ArticlePrevalence of violence and its implications for women’s health
Introduction
Violence against women is a U.S. and world-wide public health priority.1, 2 Sensational stories and horrific statistics seek to increase awareness of violence against women. However, shame, fear, and an unresponsive health care system continue to silence and isolate women who suffer abuse, rape, and other assaults.
Most of the available literature deals with specific categories of violence (eg, child abuse, rape, spouse abuse), but little is known about the implications of sexual versus non-sexual violence, or whether specific types of violence have differential health—physical and/or psychological—consequences. Much of the research is based on either nonrandom convenience samples or clinical samples that tend to be comprised of more urban, less educated, and poorer women than are representative of the general U.S. population, and this may result in an overestimation of the prevalence and associated effects of violence.3 Many of the violence—health effects studies rely on bivariate analysis and fail to take into account and control for socioeconomic status, insurance, and other access measures. Few studies have a nationally representative sample and requisite range of data for estimating burden of violence (overall and by type of violence), health effects, and relevant physician-patient communication issues.
The Tjaden study, based on a 1997 national survey, reports that 55% of women experience some type of violence in their lifetime.4 Various national and regional studies of child abuse offer a range of estimates from 7% to 40%.5, 6, 7, 8, 9 Other studies offer estimates of 13–25% for women who experienced rapes, as adolescents or adults.4, 7, 10, 11, 12, 13 The only national study to examine lifetime prevalence of physical assault by a non-spouse reports a prevalence rate of 15%,14 and the only regional study (in Georgia) of lifetime intimate partner violence reports a prevalence rate of 30%.15 Various studies also report that violence is likely to be repeated,8, 16 and that childhood abuse is a risk factor for experiencing violence as an adult.17, 18, 19
Various health effects have been linked to specific types of violence, including poorer subjective ratings of health status, disability, chronic pelvic pain, general chronic pain, headache, gastrointestinal disorders, depression, anxiety, suicide, and suicide ideation. Studies that focus on specific subgroups show significant associations between compromised physical health status and child abuse,8, 20, 21 sexual assaults,14, 18, 22 and intimate partner violence.8, 22, 23, 24 Studies also document relationships between mental health disorders and child abuse,9, 19, 20, 21, 25, 26 sexual assault,6, 7, 27, 28 and intimate partner violence.22, 23, 29 Several studies note a “dose-response” effect, with more frequent and more severe violence linked to more severe or greater morbidity.17, 24, 30
Logically, compromised health could translate into an increased use of outpatient and inpatient services. On the other hand, abused women might face barriers to seeking care, for example, prevented by the perpetrator of abuse or by her own fears or feelings (eg, embarrassment). Some studies found a greater use of health care services among women who experienced violence as an adult,30 child abuse,31, 32 rape,14, 27, 33 and intimate partner violence.8, 34, 35, 36 Studies also found that health care costs for intimate partner violence victims are significantly higher than costs for other women.36, 37 Among women abused by a male intimate, studies have documented delay in seeking care and evidence of barriers to obtaining timely care and unmet needs for medical care.8, 38, 39
Some studies indicate that patient-physician communications are less than adequate. One researcher notes that female violence survivors often have the “thick chart syndrome”—frequent visits, comprehensive exams with extensive testing, and no known physical cause for their complaints.26 Women rarely initiate the conversation about either current or past violence in their lives,24, 40, 41, 42, 43, 44, 45 and it is widely acknowledged that the vast majority of women harmed by violence are never asked about violence or identified by their health care providers as having experienced violence.46, 47 Other studies, however, report that women would welcome physician inquiries and would reveal, if asked, their abuse histories.41, 48
With data from the Commonwealth Fund 1998 Survey of Women’s Health, we seek to provide a more current and complete profile of violence against women. More specifically, we present lifetime prevalence estimates and examine several types of violence, with corresponding health effects and implications for doctors. In contrast to prior research, we classify violence to explore the differential effects of intimate sexual violence.
Section snippets
Sample
The study sample of women is drawn from the Commonwealth Fund 1998 Survey of Women’s Health, a national, cross-section sample of women 18 years of age and older. The subsample of women aged 18–64 includes 2,381 women, or 83.5% of the unweighted survey sample (2,850 women). The corresponding weighted sample is 1,840 women. For our analysis, the weighted sample includes 1,821 women (exclusive of 19 women who did not answer the requisite violence questions).
Violence
A series of survey questions asked about
Prevalence estimates
Four-in-ten (43.7%) women aged 18–64 years report at least one type of violence, at least once, in their lifetime (Table 1). This translates into a national estimate of 36 million women who experienced violence, as a child and/or as an adult. Table 1 shows the lifetime prevalence for specific types of violence in our sample and national projections for each category: 17.8% of women were abused (physical and/or sexual) as a child, 19.1% experienced at least one physical assault as an adult,
Discussion
Consistent with prior studies and smaller scale surveys, we document horrific rates of violence that women experience—as children and as adults—in the streets and in their homes. Four of ten U.S. women experience violence, at least once, in their lives, and over 50% of these women were raped or sexually violated, as a child and/or as an adult. The vast majority of sexual violence occurs at the hands of someone she knows—a spouse, partner, relative, or friend, rather than a stranger.
Several
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