MEDLINE Abstracts: Violence Against Women - Around the World

November 18, 2003

This easy-to-navigate collection of recent MEDLINE abstracts highlights studies of women who have been exposed to violence in countries other than the United States.

 


Violence Against Women: Global Scope and Magnitude

Watts C, Zimmerman C
Lancet. 2002;359:1232-1237

An increasing amount of research is beginning to offer a global overview of the extent of violence against women. In this paper we discuss the magnitude of some of the most common and most severe forms of violence against women: intimate partner violence; sexual abuse by non-intimate partners; trafficking, forced prostitution, exploitation of labour, and debt bondage of women and girls; physical and sexual violence against prostitutes; sex selective abortion, female infanticide, and the deliberate neglect of girls; and rape in war. There are many potential perpetrators, including spouses and partners, parents, other family members, neighbours, and men in positions of power or influence. Most forms of violence are not unique incidents but are ongoing, and can even continue for decades. Because of the sensitivity of the subject, violence is almost universally under-reported. Nevertheless, the prevalence of such violence suggests that globally, millions of women are experiencing violence or living with its consequences.

North America

Intimate Partner Violence and Health: A Critique of Canadian Prevalence Studies

Objective: The Canadian Public Health Association, along with other professional organizations, has identified intimate partner violence (IPV) as a priority health issue to which the health professions must respond. This study synthesizes Canadian studies on the prevalence of IPV against women, focusing in particular on the stated implications for women's health and health care.
Methods: Medical and social science databases were searched for all articles pertaining to IPV in Canada for 1974 through September 2000. Reference lists of these and other related publications were consulted to supplement the literature review. Data on study characteristics, methods, and results were extracted by two independent reviewers. Discrepancies were resolved by consensus.
Results: Sixteen studies were identified in this review, 11 population-based and 5 conducted in clinical settings. Age, ethnicity, and socioeconomic status were not consistently documented, making comparisons and evaluations of generalizability difficult. Annual prevalence of IPV in Canada was found to range from 0.4% to 23%, with severe violence occurring from 2% to 10% annually. Less than two fifths (37.5%) of the studies incorporated a health-related measure.
Interpretation: This review reveals a paucity of Canadian prevalence data on IPV, marked by design and methodological issues. Poor quality data may pose a challenge to articulating and establishing a coordinated health care response to eliminating IPV in Canada.

Latin America

From Marianism to Terrorism: The Many Faces of Violence Against Women in Latin America

Rondon MB
Arch Women Ment Health. 2003;6:157-163

Violence against women is widespread and highly tolerated in Latin America. In this paper, I will argue that this is because violence stems from deep cultural roots and because women are brought up in a patriarchal familial organization which promotes passivity and dependence. Traditional religious culture, which poses the Virgin Mary figure as role model, is ambivalent and distorted, repressing sex while overvaluing motherhood and self denial and demeaning women who do not conform to the established stereotypes. Patriarchal violence has serious emotional consequences for women. The stressful violent circumstances in women's lives lead to increased drug abuse that further exposes them to police and institutional violence. Political instability and civil wars in South America have caused many deaths, and have left many women with traumatic sequelae. Efforts at improving quality of life and diminishing violent conditions for women and girls in Latin America should include consideration of local cultural, political and economic peculiarities.

Violence Against Women Increases the Risk of Infant and Child Mortality: A Case-Referent Study in Nicaragua

Asling-Monemi K, Pena R, Ellsberg MC, Persson LA
Bull World Health Organ. 2003;81:10-16. Epub 2003 Mar 11

Objective: To investigate the impact of violence against mothers on mortality risks for their offspring before 5 years of age in Nicaragua.
Methods: From a demographic database covering a random sample of urban and rural households in Len, Nicaragua, we identified all live births among women aged 15-49 years. Cases were defined as those who had died before the age of 5 years, between January 1993 and June 1996. For each case, two referents, matched for sex and age at death, were selected from the database. A total of 110 mothers of the cases and 203 mothers of the referents were interviewed using a standard questionnaire covering mothers' experience of physical and sexual violence. The data were analysed for the risk associated with maternal experience of violence of infant and under-5 mortality.
Findings: A total of 61% of mothers of cases had a lifetime experience of physical and/or sexual violence compared with 37% of mothers of referents, with a significant association being found between such experiences and mortality among their offspring. Other factors associated with higher infant and under-5 mortality were mother's education (no formal education), age (older), and parity (multiparity).
Conclusions: The results suggest an association between physical and sexual violence against mothers, either before or during pregnancy, and an increased risk of under-5 mortality of their offspring. The type and severity of violence was probably more relevant to the risk than the timing, and violence may impact child health through maternal stress or care-giving behaviours rather than through direct trauma itself.

Violence Against Women in Mexico: A Study of Abuse Before and During Pregnancy

Castro R, Peek-Asa C, Ruiz A
Am J Public Health. 2003;93:1110-1116

Objective: We identified the prevalence and types of violence experienced by pregnant women, the ways victimization changed during pregnancy from the year prior to pregnancy, and factors associated with violence during pregnancy.
Methods: We interviewed 914 pregnant women treated in health clinics in Mexico about violence during and prior to pregnancy, violence during childhood and against their own children, and other socioeconomic indicators.
Results: Approximately one quarter of the women experienced violence during pregnancy. The severity of emotional violence increased during pregnancy, whereas physical and sexual violence decreased. The strongest predictors of abuse were violence prior to pregnancy, low socioeconomic status, parental violence witnessed by women in childhood, and violence in the abusive partner's childhood. The probability of violence during pregnancy for women experiencing all of these factors was 61%.
Conclusions: Violence is common among pregnant women, but pregnancy does not appear to be an initiating factor. Intergenerational violence is highly predictive of violence during pregnancy.

