The Effects of W o m a n A b u s e on Health Care Utilization and Health Status: A Literature Review Stacey Plichta, ScD School of Hygiene and Public Health The John Hopkins University Baltimore, Maryland
Estimates of the physical abuse of women by husbands or boyfriends in the United States range from 85 per 1000 couples to 113 per 1000 couples per year. Victims of abuse are much more likely than nonvictims to have poor health, chronic pain problems, depression, suicide attempts, addictions, and problem pregnancies. Abused women use a disproportionate amount of health care services, including emergency room visits, primary care, and community mental health center visits. Despite its high prevalence and the disproportionate use of health care services it causes, woman abuse is rarely recognized by health care providers. Even when the abuse is recognized, health care professionals often provide inappropriate or even harmful treatment. Because many abused women pass through the health care system, it is important that providers learn how to identify those who are abused, treat all the effects of the abuse, and make appropriate referrals. Abstract
he prevalence of abuse of w o m e n by h u s b a n d s or boyfriends in the United States is high. The health effects of this abuse go beyond the immediate injury that the w o m a n may sustain; abuse has been s h o w n to be related to m a n y health problems, including chronic pain, depression, and substance abuse. It is important for health care systems to identify w o m e n w h o are abused, provide appropriate referrals, and treat the effects (both immediate and long-term) of the abuse. Currently, most health care systems have no mechanisms to help those w h o are being abused; m a n y providers know little or nothing about w o m a n abuse and its effects. Some educational efforts, like those of the American College of Obstetricians and Gynecologists (which recently released a technical bulletin on w o m a n abuse to all 31,000 of its members), 1 have been u n d e r taken. The p u r p o s e of this review is to e x p a n d u p o n these efforts by providing some additional b a c k g r o u n d about the prevalence of w o m a n abuse, more detailed information about effects u p o n physical and mental health, c o m p r e h e n s i v e information on the utilization of the health care system by abused w o m a n , and r e c o m m e n d a t i o n s to help providers detect and meet the needs of abused w o m e n . W o m a n abuse is defined in this review as any physical abuse d o n e to a w o m a n by an intimate male partner. This includes throwing s o m e t h i n g at
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the woman; pushing, shoving, or grabbing her; slapping her; kicking, biting, or hitting her with a fist; hitting or trying to hit her with an object; beating her up; burning or scalding her; threatening her with a knife or gun; or using a knife or gun on her. Severe abuse is used to describe abuse ranging from kicking, biting, or hitting with a fist, to using a knife or gun. These definitions are based upon the Conflict Tactics Scale, 2 which is the most widely used and accepted measure of intrafamilial violence in the literature.
PREVALENCE A N D SEVERITY OF W O M A N ABUSE A number of studies have been done in an attempt to estimate the prevalence of woman abuse in the United States. Table 1 presents the results of many of the larger studies done from 1979-1991. These include three representational, random-sample studies of large geographic areas, as well as various "convenience samples" of community and medical populations. It should be noted, however, that accurately estimating the prevalence of woman abuse in the United States is a difficult task. No widely recognized definitions of woman abuse exist, no universal identification procedures have been adopted, and reporting is sporadic even in states where it is mandatory. 3 The only national survey of family violence reported the 1-year prevalence rate of any woman abuse for couples currently residing together to be 113 per 1000 couples and the rate of severe abuse to be 30 per 1000 couples. 4 The two other representative studies, one in Texas s and one in Kentucky, 6 found the 1-year rates of any woman abuse to be 8.5 and 10%, respectively. The only other nationwide indicators of prevalence are national crime statistics. These chronically underreport abuse because about half the crimes of violence against women by people they know go unreported. 7 The National Crime Survey (NCS) is a semiannual interview of 60,000 households designed to measure both reported and unreported incidents of crime. It found an overall prevalence rate of wife abuse of 2.7 of 1000 for abuse incidents thought to be severe enough by the victim to be criminal in nature. 8 Smaller studies, of community groups, have found rates of any woman abuse for partners living together ranging from 10-35%, and rates of severe abuse from 6--11%. 9-11 Pregnant women were also found to be at risk, with reported rates of abuse of 7, 8, and 20%. 12-14 One study showed abused women three times more likely to be injured while pregnant than nonabused women. 15 Single women and adolescent women are also at risk of partner abuse. Several studies of single women, usually college populations, reported rates of premarital abuse around 20%. 16-19 The few studies that have examined woman abuse in adolescent populations reported rates of 10-34%. 17'2°'21 Woman abuse is rarely an isolated incident. The NCS study 8 and the Texas studys both showed that between 25-30% of abused women are beaten on a cyclical basis; many are beaten as often as once a week. Bowker and Maurer, 22 in a nonrandom sample of 1000 abused women, found that batterings are common and severe, with 46% reporting 20 or more beatings and 56% reporting being raped by their partners as well as abused. Woman abuse often takes the form of sexual assault. A ground-breaking study 23 of 914 married or once-married women found that 14% had been raped or sexually assaulted at least once by their husbands; this was twice the number that had been victimized by strangers. A study of women attending primary care clinics found that 15% had been raped or sexually assaulted by their husbands. 24
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Table 1.
