Mental Health Effects of Intimate Partner Violence IPV Across Cultures: A Coherent Mechanism for SUICIDALITY

1. Mental Health Effects of Intimate Partner Violence (IPV) Across Cultures: A Coherent Mechanism for SUICIDALITY Gregory Luke Larkin, MD, MS, MSPH, FACEP Professor of Surgery, Emergency Medicine, & Public Health The University of Texas Southwestern Medical Center at Dallas Director of Academic Development Medical Director Violence Intervention & Prevention Center Parkland Health & Hospital System Chair, Section of Injury Control and Prevention American College of Emergency Physicians Dallas, Texas USA

2. Injury Related Mortality, World 1998

3. Leading Causes of Death 15-44 yrs.

4. Leading Causes of Death 15-44 yrs. (continued)

5. Intimate Partner Violence (IPV) Largest contributor of the injury burden to women in the world (4.4 million adult women in US/yr) Over 10 billion/yr lost productivity, criminal justice interventions, & physical & mental healthcare cost annually Approx one of every 3 women experiences IPV in her lifetime (number varies cross cultures) High prevalence in the ED/A&E setting Over 1 million A&E visits/year; 25% A&E patients lifetime exposure Emphasis on screening & identification Little focus on cross cultural opportunities to date

6. Asian Invasion � IPV in US In US, Asian population growing at 4.5% every year Over represented in domestic violence cases example: Massachusetts Over 10% of IPV cases are Asian Asians only 2.4% of population in Massachusetts

7. South Asian women, psychological distress & self-harm: lessons for primary care trusts (Chew-Graham et al., 2002) Needs of South Asian womem suffering distress & mental health problems may lead to self-harm & suicide Qualitative study (focus groups) of South Asian women in Manchester, UK Systemic risks for mental distress: Social, political & economic pressures Domestic violence Poverty Language problems Family & children�s issues Health Women saw self-harm as a usable coping strategy Services accessed only at a point of desperation

8. Epidemiology of IPV in China? Chinese people comprise 21% of the world�s population (1.3 billion) Little is know regarding the prevalence, risk factors & health outcomes of IPV in China Few studies have been conducted in China Current laws are inadequate for meeting the needs of women who are abused Studies of IPV in Chinese are needed to increase the Chinese public�s recognition of his social problem & its impact on women�s rights & health US State Dept estimates (1995) one-fifth of Chinese wives are beaten No original source or data cited

9. Violence Against Women in China Chinese custom requires that women submit to husbands Endure humiliation for the families & children �Don�t wash your dirty linen in public� Tradition for Chinese women to suffer Public rarely pays attention to issues of IPV

10. IPV in China Dramatic economic & social changes since the late 1970�s Third World Women�s Conference in 1985 Fourth World Women�s Conference in Beijing in 1996 1993, a group at Chinese Women�s College conducted face-to-face interviews with 30 female victims of violence in Pinggu But investigators did not release the results to Western society

11. Epidemiology of IPV in China Survey on marriage quality in Beijing, 21% of 2,118 respondents indicated they had been beaten by their husbands (Sun; 1995) Shanghai in 1992, 61.5% of 3,899 reported abuse cases were for intimates. 1999, Women�s Studies & Information Center in Beijing surveyed 4,000 women in 4 cities in China, 1,000 participants from each city

12. Epidemiology of IPV in China Masses� attitudes toward IPV in China Four cities for inclusion The capital Southeastern coastal areas Areas with high ethnic minority density Northern poor rural areas Violent acts reportedly happened more frequently in the economically advanced SE region High minority density, high incidence of severe violence (wife in iron underpants) Investigators have not released the results to Western society (Sun, 2002)

13. Chinese Women�s Position in Society & Family Subordinate/Hierarchical �Three Obediences� Before marriage, woman follows & obeys father After marriage, she follows & obeys husband After death of husband, she follows & obeys son (Arsella, DeVos, & Hsu, 1985; Lum, 1988) China is a country with little individual privacy, but IPV is stubbornly protected as inviolably private & is often overlooked & ignored.