Prevalence of Battering Among 1780 Outpatients at an Internal Medicine Institution in Mexico

Diaz-Olavarrieta C, Ellertson C, Paz F, de Leon SP, Alarcon-Segovia D
Soc Sci Med. 2002;55:1589-1602

Violence against women has recently drawn attention in the medical community as a leading cause of preventable morbidity and mortality. Specific algorithms designed to identify women at risk can be applied to create an opportunity for screening, diagnosis and treatment during medical care initiated for common conditions. This study investigated the incidence and history of battering among women seeking general medical care, and looked for potential risk factors and associations with presenting symptoms. We used a self-administered, anonymous survey to question 1780 adult female outpatients visiting a tertiary care internal medicine teaching hospital in Mexico City. We calculated current abuse (physical and/or sexual abuse by a partner within the past year), abuse during pregnancy, childhood abuse, and lifetime abuse. We found levels of violence against women in Mexico comparable to those reported from other countries. 152 women (9%) reported current physical and/or sexual abuse. An identical number also reported abuse during pregnancy. Lifetime prevalence was 41%. Women currently or previously abused reported more physical symptoms in the last six months than did non-abused participants. Pelvic pain, depression, headache and substance abuse were frequent among abused women. Currently abused women also scored higher (p<0.01) on indicators of depression. Current abuse correlated strongly with a childhood history of physical and/or sexual abuse, with low educational level of the victim, with substance abuse by the partner or by the woman herself, and with higher parity.

Physical Partner Abuse During Pregnancy: A Risk Factor for Low Birth Weight in Nicaragua

Valladares E, Ellsberg M, Pena R, Hogberg U, Persson LA
Obstet Gynecol. 2002;100:700-705

Objective: To assess whether being physically abused during pregnancy increases the risk of a low birth weight (LBW) infant.
Methods: We conducted a hospital-based case-control study in Leon, Nicaragua. Cases consisted of 101 newborns with a birth weight under 2500 g, and for each case two controls with a birth weight over 2500 g were selected randomly from infants born the same day. Anthropometry of newborns was done immediately after birth, and background information and data on experiences of violence and potential confounders were obtained through private interviews with mothers. Crude and adjusted odds ratios (ORs) and population-attributable proportion were calculated for exposure to partner abuse in relation to LBW. Multivariate logistic regression analysis was used to control for potential confounding.
Results: Seventy-five percent of LBW newborns (cases) were small for gestational age and 40% were preterm. Twenty-two percent of the mothers of LBW infants had experienced physical abuse during pregnancy by their intimate partners compared with 5% of controls. Low birth weight was associated with physical partner abuse even after adjustment for age, parity, smoking, and socioeconomic status (OR 3.9; 95% confidence interval 1.7, 9.3). Given a causal interpretation of the association, about 16% of the LBW in the infant population could be attributed to physical abuse by a partner in pregnancy.
Conclusion: Physical abuse by a partner during pregnancy is an independent risk factor for LBW.

United Kingdom and Continental Europe

Emotional, Physical, and Sexual Abuse in Patients Visiting Gynaecology Clinics: A Nordic Cross-Sectional Study

Wijma B, Schei B, Swahnberg K, et al.
Lancet. 2003 Jun 21;361:2107-2113

Background: Abuse against women causes much suffering for individuals and is a major concern for society. We aimed to estimate the prevalence of three types of abuse in patients visiting gynaecology clinics in five Nordic countries, and to assess the frequency with which gynaecologists identify abuse victims.
Methods: We did a cross-sectional, multicentre study of women attending five departments of gynaecology in Denmark, Finland, Iceland, Norway, and Sweden. We recruited 4729 patients; 3641 (77%) responded and were included in the study. Participants completed a postal questionnaire (norvold abuse questionnaire) confidentially. Primary outcome measures were prevalences of emotional, physical, and sexual abuse, and whether abused patients had told their gynaecologist about these experiences. We assessed differences between countries with Pearson's chi(2) test.
Findings: The ranges across the five countries of lifetime prevalence were 38-66% for physical abuse, 19-37% for emotional abuse, and 17-33% for sexual abuse. Not all abused women reported current ill-effects from the abusive experience. Most women (92-98%) had not talked to their gynaecologist about their experiences of abuse at their latest clinic visit.
Interpretation: Despite prevalences of emotional, physical, and sexual abuse being high in patients visiting gynaecology clinics in the Nordic countries, most victims of abuse are not identified by their gynaecologists. This lack of discussion might increase the risk of abused patients not being treated according to their needs. Gynaecologists should always consider asking their patients about abuse.

Lifetime Prevalence of Sexual Abuse in a Swedish Pregnant Population

Stenson K, Heimer G, Lundh C, Nordstrom ML, Saarinen H, Wenker A
Acta Obstet Gynecol Scand. 2003;82:529-536

Background: Our primary purpose was to determine the prevalence of sexual abuse in a non-selected pregnant population. We also endeavored to establish the age at which the abuse had occurred and the identity of the perpetrator and to analyze in sexually abused vis-a-vis non-abused women, various socio-economic and clinical variables.
Methods: Over a period of 6 months, all women registered at antenatal clinics in Uppsala, Sweden, were questioned by their midwives regarding exposure to sexual abuse. Data from antenatal records were used to compare abused with non-abused women concerning socio-economic characteristics, previous ill health, reproductive history, pregnancy complications, and pregnancy outcome. Continuous variables were compared using the Student's t-test or the Mann-Whitney U-test and categorical variables using the chi-square test or Fisher's exact test.
Results: Of 1038 women assessed, 84 (8.1%) reported that at some time in their life they had been forced to participate in or subjected to sexual activity against their will. In most cases the perpetrator was someone the woman knew. When compared with non-victims, those abused were more likely to report general health problems, especially gynecologic ill health and surgery, pulmonary disease/asthma, and/or psychiatric care. However, no differences were found regarding pregnancy outcome.
Conclusions: It was found that one pregnant woman in 12 had reported sexual abuse at some time in their life. To midwives and obstetricians who work closely both physically and emotionally with pregnant women, an awareness of the extent of the problem and of possible sequelae is essential.

