Abuse effects on women

Running head: THE EFFECTS OF ABUSE ON WOMEN

Assignment #3: Quantitative Research Focus The effects of abuse on women: A quantitative literature review By Dawn Beazer adamld00@uleth.ca

For Noella Piquette CAAP 6617: Research Program Evaluation University of Lethbridge

Assignment Deadline: November 20, 2011 Assignment Submitted: November 20, 2011

Abuse effects on women

The Effects of Abuse on Women: A Quantitative Literature Review Overview What is the impact of abuse on womens health? The following review of quantitative research will address this question, and the impending consequences to practice in working with abused women and perhaps more globally, with women presenting with health problems. This is an important area of research and an area requiring more attention and change for those who work with women who have experienced interpersonal violence. The World Health Organization (2011) recognizes violence against women as a major concern in public health. Ellsberg, Jansen, Heise, Watts, and Garcia-Moreno (2008) state that in addition to being a breach of human rights, intimate partner violence is associated with serious public-health consequences that should be addressed in national and global health policies and programmes. (pp. 1165) Additionally they explain that the health problem created by violence against women not only exists in its direct effects such as injury, but it also contributes to other serious health problems, and that the reported health problems are mostly outcomes of abuse instead of precursors. Evidently this is an important area of concern and study, especially when considering that according to Bonomi, Thompson, Anderson, Reid, Carrell, Dimer, Frederick, and Rivara (2006) intimate partner violence affects between 25% and 54% of women in their adult lifetime. (pp. 458) Most detrimentally this concern is evident when explained by Romito, Turan, and DeMarchi (2005) that violence and its consequences are still quite invisible in most health and social services. (pp. 1723) Review of Literature and Importance for Competent Practice A study by Eberhard-Gran, Schei, and Eskild (2007) found that women who are exposed to physical or sexual violence were significantly more likely to experience somatic symptoms and comorbid diseases. Bonomi et al. (2006) also report an association of interpersonal violence with chronic physical and somatic illness, and Coker, Davis, Arias, Desai, Sanderson, Brandt and Smith (2002) found interpersonal violence associated with chronic disease for women. Due to this relationship, Eberhard-

Abuse effects on women

Gran et al. (2007) recommended that it is necessary for clinicians who encounter women presenting with somatic symptoms to inquire about physical and sexual violence. In 2006, Vos, Asturbury, Piers, Magnus, Heenan, Stanley, Walker, and Webster completed a study which found that interpersonal violence creates a major risk to womens health, with the largest contribution to the burden of disease being poor mental health. Several studies noted that increases were found in mental health problems such as depression, anxiety, phobias, and PTSD (Bonomi et al., 2006; Carbone-Lopez, Kruttschnitt, & Macmillan, 2006; Coker et al., 2002; Ellsberg et al., 2008; Johnson, 2008; McGarry, Simpson, & Hinchliff-Smith, 2011; Romito, Turan, & DeMarchi, 2005; Statistics Canada, 2006; Tutty & Goard, 2002; Vos et al, 2006; World Health Organization, 2011). Additionally, Devries, Watts, Yoshihama, Kiss, Schraiber, Deyessa, Heise, Durand, Mbwambo, Jansen, Berhane, Ellsberg, and Garcia-Moreno (2011) and Ellsberg et al. (2008) found a correlation between intimate partner violence and suicidality and suicide attempts. Consequently, Vos et al. (2006) suggest that practitioners need to be aware of the association of common mental health disorders with interpersonal violence. They also advise that awareness of interpersonal violence as a health risk to women be addressed through media and the general public to increase population-wide and community-based interventions aimed at decreasing violence. McGarry et al. (2011) found that women experiencing domestic abuse at an earlier point in their life which remains unresolved, can experience a number of related emotional problems such as frustration, anger, helplessness, hopelessness, and low self-esteem. Similarly, a 2006 Statistics Canada report shows that female victims of spousal assault reported being upset and confused, suffering low self-esteem, suffering shame and guilt, having sleeping problems, and fearing for themselves and their children. In regards to the McGarry (2011) study, older women who have had such feelings for longer periods of time may be less likely to disclose the domestic abuse to others, which can lead to emotional isolation and powerlessness, which then in turn, further complicates the impact on self-esteem, self-worth, and physical health.

