scottish Executive, and Xavier Patry of Statistics Canada, for their helpful responses to my requests for information. Laurie Matthew and Molly Finn read early drafts, commented, encouraged, and along with Sandy Brindley and Marsha Scott, provided much needed moral support. My colleagues at the EVA Project were similarly supportive, and their patience with my somewhat distracted state is very much appreciated. Marley Laurie proofread to a very tight deadline; any remaining errors are mine. I would also like to thank Martin, who started.

I consider myself privileged to have been part of the movement to challenge violence against women in Scotland during the last 20 years, and in that time I have met many women who were survivors of male violence. Their stories are with me still, and I thank them for the lessons learned.

Definition

"The term "violence against women" means any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life. Accordingly, violence against women encompasses but is not limited to the following:

a) Physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation;

b) Physical, sexual and psychological violence occurring within the general community, including rape, sexual abuse, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women and forced prostitution;

c) Physical, sexual and psychological violence perpetrated or condoned by the State, wherever it occurs."

UN Declaration on Violence Against Women, 1992

CEDAW, Recommendation No 19, 1993

Beijing Platform for Action 1995

Executive summary

• Violence against women is widespread, and may affect women of any age, class, race, religion, sexuality, or ability. Factors which may increase women's vulnerability to some types of violence include age, disability, and poverty. Across all forms of violence and abuse, women are most at risk from men they know.

• Significant numbers of women experience more than one type of violence. Prevalence surveys which address violence against women in all its forms may yield more information than 'single issue' surveys about the meaning and impact of violence in women's lives. Few studies have been designed specifically to record the experiences of marginalised groups of women, including black and minority ethnic women, women with disabilities, lesbian women, women working in prostitution and home less women. Attempts to document the experiences of marginalised groups of women must go beyond merely ensuring their 'inclusion', numerically speaking, in general population studies.

• Recurring themes in women's descriptions of male violence include the use of tactics of control, humiliation and degradation, the abdication of responsibility by the male abuser, and the attribution of blame to the woman. These are found regardless of the woman's relationship to the perpetrator, and regardless of whether the experience is a discrete event or part of a pattern of abuse.

• Violence against women has a significant impact on the health and socio-economic status of women. It affects the health and wellbeing of children and young people who witness violence against their mothers and other women. The costs to society of responding to violence against women, and the overall economic impact, are significant and measurable. However, there is a need for improved data collection systems across all agencies involved in responding to women who have experienced violence.

• Although there has been an increase in the number and range of services available to women who have experienced violence, there is relatively little evaluative research. The available research suggests that women value advocacy and support, and want service providers to be more proactive in offering these. Research into interventions tends to focus on discrete aspects of violence against women, reflecting the way in which women's experiences are compartmentalised by service providers and policy makers. Although some comparative research has been undertaken, no studies were identified which evaluated interventions to respond more broadly to women's experiences of violence.

• Research on interventions with rape survivors is primarily focussed on medico-legal responses, with some literature on therapeutic interventions, but little on interventions by primary care workers. Rape crisis provision is still poor across Scotland , and there is a lack of independent evaluation of the approach. There is a similar lack of evaluation of sexual assault referral centres (SARCs), although a forthcoming report from the Home Office should address this.

• Much of the literature on women working in prostitution is taken up with questions of definition and agency, and in this, it reflects early debates about how far women 'choose' to stay with violent partners. There is also a significant body of literature which considers crime management interventions. There is little on interventions which support women abused in prostitution, or assist them in leaving.

• Research on interventions with adult survivors of childhood sexual abuse is primarily found in the mental health literature. Although some work has been carried out which explores the links between childhood sexual abuse and chronic physical health problems, no research was identified which addressed how healthcare staff should acknowledge this or respond to it. No research into the criminal justice response to adult survivors of childhood sexual abuse was identified.

• By comparison, research on interventions with domestic abuse survivors cuts across several sectors, including criminal justice, acute and primary care health services, social work services and outreach and advocacy services.

• The scarcity of research on interventions for black and minority ethnic women, women with disabilities, lesbian women, and older women affected by male violence against women is perhaps a reflection of the dearth of services for these groups.

• Research on violence against women cuts across academic boundaries, and is found in several fields, including law, social sciences and health. This is a reflection of the diverse range of responses violence against women demands. However, multidisciplinary research is rare, and consequently opportunities for 'cross-fertilisation' are missed.

• Services for children and young people affected by violence against women are still relatively scarce. Although not addressed directly in this review, an early trawl of the literature identified little research on effective interventions. The existing body of research focuses primarily on the impact of domestic abuse on children and young people.

• It is acknowledged that the involvement of women survivors of male violence in contributing to the development and design of services increases effectiveness and accountability. However, there are still few examples of how this is achieved in practice.

• In describing the acts of abuse perpetrated by different men, at different points in their lives, women survivors of male violence consistently make the connection between child abuse, rape, domestic violence and commercial sexual exploitation. There are demonstrable links between different forms of violence against women, in the nature of the violence, the consequences of it, and the interventions required. Whether or not these links are made visible in policy and practice is to some extent governed by how far violence against women is regarded as symptomatic of wider gender inequalities in society, and how far initiatives to tackle violence against women are located within this context.

d

In Western society, the most recent efforts to acknowledge, explain and challenge male violence against women coincide with the re-emergence of the feminist movement in the early 1970s. Feminist activists identified male violence against women as central to the perpetuation of women's oppression, seeing sexual assault, rape, sexual harassment, domestic violence and other forms of male violence as part of a continuum of violence against women and children (Kelly, 1987; Radford et al, 2000). Violence against women is experienced by women of all ages and social classes, all races, religions and nationalities, all over the world. It is overwhelmingly perpetrated by men (Krug et al, 2002).

Individual characteristics and circumstances alone cannot explain why this should be the case. Feminist commentators suggest that the context for violence against women is a cultural and political framework in which women are not equal partners with men. Violence against women is both the result of gender inequality and the means by which it is perpetuated (Brownmiller, 1976; Dobash and Dobash, 1979; Radford et al, 2000). This analysis of violence against women as a reflection of the power imbalance in society has largely informed the development of work to challenge violence against women in the United Kingdom, and in Scotland, over the last 30 years.

The first Women's Aid groups in Scotland opened refuges in Glasgow and Edinburgh in 1973 (Scottish Women's Aid, 2002), and by 1976, the Scottish Office had provided some funding towards a national office (Cuthbert and Irving, 2001). Rape Crisis centres soon followed, with centres opening in Glasgow in 1976 and Edinburgh in 1978 (Christianson and Greenan, 2001). Since then women's organisations and individual women in Scotland have continued to develop responses to violence against women, campaigning for recognition of the issues and for change and improvement in statutory responses to women who had experienced violence. [1] On the whole, work to challenge violence against women in Scotland split early on into separate campaigns against domestic violence and against rape, although in both areas of work the links between different forms of abuse continued to be made. The inclusion of child sexual abuse, and the legacy for adult survivors, into the sexual violence agenda dates from the early 1980s, as survivors began to make contact with Rape Crisis and other support services. By the early 1990s, separate services for survivors of child sexual abuse had begun to develop (Kerr, 1990).

By 1987, there was a strong and vibrant women's movement in Scotland developing new ways to challenge male violence against women, despite sometimes very limited resources. The 1987 Scottish Women's Liberation Movement Conference, "Working Against Violence Against Women" was attended by over 260 women (and about 150 children) who discussed a wide range of issues related to violence against women, including the need for "intensified campaigning on the issue of child sexual abuse; awareness-raising and action on racism and classism, heterosexism and oppression in disability; creating international links; addressing the problems of women organising in rural areas" (Jennings, 1990, in Henderson and Mackay, 1990: 115).

As awareness of the prevalence and impact of violence against women increased, institutional responses to the issue gradually shifted. Throughout the 1970s and early 1980s, for example, the police response to allegations of rape was characterised by aggressive questioning of complainers based on an assumption that women were lying. Following research into the investigation of sexual assault in Scotland (Chambers and Millar, 1983), a significant policy shift began, with the publication in 1985 of guidelines to chief constables on responding to women alleging rape (Scottish Office, 1985). The first 'female and child unit', designed to provide a more sympathetic response to sexual offences complainers, was established in Glasgow in 1987 .

Guidelines on police responses to domestic violence were published in 1990 (HMIC, 1997), and a 'specialist officer' approach to domestic abuse was adopted by Lothian and Borders Police from the early 1990s. This specialist approach has continued to develop since then. Strathclyde Police, the largest of the Scottish forces, established divisional 'family protection units' towards the end of 2002, providing a specialist response to rape and sexual assault complainers and child abuse complainers as well as to women reporting domestic violence.

These developments have been supported by the involvement of women's organisations in delivering training to police officers. The involvement of Women's Aid in awareness training for police officers is acknowledged to have increased understanding of women's experiences of domestic violence (HMIC, 1997), and Rape Crisis Centres fulfilled a similar function in providing input to police training on rape and sexual assault (Christianson and Greenan, 2001). The Glasgow-based Women's Support Project was involved in providing training to experienced officers at Tulliallan Police Training College on the links between domestic violence and child protection from 1998, and this training has been continued by Women's Aid.

