Health Impacts of Violent Victimization on Women and their Children

1. Introduction

Violence against women and children is a pervasive social problem in Canada, with significant impacts on a broad range of social and economic outcomes for women, children, families and communities. The present report examines the consequences of intimate partner violence (IPV) against women, and child witnessing of IPV, emphasizing their association with specific physical and mental health outcomes, including health-related quality of life (QoL) and health risk behaviours, where available. While not a primary emphasis of the report, key evidence on the other forms of violence against women and children (sexual assault of women by strangers and child sexual abuse) will also be summarized. The various types of violence against women, including IPV and sexual assault, often result in similar patterns of health impairment (Jordan et al., 2010), as do the impacts on children of witnessing IPV, and being victims of other forms of maltreatment.

1.1 Purpose of this Report

The specific objectives of the report are to:

  1. Provide a synthesis of current research on the links between violence and health, both physical and mental health, as in many instances, the two cannot be separated. Given that most of the research in this area focuses on intimate partner violence (IPV) and children witnessing violence, this will be a focus. The synthesis will highlight key findings, trends, common themes and gaps in the research, and will include Canadian research, as well as major studies from the US (e.g. the Adverse Childhood Experiences (ACE) Study), Australia and the UK, as appropriate.
  2. Ensure that links between sexual violence and health in cases of intimate partner violence, familial and non-familial child sexual abuse and sexual assaults perpetrated by strangers are also explored.

2. Definitions and Epidemiology

This section defines key concepts and presents the best available evidence regarding the prevalence of, and risk factors for, each type of violence, in Canada.

2.1 Intimate partner violence (IPV) against women

Defined as physical violence, sexual violence, or emotional or financial abuse between current or former married or common-law spouses (Statistics Canada, 2011), IPV is a significant public health and social problem occurring in all countries and all economic, social, religious and cultural groups, and results in significant personal, economic and social costs (World Health Organization, 2002; Garcia-Moreno & Watts, 2011;Ellsberg et al., 2008,Centers for Disease Control and Prevention, 2011). While affecting both men and women, IPV morbidity and mortality are higher for women (Statistics Canada, 2011;Centers for Disease Control and Prevention, 2011,Black & Breiding, 2008), with women exposed to IPV being at increased risk of injury and death, as well as a range of physical, emotional and social problems (reviewed below).

Different types of violent relationships exist, and these are well-described in the typology developed by Johnson (2006). A key contribution of this typology is that it distinguishes between situational couple violence (i.e., less violent, usually episodic conflict between partners which is often bilateral) and intimate partner terrorism, a pattern of physical, sexual and/or emotional abuse almost always directed toward women (Johnson, 2006) with the underlying motive being control. IPV against women characterized by coercive control is both more frequent and severe than IPV against men, and women are more likely to sustain injury and to fear for their lives (Ansara & Hindin, 2010; Leone et al., 2004); for example, in Canada, far more women than men are killed by an abusive partner (General Social Survey, Victimization; Statistics Canada, 2011). It is this type of violence that is more likely to result in the kinds of health consequences described below.

Studies of IPV between women in same-sex relationships suggest that the dynamics of abuse are similar to those experienced by women in heterosexual relationships (Eaton et al., 2008; Tjaden & Thoennes, 1999). Clinically-oriented guidance for those serving LGBT clients indicates similar mental and physical health consequences of abuse as for heterosexual victims (e.g., Ard and Makadon, 2011; McClennen, 2005; Balsam, Lehavot and Beadnell, 2011; Kulkin, Williams, Borne, de la Bretonne and Laurendine, 2007), however these studies also outline that some risk factors may differ (e.g., the threat or “outing” as a form of abuse) and that the availability of services specific to LGBT people lags far behind those for heterosexual victims of violence, which themselves are often insufficient (e.g., lack of emergency shelters for abused gay men). Thus in considering the health impacts of victimization reviewed below, it should be noted that, based on current research evidence, they are equally likely to apply to female victims of same sex violence (or adult lesbians exposed to child sexual abuse or sexual assault as an adult), as to heterosexual women.

