Health Impacts of Violent Victimization on Women and their Children
3. Health Consequences of Violent Victimization
In Canada and worldwide, violence is a significant cause of morbidity and mortality for women aged 15-44 years (WHO, 2005). The long-term health consequences of abuse are well documented and vary by the form (i.e., bilateral couple conflict versus intimate partner terrorism), severity and chronicity of abuse, and by exposure to multiple types of abuse (physical, sexual, psychological) that co-occur and recur across the lifespan. Thus, women’s health is affected not only by IPV but also their lifetime cumulative abuse experiences, including other forms or sexual assault and abuse during childhood (Scott-Storey, 2011).
This section provides data on the physical and mental health consequences of the various kinds of violence that are the subject of this report. While there are significant physical health consequences of violence against women and children, including injury, death and specific infectious and chronic diseases, much of the burden of suffering arising from violence exposures manifests itself in acute and chronic mental health conditions. Mental health disorders generally account for 13% of total global disease burden (World Health Organization, 2011), and while the overall prevalence of mental health problems is similar in men and women, women experience almost twice as much depression and anxiety as men (Johnson & Stewart, 2010), differences accounted for, in part, by more negative life events including a greater burden of violent victimization (Astbury & Cabral, 2000; Hegarty, 2011).
As reviewed below, the key types of mental health disorders that have been established, through research, to be associated with violence are mood disorders, primarily depression, anxiety disorders, primarily post-traumatic stress disorder (PTSD), substance use disorders and somatic disorders. These and others referred to below are briefly defined and described in Appendix 1.
Another way that research has assessed the impact of violence, and also the impact of interventions meant to reduce violence, is through the concept of quality of life, specifically health-related quality of life. Data on this kind of outcome is also presented, where available and appropriate.
The section is organized such that the main types of violence exposures – IPV and child witnessing of IPV, along with sexual assault of women and child sexual abuse – are each reviewed in terms of the research available on their physical and mental health consequences. Where available, Canadian data are presented and given priority, but in many cases these data are either not available, or not of sufficient scope and quality to provide a complete picture. In these cases, data from comparable settings and jurisdictions (i.e., USA, UK, Australia) are presented. The goal is to present “best available evidence” for each type of health outcome from relevant jurisdictions, highlighting their strengths and limitations. This will provide insight on what will be ‘highly’ versus ‘probably’ versus ‘probably not’ relevant to Canada, and also where specific knowledge gaps exist.
3.1 Health consequences of intimate partner violence
3.1.1 Physical health consequences
18.104.22.168 Injury and Death
Between 2000 and 2009, there were 738 spousal homicides in Canada, representing 16% of all solved homicides and nearly half (47%) of all family-related homicides; women are about three times more likely to be victims of spousal homicide (Statistics Canada, 2011). In 2010, there were 89 victims of homicide by an intimate partner (including a dating partner). However, trends in spousal and dating partner homicide are gradually declining (Statistics Canada, 2011; Hotton Mahoney, 2011). Specifically, the rate of intimate partner homicide decreased 32% from 1980 to 2010 (Hotton Mahoney, 2011). This decline has been attributed to different factors, including improvements in women’s socioeconomic status and the increased availability of resources for victims of violence (Dawson et al. 2009; Pottie Bunge 2002; Dugan et al. 1999).
Few comparative studies have examined specific differences in injury patterns indicative of IPV, versus other potential causes (i.e., unintentional injuries). However, a recent systematic review and meta-analysis by researchers at Canada’s McMaster University examined all available studies with data comparing injury patterns of those with and without IPV exposures, among women presenting in emergency departments (Wu, Huff & Bhandari, 2010). Wu et al. found that specific injury patterns can differentiate those exposed to IPV versus other kinds of injurious events; specifically head, neck, or facial injuries that were not witnessed (i.e., as would be a car accident); as well, multiple injuries were associated with IPV exposure, whereas thoracic, abdominal, or pelvic injuries, or extremity injuries alone, did not differentiate between abused and non-abused women (Wu et al., 2010). This is consistent with individual, non-comparative studies, which also find that head, especially oral/dental injuries, ocular injuries, strangulation wounds, concussion, internal and external contusions, fractures and open wounds are strongly associated with IPV assaults (WHO, 2005; Fanslow et al., 1998; Sheridan & Nash, 2007).
