Intersections of Harm and Health
Identifieur interne : 000367 ( Istex/Corpus ); précédent : 000366; suivant : 000368Intersections of Harm and Health
Auteurs : Kristie A. Thomas ; Manisha Joshi ; Eve Wittenberg ; Laura A. MccloskeySource :
- Violence Against Women [ 1077-8012 ] ; 2008-11.
Abstract
Eight focus groups of women with recent exposure to intimate partner violence (IPV) were conducted to elicit women's descriptions of how IPV affects their health. Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. Service providers, including physicians, need to better understand the myriad ways that abuse affects women's health.
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DOI: 10.1177/1077801208324529
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Intersections of Harm and Health</title><author wicri:is="90%"><name sortKey="Thomas, Kristie A" sort="Thomas, Kristie A" uniqKey="Thomas K" first="Kristie A." last="Thomas">Kristie A. Thomas</name><affiliation><mods:affiliation>University of Pennsylvania</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Joshi, Manisha" sort="Joshi, Manisha" uniqKey="Joshi M" first="Manisha" last="Joshi">Manisha Joshi</name><affiliation><mods:affiliation>University of Pennsylvania</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Wittenberg, Eve" sort="Wittenberg, Eve" uniqKey="Wittenberg E" first="Eve" last="Wittenberg">Eve Wittenberg</name><affiliation><mods:affiliation>Brandeis University</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Mccloskey, Laura A" sort="Mccloskey, Laura A" uniqKey="Mccloskey L" first="Laura A." last="Mccloskey">Laura A. 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Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. Service providers, including physicians, need to better understand the myriad ways that abuse affects women's health.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>intimate partner violence</json:string><json:string>focus groups</json:string><json:string>abusive</json:string><json:string>abuser</json:string><json:string>abusive partners</json:string><json:string>pathway</json:string><json:string>health conditions</json:string><json:string>past year</json:string><json:string>coker</json:string><json:string>mccloskey</json:string><json:string>nosek</json:string><json:string>abusive relationships</json:string><json:string>domestic violence</json:string><json:string>adverse health effects</json:string><json:string>abusive partner</json:string><json:string>physical health</json:string><json:string>chronic health conditions</json:string><json:string>core categories</json:string><json:string>health care</json:string><json:string>physical abuse</json:string><json:string>disability</json:string><json:string>mental health</json:string><json:string>qualitative research</json:string><json:string>health problems</json:string><json:string>research team</json:string><json:string>focus group</json:string><json:string>emotional abuse</json:string><json:string>disability increase dependency</json:string><json:string>dependency</json:string><json:string>public health</json:string><json:string>focus group methodology</json:string><json:string>tjaden thoennes</json:string><json:string>service providers</json:string><json:string>complex relationship</json:string><json:string>serious health conditions</json:string><json:string>health quality</json:string><json:string>sexual abuse</json:string><json:string>partner violence</json:string><json:string>health effects</json:string><json:string>permanent vision loss</json:string><json:string>blood pressure</json:string><json:string>chronic pain</json:string><json:string>participant</json:string><json:string>physical disability</json:string><json:string>cervical cancer</json:string><json:string>qualitative methods</json:string><json:string>domestic violence shelter</json:string><json:string>myriad ways</json:string><json:string>male partner</json:string><json:string>conflict tactics scale</json:string><json:string>subject participation</json:string><json:string>health policy</json:string><json:string>relationship status</json:string><json:string>maxillofacial injuries</json:string><json:string>nonabused women</json:string><json:string>data analysis</json:string><json:string>many women</json:string><json:string>story line</json:string><json:string>core themes</json:string><json:string>social policy practice</json:string><json:string>ovarian cancer</json:string><json:string>qualitative study</json:string><json:string>abusive relationship</json:string><json:string>abusive boyfriend</json:string><json:string>similar feelings</json:string><json:string>covert tactics</json:string><json:string>economic dependency</json:string><json:string>immune system</json:string><json:string>romantic partner</json:string><json:string>financial dependence</json:string><json:string>other women</json:string><json:string>health care providers</json:string><json:string>subjective experiences</json:string><json:string>such findings</json:string><json:string>physical health consequences</json:string><json:string>internal medicine</json:string><json:string>family medicine</json:string><json:string>family violence</json:string><json:string>american journal</json:string><json:string>specific ways</json:string><json:string>public health reports</json:string><json:string>physical disabilities</json:string><json:string>harvard university</json:string><json:string>medication</json:string><json:string>abuse</json:string></teeft></keywords><author><json:item><name>Kristie A. 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Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. 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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Thomas</surname><given-names>Kristie A.</given-names></name><aff>University of Pennsylvania</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Joshi</surname><given-names>Manisha</given-names></name><aff>University of Pennsylvania</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Wittenberg</surname><given-names>Eve</given-names></name><aff>Brandeis University</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>McCloskey</surname><given-names>Laura A.</given-names></name><aff>University of Michigan</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>11</month><year>2008</year></pub-date><volume>14</volume><issue>11</issue><fpage>1252</fpage><lpage>1273</lpage><abstract><p>Eight focus groups of women with recent exposure to intimate partner violence (IPV) were conducted to elicit women's descriptions of how IPV affects their health. Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. Service providers, including physicians, need to better understand the myriad ways that abuse affects women's health.</p></abstract><kwd-group><kwd>focus groups</kwd>
<kwd>intimate partner violence</kwd>
