Transcript Abuse? The Hidden Reality’ Patterns of Violence and Abuse

‘Abuse: The Hidden Reality’
Patterns of Violence and Abuse,
Impact on Health and Well-Being
Dr Jo Nurse
Consultant in Public Health
SE Regional Public Health Group
[email protected]
Violence and AbuseA hidden determinant of inequalities in Health
• Visible forms of violence:
- Youth Violence- Assaults in Public Places
- Young men, alcohol and the night time economy
• Invisible forms of violence:
- Child Sexual Abuse
- Sexual Assault
- Domestic Violence
Patterns of Violence and Abuse,
Impact on Health and Well-Being
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•
•
•
•
Prevalence
Risk Factors
Associated Health Consequences
Life Course impact
Reducing Harm and Prevention
Prevalence of Child Sexual Abuse,
Sexual Assault and Domestic
Violence
The Tip of the Iceberg
Prevalence of Child Sexual Abuse- UK
An NSPCC, UK study a random sample of 2,869 eighteentwenty four year olds (69% response rate), on child
abuse in the UK found:
• 21% of young women reported experiencing child
sexual abuse, (16% involved contact abuse)
• 11% of young men reported experiencing child
sexual abuse, (7% involved contact abuse)
-Sexual
abuse was defined as sexual contact or non-contact, that was
either under the age of 12 or non-consenting, (Cawson, 2000).
Child Sexual Abuse- Global Studies
A meta-analysis of studies from across the world consisting
of 584 articles:
• Females: Overall prevalence of sexual abuse was 25% (7% noncontact, 13% contact abuse, 5% involving intercourse)
• Males: Overall prevalence of sexual abuse was 8% (3% noncontact, 3% contact and 2% involving intercourse)
Comparable studies based in High Income Countries have
found the prevalence of child sexual abuse to range from
8-42% for girls and 3-25% for boys (Creighton, 2004)
-Comparative
Risk Assessment: Child Sexual Abuse. WHO Collaborating Centre for Evidence and
Health Policy in Mental Health, St Vincent's Hospital, Sydney, Australia, May 2001
Number of children on child protection register per 10,000 under 18 year olds, 2004
0
10
Milton Keynes
12
Wokingham
15
West Berkshire
15
Buckinghamshire
31
Oxfordshire
35
Surrey
36
Hampshire
19
West Sussex
19
Isle of Wight
19
Bracknell Forest
21
Windsor & Maidenhead
Kent
26
Slough
27
East Sussex
28
Reading
30
Southampton
Medway
40
Brighton & Hove
Portsmouth
20
SOUTH EAST
25
ENGLAND
Children on the Child Protection Register in the SE for
all categories, rate by Local Education Authority, 2004
45
40
England
South East England
Local education authority
24
26
21
18
15
13
11
9
6
5
Estimated number of children who may
have been sexually abused in the SE
• Total number of children in SE for all categories on the
Child Protection Register: 3,400
• Nationally, there are 2,500 children on the child
protection register for sexual abuse
• This would represent approximately 320 children in the
SE who are known by the services to have been sexually
abused
Below the iceberg:
• From prevalence studies, there would be an estimated
182,000 girls (21%), and 83,600 boys (11%), in the SE
who have been sexually abused.
• For children, we are probably only aware of
approximately 1 in 800 cases of child sexual abuse.
Prevalence of Sexual Assault
The British Crime Survery (2001) randomly selected a sample of
22,500 women and men aged 16-59 who filled out a self-completion
module on sexual assault. Key findings from this study include:
• One in four (24%), women had experienced some form of
sexual assault in their lifetime
• One in 20 (5%), women said they had been raped on at least
one occasion during their lifetime.
• This represents approximately 750,000 women in England in
Wales, and 125,000 in the SE of England, who have been raped.
• 1.5% of men had suffered a serious sexual assault at some
point in their lives, with 1% reporting rape.
(BCS 2001, Domestic Violence, Sexual Assault and Stalking: Findings from the 2001
British Crime Survey, Home Office Research Study 276,
www.homeoffice.gov.uk/rds/index.htm Walby and Allen, 2004).