In Canada, Aboriginal women exposed to IPV are more likely to report injuries than are non-Aboriginal women (59% versus 41%), and they are also more likely to report fearing for their lives (52% versus 31%) (Brannen, 2011).
22.214.171.124 Other physical health outcomes
IPV has been linked to a number of other physical health outcomes, including those related to reproductive health, and chronic and infectious diseases. An international systematic review and meta-analysis by the World Health Organization (WHO) found IPV to be associated with, in addition to the injuries above: chronic pain syndromes (see also below), disability, fibromyalgia, gastrointestinal disorders, irritable bowel syndrome, sleep disorders and general reductions in physical functioning/health-related life quality (AuCoin & Beauchamp, 2007; WHO, 2005).
IPV is also associated with gynaecological disorders, infertility, pelvic inflammatory disease, pregnancy complications/miscarriage, sexual dysfunction, sexually transmitted diseases, including HIV/AIDS, unsafe abortion, and unwanted pregnancy (WHO, 2005). A number of studies of IPV during pregnancy show it to be significantly associated with femicide (Campbell et al., 2003), and causing direct harm to the fetus, which can result in pre-term birth or injury and low birth weight (WHO, 2005; Campbell et al., 1999; Murphy et al., 2001; Shah & Shah, 2010; Cokkinides et al., 1999).
IPV is associated with health risk behaviours, including alcohol and drug abuse, smoking, unsafe sexual behaviour and physical inactivity (WHO, 2005).
3.1.2 Mental health consequences
IPV is consistently associated with high rates of depression, anxiety disorders (especially PTSD), protracted disabling sleep disorders, phobias and panic disorder, psychosomatic disorders, and suicidal behaviour and self-harm (see reviews by WHO, 2005 and Jordan et al., 2010). Depression and PTSD are the most prevalent mental health impacts of IPV, with considerable co-morbidity of the two disorders (Jordan et al., 2010, Basile et al., 2004). In a meta-analysis of studies of female IPV victims, the mean prevalence of depression was estimated at 47.6% and of PTSD at 63.8% (3-5, and 5 times the general female population rates, respectively) (Golding, 1999). Loss, feelings of shame and guilt, humiliation, entrapment, and lack of control contribute to the development of poor self-esteem and depression (WHO, 2005; Astbury & Cabral, 2000), findings also seen in the 2004 Canadian General Social Survey (AuCoin & Beauchamp, 2007).
Other studies have also identified increased rates of eating disorders, substance dependence, antisocial personality disorders, and nonaffective psychosis (WHO, 2005; Jordan, 2010; Danielson et al., 1998; Golding, 1999; Afifi et al., 2009; Ehrensaftet al., 2006; Ellsberg et al., 2008; Golding, 1999).
For Aboriginal women with abuse histories, colonization and racism may contribute to higher rates than among non-Aboriginal women, of mental health problems such as depression and substance use (MacMillan et al., 2008; Varcoe and Dick, 2008). However Canadian data from the 2009 General Social Survey indicate that Aboriginal women’s self-rated mental and physical health does not differ from that reported by non-Aboriginal women (Brannen, 2011), even though, as indicated above, the frequency and severity of their violence exposures are significantly greater.
Because evidence is mounting that depression and PTSD are pathways by which abuse affects physical health (Sutherland et al., 2002; Weaver & Resnick, 2004; Wuest et al., 2009), addressing mental health effects may be important to preventing physical health problems such as chronic pain or cardiac disease. It has also been found that when violence decreases or is eliminated, physical and mental health both improve (Bybee & Sullivan , 2002). However, simply ending a relationship does not mean that the violence and harassment end, as indicated by the Canadian criminal harassment data presented in Section 1 (Milligan, 2011). Recent Canadian data indicate that the ongoing intrusion of former partners impacts women’s health for years after they leave the abusive relationship (Wuest et al., 2009).
3.2 Health consequences of sexual assault
Many of the mental and physical health consequences of sexual assault by non-partners mirror those described above, with the significant difference being the generally acute nature of sexual assault, when compared to the more chronic nature of IPV, which often takes multiple forms of physical, sexual and psychological abuse and control. This aspect of chronicity may be why most reviews that evaluate especially the mental health consequences of violent victimization find that IPV has more severe and far ranging consequences on these aspects of women’s health. That said, the specific type of sexual assault suffered by a woman, along with any previous history of trauma and abuse, will make each woman’s response to victimization unique. Presented below are data from high quality reviews indicating the main types of health consequence of sexual assault of women outside the context of IPV.