14. Societal Rationale/5 Common Reasons for IPV Among Chinese: (Xie, 1992; Xu et al., 2000) 1. Male chauvinism & sexism used to make one�s wife obey (Gallin,1992:Xie, 1992) As less traditional economic & gender role norms accompany increasing westernization, men may try to reassert their traditional prerogatives with violence (Gallin, 1992) 2. Women may be beaten for giving birth to a girl or not producing children (XU et al., 2000) Her fault/ her crime Bad progeny supports Husband�s right to divorce or take a concubine More severe in after institution of one child per family policy in 1979 3. A man with a lover may use abuse/violence to force wife into divorce 4. Man has some vice, gambling or alcohol 5. Sex related

15. Chinese Literature on Prevalence of IPV in China Wuhan,1983; 43% of 760 divorce cases wife initiated because of husband�s chauvinism and/or abuse (Xie, 1992) Tianjin, 1984;100 randomly selected divorce cases: 41% IPV & 1986, 51% IPV (wife beating) 1991, 106 divorced women interviewed (Pi, 1991) 46% women asked for divorce because �they could no longer stand the beating endured from husband� 70% reported being beaten by husbands at some time during their marriage 1997, Qindao Women�s Federation (QDWF) Of 2,348 QDWF cases reviewed 1991-1997, 15% related to IPV (Tan, 1997) 1996, Of 205 divorces 25.3% were caused by IPV (Tan, 1997) 1998, Voice of America (VOA) �wife beating causes 70-80% of divorces in China.�

16. Chinese Literature on Prevalence of IPV in China (cont) Above statistics cannot be generalized; divorce cases increased from 300,000 (0.3%) in 1980 to 1,113,000 (1.1%) in 1996 (VOA 1998) None of the studies had operational definitions of domestic violence Peer-reviewed Hong Kong prevalence studies published (Leung, Leung, Lam, & Ho, 1999; Tang, 1994, 1999) Tang, 1994; N=482 undergraduate students; CTS 14% of parents used physical violence against each other 75% used verbal aggression during the prior year Tang, 1999 67% reported at least one incident of verbal aggression, 10% experienced at least one incident of physical aggression by husband/partner during prior year.

17. Chinese Literature on Prevalence of IPV in China (cont) Leung et al (1999) Abused Assessment Screen (AAS) convenience sample of pregnant women (N=631) OB clinic in Hong Kong first known IPV study in a health care setting in China 18% women reported history of abuse 5% reported IPV while pregnant 16% reported abuse in the year prior 9% reported sexual abuse in the year prior No assessment of AAS instrument cultural appropriateness Mainland China (Xu, Zhu, & Campbell, 2000) only 3% sample of 30 women reporting physical violence, 10% reported forced sex, 7% reporting verbal abuse

18. Likely Explanations for Inaccurate IPV Estimates Socialized to accept physical & emotional abuse Doctors and patients adverse to reporting Victims Fear of retaliation Not a priority yet, but that can change: Media coverage Advocate by putting a face on the problem Start the process of gathering hard data

19. Two HK Population Studies That Identify Risk Factors for IPV Leung et al.�s (1999) study of pregnant Chinese women in Hong Kong found that unplanned pregnancy was one of the main risk factors for abuse Husbands/partners unemployed or manual workers, permanent local resident, immigrants were at risk for IPV Tang (1999) education level, difference in education, occupation, family, number of children were not related to various forms of wife abuse In Hong Kong Couples age, age difference, length of marriage & marital satisfaction correlates wife abuse

20. Barriers to Obtaining Help Violence in home viewed as family matter Loss of face Leaving one�s spouse can result in ostracism Loss of community respect, connection to only existing support system Conditioned to fear uniformed authorities Less likely to report accounts of IPV to the police Language /educational/literacy skills Trapped in violent & potentially violent homes

21. Barriers to Obtaining Help (cont) Many are note even aware domestic violence is a crime because of cultural norms related to women Lack of community support services no women�s shelters in China limited domestic violence hotlines Eg. Local Women�s Federation Having affairs/lovers outside of home currently in fashion in China (as elsewhere!) increases spead of IPV as well as HIV/AIDS (Xu 1999;VOA, 1998)

22. Why Do IPV Research in China? IPV research has lead to important health & public policy change in the west only (criminal) IPV largely ignored in China Prevalence of violence among Chinese populations not yet established Lack of culturally appropriate instruments for assessment of IPV against Chinese women, cross-cultural comparisons impossible Literature addressed the reasons IPV against Chinese women, no research has tested those reasons as risk factors Two studies from HK identified some sociodemographic risk factors of IPV but results were inconsistent and failed to assess factors unique to HK culture WHO/CDC others may support measures of prevalence, risk factors, & health outcomes among different cultures