Prevalence of Sexual and Physical Abuse and Its Relationship With Symptom Manifestations in Patients With Chronic Organic and Functional Gastrointestinal Disorders

Baccini F, Pallotta N, Calabrese E, Pezzotti P, Corazziari E
Dig Liver Dis. 2003;35:256-261

A history of physical and/or sexual abuse is a frequent occurrence in patients referred for chronic gastrointestinal disorders and it may predispose to the development of functional gastrointestinal disorders, and multiple medical complaints. This study was aimed to determine: (a) prevalence of abuse history in Italian patients with chronic gastrointestinal disturbances, and (b) relationship between abuse history and clinical manifestations.
Subjects and Methods: Consecutive gastrointestinal out-patients filled in a self-administered standardised questionnaire, made up of two separate sections: (1) a medical section enquiring on gastrointestinal and extra-gastrointestinal symptoms, and (2) a section on abuse enquiring on the presence and type of abuse suffered during their lifetime. Associations between number of symptoms and abuse history were evaluated using univariate and multivariate logistic models.
Results: Questionnaires were handed out to 260 patients; 13% of whom did not fill in the questionnaires. Functional gastrointestinal disorders were diagnosed in 72.5% of patients and organic gastrointestinal diseases in 27.5%. A total of 31% of patients with organic gastrointestinal diseases and 32% of those with functional gastrointestinal disorders referred to a history of sexual or physical abuse. Histories of physical plus sexual abuse, sexual abuse, childhood abuse and female gender, were statistically associated with an increased number of gastrointestinal and extra-gastrointestinal symptoms irrespective of functional or organic disorders, whereas there was no statistical association with physical abuse only. Furthermore, diagnosis of functional gastrointestinal disorders was associated with a significantly (p<0.001) greater number of gastrointestinal symptoms than the diagnosis of organic gastrointestinal diagnosis. A total of 10 patients met the diagnostic criteria of somatization disorder. Of these, eight reported a history of severe physical and sexual abuse that had occurred, in all but one, during childhood.
Conclusions: A history of physical and/or sexual abuse has a high prevalence in Italian patients with chronic gastrointestinal disorders, irrespective of organic or functional diagnosis. Abuse history has no relevant role in the pathogenesis of either functional or organic chronic gastrointestinal disorders but it can affect their clinical expression irrespective of functional or organic diagnosis. Severe physical and sexual abuse and childhood abuse were found in patients who met diagnostic criteria for somatization disorder, suggesting a role of abuse history in this subset of patients.

Analysis of 418 Cases of Sexual Assault

Grossin C, Sibille I, Lorin de la Grandmaison G, Banasr A, Brion F, Durigon M
Forensic Sci Int. 2003;131:125-130

The aim of the study was to describe victim, assailant, assault characteristics for sexual assault victims according to the time between the last sexual assault and the examination, and to provide descriptive data on medico-legal findings. The study was based on 418 examined victims of sexual assault during the year 1998. Victims were referred from investigating police authorities. All examinations were performed with the use of colposcopy by physicians with special training in forensic medicine. Two groups of victims were defined: a first group of victims examined in emergency within 72 h after the last sexual assault; a second group of victims examined after 72 h. About 86% of the cases were female victims. The mean age of the cases of the first group was 22.4 years. Conversely, 76% of the victims examined after 72 h were under the age of 15 years. Vulnerability was present in 31% of the cases examined in emergency, including disabled and pregnant victims. Sexual assault happened once in 87% of the cases of the first group and in 64% of the cases of the second group. The victim's home was the most frequent place of sexual assault (35% of the cases of the first group and 56% of the cases of the second group). The assailant was a stranger in 51% of the cases of the first group. In the second group of the victims, the assailant was a family member in 58% of the cases (the father in 30% of the cases). There was a single assailant in the majority of the cases for the two groups. Threats were used by the assailant in 66% of the victims examined in emergency and in 33% of the cases of the second group. The type of sexual assault was penetration in the majority of the cases for the two groups. Vaginal, oral and anal penetration was respectively involved in 55, 23 and 13% of the cases of the first group. General body trauma was found in 39.1% of the cases examined in emergency and in 6.3% of the cases of the second group. Genital trauma occurred in 35.7% of the cases of the first group and in 19.5% of the cases of the second group. Hymenal, vulvovaginal and anal lesions were respectively found in 11, 20 and 7% of the cases examined in emergency. Toxicological analysis was performed in 14.3% of the cases examined in emergency. In 47% of the tested cases, drug was detected. Cytology was performed in 61.5% of the cases examined in emergency. Detection of spermatozoa was found in 30.3% of these cases. Our study has shown that sexual assault victims had different characteristics according to the time between the sexual assault and the examination. Public health campaigns against sexual abuse and rape as well as medical management of the sexually assaulted victims should adapt to the needs and the characteristics of these two different populations of victims.

The Haven: a Pilot Referral Centre in London for Cases of Serious Sexual Assault

Kerr E, Cottee C, Chowdhury R, Jawad R, Welch J
Br J Obstet Gynecol. 2003;110:267-271

Objective: Several schemes have been reported to improve treatment of rape and to encourage reporting. The development of a comprehensive forensic and follow up service for complainants of sexual assault is described, and activities of the first year are reviewed.
Design: Retrospective review of case records of complainants examined in The Haven.
Setting: Department of Sexual Health in a London teaching hospital.
Sample: All case records, 676 complainants, from the first year of cases seen in The Haven.
Methods: Description of setting up a service in partnership between the National Health Service and the Metropolitan Police, called The Haven. Analysis of a standardised proforma used for case records.
Results: Mean age of complainants is 26 years (range 11-66); 6% were male. Assailant was categorised as a stranger in 52% of cases; attack involved physical violence in 50% of cases; 24% of victims had genital injuries; 39% had other physical injuries. Immediate care given at time of forensic examination included 30% of women receiving emergency contraception and 5% of clients receiving post-exposure prophylaxis against HIV. Fifty-five percent of clients returned for a sexual health screen and/or counselling. Thirty-one percent received screening for sexually transmitted infections and 12% were diagnosed with one or more infections.
Conclusions: Requirements following sexual assault include forensic examination, first aid, postcoital contraception, prevention and management of sexually transmitted infections and psychosocial support. Provision of these services within a sexual health setting is feasible.