There have also been changes in the wider criminal justice response to crimes of violence against women. The process of restricting the use of sexual history evidence in sexual offences trials, begun in 1985 [2] , has been taken a step further with the passing of the Sexual History (Procedures and Evidence) (Scotland) Act 2002, more than 20 years after Rape Crisis centres began campaigning on the issue [3] . The progress of the current Vulnerable Witnesses Bill through the Scottish Parliament is the latest outcome of a process of campaigning for improved treatment by the courts of women complainers, and other 'vulnerable' groups, which has been ongoing for more than two decades.

Since the passing of the Matrimonial Homes (Scotland) Act 1981 there have also been gradual legislative changes which have increased the protection available for women from their violent partners/ex-partners. Most recently, the Protection from Abuse (Scotland) Act 2001 is slowly beginning to have an impact, providing more women with the option of having powers of arrest attached to a common law interdict (Cavanagh, Connelly and Scoular, 2003). Despite ongoing, and justified, concern at the high attrition rates associated with the prosecution of all crimes of violence against women through the courts (see, for example, Hester, Hanmer et al, 2003; Jamieson, 2001; Kelly, 2003), the general trend is forward-moving, if slow.

Local authorities engaged with the issue of violence against women initially at a service level, through the provision of emergency accommodation and social work services. Throughout the late 1980s and early 1990s, however, local authorities played an increasing role in raising awareness and challenging the norms which underpin violence against women. Much of this work was undertaken by women's units, equalities units, and later, community safety units. Undoubtedly the most high profile example of this was the development in 1992/1993 of the Zero Tolerance poster campaign by Edinburgh District Council Women's Unit (Mackay, 2001).

Local government reorganisation in the mid 1990s provided another impetus for the development of local partnerships to tackle violence against women, and this was further supported by the publication of guidance on developing such partnerships (CoSLA, 1998). Although some of these early partnerships took the form of domestic violence fora, a few (for example in Edinburgh and Glasgow) adopted a broader position on violence against women.

There have always been supportive individual clinicians and practitioners in the various areas of the health service women have approached for health care as a result of violence. Some have developed local initiatives which have contributed valuable information to the knowledge base within their own discipline or their own locality - for example, a local training programme for midwives in Inverclyde Hospital (Scobie, 1999), and a domestic abuse monitoring exercise in the A&E department at Law Hospital (Guthrie, 1998). Institutional developments in the health service, however, were inclined to be piecemeal and inconsistent through most of the 1980s and early 1990s. The publication of the SNAP [4] report on domestic violence in 1997 focussed attention on the failure of the health service in Scotland to adequately address the health needs of women experiencing domestic violence. At a practice level, the Castlemilk Demonstration Project ran from 1996-98 from Castlemilk Health Centre, and was managed by the Department of Public Health in Greater Glasgow NHS Board. The project aimed to "improve the safety of women in the home through the development of an interagency approach" (Cosgrove, 1998: i) and alongside this also explored ways to improve the responses of primary health care staff to domestic violence.

The Women's Public Health Team at Greater Glasgow NHS Board continues to develop innovative, replicable work on the impact of gendered violence on women's health. They have worked to address the training needs of health staff in relation to domestic violence, and have also been active in addressing the development of services for survivors of sexual assault and childhood sexual abuse. Elsewhere in the health service, initiatives to address domestic abuse have far outnumbered broader interventions. An exception is the EVA Project, a multi-disciplinary project currently funded by NHS Lanarkshire to provide services and improve service provision for women who have experienced violence at any point in their lives (EVA, 2001).

The recent publication of NHS guidance for health staff on responding to domestic abuse continues the more general trend, although there are signs that other areas are beginning to attract attention. A Scottish Executive short life working group on the care needs of adult survivors of sexual abuse has recently produced a consultation report, and in Glasgow, a recent survey explored the responses of clinical psychologists to survivors of sexual abuse and sexual assault (Biggam and Johnson, 2003).

Against this background of 25 years of campaigning and service development, the Scottish Office announced the establishment, in 1998, of the Scottish Partnership on Domestic Violence, subsequently renamed the Scottish Partnership on Domestic Abuse. Chaired by Anne Smith QC, the group comprised representatives from the key Scottish office departments, the judiciary, the police, the legal profession, and the voluntary sector. The group was remitted to develop an action plan leading to a national strategy on domestic abuse, which was published in November 2000.

The aims of the National Strategy to Address Domestic Abuse in Scotland are based on the '3 P's' first used in the Zero Tolerance campaign:

· Prevention - active prevention of domestic abuse of both women and children

· Protection - appropriate legal protection for women and children who experience domestic abuse

· Provision -adequate provision of support services for women/children

The Strategy identified key policy and practice areas to be developed and improved in order to achieve these aims. It also placed a requirement on local authorities and health boards to establish local partnerships to tackle domestic abuse. The Scottish Executive provided £18 million through the Domestic Abuse Service Development Fund to support the work of these local partnerships, and established the National Group on Domestic Abuse to monitor the implementation of the strategy. The National Group includes representatives from the police, the judiciary, women's support organisations and local authorities. It is chaired by the Minister for Communities .

There are now 32 local partnerships, covering all local authority areas in Scotland. Some of these predate the National Strategy, having developed either from local domestic violence fora, or from multi-agency groups set up to tackle violence against women in a broader sense. Of the 32 groups, only four currently have a focus on aspects of violence against women other than domestic abuse.

In November 2002, the Scottish Parliament debated the issue of 'violence against women'. The then Minister for Social Justice, Margaret Curran MSP, announced that the National Group to Address Domestic Abuse would widen its remit to include all forms of violence against women, and would be renamed the National Group to Address Violence Against Women.

The National Group has commissioned this literature review to inform the development of the agenda on violence against women. Accordingly, this report will:

· review the available literature on the prevalence and impact of violence against women, and on interventions

· the review will consider sexual violence, sexual harassment, domestic violence, and commercial sexual exploitation

· identify examples of good practice

· identify gaps in research, policy and practice on violence against women in Scotland

The review will primarily focus on work carried out in Scotland and the U.K., with some reference to international work, in particular in Canada. With the exception of some 'benchmark' works, the literature search has been limited to a five-year period from 1998-2003.

The subject of 'violence against women' is huge. There are acknowledged links between violence against women and violence against children. However, time constraints mean that this review cannot adequately consider the impact of violence against children, although some attention is given to the impact of childhood sexual abuse on adult women survivors. For similar reasons, the review does not cover the sizeable body of literature on sex offenders, although some consideration is given to work with men who abuse their partners, in the context of exploring a multi-agency response to domestic abuse. Nor does the review cover the body of literature on prevention initiatives.

There are bound to be omissions in a review covering a subject area as vast as this. This report must therefore be seen as indicative, aiming to identify and examine some of the key issues in some depth rather than provide a comprehensive guide to all that has been researched and written about violence against women.

A word on terminology - throughout the research literature, the phrase 'violence against women' is used interchangeably with 'domestic violence' and 'domestic abuse', i.e. in contexts where what is being discussed is violence against women by an intimate partner or ex-partner. For the sake of clarity, in this report, 'violence against women' is used as a generic term, indicating the whole spectrum of abuse which may be experienced by women. Where the report refers specifically to violence perpetrated against women by intimate partners, the terms 'domestic violence' or 'domestic abuse' are used.

"Whilst clear categories and definitions are important for statistical and research purposes, we must never forget that these are abstract analytic concepts developed for a specific purpose - to count the extent of violence. They do not reflect experiential reality, which is always more complex...."

Liz Kelly, Domestic Violence: Enough is Enough conference, London, October 2000

What, why and how to measure the true extent of violence against women are questions which have stimulated much debate among practitioners, policy makers and researchers (Desai and Salzman, 2001; Dobash and Dobash, 1998; Hester, Kelly and Radford, 1996). In relation to domestic abuse, at both national and local level, much effort has gone into trying to identify how a common approach to data collection might be achieved. Attempts to evaluate new service developments and public education initiatives are hampered by the lack of available 'benchmarks'. Differences in data systems and data collection, uncertainty about how to overcome 'double counting', and concerns about the legal aspects of data sharing, are some of the issues currently under debate.

B. 2.1 Recorded crime

Statistical Bulletins produced by the Scottish Executive are the main source of official information on violence against women in Scotland. Information about recorded crime is collected quarterly and published annually. The data is 'offence based' rather than 'incident based' - several offences may be involved in one incident, there may be more than one offender and there may be more than one victim. The figures therefore provide a record of the levels of crime occurring in Scotland, but not the numbers of individuals affected by it (Scottish Executive, 2003). Since what is being counted is 'offences' rather than individuals, gender disaggregation is not possible, with one notable exception.

