Women with HIV/AIDS and women victims of intimate relationship violence "Are the same women" said Francess Page, RN, MPH, senior public health advisor in the US Public Health Service's Office of Women's Health, in her address to attendees of the Ninth Annual International Nursing Conference on Ending Violence Against Women. Page's words echoed a larger theme of the conference: women who are victims of intimate partner violence are the same women seen by healthcare providers for other health-related concerns. The healthcare system may be the first, and in some cases only, help system they access.
Presenters, organizers, and conference participants found some agreement on the role of healthcare providers in ending domestic violence: a call for universal screening of women for intimate partner violence was heard from the gathering. Much more elusive was consensus on the issues of culture, race, and feminism as they relate to violence against women. Can women and healthcare providers come together effectively to work on this issue within culturally diverse countries and around the globe? Can the issue of women's rights be paramount or even visible in this work as science, healthcare, and government bureaucracies become involved?
The Role of Healthcare Providers in Ending Violence Against Women
In 1994, an estimated 250,000 American women sought care from assaults by intimate partners (husbands, boyfriends, ex-boyfriends, etc), according to US Justice Department statistics.1 Women were also nearly two-thirds more likely than men to be victims of violence in 1994:2 overall trends suggest that the rates of victimization for men are decreasing while rates for women are increasing in the United States. Violence against women, especially at the hands of intimate partners, is increasingly recognized as a major law enforcement, social, and health issue. Nurses, women's advocates, and researchers gathered in Austin, Texas not to establish the seriousness of this problem, but to focus on who these women are, and to see signs of abuse where they are not obvious.
HIV/AIDS and Violence Against Women
"Sometimes I had to do things just to put food on the table for my children. I'm not proud of what I had to do; I just wanted to survive. Strength comes from how you handle life's problems. You cope as best you can." Francess Page quoting women with HIV/AIDS.
In quoting these women, Page pointed out that if you did not know these were women with HIV/AIDS, you would think they were women talking about their battering situation. Women who reveal a positive HIV status to their partners have a significantly increased risk of becoming victims of abuse. According to Page, partners may interpret this information as indicative of sexual activity outside the relationship, even though the abusive partner may also carry the disease. This is one way that HIV/AIDS and domestic violence overlap, and one that touches the controversial issue of partner notification.
In the intersection of domestic violence and the disease, AIDS prevention is the most pressing and troublesome issue to Page. "With HIV/AIDS prevention, behavior modification is noted as the one prevention tool available to us. However, women in a battering situation cannot change condom use behavior without a lot of support." The solution that may seem obvious to outsiders, that of leaving a partner who will not consent to condom use, often puts the woman at the greatest risk of violence.
The use of drugs and abuse of alcohol are often complicating factors in an abusive relationship, and, of course, in HIV prevention. Here again, these two issues overlap and challenge women in their attempt to control their lives. Young women and women of color are particularly at risk. Page illustrated this potential overlap with a newspaper story, headlined "Murder-Suicide in the City: Children Left for 10 Days." Mary, mother of two, was murdered by Bob, who had been fired for drug use on a job he had started two days before the incident. On the way home he got high; once home and behind closed doors he viciously beat and raped Mary. She told him to stop and disclosed her HIV-positive status. Bob strangled her, then got his gun and killed himself. "This is where domestic violence and sexual behavior proved to be a double whammy for Mary," said Page. "Many healthcare providers overlook the impact that power and control have in the lives of women."
Obstetrics, and Intimate Partner Abuse
"Pregnant women are such a rich resource in ending violence against women because the one common experience of women worldwide is pregnancy. Up to 95 percent of women worldwide will have at least one pregnancy." Judith McFarlane, RN, DrPH, SPAN, Texas Women's University.
McFarlane was one of several researchers who reported on domestic violence data from and interventions with women in prenatal clinics. Her "Advocacy Intervention Model for Pregnant Abused Women" tested the efficacy of domestic violence screening and three interventions for women who responded positively to questions on abuse at an inner city prenatal clinic in Houston. Screening of over 12,000 primarily low-income Hispanic women identified ten percent as experiencing physical or sexual intimate partner violence. Those who screened positively for abuse were invited to participate in the project, and most agreed. The researchers postulated that the more intensive the intervention, the more likely the violence would decrease in frequency and severity. In the minimum, standard intervention, a counselor gave women a wallet-sized card with local resource numbers for shelters and other relevant help avenues. The enhanced intervention added onsite counseling and referral by trained counselors at the clinic. The most intensive intervention was a lay health approach using "indigenous mothers," part-time, paid women in the community who were trained to provide advocacy for pregnant abused women.
