Types of violence against women: who is affected? What is the impact?

Domestic abuse: physical, emotional, and sexual

Definition

Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence, or abuse between those aged 16 or over who are, or have been, intimate part­ners or family members regardless of gender or sexuality.

At least 4.5 million women (27.1% of women) aged between 16 and 59 experienced domestic abuse in England and Wales in the year ending March 2015. These figures are thought to be an underestimate (7).

Domestic violence cuts across all strata of society regardless of age, ethnicity, religion, social class, and income or where people live (8). However, the variation in the prevalence of violence seen within and between communities, countries, and regions, highlights that violence is not inevitable, and that it can be prevented (3).

Risk factors

Risk factors for domestic violence include:

• female gender

• young women (age group 16-24 years)

• long-term illness or disability with almost double the risk

• substance and alcohol misuse and mental health problems

• women who are separated

• pregnancy and delivery: this is said to offer protection to some women but for others it increases the risk with a strong correlation between postnatal depression and domestic violence and abuse (9, 10).

Signs and symptoms of domestic violence

Women who have experienced partner violence have higher rates of several important health problems and risk behaviours com­pared to women who have not experienced partner violence: they have 16% greater odds of having a low-birthweight baby; are more than twice as likely to have an induced abortion; are more than twice as likely to experience depression.

Health conditions associated with domestic violence include asthma, genitourinary symptoms, including frequent bladder or kidney infections, circulatory conditions, cardiovascular disease, fibromyalgia, irritable bowel syndrome, chronic pain syndromes, unexplained central nervous system disorders, un­explained gastrointestinal disorders, joint disease, migraines, and headaches (12).

Other psychological presentations include symptoms of depres­sion, anxiety, post-traumatic stress disorder (PTSD), sleep dis­orders, suicidal tendencies or self-harming, and alcohol or other substance use (13).

Reproductive problems associated with domestic violence include pelvic pain and sexual dysfunction, adverse reproductive outcomes, including multiple unintended pregnancies or terminations, de­layed pregnancy care, miscarriage, premature labour and stillbirth, unexplained vaginal bleeding or sexually transmitted infections, and chronic pain (unexplained) (13). Women who have experienced domestic violence may be more likely to consult their doctors and present with gynaecological problems (14).

Other indicators of domestic violence include traumatic injury, particularly if repeated and with vague or implausible explanations, and repeated health consultations with no clear diagnosis (13).

Adverse mental and physical health outcomes sometimes con­tinue after the violence has ended (15).

Studies globally show that as adults, children who have witnessed violence and abuse are more likely to become involved in a violent and abusive relationship themselves. There is a strong likelihood that this will be a continuing cycle for the next generation with a significant risk of ever-increasing harm to the child's physical, emo­tional, and social development (16, 17).

Males who have personal experience of childhood emotional abuse and who have witnessed their mother being beaten demon­strate a large increase in the prevalence for them becoming per­petrators of intimate partner violence in studies from Asia and the pacific region.

In relationships where there is domestic violence and abuse, chil­dren witness about three-quarters of the abusive incidents. About half the children in such families have themselves been badly hit or beaten. Sexual and emotional abuse is also more likely to happen in these families (17).

Personality and behavioural problems among children exposed to violence in the home can take the forms of psychosomatic illnesses, depression, suicidal tendencies, and bed-wetting. Later in life, these children are at greater risk for substance abuse, juvenile pregnancy, and criminal behaviour than those raised in homes without violence.

Management of domestic violence

Healthcare professionals should be trained to recognize indicators of domestic violence and to be able to sensitively enquire about do­mestic violence and abuse. When domestic violence or abuse is dis­closed, care should be individualized and support tailored to suit their individual needs immediately and in the long term with the safety of the women always a priority.

Women with additional support needs should be referred to specialist domestic violence services. Domestic violence specialist services may be able to offer advocacy and support. It also includes housing workers, independent domestic violence advisers, or a mul­tiagency risk assessment conference for high-risk clients (9).

Referrals to other relevant specialist services should be made if there are indications that someone has alcohol or drug misuse or mental health problems.

Screening in healthcare settings increases the identification of women experiencing domestic violence and abuse. Overall, how­ever, rates are low relative to best estimates of prevalence of do­mestic violence in women seeking healthcare (19). Barriers to routine screening for intimate partner violence are time constraints, a lack of protocols and policies, and departmental philosophies of care that may conflict with intimate partner violence screening re­commendations (20).