Estimates of the Yearly Prevalence of Wife Abuse in the United States (Studies of 100 or More W o m e n , 1979-1990)
Study
Year
Population based Straus 4 1986
N 3250*
Teske s
1983
1210
Schulman 6
1979
1793
C o m m u n i t y groups Follingstad 16 1988 Lockhart 11 1987 Smith 9 1986 Meredith TM 1986 Cate 17 1982 Laner ~8 1982 Makepeace 19 1981 Clinical studies Amaro 12 1990 Rath 24 1989 Bullock 49 1989
National probability sample Driver's license (TX) R a n d o m dialing (KY)
Any Abuse
Severe Abuse
11%
3%
9% 10%
221 307 312 304* 355* 371" 2338
College students C o m m u n i t y groups Telephone survey Married parents College students College students College students
10%§ 35% 21%t" 22% 22%¢ 29% 21%
1243 218 589
Prenatal clinics Primary care clinics Postpartum, hospital Planned Parenthood Prenatal clinic Chronic pain clinic Hospital e m e r g e n c y room
7%** 44% 20%**
Bullock 13
1989
793
Helton TM Haber 35 Goldberg 2s
1987 1985 1984
290 150 492*
Medical record review McLeer 5s 1989
Source of Subjects
470
Flaherty 32
1985
2339
Carmen 44
1984
122
Stewart 31
1981
122
Stark is
1979
481
Hospital e m e r g e n c y room Hospital e m e r g e n c y room Inpatient psychiatric discharge Child psychiatric clinic Hospital e m e r g e n c y room
11% 6% 9%~: 9%
28%
8% 23% 53% 24%
8%**
8%" 7% 4 33%
41% 10%*
All studies but medical record review interviewed the women. Any abuse includes physical abuse from shoving to using a weapon. Severe abuse includes hitting with fist or object, beating up, kicking, biting, and threatening to use or using a weapon. These categories are consistent with the Conflict Tactics Scale. 2 *Both women and men in the sample. "fEver abused, lifetime prevalence. :[:Either victim or perpetrator of abuse. §Multiple incident--another 11% reported only one incident. lIRate of injuries in the past year with abuse listed as a cause. SAnother 7-10% had injuries highly suggestive of abuse. aAnother 15% had medical histories highly suggestive of abuse. **During pregnancy.
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THE POPULATION AT RISK FOR W O M A N ABUSE All women are at risk of being physically abused by men with whom they become intimately involved. Although many studies have tried to find factors that would identify those woman who are at an elevated risk of abuse, few have found any factors that would identify those women who are more likely to be abused. An extensive review 2s of 52 case-comparison studies of woman abuse (done between 1970-1985) failed to determine any consistent personality or background factor predictive of a woman being abused as an adult; other studies also found no evidence for specific personality factors that would predispose a woman to abuse. 26'27 No demographic factors other than age have been found to be related to being abused. The only study designed to examine racial differences (controlling for socioeconomic status) 6 in abuse rates failed to find any overall differences in rates by race. 11 Other studies also failed to find racial differences, 13"14"28although two studies found higher rates of abuse among blacks and other nonwhites 6'29 and one found higher rates among whites. 12 Several studies found that there was no relationship between socioeconomic status and w o m a n a b u s e , 6"HA4'28'3° whereas three found that lower socioeconomic status is related to higher rates of abuse. 12,24,31 The only risk factors for abuse that consistently appeared in the literature were being younger, being in a long-term sexual relationship with a male, being divorced or separated, 7"8"17A8"24"32-'37and having a high violence level in the family of origin (with early and repeat sexual abuse a factor of special importance). 16"2s'27'34'38'39 However, two studies 3"31 reported that the level of violence in the family of origin was not predictive of subsequently being abused. Overall, these risk factors for abuse apply to many women and thus have limited usefulness in predicting which women will be abused.
