Violence against women

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

This article have been viewed 1210 times

CHAPTER 66 Violence against women

Mary Hepburn, Kirstyn Brogan

Background

Violence against women is prevalent worldwide and is most commonly inflicted by men. Such violence takes many forms in different settings, sometimes legally sanctioned by the state and/or morally sanctioned by the society within which it occurs. However, while women can be at risk in many settings, the most common form of violence against women is domestic violence or abuse inflicted by the woman’s partner or ex-partner, and the violence usually takes place in the home.

While the term ‘domestic violence’ could imply violence or abuse from either partner in a heterosexual or homosexual relationship, a United Nations report in 1995 recognized that the most common manifestation is violence against women by male partners (United Nations 1995). In the 1992 British Crime Survey (Mayhew et al 1993), domestic violence constituted the single largest category of assaults, with 80% directed against women. In the USA, it is estimated that 95% of battered partners are women (Jones 1997). The United Nations report highlighted the range of types of physical abuse suffered worldwide by women at the hands of their partners, including battering, marital rape, dowry violence, domestic murder, forced pregnancy, abortion, sterilization and forced prostitution. During pregnancy, violence may also cause miscarriage or fetal injury and/or death. Women also experience non-physical abuse in the form of psychological, emotional and economic abuse.

Domestic violence or abuse is difficult to define but a definition such as ‘the psychological, emotional and economic as well as physical and sexual abuse of women by male partners or ex partners’ (Scottish Needs Assessment Programme 1997) indicates the range of ways and circumstances in which women can be abused by their partners. Thus, while society’s perception is that the greatest risk of violence comes from strangers outside the home, statistics confirm that this is not the case for women. Nevertheless, in addition to beating of a wife by her husband, violence against women includes other types of abuse such as abortion of female fetuses, female genital mutilation, forced prostitution by non-partners, rape (including rape and sexual violence as a war strategy) and murder. Women are also at risk of violence or abuse from any relationship or interaction with men in which sex is a factor; thus, while forced prostitution by a partner is itself a form of partner violence, women working as prostitutes, whether for a partner, another man or independently, are also at risk of violence from their clients. However, it is important to recognize that prostitution encompasses a wide spectrum of circumstances; while violence may occur as part of the practice of prostitution, it does not follow that all prostitution constitutes violence against women.

Violence against women is important to those providing reproductive health care. Women experiencing or at risk of violence are particularly vulnerable during pregnancy. Domestic violence often starts or escalates during pregnancy, and since the circumstances that drive a woman to commercial sex do not change because she has become pregnant, prostitution continues throughout pregnancy. Violence during pregnancy has obvious implications for the health of both mother and baby, and consequently has relevance for those providing maternity care (although recognition of this has been slow to develop). The relevance of violence to non-pregnant women is often only viewed in terms of rape. However, violence can cause or affect other gynaecological conditions, as well as having implications for other types of reproductive health care. It is therefore important to recognize that the entire spectrum of violence against women is of relevance to all aspects of reproductive health care.

The last 20 years has seen a worldwide increase in recognition of the health consequences of violence against women and the large spectrum of types of violence. This was accompanied by considerable research, the findings of which are supported by ongoing work in this area (Tjaden and Thoennes 2000, Watts and Zimmerman 2003).

Prevalence

The true prevalence of violence against women is difficult to determine. This is largely because of underidentification, but also because prevalence will depend on the definition of violence adopted. Studies in many countries have produced a range of estimates of prevalence for various categories of domestic violence and/or abuse. While the figures vary according to the type of abuse recorded, all are likely to be underestimates. The World Health Organization’s Multi-country Study on Women’s Health and Domestic Violence Against Women (2005) surveyed 10 countries, representing diverse cultural settings including urban and rural areas within the same country. It obtained information from over 24,000 women. The prevalence of women who reported episodes of domestic violence ranged between 15% and 71%, with the greatest amount of violence being reported in provincial settings in Bangladesh and Peru. In countries where large cities and rural areas were studied, partner violence was consistently higher in provincial settings. Women’s attitudes to violence and acceptance also varied; violence was condemned in urban areas, whereas in some rural areas, violence was accepted and justified, especially in situations such as female infidelity.