2.1.1 Prevalence of IPV in Canada 

According to Statistics Canada’s General Social Survey, approximately 6-7% of Canadian women report exposure to IPV in the past 5 years (Statistics Canada, 2011), and IPV has been estimated to affect one third (Cohen & MacLean, 2004) of Canadian women, while lifetime violence victimization of all types is reported by up to one half of Canadian women (Johnson, 2005). However, this kind of self-reporting is known to underestimate IPV, as are estimates made based on official reports to police or other authorities (Johnson, 2005). Additionally, reported rates of IPV will vary according to where and how women are asked. Studies that use brief screening-type questions may overestimate abuse (Wathen et al., 2008), whereas those that focus solely on physical or sexual violence may underestimate it. Studies that ask women presenting to health settings, or to hospitals versus community clinics, may also not represent all women experiencing violence. For example, in two large-scale Canadian studies set in hospital emergency departments, community-based clinics or family doctors’ offices, the prevalence of IPV ranged (in one study of over 2400 women), from 4% (using a screening tool focused on physical and sexual abuse only) to almost 18% (in emergency departments) – across settings, women least preferred being asked about abuse in face-to-face interviews (versus written or computerized forms), and reported lower rates of abuse when asked this way (MacMillan et al., 2006). Similarly, in a study of over 5600 women presenting to one of 26 Ontario health care sites, IPV assessment using a longer, validated measure that accounts for different types and severity of violence identified 14.4% of these women as experiencing IPV in the past year (Wathen et al., 2008; MacMillan et al., 2009). While it may be that women using health care are more likely to be exposed to violence than those not using health care, it is also likely that these data reflect an underestimation of IPV when relying solely on self-report population surveys.

Based primarily on US data, rates of IPV during pregnancy range from 0.9% to 20.1% with the most stable estimates being 4 to 8% (Shah & Shah, 2010; Devries et al., 2010; Gazmararian et al., 1996; Gazmararian et al., 2000; Martin et al., 2001; Gielen et al., 1994). Estimates from clinical samples of Canadian women place the prevalence of IPV during pregnancy at approximately 6% (Muhajarine and D’Arcy, 1999; Stewart and Cecutti, 1993); in the 1993 Canadian Violence Against Women Survey (VAWS), 21% of women reported abuse during pregnancy, and in under half (40%) of these, the abuse began during pregnancy (Statistics Canada, 1993).

Aboriginal women in Canada are 2-4 times as likely to experience violence by a male partner (Perreault, 2010; Brownridge, 2008), with the most recent GSS data indicating that Aboriginal women report about 3 times more spousal violence than do non-Aboriginal women (about 15% versus 6%), and were more likely to report more severe forms of violence (Brennan, 2011). The dynamics of violence in Aboriginal communities has been partially attributed to the unique experiences of colonization, including ongoing racism and discrimination (Brownridge, 2003; 2008).

IPV does not always end when a relationship ends. Canadian criminal harassment data from the Uniform Crime Reporting (UCR) Survey and the Adult Criminal Court Survey (Milligan, 2011) indicate that women accounted for three-quarters of all victims (76%) of criminal harassment in 2009, with 45% being harassed by a former partner and an additional 6% harassed by a current partner. This differs significantly from patterns of criminal harassment among men (Milligan, 2011). These ongoing forms of harassment and abuse continue to have health and economic impacts on women (see below).

2.1.2 Risk factors for IPV 

Many Canadian studies, including national, population-based surveys (Johnson, 2005), as well as large-sample research studies in different settings (e.g., Wathen et al., 2007) have shown a fairly consistent pattern in demographic and relationship- and partner-specific indicators associated with IPV, including: being young, being in a common-law (versus legally married) relationship or being separated; substance abuse by, or un- or under-employment in, male partners; and controlling behaviours on the part of male partners. In addition, witnessing violence in childhood raises the risk of both victimization and perpetration of partner violence (Johnson, 2005).

Exposure to abuse prior to pregnancy is the strongest predictor of victimization during pregnancy (Martin et al., 2001).

2.2 Sexual assault of women

Sexual assault, including rape, is defined as “forced sexual activity, an attempt at forced sexual activity, or unwanted sexual touching, grabbing, kissing, or fondling” (Perreault & Brennan 2010). Rates of sexual assault in Canada, as calculated using Statistics Canada’s population-based General Social Survey (GSS), are relatively stable, with a significant increase in the 2009 cycle, as follows: 1999 – 21 per 100,000 (502,000 assaults); 2004 - 21 per 100,000 (546,000 assaults), 2009 - 24 per 100,000 (677,000 assaults), with the majority of reported assaults being the least serious forms (sexual touching, unwanted grabbing, kissing, or fondling) (Perreault & Brennan 2010, Table 6; Dauvergne & Turner 2010). However, rates of sexual assault are almost twice the rate for women as for men, accounting for approximately 70% of all sexual assaults. In just over half (51%) of the cases of self-reported sexual assault, the perpetrator was known to the victim (friend, acquaintance, or neighbour of the victim) (Perreault & Brennan 2010).