McFarlane accumulated interesting data and made thought-provoking conclusions on the participation of women in the different aspects of the intervention and the potential benefits to women's self-esteem and coping skills from having an assigned advocate they could relate to and trust.3 But, ultimately, she found that, in terms of a decrease in frequency and severity of violence, the level of intervention did not matter. The intervention itself did make a difference: women in the study experienced a greater decrease in violence in their lives than did a control group. But women who received just a card with resource numbers were just as successful at reducing or eliminating the violence during their pregnancies as were women who had counseling or a lay advocate. Her conclusions supported others in a call for universal screening: being asked, having the abuse acknowledged, or admitting what was going on to a supportive and authoritative listener seemed to turn the tide in these women's lives.
Mary Ann Curry, RN, DNSc, FAAN, of Oregon Health Sciences University also looked at abuse in pregnant women, especially adolescents. Research assistants interviewed 1987 women at about 16 weeks gestation in five clinics. Of the 559 teens in the study, 37 percent reported abuse. In every age group, incidence of low birth weight was higher in those who had been abused.4 The incidence of abuse by age climbed from age 13 to 17, then dropped precipitously to age 18. McFarlane and colleagues hypothesize that the abuse declined because the young women left home, fleeing a familial abuser. (They did not ask the women their relationship to the perpetrator.)
Fifteen-year-olds reported the highest rate of sexual abuse, the same age group characterized by heightened sexual experimentation. Adolescents who reported abuse were more likely to be high school dropouts, reported more smoking, and experienced more second trimester bleeding. Again, researchers called for universal screening: "The high rates of abuse reported by both adolescent and adult women in this study emphasize the need for nurses in every setting to incorporate routine screening for abuse into their nursing assessments."
STD Clinics and Sexual Assault
"Have you ever had a really bad sexual experience, like sexual abuse or rape?" A screening question from a San Antonio study of women with sexually transmitted diseases.
According to Jane Dimmett Champion, RN, PhD, a staff member of a Centers for Disease Control and Prevention-funded sexually transmitted disease (STD) intervention project in San Antonio, Texas, decided "incidentally" to look at violence, according to researcher. Anecdotally, clinicians in the study were hearing about violence in the lives of their patients, especially those with high rates of reinfection. They decided to look at the connection more formally. Beginning in 1991, they added one simple question on sexual violence to their intake: Have you ever had a really bad sexual experience, like sexual abuse or rape?
The idea of a correlation between sexual violence and STDs is not new. The surprise from this screening question was how effectively it identified those at highest risk. Thirty-one percent of the women entering the San Antonio project answered affirmatively to the sexual violence question. (The San Antonio study includes Mexican-American and African-American women: the percent screening positive for sexual violence was exactly the same in both of these groups.) These women had more partners, an earlier age of first sexual experience, engaged in riskier sexual activities, considered themselves more at risk for HIV, were less likely to have been tested for HIV, and had more partners who had sex with commercial sex workers. "What was so interesting," said Champion, "was that with one question, we got to this group."
For the next phase of the study, Champion and colleagues expanded the sexual violence portion to a ten-question assessment of a broader range of violence exposures. Three subscales measured sexual, physical, and emotional abuse. Initial data from this research indicate dramatic differences in reinfection rates between abused and non-abused teenagers. At six months, women aged 14 and 15 years who reported physical and/or sexual abuse had a 37.8 percent reinfection rate, as opposed to 15.4 percent for non-abused. The 16 - 18-year-olds had a 27.7 percent reinfection rate for abused, 16.3 percent for non-abused. In contrast, those age 19 and over had much more similar results between groups: 9.3 percent of those reporting abuse were reinfected, close to the 7.3 percent of non-abused reinfected. Those who only suffered emotional abuse did not show higher STD risk or reinfection rate.