Percentage of women experiencing Sexual Assault
during the last year by Government Office Region
BCS Walby and Allen, 2004
3
2.5
2
% Sexual
Assault in
last year
1.5
1
W Mid
NE
E Mid
London
NW
SW
Yorks &
Hum
SE
0
Eastern
0.5
Summary of top 15 areas for reported rape cases
(total numbers) in England and Wales 2003-04
Force
Metropolitan Police
Number of
Offences
Number of No
Crimes
Total
No crimes as %
of total
2571
0
2571
0
Greater Manchester
846
210
1056
20
West Midlands
814
207
1021
20
West Yorkshire
627
41
668
6
Hampshire
462
144
606
24
Avon & Somerset
482
52
534
10
Thames Valley
436
82
518
16
Merseyside
383
84
467
18
Essex
335
69
404
17
Northumbria
338
61
399
15
Humberside
350
48
398
12
Sussex
305
86
391
22
Nottinghamshire
303
52
355
15
Devon & Cornwall
329
17
346
5
Kent
286
28
314
9
Prevalence of Domestic Violence
• 1 in 5 women and 1 in 10 men, had experienced at
least one incident of non-sexual domestic threat or force
since they were 16.
• 1 in 4 women and 1 in 6 men, had experienced at least
one incident of non-sexual domestic threat or force,
financial or emotional abuse, since the age of 16.
• Women were more likely to be heavily abused than men,
of those experiencing abuse, 32% of women were
subject to 4 or more attacks compared to 11% of men.
BCS, Walby and Allen, 2004
Percentage women and men experiencing nonsexual domestic violence in the last year by
Government Office Region
BCS Walby and Allen, 2004
7
6
% DV in
last yearfemales
5
4
% DV in
last year males
3
2
W Mid
NE
E Mid
London
NW
SW
Yorks &
Hum
SE
0
Eastern
1
Risk Factors for Child Sexual
Abuse, Sexual Assault and
Domestic Violence
Risk Factors for CSA
Victims:
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Perpetrators:
• Male- 90% of abusers
Females are at greater risk of
• Older- majority are young men,
abuse compared to males (ratio
also includes adolescents
of approximately 3:1)
• A study in Switzerland found a
The highest risk age group is
third of abusers came from the
between 5- 14 years
same peer group.
33% had more than one abuser
• The majority (two thirds) of
and 60% were repeatedly
abusers are known to the child
abused, (Singh, 1996).
or adolescent.
Families experiencing
increased arguments and
• Step father, other family
physical violence between other
member, acquaintance of the
family members (Silverman AB,
family, or father
1996).
• Females more likely to be
Comparative Risk Assessment: Child Sexual Abuse.
abused by a family member
WHO Collaborating Centre for Evidence and Health
Policy in Mental Health, St Vincent's Hospital,
(20%), compared to males (6%)
Sydney, Australia, May 2001
(Halperin et al, 1996; Krug, 2002).
Risk Factors for Sexual Assault
• Overlap between Domestic Violence
and Sexual Assault- 50% rape and
sexual assault by partner or ex-partner,
18% by stranger.
• Increased risk of repeat victimisation –
small minority suffer heavy and multiple
abuse
BCS Walby and Allen, 2004
Percentage women experiencing Sexual
Assault by age in the last year
BCS Walby and Allen, 2004
8
7
6
5
4
Female %
Sexual Assault
in last year
3
2
1
0
1619
2024
2529
3034
3539
Age
4044
4549
5054
5559
Percentage experiencing Domestic
Violence by age and sex in the last year
BCS Walby and Allen, 2004
10
9
8
7
6
5
4
3
2
1
0
Female % DV in
last year
Male% DV in
last year
1619
2024
2529
3034
3539
Age
4044
4549
5054
5559
Young Age:
Sexual Relationship Violence in
Adolescents and Young People
• Age: A recent UK study on teen abuse, found that 16%
of teenage girls have been hit by a boyfriend, and 6%
were forced to have sex by a boyfriend. Regional
variations existed, with 80% of teenagers in the South,
believing hitting a boyfriend of girlfriend was acceptable,
(NSPCC, 2005).