'Crimes of indecency' is the category which includes figures relating to sexual violence. Prior to 2001, this was broken down into sub headings of 'sexual assault', 'lewd and indecent behaviour' and 'other'. From 2001, the sexual assault category was split into 'rape and attempted rape' and 'indecent assault'. The purpose of this was to allow easier counting of offences covered by the police Statutory Performance Indicator of serious violent crime. An interesting by-product, given that in Scotland the legal definition of rape is gender specific, is that there will now be the possibility of analysing reporting trends in this one area of sexual violence against women.

For the year from 1 ^st January to 31 ^st December 2002, there were 913 crimes of rape or attempted rape in Scotland. It is noted that this represents an increase of 21% on 2001, and is the highest level of rapes and attempted rapes ever recorded in Scotland (Scottish Executive, 2003). No particular reason is offered for this Scottish-wide phenomenon. However an increase of 37% in crimes of indecency recorded by two Scottish forces, in Lothian and Borders and in Tayside, is attributed variously to increased reporting of 'historical' abuse, a rise in indecent assault reports as a result of proactive work with children and young people, and a more proactive approach to working with women's support organisations to encourage reporting by their service users (Scottish Executive, 2003).

Incidents of violence against women may involve a range of crimes and offences including serious assault, petty assault, sexual offences and breach of the peace. Women's Aid groups and other women's support organisations have been aware of an increasing use of mobile phones by abusive men as a means of harassing and intimidating women. An increase of 23% in offences involving 'threats or extortion' as a result of this increase in threatening phone calls or text messages is noted by Lothian and Borders Police. Again, because the focus is on the incident rather than the people affected by it, it is not possible to see how far this might relate to violence against women.

Specific statistics on domestic abuse have been collected by the Scottish police forces since 1999. These give more detail about recorded incidents of domestic abuse. 36,010 incidents were recorded in 2002, the majority of which (59%) did not go on to be recorded as a crime or an offence. 90% of the incidents involved a female victim and a male perpetrator (Scottish Executive, 2003). A particular concern raised in the most recent report is the level of repeat victimisation - where the information was available, about half of the cases involved repeat victimisation (Scottish Executive, 2003).

The data from different police forces raises some questions about differences in police recording. Some forces do not record a crime or offence if no further action is taken after the initial report, for example if the victim does not wish to pursue the matter, while other forces will record. As a result, Central Scotland shows only 24% of incidents leading to the recording of a crime or offence, while Grampian shows 98% of incidents being recorded as a crime or offence. The report notes that "these recording practices are under continuing review with the intention of achieving consistency across Scotland" (Scottish Executive, 2003: 27)

C. 2.2 Agency statistics

There is, then, some information available on the incidence of violence against women as encountered by the criminal justice system. Clearly this does not provide a full picture of the extent of the problem. If the numbers of workers seeking training on how to respond to women who have experienced violence is anything to go by, there are many more women seeking help, support or information from agencies outwith the criminal justice system. Women present to housing departments, social work departments and health professionals looking for a range of services. However, this is not reflected in the statistical information available from these agencies. In some instances, the options available to staff when recording the reason for a referral do not include 'violence'. Where it is recorded, it may not be in a format which enables collation. Health professionals, for example, will record the information that a patient has disclosed violence or abuse, but this will be in a narrative form in the patient's record. Even where these records are held on a computer system, it is not possible to extract only information about 'violence as a reason for referral' without an appropriate coding system.

Recognising the need to address this difficulty with data collection, the Scottish Executive undertook a three day snapshot in December 2003 to gauge the extent to which women are presenting to agencies as a result of domestic abuse. Participating agencies across Scotland included Women's Aid, accident and emergency departments, primary care teams, social work teams and home lessness units. A report on the outcomes is expected shortly.

Women's voluntary organisations are the other main source of data about the numbers of women experiencing violence. The 40 affiliated local groups in the Scottish Women's Aid network received 72,029 requests for information and support between April 2002 and March 2003, a 10.3% increase on the previous year. In addition, 5,873 women requested refuge, this need for emergency accommodation implying a recent history of abuse by a partner (Scottish Women's Aid, 2003). The Women's Support Project, a Glasgow based organisation working with women affected by any form of violence or abuse, received 1550 requests for support between April 2002 and March 2003 (Women's Support Project, 2003). Statistics will be available shortly from Rape Crisis Scotland, the national office for the network of Rape Crisis Centres in Scotland. A new database is due to come on stream to allow routine collation of statistics from all local groups.

The under-reporting of violence against women to any agency is well documented. A survey of women in Edinburgh found that although over half of the respondents had experienced some form of violence, only 21% of those who had experienced physical or sexual violence had approached a support agency for help (Henderson/CEC [5] , 1997). Sources other than agency statistics must be examined in order to assess the true extent of violence against women.

D. 2.3 Crime surveys

Survey results on the prevalence of violence against women may vary depending on a range of factors including the definitions used, the methodology used, and the context of the survey (Johnson, 1998; Walby and Myhill, 2001). However, it is estimated that between one in two and one in ten women will experience some form of violence at some point in their lives, with between 0.4% and 10% of women experiencing violence in any 12 month period (see, for example, Budd, Mattinson and Myhill, 2000; Henderson/CEC, 1997; Macpherson, 2002; Mirrlees-Black, 1999; Mooney, 1993; Myhill and Allen, 2002; Statistics Canada 1993, cited in Johnson, 1998; World Health Organisation, 2002).

National crime surveys have provided some extension of the data available from official statistics. The Scottish Crime Survey (SCS) has run independently of the British Crime Survey (BCS) since 1993, and was repeated in 1996 and 2000. The SCS 2000 survey included a self-completion questionnaire which asked about domestic violence. 6% of women responding had experienced either threats or force from a partner during 1999; 19% of women had experienced threats or force from a partner at some point in their lives (Macpherson, 2002). Similar self-completion modules on rape and sexual assault were included in the BCS in 1998 and 2000. A report based on findings from both of these surveys noted that 0.9% of women had experienced some form of sexual victimisation in the previous 12 months; 9.7% in their lifetime. Partners were the perpetrators in 32% of cases (Myhill and Allen, 2002).

Walby and Myhill note that reporting of violence against women in these generic crime surveys increases over time and as survey methodology is refined and developed, and consider whether the methodology applied by some of the national surveys on violence against women might improve reporting rates still further (Walby and Myhill, 2001). They identify some problems with generic crime surveys, including limited time available to build a rapport with survey participants, or to ask "nuanced questions" [6] about women's experiences of violence. They also consider whether, in generic surveys, less priority might be given to selection and training of interviewers. Finally, they raise the question of how far women see what has happened to them as 'a crime' and whether questions of definition influence how far women report their experiences (Walby and Myhill, 2001). They are not convinced that this is a major problem and cite the 1996 BCS survey on domestic violence, in which "significant numbers of people did in fact report domestic violence even when they said they did not consider it a crime" (Mirrlees-Black, 1999, cited in Walby and Myhill, 2001: 508).

Crime surveys tend to focus on a single aspect of violence against women, and by the nature of their perspective - violence as crime -are inclined not to consider in depth areas of women's experience which are harder to frame as 'crime'. They may not address the particular issues related to violence against women from marginalised groups, including black and minority ethnic women, women with disabilities, lesbian women, and women working in prostitution. Women from these groups may be subject to higher levels of some types of violence than women in the general population, and the violence they experience may impact on their lives in different ways (Barnard et al,

The authors of a report which addresses the intersection of domestic violence and 'minoritisation' [7] make the point that whilst it is important to acknowledge that domestic abuse happens across all ethnic and socio-economic groups, by doing so there is a danger of making the specific experiences of 'minoritised' groups invisible (Batsleer et al, 2002). Similar difficulties have been noted in relation to women with disabilities (MacLeod, 1995, Nosek and Howland, 1998)). For both of these groups of women, the standard obstacles to reporting which may be experienced by many women - fear of the consequences, fear of not being believed, lack of access to information about services which might assist - are compounded by additional barriers, such as lack of information in appropriate languages or formats, lack of cultural awareness within agencies and greater dependency on the abuser, who may be the main carer or interpreter for the woman.

The experiences of older women may not be considered. Although older women are deemed to be at less risk of violence than younger women and girls (Statistics Canada, 1993; VAWS, 1996; Henderson/CEC 1997), they consistently express more anxiety about their safety than younger women (Henderson/CEC, 1997; Home Office, 2003; SCS, 2002). There has been little specific research on the extent of violence against older women, and the possibility that older women are less likely to report violence cannot be discounted. The Scottish Executive has commissioned research into older women's experiences of domestic violence which was completed in May 2003 and is due to be published in Spring 2004.

Poverty may also make women more vulnerable to violence. It limits choices and forces women into types of employment which carry more risks of violence, for example prostitution, or work in the service industries. It may also put women in the position of having to take on shift work or work which is far from home , reliant on public transport, and they may be more at risk for this reason (

E. 2.4 Counting the gaps

There can be difficulty in extracting from a general crime survey the significance of the event in a woman's life and a sense of the interconnectedness of the issues. The prevalence of experiences of stalking and sexual harassment, the involvement of women in pornography, prostitution and organised or ritual abuse, and the extent to which women experience violence in more than one context and at more than one point in their lives has been largely unexplored until relatively recently. Some areas of women's experience remain invisible in any attempt at 'counting'. Those studies which have been done indicate that significant numbers of women have been affected by these issues.