<kwd>women's health</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>1252 Intersections of Harm and HealthA Qualitative Study of Intimate Partner Violence in Women's Lives SAGE Publications, Inc.200810.1177/1077801208324529 Kristie A.Thomas University of Pennsylvania ManishaJoshi University of Pennsylvania EveWittenberg Brandeis University Laura A.McCloskey University of Michigan Eight focus groups of women with recent exposure to intimate partner violence (IPV) were conducted to elicit women's descriptions of how IPV affects their health. Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. Service providers, including physicians, need to better understand the myriad ways that abuse affects women's health. focus groups intimate partner violence women's health urveys and interview-based studies establish a link between intimate partner S violence (IPV) and adverse health effects; however, the mechanisms by which violence threatens health remain unclear. Confirming an association between IPV and compromised health leaves open the possibility that the relationship is actually bidirectional. However, there is little research exploring women's own perceptions of how IPV affects their health or how their health conditions affect their relation- ships to partners. Specifically, the subtle or covert ways that violence affects health or that health intersects with violence deserve further empirical study. To clarify the Authors' Note: Partial funding for this work was provided by the Centers for Disease Control and Prevention, contract No. 200-2005-M-12079 to Dr. Eve Wittenberg. Research was conducted with the full Human Subjects IRB approval of the Massachusetts General Hospital and the University of Pennsylvania. The views expressed are those of the authors and do not necessarily represent the views of the funding agency. We thank the women who participated in the focus groups and who shared their life experiences with us and with each other. 1253 potential bidirectional influences in the association of IPV and health and to better understand the relationship dynamics that underlie this association, we have ana- lyzed women's subjective experiences of how IPV intersects with their health. The current study relies on qualitative methods to illuminate the underlying pathways between IPV and health that are not self-explanatory in order to build on prior sur- vey results. Intimate Partner Violence Leads to Adverse Health Effects It is well documented that women who experience IPV are more likely to report diminished physical and mental health (Campbell, 2002; Campbell et al., 2002; Coker, Smith, Bethea, King, & McKeown, 2000). Abused women are more likely to be diagnosed with serious health conditions such as migraines, gastrointestinal dis- orders, diabetes (Coker, Smith et al., 2000), sexually transmitted infections (Johnson & Hellerstedt, 2002; Martin et al., 1999), and cervical cancer (Coker, Sanderson, Fadden, & Pirisi, 2000). They report more chronic physical symptoms such as headaches, chronic pain, and chronic fatigue (Nicolaidis, 2004). Depression and other psychiatric symptoms such as posttraumatic stress disorder (PTSD) are more prevalent in women exposed to IPV (Golding, 1999). In addition, IPV is associated with women's behavioral health—for instance, abused women drink and smoke at higher rates than women who are not in abusive relationships (Gerber, Ganz, Lichter, Williams, & McCloskey, 2005). Injuries. Physical injuries are perhaps the most visible direct consequence of IPV on women's health. Injuries sustained by women with abusive partners can range from cuts, scrapes, and bruises (Sutherland, Bybee, & Sullivan, 2002; Tjaden & Thoennes, 2000) to broken bones (Coker, Smith et al., 2000), gunshot and knife wounds (Sutherland et al., 2002), fractures (Petridou et al., 2002), lacerations, max- illofacial injuries (Le, Dierks, Ueeck, Homer, & Potter, 2001), dental trauma, loss of teeth (Kenny, 2006), broken or chipped teeth, internal injuries (Tjaden & Thoennes, 2000), head and neck injuries (Halpern & Dodson, 2006), and cases of poisoning (Kernic, Wolf, & Holt, 2000). Although some injuries may heal, others can result in life-changing disabilities. There are wide parameters for defining disability, but the World Health Organization's (1980) definition of disability has been commonly used. A key element is that disability results in a condition restricting an individual's ability to perform a range of normal social, work-related, cognitive, or physical self- care activities, taking into account age and other demographic characteristics for that person. Women reporting current IPV are more than twice as likely to report having a disability as nonabused women (Coker, Smith, & Fadden, 2005). In the same study, almost 42% of those women with past IPV histories, compared to 24% of those with- out, reported that an injury caused their disability. 1254 Stress. Although not as visible as injuries, stress as a result of violence is another mechanism by which women's health can be compromised. Relationship stress has been shown to directly result in reduced immunity, heightened cortisol, and other related health problems (Robles & Kiecolt-Glaser, 2003). Women who experience IPV experience significantly more stress than nonabused women (Eby, 2004; Sutherland et al., 2002). There are numerous stressors that can directly and indirectly relate to abuse, leading women to develop illnesses more often (Eby, 2004). Sutherland et al. (2002) examined the direct and indirect effects of injuries, depres- sion, life stressors, and stress from abusive relationships on the physical health of women who had experienced IPV. They found that stress significantly mediated the direct relationship between abuse and physical health, accounting for 80% of the indi- rect effect of abuse on women's physical health. Stress also significantly mediated the relationship between abuse and depression. Such findings suggest that stress can lead to reduced physical and mental health in abused women; however, these studies relied primarily on standardized measures to assess stressors. Forms of stress resulting from abuse that fall outside the range of standardized instruments require qualitative methods for assessment. Qualitative work can provide a window into the unique stres- sors inherent in abusive relationships that ultimately affect women's health. Intimate Partner Violence Worsens Pre-Existing Conditions Although women with disabilities are at risk for abuse from family, friends, and caretakers, intimate male partners are the most common perpetrators of abuse against women with disabilities (Milberger et al., 2003; Young, Nosek, Howland, Chanpong, & Rintala, 1997). Women with disabilities have been shown to experi- ence all forms of IPV at rates comparable to women without disabilities; however, the length of their abuse lasts for significantly longer periods of time than women without disabilities (Young et al., 1997). Abuse against women with disabilities and chronic health conditions can further compromise their health. In addition to causing additional injuries, abusers may sab- otage victims' efforts of self-care. Recent results from a survey of more than 2,000 women outpatients show that as many as 17% of physically abused women report partner interference with health care during the past year (McCloskey et al., 2007). In a qualitative study with abused HIV-positive women, participants described vari- ous incidents and controlling behaviors that limited their access to medical treatment for