Abuse effects on women

Several studies report that abused women are found to engage in harmful healthrelated behaviours such as tobacco, alcohol, and illicit drug use (Bonomi et al., 2006; Carbone-Lopez, et al., 2006; Coker et al., 2002; Ellsberg et al., 2008; Johnson, Ollus, & Nevala, (2008); Romito et al., 2005; Vos et al, 2006) However, Ellsberg et al. (2008) point out that the misuse of substances such as alcohol can increase the risk of bad health and violence. Ellsberg et al. (2008) state that physical abuse is a chief cause of injury in women, but that injury is not the most common physical health outcome of abuse, rather a broad array of physical symptoms such as difficulty walking, difficulty with daily activities, pain, and dizziness are reported. A study in 2006 by Carbone-Lopez et al. reports that exposure to interpersonal violence by women is associated with increased potential for poor physical health and physical disability. Similarly, McGarry et al. (2011) claim that physical abuse over time has a potentially significant impact upon both long and short term health status of women, including permanent physical damage and disability. Additionally, Coker et al. (2002) found a correlation between interpersonal violence and becoming injured. McGarry et al. (2011) purport that professionals may overlook injury from domestic abuse and see them as age-related conditions in older patients. In regards to sexual problems associated with abuse, Romito et al. (2005) found symptoms to be gynaecological and sexual issues. In addition, Ellsberg et al. (2008) cite resulting symptoms of violent sexual acts by intimate partners to be gynaecological disorders and adverse pregnancy outcomes. Ellsbert et al. (2008) report that they combined physical and sexual violence together. However, they note that the two types of abuse could affect womens health in different ways McCaw, Golding, Farley, and Minkoff (2011) claim that domestic violence is associated with a significant decline in social functioning and that significantly less social support is reported among women who have been abused. Bonomi et al. (2006) also found that women having experienced interpersonal violence were at increased risk for having limited involvement in volunteer opportunities and a distrust of their community members. Due to a finding of emotional abuse alone initiating limitation in

Abuse effects on women

social functioning, McCaw et al. (2011) suggest that clinicians not overlook emotionally abusive behaviors such as threats, humiliation, unwanted sexual activities, and controlling behavior as being capable of having an impact on health. The 2006 study by Bonomi et al. found numerous health impacts on women who have experienced interpersonal violence. They recommended a focus on prevention in primary and secondary healthcare settings, such as routine inquiry, dialogue, and education for adolescents and adult women about partner violence in primary prevention programs. Secondary prevention programs could focus on referral for women reporting interpersonal violence. In addition to this, Carbone-Lopez et al. (2006) suggests a need for increased screening of interpersonal violence in clinical settings both to initiate more immediate victim services and medical help, as well as acting as an early detection and intervention system leading to prevention of further serious violence. Further to the topic of routine screening, Coker et al. (2002) suggest that screening needs to be extended to include physical, sexual, as well as psychological abuse or battering. Integration of Literature Review Arguments for Integrating Key Issues into Practice The following section consists of a number of arguments that raise critical issues of importance to the field of abuse and women. Although these arguments stood out in this particular review of literature, it was obvious that there are insurmountable reasons that abuse against women and its consequent impact on the health of women is a paramount concern in research, practice, and social justice. Eberhard-Gran, Shei and Eskild (2007) suggest that due to the high correlation of physical and sexual violence to somatic symptoms, clinicians should inquire about physical and sexual violence with women who present with somatic symptoms. Similarly, Vos et al. (2006) suggest that practitioners be aware of the relationship between interpersonal violence and common disorders. Practitioners who work with abused women should be aware of the link between physical and sexual violence to somatic symptoms. If women are experiencing somatic symptoms, counsellors should

Abuse effects on women then inquire about abuse history. The same holds true for the other effects on womens health in relation to interpersonal violence, such as mental health issues and substance misuse. In regards to emotional symptoms resulting from domestic abuse, McGarry et al. (2011) raise the importance of a catch twenty two that occurs with older women. If abuse is experienced when the woman is younger and it remains unresolved, she may be less likely to disclose the abuse, which can then lead to further complications to selfesteem, self-worth, and physical health problems. Practitioners should be aware of the potential for older women to with-hold their history of abuse. The practitioner may inquire about interpersonal violence history with older women who present with feelings of low self-esteem, low self-worth, and physical health problems. Or a counsellor may also include a routine inquiry about history of abuse with all older women upon intake. Tutty and Goard (2002) report a correlation between women seeking help for domestic abuse, particularly more severe abuse, greater threat, and more forced sex and having clinical levels of PTSD. Tutty and Goard suggest that in such circumstances, the consideration of psychiatric diagnosis should take into account the context of the relationship. As well, they contend that the practitioner consider the potential impact of stigmatization should a medical diagnosis be given. Taking into account the day-to-day living situation of the abused woman is important, and that dealing with it may simply involve a support group with women in similar situations. It is evident that a counsellor working with abused women be cognizant of how a diagnosis could impact her life. For example, it could influence her in the legal realm, through divorce and custody dealings, and be used as a weapon by an abusive partner. As per the research, a counsellor may begin by helping a woman engage in a support group for abused women and look for other additional options for addressing the PTSD, prior to delving into diagnosis. Romito et al. (2005) claim that interpersonal violence can lead to social problems that are in themselves independent risk factors for psychological distress or bad health. (pp. 1718) For example, domestic violence is associated with loss of educational opportunities, precarious professional position, vulnerability to sexual harassment, and increased poverty. Practitioners needs to be aware that women