23. Key Points of Research Reviews Intimate partner violence (IPV) exits among Chinese, yet little known about extent or nature of IPV in Chinese either in China or US Chinese authorities have tended to overlook & ignore IPV Violence against women by husband is considered one of the few categories of life protected as inviolably private In traditional Chinese families, the family structure is hierarchical & husband assumes highest authority Even though literature has cited 5 societal rationales for IPV among Chinese women, not research studies have been conducted to test or validate those premises.

24. Key Points of Research Reviews (cont) Available data on IPV prevalence in Mainland China is mainly from physical abuse among divorce cases National data in US do not include Chinese-Americans as a separate group. Inconsistencies in sampling, design, IPV definitions, and measurements have made it difficult to compare IPV prevalence cross-culturally. Battered Chinese women face unique barriers to obtaining help Even though Western societies have reported adverse health outcomes associated with IPV for many years, but no study to date has examined health ramifications of IPV among Chinese women

25. Implications for Policy, Practice & Research In order to affect policy change in China in terms of IPV & women�s rights issues, the Chinese society & government�s awareness of IPV must be increased IPV Research is central to increasing spousal assault awareness As well as research, public education through mass media & educational courses is essential to increase public awareness of IPV Researchers need to investigate the unique culturally related issues (e.g. barriers, risk factors) of IPV among Chinese populations Culturally valid instruments with the same operational definitions of IPV are needed in order to make cross-cultural comparisons of IPV Health care providers need to screen for IPV, conduct culturally appropriate assessments of IPV, and measure mental & physical health impact on patients.

26. SUICIDE: A Worldwide Epidemic �There is only one serious philosophical question, and that is suicide.� Albert Camus, in The Myth of Sisyphus Definition: Suicide is voluntarily and deliberately taking one�s own life.

27. Suicide: Global Burden Approximately 1M people per year Among top 10 causes of death in every country 8th in the US 1 of the 3 leading causes of death for 15-35 yr age Each suicide affects at least 6 other people 1.8% of the total world wide burden of disease 2.3% in high income countries (DALYs) 1.7% in low income countries Equal to burden due to wars & homicide Twice the burden of diabetes

28. Suicide Epidemiology 5% overall attempt sometime during lifetime (Kessler 1999) 18 attempts per each completion 10-15% of attempters ultimately complete Estimated 12 month incidence is 1% (Crosby et al 1999).

29. Suicide Epidemiology Top 5 cause of death 15 - 19 yrs. First or second in many countries Less common under 15 yrs but this younger group increasing Boys die more often than girls in most countries.... Except China Rural females outnumber males in China Female & male approximately equal in urban China Elsewhere, boys use more violent means (hanging, guns, explosives)

30. Difference Between Attempters & Non-attempters on Risk Factors Compared with non-attempters, attempters reported: Higher stressful events Childhood trauma Psychological distress Depression Hopelessness Alcohol use Drug use

31. Difference Between Attempters & Non-attempters on Protective Factors Attempters significantly lower scores on: Hopefulness Self-efficacy Coping skills Family/friend support Effectiveness obtaining material resources Spiritual well-being

32. Risk Factors for Suicide in USA Kaslow et al 2000; Compared to non-attempters, African American attempters more likely to report: Global psychological distress Symptoms of PTSD Hopelessness Drug abuse Relationship discord Childhood maltreatment Poor interpersonal conflict resolution Low level of self-efficacy

33. Wild Swans � Three Daughters of China (Chang; 1992) Jing Wang dreads her inevitable, arranged marriage to Rui Xiao. After an unsuccessful attempt to escape with the man she wishes to marry, the reluctant bride is held captive & beaten by her prospective husband & father-in-law who feel humiliation & lose face at her rejection. After several days of torment, Jing Wang returns to her unsympathetic family which considers her renunciation to their traditional values & customs unfilial. Later that week, Jing Wang is found dead; an apparent suicide. Relatives describe suicide as her sole means of resistance & her ultimate effort to be taken seriously.

