Tackling Domestic & Sexual Violence-- a Public Health

Perspective

HK Council of Social Service

20 May 2003

T W Wong

WHO defines violence as:

The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.

Different Approaches: violence as

Crime

Human right violation

Public health problem

Why Public Health Approach?

Violence

affects the health of a significant proportion of the population

Public Health

Treating a population

Collective action

Interdisciplinary Science-based

Prevention

Public Heath Hygiene

Broad street pump and cholera in London 1854

Blumer’s model of social problem

• Emergence of a problem

• legitimization of the problem

• mobilization of action

• formulation of an official plan

• implementation of the plan

Violence

ScopeMagnitude

CharacteristicsConsequences

Surveillance System

What is the problem?

ChildAbuse

YouthViolence

IntimatePartner

ElderAbuse

SexualViolence

Self Directed

CollectiveViolence

sexual physical psycho neglect

Scope

IntimatePartnerViolence

SexualViolence Woman

Magnitude of the problem

Domestic Violence is a “silent epidemic”

Violence Leading cause of deathage group:15-44 years

What about survivors?

Magnitude

National survey statistics

Physical assault:

• Philippines 10%• USA 22%• Canada

29%• Egypt 34%

Sexual Assault:

• Toronto15%

• London23%

HKSAR?

Magnitude

Incidence of DV in ED

• Mackay & Lo,1985 estimated:

one case per day in local ED

• PYNEH 1995: 1.5 case per week

• TMH 1998: 3 cases per week

• Only tip of iceberg

Magnitude

Prevalence in an ED population 1996

• 161 female patients (16-60 yr) approached

• 30% refused to be interviewed

• 5.3% have been battered (past 6 months)

• 3.6% have witnessed DV at home

Chung MY, Wong TW, Chan RTF, Lau CC. A study on the prevalence of domestic violence among female patients in an emergency dept. HKJEM 1997;4(2):82-4.

Prevalence is lower than overseas reports.

Magnitude

Screening in Tsan Yuk Hospital

• Six-questions screening instrument• 631 women interviewed• In the past year

– Physical/Verbal abuse 15.7%– Sexual abuse 9.4%

• Current pregnancy 4.3%

Leung WC et al. The prevalence of domestic violence against pregnant women in a Chinese community. International Journal of Gynecology & Obstetrics 1999;66:23-30.

Magnitude

Suffering in silence

Never(%)

Police(%)

Friends(%)

Family(%)

Australia 18 19 58 53

Canada 22 26 45 44

Chile 30 16 14 32

UK 38 22 46 31

Magnitude

Magnitude

Magnitude

Magnitude

Sexual assault previous 5 yr

City Year (%)

Beijing 2000 1.6

Manila 1996 0.3

Indonesia 1996 2.7

Magnitude

９８－２００２年性罪案數字比較

１００７

９５

２００１

１１２４

１０４

２０００

１２１４

９０

１９９８

９９１ １０４７非禮

９５９１強姦

２００２１９９９年份

Magnitude

12/00-30/9/02 風雨蘭個案數目：

• 合共處理 140個個案• 強姦佔 96 個；• 非禮佔 29 個；• 性騷擾佔 5 個

Magnitude

Forensic Medicine DOH 2002

Magnitude

Tip of iceberg

Magnitude

Characteristics of victims

Duration of Battering(%)

• < 3 months 30

• 4-12 months 17

• 1-3 year 13

• >3 years 40

Wong TW, Chung M, Lau CC, Ng P, Wong WY, Ngan J. Victims of domestic violence presenting to an accident & emergency dept. Hong Kong Practitioner 1998;20(3): 107-112

Occurrence of battering (%)

• once 29

• 2-4 times 38

• 5-10 times 12• >10 21

Wong TW, Chung M, Lau CC, Ng P, Wong WY, Ngan J. Victims of domestic violence presenting to an accident & emergency dept.

