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Intimate Partner Violence
Women who are abused are frequently treated within health-care systems, however, they generally do not present with obvious trauma, even in accident and emergency departments. Intimate partner violence has long-term negative health consequences for survivors, even after the abuse has ended. These effects can manifest as poor health status, poor quality of life, and high use of health services.
Physical Health Effects Injury: IPV is one of the most common causes of injury in women. Battered women were more likely to have been injured in the head, face, neck, thorax, breasts, and abdomen than women injured in other ways. Although most battered women in the USA state that they have been injured as a result of the abuse, less than half say that they sought health care specifically for those injuries. Homicide: 40–60% of murders of women in North America are perpetrated by intimate partners. Suicide Chronic health problems: The injuries, fear, and stress associated with intimate partner violence can result in chronic health problems such as chronic pain (eg, headaches, back pain) or recurring central nervous system symptoms including fainting and seizures. Abused women frequently (10–44%) report choking—incomplete strangulation—and blows to the head resulting in loss of consciousness, both of which can lead to serious medical problems including neurological sequelae. Gastrointestinal complaints (eg, loss of appetite, eating disorders) and diagnosed functional gastrointestinal disorders (eg, chronic irritable bowel syndrome) associated with chronic stress. These disorders may begin during an acutely violent and thus stressful relationship, be related to child sexual abuse, or both. The consequent functional damage to the bowel can last far longer than the violent relationship. Cardiac Symptoms such as hypertension and chest pain have also been associated with intimate partner violence. It is plausible to postulate interactions between genetic tendencies for hypertension, lifestyle risk behaviors (such as smoking), and stress from violent relationships but mechanisms have not been thoroughly investigated. Gynecological problems are the most consistent, longest lasting, and largest physical health difference between battered and non-battered women. Differential symptoms and conditions include sexually-transmitted diseases, vaginal bleeding or infection, fibroids, decreased sexual desire, genital irritation, pain on intercourse, chronic pelvic pain, and urinary-tract infections. The combination of physical and sexual abuse that characterizes the experience of at least 40–45% of battered women puts these women at an even higher risk for health problems than women only physically assaulted. Forced sex has consequences that could explain the higher prevalence of gynecological problems, although few studies have measured forced sex separately. Possible mechanisms of increased risk include the shame and stress reported with forced sex manifesting as especially high levels of stress and depression known to depress the immune system; vaginal, anal, and urethral trauma from forced sex (direct force or lack of lubrication) leading to increased transmission of microorganisms through direct transmission into the bloodstream or back flow of bacteria in the urethra; and men forcing sex on partners and having unprotected sex with other partners. Sexually transmitted diseases, HIV, and unintended pregnancy were linked to intimate partner abuse in population-based studies in the USA and developing countries. Qualitative data from in-depth interviews show how abuse interacts with complex social, psychological, and cultural factors involved in decisions and actions to prevent pregnancy or sexually transmitted diseases, including HIV and AIDS and the difficulty of negotiation of use of condoms or contraception in violent relationships. Additionally, from the USA and developing countries come narratives of requests for condom use, HIV testing, or notification of positive-HIV status resulting in abusive incidents, often with accusations of infidelity Maternal/Child Health: The main health effect specific to abuse during pregnancy is the threat to health and risk of death of the mother, fetus, or both from trauma. Another cause of fetal death, elective pregnancy termination, has also been related to intimate partner violence in large but uncontrolled studies in the USA. Physical abuse in pregnancy is associated with health problems during pregnancy such as sexually-transmitted diseases including HIV- urinary-tract infections, substance abuse, depression, and other mental-health symptoms. Although many US studies have noted associations of abuse during pregnancy with infant outcomes such as preterm delivery, fetal distress, antepartum haemorrhage, and pre-eclampsia, evidence is inconsistent across studies. A meta-analysis of 14 published studies from North America and Europe showed a weak but significant association between abuse during pregnancy and low birthweight. Maternal low weight gain, smoking, or both were mediators of the connection between abuse and low birthweight in several studies. Abusive partners might pressure their wives or girlfriends not to gain weight, or abuse could cause stress, which has in turn been associated with smoking, low weight gain, and consequent low birthweight.
Mental Health Effects Depression and post-traumatic stress disorder, which have substantial comorbidity, are the most prevalent mental-health sequelae of intimate partner violence. Depression in battered women has also been associated with other life stressors that often accompany domestic violence, such as childhood abuse, daily stressors, many children, changes in residence, forced sex with an intimate partner, marital separations, negative life events, and child behavior problems. Some battered women might have chronic depression that is exacerbated by the stress of a violent relationship, but there is also evidence that first episodes of depression can be triggered by such violence, and longitudinal evidence of depression lessening with decreasing intimate partner violence. Post-traumatic stress disorder in battered women is much more prevalent than in non-abused women. Severity of abuse, previous trauma, and partner dominance have been identified as important precursors of post-traumatic stress disorder developing from intimate partner violence. Suicidal tendencies, although less often studied than post-traumatic stress disorder, have also been associated with intimate partner violence A Canadian population-based study found that in addition to depression, abused women had significantly more anxiety, insomnia, and social dysfunction than those not abused, with physical violence having a stronger effect than psychological abuse. Alcohol and drug abuse
is the other mental health problem most frequently seen in battered women in
industrialized countries. A postulated explanation of substance use as an
outcome of intimate partner violence is through posttraumatic stress disorder.
Women with post-traumatic stress disorder might use drugs or alcohol to calm or
cope with the specific groups of symptoms associated with post-traumatic stress
disorder: intrusion, avoidance, and hyperarousal. In a population-based study,
substance use was both a risk factor for, and effect of, post-traumatic stress
disorder and all forms of violence, especially repeated violence and childhood
trauma. Women can also begin to abuse substances through their relationships
with men or from wanting to escape the reality of intimate partner violence. It
is important to address and understand these complex relations between intimate
partner violence, mental health, and behavior to diagnose accurately and
intervene in substance-abuse problems. |
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