An Estimation of the Economic Impact of Spousal Violence in Canada, 2009

4. Victim Costs

The majority of spousal violence incidents are not brought to the attention of the criminal justice system, but all victimizations, whether reported to authorities or not, impact the victim. The GSS records that 336,000 victims experienced at least one incident of spousal violence in 2009, and that 54% of these victims were female. Given the limitations of the GSS outlined in the Methodology section, the victim cost estimates are significantly limited as they are largely based on the number of victims only, not the number of incidents. Both tangible and intangible impacts on victims are considered in this section. Table 4.1 summarizes the economic impact of spousal violence on victims.

Table 4.1: Victim Costs
  Violence against females ($thousand) Violence against males Total
Health Care $8,159,984 $12,765,853 $20,925,837
Physician visits $149,571 $39,640 $189,211
Emergency department visits $4,490,409 $1,459,282 $5,949,691
Acute hospitalization $3,520,004 $11,266,931 $14,786,935
Mental Health Issues $146,868,486 $32,613,453 $179,481,939
Medical services $38,013,972 $10,030,455 $48,044,427
Work loss $98,178,631 $21,434,414 $119,613,045
Suicide attempts * (medical cost) $10,675,883 $1,148,584 $11,824,467
Productivity Losses $37,125,687 $16,239,509 $53,365,196
Lost wages $20,943,599 $12,728,087 $33,671,686
Lost household services $15,450,178 $3,451,422 $18,901,600
Lost education $259,081 $0 $259,081
Lost child care $472,829 $60,000 $532,829
Other Personal Costs $211,865,378 $59,396,907 $271,262,285
Damaged or destroyed property $62,915,576 $26,306,202 $89,221,778
Divorce and Separation (legal costs) $134,914,290 $31,646,562 $166,560,852
Special phone features $1,791,358 $254,044 $2,045,402
Moving $12,244,154 $1,190,099 $13,434,253
 Intangible Costs $3,290,719,565 $2,169,480,155 $5,460,199,720
Pain and suffering $2,251,037,864 $1,736,911,856 $3,987,949,720
Loss of life $1,039,681,701 $432,568,299 $1,472,250,000
Total Victim Costs $3,694,739,100 $2,290,495,877 $5,985,234,977

* Loss of life due to completed suicide is included under the intangible costs.

Note: May not add to stated totals due to rounding

4.1. Health Care

The GSS asks spousal violence victims about the medical attention they received as a result of the incidents. The GSS finds that 3 in 10 victims sustained physical injuries during spousal violence incidents in 2009, with 42% of female victims reporting injuries and 18% of male victims reporting injuries. Information from the GSS, the Canadian Institute for Health Information (CIHI) and other sources pertaining to the costs of administering medical services in Canada allow estimates of health care costs for physical injuries resulting from spousal violence in three areas: medical attention from a physician or nurse, hospital emergency department visits, and acute hospitalization. All victim counts are from the GSS and most cost per service data is from the CIHI (with the exception of ambulatory service costs).

As explained in the Limitations section, the structure of the GSS leads to an underestimation of health care costs, because only the number of victims who required medical attention is counted, not the number of times that each victim required medical attention. For example, if one victim was hospitalized five times as a result of multiple spousal violence incidents, the GSS would only show that the victim was hospitalized (once) at some point during the year, not the number of hospitalizations. This limitation also partially explains the result that acute hospitalization costs are higher for male victims than for female victims, which is seemingly contradictory to research in the area. Tjaden and Thoennes (2000) use the National Violence against Women Survey conducted in the US to show that females are more likely than males to sustain injuries, receive medical care, and require hospitalization due to recent episodes of spousal violence. Since the GSS does not record the medical service requirements following each incident, the actual number of times that each victim required medical treatment is suppressed to just one time. That is to say, victims who were hospitalized five times and victims who were hospitalized one time were all recorded in the survey as simply being hospitalized, so it can only be assumed that each of these victims was hospitalized once. Therefore, the estimated health care costs are likely to be underestimated, especially for females, as female victims have a greater tendency than male victims to require medical treatment after incidents of spousal violence (Tjaden and Thoennes 2000). In addition, because the sample size of the victims who sought medical attention (particularly for acute hospitalization) is very small, the weighted population might be a misrepresentation of the actual health care requirements resulting from spousal violence in Canada.