Evidence supporting the effectiveness of routine screening of asymptomatic women in improving health status is lacking. However, identification of domestic violence within specific con­texts and provision of targeted interventions may provide health benefits (21). Screening during antenatal care is a situation where the screening and provision of substantive tailored interventions to women who disclose domestic violence may reduce the recurrence of domestic violence and improve maternal and infant outcomes (22, 23).

A randomized controlled trial was performed in 1044 pregnant African American women who were assigned to either an integrated cognitive behavioural intervention or normal care. The intervention was performed at routine antenatal appointments by Masters-level social workers or psychologists and involved specific, evidence­based, interventions for the designated psychobehavioural risks (22). Intimate partner violence was significantly reduced with a halving of the odds of further episodes of minor or severe physical violence during the antenatal or postnatal period. Furthermore, improve­ments in obstetric outcomes were also seen. These included a signifi­cant reduction in very low birthweight (waiting or loitering around home or workplace, following or watching'. Women are more affected than men.

Harassment on the other hand can include ‘repeated attempts to impose unwanted communications and contact upon a victim in a manner that could be expected to cause distress or fear in any rea­sonable person'. In relation to violence against women and girls, it involves attempts to impose explicit and implicit unwanted commu- nications/advances of sexual nature.

The Protection from Harassment Act 1997 in the United Kingdom was introduced because there was limited legal protection for victims who were upset and frightened by a series of disturbing incidents which fell short of being illegal.

Two new laws were introduced in the United Kingdom in 2012 specific to stalking offences, which fall under the Protection from Harassment Act 1997. This new legislation not only gives the police greater powers of entry to a stalker's property, so that evidence can be gained to corroborate a victim's case, but also supports a victim who is experiencing lesser or more serious stalking behaviour. A person is also guilty of an offence if it is perceived that they are using threatening words, show abusive behaviour, or act in a threat­ening manner.

A study by Edwards et al. showed that over half of women after termination of an abusive relationship reported stalking behaviours from their abusive ex-partner. This led to greater levels of post- traumatic stress symptomatology (31).

Stalking is a significant risk factor for other forms of partner vio­lence (e.g. psychological, physical, and sexual violence) and the ex­perience of being stalked by a violent partner contributes uniquely to women's perceptions of psychological distress and personal safety (32).

As well as the implications on an individual's social life and fi­nances, stalking and harassment can lead to severe mental and physical health issues such as depression, anxiety, effects of chronic stress such as headaches and hypertension, fatigue from difficulty sleeping, increased use of alcohol, cigarettes, or drugs, anxiety, panic attacks, and agoraphobia (32).

Childhood sexual abuse

Sexual violence against children is a gross violation of children's rights. Yet it is a global reality across all countries and social groups. It has been estimated that between one in ten and one in twenty

children have been subjected to child sexual abuse (33-35). One in three children in the United Kingdom who are abused by an adult do not tell anyone (35).

Types of child sexual abuse: contact abuse and non-contact abuse

Contact abuse involves touching activities where an abuser makes physical contact with a child, including penetration. It includes sexual touching of any part of the body (whether the child is wearing clothes or not); rape or penetration by putting an object or body part inside a child's mouth, vagina, or anus; forcing or encouraging a child to take part in sexual activity; making a child take their clothes off; touching someone else's genitals; or masturbating (35).

Non-contact abuse involves non-touching activities, such as grooming, exploitation, persuading children to perform sexual acts over the Internet, and flashing. It includes encouraging a child to watch or hear sexual acts; not taking proper measures to prevent a child being exposed to sexual activities by others; meeting a child following sexual grooming with the intent of abusing them; online abuse including making, viewing, or distributing child abuse im­ages; allowing someone else to make, view, or distribute child abuse images; showing pornography to a child; and sexually exploiting a child for money, power, or status (child exploitation) (35).

Most victims are female, however, male victims may be underrep­resented in the literature. For many victims of child sexual abuse in the family environment, abuse begins around age 9. Younger chil­dren may experience sexual abuse but they may not have the words to describe or explain their experiences to an adult, and they may not recognize that they are being sexually abused (35).

Victims from some black minority ethnic groups may face add­itional barriers to getting help, including, for example, a distrust of statutory services, a preference for informal community-based reso­lution, and the precedence of the ‘honour' of the perpetrator and concern for the apparent perceived ‘shame' that may be brought to the family and/or community (35).

Children with physical or learning disabilities may not have the capacity to understand or make a verbal disclosure. The symptoms of abuse, for example, inappropriate sexual behaviour, may be attrib­uted to a learning difficulty, rather than the possibility of child sexual abuse in the family (35).