Prevalence of Sexual Abuse Among Women Seeking Gynecologic Care in Germany

Peschers UM, Du Mont J, Jundt K, et al
Obstet Gynecol. 2003;101:103-108

Objective: To estimate the prevalence of sexual abuse among patients seen for gynecologic care in Germany.
Methods: A short anonymous questionnaire was distributed to 1157 women attending a gynecologic outpatient clinic at a large urban teaching hospital. Data collected using the questionnaire included patient characteristics, sexual abuse history, and screening practices. Women who reported that they had been abused were asked if they had ever discussed the issue with their gynecologist.
Results: A total of 1075 questionnaires were returned, for a response rate of 92.9%. Almost half (n = 479 [44.6%]) of the women surveyed reported that they had been the subject of unwanted sexual attention. One fifth (n = 216 [20.1%]) had been forced to engage in sexual activities: 6.8% in childhood, 10.3% during adolescence, 6.4% as an adult, and 3.5% across more than one stage. Thirteen women (6%) reported having discussed the abuse with their gynecologist. Sixty-six (30.5%) were too afraid to raise the issue, and 119 (55.1%) stated it was not relevant to their care. Only one woman (0.5%) reported that her gynecologist had asked about sexual abuse.
Conclusion: Despite the high prevalence of sexual abuse among women seeking gynecologic care, routine screening does not appear to be part of standardized practice.

What Distinguishes Unintentional Injuries From Injuries due to Intimate Partner Violence: A Study in Greek Ambulatory Care Settings

Petridou E, Browne A, Lichter E, Dedoukou X, Alexe D, Dessypris N
Inj Prev. 2002;8:197-201

Objectives: Intimate partner violence (IPV) is an important sociocultural and public health problem. This study aims to assess sociodemographic and injury characteristics of IPV victims among adults in a traditional southern European population.
Setting: Accident and emergency departments of three sentinel hospitals in Greece participating in the Emergency Department Injury Surveillance System (EDISS).
Methods: Data on sociodemographic variables, as well as event and injury characteristics were retrieved from the EDISS database during the three year period 1996-98. Out of a total of 27 319 injured women aged 19 years or more, 312 (1.1%) were reported as IPV related and were compared with 26 466 women with unintentional injuries. Among the 35 174 men with injuries 39 (0.1%) were reported as IPV related and were compared with 34 049 men with unintentional injuries. The data were analyzed through simple cross tabulations and multiple logistic regression. Positive predicted values for selected injury characteristics were also calculated.
Results: IPV is more common in rural than in urban areas of Greece. Women are 10 times more frequently IPV victims but men are also IPV victims; younger women and older men are disproportionately affected by IPV. The relative frequency of the phenomenon increases during the late evening and night hours. Certain types of injuries, notably multiple facial injuries, and presentation of the injured person on his/her own at the emergency department or combinations of predictive characteristics are strongly indicative of IPV.
Conclusions: Injuries due to IPV are not uncommon in Greece, not withstanding the traditional structure of the society and the tendency of under-reporting. Certain injury characteristics have high positive predictive values and could be used in screening protocols aiming at the correct identification of the underlying external cause in injuries that may be caused by IPV.

Reported Frequency of Domestic Violence: Cross Sectional Survey of Women Attending General Practice

Bradley F, Smith M, Long J, O'Dowd T
BMJ. 2002;324:271

Objectives: To determine exposure to violence by a partner or spouse among women attending general practice and its association with respondents' demographic and personal characteristics; frequency of inquiry about violence by general practitioners; and women's views on routine questioning about domestic violence by general practitioners.
Design: Cross sectional, self administered, anonymous survey.
Setting: 22 volunteer Irish general practices.
Participants: 1871 women attending general practice.
Main Outcome Measures: Proportion who had experienced domestic violence, severity of such violence, and context in which violence occurred.
Results: Of the 1692 women who had ever had a sexual relationship, 651 (39%, 95% confidence interval 36% to 41%) had experienced violent behaviour by a partner. 78/651 (12%) women reported that their doctor had asked about domestic violence. 298/651 (46%, 42% to 50%) women had been injured, 60 (20%) of whom reported that their doctor had asked about domestic violence. 1304/1692 (77%, 77% to 80%) were in favour of routine inquiry about domestic violence by their usual general practitioner. 1170 women (69%) reported controlling behaviour by their partner and 475 (28%) reported feeling afraid of their previous or current partner. Women who reported domestic violence were 32 times more likely to be afraid of their partner than women who did not report such violence.
Conclusions: Almost two fifths of women had experienced domestic violence but few recalled being asked about it. Most women favoured routine questioning by their practitioner about such violence. Asking women about fear of their partner and controlling behaviour may be a useful way of identifying those who have experienced domestic violence.

Identifying Domestic Violence: Cross Sectional Study in Primary Care

Richardson J, Coid J, Petruckevitch A, et al
BMJ. 2002;324:274

Objectives: To measure the prevalence of domestic violence among women attending general practice; test the association between experience of domestic violence and demographic factors; evaluate the extent of recording of domestic violence in records held by general practices; and assess acceptability to women of screening for domestic violence by general practitioners or practice nurses.
Design: Self administered questionnaire survey. Review of medical records.
Setting: General practices in Hackney, London.
Participants: 1207 women (>15 years) attending selected practices.
Main Outcome Measures: Prevalence of domestic violence against women. Association between demographic factors and domestic violence reported in questionnaire. Comparison of recording of domestic violence in medical records with that reported in questionnaire. Attitudes of women towards being questioned about domestic violence by general practitioners or practice nurses.
Results: 425/1035 women (41%, 95% confidence interval 38% to 44%) had ever experienced physical violence from a partner or former partner and 160/949 (17%, 14% to 19%) had experienced it within the past year. Pregnancy in the past year was associated with an increased risk of current violence (adjusted odds ratio 2.11, 1.39 to 3.19). Physical violence was recorded in the medical records of 15/90 (17%) women who reported it on the questionnaire. At least 202/1010 (20%) women objected to screening for domestic violence.
Conclusions: With the high prevalence of domestic violence, health professionals should maintain a high level of awareness of the possibility of domestic violence, especially affecting pregnant women, but the case for screening is not yet convincing.