34. The Suicide-IPV Link Up to 80% of female suicide attempters cite an abusive relationship as a factor in their decision to attempt suicide (Stark & Flitcraft, 1996): �In North America, abuse may be the single most important precipitant for female suicide attempts yet identified.� Abused women are more likely than nonabused women to have a history of suicide attempts (Abbott et at., 1995; Bergman & Bergman, 1991; Kaplan et al., 1995; Roberts et al.;1997; Stark & Flitcraft, 1996) Between 35%-40% attempt suicide at some point Battered women are more likely (20%) than nonbattered women (8%) to make multiple attempts (Stark & Flitcraft, 1996) IPV victims who experienced one, two, or three forms of abuse were 1.8, 2.3, or 7.8 times more likely to attempt suicide

35. The Suicide-IPV Link (cont) Increased rates of having attempted suicide were evident among women who had been sexually or physically abused (Wiederman et al., 1998) Bryant & Range (1995) found that young women with combined sexual & physical abuse displayed the greatest degree of suicidality. Risk factors for suicide on African American women IPV victims: depressive symptoms, hopelessness, drug abuse, & child abuse Compared to women with no risk factors, women with 2, 3, & 4-5 risk factors were 10, 25, & 107x respectively, more likely to commit suicide (Thompson, 2002) Experiences of more forms of child abuse also increased risks of suicide 1.8, 2.3, 7.8x for each additional form of child abuse (Anderson, 2002) Only other study outside USA was in Europe 82% of Greek women suicide attempters report being beaten by male partners 32% of Danish women suicide attempters report being beaten by male partners

36. Why Study IPV Cross Culturally? In US & West, gap in suicide completion rates between men & women is narrowing (Canto & Lester;1995) Partner abuse has only recently been investigated as a risk factor for suicidal behavior 21%-34% women are physically assaulted by an intimate partner during adult life IPV-related depression, anxiety & posttraumatic stress are major burdens Few investigations have examined the effects of partner abuse for ethnic Asian/Chinese women Both IPV & suicidality are associated with smoking, drugs, alcohol, & other high risk or harmful behaviors

37. Mechanisms of Suicidality in IPV:Independent Correlates Traumatic experience (lifetime & acute stress) Intermittent positive reinforcement punctuated by physical abuse (cycle of violence) Increase in platelet catechols, fragmented sleep, etc. Hopelessness (Walker; 1984) Derived from a learned helplessness, frustration, & relationship failure, role confusion, etc. Cognitive state and thus, modifiable Substance Abuse in IPV (Caetano, Larkin, & others) Facilitates attempts; lowers inhibitions, increases vulnerability to trauma Impulsivity/Impulsive Aggressiveness (Mann1997) Aggression is a basic factor of human personality, but in IPV and suicide, it is often turned inward on oneself.

38. IPV: Associated Risks & Outcomes Mental & psychological problems Depression, anxiety, low self-esteem, learned helplessness, PTSD, substance abuse Battering common (battered wife syndrome) Injuries secondary to battering Headache, gastric problems, anxiety & insomnia Suicidal thoughts, intentions & suicide attempts IPV Homicide African women 6/100,000 White women 1.4/100,000

39. Emergency Medicine Treatment of Potential Victims Screen for suicide & IPV both! Risk/lethality assessment for both ED based treatment Brief intervention Safety planning Drugs Motivating follow-up/help-seeking kiosk Connect to community resources

40. Why Do Many Abused Women Attempt Suicide? Limited choices for coping Powerless & depressed Abusers often control of every aspect of their lives Limited social networks & material resources Vestige of power Get attention African American women who attempted suicide more likely than non-attempters to have an IPV history (48.8% vs 22.2%) 2.5 times more likely to report physical abuse 2.8 times more likely to report nonphysical (emotional) partner abuse (Kaslow; 1998, 2000) IPV-suicidal behavior link mediated by psychological distress, hopelessness, drug abuse & moderated by social support

41. Risk Factors for Suicide in China Phillips, et al, Lancet 2002; 360:1728-36 BACKGROUND: Suicide is the fifth most important cause of death in China 287,000 deaths per year WHO 1999 World Health Report suggests that suicide is China�s fourth most important public-health problem Rural suicide rate is three-fold the urban rating More suicide deaths among women than men Different from those reported in other parts of the world