Abuse effects on women

experiencing abuse are at risk for negative social impact in their lives, and that in addition those impacts lead to further detrimental effects upon the womans psychological and physical health. If a woman presents with any type of psychological or physical health problem or social problems, a counsellor should inquire whether the woman has ever experienced abuse. Again, it would be beneficial to have a routine inquiry about abuse history upon intake with all women. The 2011 study by Devries et al. recommend that the high rate of suicidal thoughts and attempts correlating with violence against women demonstrates a need for prioritizing violence into suicide reduction programs for women. They purport that violence must be recognized as a major risk factor against womens health and should be completely integrated into mental health policies. Practitioners should be aware that in general there is a link between womens experience of abuse and suicidality. However, the literature suggests that due to the major correlation and importance of this issue that violence be a priority in suicide programs and mental health policies. A practitioner may work toward this through program development and educational components in groups, programs, and psycho-educational programs for instance. The practitioner can ensure that violence is a key topic included and work toward raising awareness of the issue. Vos et al. (2006) suggest that the demonstrable correlation of interpersonal violence to common health disorders be made public in the media and to general public to increase programs aimed at decreasing domestic violence. In line with this, Bonomi et al. (2006) suggest that public health approaches could include education about relationship violence, starting with law enforcement policies aimed at imposing stricter penalties for perpetrators of intimate partner violence. Johnson et al. (2008) recognize that womens oppression is associated with violence against them. However, instead of addressing the issue of female subordination, there is a tendency to focus on the effects of the violence against women. Johnson et al. (2008) suggests that in all societies, widespread societal changes are needed to improve womens status, break down inequalities between men and women, eliminate strict gender roles that are damaging to women, change attitudes and societal norms, and create a climate where violence is

Abuse effects on women actively discouraged and not tolerated. (pp. 169) The link between each of these pieces of literature is the need for advocacy and social justice. There are so many areas that need such work, and practitioners have a responsibility to raise awareness and work toward making changes in social justice and greater problems for their clients. Rather than thinking that they must tackle the entire issue of abuse and all of its branching issues, perhaps a practitioner can focus on one issue that he or she will engage in advocacy work, research, or raising awareness about. Several studies discussed the importance of routine screening (Bonomi et al., 2006; Carbone-Lopez et al., 2006; Coker et al., 2002). However, McCaw et al. (2011) discuss barriers to this process, which practitioners must keep in mind. First, a clinician may themselves have a hesitation to screen in fear of offending the patient assuming that women would have a resistance to disclosing such information. McCaw (2011) explains that there are indeed many reasons that a victim may not disclose their history of abuse, such as guilt, shame, confidentiality concerns, and safety issues. Therefore it is important that practitioners make such an inquiry on multiple occasions and not primarily at initial screening. On a positive note, McCaw (2011) found strong indicators that women do consider the health care setting as a suitable location to talk about and get help for domestic abuse. Overall, there must be awareness raised about the effects of abuse on women. As Devries et al. (2011) state, resources must be allocated to preventing violence against women and mitigating its consequences in order for the mental health needs of women to be effectively addressed. I would take this a step further to include all the health needs and impacts that women experience as a result of abuse. Lesson Learned Prior to engaging in this quantitative research review, I aligned most closely with qualitative research rather than quantitative research. I felt that through qualitative research, the voices of participants could be heard, and that in turn they would be better understood. Although this may be true, I have found a greater strength in quantitative research. What is evident to me now is that the quantitative research, although