P H Y S I C A L A N D M E N T A L H E A L T H EFFECTS OF ABUSE Woman abuse often results in serious physical injury. In the NCS study, 8 49% of victims of family assaults suffered some injury; 24% of abused women in the Texas studys and 17% of abused women in the Kentucky study 6 were injured severely enough to require medical attention. A study of 262 police reports on domestic calls found that 43% of the women were injured. 37 Death is also a potential outcome. Department of Justice records show that 30% of all female homicide victims were slain by husbands, ex-husbands, or boyfriends. 4° Victims of woman abuse are at an increased risk for physical and mental harm beyond that which is directly inflicted upon them by their partners. A random sample of 2000 New Zealand women found that abused women had significantly worse physical and mental health status as measured by the General Health Questionnaire (for physical health) and the Present State Exam (for mental health). 3° A case-control study of 145 U.S. women also reported significantly higher General Health Questionnaire scores for abused women. 41 A study of 481 women presenting with injuries to a hospital emergency room found that abuse severe enough to cause the woman to seek medical care may be quickly followed by psychiatric disorders, is The physical health consequences of abuse were reported in several studies. A study of injury patterns among 693 families found the number of injury incidents one had was associated with having both more acute and chronic medical problems. 42 Two clinical studies 3s'43 found that abused women are significantly more likely to experience chronic pain. WHI Vol. 2, No. 3 Fall 1992
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There are also mental health consequences associated with w o m a n abuse. The risk of suicide attempts is m u c h higher for abused than for n o n a b u s e d w o m e n . 12"15'31"44'45Amaro et aP 2 f o u n d 17% of abused w o m e n versus 5% of n o n a b u s e d w o m e n had a t t e m p t e d suicide; Stark et aP 5 f o u n d that prior to the first recorded assault, there was no significant difference in suicide attempts (6% abused versus 3% n o n a b u s e d ) but after the first assault there was (26 versus 3%). Abused w o m e n are also at increased risk for substance a b u s e . 12"15"39'45'46 Miller and colleagues 4s r e p o r t e d that spousal violence scores were the strongest predictor of alcoholism in w o m e n , e v e n after controlling for income, violence in family of origin, and having an alcoholic husband. O t h e r mental health problems related to w o m a n abuse include depressionS2'45'47; panic, phobic, anxiety, and insomnia disorders3~'4~; and emotional problems. ~3"45 Marital rape, i n d e p e n d e n t of other abuse, also increases the risk of having mental health problems. 4s'48 The children of abused mothers are also at risk. This risk begins in the womb; two studies found a weak relationship between abuse, low birth weight, and low gestational age. 12.49 Once born, these children are at high risk for child abuse. 15'38'5°-52 Often this abuse is from the father; m e n w h o abuse w o m e n are likely to be child abusers as well. sl's3 These children are also more likely to experience behavior and a d j u s t m e n t problems as well as depression.31,47.54
HEALTH CARE UTILIZATION
DUE TO WOMAN
ABUSE
Although no large-scale studies of health care utilization among abused w o m e n have been done, the literature to date indicates that they use a disproportionate a m o u n t of health care services, especially e m e r g e n c y rooms. Reports of the percent of visits due to abuse range b e t w e e n 7 and 33%. ls'32,55 A s t u d y using a protocol to detect abuse in w o m e n presenting to the e m e r g e n c y r o o m found a rate of 30% .ss A n o t h e r s t u d y 28 reported that 24% of w o m e n presenting to an e m e r g e n c y room had ever been abused (lifetime prevalence). W o m e n w h o are abused also use a disproportionate a m o u n t of care outside of the e m e r g e n c y room. H a b e r 3s reported that 53% of w o m e n seeking care at a hospital-based chronic pain clinic had been physically or sexually abused by their h u s b a n d s more than once; Rath et a124 f o u n d that 28% of w o m e n seeking care at two primary care clinics suffered severe abuse at the hands of their h u s b a n d s at least once. Abused w o m e n are also more likely to use the mental health system than are others. Stark et al is f o u n d that, c o m p a r e d with n o n a b u s e d w o m e n w h o had an e m e r g e n c y room visit, abused w o m e n were more likely to have had a stay at a state mental hospital (15 versus 1%) or have been referred to a c o m m u n i t y mental health center (26 versus 3.6%) and that these visits almost always occurred after the first trauma incident suggestive of abuse. Prior to the first incident, they f o u n d no statistical differences in psychiatric care between abused and n o n a b u s e d w o m e n . C a r m e n et a144 f o u n d that 33% of w o m e n discharged from psychiatric inpatient units had been abused wives; those patients with any history of adult abuse had significantly longer lengths of stays than other patients. Overall, w o m a n abuse results in a considerable drain of health care resources and a high cost to society. The total medical cost of abuse are not known; no study has ever explicitly calculated them. H o w e v e r , estimates of this cost in 1980 dollars, using data from a national crime survey (which underestimates prevalence of w o m a n abuse 10-40-fold), were calculated as 158
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follows: direct medical costs, $44,393,700; hospital days, 99,800; emergency room visits, 28,700. 56
D E T E C T I N G W O M A N A B U S E IN T H E H E A L T H CARE S E T T I N G Although it is not possible to predict which women will be abused, once the abuse has started, its victims can be identified. However, the reality is that although victims of woman abuse frequently pass through the health care system, receiving treatment for a variety of conditions associated with the abuse, the abuse itself often goes undetected, s7 Several studies of detection of abuse by emergency room physicians reported that the vast majority of abused women were not detected by health care providers, even when the injury they presented with was directly due to abuse. 15"24'28 It is possible to identify current or recent victims of woman abuse. Three studies that sought to detect patterns of injury and diagnoses useful in identifying abused women were done; each found similar, discernible patterns. Overall, they found that multiple injuries, injuries in different locations, and injuries located (in order of frequency) on the face, head/neck, breasts, and abdomen (in pregnant women) were highly indicative of abuse. 14"15'32Additionally, Stark et al ~s found that abused women were more likely to have spontaneous abortions, diagnoses for vague complaints and psychosomatic illness, and to be prescribed painkillers and minor tranquilizers.