4.1.1 Physician visits

The GSS finds that there were 2,719 female victims and 721 male victims who received medical attention from a doctor or nurse as a result of spousal violence in 2009. Based on data from CIHI (2007), it is estimated that a single visit to a family doctor in 2009 cost approximately $55. Multiplying the number of victims visiting a physician by the cost per visit, the total economic impact of spousal violence in 2009 through physician visits is estimated at $189,212. See Appendix B: Victim Costs – B.1 Health Care for detailed calculations and sources.

Physician visits costs – SV against females $149,571
Physician visits costs – SV against males $39,640
Total Health Care Costs, Physician Visits $189,212

4.1.2 Emergency department visits

Emergency department visit costs include both medical services and ambulatory services.

The GSS finds that 7,245 females and 2,602 males visited emergency departments to receive medical attention for injuries sustained during incidents of spousal violence in 2009. The average cost of a single visit to a hospital emergency department in 2009, as derived from CIHI (2010), was $266. The total cost of hospital emergency department visits is calculated by multiplying the number of victims requiring emergency department services by the average cost of a visit, and the resulting estimate is $1,926,564 for female victims and $691,935 for male victims.

The National Ambulatory Care Reporting System (NACRS) data provided by the CIHI[38] show that 78% of female victims and 69% of male victims of firearm offences with firearm-caused injuries who visited emergency departments in 2008 were transported to the hospital by ambulance. These figures are used as guides for the case of spousal violence as no statistics are available for victims of spousal violence specifically. Considering the seriousness of firearm-caused injuries and the wider range of injuries incurred by spousal violence, it is assumed that a lower proportion of spousal violence victims required ambulance transportation for emergency department visits: 60% (4,347) of female victims and 50% (1,301) of male victims who went to an emergency department are assumed to have required ambulance transportation. The average cost of providingground ambulance transport in 2009 is estimated at $590 per trip.[39] The total costs of ambulance services, obtained by multiplying the number of victims using ambulatory services by the cost per trip, are estimated at $2,563,845 for female victims and $767,347 for male victims.

Adding the hospital costs to the ambulance costs, the total costs of spousal violence in 2009 through emergency department visits are estimated at $5,949,691.

Emergency department visits costs – SV against females $4,490,409
Emergency department visits costs – SV against males $1,459,282
Total Health Care Costs, Emergency Department Visits $5,949,691

4.1.3 Acute hospitalization

Acute hospitalization is defined as overnight admission to hospital for a minimum of one night (i.e., overnight hospitalization). The two components of acute hospitalization costs are hospital services and ambulatory services.

The GSS finds that 1,444 female victims and 800 male victims required acute hospitalization due to injuries sustained during incidents of spousal violence in 2009. While the cost of each acute hospitalization depends on the medical condition, the specific services received, the length of stay, the sex and age of the patient, and the location of the hospital, an average daily cost can be estimated from two reports from CIHI. The first report (2008) provides information on the cost of acute hospitalization stays and the second report (2009) provides information on the average length of acute hospitalization stays. The estimated daily cost of acute hospitalization in 2009 is $1,044.

According to the GSS, the length of acute hospitalization stays differed between male and female victims. Males injured by a current spouse were hospitalized overnight for an average of 17 days, while female victims were hospitalized overnight for an average of 2.4 days. A possible explanation for this disparity is the higher prevalence of weapons used in spousal violence incidents against males; 15% of male victims had a weapon used against them, while 5% of female victims had a weapon used against them. It follows from the number of victims hospitalized and the average lengths of stay that female victims were hospitalized overnight for a total of 2,882 days and male victims were hospitalized overnight for a total of 10,521 days. Acute hospitalization costs are calculated by multiplying the number of acute hospitalization days by the average daily cost; the total costs of the hospital component are $3,009,211 for female victims and $10,983,850 for male victims.