2.2.1 Risk factors for sexual assault 

Other than being female, which carries 5 times the risk of sexual assault compared to being male, the following have been identified as increasing the risk of sexual assault: being young, attending school, and frequent participation in evening activities (Brennan & Taylor-Butts, 2008).

2.3 Child witnessing of IPV & child sexual abuse

[Both of these exposures are considered forms of child maltreatment, therefore for the purposes of describing their epidemiology, they are presented together in this section, since that is the way they are often assessed. In the review of health-specific outcomes, below, they are presented separately.]

The Canadian Incidence Study (CIS) of Reported Child Abuse and Neglect – led by the Public Health Agency of Canada (PHAC) - is a nation-wide study to examine the incidence of reported child maltreatment and the characteristics of the children and families investigated by Canadian child welfare services. It has now completed three cycles, allowing comparison of trends. While five kinds of acts are generally included in studies describing child maltreatment, the present analysis focuses on two of these: child witnessing of IPV, and child sexual abuse (the other forms: child physical abuse, psychological abuse and neglect, are reported in detail in the CIS Report – PHAC, 2010).

Witnessing, by a child, of any incident of threatening behaviour, violence, or abuse (psychological, physical, sexual, financial, or emotional) between adults who are, or have been, intimate partners or family members is defined as a form of child maltreatment (Gilbert et al., 2009), and in the context of this report, another way in which IPV victimization can have short and longer term health impacts.

Child sexual abuse (CSA) is defined as “a type of maltreatment that refers to the involvement of the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator, including contacts for sexual purposes, molestation, statutory rape, prostitution, pornography, exposure, incest, or other sexually exploitative activities. This can include the risk of sexual abuse.” (U.S. Department of Health and Human Services , 2010).

The Canadian Incidence Study (PHAC, 2010) found, in 2008, that 34% (25,259) of the over 85,000 substantiated investigations of child maltreatment were specific to witnessing IPV and 3% (2,607) were cases of child sexual abuse. However, as with IPV, official reports are known to underestimate the actual prevalence and incidence of child maltreatment. For example, findings from a large Ontario community-based survey found that 12.8% of females and 4.3% of males reported sexual abuse during childhood (MacMillan et al., 1997). While no Canadian community-based data are available for rates of witnessing IPV, a review of US community studies estimated yearly prevalence of 10–20% (Carlson, 2000), similar to other reviews that put the range of adults who report having witnessed IPV during childhood at 13% to 27% (Gilbert et al., 2009; Osofsky, 2003; Henning et al., 1996; Dube et al., 2002).

Again, the type of reporting methods used in these studies has a significant impact on reported prevalence and incidence. A recent meta-analysis of global studies conducted by Stoltenborgh et al. (2011) examined estimates by type of report, and concluded that “overall estimated CSA prevalence was 127/1000 in self-report studies and 4/1000 in informant studies. Self-reported CSA was more common among female (180/1000) than among male participants (76/1000).”

In terms of trends in the incidence of CSA, the evidence is mixed; some studies have noted that rates of CSA, along with crime rates generally, are declining, particularly in the US (Finkelhor, 2009); however more comprehensive analyses point to differences in trajectories according to type of report, type of abuse and geographic setting (Gilbert et al., 2012).

2.3.1 Risk factors for child witnessing IPV and child sexual abuse 

Risks for these kinds of child maltreatment are complex, involving the interplay of child-specific indicators as well as family and community factors. Female children are more likely to be sexually abused than male children, with international studies and reviews from developed countries finding that the prevalence of sexual abuse is 2-4 times higher among girls than boys (Gilbert et al., 2009). The Canadian Incidence Study (PHAC, 2010), reports the following factors, specific to the child’s primary caregiver, as being associated with all forms of child maltreatment, including witnessing IPV and CSA: being a victim of IPV (i.e., 46% of substantiated cases of child maltreatment occurred in situations where the primary caregiver was a victim of IPV); having few social supports (39%); having mental health issues (27%); alcohol (21%) and drug (17%) abuse; being a perpetrator of IPV (13%); physical health issues (10%); history of foster care/group home (8%) and cognitive impairment (6%). Household-level risk factors included: social assistance, employment insurance or other benefits (33% of substantiated cases of child maltreatment occurred in situations where the household was in receipt of these income supports); one move in the past 12 months (20%); at least one household hazard (i.e., drugs or drug paraphernalia, unhealthy of unsafe living conditions, weapons in the home) (12%); public housing (11); and two or more moves in the past 12 months (10%) (PHAC, 2010).