this potentially lethal disease (Lichtenstein, 2006). For instance, many women reported that abusers prevented them from taking their medications or keeping doc- tor's appointments. Partner interference in self-care can be life threatening. A study of cancer patients revealed that women with histories of violence were significantly more likely to be diagnosed at more advanced stages of breast, cervical, endometrial, and ovarian cancer than women without a history of violence, suggesting reduced 1255 access to health care (Modesitt et al., 2006). Such findings invite further inquiry to discover the particular ways abusers' actions lead to poorer health outcomes. Illness and Disability Increase Dependency on Abusive Partners Women with disabilities face unique risks for abuse including mobility impair- ments, which can affect the ability to leave; perceived vulnerability by others due to physical, mental, and emotional limitations (Young et al., 1997); decreased ability to defend oneself from sexual violence (Nosek, Foley, Hughes, & Howland, 2001); and increased social isolation (Nosek, Hughes, Taylor, & Taylor, 2006). Research indicates that women with disabilities have lower self-esteem than women without disabilities. Low self-esteem among women with disabilities is significantly related to higher unemployment and reduced health promotion behaviors (Nosek, Hughes, Swedlund, Taylor, & Swank, 2003), which may also exacerbate dependency. Economic and emotional dependency can impede a woman's ability to terminate an abusive relationship. Bornstein (2006) proposed that the relationship between economic dependency and abuse is bidirectional; that is, a woman who is financially dependent may be more likely to tolerate abuse, but the abuse itself may lead the woman to be more financially dependent. Economic dependency is a salient issue for women with reduced health quality. Women with disabling health conditions are more likely to be unemployed than women without disabilities (Young et al., 1997). Unemployment rates are even higher among women facing the double challenge of physical disability and IPV (Milberger et al., 2003). Our study contributes to the existing literature by using a sample of abused women who may not identify as disabled but who have conditions that restrict their daily activities and, therefore, have unique experiences that need to be better understood. Aims of the Study The sheer diversity of health conditions associated with IPV raises important questions about mechanisms. How does abuse influence women's health in general and in specific ways? How does an abusive partner directly or indirectly engender women's health problems? What are the specific risks and vulnerabilities for women with pre-existing health conditions? Most importantly, how do women describe the impact of abuse on their health; that is, what are their subjective experiences, and do these experiences shed light on mechanisms that have not previously been consid- ered? We use focus group methodology to address these questions. Focus groups can provide rich, complex details about women's experiences because the data come from the participants' interactions with each other (Morgan, 1996); these interactions prompt discussions about aspects of life that researchers may not have anticipated, yielding new and important insights. Additionally, feminist researchers endorse 1256 focus groups because they encourage researchers to listen to the voices of women from diverse backgrounds, including those whose voices have been subjugated (Madriz, 2000; Reinharz, 1992). Method Recruitment Recruitment for research volunteers took place over a 5-month period starting in October 2005 from eight Philadelphia social service agencies serving women with diverse needs (e.g., one domestic violence shelter, two agencies providing domestic violence advocacy, two housing agencies, one women's health clinic, and two orga- nizations providing life skills training). Agency staff members were given fliers to hand out to clients and to post on bulletin boards in communal spaces. In addition, we posted recruitment fliers at grocery stores, pharmacies, and hospitals near the university. The fliers asked interested volunteers to call a number at the University of Pennsylvania. Fliers recruited for women volunteers 18 years and older with recent (past year) experiences of physical abuse or control from a male partner and who were willing to talk about their experiences in a group of other abused women. No mention of health or illness was contained in the fliers. We performed phone intakes and scheduled 47 women, 40 (86%) of whom kept their appointments. Although women continued to call our project (n = 12), we ended the study at the eighth focus group to avoid data saturation (Morgan, 1996). This determination was possible because two of the authors (Thomas and McCloskey) led the focus groups, consulting after each group and assessing the content. Screening and Participation Women who called were screened over the phone with an intake form using ques- tions adapted from the Revised Conflict Tactics Scale (CTS; Straus, Hamby, Sherry & Boney-McCoy, 1996) and Women's Experience with Battering Scale (WEB; Smith, Earp & DeVellis, 1995; see Appendix A). To be eligible, women had to be 18 years of age or older and had experienced physical and emotional violence and/or controlling behavior from a male partner in the last 12 months. To minimize poten- tial emotional trauma resulting from answering questions about experiences of vio- lence, the intake was designed so that if a woman answered yes to the first question, no further questions were asked and she was then scheduled for a group. Eight focus groups were conducted over 4 months (January-April, 2006). Focus groups were scheduled at various times to offer eligible women the opportunity to select the most convenient time and day. Women were provided with transportation, childcare, food, and $50 compensation to ease potential burdens related to participation. 1257 A clinical social work consultant was on site during the focus groups to speak with participants in the event that they experienced emotional trauma from the group or disclosed life-threatening circumstances. If the moderator felt that a participant was in danger from her abuser or herself, she asked the participant to meet with the con- sultant after the group to discuss follow-up counseling and referrals. The consultant assessed and followed up with a total of nine participants. Subject participation lasted approximately 3 hours, including the 1 1/2 hour focus group session. Upon participant arrival, a member of the research team read aloud the consent form, which explained the following: the purpose of the study, which was to learn more about the specific words women who experience IPV use to describe their quality of life; participants' rights; the requirements of subject partic- ipation, including maintaining confidentiality of fellow focus group members; and that the focus groups were being audio taped for research purposes only. All subjects gave verbal rather than written consent, a requirement laid out by the University of Pennsylvania's IRB to ensure full