Asking Patients About Violence: A Survey of 510 Women Attending Social and Health Services in Trieste, Italy

Romito P, Gerin D
Soc Sci Med. 2002;54:1813-1824

Violence against women is frequent, and has serious consequences for their physical and mental health. Until now, a common response of health services and professionals to victims has been the denial of the violence. The aims of this study were to estimate the prevalence of present and past violence among women attending social and health services in Trieste (Italy) for any reasons, and to evaluate the feasibility of asking them about violence. Five public health care facilities were involved: a hospital-based Emergency Department, two "Consultorio Familiare", and two community-based Social service centers. The final sample consisted of 510 women; the response rate among eligible women was 76% across all facilities. The study revealed a high prevalence of different kinds of violence, mostly perpetrated by men well known to the victim. Among the women interviewed, 10.2% had experienced physical/sexual violence in the last 12 months, regardless of perpetrator. Violence by a male partner or former partner, occurred in 6.4% of women; by other relatives, 1.6% of women; and by "other" persons 3.3% of women. The results demonstrated the feasibility of "asking about violence" in all cases; moreover, those women who had been abused were often eager to talk about it. A systematic approach to the issue of violence is a necessary condition for responding appropriately to the needs of women who have experienced or are experiencing violence. Nevertheless, to avoid the replication of a common bias against victims of violence, health and social personnel should be appropriately trained before "asking all cases" becomes a policy within health and social services.

Middle East

Violence Against Women in Arab and Islamic Countries

Douki S, Nacef F, Belhadj A, Bouasker A, Ghachem R
Arch Women Ment Health. 2003;6:165-171

In Arab and Islamic countries, domestic violence is not yet considered a major concern despite its increasing frequency and serious consequences. Surveys in Egypt, Palestine, Israel and Tunisia show that at least one out of three women is beaten by her husband. The indifference to this type of violence stems from attitudes that domestic violence is a private matter and, usually, a justifiable response to misbehaviour on the part of the wife. Selective excerpts from the Koran are used to prove that men who beat their wives are following God's commandments. These religious justifications, plus the importance of preserving the honour of the family, lead abusers, victims, police and health care professionals to join in a conspiracy of silence rather than disclosing these offences. However, a fair reading of the Koran shows that wife abuse, like genital mutilation and "honour killings" are a result of culture rather than religion.

Domestic Abuse in Pregnancy: Results From a Phone Survey in Northern Israel

Fisher M, Yassour-Borochowitz D, Neter E
Isr Med Assoc J. 2003;5:35-39

Background: Domestic violence is considered a major risk factor in pregnancy.
Objectives: To assess the prevalence of different kinds of abuse (physical, psychological, sexual) of pregnant as compared to non-pregnant women, and to identify demographic risk factors for physical abuse that characterize the woman and her partner.
Methods: A cross-sectional survey was conducted in 270 women seeking gynecologic care at women health centers in northern Israel. Information was collected by means of a standardized questionnaire administered via phone, and addressing demographic data, interaction with the partner, and reporting of physical abuse. All information was obtained from the respondents (including information about her partner).
Results: Four abuse scores were computed: severe physical attack, minor physical attack, psychological abuse, and sexual coercion. Psychological abuse was found to be the most prevalent (24%), followed by minor and severe physical attack (17% and 8.1%, respectively), and sexual coercion (5.6%). Physical attacks related to pregnancy (directed at the abdomen) occurred in 5.4% of the pregnant women. There was no significant difference in the prevalence of the different types of abuse between pregnant and non-pregnant women. Physical attack was associated with socioeconomic status, work status, and degree of religiosity.
Conclusion: Pregnant women were at a similar risk for abuse as non-pregnant women in all abuse categories. Predictors for abuse--socioeconomic status and religiosity--were reviewed primarily in a cultural context.

Cultural Norms Versus State Law in Treating Incest: A Suggested Model for Arab Families

Baker KA, Dwairy M
Child Abuse Negl. 2003;27:109-123

Objective: This article examines problems of intervention in sexual abuse cases among collective societies and offers a culturally sensitive model of intervention.
Method: The manuscript is based on cross-cultural literature and clinical cases within the Palestinian community in Israel.
Results: Unlike Western societies in which the state takes responsibility for the needs of its citizens and has laws that aim to protect victims of sexual abuse and to punish the perpetrators, in many collective societies people live in interdependence with their families. The family, rather than the state, is the main provider and protector. Enforcing the laws against sexual perpetrators, typically, threatens the unity and reputation of the family, and therefore this option is rejected and the family turns against the victim. Instead of punishing the perpetrator, families often protect him and blame the victim for the resulting mess. The punishment of the abuser results in the re-victimization of the abused since the family possesses supreme authority. We suggest a culturally sensitive model of intervention that includes six stages: (1) verification of information, (2) mapping the family, (3) bonding with progressive forces, (4) a condemning, apologizing, and punishing ceremony, (5) treatment, and (6) follow-up.
Conclusion: Culturally sensitive intervention that exploits the power of the family for the benefit of the victim of abuse before enforcing the law, may achieve the same legal objectives as state intervention, without threatening the reputation and the unity of the family, and may therefore save the victim from harm.

An Unaddressed Issue: Domestic Violence and Unplanned Pregnancies Among Pregnant Women in Turkey

Sahin HA, Sahin HG
Eur J Contracept Reprod Health Care. 2003;8:93-98

Objective: The aim of this study was to estimate the prevalence and type of domestic violence during pregnancy in Turkey and to compare socioeconomic background factors.
Methods: A survey was carried out among a representative sample of 475 pregnant women. Data were collected on the incidence and the nature of domestic violence perpetrated by the woman's spouse or other family members during her current pregnancy and before. Sociodemographic characteristics such as age, duration of marriage, number of children, monthly income, education, occupation of the husband, domestic violence towards children, contribution to family decisions, smoking habits, sexual relations and whether the pregnancy was planned or not, were also recorded.
Results: Of the 475 women screened for domestic violence during pregnancy, 158 (33.3%) reported physical or sexual abuse since they had become pregnant. The source of the domestic violence was mainly the husband in 105 (66.5%) women. Types of abuse were psychological in 71 (44.9%) and physical in 87 (55.1%) women. The rate of women's satisfaction with their sexual life among abused women was 43.67% compared to 61.2% among non-abused women. Abused pregnant women were less educated, had lower income, had more children, had a longer duration of marriage, were applying violence towards their children, were not contributing to family decisions, were less satisfied with their sexual life and were more likely to have unplanned pregnancies when compared to non-abused women.
Conclusion: Antenatal care protocols should be modified to address domestic violence and contributing factors during pregnancy so that identified women can be counseled appropriately and attempts can be made to intervene to prevent further episodes of domestic violence in primary care settings.