Hong Kong Practitioner 1998;20(3): 107-112

受侵犯時年齡

521246 或以上140152996總數

1652936-45

37552725-35

443103117-24

14031113-16

2408160-12

總數性騷擾非禮強姦

Consequences of violence

Mortality

Morbidity

Economic costs

Not many local studies available

Health Consequences

Physical:

• Injuries• Functional disorders

– Irritable bowel

– fibromyalgia

– Chronic pain

Sexual /Reproductive

• unwanted pregnancy• unsafe abortion• infections• infertility

Psychological problems

• Depression

• anxiety, phobia, panic

• eating and sleep disorders

• poor self-esteem

• Post Traumatic Stress Disorder

• Suicide / Self harm

Post Traumatic Stress Disorder

• Gulf War soldiers = 3%

• Earthquake survivor = 5%

• Fatal car crash =20%

• Rape =50% (6 mths)

Effect on abused women

• 57% have 6 negative answers to the general health questionnaire

家庭暴力對被虐婦女及其子女的影響研究基督教家庭服務中心及港大陳高凌

Effect on child• 100% witnessed violence

• 50.5% also victims of abuse– 68% physical abuse– 60% psychological abuse

• emotional distress

• feeling helpless

• low self esteem家庭暴力對被虐婦女及其子女的影響研究

基督教家庭服務中心及港大陳高凌

Children who witnessed DV

• Canadian National Longitudinal Survey of children and youth (1994/95)

• children exposed to DV had– lower health status– more condition and health problems limiting

participation in normal age-related activities

• more use of prescription medicine

Onyskiw JE. Health and the use of health services of children exposed to violences in their families.2002

The Costs of violence

Health care

Law enforcement

Days lost from work

Invisible pain and suffering

What are the causes of violence

Causes and correlates

risk factors

(victims/ perpetrator)

Ecological model

Individual factors

• Biological

• Demographic

• Education

• Substance Abuse

• Prior history of aggression/abuse

Relationship

• Social relationships

• Peer

• Intimate partner

• Family members

Community level

• Community context

• population density

• unemployment

• social isolation

• poverty

• support network

Society at large

• Cultural norms that support violence

• Parent rights over child welfare

• Male dominance

Spare the rod and spoil the child.

Certain women should be struck regularly, like gongs.Noel Coward 1899-1973 British dramatist

家庭暴力對被虐婦女及其子女的影響研究基督教家庭服務中心及港大陳高凌

家庭暴力對被虐婦女及其子女的影響研究基督教家庭服務中心及港大陳高凌

Attitudes and beliefs of ED doctors, nurses and student

nurses

Questionnaire survey

1994

1999

Chung MY, Wong TW, Yiu JJK.. Accident & Emergency Nursing 1996;4:152-55.Wong TW, Chung MY, Yiu JJK.. Emergency Medicine 1997;9:113-6.

Cultural Norm

清官難斷家庭事Agree(%)

Neutral(%)

Disagree(%)

Doctors 45 24 31

Nurses 57 19 34

Student 27 26 46

Cultural Norm

寧教人打仔、莫教人分妻

Agree(%)

Neutral(%)

Disagree(%)

Doctors 18 26 54

Nurses 23 15 62

Student 8 28 72

Cultural Norm

SWDHA

DOHED

HKCSSRHKPF

Legal DeptLegal Aid DeptHousing Dept

ISD

SWD Apr 00--Mar 01

二零零二年八月十三日

處理性暴力個案程序指引

簡介會關注暴力工作小組

Co-ordination council beware

• …focus primarily on coordinating refuge and the criminal justice system, at the expense of wider involvement of religious communities, schools, the health system, or other social service agencies.

Co-ordination for what?

• …while coordinating councils can improve the quality of services offered to women and children, interagency work can act as a smokescreen concealing the fact that little actually changes.

Winning hearts and minds

• Efforts to reform the responses of institution--including the police, health care workers and the judiciary-- should extend beyond training to change institutional cultures.