Stalking, defined as 'persistent and unwanted behaviour', affected 17% of women at some point in their lives in a study of stalking and harassment in Scotland (Morris, Anderson and Murray, 2002). When asked about experiences they would categorise as 'stalking', only 10% of women reported a lifetime experience. This is closer to the findings from the U.S. national survey on violence against women, which asked respondents about stalking which 'involved a high level of fear'. In this study, 8% of women reported a lifetime experience of behaviour which fitted the description they were given (Tjaden and Thoennes, 1998).

The trafficking of women for sexual exploitation has gained increasing attention over the last few years, as awareness has increased of global trafficking in persons. The hidden nature of trafficking makes it difficult to assess accurately the numbers of women involved. Using a range of data sources, including a survey of police forces and a review of data on immigration patterns, organised crime and prosecutions for prostitution related offences, a recent study on the extent and nature of trafficking of women in the UK estimated that between 142 and 1420 might be trafficked into and within the UK per annum (Kelly and Regan, 2000).

There are similar difficulties with estimating the numbers of women working in prostitution. Routes Out Of Prostitution (ROOP), a Glasgow based project working to address prostitution as an issue of violence against women, estimates that over 1000 women in Glasgow are involved in prostitution (ROOP, 2003). This, however, is in the context of acknowledging that the 'visible' face of prostitution is on the streets, and that the numbers of women working in indoor prostitution are largely unknown and difficult to monitor (Kelly and Regan, 2000).

Women working in prostitution report much higher levels of violence than other women in the population - 82% of respondents in a San Francisco study had experienced physical assault while working in prostitution and 68% had experienced sexual assault [8] (Farley and Barkan, 1998). A study of women working in Edinburgh, Glasgow and Leeds found that two thirds of the women interviewed had experienced violence from clients (

The San Francisco study also found that 57% of the respondents had experienced sexual assault in childhood. This is at the higher end of estimates of the prevalence of experiences of child sexual abuse in the general population, which range from one in four (Creighton and Russell, 1995) to one in eight (Baker and Duncan, 1985). Although Kelly et al (1991) found that 59% of the young women they surveyed had experienced some form of sexual abuse before they reached 18, their definition of sexual abuse included the spectrum of behaviours from flashing to rape. Narrowing the definition to exclude flashing and other 'less serious' abuses, the prevalence rate drops to 1 in 20 young women. This highlights some of the difficulties inherent in comparing studies. Few prevalence studies have been done in this area, and those that have use a wide range of definitions, methodologies, and sample profiles. The study by Kelly et al was designed to address some of these issues, and to identify what adaptations to methodology might help to provide a clearer picture of childhood experiences of abuse. The authors recommend taking a broad approach to 'defining', maintaining that narrowing the definition used in a survey too much excludes the possibility of gathering valuable qualitative data, for example in relation to the seriousness of the abusive experience for the individual at the time, and also in relation to the long term consequences (Kelly, Regan and Burton, 1991).

The use of narrow definitions of violence against women excludes more than qualitative data. It is difficult to count something which has not been named; but until it is counted, how do we know it exists? For survivors of ritual abuse, the narrow focus in most surveys on the type of assault, e.g. 'rape' or 'physical assault', may exclude the possibility of naming the context in which the assault takes place, and thereby help to perpetuate the belief that such abuse does not exist (Matthew, 2001, 2002; Scott, 2001). A small scale survey which sought to assess agency awareness of ritual abuse asked respondents how many survivors of ritual abuse were known to have made contact with their agency between August 2002 and August 2003. 25 agencies responded; between them they reported contact with 96 survivors of ritual abuse (TRASH, publication pending).

It is clear that although single issue studies can be helpful in assessing the need for a specific service or policy development - for example, the need for development in housing policy to meet the needs of women fleeing domestic abuse - they do not allow the linkages between different types of gendered violence against women at different times in the lifecycle to be fully explored. In order to assess the full extent of 'violence against women' in a society, a different, broader approach may be required.

F. 2.5 National surveys

The Canadian national survey in 1993 asked questions about a wide range of experiences, and framed the questions around the theme of women's safety. The results were significantly higher than those found in other surveys. In 1993, Canadian police recorded 15,200 sexual assaults against women; the General Social Survey (GSS) [9] recorded 316,000 sexual assaults against women. Based on responses from 12,300 women, the Violence Against Women Survey (VAWS) estimated that there had been 572,000 sexual assaults against women in Canada that year. The pattern for assaults against women by their partners was similar - 46,800 'assaults against wives' were recorded by the police, 107,500 assaults were recorded by the GSS, and 201,000 assaults were estimated by the Violence Against Women Survey. Citing these figures in 1998, Johnson notes:

"The specialized survey of violence against women captures almost twice as many incidents as the traditional crime-victim survey, four times as many cases of wife assault as are reported to the police, and about 38 times as many cases of sexual assault as police statistics." (Johnson, 1998: 39-40)

She attributes this increase in large part to a meticulous design process, in which every effort was made to create an approach which would encourage women to discuss their experiences of violence as fully and as safely as possible with the interviewers. The design team consulted with academic researchers, frontline practitioners, policy makers and women survivors of male violence. A random sample telephone survey was deemed to be the best approach, for a population with 99% access to a phone. The questionnaire design involved a rolling programme of consultation through focus groups, moving from general discussion through detailed analysis and testing of the content of the questionnaire. Consideration was given to how the questionnaire would be administered, including the selection and training of interviewers. It was held to be important that the interviewers be women, removing one perceived barrier to disclosure. Potential interviewers went through standard job screening to assess their suitability for the post and then underwent a second interview with a clinical psychologist to assess their ability to deal with the particular stressors associated with a large scale survey about violence and abuse. Interviewers were provided with eight days training which focussed on issues such as responding to disclosure and distress and ensuring that interviewees were in a safe place to participate in the interview. During the initial stages of phone contact, interviewers provided women with a 'toll-free' number to call if the interview was interrupted, or to discuss anything raised for them by the interview (Johnson, 1998).

The results of the Canadian survey are significant, not just because of the numbers of women who reported violent experiences, but because of the links made between different experiences of violence at different times in women's lives, and in what is revealed about the context, meaning and impact of violence in women's lives. Of the 12,300 women surveyed, 51% had experienced at least one physical or sexual assault since age 16 and almost 60% had been assaulted more than once. 25% of the women surveyed had been physically and/or sexually assaulted by partners or ex-partners - 20% of the women who were assaulted by a partner were sexually assaulted. In all, 45% of the women surveyed had been assaulted by someone known to them, compared with 23% who had been assaulted by strangers. 38% of women had been sexually assaulted by a man known to them (Status of Women Canada, 2002).

Since 1983, Canada has had no specific offences of rape, attempted rape or indecent assault. Instead, there are three levels of 'sexual assault' ranging in severity from "unwanted sexual touching" to "sexual violence resulting in serious physical injury sustained by the victim" (Status of Women Canada, 2002: 20). Over 90% of all incidents reported to the police are recorded as level 1 assaults - minor physical injuries or no injuries to the victim, with a maximum possible sentence of 10 years. The 1993 survey found that only 6% of all sexual assault incidents had been reported to the police, and only 4% of incidents involving 'unwanted sexual touching' (Status of Women Canada, 2002). The survey explored reasons for low reporting, which were similar to those reported in UK surveys - the incident was considered too minor (44%), women didn't think the police could do anything (12%), or they wanted to keep it private (12%). Interestingly, given how many sexual assaults were committed by men known to women, fear of the perpetrator, and not wanting the perpetrator arrested or jailed, were given as reasons for not reporting by only 3% of the women.

In their review of the development of national surveys on violence against women, Walby and Myhill attempt to define 'state of the art methodology'. They identify several issues to be considered, including the context of the survey; interviewing practices; training for interviewers and ensuring a 'good fit' between interviewer and interviewee; the sampling frame; the mode of enquiry, and situating the event in relation to others (Walby and Myhill, 2001). They conclude that dedicated surveys on violence against women are likely to be more effective than general crime surveys which include questions about violence against women, since they pay greater attention to maintaining the safety of interviewees, building rapport and focussing on the meaning and impact of the violence as much as on the act itself.

In their 2002 report on assessing violence against women, Status of Women Canada [10] identify a set of indicators to be used as benchmarks against which to measure progress on tackling violence against women. These are designed to parallel the Economic Gender Equality Indicators released in 1997 by the F/P/T [11] Ministers Responsible for the Status of Women. The violence against women indicators follow six themes:

· Severity and prevalence of violence against women

· Impact of violence against women

· Risk factors associated with violence against women

· Institutional and community based responses

· Victims' use of services

· Public attitudes and perceptions

The authors stress that these indicators are limited by the quality of the data available, and note that as data collection methods improve, so must the indicators expand and adapt over time (Status of Women Canada, 2002). However, it is undoubtedly the case that the baseline data gathered in Canada through the national surveys of violence against women provide an invaluable benchmark against which to measure the effectiveness of policy development and legislative change (Hague, Kelly and Mullender, 2001).

