Echoes of Violence: A Study Makes a Connection Between Recent Abuse and Mortality
KM: I don't think any one of us felt that abuse doesn't impact people and women's health outcomes. Of course it does. But it's a whole different thing when you can document it. People always want to see the evidence, because if there's no clear evidence that there's a direct link or what the link is and through what mechanism, you don't know how to intervene. You don't know what's going to be most effective.
So we really look at this as a first step in documenting that there is a clear association with something as severe as mortality. It cannot get any more severe in terms of a health outcome than that, right? So if you back up from mortality, now we're starting to look at earlier health outcomes. Do you see this manifest with respect to cardiovascular disease in HIV-infected women? Diabetes? Is this affecting other co-morbidities much earlier? But as a first step for us, if you can see it with mortality, than you're going to be able to find it elsewhere too. Mortality is a profound outcome. If you go for something so profound as your starting point and you find it there, then you can bet that it's starting much earlier than that.
Something's driving this mortality. This isn't because women were beaten up. This is not because women were thrown down the stairs or thrown in front of trains. This isn't homicide or suicide. Those things contribute a little bit to the findings, but they don't explain everything that we're finding as a relationship between current abuse and mortality. There's some biologic change that occurs as a result of being in an abusive relationship.
EV: I worked on an issue with women from the West Side, in the Project WISH study at the University of Illinois, and it was astounding to me to hear the same story of abuse over and over again from each woman. You talked about women not being allowed to go to their medical visits by their [male] partner. Talk about some of these influences and inspirations you had for the study.
KM: In the WIHS, in the section where we ask about violence, that is one of the questions. Does your partner prevent you from using the phone? From contacting your friends? From going to your necessary medical visits? Those are questions that are asked. For me, thinking that anybody would be able to stop you from going to your medical visit in this country, in this day and age, is really baffling. You're sitting at home and you know you need your HIV care, you need your HIV medications, and someone is actually preventing you from doing that or from seeing friends. Sure, there's some level of lack of social support and external contact if someone is really controlling you to the point that he is preventing you from leaving your home, preventing you from doing the things you like to do. I guess in many ways you can imagine that the lack of social support and activity with people who care about you would have some impact, the direct effect of not being able to go to your research facility or care appointment. I think in Rwanda [where Dr. Cohen is working with HIV-positive women] Mardge talked about some examples of this in which the women were HIV-infected and the husbands were HIV-infected, but they didn't want to be seen going into the HIV clinic, so they weren't going to the clinic for their own medication and they were taking their wives' medications. Those different levels and types of abuse really drove us to look at the data to see if we can see in the data what we see when women are in front of us actually telling their stories. You can tell how horrible this makes them feel. I think we always thought this finding would come out. It's just that so many of the ways in which we were handling the data before [weren't right for our study] -- for example, with depression -- as people have more abuse, they become more abused, and it's a cyclical thing. So the new approach we were able to take with this collaborate from the University of North Carolina really helped us look at the data and use some models that we didn't have available to us before.
EV: You're talking about the marginal structural models? I didn't discuss that aspect in my article.
KM: It is a mechanism where we can look at longitudinal data and you can make more sense out of all the contributing factors and then how those individual factors change over time. If you were just looking at it cross-sectionally, one time point, you probably wouldn't be able to appreciate the findings as much. It wouldn't have shown up as glaringly.
EV: What message would you like to give to women, to men, to any group?
KM: For me, I just feel that the most important message is really that abuse does have a profound effect on women. If it manifests itself in an outcome as terminal as mortality, it's really something that deserves attention. I just really don't feel like enough attention has been placed on the impact of violence on the health of women. I feel that you see a lot more attention now on violence against girls and women, and I think it's really becoming a topic to think about. I think it has to take place in every venue. It has to be a community discussion. It has to be a health care provider question as they come in for care, for every type of contact. It has to become more a discussion that we have openly to increase awareness. I think there's a lot more awareness in this country than there used to be, but we have a long way to go. And then you think about what it's going to take to really change and reduce the amount of violence that women and children really experience. Our women in the study have a really high rate of childhood violence exposure as well, directly and indirectly. So I just think it's good to begin to have some data to have dialogue about the effects of violence on health.
EV: Are the effects of violence the same on men?
KM: Absolutely! There is literature [research] describing the association between being abused and subsequently being more likely to abuse others. Men are most definitely not exempt from the violence epidemic. If we begin to ask, certainly we will find (and others have already reported) that abuse is as common among men as it is among women and that the impact of abuse is just as devastating.
While special attention needs to be paid to the most vulnerable groups, those least likely to protect and advocate for themselves, the message really is ... we need to collectively work toward ending violence of all kinds against all individuals by speaking out and adopting a zero tolerance approach in all settings (public and private, domestic and international, etc).
Vulnerability and Empowerment: At the International AIDS Conference, an Examination of Sexual Abuse and Violence Against Women -- and Men
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