BARRIERS TO THE REFERRAL A N D T R E A T M E N T OF A B U S E D W O M E N Even when physicians detect woman abuse, they often provide ineffective or harmful treatment to the woman. A volunteer survey of 1000 battered women found that women rated health care practitioners as the least helpful of all professional help sources. 38 Of the 334 women who reported seeking medical care for the abuse, 45% reported that medical services were not effective in decreasing or ending the violence, and 8% reported that seeking medical services actually led to increased violence. Woman abuse is a unique health care problem in that its etiology lies outside the patient (ie, is caused by a violent male) and its solution involves more nonmedical components (such as the legal and welfare systems) than medical ones. This is often not recognized by health care workers. Rather than address the underlying causes of women abuse, they frequently break down the visible effects of woman abuse into medical signs and symptoms that are then "appropriately" treated separately. 3 Instead of focusing on the woman's need for safety and support and of confronting issues of male violence, they may choose to focus on the victim's "pathology" and personality. The effect of the violence is often confused with the cause; professionals may say there is something wrong with the woman's personality and conclude that is w h y she is battered and/or will not leave the relationship. $8 Because they lack training in and knowledge about woman abuse, clinicians may minimize the significance of the abuse, emphasizing family maintenance and compliance with role expectations over stopping the violence. A survey of all U.S. medical schools found that 53% provided no instruction at all about domestic violence; another 5% had no required instruction, but provided information in electives, s9 Additionally, many physicians hold at-
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titudes that prevent them from addressing woman abuse. These include: "family matters are private," "violence against women is not a health issue," and "working with victims of violence is a hopeless cause. "6°
THE NEED FOR I N T E R V E N T I O N IN THE H E A L T H CARE S E T T I N G It is especially important for health care providers to be able to detect and effectively aid women who are victims of violence. Women who are abused turn most often to physicians (directly or indirectly) for help. 6° This, and the fact that the effects of abuse are physical and psychological in nature, makes it especially important for the medical community to recognize and appropriately treat or refer victims of woman abuse. Screening and referral of battered women through the medical system has been recommended by several researchers. 26'61-63 The few studies that have attempted to screen for abuse have shown screening to be both effective and feasible. 15"31'44'56 It is possible for health care workers to intervene effectively in ongoing abusive situations. Several researchers have developed and tested protocols for detecting abuse in medical care populations. One major health center reported developing and successfully using a protocol for identification and intervention in cases of woman abuse. 64 A review by Stenchever and Stenchever6s contains recommendations for the physicians' role, which include detecting evidence that abuse has occurred, treating the injury, suggesting that the patient and her children leave the violent situation, developing an exit plan with the patient, and providing referrals for long-term help such as shelters, counseling, and legal avenues. Nursing interventions have also been designed and put in place by several researchers. Many of these interventions recommend screening for abuse in a variety of medical settings other than the emergency room. Components of these interventions include interviewing the woman away from the violent partner, using interviewing techniques to facilitate disclosure of the battering (questions such as "It is not uncommon for a husband to hit a wife; has this happened to you?"), and eliciting and recording a detailed description of present and past abuse, including photographs and/or a "body map" of any injuries. Some of the nursing interventions also stress the importance of screening for other risks to the woman's health, such as the likelihood of her committing suicide, the presence of a gun in the household, the presence of sexual abuse, and risks to the woman's children. Additionally, all interventions recommend discussing the woman's immediate plans and the resources that the woman has used in the past and those available at present. They also recommend discussing community-based resources with women, such as shelters and support groups, as well as legal rights and resources. 3s,66,67
CONCLUSIONS The prevalence of woman abuse in the United States is high, and the physical and emotional damage done to women by this abuse is substantial. Health care providers are in a unique position to identify and help women who are victims of abuse. This presents a challenge to providers because the cause of the abuse lies outside the woman and the "cure" involves social and legal systems as well as medical treatment. Health providers need to educate themselves about woman abuse, know community and legal sources to which to 160
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refer a b u s e d w o m e n , a n d d e v e l o p protocols for identifying a n d caring for such w o m e n .
ACKNOWLEDGMENTS
I a c k n o w l e d g e the s u p p o r t of Drs. Donald Steinwachs, Carol W e i s m a n , a n d M a r y Stuart in p r e p a r a t i o n of this review. I w o u l d also like to t h a n k the State of M a r y l a n d D e p a r t m e n t of H e a l t h a n d Mental H y g i e n e , H e a l t h Policy a n d Statistics A d m i n i s t r a t i o n for their s u p p o r t of this work.