confidentiality. Participants Forty women participated in one of eight focus groups. The women's mean age was 43 years (range 18-64 years). Seventy-nine percent of the women self-identified as African American, 8% as White, 5% as Latina, and 8% as multiracial or ethnic. Seventy-eight percent of the women reported having at least one child (M = 3, SD = 1.7). Of the 39 participants who reported their relationship status, 31% were living with their current partner; 13% were living in separate residences, but were still see- ing their partner; 54% were separated; and 3% (n = 1) did not report her status. Most of the participants (72%) were not employed at the time of their focus group partic- ipation; 13% were working full time and 15% had part-time jobs. Questionnaire Measurement Between obtaining verbal consent and the start of the focus group, participants were given three questionnaires to assess demographic information and history of IPV. Demographic questionnaire items included age, marital and relationship status, ethnicity, number of children, and so forth. In addition, they filled out the 10-item WEB scale (Smith et al., 1995). The questionnaire probes for psychological and emotional abuse underlying battering relationships and has excellent psycho- metric properties, convergent with other measures of psychological and physical abuse (Smith, Smith & Earp, 1999). A score of 20 or higher is recommended for identifying women with clinical levels of emotional abuse in their relationships (Smith et al., 1999). In addition, women were administered 20 items from the Revised CTS (Straus et al., 1996) to screen for the presence of physical abuse during the past year. 1258 Focus Group Protocol The focus groups comprised between four and six participants. Focus groups of this size are called minifocus groups and tend to facilitate more personal and detailed sharing (Krueger & Casey, 2000). Focus groups were semistructured and used a mod- erator's guide (see Appendix B). Each focus group was opened with the following ice-breaker question (Morgan, 1997): “If you ran into a good friend who you hadn't seen in awhile, how would you say your quality of life has been over the course of the past year?” Follow-up questions asked the women how they felt violence had affected their lives, especially their health, emotions, and relationships. These questions were influenced by the authors' knowledge of the existing literature on IPV and health but were broad enough to allow new domains to emerge. Moderators prompted for spe- cific domains such as emotional and physical health, work, and relationships with family and friends if the subjects did not bring them up themselves. Prior to the study, we performed a pilot focus group session with graduate students to test the protocol and the facilitation style of the moderators. Focus Group Analysis The focus group audiotapes were transcribed verbatim by three research assis- tants, none of whom had contact with the women during the data collection phase. Once the transcripts were complete, the authors who had had contact with the par- ticipants (Thomas and Joshi) listened to the audiotapes to identify the names of dif- ferent speakers. This was done so that they could better trace the women's individual stories throughout the focus group. The identity of speakers is protected in our pre- sentation of results through the assignment of pseudonyms. To check for transcriber accuracy, two focus group transcripts were randomly selected using a custom ran- dom number calculator (focus groups numbers 2 and 7). Two of the authors (Thomas and Joshi) listened to 10 minutes of each recording and found discrepancy rates of 9.7% and 2%. Most discrepancies related to wording differences or word omissions; very few discrepancies changed the actual meaning of the women's conversations. Data analysis involved selective coding as specified by Strauss and Corbin's (1990) grounded theory. During the first round of coding, each of the eight tran- scripts was analyzed by the research team to explicate core thematic categories. The narratives were rich in detail and covered a number of topics. As a result, the initial read of the transcripts was centered within a general framework of IPV and health. This framework was informed by the authors' knowledge of previous literature regarding the interface of health and IPV; it guided the way the data were approached and it confirmed the core categories that emerged from the women's narratives. The three core categories that surfaced across the eight focus groups were the following: IPV leads to adverse health effects; IPV worsens already compromised health; and illness and disability increase dependency on abusive partners. 1259 Grounded theory stresses the importance of finding the story line, which is “the conceptualization of a descriptive story about the central phenomenon of the study” (Strauss & Corbin, 1990, p. 119). The story line that emerged from the data analysis was the complex and cyclical nature of the relationship between IPV and health. Discovering the recursive narrative of violence and health helped to anchor and sup- port the three core categories. From these three core themes, further subsidiary cate- gories were developed. In the final round of coding, the three core categories were validated against the transcripts. This entailed dividing the women's stories into pas- sages and then sorting the passages to evaluate their relevance to each of the three main categories. Once the core categories had been established, each of the transcripts was coded separately by two members of the research team to check reliability; any coding discrepancies were reconciled with a third member of the research team. Results Thirty-eight out of 40 participants endorsed at least one item describing exposure to physical or sexual abuse during the past year from the Conflict Tactics Scale (Straus et al., 1996); the other two participants reported exposure in their lifetime. Many of the women experienced life-threatening violence: Nine women reported that their partner had used a knife on them; five said that a gun had been used on them; and seven had been burnt on purpose by a partner during the past year. More than half of the women (55%) reported experiencing sexual abuse by a partner dur- ing the past year. A majority of the women (93%) reported experiencing psycholog- ical or emotional abuse in their lives, as indicated by a score of 20 or higher on the WEB scale (Smith et al., 1999). Focus Group Narratives Women disclosed various ways that IPV influenced their health, ranging from injuries to stress effects. They also described how chronic health conditions made them vulnerable to abusive partners (see Table 1). Table 1 provides an outline of how violence and health intersect with specific examples derived from women's narra- tives. We present examples of how violence damages women's health, how it worsens pre-existing health conditions, and how ill health or disability makes women more vulnerable to potential abuse. How Intimate Partner Violence Leads to Adverse Health Effects Overt attacks. Many of the women described overt physical attacks and injuries from partner