Tackling Domestic & Sexual Violence-- a Public Health Perspective

1. Tackling Domestic & Sexual Violence-- a Public Health Perspective HK Council of Social Service 20 May 2003 T W Wong

2. 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.

3. Different Approaches: violence as Crime Human right violation Public health problem

4. Why Public Health Approach? Violence affects the health of a significant proportion of the population

5. Prevention Public Health Treating a population Collective action Science-based Interdisciplinary

6. Public Heath  Hygiene

7. Broad street pump and cholera in London 1854

9. 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

10. What is the problem? Scope Magnitude Characteristics Consequences Violence Surveillance System

11. Scope Child Abuse Youth Violence Intimate Partner Elder Abuse Sexual Violence Self Directed Collective Violence neglect sexual physical psycho

12. Intimate Partner Violence Sexual Violence Woman

13. Magnitude of the problem Domestic Violence is a “silent epidemic”

14. Magnitude Violence Leading cause of deathage group:15-44 years What about survivors?

15. Physical assault: Philippines 10% USA 22% Canada 29% Egypt 34% Sexual Assault: Toronto 15% London 23% Magnitude National survey statistics HKSAR?

16. 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

17. 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.

18. 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.

19. Magnitude Suffering in silence

20. Magnitude

21. Magnitude

22. Magnitude

23. Magnitude Sexual assault previous 5 yr

24. Magnitude 年份 １９９８ １９９９ ２０００ ２００１ ２００２ 強姦 ９０ ９１ １０４ ９５ ９５ 非禮 １２１４ １０４７ １１２４ １００７ ９９１ ９８－２００２年性罪案數字比較

25. 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

26. Magnitude Forensic Medicine DOH 2002

27. Magnitude Tip of iceberg

28. Characteristics of victims

29. 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

30. 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

31. 強姦 非禮 性騷擾 總數 0-12 16 8 0 24 13-16 11 3 0 14 17-24 31 10 3 44 25-35 27 5 5 37 36-45 9 2 5 16 46或以上 2 1 2 5 總數 96 29 15 140 受侵犯時年齡

32. Consequences of violence Mortality Morbidity Economic costs Not many local studies available

33. Physical: Injuries Functional disorders Irritable bowel fibromyalgia Chronic pain Sexual /Reproductive unwanted pregnancy unsafe abortion infections infertility Health Consequences

34. Psychological problems • Depression • anxiety, phobia, panic • eating and sleep disorders • poor self-esteem • Post Traumatic Stress Disorder • Suicide / Self harm

35. Post Traumatic Stress Disorder • Gulf War soldiers = 3% • Earthquake survivor = 5% • Fatal car crash =20% • Rape =50% (6 mths)

36. 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

38. 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

39. 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

40. The Costs of violence Health care Law enforcement Days lost from work Invisible pain and suffering

42. What are the causes of violence Causes and correlates risk factors (victims/ perpetrator)

43. Ecological model

44. Individual factors • Biological • Demographic • Education • Substance Abuse • Prior history of aggression/abuse

45. Relationship • Social relationships • Peer • Intimate partner • Family members

46. Community level • Community context • population density • unemployment • social isolation • poverty • support network

47. 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

48. 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

49. 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

50. Cultural Norm 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.