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Estimates of the physical abuse of women by husbands or boyfriends in the United States range from 85 per 1000 couples to 113 per 1000 couples per year. Victims of abuse are much more likely than nonvictims to have poor health, chronic pain problems, depression, suicide attempts, addictions, and problem pregnancies. Abused women use a disproportionate amount of health care services, including emergency room visits, primary care, and community mental health center visits. Despite its high prevalence and the disproportionate use of health care services it causes, woman abuse is rarely recognized by health care providers. Even when the abuse is recognized, health care professionals often provide inappropriate or even harmful treatment. Because many abused women pass through the health care system, it is important that providers learn how to identify those who are abused, treat all the effects of the abuse, and make appropriate referrals. Abstract
he prevalence of abuse of w o m e n by h u s b a n d s or boyfriends in the United States is high. The health effects of this abuse go beyond the immediate injury that the w o m a n may sustain; abuse has been s h o w n to be related to m a n y health problems, including chronic pain, depression, and substance abuse. It is important for health care systems to identify w o m e n w h o are abused, provide appropriate referrals, and treat the effects (both immediate and long-term) of the abuse. Currently, most health care systems have no mechanisms to help those w h o are being abused; m a n y providers know little or nothing about w o m a n abuse and its effects. Some educational efforts, like those of the American College of Obstetricians and Gynecologists (which recently released a technical bulletin on w o m a n abuse to all 31,000 of its members), 1 have been u n d e r taken. The p u r p o s e of this review is to e x p a n d u p o n these efforts by providing some additional b a c k g r o u n d about the prevalence of w o m a n abuse, more detailed information about effects u p o n physical and mental health, c o m p r e h e n s i v e information on the utilization of the health care system by abused w o m a n , and r e c o m m e n d a t i o n s to help providers detect and meet the needs of abused w o m e n . W o m a n abuse is defined in this review as any physical abuse d o n e to a w o m a n by an intimate male partner. This includes throwing s o m e t h i n g at
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the woman; pushing, shoving, or grabbing her; slapping her; kicking, biting, or hitting her with a fist; hitting or trying to hit her with an object; beating her up; burning or scalding her; threatening her with a knife or gun; or using a knife or gun on her. Severe abuse is used to describe abuse ranging from kicking, biting, or hitting with a fist, to using a knife or gun. These definitions are based upon the Conflict Tactics Scale, 2 which is the most widely used and accepted measure of intrafamilial violence in the literature.
PREVALENCE A N D SEVERITY OF W O M A N ABUSE A number of studies have been done in an attempt to estimate the prevalence of woman abuse in the United States. Table 1 presents the results of many of the larger studies done from 1979-1991. These include three representational, random-sample studies of large geographic areas, as well as various "convenience samples" of community and medical populations. It should be noted, however, that accurately estimating the prevalence of woman abuse in the United States is a difficult task. No widely recognized definitions of woman abuse exist, no universal identification procedures have been adopted, and reporting is sporadic even in states where it is mandatory. 3 The only national survey of family violence reported the 1-year prevalence rate of any woman abuse for couples currently residing together to be 113 per 1000 couples and the rate of severe abuse to be 30 per 1000 couples. 4 The two other representative studies, one in Texas s and one in Kentucky, 6 found the 1-year rates of any woman abuse to be 8.5 and 10%, respectively. The only other nationwide indicators of prevalence are national crime statistics. These chronically underreport abuse because about half the crimes of violence against women by people they know go unreported. 7 The National Crime Survey (NCS) is a semiannual interview of 60,000 households designed to measure both reported and unreported incidents of crime. It found an overall prevalence rate of wife abuse of 2.7 of 1000 for abuse incidents thought to be severe enough by the victim to be criminal in nature. 8 Smaller studies, of community groups, have found rates of any woman abuse for partners living together ranging from 10-35%, and rates of severe abuse from 6--11%. 9-11 Pregnant women were also found to be at risk, with reported rates of abuse of 7, 8, and 20%. 12-14 One study showed abused women three times more likely to be injured while pregnant than nonabused women. 15 Single women and adolescent women are also at risk of partner abuse. Several studies of single women, usually college populations, reported rates of premarital abuse around 20%. 16-19 The few studies that have examined woman abuse in adolescent populations reported rates of 10-34%. 17'2°'21 Woman abuse is rarely an isolated incident. The NCS study 8 and the Texas studys both showed that between 25-30% of abused women are beaten on a cyclical basis; many are beaten as often as once a week. Bowker and Maurer, 22 in a nonrandom sample of 1000 abused women, found that batterings are common and severe, with 46% reporting 20 or more beatings and 56% reporting being raped by their partners as well as abused. Woman abuse often takes the form of sexual assault. A ground-breaking study 23 of 914 married or once-married women found that 14% had been raped or sexually assaulted at least once by their husbands; this was twice the number that had been victimized by strangers. A study of women attending primary care clinics found that 15% had been raped or sexually assaulted by their husbands. 24
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Table 1.