The disclosure or discovery of sexual abuse within a family is likely to have an enormous impact on the victim and their relationship with other family members. Fear, coercion, loyalty to the perpet­rator, and/or a desire to protect other family members may prevent a victim of child sexual abuse from telling anyone (35).

Signs and symptoms of child sexual abuse

Children who are sexually abused may stay away from certain people, show sexual behaviour that is inappropriate for their age, and may become sexually active at a young age. Physical symptoms include anal or vaginal soreness, an unusual discharge, sexually transmitted infections, and pregnancy (36).

The child may also display unusual behaviour: be withdrawn, sud­denly behaving differently, or be anxious, clingy, or depressed. They can sometimes appear aggressive with difficulties at school, have problems sleeping, and develop eating disorders and bed wetting problems. Obsessive behaviours and nightmares sometimes occur. They may also self-harm and have suicidal thoughts (36).

Several studies show that childhood sexual abuse often leads to long-term mental and physical health problems that continue into adulthood. In a report by Ports et al., it was suggested that adverse childhood experiences including childhood sexual abuse increase the risk of sexual victimization as an adult (37). Childhood sexual abuse may also occur between peers (38).

A study by the NSPCC identified, however, that therapeutic inter­vention had many beneficial outcomes. These include improved mood, confidence, and being less withdrawn, a reduction in guilt and self-blame, reduced depression, anxiety, and anger, improved sleep patterns, and better understanding of appropriate sexual behaviour (39).

It is argued that the true magnitude of sexual violence is hidden because of its sensitive and illegal nature. Most children and fam­ilies do not report cases of abuse and exploitation because of stigma, fear, and lack of trust in the authorities. Social tolerance and lack of awareness also contribute to under-reporting (40).

Commercial sexual exploitation

Commercial sexual exploitation includes sexual activities which ob­jectify and harm others (usually women) such as prostitution, phone sex, stripping, Internet sex/chat rooms, pole dancing, lap dancing, peep shows, pornography, trafficking, sex tourism, and ‘mail-order brides'.

It legitimizes negative attitudes towards women and is inex­tricably linked to gender inequality and sexual violence (41). Commercial sexual exploitation can happen to both women and men but women are more commonly affected. Women involved are often on low incomes, are substance abusers, and there is strong evidence that they have experience of other forms of gender-based violence (41).

It is difficult to quantify the numbers of women involved in com­mercial sexual exploitation, partly because some activities, such as pole dancing, are seen as ‘normal' and others, such as trafficking into prostitution, are criminal and therefore hidden (41).

Sex trafficking is a modern-day form of slavery in which a com­mercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act is under the age of 18 years (42).

The Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children is the first international consensus definition of the problem. The Protocol defines ‘traf­ficking in persons' as the recruitment, transportation, transfer, har­bouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude, or the removal of organs (43).

Commercial sexual exploitation adversely affects physical, sexual, and mental health and is a serious public health issue. The health impact of commercial sexual exploitation can be profound, both as a result of coping with the consequences of exploitation and because of the greater exposure to violence and other forms of abuse inherent in this activity (41).

Signs found in an individual who has undergone commercial sexual exploitation include substance misuse, headaches, fatigue, dizzy spells, back pain, depression, anxiety, hostility, dissoci­ation and signs of PTSD, suicide ideation, signs of physical as­sault, rape and sexual assault, HIV infection, sexually transmitted infections, urinary tract infections, and repeated terminations of pregnancy (41).

Other signs of commercial sexual exploitation include difficulty in getting to health services during normal working hours, inability to keep appointments (through drug addiction/intoxication, lack of money to travel to appointments or pay for prescriptions), disclosure of child sexual abuse or domestic abuse, homelessness, or any evi­dence to suggest control or domination by a partner or pimp (41).

Health workers are again in a unique position to respond to women and girls affected by commercial sexual exploitation. It is important to treat them with dignity and respect. Help can be offered by recog­nizing possible indicators of abuse, initiating discussion, providing clinical care if necessary, and helping women access safety (41).

It is important to be sensitive to different needs and ensure all patients can access services equally, for example, by providing pro­fessional interpreting services (41).

'Honour' crimes

There is no specific offence of ‘honour’-based crime. It is an umbrella term to encompass various offences covered by existing legislation. ‘Honour’- based violence can be described as a collection of practices which are used to control behaviour within families or other social groups to protect perceived cultural and religious beliefs and/or ‘honour’. Such violence can occur when perpetrators perceive that a relative has shamed the family and/or community by breaking their honour code.