Africa

Interventions for Violence Prevention Among Young Female Hawkers in Motor Parks in South-Western Nigeria: A Review of Effectiveness

Fawole OI, Ajuwon AJ, Osungbade KO, Faweya OC
Afr J Reprod Health. 2003;7:71-82

An intervention study was carried out among hawkers, drivers, instructors, police and judicial officers to reduce the incidence of violence against young female hawkers in three states of south-western Nigeria. Knowledge and experience of violence among the hawkers before and after the interventions were then compared. Findings show that they had greater knowledge of the different types of violence (p < 0.05), were more aware of their vulnerability to violence (99.4% after compared to 82.7% before intervention) and sought help or redress (76.3% after compared to 45.8% before intervention) following violent acts. Sexual violence was the commonest type experienced (30.4% and 15.7% at base line and end line respectively). The rate of violence also decreased. We conclude that multidisciplinary interventions that empower women economically and educationally and involve all stakeholders are effective in preventing violence against women.

Domestic Abuse--An Antenatal Survey at King Edward VIII Hospital, Durban

Mbokota M, Moodley J
S Afr Med J. 2003;93:455-457

Objectives: To determine exposure to domestic violence by a partner or spouse among pregnant women attending a public sector hospital in Durban, South Africa.
Design: Six hundred and four randomly chosen women from a low-income community were interviewed over a 6-month period using a standardised questionnaire.
Results: Thirty-eight per cent had experienced domestic violence at some point in their lives. Physical abuse (52%) was the most common, and 35% had been abused during the current pregnancy.
Conclusion: Domestic violence is common in pregnancy among women attending a public sector hospital.

Domestic Violence in Rural Uganda: Evidence From a Community-Based Study

Koenig MA, Lutalo T, Zhao F, et al.
Bull World Health Organ. 2003;81:53-60. Epub 2003 Mar 11.

Although domestic violence is an increasing public health concern in developing countries, evidence from representative, community-based studies is limited. In a survey of 5109 women of reproductive age in the Rakai District of Uganda, 30% of women had experienced physical threats or physical abuse from their current partner--20% during the year before the survey. Three of five women who reported recent physical threats or abuse reported three or more specific acts of violence during the preceding year, and just under a half reported injuries as a result. Analysis of risk factors highlights the pivotal roles of the male partner's alcohol consumption and his perceived human immunodeficiency virus (HIV) risk in increasing the risk of male against female domestic violence. Most respondents -- 70% of men and 90% of women--viewed beating of the wife or female partner as justifiable in some circumstances, posing a central challenge to preventing violence in such settings.

Gender Inequalities, Intimate Partner Violence and HIV Preventive Practices: Findings of a South African Cross-Sectional Study

Jewkes RK, Levin JB, Penn-Kekana LA
Soc Sci Med. 2003;56(1):125-134

The aim of the paper is to investigate associations between a range of markers of gender inequity, including financial, psychological and physical violence, and two proximal practices in HIV prevention, namely discussion of HIV between partners and the woman suggesting condom use. The paper presents an analysis of data from a cross-sectional study of a representative sample of women from three South African Provinces which was primarily undertaken as an epidemiological study of gender-based violence. A multi-stage sampling design was used with clusters sampled with probability proportional to number of households. Households were randomly selected from within clusters. One randomly selected woman aged 18-49 years was interviewed in each selected home. One thousand three hundred and six women were interviewed (90.3% of eligible women). One thousand one hundred sixty four women had a partner in the previous year and were asked questions related to HIV prevention and gender inequalities in the relationship. The results indicate that discussion of HIV was significantly positively associated with education, living in Mpumalanga Province, the man being a migrant, the woman having multiple partners in the past year and having no confidante. It was significantly negatively associated with living in the Northern Province, the relationship being poor and there being a substantial age difference between partners. The woman suggesting condom use was significantly positively associated with her education, her having multiple partners, domestic violence prior to the past year and financial abuse. It was negatively associated with the relationship being poor. We conclude that this suggests that some indicators of gender inequalities are significantly associated with discussion of HIV and condom use but the direction of association found was both positive and negative. This highlights the need for a more nuanced understanding of gender inequalities and their relationship to HIV risk. Suggestions for key research questions are made.

The Myth of Child Rape as a Cure for HIV/AIDS in Transkei: A Case Report

Meel BL
Med Sci Law. 2003;43:85-88

South Africa has one of the highest cases of HIV/AIDS infection in Africa, and Transkei, a former black homeland, now a part of the Eastern Cape Province, is one locality with a large number of HIV/AIDS sufferers. The unemployment level is very high and crime, including child rape, is very common. This report presents the case of a victim of rape, a nine-year old female child who was brought to the Umtata General Hospital, a victim of the mistaken belief that sex with a virgin will cure an HIV-infected person or AIDS sufferer of his illness. The alleged rapist was an HIV-positive uncle of the child. The myth of the 'HIV/AIDS virgin cure' is prevalent in the community. The history, physical examination and laboratory investigations of this case are given. A conclusion is drawn and preventive methods are suggested.

Risk Factors For Domestic Violence: Findings From A South African Cross-Sectional Study

Jewkes R, Levin J, Penn-Kekana L
Soc Sci Med. 2002;55:1603-1617

In 1998 a cross-sectional study of violence against women was undertaken in three provinces of South Africa. The objectives were to measure the prevalence of physical, sexual and emotional abuse of women, to identify risk factors and associated health problems and health service use. A multi-stage sampling design was used with clusters sampled with probability proportional to number of households and households were randomly selected from within clusters. One randomly selected woman aged 18-49 years was interviewed in each selected home. Interviews were held with a total 1306 women, the response rate was 90.3% of eligible women. For the risk factor analysis, multiple logistic regression models were fitted from a large pool of candidate explanatory variables, while allowing for sampling design and interviewer effects. The lifetime prevalence of experiencing physical violence from a current or ex-husband or boyfriend was 24.6%, and 9.5% had been assaulted in the previous year. Domestic violence was significantly positively associated with violence in her childhood, her having no further education, liberal ideas on women's roles, drinking alcohol, having another partner in the year, having a confidant(e), his boy child preference, conflict over his drinking, either partner financially supporting the home, frequent conflict generally, and living outside the Northern Province. No significant associations were found with partners' ages, employment, migrant status, financial disparity, cohabitation, household possessions, urbanisation, marital status, crowding, communication, his having other partners, his education, her attitudes towards violence or her perceptions of cultural norms on women's role. The findings suggest that domestic violence is most strongly related to the status of women in a society and to the normative use of violence in conflict situations or as part of the exercise of power. We conclude by discussing implications for developing theory on causal factors in domestic violence.

