The Consequences of Violence against Women

Because violence against women largely takes place at home, it has a particularly insidious character and effect. Women are seven times more likely than men are to experience violence committed by someone close to them, by a lover, spouse or ex-lover. This corruption of trust and intimacy means that primary relationships are disrupted throughout the household and that a vicious cycle is set in motion--one that is at risk of being perpetuated by the next generation.

Violence and neglect beget violence and neglect. All children can become scarred and depressed by abuse that they observe or receive. Although most mistreated children do not become violent adults, one third may become abusive or neglectful parents; one third are at risk of becoming violent. Only by realistically assessing and facing the full scope and consequence of violence against women can health care professionals and political advocates make some headway in combating it. Fortunately, better-designed epidemiological studies are clarifying prevalence and are increasingly documenting the long-term medical and psychological effects of violence on women and their children.

Numbers at Odds

Arguments revolving around statistics have long plagued discussions about how to gauge the prevalence of violence. In part, the problem has arisen from semantics. Survey results differ depending on how exactly terms are defined. For instance, various studies have imprecisely defined terms such as "rape" or "domestic violence." Domestic violence has sometimes been interpreted as being hit repeatedly and other times as being grabbed once in the course of a relationship. The same problem applies to the ambiguous phrases "intimate relationship" and "physical injury." In addition, methodology shapes outcome. Face-to-face interviews, for example, yield higher numbers than do those conducted over the telephone. (The figures given in this article are the best ones available to date, but it is certain that some of them also suffer from these confounding factors.)

Only recently have epidemiologists precisely clarified their terms. Today we know from solid studies that 36 percent of American women--that is, more than 34 million women--report experiencing violent events (including rape and sexual or physical assault) or the homicide of someone they knew well. And between 9 and 12 percent of women report being raped at least once.

The data on violence by intimate partners remain less clear, however. Research using more exact methodology and larger samples is under way, including a large study funded by the Centers for Disease Control and Prevention (CDC) and the National Institute of Justice (NIJ). Results from this study will be available later this year. But for now we have to rely on older estimates: every year between 1.8 and four million women are battered by their partners.

Assessing the medical and psychological aftermath of this violence has been difficult to quantify as well, but for reasons other than terminology. Instead the challenge has been establishing causality between a violent event and a later physical or psychiatric symptom. Women often experience more than just violence: familial dysfunction and neglect usually coexist with physical or sexual abuse, or both. This confluence makes it difficult for physicians to tease apart which factors are contributing to an illness. In addition, abused women may develop more than one psychiatric disorder and may show symptoms long after a traumatic event took place.

These complexities are further compounded by the stigma and shame that abused women feel. According to a report by the Commonwealth Fund, 90 percent of women who described themselves as physically abused by their partner or spouse had never told a doctor. Even when directly asked, women often deny being beaten or assaulted. Some feel embarrassed about their situation and frightened of their batterer; others are understandably terrified about addressing the serious problems of their relationship. To confront the batterer means risking his denial or revenge. To leave means facing the daunting task of securing housing and work--efforts often complicated by the need for child care and the lack of economic or emotional self-sufficiency.

A Nightmare of Body...

Although precise numbers remain elusive for the time being, the medical and psychological effects of domestic violence are nonetheless becoming terribly clear. In 1991 the American Medical Association began a campaign to educate physicians--and the country at large--about domestic violence. Studies have documented that victims of violence and their children make more visits to physicians and have more medical complaints than most people do. Indeed, researchers found that the average number of physician visits increased 31 percent for assaulted women and 56 percent for rape victims in the year after the crime against them. Only in the past few years, however, have physicians begun to be trained to recognize and treat abuse.

Even a cursory look at the injuries women incur explains why the resulting medical costs for domestic violence in the U.S. have been estimated at between $5 billion and $67 billion annually. Women suffer not only transitory injuries such as bruises, cuts, broken bones, concussions and urinary tract infections but also permanent ones: joint damage, hearing or vision loss, chronic pain, irritable bowel syndrome and sexually transmitted disease, including HIV infection.