The method used to calculate ambulatory service costs for Emergency department visits (above)is also used in this section, though with one adjustment: both female and male victims hospitalized overnight are assumed to have required ambulance services at a rate of 60% because of the implied severity of injuries requiring acute hospitalization. Applying the $590 average cost per ambulance trip, total ambulance costs are estimated at $793,873.

Total acute hospitalization costs are acquired by adding the hospital and ambulance costs. The total economic impact of spousal violence in 2009 through acute hospitalization is estimated at $14,786,935.

Acute hospitalization costs – SV against females $3,520,004
Acute hospitalization costs – SV against males $11,266,931
Total Health Care Costs, Acute Hospitalization $14,786,935

4.2 Mental Health Issues

The adverse health consequences of spousal violence are manifested both mentally and physically, and the link between spousal violence against women and mental health issues is well documented. Weinbaum et al. (2001) finds that 48% of women who had been battered stated that they had “wanted help with mental health in the past 12 months.” Many studies show that women who have been abused by intimate partners are at greater risk for developing certain mental health issues, including depression, post-traumatic stress disorder (PTSD), substance abuse, and suicidal behaviour. American and Canadian studies find that women receiving services for domestic violence experience depression at a rate ranging from 17% to 72% and PTSD at a rate ranging from 33% to 88% (Arias and Pape 1999; Astin et al. 1993; Astin et al. 1995; Campbell et al. 1995; Cascardi and O'Leary 1992; Humphreys 2003; Humphreys et al. 2001; Kubany et al. 1996; Sackett and Saunders 1999; Street and Arias 2001; Torres and Han 2000). A meta-analysis of studies of battered women by Golding (1999) suggests a weighted mean prevalence among female victims of 48% for depression, a weighted mean prevalence among female victims of 64% for PTSD, and a weighted mean prevalence among female victims of 18% for suicide.

There is less evidence pertaining to the mental health effects of spousal violence on men. Hines and Douglas (2010) conducted a study of 302 men who were victims of intimate partner violence (IPV) perpetrated by women, and they find that 9.6% of the men had been diagnosed with a mental health issue since being in the abusive relationship. The most common mental disorder was depression (64.8% of all sample men with a mental illness), followed by anxiety (47.9% of all sample men with a mental illness) and PTSD (12.7% of all sample men with a mental illness).

Estimation of the number of victims who have developed a mental health issue as a result of spousal violence is complicated by the wide range of possible mental health issues, the criteria used to determine morbidity, and the possibility of one victim developing multiple health issues.In light of these complications and the data limitations, depression and anxiety are used as proxies for all mental health issues associated with spousal violence. Depression is one of the most widespread mental health issues in Canada,[40] and the GSS contains useable data on depression. Therefore, only three individual cost items associated with mental health issues are examined in this section, and only the incremental costs, those costs that are incurred by people with mental health issues that are not incurred by people with no mental health issues, are included in each cost item. The three cost items are: medical services, productivity losses, and hospital costs due to suicide attempts. Following Lim et al. (2008b), both diagnosed and undiagnosed mental health issues are analyzed.

4.2.1 Medical services

Mental health medical services are offered by a diverse range of service providers in Canada. Services specific to the treatment of mental health issues include specialist services, hospital programs focusing on mental health (including outpatient and inpatient care), and community mental health centres that offer counselling and home-based or community-based mental health treatment. Individuals with mental health issues are also more likely to use mainstream health services more frequently than people with no mental health issues; Mai et al. (2010) find that users of mental health services visit general practitioners (GPs) more often than those without mental health problems. At the primary level of health care, GPs are the most frequently consulted health professionals for mental health matters and are responsible for much of the treatment of mental illness (Health Canada 2002).

Lim et al. (2008b) utilize data from the 2003 Canadian Community Health Survey to examine the incremental use of health care services by people with mental illness. They classify respondentsas having a diagnosed mental illness, an undiagnosed mental illness, or no mental illness; respondents are classified as having an undiagnosed mental illness if the respondents reported their own mental health as poor, contacted a mental health professional at least twice, scored at a certain level in a depression screening module, or reported serious ideations of suicide.