42. Risk Factors: Suicide in China (cont.) Phillips, et al, Lancet 2002; 360: 1728-36 8 significant predictors of suicide remained in the final unconditional logistic regression model. High depression symptom score Previous suicide attempt Acute stress at time of death Low quality of life High chronic stress Severe interpersonal conflict in 2 days before death A friend or associate with previous suicidal behavior A blood relative with previous suicidal behavior

43. Risk Factors: Suicide in China (cont.) Phillips, et al, Lancet 2002;360:1728-36 Risk Increased with exposure to multiple risk factors. Exposed to one or fewer risk factors died by suicide 30% with two or three risk factors 85% with four or five risk factors 96% with six or more risk factors died by suicide Risk factors for suicide do not differ greatly Preventative efforts should focus on individuals exposed to multiple risk factors

44. Suicide in Hong Kong Stable crude suicide rate High female suicide rates compared with west Decline in hanging, jumping most common method Charcoal/CO is emerging trends Yap(1958), Lo & Leung(1985), Hau(1993), Ho et al(1995) & Yip(1996,1997) Hong Kong more YPLLs from suicide than Beijing & Taiwan Yip (1996)

45. Suicide in Hong Kong (cont) 496 in 1981 to 718 in 1995 Proportion of total deaths 2% in 1981 to 2.4% in 1995 Crude suicide increased 20%, 9.5% to 11.5 deaths per 100,000 1981-1995

46. Elderly Suicide in Hong Kong One of highest suicide rates in the world. 33% of all suicides 1% all deaths among persons aged 60 or above 12x higher for over 60 yrs; highest over 75 yrs 4 to 5 times above average Male to female ratio 1.3:1 (vs 3:1 in most countries) Single males higher than single females Married males higher rate than widowed Jumping has become increasingly common Winter months & Chinese New Year lowest rates?

47. Elderly Suicide in Hong Kong (cont) Elderly suicide rates/100,000 Never married 43 Married 35 Widowed 11 Divorced/separated 22 Rates closer to rural Beijing than urban Beijing Urban Beijing 13/100,000 Rural 38/100,000 Hong Kong rates higher than Austrailia, New Zealand & USA

48. Suggestive Evidence of Partner Violence Risk in Hong Kong Elderly Married females suicide rate higher than male, 42 vs. 31 per 100,000 Married females� rate > never married females Widowed (both male & female) < than married Suicide rate for divorced female elderly less than married female 1995 four economically active vs. 213 inactive elders committed suicide (3 vs 30/100,000)

49. Suicide Risk Factors Not present in every case Vary from one country to another dependent on cultural, political, economic features Some genetic and some environmental Risk for attempts in the West Female Lesbian or gay Previously married Younger age Low education Unemployed (Kessler et al 1999)

50. Suicide Risk Factors: Cultural and Socio-demographic Low socioeconomic status/economic stress Poor education Unemployment in the family Recent change in economic or social status Indigenous or immigrants Linguistic, emotional, social network skills Torture, war injuries, isolation, value conflicts especially for girls raised in new/freer country with roots in parents strong, conservative culture Low participation in societal activity

51. Family Pattern Risk Factors Destructive family patterns and traumatic events in childhood Parental psychopathology (affective) Alcohol, substance abuse Antisocial behavior/poor communication Family history of suicide attempts Violent and abusive family (physical/sexual) Divorce, separation or death of parents/guardians Frequent moves to different residential area Family rigidity Foster/adoptive family Very high or very low parental expectations

52. Suicide & Physical Disorders Chronic physical illness especially if disabled or poor prognosis; often coexists with depression Neurologic diseases Epilepsy (impulsivity, aggressivity, chronic disabililty) Spinal & brain injuries eg post stroke 19% depressed and suicidal Neoplasms esp at time of diagnosis or in first two yrs. Pain significant association with suicide HIV/AIDS esp in young & in early stages of illness

53. Suicide: Psychiatric Risk Factors  Suicide is a multidimensional disorder Biological, genetic, psychological, sociological, & environmental 40-60% of completers saw physician in a month prior to suicide (usually a GP) Not in itself a disease but mental disorders in 80-100% of completers Lifetime risk for mood disorder (mostly depression) is 6-15%; alcoholism 7-15%, schizophrenia 4-10% Hopelessness Poor coping skills