violence. These attacks resulted in physical disability, chronic pain, chronic health conditions, impaired mobility, and disfigurement, 1260 1261 which affected the participants' long-term physical and emotional health. For instance, eight of the women in our sample had lost teeth—some as many as five teeth—as a result of violence. One attack resulted in permanent vision loss. Lillian, who recently separated from her abusive partner of more than 15 years told us the following: “[He] stabbed me in my eye…then about a year later he hit me in this eye, now I got a little vision in this eye.” The two attacks on her eyes resulted in perma- nent vision loss in one eye and impaired vision in the other, dramatically changing her life. She can no longer work and lives on disability benefits. Camille, who also recently left her abusive boyfriend, survived a nearly lethal stabbing. She now lives with a severe scar that runs from her neck down to her chest, and she endures painful spasms that temporarily paralyze her neck. Experiencing such disfigurement can be emotionally traumatic. Camille recalls: “I went to my dad, and my dad said `Lord, I've been in three wars and I ain't got as many scars as you do.' I was crushed, you hear me?” Geraldine, a woman in her late 50s, expressed similar feelings about losing her teeth: “He really hit me…My teeth had to come out….It was really traumatic…I been feeling bad, feeling sad ever since….I do want my teeth back if I can get some.” Covert attacks. Women also described the use of covert tactics that directly led to health complications. A primary example of this was controlling or tampering with women's food and drink intake. Kendra's boyfriend was extremely controlling, and he constantly told her that she was not “big enough” for him. He would wake her up in the middle of the night and make her eat until she was sick, causing per- manent physical damage: “We rode, sometimes we drove for hours to…just eat, eat, eat, eat. And I developed a problem with my esophagus from eating so much.” Letysha described how her ex-boyfriend had locked her up in his house for 2 days. During this time, he withheld all fluids, severely dehydrating her. He eventually gave her water to drink, but mixed a poisonous cleaning agent into it. As a result, she developed, and still suffers from, chronic respiratory problems that impact her life. Her condition causes not only physical discomfort but also embarrassment because the medication she takes inflames and irritates her skin. In Letysha's words, “He messed me up for life.” Stress from physical and psychological abuse. In addition to the impact of direct attacks, we found that many of the women suffered intense stress from their abu- sive situations. For these women, stress was the conduit by which IPV led to the development of physical illness and to poor behavioral health. Sheneka told the group how the stress of the relationship affected her: Anxiety can make you sick. It can make you very sick....I'd be fine all day long. As soon as I heard his key turn in that door, heard his voice, I'd be sick as a dog. I'd be sick, vomiting in the kitchen sink. 1262 Angelique talked about how the abuse would raise her blood pressure and her heart rate, leading to severe headaches, “I remember, just like you was saying, waiting for the bomb to drop…that's where I was, for a long time, for years…the blood pressure, I used to get pounding headaches…I used to get palpitations.” A number of other participants echoed similar thoughts about the effects of stress from abuse, saying, “Stress can kill you,” and “It's [stress] in my physical form….I carry this all over.” The direct impact of violence and abuse on increased chemical dependency has not been established. For instance, women who smoke, drink, and use drugs may be more likely simply to have abusive partners; the abuse itself may not increase drug dependency. However, the stress in the relationship may prompt women to seek or return to drugs or alcohol to cope. Some of the women in the study described this specific causal chain; stress from threats of violence moved some women toward drugs. Alisha stated, “I'm coming up to 16 months of sobriety and it's like some days I just want to leave my apartment…cause he's getting on my nerves so bad….I'd be ready to run or go use.” Tonya shared similar feelings: I even relapsed behind this person, because this person brought me back to a place I was so many times…the worthlessness…the rejection issues, the abandonment issues….This person brought me back to that place and that's what made me relapse. Robin, in recovery for alcohol addiction, had a different situation; for her, drink- ing eclipsed dealing with the abuse. This may have kept her in the relationship longer than if she were sober. She said, “The only thing you want is another drink…you ain't worried about what he did to you, he get you a drink, and you and him drink- ing again.” How Intimate Partner Violence Worsens Already Compromised Health A number of women had health conditions that were not a result of IPV. However, they described many ways in which abuse, and stress from abuse, exacerbated their health conditions, resulting in a reduced quality of health. For instance, Alisha is diagnosed with nonsymptomatic HIV (“been living for 17 years never been sick, hospitalized or on medication”). Yet she is apprehensive that the stress in her relation- ship might compromise her immune system: “I don't want to continue a marriage where he's gonna, you know, stressing me out so bad that my immune system gonna break and I'm going to get sick.” Alisha also described the feelings that result from living with her explosive, abusive partner: “Feeling like I'm on the edge, or walking on pins and needles—eggshells.” Many of the women echoed their feelings of subjective stress, and they related the stress of their relationships to ill health. Mildred, who battled cervical cancer while in an abusive relationship, talked about how the stress of the relationship affected her health: “Having cancer and all, when you're stressed, if your blood count is as much 1263 as mine, it go drastically down. I have crashed to a point that I got all these kinds of sicknesses coming out of me.” Some women with pre-existing medical conditions described ways that their abusive partners undermined the control and treatment of their chronic diseases, jeopardizing recovery from acute conditions. Mildred, who recently separated from her abusive second husband, has AIDS. Although she retains a remarkably good outlook (“I am living with AIDS, not dying of AIDS”), her partner compromised her medical status by exposing her to sexually transmitted infections: “[H]e didn't infect me with AIDS, but he gave me all the rest of the complications, he brings home chlamydia, gonorrhea and all that kind of stuff.” Rose's boyfriend would pick up her medicine from the pharmacy as an excuse to come and see her, even though she told him not to. This upset her because she feared that he tampered with her medication: “Cause I don't trust him. He might open up my medicine and put some- thing else in them…he gets just that evil.” As a result, she would often have to order new medication. In