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Violence against Women: A literature
review commissioned by the National Group to Address
Violence Against Women
3. Consequences of violence against women
3.1 For women
3.1.1 Fear of violence
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.
3.1.2 Health 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.
3.1.3 Socioeconomic consequences
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).
3.2 Consequences of violence against women for
children and young people
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.
3.3 Consequences of violence against women for
society
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).
3.4 Consequences of violence against women -
conclusions
- 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.
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