Estimates of the Yearly Prevalence of Wife Abuse in the United States (Studies of 100 or More W o m e n , 1979-1990)
Study
Year
Population based Straus 4 1986
N 3250*
Teske s
1983
1210
Schulman 6
1979
1793
C o m m u n i t y groups Follingstad 16 1988 Lockhart 11 1987 Smith 9 1986 Meredith TM 1986 Cate 17 1982 Laner ~8 1982 Makepeace 19 1981 Clinical studies Amaro 12 1990 Rath 24 1989 Bullock 49 1989
National probability sample Driver's license (TX) R a n d o m dialing (KY)
Any Abuse
Severe Abuse
11%
3%
9% 10%
221 307 312 304* 355* 371" 2338
College students C o m m u n i t y groups Telephone survey Married parents College students College students College students
10%§ 35% 21%t" 22% 22%¢ 29% 21%
1243 218 589
Prenatal clinics Primary care clinics Postpartum, hospital Planned Parenthood Prenatal clinic Chronic pain clinic Hospital e m e r g e n c y room
7%** 44% 20%**
Bullock 13
1989
793
Helton TM Haber 35 Goldberg 2s
1987 1985 1984
290 150 492*
Medical record review McLeer 5s 1989
Source of Subjects
470
Flaherty 32
1985
2339
Carmen 44
1984
122
Stewart 31
1981
122
Stark is
1979
481
Hospital e m e r g e n c y room Hospital e m e r g e n c y room Inpatient psychiatric discharge Child psychiatric clinic Hospital e m e r g e n c y room
11% 6% 9%~: 9%
28%
8% 23% 53% 24%
8%**
8%" 7% 4 33%
41% 10%*
All studies but medical record review interviewed the women. Any abuse includes physical abuse from shoving to using a weapon. Severe abuse includes hitting with fist or object, beating up, kicking, biting, and threatening to use or using a weapon. These categories are consistent with the Conflict Tactics Scale. 2 *Both women and men in the sample. "fEver abused, lifetime prevalence. :[:Either victim or perpetrator of abuse. §Multiple incident--another 11% reported only one incident. lIRate of injuries in the past year with abuse listed as a cause. SAnother 7-10% had injuries highly suggestive of abuse. aAnother 15% had medical histories highly suggestive of abuse. **During pregnancy.
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THE POPULATION AT RISK FOR W O M A N ABUSE All women are at risk of being physically abused by men with whom they become intimately involved. Although many studies have tried to find factors that would identify those woman who are at an elevated risk of abuse, few have found any factors that would identify those women who are more likely to be abused. An extensive review 2s of 52 case-comparison studies of woman abuse (done between 1970-1985) failed to determine any consistent personality or background factor predictive of a woman being abused as an adult; other studies also found no evidence for specific personality factors that would predispose a woman to abuse. 26'27 No demographic factors other than age have been found to be related to being abused. The only study designed to examine racial differences (controlling for socioeconomic status) 6 in abuse rates failed to find any overall differences in rates by race. 11 Other studies also failed to find racial differences, 13"14"28although two studies found higher rates of abuse among blacks and other nonwhites 6'29 and one found higher rates among whites. 12 Several studies found that there was no relationship between socioeconomic status and w o m a n a b u s e , 6"HA4'28'3° whereas three found that lower socioeconomic status is related to higher rates of abuse. 12,24,31 The only risk factors for abuse that consistently appeared in the literature were being younger, being in a long-term sexual relationship with a male, being divorced or separated, 7"8"17A8"24"32-'37and having a high violence level in the family of origin (with early and repeat sexual abuse a factor of special importance). 16"2s'27'34'38'39 However, two studies 3"31 reported that the level of violence in the family of origin was not predictive of subsequently being abused. Overall, these risk factors for abuse apply to many women and thus have limited usefulness in predicting which women will be abused.