A striking 50 percent of 14- to 17-year-olds with STDs in the San Antonio sample reported sexual abuse. The women who reported abuse in this study were more likely to seek healthcare later, when symptoms were more severe, but then came back more often. They were more likely to seek healthcare because they were experiencing symptoms, while non-abused women were more likely to find out they had an STD at routine gynecological check-ups. Women who reported sexual abuse in this study were more likely to have unprotected sex before taking medications and before their partners were treated. "Sexual abuse must be addressed to make treatment effective," said Champion.
Soave suspects, "that the lack of therapeutic efficacy in these patients could very well reflect their profound immune defect, as opposed to merely reflecting the absence of drug activity."
Healthcare Providers as Victims, Perpetrators, and Reactors
"Many female employees also in the healthcare setting may themselves be victims and are held silent by the absence of resources within their healthcare setting. It may also be a factor that some [providers] may also be batterers themselves and would need counseling to help with this maladaptive behavior." Francess Page.
Page pointed out that the responses of healthcare providers to violence against women can be greatly complicated by the fact that they are human. Whether violence/ abuse screening of all women in healthcare settings proves to be scientifically and socially sound will not be independent of the attitudes and experiences of healthcare providers. Many health professionals have been victims or perpetrators of violence themselves. Their response to women in danger will be greatly influenced by their life experiences. Attitudes about violence, gender relations, race, and class influence response to abused women.
Engaging women in conversation about problem solving around violence may also take its toll on the provider. Several conference attendees addressed or alluded to the issue of vicarious victimization of those who counsel survivors of violence. Kimberly Crocker, MS, RN, CS, FNP, of Regis College cited several terms used to describe and diagnose this phenomenon, including: countertransference, empathic stress, compassion fatigue, rape counselor syndrome, and secondary traumatic stress disorder (STSD). Primary research on STSD was conducted by psychologists at several institutions, caring for Vietnam veterans, and it has since been documented in police officers and rape counselors. Long-term interactions with survivors of violence can actually elicit feelings of fear, pain, and suffering similar to those of the person experiencing the actual trauma. For providers who are survivors of violence, hearing others' stories can also reopen old wounds. Healthcare workers may need to explore resources to deal with this work-related risk.
Culture, Race, Racism, and Ending Violence Against Women
Several presenters at the Conference on Violence Against Women challenged participants to look boldly at their own prejudices and their roles in perpetuating discrimination. Colleen Varcoe, RN, PhD, a nurse researcher in British Columbia, Canada, asked healthcare providers and others to see race as a socially constructed phenomenon often based on irrelevant or incorrect facts and assumptions such as hair and skin color. She urged that approaches to work on violence issues include "anti-oppression" efforts as well as "cultural sensitivity" education.
Several researchers proposed ethnographic research and in-depth one-on-one interview techniques as appropriate tools for research with women, especially populations often not visible in health research, including women of color, women in prison, and migrant and rural women.
Being Careful with Culture
"Look at culture as borders, borders that are permeable and changing. Where people remember, where people forget...We are all world travelers. We are all entwined in cultural production. Without her, I am nothing." Sujata Warrier, PhD, Director, New York City Program of NY State Office for the Prevention of Domestic Violence.
Warrier directed conference attendees to be conscious not only of cultural differences, but of how the elusive concept of culture is defined. Where individuals locate themselves culturally affects how they see and relate to each other. Warrier describes herself as a third-world feminist in a first-world culture. "I am defining it for myself. Many women cannot self-define," she asserts. In self-defining, we leave room for others to define themselves, and are more aware of the particular lenses through which we see each other according to Warrier.
More critically self-aware and open to the self-definition of others, women can then begin to look at violence against women as a bigger issue, one that is simultaneously global and local. Warrier addressed violence against women as an issue of broad spectrum, including disfavor of female children, genital mutilation, and domestic violence. (Other presenters followed this lead by drawing attention to gender-based human rights issues such as the abuse of Latina workers in American-owned maquiladoras and female genital mutilation/female circumcision.)
Warrier warned US and Canadian women, especially those who are members of the dominant culture, against seeing violence against women in other groups and countries as different from violence in their own communities. "Dowry murders are framed as cultural," she illustrated, "domestic violence murders in the US are not. What ends up happening is a perception that women in India and minority women in the US are killed by culture, but mainstream women are not." Eliminating the myth that domestic violence is separate from US culture will enable Americans to both address the problem more effectively and to be more empathic and more helpful toward women battling violence in other countries and communities.