In the USA, estimates ranged between 2 million (United Nations 1995) and 4 million battered women, with 2000 women murdered each year (30% of female homicides) in association with battering (Jones 1997). In a Canadian survey of 12,300 women, 29% reported that they had experienced violence from a current or previous marital partner since 16 years of age (Johnson and Sacco 1995). In the UK, the Home Affairs Select Committee Report on Domestic Violence (1993) concluded that domestic violence is ‘common’. While the 1992 British Crime Survey (Mayhew et al 1993) found that 11% of women reported physical violence in their relationships, a 1993 crime survey in Islington, London (Mooney 1994) found that one in four women reported a lifetime experience of domestic violence. In a study of 930 women in San Francisco, 12% reported rape by their husbands (Russell 1982), while in a UK study of 1000 women, one in four reported that they had experienced marital rape. The prevalence of violence to prostitutes from both clients and pimps (regardless of whether or not the latter is the regular sexual partner) is also difficult to assess. Nevertheless, its occurrence is well recognized by those who work with prostitutes, although not necessarily by the criminal justice system whose response has often been inappropriate (Kennedy 1993).

The abuser, the abused and patterns of abuse

Many of the forms of violence described above occur in the UK. It is widely believed that such violence is largely confined to the lower social classes, but this is a misconception. Domestic abuse occurs across the social spectrum, and is inflicted by men who are not necessarily mentally ill but who have a range of personality defects (Mezey 1997). Various factors may coexist with violence either as cause or effect. While abuse occurs throughout society, socioeconomic deprivation, unemployment and lack of education are cited as precipitating and perpetuating factors (Kennedy and Dutton 1989). Whatever the precise relationship, women from backgrounds of socioeconomic deprivation may have fewer resources and fewer options for dealing with the abuse.

Problem drug and alcohol use are often thought to be linked to abuse and are often offered as an excuse or justification. While men with substance misuse problems may be more likely to abuse their partners, this may not be because they are intoxicated, and they may do so while sober. The 1996 British Crime Survey showed that intoxication of the perpetrator with alcohol or drugs was less common in the case of domestic violence than in stranger and acquaintance violence (Mirrlees-Black et al 1996). Additionally, abusive men may cite substance misuse by the partner as the cause or justification for their abusive behaviour. While there is no evidence to support this, it is true that women suffering abuse may develop drug and/or alcohol problems as a consequence of the abuse (Stark and Flitcraft 1991, Plichta 1992).

Women working as prostitutes experience poverty and many have drug or alcohol problems. Many such women will have a history of abuse, including sexual abuse by a family member, partner or other person. Their partner may also have problem substance use financed by the prostitution. The more chaotic the woman’s lifestyle, the greater her financial need, the less she is paid, the more clients she has to service to raise the necessary money, the more dangerous the circumstances in which she must work and the greater her exposure to the risk of violence.

However, while associations with various factors do exist and some groups of women are consequently at increased risk of violence, it is important to remember that these factors are not necessarily obvious. Moreover, there is no typical abuser and no typical abused woman.

Reproductive Health Consequences

Women who experience violence are more likely to suffer a number of consequences relevant to reproductive health services. More than 30% of domestic violence begins during pregnancy (CEMACH 2004), and more than 14% of maternal deaths occur in women who had told their health professional that they were in an abusive relationship (CEMACH 2007).

During pregnancy, the injury sites include breasts and abdomen with consequent risk of injury to the fetus, including miscarriage, premature delivery and fetal death (Mezey and Bewley 1997). Women who have experienced violence are more likely to suffer miscarriage (Stark and Flitcraft 1996). Pregnancy, genital tract infections and genital tract injury are possible consequences of sexual violence, while other persistent gynaecological problems, especially abdominal pain, may be the presentation of abuse. Such women may find it difficult to undergo pelvic examination.