Intimate Partner Violence Among Women of Childbearing Age in a Primary Health Care Centre in Nigeria

Ilika AL, Okonkwo PI, Adogu P
Afr J Reprod Health. 2002;6:53-58

This study assessed the prevalence and characteristics of intimate partner violence among women of childbearing age in a primary health centre. With interviewer-administered questionnaire, information on partner violence was elicited from three hundred women of childbearing age selected by systematic sampling in a primary health care (PHC) centre. Over 40% had experienced violence within the last 12 months. Type of marriage and partner's education had effect on violence. Perceived reasons for violence were economic demand (56.1%), reproductive issues (42.5%), alcohol and drugs (61.2%). Forty eight per cent reported to family members. Only 1% reported to the Police. Intimate partner violence is a prevalent public health problem in eastern Nigeria. Health workers and social organisations should recognise the problem and offer necessary support, and women should be empowered to navigate through the problem.

HIV-Positive Women Report More Lifetime Partner Violence: Findings From a Voluntary Counseling and Testing Clinic in Dar Es Salaam, Tanzania

Maman S, Mbwambo JK, Hogan NM, et al
Am J Public Health. 2002 Aug;92(8):1331-7.

Objectives: Experiences of partner violence were compared between HIV-positive and HIV-negative women.
Methods: Of 340 women enrolled, 245 (72%) were followed and interviewed 3 months after HIV testing to estimate the prevalence and identify the correlates of violence.
Results: The odds of reporting at least 1 violent event was significantly higher among HIV-positive women than among HIV-negative women (physical violence odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.23, 5.63; sexual violence OR = 2.39; 95% CI = 1.21, 4.73). Odds of reporting partner violence was 10 times higher among younger (< 30 years) HIV-positive women than among younger HIV-negative women (OR = 9.99; 95% CI = 2.67, 37.37).
Conclusions: Violence is a risk factor for HIV infection that must be addressed through multilevel prevention approaches.

Severity of Intimate Partner Abuse Indicators as Perceived by Women in Mexico and the United States

Peek-Asa C, Garcia L, McArthur D, Castro R
Women Health. 2002;35:165-180

Objective: Women in Cuernavaca, Mexico and Los Angeles, California were surveyed to examine differences in their perceptions of the severity of domestic violence indicators.
Methods: One hundred twenty women in each country rated the severity of 26 domestic violence indicators which were part of an abuse screen used for an ongoing study of the prevalence of abuse. Rasch analysis was conducted to determine the linear relationship in the perceptions of the severity of each event between the two countries.
Results: The Rasch calibrated logit values show that women in the US rated 24 of the 26 events as more severe than women in Mexico. However, items were ranked in similar order and a clear linear pattern was established. In both countries, being shot with a gun was the most severe event and a partner becoming jealous was the least severe.
Conclusion: The country of origin did not dictate which events were most severe but did influence how severe these events were perceived.

Asia and the Pacific

Violence Against Women in South Asian Countries

Niaz U
Arch Women Ment Health. 2003;6:173-184

In South Asian countries the amalgamation of Buddhist, Confucian, Hindu, Islamic and Christian traditions have shaped the personalities of women and determined their social status. Rigid cultures and patriarchal attitudes which devalue the role of women, result in the wide spread occurrence of violence against women. The family structure, in which the man is the undisputed ruler of the household, and activities within the family are seen as private, allows violence to occur at home. As well as traditional forms of violence such as wife-battering and sexual assault, women in these countries are also exposed to dowry crimes such as bride burning, kidnapping for the purposes of prostitution, and "honour killings". Laws permit discrimination against women and discourage reporting of violent acts. Efforts to remedy this situation must include changes in local laws as well as assistance from the United Nations and the international community.

Is Child Sexual Abuse Declining? Evidence From a Population-Based Survey of Men and Women in Australia

Dunne MP, Purdie DM, Cook MD, Boyle FM, Najman JM
Child Abuse Negl. 2003;27:141-152

Objective: Substantiated cases of child sexual abuse (CSA) in the United States have declined significantly over the past decade. This may, or may not, reflect change in the underlying rate in the general population. This study examines age-cohort differences in the prevalence of self-reported CSA experiences of men and women aged 18-59 years in a community-based sample from a comparable western nation.
Method: In April 2000, we completed a cross-sectional, telephone-based survey of a randomly selected national sample of men and women in Australia. Volunteers (876 males, 908 females) answered a range of questions about health status and sexuality, including unwanted sexual experiences before the age of 16 years. Of selected adults with publicly-listed telephone numbers, 61% agreed to participate. There were few differences between the volunteers and the Australian population on demographic variables and health indicators.
Results: Non-penetrative CSA was twice as common among women (33.6%) than men (15.9%). Approximately 12% of women and 4% of men reported unwanted penetrative experiences. CSA was reported significantly less often by younger males, with a linear decline from the oldest to youngest men. Among all females who had intercourse before age 16, older women were much more likely than younger women to say they were an unwilling partner on the first occasion. If first intercourse occurred at age 16 or later, there were no age-cohort differences in risk of first-time abuse. Self-reported "openness" and "comfort" during the telephone interviews was not systematically related to prevalence of CSA.
Conclusion: These population-based findings provide evidence of a decline in the underlying rate of CSA in Australia. Although every measure of CSA inevitably is flawed to some extent, these trends in self-report complement official statistics that show substantial decline in recent years.