African-American Women Surviving Violence
"Being a Black woman does not mean that you can be tortured and forced to accept this torture. I never understood this. If I had gotten this message earlier, I could have valued myself as an individual and a productive person. And I had rights like everybody else in this society that I lived in ... I never understood that." Anonymous 47-year-old domestic violence survivor, quoted by Jannette Y. Taylor.
Jannette Taylor, PhD, RNC, used this quotation as an introduction to resilience strategies for African-American women in her ethnographic study. Her grouping of themes presented in the women's words are powerful testimonies and tools for better understanding Black women's experience of surviving abusive relationships. Tellin' Our Business, Reclaiming Ourselves, Renewing the Spirit, Building a New Foundation, Knowing My Place, Forgiving, Being Your Own Woman, Beating Back the Barriers, and Looking Forward were strategies used by these women. Taylor began to glean wisdom from women who "successfully transcend a nonsupportive environment of domestic violence and maintain resiliency in the face of continual sociocultural adversity and oppression."
Melinda Kai Smith, RN, PhD, of the University of Florida also investigated the African-American woman's experience of partner abuse. From semi-structured life interviews of Northeastern urban women, she found a pattern of relational dynamics that eventually involved, in the words of the women, "hitting bottom," or reaching "a low point in their soul," which precipitated a decision to leave the relationship. She also found that African-American women who had strong family support systems sometimes forfeited that support for fear that telling male family members would precipitate not only violence between them and her partner, but also possible interaction for the men with a racist judicial system.
As research with African-American women continues, the addition of their perspectives on the dynamics of abusive relationships and the interaction between abuse and larger social injustice will undoubtedly enrich knowledge about violence against women and enhance prevention and intervention efforts.
Latina Women in the Americas Experience and Combat Violence
"I am your Merciful Mother, come down from heaven, to give birth to a new nation, of people that will transform, the acrid smell of victims' blood, into the most noble fragrance of fresh roses, and the divine virtues of compassion and love." La Virgin de Guadalupe (in her appearance to a Juan Diego).
The Texas location of this international conference facilitated a focus on Latina issues. Folklorist Mary Margaret Navar helped participants commemorate the Mexican celebration of the Virgin of Guadalupe, December 12, and led an altar building ceremony remembering those women who have suffered violence. Women and men from throughout Mexico, the US, Canada, and other countries added personal mementos to the shrine. The altar-building not only highlighted the personal and emotional impact of the issue of violence against women in the lives of healthcare providers, it also set the stage for dialogue on violence in the lives of Latina women in the US and the rest of the Americas.
The Virgin's appearance in Mexico in 1531, to Juan Diego, a Mexican Indian helped sway European Catholic hierarchy to declaring that continent's residents did in fact have souls and were, therefore, worthy of conversion efforts. Whether this declaration was ultimately to the profit or demise of indigenous peoples is a matter of historical debate, but the Virgin became dear to Mexican people not only as the embodiment of the virtues of compassion and love, but as a defender of their worthiness and humanity. She was a fitting symbol for the inclusion of Latinas in the violence against women movement.
Women from Texas and California presented research on domestic violence in Mexican-American communities. In interviews with Nancy Coffin-Romig, RN, DNSc, women in agencies on the California-Mexico border, the phrase aguantando no mas emerged repeatedly in these women's stories. Aguantando, or enduring, characterized the experience of these women during the time they remained in abusive relationships. Reasons to endure included fulfilling a commitment, having a family, and lacking economic resources. Conditions for no longer enduring were: forming alliances (telling the secret, linking to resources), realizing the harm (often in relation to children), perdiendo la esperanza or losing hope, hasta aquí or drawing the line, and saliendo adelante or forging ahead. Coffin-Romig stressed that a woman's decision to leave might be greatly influenced by the availability of bilingual law enforcement and social services, her immigration status, the proximity and availability of extended family, education, language skills, and job training.