addition to interfering with disabilities and conditions, abusers may also sabo- tage and interfere with women's recovery from addiction, subsequently affecting their health. Sherisse, who recently began to live on her own and is recovering from drug addiction, said the following: When I used to use, get high…it was ok for him, now that I have a year clean…it's would try to stop me from going to my support groups…I was an outpatient, and…he would call down there and tell my counselor that I was using drugs. How Illness and Disability Increase Dependency on Abusive Partners The women's comments illuminate how IPV can contribute to and exacerbate health conditions and disabilities. Additionally, many of the participants in the focus groups discussed how their health conditions contributed to a sense of dependency on their abusers. Such dependency extended the length of abusive relationships and interfered with their ability to address their ill health. Fear of being alone. Many women remarked on their loneliness and the fear of not being able to find another romantic partner because their health conditions had either impaired their mobility or affected their physical appearance. For instance, Ingrid, who has had a double mastectomy to treat breast cancer, faces the following dilemma: tolerate abuse or be without a romantic partner. She said, My fears of…never meeting somebody else is part of what keeps me with him, and the fact that I have all this scarring on my body now makes me feel like now what man is gonna, you know, want to look at me? 1264 Similarly, Rose, who lives with emphysema, describes her own internal conflicts relating to her need for a partner and her frustration with her partner's abuse and con- trol. She expresses the fear that if she were to expel her abusive partner she would be unable to replace him because she is a middle-aged woman on continual oxygen: “I have friends come through every now and then, you know, but I do want a man, you know, come see me…some reason I'm always clinging to him.” Another woman in the group reflected back to Rose, “That's low self-esteem.” Women's weight also served as a complex mechanism for dependency on abusive partners. Tiffany, who is 30 years old and weighs almost 300 lbs, was being forced to choose between her partner and her health: I wanted to get the surgery, the bypass surgery, because of my health, because I have…borderline diabetes and all that, and he said “well if you lose weight I'm gonna leave you.” It's scary cause it's like he gonna leave me…I don't wanna lose him and all that, but my health is being put on the back burner. Sharon expressed that the constant verbal attacks about her weight affected her self- esteem: “[He said] I was ugly, I was fat, `you ain't gonna find nobody, who's gonna want a fat pig like you.' I kept believing him, like it's true, like I ain't gonna find nobody, nobody's going to want me.” It is clear that the pressure from abusive partners regarding weight issues can be particularly dangerous for women who are seriously overweight. For some of the women, their partners' comments were often contradic- tory, accusing them of being overweight one minute and too thin the next minute. Such back-and-forth verbal abuse can be mentally and emotionally harrowing. Need for caretaking. Some of the women's abusive partners played the crucial role of caretaker when they faced serious health challenges. This dependency, cou- pled with the partners' responses to them, reveals the complexity of these relation- ships, and how difficult it can be for women to leave them. Sheneka's husband was emotionally and financially abusive toward her, but when she was sick, he took on the responsibility of caring for her: I'm a breast cancer survivor, I've been diagnosed with lymphedema, I've had a hys- terectomy…to put it in a nutshell, in 2004, I had six surgeries. Now at the time I was still living with my husband. This man dressed my wounds, he washed me, he cooked, he cleaned, he ironed, he did every single thing that I couldn't do. Some of the men promote dependency by doing favors, flattering women, and creating expectations of care. In Rose's case, her abusive boyfriend was helpful to her if he was in a good mood. He brought her flowers, bought her groceries, and cooked for her. She said she needed and liked his care; however, she worried because 1265 she could never predict when his visits would be helpful or violent. Her need for his help left her vulnerable to future abuse. Miranda's situation was different from that of Rose and Sheneka. She did not have a pre-existing condition; rather, she became dependent on her abuser for care- taking after an extremely severe beating left her immobile for weeks. Miranda's family, who blamed her for choosing an abusive partner, distanced themselves early in her relationship. She received no family or personal support during her recovery from her injuries. Until she could heal and find the support she needed, she remained physically dependent on her partner. A lack of support from family or friends can be isolating for women and can push them closer to their abusers, continuing the pattern of abuse. Fear of relapsing. Mildred, who started using drugs as a result of abuse in her first marriage, explained how she became dependent on her second husband to keep her from relapsing. They met while in treatment and although he was abusive, he played an instrumental role in her sobriety: Aside from what he did, every time I had a feeling of I want to use, he would say come on and we would get in the car and ride around and he would show me the bad lands again, “This is what you want to look like?” And by the time he was done I was right back, I don't want to use. Financial dependence. Financial dependence on abusers because of health problems was an issue for some of the women in the study. Health conditions often prevented women from earning the kind of income they needed to survive. For instance, Lillian discussed how she could not leave her abuser because the disabil- ity he caused prevented her from working and being independent. She said, “I can't work, I'm on disability, so I was living with him cause I couldn't afford no apart- ment, nothing like that.” Living with him created a situation in which he could con- tinue his abuse, leading to additional serious injuries. Other women separated their partner's role as abuser from that of provider. Mildred, who receives disability, talked of her ex-husband's generosity with money for her and her grandchildren, saying that no matter what happened between them, he always gave her money. The Convergence of Three Pathways: A Case Example Each of the pathways highlighted above can converge to permanently mark women's lives. When abuse causes injury or disease, derails recovery, and creates conditions for dependency, women may become trapped in a cycle that is hard to escape. To illustrate such a complex pattern, we describe the circumstances surrounding Esther's abuse. A year before we held our focus group, Esther weighed 1266 more than 400 lbs (with a height under 5 feet) when Esther decided to have gastric bypass surgery. Her weight affected all areas of her life, including