Lim et al. (2008b) find that the average number of GP visits per year is 6.7 for people with a diagnosed mental illness, 4.8 for people with an undiagnosed mental illness, and 2.9 for people with no mental illness. Similar trends are seen in the use of other health care services such as specialist visits and hospital days (see Table 4.2). The completeness of data in Lim et al. (2008b) is limited by: the diagnosis method, which requires predefined symptoms to be observed for a diagnosis, thereby potentially omitting some people who experience non-traditional symptoms for a mental health issue, and the potential choice of a person with a mental health issue to not seek medical attention, which results in no diagnosis and no use of medical services even though the person is affected by the disorder.

Table 4.2: Medical Service Utilization by Mental Health Status in Canada
Medical Services No Mental Illness Diagnosed Mental Illness Undiagnosed Mental Illness
GPs visits 2.9 6.7 4.8
Specialist Visits 0.7 2.5 1.7
Hospital Days 0.5 2.2 1.2

The estimate for this section includes the incremental medical costs for people with a mental health issue, but due to data limitations, community mental health services and drug expenditures are not included. The GSS is used to determine the number of Canadians who developed a mental health issue as a result of spousal violence victimization. Specifically, the GSS finds that 38,332 females and 10,320 males reported suffering from depression or anxiety within a year of being a victim of spousal violence, representing 21.3% of all female victims and 6.6% of all male victims of spousal violence that year. The GSS rate for females falls within the 17% to 72% range of results in the Canadian and US studies cited earlier, suggesting that the GSS rate is a reasonable finding.

Among spousal violence victims who suffered from depression or anxiety, the GSS shows that 30.9% of females and 19.5% of males used medication for treatment (either prescribed or over-the-counter). This group of victims (including both females and males: 13,848) is categorized as having diagnosed mental health issues. The remaining victims, who reported depression or anxiety but did not report the use of medication to address the issues, are classified as having an undiagnosed mental health issue (including both females and males: 34,804).

Lim et al. (2008b) provide the incremental health care costs for people with diagnosed or undiagnosed mental health issues as compared to people with no mental health issue. Each classification of people (diagnosed, undiagnosed, or none) is further divided into five age groups, and the GSS allows for the same grouping of ages. For example, Lim et al. (2008b) find that for the 20 to 34 age group, the incremental medical costs for people with a diagnosed mental health issue were $1,246 and the incremental medical costs for people with an undiagnosed mental health issue were $382. Each incremental cost estimate for each age group from Lim et al. (2008b) is multiplied by the number of victims with a mental health issue in that age group from the GSS. The total economic impact of spousal violence in 2009 through mental health medical services is estimated at $48,044,427.

Medical costs for mental health issues – SV against females $38,013,972
Medical costs for mental health issues – SV against males $10,030,455
Total Costs of Mental Health Issues, Medical Services $48,044,427

4.2.2 Work loss

This section addresses work loss associated with absenteeism due to mental health issues; productivity losses associated with absenteeism due to physical injuries are estimated in this section under Productivity Losses. Lim et al. (2008b) find that the average number of missed work days per year due to short-term disability is 33 days for people with diagnosed mental health issues, 27 days for people with undiagnosed mental health issues, and 10 days for people with no mental health issues (see above in Medical services for a description of diagnosed and undiagnosed classifications). This implies that the incremental work loss of people with diagnosed mental health issues is 23 days and the incremental work loss of people with undiagnosed mental health issues is 17 days. Long-term work loss (unemployment) due to mental health issues is not examined due to data limitations.

The number of work days missed because of mental health issues is used by Lim et al. (2008b) to calculate the incremental costs of work loss, where the diagnosed and undiagnosed categories of people are further subdivided into age groups. For example, the incremental costs of work loss for people with a diagnosed mental health issue and aged 20 to 34 was $3,454 in 2009, while the incremental work loss of people with an undiagnosed mental health issue in the same age group was $2,023 in 2009.