Abuse effects on women statistical and mathematical, also allowed a picture of womens experience to be seen. Yet, because of the scientific nature, it holds more bearing and strength behind it. I had previously become aware of the possibility of this strength to be used in making changes to policy and programs and in advocating for social justice. I was surprised to see such recommendations already being made throughout the research. Although both forms of research have their strengths, I feel that the scientific underpinnings of validity, reliability, and trustworthiness in quantitative research are needed in order to make necessary changes in clinical practice and society at large. Summary Abuse against women is a critical concern for womens health in many forms: somatic symptoms, mental health, suicidality, emotionally, substance misuse, physically, and socially. This is of particularly importance for those working directly with abused women, as well as for those in a position to engage in preventive measures. The quantitative research studies evaluated in this review clearly demonstrate through statistical and numerical data, the impact upon womens health, and the need for this issue to be addressed in the therapeutic context. Where qualitative research may give us an understanding of what women experience and to hear their voice, quantitative research give concrete, statistical and solid evidence that can be used to demonstrate the need to address the issue of violence against women, for programs and policies that will change the situation that women face.

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References Bonomi, A.E., Thompson, R.S., Anderson, M., Robert, M.S., Reid, R.J., Carrell, D., Dimer, J.A., & Rivara, F.P. (2006). Intimate partner violence and womens physical, mental, and social functioning. American Journal of Preventive Medicine, 30(6), 458466. doi: 10.1016/j.amepre.2006.01.015 Carbone-Lopez, K., Kruttschnitt, C., & Macmillan, R. (2006). Patterns of intimate partner violence and their associations with physical health, psychological distress, and substance use. Public Health Reports, 121(July-August), 382-392. Coker, A.L., Davis, K., Arias, H., Desai, S., Sanderson, M., Brandt, H.M., & Smith, P.H. (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23(4), 260-268. Devries, K., Watts, C., Yoshihama, M., Kiss, L., Schraiber, L.B., Deyessa, N., Heise, L., Durand, J., Mbwambo, J., Jansen, H., Berhane, Y., Ellsberg, M., & GarciaMoreno, C. (2011). Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on womens health and domestic violence against women. Social Science & Medicine, 73, 79-86. doi: 10.1016/j.socsimed.2011.05.006 Eberhard-Gran, M., Schei, B. & Eskild, A. (2007). Somatic symptoms and diseases are more common in women exposed to violence. Journal of General Internal Medicine, 22(12), 1668-1673. doi: 10.1007/s11606-007-0389-8 Ellsberg, M., Jansen, H.A., Watts, C.H., & Garcia-Moreno, C. (2008). Intimate partner violence and womens physical and mental health in the WHO multi -country study on womens health and domestic violence: An observational study. Lancet, 371, 1165-1172. Johnson, H., Ollus, N. & Nevala, S. (2008). Violence against women: An international perspective. New York, NY: Springer Science+Business Media, LLC.

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Johnson, M.P. (2008). Intimate terrorism, violent resistance, and situational couple violence: A typology of domestic violence. Lebanon, NH: University Press of New England. McCaw, B., Golding, J.M., Farley, M. & Minkoff, J.R. (2007). Domestic violence and abuse, health status, and social functioning. Women & Health, 45(2), 1-23. doi: 10.1300/J013v45n02_01 McGarry, J., Simpson, C., & Hinchliff-Smith, K. (2011). The impact of domestic abuse for older women. Health and Social care in the community, 19(1), 3-14. doi: 10.1111/j.1365-2524.2010.00964.x Romito, P., Turan, J.M., & De Marchi, M. (2005). The impact of current and past interpersonal violence on womens mental health. Social Science & Medicine, 60, 17171727. doi: 10.1016/j.socsimed.2004.08.026 Statistics Canada. (2006). Measuring violence against women: Statistical trends 2006 (Catalogue no. 85-570-XIE). Ottawa, ON: Minister of Industry. Tutty, L.M., & Goard, C. (2002). Woman abuse in Canada: An overview. In Tutty, L.M., & Goard, C. (Eds.), Reclaiming self: Issues and resources for women abused by intimate partners (pp. 10-24). Halifax, NS: Fernwood Publishing. Vos, T., Astbury, J., Piers, L.S., Magnus, A., Heenan, M., Stanley, L., Walker, L. & Webster, K. (2006). Measuring the impact of intimate partner violence on the health of women in Victoria, Australia. Bulletin of the World Health Organization, 84(9), 739-744. World Health Organization. (2011). WHO Multi-country study on womens health and domestic violence against women. Retrieved from http://www.who.int/gender/violence/who_multicountry_study/summary_report/chapter4/ en/index.html (accessed November 17, 2011).