her ability to work, increasing her dependency on her husband (“I had to lose the weight because I couldn't do anything for myself. And that was going to keep me tied to him”). Esther's husband had been verbally abusive toward her, but he escalated to physical abuse when she decided to go through with the surgery: “Two days before I was to go in the hospital, he put me in the hospital.” She said that he did not want her to have the surgery because he wanted to keep her “big and fat.” After the surgery, his physical abuse continued, using tactics that seriously jeopardized her health: When I had the surgery, I really couldn't do anything. I had tubes everywhere and I came home with a drain and everything. So my kids were taking care of me. I had to go to the hospital because he had pulled the drain. I had to have surgery. Um, I had stitches here, stitches here. They were busted another time about 2 or 3 days later. It just got really ridiculous after the surgery. When asked by the moderator if she was scared, she replied: “Scared to death. I really didn't want to take the pain medication cause I went to sleep, but my 15-year- old daughter stayed home….When I slept, she was awake.” The combination of the abuse and her weight led to low self-esteem, which prevented her from leaving the relationship. “But I didn't leave! Isn't that crazy? I still blamed myself…my self esteem was just like…it was down, in the toilet.” It wasn't until Esther lost weight and became more self-sufficient that she was able to leave her husband. Examining Esther's situation illuminates the cycle that can exist for women in IPV situations. It is difficult to find a starting point in the cycle. Esther's health was compromised by her weight, making her financially dependent on her husband. However, did the cycle begin with the verbal abuse that contributed to low self- esteem and a fear of being alone? Having bypass surgery left her vulnerable to his life-threatening abuse, which further reduced her physical and mental health. Although she was eventually able to terminate the relationship when her health improved and her physical mobility increased, the chronic nature of some health conditions suggests that breaking this cycle can seem virtually insurmountable. Discussion Our findings demonstrate that the pathways linking IPV and health are often bidi- rectional and cyclical, ultimately resulting in compromised health quality over the long term. Three overall pathways between IPV and health emerged: (a) IPV directly produces adverse health effects; (b) IPV worsens already-compromised health; and (c) ill health and disability increase dependency on abusive partners (see Figure 1). Women described myriad ways that these three pathways played out in their lives. 1267 Figure 1 Cyclical Pathways Connecting Intimate Partner Violence and Health Although the mechanism can be subtle at times, most participants are aware of the connection between IPV and their health. In the first pathway, violence from partners leads to the development of serious health conditions, disabilities, and disfiguring injuries. Abusers used overt tactics such as stabbing and covert tactics such as forcing them to overeat. Women described various consequences resulting from such abuse, including chronic pain, lowered self-esteem, embarrassing scars, and permanent vision loss. Stress from the abuse directly affected women's health by leading to headaches, heightened blood pressure, and nausea. Such findings support previous work linking stress to physical health in abused women (Eby, 2004; Sutherland et al., 2002). Additionally, we found that stress from the abuse compromised women's sobriety, prompting some to return to drugs or alcohol to cope with the abuse. We did not specifically recruit women with health problems or disabilities. The high number of women who disclosed health-related problems associated with vio- lence but with minimal interviewer prompting validates research documenting the association between IPV and health (Campbell, 2002; Campbell et al., 2002; Coker et al., 2005; Coker, Smith et al, 2000; Tjaden & Thoennes, 2000). The women's nar- ratives add to our understanding of the violence and health spectrum through their disclosures of specific tactics and actions abusers sometimes use—often with the 1268 expressed intention of controlling or damaging a woman's health. Furthermore, the women's harrowing descriptions suggest that survey research may underestimate the long-term effects of IPV on women's health. The range of conditions and resulting consequences disclosed by participants has important implications for service providers. Women who present for services may be dealing with a variety of condi- tions because of illness or former injuries that are not immediately visible, but which continue to affect their health. This is especially relevant when women enter shelter services, because impaired health can impede the ability to “get back on one's feet,” so to speak. Unfortunately, unless women have visible symptoms, health takes a backseat to issues of employment and housing. Increased collaboration between shelters and health care providers could help identify less obvious conditions so that women can better care for themselves. The second pathway that emerged illustrated the role of IPV as a compounding or worsening agent to women's health. Many of the women revealed that they were living with, or had battled, serious health conditions such as cancer and HIV/AIDS. They felt their partner's abuse exacerbated their conditions and, in effect, reduced their health quality. Women linked the stress from the abuse to compromised immune systems, lowered blood counts, and increased sicknesses. Abusers also directly compromised the status of women's health by interfering with their self- care. Examples of this included infecting them with sexually transmitted infections, tampering with medications, and sabotaging efforts at addiction recovery. Understanding the first two pathways has particular relevance for health care providers; they especially need to be aware of how abusive relationships can impinge on women's health. Women who are treated for chronic conditions that often entail help from family members may show little improvement because of IPV, especially if partners are actively interfering with access to health care. Conversely, physicians who are aware of the complex relationship between IPV and health can help patients better recognize IPV as a source of ill health. Findings indicate that physician detec- tion and referral to intervention services confers health benefits to abused women (McCloskey et al., 2006). Furthermore, another study revealed that women's recog- nition of the harmful effects of IPV is a two-step process in which physicians play a critical role. When physicians sensitively engage women in conversations about IPV, they can facilitate greater patient awareness of connections between IPV and health (Zink, Elder, Jacobson, & Klostermann, 2004). The third pathway linking IPV and health highlighted the bidirectional nature of the association: Women with poor health expressed heightened dependency on abu- sive partners, leading them to