Nikki VanHightower, PhD, School of Rural Public Health, Texas A&M University, presented findings from a nine-state Migrant Clinicians Network study of the prevalence of domestic violence among patients at rural community and migrant healthcare clinics. Survey data from 1001 women revealed a 20 percent domestic violence rate and 25 percent of abused women reported forced sexual contact. VanHightower found that age, children, race/ethnicity and marital status were not correlates of abuse among this farmworker sample, whereas drug/alcohol use, non-pregnancy, and migrant status did correlate with abuse in the women's lives.
Contingents of nurses from Mexico and Ecuador also attended and presented at the conference. They described efforts of healthcare professionals and women's groups in their countries to provide services for abused women and to prevent domestic violence by enhancing the status of women and increasing educational and professional opportunities for women.
Yolanda Renteria Huacuz, ESP, connected domestic violence to the decline of the Mexican family. Modernization and industrialization afford Mexicans some benefits, she conceded, but an acculturation of beliefs and practices from other countries threatens to precede Mexican values. Nurses have some status in Mexico and are more educated than most women, placing them in a position to take leadership on this issue.
Ecuadorian researchers presented findings on the dynamics of abusive relationships and the responses of police and of the military (in families living on military bases). Sara Vicente Ramon, found that some women could not articulate the abuse, did not know that they had legal or basic human rights. She advocated changes in child rearing toward more equitable practices for male and female children. Yolanda Caicedo, explained a plan by the nurses group to decrease domestic violence through better nursing training on the issue and on self-esteem. "We need to start with ourselves, build the self-esteem of nurses so that they can transfer that to other women," said Caicedo through an interpreter.
Keeping Women's Rights at the Forefront
Many women's advocates fear that the hard-won recognition of domestic violence as a health issue will prove to be costly. Public health funding and research tend to present the problem in terms of injury statistics and use gender-neutral conflict scales. The feminist battered women's movement originated with the sheltering of battered women and their children, and continues to focus on issues of oppression and empowerment. The coexistence of these two approaches is sometimes an uneasy one.
Chiquita Rollins, Multomah County domestic violence coordinator, has begun work with public health agencies aimed at reducing the incidence of violence in her Oregon county. She is concerned that, "Public health does not talk about domestic violence as a crime." Further, she attests, a public health approach attempts gender-neutrality and "does not mention sexism. Public health and medicine do not link oppression to violence against women."
Domestic violence is a gender-related crime. Although some men are abused by female partners, and abuse is probably more prevalent in gay and lesbian relationships than current information suggests, the overwhelming majority of intimate partner violence involves the abuse of a woman by her male partner. The Department of Justice reports that since 1976, 30 percent of all murders of females were at the hands of intimate partners, as opposed to only six percent of all murders of males.5
A nursing conference proved to be an interesting venue for discussions about sociocultural influences on women's health and the healthcare system response. Members of this female-dominated profession seem sometimes hesitant to recognize women's oppression and the discrimination against minority groups and Third World women. Stereotypical images of nurses do not usually include a propensity toward rocking the boat. But these nurses see and care for victims of violence, and many of these nurses, including those who gathered in Texas, cannot look the other way. The witnessing of tragedy can push people past their reservations, beyond the comfortable assumptions of their upbringings, and toward a greater understanding of others and a willingness to take action.
Carmen Retzlaff is a writer and public health educator based in Austin, Texas (email: firstname.lastname@example.org)
For more information on the subject of women and violence, go to the new Women and Violence section on the IAPAC Web site (www.iapac.org). This new feature located under the Women's Health subsection of the HIV/AIDS section features additional information from this conference and will continue to feature additional information on this topic.
1. Bureau of Justice Statistics, March 1998. Violence by Intimates: Analysis of Data on Crimes by Current or Former Spouses, Boyfriends, and Girlfriends, US Department of Justice, Office of Justice Programs, NCJ-167237.
2. Bureau of Justice Statistics, 1996. Female Victims of Violent Crimes, US Department of Justice Programs, NCJ-1602.
3. McFarlane, J. Journal of Community Health Nursing, 1997, 14(4), 237-249.
4. Curry M, Doyle B, Gilhooley J, Maternal Child Nursing, Vol 23, No 3, May/June 1998.
5. Bureau of Justice Statistics, March 1998. Violence by Intimates: Analysis of Data on Crimes by Current or Former Spouses, Boyfriends, and Girlfriends, US Department of Justice, Office of Justice Programs, NCJ-167237.