Intimate partner violence and its impact on health

by Gerard Emmanuel Kamdem Kamga

 

Introduction

Increasingly research studies in recent decades have begun to document the complexities of intimate partner violence (IPV), the most common form of gender-based violence globally. Reported cases show that women are far more likely to be victims of IPV than men are. IPV is defined as domestic violence inflicted on an individual by a current spouse or partner during an intimate relationship, or after the relationship has formally ended. IPV can take a variety of forms, including physical, verbal, emotional, economic and sexual abuse. Physical violence ranges from slapping, punching and kicking, to burning the victim, assaulting her with an object or a weapon, or in extreme cases, even taking the victim’s life.  Sexual violence may include forced sex (including rape), overriding the woman’s own reproductive health choices, or forced participation in degrading sexual acts. Emotionally abusive behaviour is common in most cases of IPV, and can take the form of ongoing belittlement or public humiliation, intimidation, verbal threats, use of abusive language, and prohibiting the partner from seeing her family members or friends. Economic abuse may include preventing the partner from working, compelling her to work under inhumane conditions, or confiscating her earnings.

There is a global consensus that IPV is a social problem across the world that needs to be urgently addressed, since it infringes on the fundamental rights and dignity of its victims, and it prevents women from participating fully in society.  In 2008 the secretary general of the United Nations, Ban Ki-Moon, commented on IPV affecting women:

There is one universal truth, applicable to all countries, cultures and communities: violence against women is never acceptable, never excusable, never tolerable.

Much is already understood about the drivers of IPV, which include patriarchy, rigid gender roles, and early or forced marriage. A previous reflection, provided detailed developments on the phenomenon of IPV. However, less attention has focused on understanding the full impact of IPV on the health of victims. The purpose of this opinion piece is, therefore, to review current understanding regarding the negative health consequences of IPV. It is a widespread phenomenon, a pattern of behaviour that infringes the fundamental rights and dignity of the partners. There is an urgent need of action to address this issue and in so doing, awareness raising appears to be a good starting point.

Incidence of IPV

One report finds that one out of every four women worldwide experiences some form of IPV. Another recent estimate is even higher: it states that 35 per cent of women around the world at some point in their lives experience IPV.  In South Africa, certain studies have suggested that up to 70 per cent of women have experienced physical and/or sexual violence from an intimate partner during their lifetime (WHO 2013).  

In 2013 a joint report by the World Health Organisation (WHO), the London School of Hygiene and Tropical Medicine, and the South African Medical Research Council concluded that IPV was a major causal factor in women’s mental health problems, as well as contributing to worsening physical health.

Implications for reproductive health

A range of negative sexual and reproductive health impacts have been described as a result of IPV, including maternal health and neonatal health challenges. The joint report observes:

Women who have been physically or sexually abused by their partners … are 16% more likely to have a low birth-weight baby. They are more than twice as likely to have an abortion … and, in some regions, are 1.5 times more likely to acquire HIV, as compared to women who have not experienced partner violence. (WHO:2013).

Until relatively recently, IPV was not understood to significantly increase women’s vulnerability to sexually transmitted infections (STIs). However, it is now known that IPV is a key risk factor. Forced and unprotected sexual intercourse provides fertile ground for contracting HIV and various other STIs. The joint report said that women in violent relationships, or who live in fear of violence, are likely to have very limited or no control of the timing or the circumstances of sexual intercourse. In the same vein, behavioural evidence shows that men who are aggressors in IPV are more likely to exhibit more HIV risk behaviours, including having multiple sexual partners. Even when termination of abusive relationships take place, female IPV victims may find themselves starting new relationships with new partners in which they continue to have a greater vulnerability to HIV and STI infection from the new partner too. In some regions of the globe, female IPV victims are 1.5 times more likely to acquire HIV, and 1.6 times more likely to be infected with syphilis than females who are not subjected to violence by their male partners (WHO 2013: 1).  

A female partner who faces IPV is likely to have less control of her sexuality and her sexual life, and is probably prohibited from making autonomous decisions regarding family planning or spacing of children. An abusive male partner may interfere with her use of birth control or reject entirely use of birth control. The female partner is seldom able to negotiate condom use for fear of violent retaliation from the man (Moore et al. 2010). Hence, unwanted and unprotected sexual intercourse may result in unplanned pregnancies.

