Ch #14 Violence, Abuse, and Harassment

Elder Abuse

As the US. population has aged over the past 20 years, so has the number of abuse cases involving elderly Victims. In most cases, elders become increasingly dependent on others for their care as they get older. It is estimated that 1 to 2 million Americans age 65 or older have been victimized by someone who provided care for them. Elder abuse is in part a serious problem for women because they tend to live longer than men. However, even after accounting for their larger share of the aging population, women still account for two-thirds of all elder abuse reports. There are three major situations for abuse of the elderly: I Domestic abuse (maltreatment by someone who has a relationship with the victim) I Institutional abuse (maltreatment by staff in a residential facility) , I Self—neglect (failure to care for Oneself) Within these situations, the National Center on Elder Abuse defines seven types of elder abuse: I Physical elder abuse is the use of physical force that results in bodily injury, physical pain, or impairment. I Sexual elder abuse is nonconsensual sexual contact of any kind with an elderly person. I Emotional or psychological elder abuse is the infliction of anguish, pain, or distress through verbal or nonverbal acts. I Financial or material exploitation occurs when an abuser misuses or misappropriates an elder's funds, property, or assets. I Neglect refers to a caretaker's refusal or failure to perform his or her obligations or duties to an elderly person. Neglect can be active, when the failure or refusal to acknowledge an obligation is deliberate, or passive, when the failure is unintentional. I Self-neglect is the failure to provide oneself with adequate food, water, clothing, shelter, safety, personal hygiene, and medication, thereby threatening the elderly person's own health or safety. I Abandonment, also known as "granny dumping," occurs when a caretaker or guardian of an elderly person deserts the elder. Elder abuse occurs among people of all racial, ethnic. and economic backgrounds. In general, elders who are unable to care for themselves are more likely to suffer abuse. Researchers have found that in 90% of substantiated cases, perpetrators of elder abuse were family members, with two—thirds being adult children or spouses. Men were more likely to commit abandonment, physical abuse, emotional abuse, and financial and material exploitation, while women were slightly more likely to neglect elders. In self—neglect cases, approximately two-thirds of elders were female, 75 or older, and white. In one survey, 36% ofnursing—home staff reported having witnessed at least one incident of physical abuse of elderly patient in the previous year, 10% admitted having committed at least one act of physical abused themselves, and 40% said that they had psychologically abused patients. Institutional abuse includes physically restraining patients, depriving them of dignity and choice over daily affairs, and providing insufficient care (allowing them to develop pressure sores, for example). Factors that increase stress in a caretaker's life may increase the likelihood of that caretaker committing abuse. These factors include stressful life events, impairment of the dependent elder, and resentment of dependency, especially as the level of dependency increases. Abusive caregivers are often unprepared, unable, or unwilling to provide the care that an elderly person needs. Elder abuse is also related to emotional problems, such as alcohol or drug use by the abuser, social isolation of the abuser and the abused, and lack of community support. In some cases, an abuser may be repeating a cycle of violence, similar to the cycle identified in cases of child abuse and neglect; the abuser of an elderly parent may have been abused by the parent in childhood, or the abuser may have witnessed the same type of elder abuse by the parent against the abuser's grandparent.

Domestic Violence

Domestic violence, also referred to as battering, occurs when a person subjects a current or former romantic partner to forceful physical, social, and psychological behavior. Battering includes five types of interpersonal violence: physical, sexual, property, psychological, and social. Physical violence includes slapping, choking, punching, kicking, pushing, and using objects as weapons. Forced sexual activity constitutes sexual violence. Property violence denotes threatened or actual destruction of property. Psychological and social forms of violence include threats of harm; physical isolation of the woman; extreme jealousy; mental degradation; and threats of harm to children, pets, or other loved ones. Battering occurs in families of all racial, economic, edupcational, and religious backgrounds. Violence in a home often involves more than the adult couple. More than 15 million children in the United States live in families in which partner violence occurred at least once in the past year; nearly half of these families experienced severe partner violence. Research suggests that almost all of these children are aware of the violence in their homes; even if they do not see it, they hear the screams and see the bruises, broken bones, and abrasions sustained by their mothers. Domestic violence is more common among immigrant women than among US. citizens. Immigrants from some cultures condone the use of violence from a man toward his Wife or other women in the family. A more important factor, however, is that immigrant women are typically more vulnerable than other women and have less access to legal and social services, as well as extended family or other support networks. Immigrant women also may not feel that they are protected by the U.S. legal system or may feel that they are unable to seek help from authorities if their immigrant status is unstable. Studies involving Latina, South Asian, and Korean immigrants found that 30% to 50% of these women have been sexually or physically victimized by a male intimate partner. Although domestic violence occurs at all levels of society, intimate violence against women generally becomes more common as household income levels decrease (Figure 14.2). Spousal abuse perhaps appears more frequently in poorer households because educated, middle-class, and affluent women tend to have more resources with which to avoid or leave violent relationships. For example, affluent women may seek confidential professional help and are more likely to be able to afford and get to a safe location, such as a hotel or friend or relative's house in another city or state. Relationship violence can and often does lead to death. An intimate (or formerly intimate) partner kills about 33% offemale murder victims. In the United States, more than three women are murdered eveiy day by an intimate partner. Battering is often underdiagnosed during medical Visits because both the patient and her healthcare provider may be reluctant to initiate or discuss the topic. One study showed that 92% to 98% ofwomen did not discuss their experiences of abuse with their healthcare providers. Although most states have mandatory reporting requirements for child abuse or elder abuse, only a few have a corresponding requirement for healthcare providers to report battering of women.