G. 2.6 Extent of the problem - conclusions

In summary, a review of the research on the prevalence and incidence of violence against women tells us that:

· violence against women is widespread, affecting women of any age, class, race, religion, sexuality, or ability

· women are most at risk from men they know

· factors which may increase women's vulnerability to some types of violence include age, disability, and poverty

· when asked, significant numbers of women describe patterns of abusive behaviour and repeat victimisation, rather than discrete assaults

· women experience violence at different points in their lives, and significant numbers of women experience more than one type of violence

· surveys which address violence against women in all its forms may yield more information than 'single issue' surveys about the meaning and impact of violence in women's lives

· few studies have been designed specifically to record the experiences of marginalised groups of women

Given the prevalence rates for violence against women, it is perhaps not surprising that women feel less safe than men. However, women's perceptions of their own safety are significantly at odds with the realities of where the risk to them is located. Despite consistent research reports that women are most at risk from men known to them, the myth of the dangerous stranger prevails. Women feel most at risk on the streets, at night - 16% of women in the 2000 Scottish Crime Survey said they felt 'very unsafe' when walking alone after dark; 40% of women felt 'very or a bit unsafe'. By comparison, only 3.5% of men reported to the same survey that they felt 'very unsafe' walking alone after dark, despite the fact that they are more than three times more likely than women to experience an assault (Scottish Executive, 2000). Men are also more likely to be assaulted by strangers - only 17% of the 'stranger assaults' reported in a recent survey in England and Wales were committed against women. Conversely, 73% of the assaults designated 'domestic' were reported by women (Simmons and Dodd, 2003).

Elizabeth Stanko offers an interesting juxtaposition of the experiences of women and men and how those experiences impact on their feelings about safety and danger:

"Women's lives rest upon a continuum of unsafety. This does not mean that all women occupy the same position in relation to safety and violence. Many other features of their lives...will mean that their circumstances differ. Somehow, though, as all women reach adulthood, they share a common awareness of their particular vulnerability. Learning the strategies for survival is a continuous lesson about what it means to be female." (Stanko, 1990: 85)

In contrast, she says:

"For men, there are no tips about personal safety in crime prevention handbooks. It is assumed that men either know about avoiding dimly-lit alley ways and bus stops, or that they are able to protect themselves. While we may assume men already know how to protect themselves, they don't seem to be very successful: men's recorded levels of victimisation are much higher than women's." (Stanko, 1990: 109).

Women live with a consciousness of being 'at risk' of violence which is not experienced by most white heterosexual men, although Stanko acknowledges the connections between racist and homophobic violence and violence against women. It is this consciousness of ever present risk, she argues, which underpins the strategies women adopt to deal with the threat of violence in their daily lives, whether at home, at work, or on the street.

consequences of violence against women

The World Health Organisation defined violence as a public health issue in 1996, noting that it impacted especially on the health of women and children (WHO, 1997). Subsequently, a plan of action on violence against women drawn up by WHO identified areas of work needed in order to prevent violence and reduce violence-related morbidity and mortality among women. This work included the development of multi-country research, the need to document and test the efficacy of existing health interventions, and the need to raise awareness among health professionals of the impact of violence against women (WHO, 1997).

The latest outcome of this action plan is the World report on violence and health, a review of world literature and research on violence, including violence against women. This comprehensive report explores all aspects of the health consequences of violence against women, including injuries, pregnancy and reproductive health, chronic physical health issues, and the effects on mental health and wellbeing (Krug et al, 2002).

The 1996 national U.S. survey on violence against women found that in around a third of all rapes and physical assaults against women, the woman was injured. About one in three of those injured needed medical attention. Most of these injuries consisted of relatively minor bruising, scratches and welts (Tjaden and Thoennes, 1998). However, more severe injuries, including broken bones or fractures, burns and lacerations, are also recorded, particularly in relation to assaults by partners (Guthrie, 1998; McWilliams and McKiernan, 1993; Williamson, 2000)).

Rape and sexual assault may result in women acquiring sexually transmitted infections, including HIV and hepatitis (Winn et al, 2003; WHO, 2000). Pregnancy as a result of rape may cause psychological distress to the woman, including having to make decisions about whether to continue with the pregnancy (Lathrop, 1998; Rape Crisis Centre, 2003). If the woman decides to keep the child, there can also be difficulty for both the woman and the child in the long term (Rape Crisis, 1993). Sexual assault is linked to a range of gynaecological complications, including vaginal infection, bleeding, recurrent urinary tract infections, and chronic pelvic pain (Golding, 1996). These symptoms are reported by female survivors of both child and adult sexual assault, including women abused through prostitution (Farley and Barkan, 1998; Golding,1996).

In a sample of 892 women in two London hospitals, 2.5% of women reported experiencing domestic violence in their current pregnancy (Mezey et al, 2001). A recent study in the north of England found that 3.4% of the 475 respondents had experienced domestic violence during their current pregnancy. In both of these studies, the lifetime prevalence stood at 13-17% of the women surveyed. An earlier (1993/94) Canadian study showed slightly higher results, with 5.7% of a sample of 728 women reporting domestic violence during their pregnancy (Muhajarine and D'Arcy, 1999). Violence against women during pregnancy has been associated with miscarriage, premature birth, low birth weight, fetal injury and maternal death (RCOG, 2001, cited in Johnson et al, 2003).

Women survivors of violence also report a range of chronic health conditions, including gastro-intestinal problems (Goodwin et al, 2003), reproductive health problems, respiratory difficulties, migraine (Goodwin et al, 2003), impaired hearing or sight, joint pain, other chronic pain, and disability (Springer et al, 2003; Williamson 2000). Clinical research may focus on discrete populations with clearly defined characteristics, which has implications for the kind of research done in relation to violence against women. For example, there are a number of studies which consider the links between domestic abuse, and/or childhood abuse, and gastrointestinal disorders, but an extensive search of the same databases has failed to identify any comparable, or comparative, research with rape or sexual assault survivors. It may be that gastro-intestinal disorders are not commonly reported by sexual assault survivors. It may also be the case that, in the absence of routine screening, sexual assault survivors who do have gastro-intestinal disorders are less likely to disclose their assault history. A recent study looked at the relationship between women's history of abuse and subsequent (non-acute) surgical interventions. The study found that the number of surgeries undergone by women survivors of childhood abuse or domestic violence was significantly higher than for women with no reported history of abuse - 88.9% of women survivors of childhood abuse and 95% of survivors of domestic violence, compared with 67.3% of the control group (Hastings and Kaufman Kantor, 2003). Twice as many survivors of domestic violence as women with no abuse history had undergone major surgery. The authors acknowledge that the sample size was small (n=53) and possibly difficult to generalise from because it was predominantly made up of white women. However, they argue that the results are significant enough to warrant further investigation, particularly around the need to review perioperative nursing practice with a view to improving the identification and subsequent treatment of women survivors of abuse who are presenting for surgery (Hastings and Kaufman Kantor, 2003).

Women who have experienced violence report significant mental health difficulties (Carlson et al, 2003; Thomson, 1998; Women's Health Team, GGNHSB, 2003; Thompson et al 2002; Williamson, 2000). The mental health impact of child abuse and neglect has been relatively well documented, although research findings are not always consistent. A 1999 study of women attending GP surgeries in north London looked at the correlation between women's reported experiences of physical and sexual abuse at different points in the life cycle, and their mental health status. The study found that childhood experiences of physical abuse were associated with several mental health indicators, including depression, anxiety and self-harm. The study found that women reporting childhood experiences of sexual abuse were five times more likely to suffer from post traumatic stress disorder (Coid et al, 2003). However, it found no association between childhood experiences of sexual abuse and other adverse mental health outcomes. This is at odds with findings in other studies, which have identified a correlation between sexual abuse in childhood and adult experiences of mental health difficulty, including depression and anxiety (Fleming et al, 1999; Follette et al, 1996; Mullen et al, 1996). Coid et al acknowledge the difference in outcome between their study and others, and suggest it may be due in part to differences in methodology and in part to a different 'starting position', i.e. they made no assumptions about child sexual abuse being "the primary abusive experience associated with the psychopathological symptoms measured in adulthood" (Coid et al, 2003: 336). An invited response to this study strenuously refutes the findings in relation to child sexual abuse and psychiatric morbidity, while acknowledging the value of looking at child sexual abuse in the context of other forms of abuse (Mullen, 2003).

The north London study also reported associations between sexual assault in adulthood and substance misuse, and between rape and anxiety, depression and PTSD. Domestic violence had the strongest links across all of the mental health measures used in the study, with the exception of self injury (Coid et al, 2003).

Rates of PTSD in women survivors of violence are high (Farley and Barkan, 1998; Ullman and Brecklin, 2003). Other recent research has established an association between early onset child sexual abuse and both borderline personality disorder and complex PTSD, with the possibility that some women should be considered under the latter diagnosis rather than the former (McLean and Gallop, 2003). There is also some evidence that repeated experiences of violence or abuse have a cumulative effect, resulting in higher rates of PTSD, and more intense reactions (see Farley and Barkan, 1998, on PTSD in women working in prostitution; Ferguson (publication pending) on Complex PTSD in survivors of domestic abuse and child sexual abuse; Follette et al, 1996; Herman, 1992). Large numbers of women in acute mental health settings have histories of child sexual abuse (Nelson and Phillips, 2001).