Prevalence and Associations of Partner Abuse in Women Attending General Practice: A Cross-Sectional Survey

Hegarty KL, Bush R
Aust N Z J Public Health. 2002;26:437-442

Objective: To determine the prevalence and socio-demographic associations of physical, emotional and sexual abuse by a partner or ex-partner for women attending Australian general practices.
Method: In 1996, women attending 20 randomly chosen Brisbane inner south region general practices were screened for a history of partner abuse using a self-report questionnaire. Multivariate analyses were conducted on the data, using presence of abuse or not adjusting for cluster effect to obtain prevalence rate ratios for socio-demographic background data and history of violence in the family of origin.
Results: Thirty-seven percent (CI 31.0-42.4) of the survey participants (n = 1,836, response rate 78.5%) admitted to having ever experienced abuse in an adult intimate relationship. One in four women (23.3%) had ever experienced physical abuse, one in three (33.9%) emotional abuse and one in 10 (10.6%) sexual abuse. Abused women were 64.1 (Cl 44.4-94.1) times more likely to have ever been afraid of any partner than non-abused women. Of women in current relationships (n = 1,344), 8.0% self-reported physical or emotional or sexual abuse in the past 12 months and 1.5% all three types of abuse. Associations of abuse included being younger (< 60 years), separated or divorced, having a history of child abuse or domestic violence between their parents.
Conclusion: Partner abuse is very common in women attending general practices and clinicians need to be alert to possible indications of partner abuse (age, marital status, past history of abuse).

Management of Child Abuse in Hong Kong: Results of a Territory-wide Inter-hospital Prospective Surveillance Study

Hong Kong Medical Coordinators on Child Abuse
Hong Kong Med J. 2003;9:6-9

Objectives: To study suspected child abuse among children in hospital in terms of clinical characteristics and the outcome of multidisciplinary case conferences.
Design: Prospective observational study.
Setting: All public hospitals in Hong Kong with a paediatric department.
Methods: Anonymous data were prospectively collected from July 1997 to June 1999 using a standard report form for each case of suspected child abuse. The characteristics of the incidents and factors influencing the conclusion at the multidisciplinary case conference were studied.
Results: Data for 592 cases of suspected child abuse were evaluated. Two hundred and eighty-seven of the children were boys and 305 were girls. The mean age was 7.3 years (range, 0-16.7 years). Physical abuse, alone or in combination with other forms of maltreatment, accounted for 277 (86.6%) of the 320 substantiated cases. Either, or both, biological parents comprised 71.3% of the perpetrators. Seven (1.2%) children died. Of the 540 children about whom a multidisciplinary case conference was held, abuse was established for 281 (52.0%) children. Abuse was more likely to be established if the victim had been known to a childcare agency (odds ratio=2.2; 95% confidence interval, 1.4-3.5), the abuse was not sexual (odds ratio=2.7; 95% confidence interval, 1.4-5.0), or if the child was seen at a hospital that handled more than 100 cases of suspected abuse during the study period (odds ratio=3.6; 95% confidence interval, 2.4-5.4).
Conclusion: Child abuse identified in the hospital setting is predominantly physical in nature and death is not uncommon. Appraisal of suspected child abuse by multidisciplinary case conference appears to be influenced by the region of Hong Kong in which the case was handled.

Who's At Risk? Factors Associated With Intimate Partner Violence in the Philippines

Hindin MJ, Adair LS
Soc Sci Med. 2002;55:1385-1399

We describe the individual and household characteristics associated with intimate partner violence (IPV) in the Philippines, using data from the Cebu Longitudinal Health and Nutrition Survey (CLHNS). We also examine 56 in-depth interview transcripts to explore the context of IPV. We focus our analysis on patterns of household decision-making as a measure of the interpersonal dynamics between husbands and wives. Thirteen percent of women in our sample reported IPV. While economic factors are often implicated in the cycle of violence in households, we find employment status and relative earnings do not predict IPV. Lower levels of household wealth and urban residence are associated with a higher likelihood of IPV. Patterns of household decision-making emerge as strong predictors of violence. The greater the number of decision-making domains men dominate, the more likely they are to use IPV; however, we also find that when women dominate household decisions, they are also more likely to experience IPV. Only 6% of women reported IPV when all household decisions were made jointly compared to 25% when no decisions were made jointly.

Domestic Violence Across Generations: Findings From Northern India

Martin SL, Moracco KE, Garro J, et al.
Int J Epidemiol. 2002;31:560-572.

Background: Although one cannot underestimate the importance of macrosystem-level forces (such as cultural and social norms) in the aetiology of gender-based violence within any country, including India, individual-level variables (such as observing violence between one's parents while growing up) may also play important roles in the development of such violence. Therefore, this research studies men residing in northern India to: (1) estimate the prevalence of men's childhood experiences of witnessing parent-to-parent violence within their families of origin; (2) examine whether men raised in violent homes were more likely than men raised in non-violent homes to have attitudes supportive of husbands' control of their wives; (3) examine whether men raised in violent homes were more likely than men raised in non-violent homes to be abusive toward their own wives; and (4) estimate the extent to which wife abuse in this second generation could have been prevented had there not been parent-to-parent violence in the men's natal families.
Methods: Married men (n = 6902) were surveyed concerning: their childhood experiences of witnessing parent-to-parent violence in their families of origin; their attitudes regarding the appropriateness of husbands' control of their wives; their physically and sexually abusive behaviours toward their own wives; and sociodemographic variables. Descriptive statistics, multivariable modelling procedures, and estimation of a population attributable fraction were used to address the study questions.
Results: Approximately one-third of the men had witnessed parent-to-parent violence as a child. Compared to men raised in non-violent homes, men from violent homes were significantly more likely to believe in husbands' rights to control their wives, and to be physically/sexually abusive toward their own wives. Non-violence in the earlier generation was strongly predictive of non-violence in the second generation, with about a third of the wife abuse in the second generation being attributable to parent-to-parent violence in the first generation.
Conclusions: These findings from northern India are congruent with those from other geographical/cultural settings in suggesting that witnessing violence between one's parents while growing up is an important risk factor for the perpetration of partner violence in adulthood.

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