remain in the relationship and subsequently continue their exposure to emotional and physical violence. For some of the women, the iso- lation and stigma associated with aging and impaired health increased their reliance on partners. Women with chronic health conditions expressed particular anxiety about being completely alone if they ended their relationships. In particular, some women discussed fears of being abandoned by their partners and not being able to 1269 find new partners. These fears were reinforced verbally by partners, which height- ened insecurities and reduced their already-vulnerable self-esteem. We found that abusers can play multidimensional and often conflicting roles in women's healing processes. In their conversations, women sometimes compartmen- talized their partners' care-giving behaviors, highlighting the benefits conferred from the relationship despite the physical and emotional abuse. Indeed, we found that abu- sive partners could be helpful with recovery from illness and addiction. Women who end their relationships lose more than just tangible support; they risk experiencing feelings of loneliness and seclusion, which need to be considered when helping sur- vivors of IPV. For instance, one woman in the group said she wanted to go to sup- port groups but had no transportation, and the bus was too difficult to navigate because of her health condition. As a result, she looked forward to visits from her abusive partner because they eased her sense of loneliness. This finding has implica- tions for policy and practice surrounding women with chronic illness. Service providers must not only recognize the unique needs of women with chronic health conditions but also need to be prepared to help women fill the gaps in their lives that were once filled by abusive partners. Our findings point to the value of qualitative research in better understanding the relationships connecting IPV and health. Focus group methodology is particularly valuable in not only uncovering underlying processes but also in providing settings that facilitate disclosure in ways that espouse feminist ideology. In our own study, many of the women expressed a sense of fulfillment and gratitude at the close of focus group sessions for the chance to share their stories. They expressed the hope that their words could help other women in similar situations. Additionally, partici- pants made connections with each other at the close of the group, indicating that focus group methodology may be helpful in setting up situations to build support networks, a much needed element in women's independence from abuse (Macy, Nurius, Kernic, & Holt, 2005; Sullivan, Basta, Tan, & Davidson, 1992). Our findings have implications for future research in this area. The narratives describe extraordinary covert efforts by partners to damage women's health, which are usually undetected in research and in clinical practice. Tactics such as forced eat- ing or purposely derailing medical recovery are rarely measured or screened for in either advocacy or health venues. Our work could inform the development of instru- ments that are based on women's own descriptions of the ways abuse affects their health in order to better assess the violence-health interface. Although our sample consists primarily of low-income, urban women of color, it is unlikely that the spe- cific mechanisms of abuse or the three core themes are specific to a particular socioeconomic status or race. Nevertheless, further systematic study with a more diverse sample, including participants with a wide range of illnesses and disabilities, is needed to explore the pathways that shape women's health and well-being over time. Both qualitative and quantitative research methods are needed to illuminate the complex link between IPV and health. 1270 Appendix A Screening Questions From the Phone Intake Form Appendix B Focus Group Moderator's Guide 1271 References Bornstein, R.F. (2006). The complex relationship between dependency and domestic violence: Converging psychological factors and social forces. American Psychologist, 61, 595-606. Campbell, J. (2002). Health consequences of intimate partner violence . Lancet, 359, 1331-1336. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Intersections of Harm and Health</title><subTitle>A Qualitative Study of Intimate Partner Violence in Women's Lives</subTitle></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Intersections of Harm and Health</title><subTitle>A Qualitative Study of Intimate Partner Violence in Women's Lives</subTitle></titleInfo><name type="personal"><namePart type="given">Kristie A.</namePart><namePart type="family">Thomas</namePart><affiliation>University of Pennsylvania</affiliation></name><name type="personal"><namePart type="given">Manisha</namePart><namePart type="family">Joshi</namePart><affiliation>University of Pennsylvania</affiliation></name><name type="personal"><namePart type="given">Eve</namePart><namePart type="family">Wittenberg</namePart><affiliation>Brandeis University</affiliation></name><name type="personal"><namePart type="given">Laura A.</namePart><namePart type="family">McCloskey</namePart><affiliation>University of Michigan</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article"></genre><originInfo><publisher>SAGE Publications</publisher><place><placeTerm type="text">Sage CA: Los Angeles, CA</placeTerm></place><dateIssued encoding="w3cdtf">2008-11</dateIssued><copyrightDate encoding="w3cdtf">2008</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Eight focus groups of women with recent exposure to intimate partner violence (IPV) were conducted to elicit women's descriptions of how IPV affects their health. Their shared narratives reveal a complex relationship with three main points of intersection between IPV and health: IPV leading to adverse health effects; IPV worsening already compromised health; and women's illness or disability increasing dependency on abusive partners, thereby lengthening the duration of IPV exposure. Women describe bidirectional and cyclical ways through which IPV and health intersect over time. Service providers, including physicians, need to better understand the myriad ways that abuse affects women's health.</abstract><subject><genre>keywords</genre><topic>focus groups</topic><topic>intimate partner violence</topic><topic>women's health</topic></subject><relatedItem type="host"><titleInfo><title>Violence Against Women</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1077-8012</identifier><identifier type="eISSN">1552-8448</identifier><identifier type="PublisherID">VAW</identifier><identifier type="PublisherID-hwp">spvaw</identifier><part><date>2008</date><detail type="volume"><caption>vol.</caption><number>14</number></detail><detail type="issue"><caption>no.</caption><number>11</number></detail><extent unit="pages"><start>1252</start><end>1273</end></extent></part></relatedItem><identifier type="istex">082DB9C0F9A93613AC9EAF0C250C95B13F7E1EF4</identifier><identifier type="DOI">10.1177/1077801208324529</identifier><identifier type="ArticleID">10.1177_1077801208324529</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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