Tackling Domestic Sexual Violence a Public Health Perspective

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

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

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 What is the problem? Surveillance System Scope Magnitude Characteristics Consequences

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

Sexual Violence Woman Intimate Partner Violence

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

Magnitude Violence Leading cause of death age group: 15 -44 years What about survivors?

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

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 Prevalence is lower than overseas reports. 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.

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

Magnitude

Magnitude

Magnitude

Magnitude Sexual assault previous 5 yr

Magnitude Forensic Medicine DOH 2002

Magnitude Tip of iceberg

Characteristics of victims

Duration of Battering(%) • • < 3 months 4 -12 months 1 -3 year >3 years 30 17 13 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): 107112

Occurrence of battering (%) • • once 2 -4 times 5 -10 times >10 29 38 12 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 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

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

Health Consequences Physical: Sexual /Reproductive • Injuries • Functional disorders • • – Irritable bowel – fibromyalgia – Chronic pain 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 • Earthquake survivor • Fatal car crash = 3% = 5% =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

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.

Cultural Norm 清官難斷家庭事

SWD HA DOH ED HKCSS RHKPF Legal Dept Legal Aid Dept Housing Dept ISD

SWD Apr 00 --Mar 01

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 Universal Screening CIT More researches are needed We cannot wait to gain perfect knowledge

WHO recommendation Adopt the public health approach

Resolution WHA 49. 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 prevention and management of violence; Promote research on violence as a priority for public health research Prepare and disseminate recommendations for violence prevention program. . .

How to prevent violence Weak Primary Prevention: before violence occur Secondary Prevention: immediate response Tertiary Prevention: long-term care, rehab

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 Health care providers Church Judiciary Policy Politicians Police Multi-sectoral Social Service Education

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 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 Campaign Messages 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 longestablished 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!