Women who are victims of IPV have higher rates of most adverse reproductive events. This can be explained as a direct consequence of sexual violence and coercion, with more indirect pathways to such events involving erratic contraceptive use or no use of contraceptives at all. Women who experience unplanned pregnancies may not only themselves develop serious health issues, but there are also adverse consequences for the health of their children. Sometimes these women may elect to induce abortion in an attempt to remedy an unwanted pregnancy. Data from 31 studies shows that women with a history of IPV are more likely to report having had an induced abortion. Singh (2009) observes that of an estimated 80 million annual unintended pregnancies globally, at least half are terminated by pregnant women through some form of abortion.  A genuine concern is that nearly half of these abortions occur in unsafe circumstances, usually because abortion is procured illegally (Sedgh et al. 2012). Illegal and unsafe abortion endanger not only the health but also the lives of these women.

Both low birth weight and premature birth are common amongst women who experience IPV. Low birth weight is used to describe infants born weighing less than 2,5 kg. Premature birth is defined as birth at a gestational age of less than 37 weeks (WHO 2013:23). Premature babies have had significantly less time to develop in their mother’s wombs and are unable to gain sufficient weight prior to birth, making them more vulnerable at birth, reducing the chances of infant survival and contributing to higher rates of infant mortality, particularly in the first year of these infants’ lives.

Alcohol and substance abuse

The link between alcohol use and a higher incidence of violence in various spheres of society has long been established. In a relationship where the male partner consumes excessive amounts of alcohol or he abuses alcohol (which may result in alcoholism), not only will the man suffer negative consequences in terms of mental and physical health, but his excessive drinking also impacts on the general health of his female partner. A well-documented result of male partner intoxication is that the risk of IPV rises exponentially with alcohol and substance abuse. Paradoxically, IPV as a consequence of alcohol abuse leads to a heightened risk of women also starting to abuse alcohol.  There is evidence which shows that women on the receiving end of IPV may start consuming alcohol to cope with the physical and psychological traumas which they experience because of their partner’s abuse. Their initially limited consumption of alcohol nevertheless has a great likelihood of leading to the female partners’ long-term abuse of alcohol or even to full-blown alcoholism.  The above joint report identified 37 studies with a clear association between physical and/or sexual IPV and alcohol use (WHO 2013:24).

Longitudinal studies show that the relationship between alcohol use and violence is often bidirectional, i.e. there is a positive correlation between women’s experience of IPV and their subsequent alcohol use, as well as an association between their own alcohol use and IPV as an outcome. There is clear research evidence that women with a history of violence consume greater quantities of alcohol (perhaps as a form of self-medication) and, conversely, women who binge drink or consume alcohol in other harmful ways are more likely to report IPV (WHO 2013:24).

These concerns do not only apply to alcohol abuse. There is accumulating evidence that men who abuse substances such as opioids, stimulants and marijuana are also more likely to be abusive of their female partners (Moore et al. 2012). Women in such abusive relationships may themselves also drawn into abusing substances, and may subsequently themselves enter into physical and emotional abuse of their male partner. Escalation of levels of violence in such relationships can very easily occur.

Mental health problems

IPV results over time in the female recipient of IPV coming to perceive her home or domestic environment as frightening, unpredictable, chaotic and overwhelming, which can trigger various mental disorders. Recipients of IPV are at significantly higher risk for certain forms of mental illness, particularly depression, anxiety and post-traumatic stress disorder (PTSD). According to Hyde et al. (2008), exposure to a traumatic event such as IPV can lead to stress, fear and isolation, culminating in depression and suicidal thinking. Depression and higher suicide risk are a clear and direct consequence of being the victim of physical, sexual and emotional trauma. One study found that female victims of severe IPV are four times more likely than non-victimised women to become severely depressed or to attempt to kill themselves.

Furthermore, some 55 per cent of women who are victims of abuse experience some form of anxiety without evident cause, which may curtail their ability to function in social situations or to engage in paid employment outside the home (Karakut, Smith & Whiting 2014).