The Adverse Childhood Experiences (ACE) Study, carried out in a large primary health care organisation in the U.S. in 1995/96, is a large scale study of the health impact of a range of experiences, including physical and sexual abuse. The study gives a very clear, if depressing, picture of the degree to which adverse childhood experiences - including sexual abuse, physical abuse, and witnessing violence towards mothers - are related to some of the leading causes of death in adults - including alcoholism, drug abuse, depression and suicide attempts, ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease (Felitti et al, 1998).

Much of the chronic ill health reported by survivors of child sexual abuse has traditionally been identified as somatic. Relatively little research has been done to establish how much of what was considered 'somatic' is actually rooted in women's experiences of violence and the impact of this on their bodies. Nelson (2002) explores some of the connections between the nature of the abuse experienced in childhood and the physical health difficulties experienced subsequently. She concludes that an increased awareness of what actually happens to children who are being abused may shed light on a range of "medically unexplained symptoms" (Nelson, 2002:51).

The consequences of violence against women for women's health can be severe. However, acknowledging the potential impact on women's health must be balanced against the danger of pathologising both the causes and the consequences of violence against women.

Given the established relationship between poor health and poverty, it might be expected that violence against women will also have socioeconomic consequences.

Women living with ongoing abuse lose work days and earnings as a result of being injured (Browne et al, 1999; Lloyd and Taluc, 1999). Similarly, women may lose time at work, and sometimes be forced to leave jobs, as a result of sexual assault. Poverty can be seen as both a causal factor and a consequence of violence against women; findings from the U.S. National Comorbidity Study suggest that women living below poverty levels appear to be more vulnerable to assault, but also that women living above poverty levels at the time of an assault are twice as likely to lose income as a result (Byrne, Resnick et al, 1999).

That women become homeless as a result of domestic abuse is perhaps self-evident. Recent Scottish research has demonstrated that as a consequence of leaving a violent partner, women may go through a lengthy period of disruption before settling in a new permanent home (Edgar et al, 2003; Fitzpatrick et al, 2003). The difficulties they have been left with as a result of the violence they have experienced may be compounded by the disruption and trauma of living in temporary accommodation, perhaps moving many times before achieving safety.

The relationship between other forms of violence against women and homelessness is less well documented. Burgess and Holmstrom noted as far back as 1974 that 44 of the 92 women who took part in their landmark study on rape trauma syndrome moved house shortly after the assault. However, little has been done since then to examine the effects that relocation might have on women in this situation. Similarly, while support organisations are aware of adult survivors of child sexual abuse who move repeatedly in an effort to stay safe, it appears only peripherally in the research literature.

Farley and Kelly (2000) identified safe housing as a priority for women and girls trying to exit prostitution. For women working in prostitution, there are other compounding factors. Often precipitated into prostitution by poverty and/or abuse, women may then find themselves unable to leave if they incur fines as a result of being arrested for soliciting (Routes Out of Prostitution, 2003).

Children and young people are affected by violence against women whether they are living with it or not. Young people who are affected by violence in their own lives are most likely to turn to other young people in the first instance for support (Young Women's Centre, 1997). The attitudes of young people are shaped by the society they live in, and many young people grow up believing that at least a degree of violence against women is acceptable (Burton and Kitzinger, 1998).

In a recent Minnesota study of women who had experienced violence by a partner, 114 women were interviewed about the extent to which their children were involved in the violence - 21% reported that their children had tried to get help when they were being assaulted, and 23% reported that their children had been physically involved in the events. Factors affecting children's attempts to intervene included the stability of the woman's financial and social situation, the frequency of the abuse, and the impact of the abuse on her life and health. Children were more likely to intervene when their mother's financial/social situation was less stable, when the abuse was frequent and the greater the impact on the woman's life and health. Children were less likely to intervene if the abuser was their biological father (Edleson et al, 2003). The authors suggest that these findings demonstrate a need for more careful assessments by all of the agencies involved in responding to domestic abuse, in order to improve the safety of women and children.

In this country too, there has been a development of work which considers the implications of domestic abuse for child protection (Hester, 2000; Humphreys, 2000; McGee, 2000) and examines the need for child protection services to develop an awareness of domestic abuse. In particular, it is argued, service providers must begin to understand how the abuse of women and children is used by abusive men to maintain control over them. In doing so, it is suggested, they will have to dismantle some of their own prejudices and misconceptions about where the responsibility for domestic abuse resides and place it back where it belongs - with the abusive man (Humphreys, 2000).

Forman (1991) viewed this from the other side of the glass, so to speak. She interviewed women whose children had been sexually abused and found that all of the women had experienced some form of abuse by their partner, and 17 of the women had experienced physical violence. This suggests that in addressing issues of child protection, it may also be necessary to consider whether the mother of an abused child may herself be in need of protection and support.

The effects on children of living with domestic abuse include difficulties with sleeping and eating, disruptive or very withdrawn behaviour, and delayed development (Hague, Kelly et al, 1995). Scottish Women's Aid has produced a series of reports based on the perspectives of children themselves, and it is clear from these that many children also experience high levels of fear and anxiety. The extent to which abusive men control the behaviour of children as well as women is also evident (Scottish Women's Aid, 1996).

Women's experiences, as indicated already, do not fit neatly into boxes. Nor do the experiences of children. As with research into violence against women, studies looking at childhood experiences of violence focus largely on a single type of violence (Saunders, 2003). Multiple experiences of violence and relationships between different types of violence are less explored, and Saunders advocates that, as with research into adult experiences of violence, a more integrated approach to researching how violence affects children and young people is required and should be developed (Saunders, 2003).

The impact of childhood and adult experiences of violence on women's mental health has already been acknowledged, including the links to substance misuse. Looking at the effect this then has on children provides another way to understand the effect that violence against women has on children. For example, the importance of recognising and addressing the impact on children of living with a parent with substance misuse issues has been acknowledged by the Scottish Executive (Scottish Executive, 2003).

Violence against women can be seen as an underpinning cause of difficulty for children across a broad spectrum of issues currently being addressed by the Scottish Executive.

Crisp and Stanko (2000) observe that relatively little research had been done into the financial implications of domestic violence, particularly within the U.K., and that within the body of research which had been done, there are wide variations in the methodologies adopted. They raise questions about the lack of accurate baseline data on which to base such research, and argue the need to move beyond awareness raising of the impact of domestic violence, and to develop effective monitoring systems which allow the cost and the benefits of different interventions to be measured. They also suggest that studies carried out in one part of the country can have relevance in another, that extrapolating and contextualising data can help to avoid needless duplication - "a broken arm is a broken arm in the city as well as in the country" (Crisp and Stanko in Taylor-Browne (ed.) 2001: 354)

Subsequently, the Women and Equality Unit commissioned research into the economic costs of domestic violence. The research aims to put a monetary value on the 'cost' of domestic violence. Methodologically, the research draws on the Home Office approach to costing crime, and applies this to data drawn from the 2001 British Crime Survey report on domestic violence. Although the full report is not yet available, [12] an interim report estimates that the cost of each 'female domestic homicide' is £1.1 million, based on lost economic output, the use of public services, and 'the human and emotional impact' (Walby, 2002). [13]

If there is little on the economic impact of domestic violence, there is even less on sexual violence. An extensive database search yielded only one article specifically on the costs of rape. Post et al, writing in response to a Supreme Court ruling that rape was a "noneconomic violent crime", estimated the financial costs of sexual violence, including 'sex offense homicides' in the state of Michigan for 1996 to be $6.5 billion. This was based on an estimated 61,581 rapes and sexual assaults for that year, and estimates of $87,000 as the cost of a single incident of rape/sexual assault, and more than $3 million as the cost of a single 'sex-offense homicide'. The higher cost of homicide is attributed to the greater costs of health care, loss of productivity and lost quality of life (Post et al, 2002).

The impact of violence against women on society is about more than financial costs. Riger et al (2002) describe the "radiating impact" of domestic violence, based on an ecological approach to the issue. Using the image of a wheel, they identify the 'first order' effects, i.e. the effects on the woman, as the centre of the wheel. Second order effects, the spokes, represent the impact of violence on a woman's relationships with others, including her ability to function socially, educationally and economically. The outer rim of the wheel they identify as the third order effects, and this relates to the impact on other people in a woman's life, including her children and other family members (Riger et al, 2002). All layers in the wheel are connected. The authors use the example of how intimidation of family members (on the rim) is used by abusers to continue to control the woman. If the woman is reliant on family members for childcare to allow her to work, their reactions to intimidation by her abuser may have more than one effect on her, i.e. the fear such intimidation may engender in her, but also the threat to her livelihood (Riger et al, 2002: 196-198).

s

• Violence against women has a significant impact on the lives of individual women, their health, their safety, their self-esteem, and their ability to participate in society

• Violence against women impacts on the lives and development of children, either as a result of witnessing violence against their mothers or other significant women in their lives, or because they themselves experience violence as a result of living in a violent world

• The scale of violence against women implies the need for a response from the whole of society which is only just beginning to be acknowledged, both through the provision of appropriate interventions and the development of strategies to challenge and change the situation.