Obviously, in all of these situations, the converse does not apply and not all women with such problems or difficulties have been abused. Equally, many women who have been abused demonstrate no obvious problems or stigmata which might indicate a history of abuse.

Presentation

Women may present because of violence in a number of ways. They may specifically report physical violence, including rape (see Chapter 65), or may present for treatment of physical injuries sustained (with or without admission of the circumstances), in which case the setting is most commonly the accident and emergency department or the general practitioner’s surgery. Injuries sustained include bruises, cuts, fractured bones and internal injuries (Dobash and Dobash 1980). In pregnancy, injuries include maternal rupture of the uterus, spleen or liver; placental abruption; premature spontaneous rupture of the membranes; miscarriage and fetal death (James-Hanman and Long 1994). Other indicators of domestic abuse are late booking and poor or non-attendance at antenatal clinics, repeated attendance during pregnancy with minor ailments and unexplained admissions. Previous reports of maternal deaths involving domestic abuse recommend that all women attending maternity services should be asked specifically about domestic abuse and given the opportunity to disclose this information.

Abused women may present later with psychological problems such as anxiety, depression (including suicide attempts), and drug or alcohol problems (Stark et al 1979, Hillard 1985). They may present to reproductive health services, including obstetric and gynaecology departments, in various ways. Immediate problems prompting attendance include obstetric complications and injuries, including genital tract injuries. Women may present with clinical problems secondary to the violence, such as possible genital tract infection, the need for emergency contraception or subsequently with a pregnancy. Many women only present later with chronic gynaecological problems, such as chronic pelvic pain.

Violence, domestic or otherwise, may therefore be highly relevant to women’s attendance at obstetric and/or gynaecology services. However, irrespective of the immediacy or directness of the association, and no matter how obvious the markers, the possibility will not necessarily be recognized. Moreover, women who present in these ways rather than with a specific complaint of violence and/or rape, whether or not the perpetrator is the partner, are unlikely to admit the abusive circumstances unless asked directly. Violence and/or abuse may therefore not be identified unless healthcare workers ask; since the occurrence of abuse is often not suspected in such situations, routine direct enquiry will be necessary for effective identification and management of this problem.

Identification

Violence against women is often not identified within healthcare services because women may not volunteer the information and they are often not asked about it. In one study of 290 pregnant women in which 23% reported past or present battering, none had been questioned about violence by any healthcare providers (Helton et al 1987). Many women do not want to involve authorities such as the police or law courts, and the authorities may not consider the problem within their remit; indeed, they may not even consider it a problem at all. In the UK until 1829, a man had a right to ‘chastise’ his wife provided he used a stick ‘no thicker than his thumb’. The possible existence of rape within marriage was only recognized in Scotland in 1989 and in England and Wales in 1991. Since commercial sex is widely viewed as voluntary, with the women morally responsible, violence against prostitutes is often considered an unavoidable risk of this activity that does not justify legal pursuit. Even when the violence extends to murder, this is seen as different from murder of a ‘respectable’ woman (Kennedy 1993).

Women who experience violence from a partner often feel ashamed. They also often feel that they are at least partly to blame, and must have deserved the abuse in some way. They are also afraid that if they disclose the abuse to a third party, their partner will find out and they will suffer even more violence. Similarly, women working as prostitutes are often ashamed of their involvement in prostitution and do not want to admit it. While not necessarily believing they deserve violence, they may feel that their activities invite it and they therefore bear some responsibility. Whatever their feelings, however, most prostitutes believe that a report of violence would not be received sympathetically by the relevant services, would not lead to an effective response and would therefore be pointless. Similarly, many women suffering partner violence do not expect a sympathetic or helpful response from services. Nevertheless, evidence shows that despite their reluctance to raise the subject and report the violence, and despite the inadequacy of responses, women who suffer violence or abuse want to be asked about it and to be given an opportunity to disclose it. In one American primary care survey, 75% of women favoured routine enquiry about physical abuse, and 97% of female and male respondents said that they would answer truthfully if asked directly. However, only 7% said that they had ever been asked (Friedman et al 1992).