It is estimated that 13,848 victims were diagnosed with a mental health issue and 34,804 victims suffered from an undiagnosed mental health issue as a result of spousal violence. These groups of victims are further subdivided into age groups corresponding to those of the work loss cost estimates above. The work loss of spousal violence victims is then calculated by multiplying the number of relevant victims for each age group by the corresponding work loss cost estimates. The total economic impact of spousal violence in 2009 through mental health-related work loss is estimated at $119,613,045.

Short-term work loss – SV against females $98,178,631
Short-term work loss – SV against males $21,434,414
Total Costs of Mental Health Issues, Short-term Work Loss $119,613,045

4.2.3 Suicide attempts (medical costs)

This section draws on many sources to estimate the number of suicide attempts (including all cases of self-injury) brought about by spousal violence that resulted in hospital treatment, and the costs associated with that treatment. The two elements of healthcare involved in the treatment of self-injury are acute (overnight) hospitalizations and emergency department visits. While medical costs related to all suicide are included in this section (both those that resulted in a fatality and those that did not), the value of lost lives as a result of completed suicides will be examined in the later section on Loss of Life.

Research has shown that there are higher rates of suicide and suicide attempts among victims of spousal violence than among non-victims. Studies from many countries (including the US, the UK, Fiji, Papua New Guinea, Peru, India, Bangladesh, and Sri Lanka) show a positive correlation between domestic violence and suicide. A United Nations study (United Nations 1989) concludes that suicide is twelve times more likely to have been attempted by a woman who had been abused by a spouse than by a woman who had not been abused. Golding (1999) conducts a meta-analysis of 13 studies that find suicide prevalence rates among battered women ranging from 4.6% to 77% and Golding (1999) estimates the weighted mean rate of suicidality at 17.9%. Singleton et al. (2002) examines a sample of women in the UK who had attempted suicide at some point in their lives and finds that 34% of the women had been victims of spousal violence. Stark and Flitcraft (1996) suggest that spousal abuse may be the single most important and common cause of female suicidality.

The Stark and Flitcraft (1996) study contains results that can be used in our estimates. They find that among the 176 American women in the study sample who went to an emergency department following an attempted suicide, 29.5% had been battered. Using this result, it is assumed that 29.5% of both attempted and completed suicides by females in 2009 were committed by victims who had experienced spousal violence, but this does not necessarily mean that spousal violence was the primary reason behind the suicide attempt. Therefore, another result from Stark and Flitcraft (1996) is used to ensure that only suicide attempts with spousal violence as the impetus are included in the estimate. The study finds that 36.5% of the battered women who had attempted suicide had visited the hospital due to an injury caused by spousal abuse on the same day as, but prior to, their suicide attempt. It is assumed that for these 36.5% of victims who harmed themselves, spousal violence was the primary cause of their attempted suicide. Together, these two assumptions lead to the conclusion that 10.8% (=29.5%*36.5%) of all attempted and completed suicides committed by women are primarily caused by spousal violence.

The extensive research on the link between spousal violence against women and suicide is in contrast to the dearth of similar studies on men. The research that does exist (Ansara and Hindin 2011; Ansara and Hindin 2010) suggests that the physical and emotional consequences of spousal violence are more severe for women than for men. These findings are supported by the GSS, which finds that female victims experienced more incidents on average than male victims (4.3 incidents compared to 2.7 incidents), a higher proportion of female victims visited a hospital than male victims (5.5% compared to 1.9%), and a higher proportion of female victims were mentally or emotionally affected by the incidents (87% compared to 65%).

It is clear that the proportion found for spousal violence attempts by females caused by spousal violence cannot be directly applied to the male case. However, there is no corresponding data relating to male suicide attempts and spousal violence, so the results of the female analysis are used as the basis for estimating the number of male suicide attempts resulting from spousal violence victimization. To properly account for the greater impact of violence on females, the results of Graham-Kevan and Archer (2003) regarding the proportion of Intimate Terrorism (IT) perpetrated by males and females is used. It is assumed that IT, being the most severe form of spousal violence, is the form of spousal violence that is responsible for nearly all suicide attempts caused by spousal violence. It is also assumed that females and males who are victims of IT have the same likelihood of attempting suicide, which implies that the proportion of suicide attempts by females to suicide attempts by males will be equivalent to the proportion of IT sustained by females to IT sustained by males. As Graham-Kevan and Archer (2003) finds that 87% of IT involved female victims and 13% involved male victims, the proportion of IT sustained by females as compared to males is 6.69 (=87%/13%). Therefore, this ratio is applied to the percentage of suicide attempts by females caused by spousal violence (10.8%) to give an estimate of the percentage of suicide attempts by males primarily caused by spousal violence at 1.6% (=10.8%/6.69).