Pregnant women are especially at risk of complications related to abuse. Studies indicate battered women have almost twice the number of miscarriages as nonbattered women do. Battered women often start prenatal care late in pregnancy and may have a greater number of low-birthweight babies. Because substance abuse is more prevalent among abused women, their fetuses are more likely to suffer drug- and alcohol-related complications.

...and of Mind

The psychiatric consequences of violence are also proving to be wide-ranging and severe. Survivors often describe a pervasive sense of terror and loss of control during and after the assault. Acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) often follows violent events. Both are characterized by flashbacks and nightmares, numbness and avoidance, and heightened alertness--including irritability, vigilance, overresponsiveness to touch or sound, and an increased capacity for being startled.

Stress disorders are much more prevalent in victims of physical and especially sexual assault than they are in people who have not experienced such violence. In one survey, more than 94 percent of women who had been raped developed ASD within the first month, and 47 percent of these women had PTSD after three months. Extrapolation from several studies suggests that of the estimated 12 million or so American women who have been raped, almost four to five million have suffered PTSD.

Physiological studies demonstrate that the stress response evoked in PTSD is distinct from the normal stress response--and from the response reported in other psychiatric disorders. Individuals with PTSD have low cortisol levels and greater cortisol fluctuation, which indicates that their stress response has been biologically altered. These chemical changes may translate into a more reactive heart rate and a tendency to startle easily.

Violence and abuse are frequently associated with other disorders as well: depression, anxiety, substance abuse and feelings of being disconnected from reality. Women who were repeatedly raped in childhood are three times more likely to develop depression and almost five times more likely to develop anxiety disorders than women who have not suffered in this way. Abused women also suffer from low self-esteem and poor interpersonal skills and feel inherently bad or dirty. They blame themselves for what has happened. These feelings make them unwilling to take care of themselves--and thus unwilling to seek help or to comply with medical care.

Many women who have been victimized are at higher risk of having chronic sexual problems, mutilating themselves, running away from home as teenagers and entering into prostitution. They are more likely to abuse substances; according to one report, 75 percent of women in substance-abuse treatment programs have a history of sexual abuse. The risk of attempted suicide increases dramatically in women who were sexually assaulted before age 16.

The implications for children are immeasurable. Not only is it damaging to grow up with a primary caretaker who is consistently depressed or suffering from PTSD, but as targets of and witnesses to violence, children are deeply harmed. Basic trust, the first developmental stage in psychoanalyst Erik H. Erikson's life-cycle theory, is completely disrupted. Normal expectations--that parents and caretakers are protectors, that daily life is predictable, that your body is your own--may be permanently crushed. When violence is enacted toward a child, it may disrupt normal development, setting the stage for lifelong difficulty.

At least three million children in the U.S. witness parental abuse annually; between 40 and 70 percent of children entering battered women's shelters are abused, mostly by the mother's abuser but sometimes by the mother herself. Children suffer behaviorally and intellectually from seeing violence in abusive environments and from the nomadic life that may ensue. Many develop the same problems that plague abused adults: PTSD, anxiety, depression, suicidal thoughts. Male children are at greater risk of committing a violent offense if they have a history of abuse or neglect; female children who have been sexually abused are twice as likely as nonabused children to be abused in adulthood by their partners.

As more research emerges, the social implications of violence against women are becoming increasingly apparent. The circle of violence set in motion in the home moves out onto the streets and then back into homes, ruining the childhood of another generation and setting the stage for the perpetuation of all forms of violence and abuse. Violence against women is not a discrete phenomenon but one that underlies many aspects of our culture. It is time it was addressed as such.

Violence Against Women Office at the Department of Justice

PAVNET Online (Partners Against Violence Network)

Family Violence Awareness

Information about Shelters

developed by the State of New York Office for the Prevention of Domestic Violence

Minnesota Center Against Violence and Abuse

No Safe Place, a companion site to the PBS documentary

Violence at Home, a year-long series from the Sacramento Bee

The Clothesline Project, remembering women abused, raped and murdered

Lisa A. Mellman is an associate clinical professor at Columbia University, where she is also the associate director of residency training. Mellman directs the psychotherapy clinic for training and research at the New York State Psychiatric Institute.

The Department of Health and Human Services has a nationwide, 24-hour domestic violence hotline: 800-799-SAFE.