There are various reasons why healthcare workers do not ask about violence (Sugg and Inui 1992). They may be unaware of the possibility of abuse or think it is rare; they may not perceive violence, domestic or otherwise, as their responsibility; or they may be unwilling to ask, either because they feel they lack the necessary skills, because they fear they may cause offence or because they are afraid of broaching a problem that they would not have the time or the knowledge to deal with. In many areas, there are insufficient or inadequately resourced support services to which women could be offered referral. The advice given is often limited to a recommendation to leave the batterer, and frustration is expressed when women do not follow this advice. Consequently, many healthcare workers feel unhappy asking about abuse and would only do so if there was obvious evidence of abuse. Any injury might be expected to raise suspicion, but injuries at various sites, of different ages and for which no good explanation is offered should indicate possible abuse. However, even in the presence of obvious markers of abuse, healthcare workers do not always make the connection and, whether consciously or unconsciously, do not recognize the possibility of abuse or enquire about it. Moreover, many abused women will not demonstrate any of the recognized markers, and not all women with these markers will have been abused.

Risk markers are therefore insufficiently sensitive or specific, and should not be used as a basis for selective enquiry. As well as being ineffective, selective enquiry (if obviously selective) can also be offensive regardless of whether or not the woman has suffered abuse. Any awkwardness on the part of the healthcare worker will be conveyed to the woman. The way the question is posed is therefore important. A statement such as ‘I know this probably doesn’t apply to you but we have to ask everyone’ gives a clear indication of the ‘correct’ response and does not encourage disclosure. Identification of violence is important in reproductive health care; given the nature of services provided, it is entirely appropriate to take an adequate sexual and social history, including direct enquiry about violence and abuse in all cases.

Management of abuse

While all women should be asked about abuse, the circumstances must be conducive to disclosure. Privacy is essential and all women should have at least part of any reproductive health consultation conducted on a one-to-one basis with the doctor, nurse or midwife. The presence of a partner who is reluctant to leave will not only prevent enquiry but may be an indicator of abuse. There should be recognition that not all abused women will admit this on routine enquiry; a negative response will not preclude violence, and if there are strong suspicions, some support can often be provided in the absence of an explicit admission. Disclosure may then occur during a later consultation.

All women presenting in pregnancy should be asked about the circumstances of the pregnancy; whether the pregnancy is planned, intended and/or wanted; their relationship with their partner (or man who accompanies them) and whether he is the baby’s father. In this context, it is simple to ask the woman about the quality of the relationship and specifically whether her partner has ever been violent to her. She should also be asked whether anyone else has ever been violent to her and whether she has ever been forced to have sex with someone against her wishes. Women presenting with a gynaecological problem should similarly have a full sexual history taken. All women, pregnant or non-pregnant, presenting for any type of reproductive health care should have a social history taken. This should include questions about lifestyle, including use of tobacco, alcohol and illicit drugs, all of which can directly affect reproductive health. Women who disclose illicit drug use should be asked how this is financed, including specific enquiry about involvement in commercial sex.

There are several important aspects to management (Heath 1992). It is important that a woman who discloses a history of violence is reassured that she is believed and that she is not responsible for nor deserving of the violence. In the reproductive health setting, management of the relevant injuries or medical problems with which she presents will be a priority (management of women presenting with a present history of rape or sexual abuse is described in Chapter 65), but the healthcare worker’s responsibility does not end there. Details of the violence together with the woman’s circumstances should be elicited, and an assessment should be made of immediate risk to the woman and/or her children or others in her immediate circle. The information she provides should be documented accurately together with details of examination findings, including injuries if present and any treatment given. Such information may be required for future legal action. She should be reassured that any information she provides will be treated with confidentiality, but there should also be discussion about the meaning of and limits to confidentiality. Should the healthcare worker envisage having to disclose the information, such as to ensure child protection, this should be discussed with the woman at the outset.