‘Honour’-based violence is defined as a crime or incident which has or may have been committed to protect or defend the honour of the family and/or community. It may be a form of domestic or sexual violence (44).

Forced marriage

Forced marriage is a term used to describe a situation where one or both people do not (or in cases of people with learning disabilities, cannot) consent to their marriage and pressure or abuse is used. It is recognized in the United Kingdom as a form of violence against women, domestic/ child abuse, and a serious abuse of human rights (42).

The pressure put on people to marry against their will can be physical (including threats, actual physical violence, and sexual vio­lence) or emotional and psychological (e.g. when someone is made to feel that they are bringing shame on their family). Financial abuse (taking control of wages or not giving any independent money) can also be a factor (45).

Female genital mutilation/cutting

Female genital mutilation/cutting (FGM/C) is recognized inter­nationally as a violation of the human rights of girls and women (46). United Kingdom laws recognize the problem and the Royal College of Obstetricians and Gynaecologists has issued guidelines to medical professionals. It comprises all procedures that involve par­tial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons (46).

FGM/C constitutes a form of child abuse and violence against women and girls, and has short-term and long-term physical and psychological consequences. It has no health benefits and harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and hence interferes with the natural function of girls’ and women’s bodies (47).

The World Health Organization estimates that 2 million women undergo some form of FGM/C annually (47). Statistics from some developing countries suggest that FGM/C is decreasing with increasing awareness and education. Yet this current progress in FGM/C decline is not sufficient to keep up with the rising popula­tion growth. If the current trends continue, the proportion of girls and women undergoing FGM/C will increase significantly over the next 15 years (48).

With increasing migration to Europe and North America, obstet­ricians and midwives working in these countries have been increas­ingly exposed to, and asked to care for women who have suffered FGM/C (46).

Much of the behaviour defined as cultural is unnecessary, but for immigrant and refugee communities the maintenance of practices such as FGM/C may be a way of preserving continuity with their past lives. One implication of this is that FGM/C could increase in Western countries with growing immigrant communities.

Female genital mutilation/cutting is classified into four major types (Table 55.1) (46):

• Type 1: often referred to as clitoridectomy, this is the partial or total removal of the clitoris and in very rare cases, only the prepuce.

• Type 2: often referred to as excision, this is the partial or total re­moval of the clitoris and the labia minora with or without excision of the labia majora.

• Type 3: often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without re­moval of the clitoris (clitoridectomy).

• Type 4: this includes all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, pier­cing, incising, scraping, and cauterizing the genital area.

Deinfibulation refers to the practice of opening the sealed vaginal opening in a woman who has been infibulated, which is often neces­sary for improving physical and psychological health and well-being as well as to allow intercourse or to facilitate childbirth (46).

Table 55.1 Female genital mutilation classification (WHO 1997. Female genital mutilation: a joint WHO/UNICEF/UNFPA statement. World Health Organization).

Mental health consequences

The age at which girls undergo FGM/C varies enormously according to the community. The procedure may be carried out when the girl is newborn, during childhood or adolescence, immediately before marriage, or during the first pregnancy. However, the majority of cases of FGM/C are thought to take place between the ages of 5 and 8 years and therefore girls within that age bracket are at a higher risk (47).

There has been relatively little published research that examines the health-related psychological outcomes in black minority ethnic groups. This is also true for health-related attitudes and beliefs. Psychology has a potential to contribute to care and prevention re­lating to FGM/C. But, perhaps in common with other health pro­fessionals, psychological practitioners and researchers in the United Kingdom are relatively uninformed about FGM/C (49).

The time lag between FGM/C (typically in childhood) and the manifestation of psychological or mental health problems in ado­lescence or adulthood means that women are less likely to make a causal link between any current difficulties to FGM/C (49).

Lockhat suggests that adverse mental health effects are associated with the following factors: severe forms of FGM/C, immediate post- FGM/C complications, chronic health problems and/ or loss of fertility secondary to FGM/C, non-consensual circumcision in adolescence or adulthood, and FGM/C as punishment. By contrast, some of the ‘mitigating’ factors include post-FGM/C affirmation and social sup­port and the absence of complications in the short and long term (50).

Behrendt and Moritz argued that circumcised women showed a significantly higher prevalence of PTSD (30.4%) and other psychi­atric syndromes (47.9%) compared to uncircumcised women. PTSD was accompanied by memory problems (51).

It could be claimed that other sources of adversity, such as diffi­culties relating to cultural transition, poverty, social exclusion, and other socioeconomic factors, provide more salient explanations for mental health difficulties than FGM/C per se. Indeed, for some women, major struggles in the here and now may render unim­portant a childhood event that is only vaguely remembered.