3.2.1 Physical health consequences
As summarized in the WHO World Report on Violence and Health (Krug et al., 2002), “
physical force is not necessarily used in rape, and physical injuries are not always a consequence. Deaths associated with rape are known to occur, though the prevalence of fatalities varies considerably across the world. Among the more common consequences of sexual violence are those related to reproductive, mental health and social wellbeing (p. 162).” Thus while Canadian data from the 2004 General Social Survey indicate that most (93%) sexual assaults resulted in no physical injury to the victim, particularly for victims of sexual touching (96%) compared to sexual attack victims (78%) (Brennan & Taylor-Butts, 2008), findings in the WHO Report, which also examined sexual assault in the context of war, etc., did find a link between these kinds of assaults and reproductive health consequences, including pregnancy and gynaecological complications (vaginal bleeding or infection, fibroids, decreased sexual desire, genital irritation, pain during intercourse, chronic pelvic pain and urinary tract infections), along with sexually transmitted diseases, including HIV infection (Krug et al., 2002).
3.2.2 Mental health consequences
The mental health consequences of sexual assault mirror those outlined above for IPV, with depression and anxiety, especially PTSD, being most strongly associated with this kind of victimization (Krug et al., 2002). The WHO Report, which comprehensively examines the full range of violent victimization, across ages, genders, sites (e.g., individuals, families, communities) and countries, and their impact on health, also highlights that social stigma and ostracism among assaulted women is a significant issue, with the related risk of suicidal behaviour.
3.3 Health consequences of child maltreatment and other traumatic exposures in childhood
3.3.1 Child witnessing of IPV
Adverse outcomes that result from witnessing IPV in childhood include an increased risk of psychological, social, emotional and behavioral problems including mood and anxiety disorders (see below), and drug abuse and school-related problems in children and adolescents (Gilbert et al., 2009; Kitzmann et al., 2003; Evans et al., 2008; Osofsky, 2003).
These negative effects may continue into adulthood and become part of an intergenerational cycle of violence (Gilbert et al., 2009; Osofsky, 2003; Dube et al., 2002; Doumas et al., 1994); specifically, children who witness violence in the home are more likely to maltreat their own children (Doumas et al., 1994; Schwartz et al., 2006) and are more likely to have violent dating and intimate relationships as adults (either as victims or perpetrators) (Stith et al., 2000; Ehrensaft et al., 2003; Carr & VanDeusen, 2002). Children exposed to IPV are at increased risk of experiencing other forms of abuse by caregivers (e.g., physical and sexual abuse) (Margolin, 1998; McCloskey et al., 1995).
3.3.2 Child sexual abuse
Exposure to CSA is associated with impairment in a broad range of domains, including mental health, physical health, education, criminal behaviour and interpersonal functioning (Gilbert et al., 2009; Friesen et al., 2010), and overlap exists across these domains. For example, a girl who has suffered sexual abuse and is experiencing one or more mental health problems is also at risk for low educational achievement and involvement with the law, among other negative outcomes.
Sexual abuse of girls is associated with both short- and long-term negative effects on mental health, depending on the severity, persistence, and presence of risk and protective factors, both genetic and environmental (Fergusson et al., 1996a,b; Banyard et al., 2001; Putnam, 2003). Of particular note, children who have experienced CSA are at increased risk of exposure to other types of maltreatment, including physical abuse and neglect (Fergusson & Mullen, 1999) and for sexual re-victimization in subsequent years (Roodman & Clum, 2001). Factors associated with more negative outcomes among those exposed to CSA include severity (contact or intercourse compared with non-contact sexual abuse); frequency, duration and the occurrence of other types of maltreatment (Andrew et al., 2004).
CSA is a non-specific risk factor for both internalizing and externalizing disorders in girls and adult women; it is associated with neurobiological dysregulation in both child- and adulthood including alterations in the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic nervous system and more recently, the immune system (Nunes et al., 2010). Regardless of whether individuals exposed to CSA develop a specific psychiatric disorder, they are at risk for difficulties with affect regulation, impulse control, somatization, cognitive distortions, altered self-perceptions and socialization problems (Putnam, 2003).