• Influence of parenting styles on 10-12 year old boys
found that either perceived laxness of monitoring by
parents or overly harsh parenting practices predicted
later perpetration of dating violence when followed up at
ages 16-17. (Lavoie, 2002)
Sexual assault- drugs, alcohol and
violence
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6 % were drugged in some way
17% were incapable of consent due to alcohol
8% were unconscious or asleep
29% reported some other form of force or intimidation, (BCS, Walby
and Allen, 2004)
• One study found 58% of men imprisoned for rape had drunk
alcohol within 6 hrs preceding the assault, whilst 37% were
considered to be alcohol dependent.
• The strongest risk factor for experiencing dating violence for
adolescent females was a previous history of forced sex (OR 2.9
p<0.0001) (Kreiter, 1999).
• Longitudinal study of 16-20 year olds, found that boys who engaged
in peer violence was a significant predictor of sexual aggression or
dating violence at one year follow-up, (Ozer, 2004).
Risk Factors for Sexual Assault and
Domestic Violence
(BCS Walby and Allen, 2004)
Sexual Assault
• Young age, female,
previous abuse
• Low income (OR1.8)
• Unemployed (OR 1.8)
• Social Gradient: unclear
• Ethnicity: 30% less for
Asian vs white or Black
• Housing: Private Rented
(OR 3.1)
• Being Single
• Inner city: 3.0% vs 1.2%
rural area
Domestic Violence
• Young age, female, previous
abuse
• Low income (OR 3.4 for women,
1.6 for men)
• Unemployed (OR 1.6 women, 1.2
for men)
• Social Gradient: 1.5 times higher
for lower classes vs higher.
• Ethnicity: No difference for
women, 4x higher for white, 2.6 x
for black men vs Asian men
• Housing: Social rented (OR 3.3)
• Being single (OR 3.7) or
seperated (OR 7.3)
• Inner city (OR 2.1)
• Being Pregnant
Domestic Violence and Alcohol
Abuse
• Strong link between alcohol consumption
and intimate partner violence with 32% of
perpetrators reported as being under the
influence at time of assault.
• Alcohol abuse has been found to be 2-7
times higher for perpetrators of intimate
partner abuse than for other offenders.
Health outcomes and
risk behaviours associated with
Child Sexual Abuse,
Sexual Assault and Domestic
Violence
Health risk behaviours associated with
abuse during childhood and adolescence
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•
•
•
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Smoking (OR 2.5)
Binge Drinking (OR 1.7)
Substance misuse (Cocaine: OR 3.4)
Multiple sexual partners (OR 3.3)
First intercourse below age 15 (OR 2.4)
Not using a condom (OR 2.0)
Further risk of sexual assault
Poor Health related Quality of Life scores (OR 1.7)
Sleep difficulties
School absenteeism
Health outcomes associated with abuse
during childhood and adolescence
(Anteghini M et al, 2001; Kenney JW, 1997; Johnson PJ, 2002; Krug, 2002 Kreiter, 1999;
Silverman, 2001; Coker AL, 2000; Roberts TA, 2003; Covington, 2000)).
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•
•
•
•
Attempted suicide: (OR 8.6)
Depression and mental health problems
Bulimia (OR 3.7)
Pregnancy (OR 3.9)
Increased violence during pregnancy (OR 1.9), with an
increase in pre-term delivery (OR 3.5)
• Sexually Transmitted Infections
• Excess in physical health problems, (e.g., irritable bowel
syndrome, gynaecological problems, heart disease and
cancers)
Health related outcomes of abuse
for young men
Victim:
• Victim of dating violence associated with attempted
suicide (OR 2.3)
• Experiencing abuse associated with antisocial and
violent behaviour
Perpetrator:
• Number of times of getting someone pregnant (OR
1.7)
• Poor health related quality of life scores (OR 2.3)
• Perpetration of dating violence associated with
suicide attempts (OR 1.5)
Health Consequences
Sexual Assault - Adults
Women who had been subject to serious sexual
assault (including rape), since the age of 16:
• 52% had suffered depression (x 2 higher rate)
• 5% had attempted suicide
• 4% had become pregnant as a result of the rape
• Stopped trusting people (38%) and go out less
often (15%)
(BCS, Walby and Allen, 2004).