Some forms of FGM/C can lead to coital difficulties. While sur­gical reversal can improve the situation, some women or couples do not wish to undergo reversal and sometimes difficulties are not ef­fectively ameliorated by reversal. For example, as a result of previous experiences of pain during sexual activities, a woman may develop an anxiety response to sexual intercourse or sexual activities in gen­eral. Anxiety can hinder arousal mechanisms resulting in vaginal dryness, muscular spasm, and painful intercourse despite an ab­sence of anatomical problems. Education, counselling, and support can be helpful in these situations.

Physical health complications

Women and girls living with FGM/C have experienced a harmful practice and may experience physical health complications as a re­sult of this. These could be short- and/or long-term physical health complications.

Short-term health consequences

• Severe pain: cutting the nerve ends in sensitive genital tissue causes extreme pain. Adequate anaesthesia is rarely used and, when used, is not always effective. The healing period is also painful. Type 3 FGM/C is a more extensive procedure of longer duration, hence the intensity and duration of pain may be more severe. The healing period is also prolonged.

• Excessive bleeding (haemorrhage): can result if the clitoral artery or other blood vessel is cut during the procedure.

• Shock: can be caused by pain, infection, and/or haemorrhage.

• Infections: may spread after the use of contaminated instruments (e.g. use of same instruments in multiple genital mutilation oper­ations), and during the healing period.

• HIV: the direct association between FGM/C and HIV remains un­confirmed, although the cutting of genital tissues with the same surgical instrument without sterilization could increase the risk for transmission of HIV between girls who undergo female genital mutilation together.

• Urination problems: these may include urinary retention and pain passing urine. This may be due to tissue swelling, pain, or injury to the urethra.

• Death: can be caused by infections, including tetanus and haemorrhage.

Long-term health risks from types 1,2, and 3 (occurring at any time during life)

• Pain: due to tissue damage and scarring that may result in trapped or unprotected nerve endings.

• Chronic genital infections: with consequent chronic pain, and va­ginal discharge and itching. Cysts, abscesses, and genital ulcers may also appear.

• Chronic reproductive tract infections: may cause chronic back and pelvic pain.

• Urinary tract infections: if not treated, such infections can ascend to the kidneys, potentially resulting in renal failure, septicaemia, and death. An increased risk for repeated urinary tract infections is well documented in both girls and adult women.

• Painful urination: due to obstruction and recurrent urinary tract infections.

• Menstrual problems: result from the obstruction of the vaginal opening. This may lead to painful menstruation (dysmenorrhea), irregular menses, and difficulty in passing menstrual blood, par­ticularly among women with FGM/C type 3.

• Keloids: there have been reports of excessive scar tissue formation at the site of the cutting.

• HIV: given that the transmission of HIV is facilitated through trauma of the vaginal epithelium which allows the direct intro­duction of the virus, it is reasonable to presume that the risk of HIV transmission may be increased due to increased risk for bleeding during intercourse, as a result of FGM/C.

• Female sexual health: removal of, or damage to, highly sensitive genital tissue, especially the clitoris, may affect sexual sensitivity and lead to sexual problems, such as decreased sexual desire and pleasure, pain during sex, difficulty during penetration, decreased lubrication during intercourse, and reduced frequency or absence of orgasm (anorgasmia). Scar formation, pain, and traumatic memories associated with the procedure can also lead to such problems.

• Complications during childbirth: some studies have suggested in­creased risks of prolonged labour, postpartum haemorrhage, and perineal trauma. Affected women may also have a heightened fear of childbirth (tocophobia). One large World Health Organization study also found an increased risk of caesarean section, increased need for neonatal resuscitation, and risk of stillbirth and early neo­natal death (52, 53).

There is an increased risk of adverse health outcomes with in­creased severity of FGM/C.

It is important for healthcare providers to have a basic under­standing of the history, types, and complications related to FGM. Lack of knowledge about the cultural context and clinical best prac­tices can lead to inconsistent care and poor outcomes for women affected by FGM/C.

An aide memoire for discussing FGM/C with patients (54) includes:

• taking a basic history of when and where it was performed

• what community and in what context

• if she has had any treatment

• what beliefs she has around religion and culture

• what are her wishes/thoughts about her daughters under­going FGM/C

• and if any medical help is required for any symptoms

• any concerns.

A culturally competent, gender and ethically sensitive approach is important to ensure the provision of quality, ethical care for migrant women affected by FGM in host countries (55).