The starting point for this report is the assumption that all forms of violence against women are linked. However, the research literature focuses mainly on discrete aspects of violence against women, with different aspects attracting attention within different fields.

This section of the report reviews research which assesses the effectiveness of interventions to address violence against women, identifies some of the gaps in the literature, and attempts to assess how far what has been learned about one aspect of violence against women can be transferred to another.

1. 4.1.1 The criminal justice system response

The reporting and subsequent investigation and prosecution of rape and sexual assault are the focus of much of the available research literature on the subject, particularly in Britain. As already indicated, the establishment of specialist police units in Scotland to deal with sexual assault dates back to the mid 1980s, and followed highly publicised research which critiqued existing police practice (Chambers and Millar, 1983). The trend towards specialism in this area continued throughout the 1990s, and is now standard across the Scottish police forces. Although the model varies slightly from one force area to another, key components include dedicated interview suites, specialist officers, and a 'victim-centred' approach. In some areas there is also a dedicated forensic suite.

Practitioners acknowledge that there have been significant improvements in the police response to rape and sexual assault complainers over the last 20 years (Christianson and Greenan, 2001), and this is supported by research. A study of 23 women in Sussex who had reported to the police between 1991 and 1993 found that 57% of them felt mostly positive about the response of police officers, while 43% were mostly negative about the response of police officers (Temkin, 1997). None of the women, including those who felt negative about the service overall, felt that they were disbelieved, or that the police were 'heavy-handed ' in their approach. In addition, the majority of the women (19 out of 23) valued the manner and attitude of the police officers who dealt with them. For the women who were 'mostly negative' about their experience with the police, poor follow up, difficulty accessing information, disbelieving attitudes and insensitive handling were the main features of their complaints about the service.

Temkin concludes that "the believing, sympathetic, non-judgmental attitude of the police, the unpressured pace and supportive manner in which their statements were taken, the access which they had to police officers and to information thereafter and the help and backing they received...during the course of the investigation and afterwards" were the main reasons for women feeling positive about the experience of reporting (Temkin, 2001: 524). Follow-up, she maintains, continues to be a problem, particularly in the area of information on the progress of the case.

These findings are similar to those from a survey of 48 women who reported to police in New Zealand between 1990 and 1994, in which 40% of the women expressed some degree of satisfaction with the police response, and 38% were dissatisfied (Jordan, 2001). The author acknowledges some of the difficulties inherent in measuring 'satisfaction' with a process which by its nature is bound to be distressing. She notes:

"Because rape is such an intense and sensitive area, when the police act with professional caring and demonstrate their respect for the victim, this is noticeable and greatly appreciated. When such qualities are lacking, however, their absence is also very noticeable." (Jordan, 2001: 696).

She goes on to explore the balance to be struck between the need (of women) for the process to be manageable, and the need (of police officers) to focus on the end result of that process:

"...at the very time that a raped woman is seeking to be believed and validated, the police will be intent on obtaining proof and verification that she is telling the truth. Her need for validation may clash with the police search for verification, and the techniques used by the police in their quest for evidence may threaten and undermine her sense of confidence and safety in them. While she struggles to regain a sense of autonomy following the rape, the police feel they as professionals must retain control of the proceedings." (Jordan, 2001: 701).

Jordan asserts that the achievement of a sense of control over the proceedings need not be achieved by one party at the expense of the other. Citing Temkin, she notes the value women place on belief, respect for the complainer, and a non-judgmental approach by the police (Jordan, 2001).

Recorded crime statistics for Scotland show a steady increase in the reporting of rape (Scottish Executive, 2003). This picture is similar in England and Wales (Harris and Grace, 1999; HMIC/HMCPS, 2002) and across Europe (Regan and Kelly, 2003). However, in none of these jurisdictions has the increase in reported rapes been matched by an increase in prosecutions or convictions. In fact, the conviction rate for rape has fallen during the period in which the reporting levels have risen (Harris and Grace, 1999; Regan and Kelly, 2003).

In an attempt to identify some of the reasons for this, the Home Office requested a joint inspection by HM Inspectorate of Constabulary and HM Crown Prosecution Service Inspectorate into the investigation and prosecution of rape cases. Their report was published in April 2002. The terms of reference were:

"...to carry out an analysis of investigations, decision-making and prosecutions of allegations of rape, from initial report through to case disposal." (HMCPSI/HMIC, 2002: 2).

The review covered all offences of rape against women, men and children. In relation to the investigation stage, the key findings echo some of the research findings already discussed, included the need for consistent training of police officers and forensic examiners, and improvements in the physical environments in which interviews and examinations take place. In addition, the review identifies partnership working with other agencies (e.g. through dedicated sexual assault referral centres) as key to improving the response to victims. Improved and standardised recording systems, and a review of timescales needed for submission of files to the Crown Prosecution Service are identified as the main administrative improvements required.

Although the report does not consider the role of forensic examiners in detail, it does note the limitations on choice posed by the lack of female forensic examiners, and the implications of forensic examiners learning 'on the job' rather than through accredited training programmes. The report considers that quality of forensic evidence is crucial to effective prosecution of rape and sexual assault, increasing the likelihood that prosecution will happen, and that a conviction will result (HMCPSI/HMIC, 2002). In addition, it is suggested, any measures which reduce the trauma of the investigative process for individual women are to be welcomed, improving not only the likelihood of achieving a conviction, but also the woman's recovery rate following a sexual assault. This view is supported elsewhere in the literature (Campbell et al, 2001; Kelly and Regan, 2003).

In a study commissioned by Rape Crisis Network Europe (RCNE), Kelly and Regan reviewed recent literature on the conduct and outcomes of forensic examinations. They identify some of the key elements of good practice in relation to forensic examinations, emphasising "the rights and dignity of the victim" (Kelly and Regan, 2003: 6). These include "speedy response; avoiding the triage system in hospital A&E departments; a private dedicated space; a well equipped examination room; trained and skilled practitioners; female examiners; a streamlined victim-centred information gathering process; time to move at the speed the victim/survivor is comfortable with; protocols and evidence kits which are applied flexibly, according to the facts of the case; space to discuss the process, debrief and undertake crisis intervention, and provision of, or links to, medical follow up and advocacy/support services." (Kelly and Regan, 2003: 12)

These conditions, they argue, are crucial, both to the quality of the evidence gathered, and to the comfort and health of the complainers (Kelly and Regan, 2003: 12). In their subsequent review of five different approaches to forensic examination, they note that the use of trained doctors is one of the more common models. They identify a number of difficulties inherent in this approach, including problems with recruiting women doctors, the need for participating doctors to take on a generic forensic role, thus perhaps limiting their knowledge about sexual assault, and problems with limited availability of doctors at certain times. They also suggest that there may be limited co-ordination and integration across the services, and an absence of advocacy and support.

Some of these issues are addressed by the use of forensic nurses, who have a more extensive role in providing healthcare advice, advocacy and support to complainers, in addition to evidence gathering and providing forensic reports for the courts. This model is widely used in North America and has several advantages, including a higher degree of specialism, cost effectiveness, and a more holistic approach to health intervention following sexual assault (Kelly and Regan, 2003; Ledray, 1999).

A holistic approach is also found in the provision of Sexual Assault Centres, which in Canada are designed to "attend to the medical, emotional, social and medico-legal needs of clients in a prompt, professional, and compassionate manner and to provide leadership in the prevention of sexual assault" (Du Mont and Parnis, 2002, cited in Kelly and Regan, 2003: 15). These are usually hospital based, often attached to accident and emergency facilities, with a dedicated examination room and possibly interviewing facilities. There are several examples of similar centres in England, including The Haven, a referral centre based in a sexual health setting which provides forensic examination and sexual health follow up in southeast London (Kerr et al, 2003), and the St Mary's Centre in Manchester, which was the first such centre in England. As yet, there are no such facilities in Scotland, although discussions are ongoing in Glasgow about how such a service might be developed (Dutton and Cavanagh, 2003).

Kelly and Regan conclude by identifying the key components required in order to begin developing minimum standards:

"Privacy through the development of dedicated rooms, or a centre;

Philosophical principles underpinning practice that emphasises respect, dignity, rights and choice;

Enhancing forensic practice through capacity building - both the number of trained examiners (often through involving nurses) and their skills base;

Access to female examiners;

Ensuring that even if people have to wait for a medical practitioner, that a staff member is available to greet them, take them to the more private rooms, and explain their rights and what may happen next;

Linking provision of immediate medical care, forensic examinations, crisis and short term counselling, follow up medical care and advocacy;

Combining service provision with training, awareness raising and system advocacy;

Leadership within the service, and some form of community accountability;

Ensuring access is as wide as possible, and that outreach efforts are targeted at under-served populations."