54. Risk Situations Marked susceptibility to stress (cognitive & personality traits both learned and genetic) leads to difficulty coping with negative life events Negative life events reactivate helplessness, hopelessness & despair Beautrais AL,J Amer Acad of Child & Adol Psych, 1997, 36:1543-1551. DeWilde EJ,Amer J Psych, 149:45-51

55. Risk Situations (continued) Injuries to self image / wounded personal dignity Family disturbances Separation from friends, classmates, etc Death of a love one or other significant person Termination of a love relationship Interpersonal conflicts or losses Legal or disciplinary problems Peer-group pressure or self-destructive peer acceptance Problems are always multidimensional

56. Risk Situations (continued) Bullying & victimization Disappointment with school results High demands at school during examination periods Unemployment & poor finances Unwanted pregnancy, abortion Infection with HIV or other sexually transmitted diseases Serious physical illness Natural disasters

57. Health Impact of Intimate Partner Violence on Men and Women: Analysis of the NVAW Survey

58. Significance Few population-based studies of IPV frequency by type and by gender. Few studies assessing longer term physical and mental health effects of IPV by type (physical, sexual, psychological) in women. No such studies among men as victims. No population-based studies assessing mental and physical health effects of stalking.

59. Significance of Studying IPV in HK/PRC Few population-based studies of IPV in ASIA No population-based studies assessing mental and physical health associations with IPV in China

60. National Violence Against Women Survey Nationally representative random digit dial survey of 8,000 women & 8,000 men, 1995-6. Response rate: 72% women; 70% men. Purpose Estimate violence victimization by type. Measure financial and health effects of IPV. Assess demographic correlates of victims and perpetrators.

61. IPV: A Risk Factor for Suicidal Behavior in Western Women Abbott, Johnson, Koziol-McLain, & Lowenstein, 1995 Kaplan, Asnis, Lipshitz, & Chorney, 1995 Roberts, Lawrence, O�Toole, & Raphael, 1997 Kaslow et al., 2000; Kaslow et al., 1998 Stark & Flitcraft, 1996

62. Risk Factors for Suicidal Attempters in IPV Kaslow et al, 2002 Numerous &/or severe negative life events History of child maltreatment High levels of psychological distress & depression Hopelessness about the future Alcohol & drug problems

63. Protective Factors Associated with Non-attempter Status in IPV (Kaslow, 2002) Hopefullness (Learned Optimism � Walker,1994) Self-efficacy Coping skills Social support (empowers leaving) Browne, 1993; Sullivan, 1999; Jacobs, 1999 Material resources Employment Child care Safe housing/escape from partner May help guide intervention for abused suicidal women

64. Limitations of Previous Work Kaslow et al focused on African Americans Largely self report and retrospective data calls into question response validity Cross sectional studies cannot show causation Unclear which risk & protective factors are redundant both within & between risk & protective factor constellations Future work must include diverse ethnic groups in multiple settings longitudinally Structural equation modeling may help clarify distinct contributions of each risk & protective factor

65. Intimate Partner Violence Measures Lifetime and current IPV Intimate = spouse, live in boy/girl friend Physical (12 item Conflict Tactics Scale) Forced sex (3 items, completed sexual assault) Psychological IPV (12 item Power & Control scale) Stalking (20 items; occurred > once, victim afraid)

66. Suicide Attempts by Battered Wives 22 (19%) of battered wives mad 82 suicide attempts (16 yrs) More than 8 times of women being treated attempted suicide Predominately passive methods Conflict with husband was most common Mental disorder another main cause Doctor should consider possibility ongoing physical abuse in suicide patients

67. Suicide Attempts by Battered Wives 117 battered women, 22 (19%) made one suicide attempt resulting in inpatient care during the 16-yr study period Every year 1% of battered women attempted suicide 1,175 per 100,000

68. Health Outcomes: Mental Health Current depression (SF-36 health survey) Chronic mental schizophrenia illness (depression, bipolar disorder,); age at diagnosis Current drug use (antidepressants, pain killers, tranquilizers, �recreational� drugs, heavy alcohol use)

69. Health Outcomes: Physical Health Current self-perceived health status: excellent (1) to poor (5) Developed a chronic disease (hypertension, diabetes, arthritis, asthma or emphysema, cancer); age at diagnosis Developed an injury (head, back, neck, spinal cord); age at injury

70. Developed an Injuryand IPV by Type and Sex