P H Y S I C A L A N D M E N T A L H E A L T H EFFECTS OF ABUSE Woman abuse often results in serious physical injury. In the NCS study, 8 49% of victims of family assaults suffered some injury; 24% of abused women in the Texas studys and 17% of abused women in the Kentucky study 6 were injured severely enough to require medical attention. A study of 262 police reports on domestic calls found that 43% of the women were injured. 37 Death is also a potential outcome. Department of Justice records show that 30% of all female homicide victims were slain by husbands, ex-husbands, or boyfriends. 4° Victims of woman abuse are at an increased risk for physical and mental harm beyond that which is directly inflicted upon them by their partners. A random sample of 2000 New Zealand women found that abused women had significantly worse physical and mental health status as measured by the General Health Questionnaire (for physical health) and the Present State Exam (for mental health). 3° A case-control study of 145 U.S. women also reported significantly higher General Health Questionnaire scores for abused women. 41 A study of 481 women presenting with injuries to a hospital emergency room found that abuse severe enough to cause the woman to seek medical care may be quickly followed by psychiatric disorders, is The physical health consequences of abuse were reported in several studies. A study of injury patterns among 693 families found the number of injury incidents one had was associated with having both more acute and chronic medical problems. 42 Two clinical studies 3s'43 found that abused women are significantly more likely to experience chronic pain. WHI Vol. 2, No. 3 Fall 1992
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There are also mental health consequences associated with w o m a n abuse. The risk of suicide attempts is m u c h higher for abused than for n o n a b u s e d w o m e n . 12"15'31"44'45Amaro et aP 2 f o u n d 17% of abused w o m e n versus 5% of n o n a b u s e d w o m e n had a t t e m p t e d suicide; Stark et aP 5 f o u n d that prior to the first recorded assault, there was no significant difference in suicide attempts (6% abused versus 3% n o n a b u s e d ) but after the first assault there was (26 versus 3%). Abused w o m e n are also at increased risk for substance a b u s e . 12"15"39'45'46 Miller and colleagues 4s r e p o r t e d that spousal violence scores were the strongest predictor of alcoholism in w o m e n , e v e n after controlling for income, violence in family of origin, and having an alcoholic husband. O t h e r mental health problems related to w o m a n abuse include depressionS2'45'47; panic, phobic, anxiety, and insomnia disorders3~'4~; and emotional problems. ~3"45 Marital rape, i n d e p e n d e n t of other abuse, also increases the risk of having mental health problems. 4s'48 The children of abused mothers are also at risk. This risk begins in the womb; two studies found a weak relationship between abuse, low birth weight, and low gestational age. 12.49 Once born, these children are at high risk for child abuse. 15'38'5°-52 Often this abuse is from the father; m e n w h o abuse w o m e n are likely to be child abusers as well. sl's3 These children are also more likely to experience behavior and a d j u s t m e n t problems as well as depression.31,47.54
HEALTH CARE UTILIZATION
DUE TO WOMAN
ABUSE
Although no large-scale studies of health care utilization among abused w o m e n have been done, the literature to date indicates that they use a disproportionate a m o u n t of health care services, especially e m e r g e n c y rooms. Reports of the percent of visits due to abuse range b e t w e e n 7 and 33%. ls'32,55 A s t u d y using a protocol to detect abuse in w o m e n presenting to the e m e r g e n c y r o o m found a rate of 30% .ss A n o t h e r s t u d y 28 reported that 24% of w o m e n presenting to an e m e r g e n c y room had ever been abused (lifetime prevalence). W o m e n w h o are abused also use a disproportionate a m o u n t of care outside of the e m e r g e n c y room. H a b e r 3s reported that 53% of w o m e n seeking care at a hospital-based chronic pain clinic had been physically or sexually abused by their h u s b a n d s more than once; Rath et a124 f o u n d that 28% of w o m e n seeking care at two primary care clinics suffered severe abuse at the hands of their h u s b a n d s at least once. Abused w o m e n are also more likely to use the mental health system than are others. Stark et al is f o u n d that, c o m p a r e d with n o n a b u s e d w o m e n w h o had an e m e r g e n c y room visit, abused w o m e n were more likely to have had a stay at a state mental hospital (15 versus 1%) or have been referred to a c o m m u n i t y mental health center (26 versus 3.6%) and that these visits almost always occurred after the first trauma incident suggestive of abuse. Prior to the first incident, they f o u n d no statistical differences in psychiatric care between abused and n o n a b u s e d w o m e n . C a r m e n et a144 f o u n d that 33% of w o m e n discharged from psychiatric inpatient units had been abused wives; those patients with any history of adult abuse had significantly longer lengths of stays than other patients. Overall, w o m a n abuse results in a considerable drain of health care resources and a high cost to society. The total medical cost of abuse are not known; no study has ever explicitly calculated them. H o w e v e r , estimates of this cost in 1980 dollars, using data from a national crime survey (which underestimates prevalence of w o m a n abuse 10-40-fold), were calculated as 158
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follows: direct medical costs, $44,393,700; hospital days, 99,800; emergency room visits, 28,700. 56
D E T E C T I N G W O M A N A B U S E IN T H E H E A L T H CARE S E T T I N G Although it is not possible to predict which women will be abused, once the abuse has started, its victims can be identified. However, the reality is that although victims of woman abuse frequently pass through the health care system, receiving treatment for a variety of conditions associated with the abuse, the abuse itself often goes undetected, s7 Several studies of detection of abuse by emergency room physicians reported that the vast majority of abused women were not detected by health care providers, even when the injury they presented with was directly due to abuse. 15"24'28 It is possible to identify current or recent victims of woman abuse. Three studies that sought to detect patterns of injury and diagnoses useful in identifying abused women were done; each found similar, discernible patterns. Overall, they found that multiple injuries, injuries in different locations, and injuries located (in order of frequency) on the face, head/neck, breasts, and abdomen (in pregnant women) were highly indicative of abuse. 14"15'32Additionally, Stark et al ~s found that abused women were more likely to have spontaneous abortions, diagnoses for vague complaints and psychosomatic illness, and to be prescribed painkillers and minor tranquilizers.