Finding out what works

We cannot wait to gain perfect knowledge

More researches are needed

CITUniversalScreening

WHO recommendation

Adopt the public health approach

Resolution WHA49.25 1996

Preventing violence: a public health priority

United Nations' Fourth World Conference On Women

• "Governments should take urgent action to combat and eliminate all forms of violence against women in private and public life, whether perpetrated or tolerated by the State or private persons." - Platform for Action, Beijing 1995, p. 109

WHO recommends steps to

Improve recognition, reporting and management of consequences of violence;

Promote greater intersectoral involvement in the preventionand management of violence;

Promote research on violence as a priority for public healthresearch

Prepare and disseminate recommendations for violenceprevention program...

How to prevent violence

Primary Prevention: before violence occur

Secondary Prevention: immediate response

Tertiary Prevention: long-term care, rehab

Weak

Targeted Intervention Approach

Universal: population at large e.g. media campaign

Selected: high risk group

Indicated: known case e.g. perpetrator

Intervene at different levels

Individual: risk factor modification

Relationship: family life education

Community: school, workplace, neighbourhood

Social: gender inequality, attitudes, socio-economic

Comprehensive approach

Multi-sectoral

Health careproviders

PoliceEducationPoliticians

Judiciary

ChurchSocial

ServicePolicy

Policy of HKSAR on violence

?

USA

• The passage of the Violence Against Women Act as a component of the 1994 Crime Bill was the creation of a national policy to address domestic violence.

Objectives and Targets

• 15-34. Reduce the rate of physical assault by current or former intimate partners.

• Target: 3.3 physical assaults per 1,000 persons aged 12 years and older.

• Baseline: 4.4 physical assaults per 1,000 persons aged 12 years and older by current or former intimate partners occurred in 1998.

Objectives and Targets

• 15-35. Reduce the annual rate of rape or attempted rape.

• Target: 0.7 rapes or attempted rapes per 1,000 persons.

• Baseline: 0.8 rapes or attempted rapes per 1,000 persons aged 12 years and older occurred in 1998.

National Advisory Committee on Violence Against Women

• President Bush, in his proclamation declaring October 2002 as National Domestic Violence Awareness Month said that, “Domestic violence in America is intolerable and must be stopped.”

UK Policy

• Launching Living Without Fear, a joint Home Office/Women’s Unit initiative, Margaret Jay, Minster for Women, said 6 million pounds would be made available to front-line agencies tackling domestic violence, rape and sexual assault. (1999)

Living Without Fear is the first document produced by a UK government to address violence against women.

Margaret Jay said:

‘Violence against women ruins lives and is unacceptable in a modern society. We are not prepared to let it be swept under the carpet...

‘Research shows victims of violence can have to go to up to ten organisations before receiving the help and advice they need. We have produced Living Without Fear to show how we can put an end to this unnecessary heartache and upset.

‘Through this document we are building on what we know works and spreading good practice which will benefit all women.’

European Parliament Resolution 1997

Need to establish a European Union wide campaign for zero tolerance of

violence against woman

European Commission CampaignMessages 1999/2000

Eliminate all forms of violence, including DV, is an absolute priority

zero tolerance of violence against women

Issues for policy makers

• Public health vs crime problem

• Recognise that only tip of iceberg is visible

• (hidden epidemic)

• Violence as a preventable social malady

• Political courage to challenge long-established attitudes and practices

What the government need to do...

Establish plan and policies to prevent violence, building important

partnership between sectors and ensuring a proper allocation of resources to prevention efforts.

Lessons to be learnt

Integration of violence prevention interventions into national policy

scheme

Lessons to be learnt

Mobilisation of internal and external resources for the initiation,

development and sustainability of violence prevention interventions

Lessons to be learnt

Primary Prevention should be our long-term goal

Violence is hazardous for your health

Stop Violence!

Thank You!