While the acute hospitalization estimate in this section accounts for victims between the ages of 15 and 69 only, minimal costs are omitted with this method as hospitalizations resulting from suicide attempts decrease markedly among people aged 50 and older (CIHI 2011). One aspect of the hospitalization estimate that enhances its accuracy is that it is based on the number of hospitalizations, not the number of victims, as is the case in most other sections of this report. The estimate will therefore capture all hospitalizations for cases in which patients might be hospitalized multiple times. For example, CIHI (2011) states that 6% of patients admitted for suicide attempts in 2009-2010 had two hospitalizations and 1% of such patients had three or more hospitalizations. CIHI (2011) records 16,930 hospitalizations for suicide attempts or self-inflicted injury in 2009 in the 15 to 69 age range, 9,843 of which were hospitalizations of female patients. Using the rates of suicide attempts caused primarily by spousal violence as calculated above (10.8% for female suicide attempts and 1.6% for male suicide attempts), it is estimated that there were 1,060 hospitalizations of females and 114 hospitalizations of males for suicide attempts motivated by spousal violence. The average length of acute hospitalization for incidents of self-harm was 7.74 days in 2009-2010 (CIHI 2011), and thus the total number of days in hospital for spousal violence victims who attempted suicide is estimated at 9,086. The average daily hospitalization cost in Canada is calculated at $1,044, leading to total hospitalization costs of $9,485,530 for suicide attempts.

Emergency departments are also major centres of care for people sustaining self-inflicted injuries. Data from Ontario, Alberta, and Yukon show that patients who require overnight hospitalization for self-inflicted injuries visit an emergency department two to three times. It is therefore assumed that each acute hospitalization is accompanied by 2.5 emergency department visits and using the data from the acute hospitalization calculations above (1,060 hospitalizations for female victims and 114 hospitalizations for male victims), it is estimated that the total number of emergency department visits due to suicide attempts caused by spousal violence was 2,935 across Canada in 2009. It is assumed that persons who attempt suicide and are hospitalized for related injuries likely require ambulance transportation to the emergency department since they are unlikely to request medical attention of their own volition, despite the need for it. Therefore, it is assumed that ground ambulance transportation was required in 90% of relevant emergency department visits. As one emergency department visit cost $266 and one ground ambulance trip cost $590 in 2009, the total costs associated with emergency department visits for suicide attempts caused by spousal violence were $2,338,937.

Combining acute hospitalization and emergency department visit costs, the total economic impact of spousal violence through hospital treatment for suicide attempts in 2009 is estimated at $11,824,467. Again, please see Appendix B: Victim Costs – 4.2 Mental Health Issues – B.2.3 Suicide attempts – for detailed calculations and sources.

Medical costs for suicide attempts – SV against females $10,675,883
Medical costs for suicide attempts – SV against males $1,148,584
Total Costs of Mental Health Issues, Suicide Attempts $11,824,467

In terms of completed suicides motivated by spousal violence, we multiply the total number of completed suicides by the proportions which represent the percentage caused by spousal violence. As suicide statistics for 2009 were not available, we use the average number of the completed suicides of the most three recent years where such information is available. Between 2005 and 2007, the average number of completed suicides among people aged 15 to 69 in Canada was 3,254, of which 2,488 were committed by men. As estimated above, the proportions of female and male suicides caused by spousal violence were 10.8% and 1.6% respectively. Multiplying these rates by the total number of suicides yields the estimates of completed suicides caused by spousal violence: 82 for female victims and 40 for male victims. The value of lost human life will be examined and presented in Section 4.5 – Intangible Costs.