Health Consequences associated with
Domestic Violence ever since age of 16
(BCS, Walby and Allen, 2004).
Females:
• 48% minor injury
• 26% moderate injury
• 8% severe injury
• 37% mental or
emotional problem
Males:
• 35% minor injury
• 15% moderate injury
• 2% severe injury
• 10% mental or
emotional problems
Health Consequences associated
with Domestic Violence
• Chronic physical health problems eg irritable
bowel syndrome, backache and headaches,
(Campbell 2002).
• Reproductive health: increased rates of
unintended pregnancies, terminations
(Gazmararian et al 2000), and low birth weight
babies (OR 1.4, 95% CI 1.1-1.8) (Murphy et al
2001).
• Sexual health: lower rates of contraceptive use,
higher rates of sexually transmitted infections,
(Garcia-Moreno and Watts C, 2000).
Health Consequences associated
with Domestic Violence
• Mental health: higher rates of depression, anxiety, selfharm and suicide (Campbell 2002).
• Depressed women 6 times more likely to have
experienced severe combined abuse than nondepressed women, (OR: 5.8, CI: 2.8-12.0), (Hegarty,
2004).
• Health of children increase in short & long-term antisocial behaviour, (missing school, getting into fights, and
cruelty to animals); mental health problems: depression,
anxiety, substance misuse & suicidality, (Shipway, 2004;
McFarlane, 2003; Roberts, 2003).
Life-course risk of further abuse
• Any history of previous sexual abuse at whatever age,
but especially between 14-18 years, increased the risk of
sexual assault in late adolescence and early adulthood
compared to non- abused students. Risk of repeat
assault increased according to the degree of severity of
the initial assault. (Humphrey JA, 2000).
• Longitudinal study of US female college students found a
previous history of physical assault in adolescent
dating relationships, increased the risk of further physical
assault during their first year at college, (RR: 2.96). After
four years at college, any history of physical assault in a
dating relationship, increased the risk of further physical
assault and sexual assault, (Smith, 2003).
Uncovering the Hidden Life-course Impact of Child Sexual Abuse on Health Inequalities
Determinants
of
Childhood
Health
Inequalities
A
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H
O
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Disability
Power
Inequalities
CHILD
SEXUAL
ABUSE
SocioEconomic
Prevalence:
Females: 22%
Males: 11%
Increased Health
Risk Behaviours:
•Smoking
•Substance Misuse
•Obesity
Increased Mental
Health Problems:
•Depression
•Self Harm
•Suicide
Abusers: Increased
Suicide/ Poor QoL
Increased Health
Risk Behaviours:
•Smoking & Alcohol
•Obesity
Poor Long-term
Health Outcomes:
•CHD & Cancer
•Chronic Diseases
Increased Mental
Health Problems:
•Depression
•Self Harm
•Suicide
Abusers: Poor MH &
Alcohol Misuse
Age:
Power
Inequalities
Gender
Female> Male
Ethnicity
Increased
Sexual Relationship
Violence
Increased STIs
Teen-Pregnancy
Increased
Intimate Partner
Violence
•Increased STIs
•Poor Preg. Outcomes
•Chronic Gynae
•Problems
Nurse J, 2004
Seeking Help and Reducing Harm
Disclosing abuse
• 34% of women and 62% of men had never told
anybody about their experience of Domestic
Violence prior to the survey
• Most likely to tell friends or family, followed by
the police.
• Those suffering the worst abuse were more
likely to tell someone
• Sexual assault (and CSA) even less likely to
have told anyone.
• Police came to know about 15% of rapes in
females over 16.
(BCS, Walby and Allen, 2004).
Seeking Help
• More likely to seek help (police or medical) if repeated
attacks, more serious injuries, if older, on lower incomes,
and if they’ve told someone else.