Of real concern is the research finding that between 40% and 60% of women who are the victims of IPV are also likely to suffer from PTSD. PTSD occurs because these individuals are repeatedly exposed to severely traumatic stressors in the form of violence, which is followed by the women developing excessive fear regarding personal safety, together with an overwhelming sense of helplessness – i.e. they come to believe that they are trapped, and cannot exert any influence over, or control of the abusive situation.

Damage to a woman’s self-esteem may occur if family members or health-care workers blame the woman for the IPV, rather than allocating responsibility for the violence to the male offender. Female victims of violence are likely to feel guilt and shame, and they come to reproach themselves for the abuse, which contributes to lower self-esteem. Unfortunately, a vicious cycle may develop, as women who have low self-esteem are less likely to take steps to avoid abusive relationships or to leave them, and so have a greater likelihood of staying in the abusive environment or repeatedly choose different partners, all of whom are violent and abusive (Delara 2016).

Earlier experience of abuse (i.e. in childhood) puts a woman at far greater risk of entering into a relationship in adulthood which is characterised by IPV (Ouellet-Morin et al. 2015).  When a woman has suffered severe abuse during childhood – particularly sexual abuse or harsh forms of physical abuse – then the impact of IPV in adulthood on her mental health is likely to be much greater – both more distressing and more damaging of her ability to function normally, and IPV is then more likely to trigger severe manifestations of mental illness (Delara 2016).  Women with traumatic early experiences are also at increased risk for low self-esteem and self-blame when IPV takes place. There is a higher risk for women who face abuse in two different stages of their lives of dissociation from reality as a coping strategy, which can lead to impaired judgement and reduced capacity to cope with the ordinary demands of everyday life. In very severe cases of childhood and adult abuse there may even be a break with reality, i.e. women may become psychotic or delusional, both requiring urgent hospitalisation. 

In a similar way to the relationship between excessive use or abuse of alcohol and IPV, the linkages between IPV and women subject to depression and suicide may also be bidirectional. It has been suggested that women with severe mental health difficulties are much more likely to experience violent victimization.

Non-fatal injuries

IPV results in various forms of injury, ranging in their degree of severity and their negative impact on women’s health. The joint report (WHO 2013: 25-26) states that the head, neck and face are the most common locations for injuries related to partner violence, followed by musculoskeletal injuries and injuries to the genitals. Regardless of the health services in their country and locality, many women are reluctant to seek health care for injuries caused by partner violence (Tjaden & Thoennes 2000). Moreover, when asked by health-care workers about the cause of their injuries, women tend to conceal the real events, often attributing injuries to random accidents, rather than linking them to the violent partner (WHO 2013:26). The proportion of women who experience partner violence which results in physical injury is high – 41.8 per cent (WHO 2013: 26). This attests to a potentially significant health burden for IPV victims as a result of their injuries (WHO 2013:26).

Fatal injuries and homicide

Fatal injuries from IPV are influenced by various factors, including cultural norms such as whether or not it is socially acceptable for a man to beat or abuse his female partner. In more patriarchal societies, where women have greatly curtailed freedoms, IPV may be perceived as a natural expression of a man’s right to discipline his wife or female partner. In South Africa 3.3 per cent of men and 2.3 per cent of women consider it acceptable for a man to hit a woman (Crime Statistics Series 2018). Regional differences in intimate partner homicide may represent real differences in homicide patterns, and may also correlate with the degree to which violence against women is seen as culturally appropriate (WHO 2013:26-27).

Conclusion

This paper aimed to explore and comprehend negative health consequences for victims of IPV. It is now evident from extensive research that IPV is a major contributory factor to women’s physical, sexual and reproductive health problems, including difficulties with maternal health, as well as leading to poorer infant health. A further significant impact for women is the range of mental health, emotional and behavioural problems they may experience, including depression, anxiety and PTSD. Alcohol and substance abuse may also play a role in escalating partner abuse, but its effects seem to be bidirectional.

Ultimately the fundamental rights of the abused partner are at stake. Therefore, urgent initiatives are required address this situation. If IPV leads to negative outcomes for women’s physical and emotional health, it constitutes a serious impediment to women’s right to life and dignity. These findings underscore the importance of addressing IPV at national and local levels, as well as in health settings and through careful policy design.

References

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