(Kelly and Regan, 2003: 17)

Finally, they note the emerging debate about how far forensic evidence actually influences the outcome of sexual assault trials, citing Canadian research which demonstrates that only documented injury appears to have a predictive influence on convictions (Du Mont and Myhr, 2002; cited in Kelly and Regan, 2003). Given the trauma for women undergoing forensic examination, further research would seem to be indicated in this area.

In another report for Rape Crisis Network Europe, Regan and Kelly address the issue of attrition in reported rape cases, raising serious concerns about the extent to which convictions for rape have fallen across Europe, as shown in their pan-European study (Regan and Kelly, 2003). They maintain that this downward trend in conviction rates is contrary to what might be expected, given the role of the women's movement in raising awareness and challenging rape stereotypes, the development of rape crisis lines and other women's counselling projects, the development of training and practice guidelines, increased media awareness and legal reforms. However, they argue that it is symptomatic of a situation in which rape has received little attention compared with domestic violence and trafficking. The study indicates that countries with adversarial legal systems have the highest attrition rate - England and Wales, Scotland and Ireland all have conviction rates below 10%. At 6%, the conviction rate for rape in Scotland is second only to that in Ireland.

The Justice ministries for the countries involved in the study offered a range of technical and procedural 'barriers to successful prosecution', including limited or absent evidence, under-reporting or delayed reporting, lack of support services, delays in court proceedings and 'limited incentives for prosecutors'. The authors contend that, despite a wide range of legal and procedural reforms which have been enacted across Europe since 1980, there is still an absence of good practice in enabling rape complainers to give their best evidence or in supporting and protecting "their dignity and integrity" during the trial process (Regan and Kelly, 2003: 17).

Overall, they argue, rape is very much 'a forgotten issue' on political and social policy agendas, attracting neither the debate nor the resources which have gone into highlighting domestic violence as a social policy priority. They make a number of recommendations for change, including the suggestion that research should be undertaken to explore the points of attrition in rape cases and identify possible reasons for the increase in attrition.

A small scale pilot study which addresses these issues has already been undertaken in Scotland. The study retrospectively tracked the progress of 191 complaints involving sexual offences through the criminal justice system, by examining crime reports, interviewing police officers, examining fiscal files and interviewing precognition officers and procurators fiscal. Two police forces were involved, one urban and one rural, and seven fiscal offices. Of a total of 47 cases which began as complaints of rape, 17 did not progress beyond the police, a further 15 did not progress beyond the fiscal, and of the 15 which went to court, eight resulted in a conviction (Jamieson, 2001).

Although this seems an improvement on the 22% conviction rate reported in an earlier study (Brown, Burman, Jamieson, 1992), Jamieson notes that more than half of the cases which proceeded to court involved child complainers. A further breakdown of the figures shows that of the nine cases involving child complainers, five resulted in a conviction, compared with only two out of the 14 cases involving an adult complainer. Although Jamieson comments on the range of reasons given in police crime reports for not proceeding, including withdrawal of the complaint, false allegation, and no known suspect, she does not identify any one area of police procedure as particularly problematic. In relation to cases marked 'no proceedings' by the procurator fiscal, she suggests that the basis for deciding there is 'insufficient evidence' might bear further exploration. Acknowledging that the fiscals interviewed all maintained that decisions should be made on the basis of sufficiency of evidence, and not on the credibility of the complainer, she nonetheless notes:

"In the case files we examined, we formed the impression that judgements about credibility were most often recorded in cases in which there is equivocation about the sufficiency of the evidence." (Jamieson, 2001: 80).

The HMCPSI/HMIC report also notes concern about the role of the complainer's credibility in cases where there is limited evidence, and in particular "...found that the prosecutor's approach too often tended to be one of only considering any weaknesses, rather than also playing a more proactive role in seeking more information and trying to build or develop the case." (HMCPSI/HMIC, 2002: 9). Amongst a raft of measures outlined in the subsequent Action Plan it is noted that revised guidance on rape has already been made available to prosecutors, and that a revised training package for sexual offences will be commissioned. In addition, it is noted that the CPS agrees with the recommendation that rape cases should be handled by specialist prosecutors, and that consideration is already being given to how to implement this.

There have been some significant changes in the legislative response to rape and sexual assault over the past three years in Scotland. A recent Lord Advocate's reference on the definition of rape clarifies Scots law and makes it clear that rape is based on an absence of consent, and does not require the use or threat of force. The introduction of the Sexual Offences (Procedure and Evidence) (Scotland) Act 2002 prohibits the accused in sexual offence trials from conducting his own defence, and tightens the restrictions regarding use of sexual history/character evidence. The Solicitor General has recently announced a review of the prosecution of rape and sexual offences in Scotland. All of these initiatives might be expected to improve the treatment of rape complainers and hopefully the attrition rate. Regan and Kelly (2003) recommend that governments evaluate recent and new legal and procedural reforms. A precedent has been set in Scotland with the evaluation of the Protection from Abuse (Scotland) Act 2001, and it would seem that this exercise would bear repeating in relation to the recent sexual offences legislation.

A search of the literature produced little from Canada on rape or sexual assault. As noted earlier in this report, Canada has no specific offence of rape, having made the shift to a broader 'sexual assault' spectrum of offences in the early 1980s. In a recent overview of the Canadian experience, Hague et al note that this creates some difficulty in trying to compare reporting and prosecution of rape in Canada with experiences in the UK, as the figures available from Justice Canada provide the totals for all sexual assaults, across all three of the levels of sexual assault defined in law, and with no distinction made between offences against children and offences against adults (Hague, Kelly and Mullender, 2001).

The legislative reform in Canada also included the removal of the requirement for corroborative evidence in sexual assault cases. In practice, however, it would seem that prosecutors are still reluctant to proceed with cases which do not have some form of corroboration (Du Mont and Myhr, 2000, cited in Krug et al, 2003: 170).

Hague et al note with some surprise a decline in reported sexual assaults over the five years before their report, and with some disappointment the absence of the kind of detailed data that is available on 'family violence' from Statistics Canada (Hague, Kelly and Mullender, 2001). It would seem that in Canada, as in Europe, rape and sexual assault are 'forgotten issues', despite the best efforts of women's advocacy services.

Rape crisis centres have provided support services for rape and sexual assault survivors in Scotland since the 1970s. In common with similar services in other parts of the world, centres were usually based on a feminist political perspective, with support provided 'by women, for women'. The support aimed to be woman-centred, non-judgmental and non-directive. It was free, and it was confidential. The stated goal was to help the woman regain control over her life, and support was delivered in ways designed to enhance this:

"Most women have their initial contact with us through the telephone. Women assaulted by men have had their sense of control over their own lives and bodies destroyed. In using the telephone a woman has the power over her contact with us - by hanging up when she wants, by ringing back if she wants, by making arrangements to meet face-to-face and keeping or breaking them - she chooses the extent of her involvement." (Edinburgh Rape Crisis Centre, 1981: 6).

The mechanics of service delivery varied from one area to another, often dependent on funding. Where possible, centres provided medical and legal advocacy for women, and accompaniment through the criminal justice process. Until the late 1980s, most centres were run entirely by volunteers.

Believing women and validating their reactions to sexual assault were core to the process. Challenging the social norms of the time, rape crisis centres gave a clear message to individual women and to the rest of society - women were not responsible for rape, men were:

"When a woman has been raped she often encounters disbelief and blame from all corners - family, friends, police, doctors. She suffers from the fear that somehow she contributed to the attack. Our acceptance without judgement of whatever the woman wants to tell us can help begin the process of banishing this guilt. We do not doubt or question what she says." (Edinburgh Rape Crisis Centre,1981:6).

Belief and unconditional acceptance continue to be central to the ethos of rape crisis. In a recent handbook on rape and sexual assault, "believe the woman" is still at the top of the list (Rape Crisis Centre, Glasgow, 2003).

The basic philosophy has changed little over the last 20 years. The services, however, have changed and adapted, partly in order to meet the requirements of funding and regulatory bodies. However, change has also been prompted by the demands of women using the services. Services which were established around a 'crisis line' as the primary source of support have shifted emphasis, as women making contact with centres have developed more of an expectation of receiving 'counselling', reflecting a wider public acceptance of counselling than was the case in the early days of the movement (Christianson and Greenan, 2001). Rape crisis centres today are more likely to offer face-to-face support routinely, using a formal appointment system (Rape Crisis Scotland, 2003). Centres also develop their services in response to the needs of particular women, for example women asylum seekers and women working in prostitution (Rape Crisis Scotland, 2004).

Although some centres carry out in-house evaluations of their service, usually based on feedback questionnaires from service users, there has been little formal or independent evaluation of the rape crisis response to survivors of rape and sexual assault anywhere. One U.S. study which sought the views of rape survivors on the responsiveness of services following an assault found that 75% of women rated their contact with rape crisis centres positively (Campbell et al, 2001). Elsewhere, the same group of authors note that evaluation of rape crisis services in the U.S. has come hand-in-hand with increased depen