There should be discussion with women experiencing domestic violence or abuse about the possibility of leaving the abuser. Information including contact telephone numbers should be provided about residential and non-residential services for women experiencing violence, as well as availability of any other alternative accommodation. However, it is important to recognize that it is often not feasible for women to remove themselves from the situation. For example, they may be financially, emotionally or otherwise dependent on the abuser, or it might not be possible for them to take their children with them for various reasons. Moreover, when the woman appears to be at significant and imminent risk of further violence, leaving the situation may increase that risk; women are especially likely to suffer significant injury or even be killed when they leave a violent domestic environment (Browne 1987, Geberth 1992). It is therefore essential that women are reassured that there is recognition of and sympathy for the limitations to their options, and are not given the impression that they are expected to leave or will be considered stupid or weak if they fail to do so.

Regardless of their circumstances or chosen action, women should be provided with information about services and also the offer of direct referral. Where specific problems (whether cause or effect) are identified, such as mental health or substance misuse problems, appropriate referral for specialist management will be helpful even if it does not resolve the problem of violence. Moreover, problem drug and/or alcohol use can have direct effects on reproductive health, which merit treatment of the problem in their own right. This is therefore discussed later.

Management of Prostitution

At present, approaches to legislation differ across countries with regards to prostitution. In the UK, a Home Office consultation paper, ‘Paying the Price’ (Home Office 2004), prioritized the needs of communities in preference to the health and safety of sex workers. This led to publication of the Coordinated Prostitution Strategy (Home Office 2006) that focuses on criminalization of prostitution. In a Canadian study, Lowman et al found that a criminalized system increased the risks to vulnerable women, and they were more likely to be vulnerable to predatory and premeditated forms of violence in comparison with women working within a legalized framework where violence was often situational (i.e regarding non-payment for services) (Lowman 2000).

In contrast to the UK, countries such as New Zealand and the Netherlands have focused on decriminalizing sex work; a decision based on a duty to protect sex workers. The Prostitution Reform Act 2003 in New Zealand decriminalized sex work and improved workers’ health, safety and job satisfaction. Women found that they could use the law to encourage condom use and reduce their risk of sexually transmitted infections, and were more confident at refusing clients who did not adhere to this.

Criminalizing prostitution forces the most vulnerable women away from health services, and increases the risk of violence and other health consequences.

Women experiencing violence in non-domestic settings receive similar support. Women seen at reproductive health services who admit involvement in commercial sex will invariably have attended for some other reason and the presenting problem will obviously need to be dealt with. Nevertheless, an admission of prostitution should prompt a full relevant history, including details of type of services offered and clients buying them. Sexual behaviour and consequent risks, together with relevant signs and symptoms, should be explored. In the obstetric context, women engaging in commercial sex will often claim that paternity is not in doubt and the pregnancy is definitely to their partner. However, clients often pay more for unprotected intercourse and a carefully taken sexual history may indicate that such confidence is misplaced. Nevertheless, such self-deception by a woman and/her partner, whether conscious or unconscious, is often an essential coping strategy, so it is not necessarily helpful to comment on it unless specifically asked to do so, when it should be discussed with the woman on her own. Even if not explicitly admitted, however, uncertainty or concern about paternity may increase the risk of violence to the woman from her partner. It is, of course, entirely reasonable and appropriate to discuss strategies for risk reduction in terms of sexually transmitted infections and unplanned/unwanted pregnancies with non-pregnant women involved in prostitution. In this context, it would also be appropriate to discuss possible paternity problems if the woman is not pregnant but keen to conceive to her partner. Preconception counselling about risks to a pregnancy from sexually transmitted infections (including bloodborne viruses such as human immunodeficiency virus) would also be desirable in this situation.

