The consequence of domestic violence for womens physical health Gene Feder

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The consequence of domestic violence for
womens physical health Gene Feder

• Manchester Womens Conference
• The physical health
• of women with mental illness
• 8th May 2008

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outline

• prevalence of domestic violence
• injuries
• chronic physical illness
• sexually transmitted infection
• mediators

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nature of domestic violence

• physical, sexual, emotional abuse perpetrated by
  a spouse or partner
• violation of human rights with health
  consequences
• characterised by coercive control and systematic
  abuse
• not confined to violence against women by men

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gender asymmetry

• comparable frequency of violent acts
• best population study Canadian General Social
  Survey where 8 women and 7 of men living
  together in the past year experienced some form
  of family violence
• women sexually assaulted by partner 7X more often
  than men
• women more than 3x more likely to sustain serious
  injury (40 vs. 13 of all violent
  relationships)
• 38 of women and 7 of men in violent
  relationships feared for their lives
• violence against women was more frequent and more
  severe (beaten, choked or raped vs. slapped,
  kicked, bitten or hit)

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nature of intimate partner violence

• physical, sexual or emotional abuse perpetrated
  by a spouse or partner
• characterised by coercive control
• Violation of human rights with health
  consequences
• not confined to violence against women by men,
  but severity and consequences are more severe
  than violence perpetrated by women against men
• also manifests in gay and lesbian relationships

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same sex partner violence

• 11 of women living with a same sex partner
  report being ever raped, physically assaulted or
  stalked by a female co-habitant
• 15 of men living with a same sex partner report
  having experienced violence
• Tjaden and Thoennes 2000

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prevalence of violence perpetrated by men against
women

• depends on definition of violence, measurement
  tool, type of sample, and geography
• lifetime prevalence of physical violence
• 1/3 (10-40)
• physical violence in past year
• 1/10 (2-20)

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domestic violence prevalence (British Crime
Survey 2001)
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sexual assault prevalence(British Crime Survey)
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prevalence of lifetime physical and sexual
violence by an intimate partner among ever
partnered women WHO 15 country study
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east London cross-sectional study of a clinical
population

• 1027 women in 13 general practice waiting rooms
• 41 (95 c.i. 38 to 44) lifetime experience of
  violence (physical or sexual assault) ever from a
  partner
• 17 (95 c.i. 14 to 19) experienced violence
  from a partner in the past year
• Richardson et al 2001

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prevalence in UK clinical settings
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comparison of mean (range) consultation rate per
patient/year between study group and national
survey (Lo Fo Wong 2007)
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comparison of mean prescriptions per patient/year
between women in study group and national survey
(Lo Fo Wong 2007)
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mental health effects

• meta-analysis by Golding (J Fam Violence 1999)
  of studies of populations of women who have
  experienced partner violence
• OR (95 c.i.)
• depression 18 studies 3.8 (3.2 to 4.6)
• PTSD 11 studies 3.74 (2.1 to 6.8)
• alcohol abuse 9 studies 5.6 (3 to 9)
• suicidality 13 studies
  3.55 (2.7 to 4.6)

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percentage of ever-partnered women reporting
suicidal thoughts, according to their experience
of domestic violence WHO 15-country study
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injuries

• majority of women do not present with obvious
  trauma in health care settings, even in AE
  departments
• one of most common causes of injury in women
  (11-30)
• fractures, lacerations, contusion, tendon or
  ligament damage to face, neck, upper torso,
  breast or abdomen
• at least half of women who experience physical
  violence sustain injuries

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Health consequences - pooled data from WHO 15
country study
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long term physical health sequelae

• National violence against women survey
• physical domestic violence 1.6 (1.3 to 2.0)
  relative risk of chronic physical
  condition Coker 2002
• past history of abuse 1.58 (1.34 to 1.86)
  increased risk of all physical health problems
• Campbell 2002

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chronic physical symptoms

• chronic pain (eg. headaches, back pain)
• Increased minor infectious illnesses
• neurological symptoms (fainting and dizziness)
• GI symptoms and chronic IBS
• raised blood pressure and coronary artery disease

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gynaecological problems

• most consistent, longest lasting and largest
  health difference between women who have and have
  not experienced abuse
• 3X increased risk of gynaecological problems,
  with dose-response relationship and increased
  risk with combination of sexual and physical
  abuse
• recurrent urinary tract infections
• abnormal vaginal bleeding
• dyspaerunia
• chronic pelvic pain

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sexually transmitted infections

• 2-4x relative risk in abused vs. non-abused
• population-based study in women lt 50 years found
  41 vs. 9 in past 5 years
• Plichta 1996
• CIN 4x relative risk

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antenatal effects

• probably lower incidence than in non-pregnant
  women
• inconsistent evidence of foetal distress,
  ante-partum haemorrhage and pre-eclampsia
• co-morbidities STI, substance abuse, post-natal
  depression
• clear evidence of low birthweight (OR 1.4 in
  meta-analysis of 8 studies)

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odds ratio between abuse during pregnancy and low
birth weight (Murphy 2001)
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physical health outcomes of childhood exposure to
domestic violence (Bair-Merritt 2006)

• uncertain effect on breastfeeding, infant weight
  gain, use of health services and general health
• reduced completion of immunisation
• Increased risk taking behaviour in adolescence
  and early adulthood (ACE)
• Smoking OR 1.6 (1.3 to 2.0)
• Alcoholism OR 1.7 increasing to 3.6
• IV drug use OR 1.8 increasing to 3.2

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mechanisms

• living with abuse combines continuous chronic
  stress with acute exacerbations related to
  physical, sexual and emotional violence

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mechanisms

• living with abuse combines continuous chronic
  stress with acute exacerbations related to
  physical, sexual and emotional violence
• symptoms and conditions related to old injuries,
  perhaps inadequately diagnosed or treated
• related to type of abuse or stress and its
  pathophysiological impact
• little research on causal pathways and mechanisms

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direct effect of physical trauma

• head trauma or choking/ incomplete strangulation
  headaches, dizziness, seizures
  (Diaz-Olavarrieta 1999)
• blows to abdomen gastrointestinal
  disorders
• forced sex and high risk sex genital,
  injury, pelvic pain, STI

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effects of chronic stress

• mediated by increased cortisol and catecholamines
• over-responsiveness of autonomic nervous system
• direct effect on muscle contraction (tension
  headache and low back pain) and vasoconstriction
  (migraine)
• peripheral vascular resistance and hypertension
• impaired immune function cytokine and T-cell
  function
• compounded by smoking, alcohol and illicit
  substance abuse

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studies in abused women

• correlation of T-cell dysfunction and depression
  stronger in women who have been abused
  (Constantino 2000)
• increased immune activation (CD45RORA lymphocyte
  ratio) in women with PTSD associated with CSA
• (Wilson 1999)

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limitations of current studies

• convenience samples
• cross-sectional
• poor measurement of abuse and of morbidity
• poor measurement and incorporation of potential
  confounders
• no theoretical model guiding data specification

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Theoretical model linking a risky family
environment and poor health
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question

• Is a better understanding
• of the pathophysiological effects
• of domestic violence
• a research priority?