Children who have been sexually abused may present with a wide range of symptom patterns, including no symptoms (Kendall-Tackett et al., 1993). In a comprehensive review of studies that involved predominantly samples from sexual abuse assessment or treatment programs, between 21% and 49% were asymptomatic at the time of initial assessment. Sexually abused children were more symptomatic than non-abused children in a broad range of domains that included depression, PTSD, somatic complaints, aggression, behaviour problems and sexualized behaviour. For two other outcomes – suicidal behaviour and poor self-esteem – minimal differences were found.
CSA has mental health impacts into adulthood (Mullen et al., 2000; Andrew et al., 2004). Among adult women, there is strong evidence of significant associations between CSA and depression, PTSD, panic disorder, drug and alcohol dependence and suicide attempts (Andrew et al., 2004). Other mental health conditions related to CSA exposure include somatization, eating disorders, personality disorders and, more recently, psychotic symptomatology (Maniglio, 2009; Afifi et al., 2011). Most studies have found that although the effect of CSA on mental health problems is reduced when family environment is controlled for, CSA still has a significant association with a broad range of adult mental health outcomes.
Some literature suggests that exposure to CSA is linked with higher risk of impairment among adult women compared with men (MacMillan et al., 2001; Molnar et al., 2001), while others have concluded there is no significant difference (Andrew et al., 2004) or that males have higher rates of impairment for some outcomes (Rhodes et al., 2011). It is clear, however, given the higher prevalence of CSA among girls, that CSA is associated with a higher percentage of disability-adjusted life years for females compared with males (Andrew et al., 2004).
3.4 Multiple forms of child maltreatment/adverse childhood experiences
IPV, sexual violence, and child maltreatment often overlap in families (Gilbert et al., 2009; Dong et al., 2004), and, as mentioned above, many studies evaluate the impact of multiple forms of child maltreatment at once, including physical and sexual abuse, neglect and exposure to IPV. While the above sections have identified studies which have looked at the impacts of the two forms of violent victimization of children that are the focus of this report, the next section provides an overview of major studies that have looked more comprehensively at child maltreatment exposures and different kinds of health outcomes across the lifespan.
Data from the Canadian Incidence Study (CIS) of Reported Child Abuse and Neglect (PHAC, 2010) indicate that few cases of substantiated abuse result in physical injury, with 8% reporting some kind of injury, and most of these (6%) being cuts, scrapes and bruises. Disaggregated by type of abuse, these data showed that sexual abuse more often accounted for these injuries (11%) than did witnessing IPV (1%) (physical abuse accounted for 26% of these injuries, emotional abuse 5% and neglect 6%).
In terms of short-term emotional harm, the CIS found that 29% of cases of substantiated abuse result in some form of harm apparent to the assessors (note, these were not clinically diagnosed) including bed-wetting, nightmares and social withdrawal. Disaggregated by type of abuse, these data showed that sexual abuse more often accounted for this kind of harm (47%), which was more severe, than did witnessing IPV (26%) (physical abuse accounted for 26% of emotional harms, emotional abuse 36% and neglect 30%). The CIS does not follow cases to assess long-term consequences of this kind of abuse.
The US Adverse Childhood Experiences (ACEs)Footnote 1 Study is a very large, longitudinal study designed to assess the impact into adulthood of exposure to 10 types of ACEs, grouped into three categories that occurred in the participant's first 18 years of life. These ACE categories and events are:
- emotional, physical or sexual abuse;
- emotional or physical neglect; and
- five kinds of household dysfunction:
- mother treated violently;
- household substance abuse;
- household mental illness;
- parental separation or divorce;
- incarcerated household member.
The ACE Score is calculated by assessing the cumulative exposure to different types of ACE. Generally, the higher the ACE score, the more significant the association with negative health impacts.
The primary findings of various ACE Study analyses indicated the following relationships between ACE exposures and adult health:
- Physical health : chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), liver disease, sexually transmitted diseases (STDs), fetal death, and unintended and adolescent pregnancies.
- Mental health : depression, suicide attempts, sleep disorders, and health-related quality of life.
- Health risk behaviours : alcoholism and alcohol abuse, illicit drug use, risk for intimate partner violence, multiple sexual partners, smoking and early initiation of smoking, and early initiation of sexual activity.
While the ACE cohort sample is very large (over 17,000 participants), and follows people longitudinally, the sample was drawn from a US Health Management Organization (HMO) population, which might limit its generalizability to other groups, for example more poor or marginalized people without health insurance (in the US context), or to other countries with different health systems.
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