Women engaged in commercial sex will escape the consequent violence by ceasing prostitution. For those women whose prostitution is directed and controlled by their sexual partner, this may be achieved by leaving the partner as in other domestic abuse situations; however, for similar reasons, this may be difficult or impossible. In addition, some such women and many working independently will have to continue working because of their own financial needs. There is a social hierarchy of prostitution. At the upper end of the market, in saunas and other indoor settings, there is less risk, often less financial pressure but greater financial rewards. At the more risky, lower end of the market, financial need is often greater or more acute but income is lower. Amongst the most vulnerable women working on the streets, factors such as problem drug and/or alcohol use that necessitate prostitution are also much more common. Nevertheless, all women engaged in prostitution, regardless of the circumstances, are at risk of violence. An approach similar to that described for domestic abuse should be adopted. An adequate history and examination are essential, as is accurate documentation of relevant information. Immediate healthcare needs should be assessed and appropriate management instigated; in this situation, the presence of any genital tract trauma or infection, whether the woman is pregnant, and consequently whether she requires maternity care, a termination of pregnancy, effective contraception or preconceptual care.

While some women working as prostitutes might be able to leave the violent situation by leaving a violent partner or pimp for whom they were earning money, most would only be able to stop prostituting if their own financial needs were resolved. For many, this would require effective management of their drug or alcohol problem.

Management of Problem Substance Use

Problem drug and/or alcohol use is often associated with poor nutrition which, in turn, may cause amenorrhoea. Heroin use can also cause amenorrhoea with or without anovulation. Methadone substitution therapy improves social stability and general health, including nutrition; commencement of therapy is often followed by return of fertility which can precede return of menstruation.

Many drug-using women incorrectly assume that their amenorrhoea indicates infertility, but they must be warned this is not so and provided with effective contraception if they do not want to become pregnant. Conversely, however, drug-using women who experience difficulty in conceiving should be advised that stabilization of their drug use, and consequently their lifestyle, with methadone substitution therapy where appropriate will increase their chances of conception. Such measures would also improve the baby’s health as well as the mother’s parenting abilities. This advice also holds true for their partners, since reduced sperm motility is often observed in association with use of sedative drugs including benzodiazepines and opiates/opioids (including methadone). Although the precise functional significance of this is uncertain, in the absence of successful conception, it seems reasonable to give both partners general advice about reduction in levels of drug use, and for those on substitute medication, to recommend stabilization at the lowest level compatible with stability.

Management of the drug problem per se is obviously not the clinical responsibility of reproductive healthcare professionals. However, if such a problem is identified, whether incidentally or in association with prostitution, violence or reproductive health problems, women should be given appropriate information about possible effects on pregnancy, fertility and effective contraception if indicated. This should be provided together with information about specialist services and the offer of referral.

Sexual Violence in War

The use of sexual violence as a strategy in war has been observed and reported by healthcare workers, humanitarian organizations and others working in such settings (Shanks et al 2001). Women who have experienced such violence may move to other countries as refugees or asylum seekers, and may then present to healthcare workers who do not have direct experience of such problems. Refugees presenting for reproductive health care may have experienced violence; their trauma may be exacerbated by being in a culturally unfamiliar environment, possibly without the support of family or friends, often with language and communication difficulties, and encountering healthcare workers who are unaware of or have no understanding of their previous circumstances and experiences. Some such women may be in the country illegally or awaiting the outcome of an asylum application. They may consequently be unable or afraid to access services, or to admit or discuss their problems when they do so. Similarly, other Black or ethnic minority women may be reluctant to seek help because of previous experience of racism from public services or institutions (Mama 1989), and expectation of repetition and/or fear of deportation. They may also have problems in accessing services or obtaining financial support, making it even more difficult for them to leave an abusive partner.