• 30% women, 14% of men sought medical help following
domestic violence resulting in injuries
• Only 29% of women suffering a serious sexual assault
sought medical help
• 27% with serious medical injuries sought no medical
attention
• Of those who sought medical help, 65% did so with their
GP, 35% at A & E, and 10% with mental health services
(BCS, Walby and Allen, 2004).
Reducing Harm
• 94% of women were asked about the cause of
injury by GP or in A & E, and 74% said they
disclosed the abuse
• 79% of women who told someone about their
experience of domestic violence in the last year
found that person or service was able to help
• Treatment was offered in 36% of women who
disclosed abuse
• 13-15% of female and male perpetrators were
offered either counselling, therapy, treatment for
alcohol abuse or a DV programme
Preventing Child Sexual Abuse,
Sexual Assault and Domestic Violence
Violence Prevention Framework
Prevention Focus
Secondary
Primary
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Societal
And
Community
Interventions
Legislation
-Alcohol
-Inequalities
Partnerships
CDRPs
Alter
Environment
Community
Awareness
Campaigns
Information
Help
Lines
Tertiary
Home Visitation Programmes/ Parent Skill Training
Social Development Training & Pre-School Enrichment
School Based Child Bullying & Abuse Prevention
School Based Skills and Education
•Positive Relationships & Communication
•Protective Skills & Abuse Awareness
•Conflict resolution skills
•Anti-Bullying programmes
•Seeking Help & Peer Support
•Educational enrichment
Links with Health Promotion:
•Substance Abuse & Alcohol
•Sexual Health
Enhance Adult Skills:
Opportunities with
Ante-natal classes:
-Conflict resolution
-Communication
-Protection
Societal
Child &
Family
Therapy
Identify high
Risk Groups
For Abusing to
intervene early
Early Identification of
Abused for:
•Therapy/ support
•Protective skills
•Family Therapy
•Mentoring
Early Identification of Abused:
•Safety skills and procedures
•Support & manage related issues
•Therapy and preventive skills
•Referral to support agencies
Ecological Model
Community
Relationship
Child
Protection
Procedures
Identification
& early
Treatment
Of Abusers
Containment
&
Restriction
Of Abusers
Treatment
&
Management
Of
Abusers
-Alcohol
Protection &
Containment
Individual
Effective approaches for prevention
targeted at children
• Home Visitation Programmes- (eg Sure Start)
fifteen year follow-up study found reduction in
child abuse
• Sexual abuse prevention training in early
childhood whilst at school. For college women
studied: 8% had subsequently experienced
sexual abuse, compared to 16% of those who
had no training as a child
Effective approaches for prevention
targeted at Adolescents & Young People
• School Based Education Programmes: Developing
‘positive relationships’ and how to seek help- found
reduced rates of perpetration and experience of dating
violence after 4 year follow-up
• 2-3 hour brief interventions on protective skills for
young women- reduce the rate of subsequent sexual
assault by 50%
• Targeting high risk groups of young people with
additional interventions is also effective at reducing
further sexual assault
Effective approaches for prevention
targeted at Adults
• Referring to Support and Advocacy services for
women leaving violent relationships is effective in
reducing further abuse
• Alcohol abuse treatment services for male perpetrators
of domestic violence are effective for reducing further
perpetration of abuse- (whilst there is mixed evidence on
the evidence of perpetrator programmes)
• Working in Partnership via CDRPs to reduce
populations of alcohol consumption potentially will have
an impact on reducing all alcohol related violent crime
Victims of Violence & Abuse
Prevention Programme- VVAPP
• CSA, Domestic Abuse & Sexual Assault
• Childhood & adult victims & perpetrators
• Research- Mapping, Literature review, Delphi
consultation, Expert groups- to inform future
action.
• Improve service responses – SARCs; routine
enquiry in ANC & training for pilot MH services.
• Prevention: working with DH, HO & DfES to
develop joined up approach to earlier prevention
at national & regional levels.
For more details about the
presentation and on prevention
please contact
Dr Jo Nurse
Consultant in Public Health
SE Regional Public Health Group
[email protected]