BARRIERS TO THE REFERRAL A N D T R E A T M E N T OF A B U S E D W O M E N Even when physicians detect woman abuse, they often provide ineffective or harmful treatment to the woman. A volunteer survey of 1000 battered women found that women rated health care practitioners as the least helpful of all professional help sources. 38 Of the 334 women who reported seeking medical care for the abuse, 45% reported that medical services were not effective in decreasing or ending the violence, and 8% reported that seeking medical services actually led to increased violence. Woman abuse is a unique health care problem in that its etiology lies outside the patient (ie, is caused by a violent male) and its solution involves more nonmedical components (such as the legal and welfare systems) than medical ones. This is often not recognized by health care workers. Rather than address the underlying causes of women abuse, they frequently break down the visible effects of woman abuse into medical signs and symptoms that are then "appropriately" treated separately. 3 Instead of focusing on the woman's need for safety and support and of confronting issues of male violence, they may choose to focus on the victim's "pathology" and personality. The effect of the violence is often confused with the cause; professionals may say there is something wrong with the woman's personality and conclude that is w h y she is battered and/or will not leave the relationship. $8 Because they lack training in and knowledge about woman abuse, clinicians may minimize the significance of the abuse, emphasizing family maintenance and compliance with role expectations over stopping the violence. A survey of all U.S. medical schools found that 53% provided no instruction at all about domestic violence; another 5% had no required instruction, but provided information in electives, s9 Additionally, many physicians hold at-
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titudes that prevent them from addressing woman abuse. These include: "family matters are private," "violence against women is not a health issue," and "working with victims of violence is a hopeless cause. "6°
THE NEED FOR I N T E R V E N T I O N IN THE H E A L T H CARE S E T T I N G It is especially important for health care providers to be able to detect and effectively aid women who are victims of violence. Women who are abused turn most often to physicians (directly or indirectly) for help. 6° This, and the fact that the effects of abuse are physical and psychological in nature, makes it especially important for the medical community to recognize and appropriately treat or refer victims of woman abuse. Screening and referral of battered women through the medical system has been recommended by several researchers. 26'61-63 The few studies that have attempted to screen for abuse have shown screening to be both effective and feasible. 15"31'44'56 It is possible for health care workers to intervene effectively in ongoing abusive situations. Several researchers have developed and tested protocols for detecting abuse in medical care populations. One major health center reported developing and successfully using a protocol for identification and intervention in cases of woman abuse. 64 A review by Stenchever and Stenchever6s contains recommendations for the physicians' role, which include detecting evidence that abuse has occurred, treating the injury, suggesting that the patient and her children leave the violent situation, developing an exit plan with the patient, and providing referrals for long-term help such as shelters, counseling, and legal avenues. Nursing interventions have also been designed and put in place by several researchers. Many of these interventions recommend screening for abuse in a variety of medical settings other than the emergency room. Components of these interventions include interviewing the woman away from the violent partner, using interviewing techniques to facilitate disclosure of the battering (questions such as "It is not uncommon for a husband to hit a wife; has this happened to you?"), and eliciting and recording a detailed description of present and past abuse, including photographs and/or a "body map" of any injuries. Some of the nursing interventions also stress the importance of screening for other risks to the woman's health, such as the likelihood of her committing suicide, the presence of a gun in the household, the presence of sexual abuse, and risks to the woman's children. Additionally, all interventions recommend discussing the woman's immediate plans and the resources that the woman has used in the past and those available at present. They also recommend discussing community-based resources with women, such as shelters and support groups, as well as legal rights and resources. 3s,66,67
CONCLUSIONS The prevalence of woman abuse in the United States is high, and the physical and emotional damage done to women by this abuse is substantial. Health care providers are in a unique position to identify and help women who are victims of abuse. This presents a challenge to providers because the cause of the abuse lies outside the woman and the "cure" involves social and legal systems as well as medical treatment. Health providers need to educate themselves about woman abuse, know community and legal sources to which to 160
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refer a b u s e d w o m e n , a n d d e v e l o p protocols for identifying a n d caring for such w o m e n .
ACKNOWLEDGMENTS
I a c k n o w l e d g e the s u p p o r t of Drs. Donald Steinwachs, Carol W e i s m a n , a n d M a r y Stuart in p r e p a r a t i o n of this review. I w o u l d also like to t h a n k the State of M a r y l a n d D e p a r t m e n t of H e a l t h a n d Mental H y g i e n e , H e a l t h Policy a n d Statistics A d m i n i s t r a t i o n for their s u p p o r t of this work.
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