Family and Intimate Violence

Family and intimate violence refers to violence directed toward former or current spouses or partners, dates, elders, and children. Most violence against women is intimate violence. In the United States, one out of every four women will experience violence by an intimate partner at some point during her life. Family and intimate violence includes many forms of mental and physical harm, as well as threats of injury (see Self-Assessment 14.1).

Domestic Violence in Same-Sex Relationships

Gay men and lesbians also have to contend with domestic abuse, and often face difficulties that other people dealing with domestic abuse do not. Many lesbians perceive battering as a heterosexual phenomenon and therefore may not recognize the patterns of abuse within their own relationships. Additionally, fewer protective measures from the legal system are available to lesbians. In 2010, one out of every four gay, lesbian, or transgendered people reporting domestic violence were either arrested themselves or were arrested along with their battering partners. In the same year, more than half of gay, lesbian, and transgender survivors of violence were turned away from shelters. Most battering-related services are designed for heterosexual female victims and heterosexual male offenders, making it diflicult for lesbians to find support. This lack of services further contributes to the lack of recognition of lesbian, bisexual, and gay domestic violence.

Poverty Influences

Poverty and joblessness are strongly connected with violence, including Violence that occurs within the family. The relationship between violence, poverty, and joblessness may result from feelings of inadequacy and low self-esteem brought on by unemployment, stress associated with financial instability, and/ or an inability to provide for ones family. Often, these emotions turn to frustration and anger, and eventually lead to lighting within the household or violence toward one's partner or children. Unemployed individuals also spend significantly more time in the home, allowing greater opportunities for tensions to rise. When poverty inspires violence, women and Children are overwhelming the victims. Women often remain trapped in abusive relationships because of their financial dependence on the abuser. In households with incomes under $15,000 per year, one in three (35.5of women suffer violence from an intimate partner. Living in circumstances of stress and poverty can also lead some women to act Violently against their children, spouses, or family members.

Rape and Sexual Assault

Rape and sexual assault are violent crimes of aggression. Rape is a nonconsensual event, involving the use of force or the threat of force to sexually penetrate the victim's vagina, mouth, or rectum. Sexual assault often refers to forced sexual contact, but this term frequently acts as an all—encompassing descriptor for any type of unwanted sexual advances, including rape. The National Institute of Justice and the Centers for Disease Control and Prevention estimate that one in six women and one in 33 men in the United States have been the victim of attempted or completed rape as a child or an adult. More than 9 out of every 10 rape victims are female. Determining an accurate estimate of how often rape occurs is difficult given the significant underreporting of the crime. Fortunately, rates of rape and sexual assault have fallen over the past decade. In 2010, there were 184,400 reported victims of rape, attempted rape, or sexual assault in the United States, a drop of about 24% compared to 2001. Rape may occur among strangers or intimates. Acquaintance rape, or date rape, occurs when the victim and the rapist either previously knew each other or have interacted in some socially appropriate manner. About three-fourths of rape victims in the United States know their assailant: Approximately 48% were raped by a friend or acquaintance, 17% by a current intimate partner, and 8% by another relative (see Figure 14.5). Rape by a coworker, teacher, pro- fessor, a husband's friend, or boss—-anyone the individual knows—is considered acquaintance rape. Many victims of rape are children and adolescents; about 44% of rape victims are younger than age 18 and about 15% are younger than age 12. Although physical abuse and neglect account for the greatest portion of child abuse incidents, child sexual abuse is another tragic dimension of child abuse in general. Sexual abuse accounts for about 1 in 10 cases ofchild abuse. It is difficult to determine the incidence rate of sexual abuse among children. One report found that 13% of girls and 3.4% of boys had been sexually abused. In reported cases, three—fourths of adolescent sexual assault victims knew their attackers—21% were family members and 33% were acquaintances or friends. Males are reported to be the abusers in most sexual abuse cases involving children. In many cases of date or acquaintance rape, aggressors use drugs to render the victim unconscious or incapacitated. Flunitrazepam, commonly known as Rohypnol, is one type of "date rape drug." This drug is 10 times as strong as Valium and is tasteless and odorless. It dissolves in liquid, takes effect quickly, and produces memory loss for as long as 8 hours. Rohypnol is especially popular on high school and college campuses, as well as in nightclubs. Many women have been raped after consuming a drink with the drug dissolved in it. The use of the drug is extremely dangerous and can cause death. Gamma hydroxybutyrate (GHB) and gamma butyrolactone (GEL) are found in liquid form and have also been associated with sexual assault. Abuse of GHB and GBL can lead to coma and seizures. Ketamine, used as a tranquilizer in veterinary medicine, is another common date rape drug that is snorted or injected. It is referred to as "special K" and can cause death. Rape also happens in marriages, during legal separation, or after divorce. Rape in marriage is often called spousal rape or marital rape. Historically, husbands had unlimited sexual access to their wives and, therefore, rape within marriage was not recognized as a crime: Marital rape has only been a crime in all 50 states since 1993. Many states provide exemptions for certain situations, such as mental or physical impairment ofa woman rendering her unable to consent that protect husbands from being prosecuted for rape. In addition, rape can occur between people of the same sex. The National Violence Against Women Survey found that 10.8% ofwornen rape or sexual assault victims were assaulted by a female. Rape is often characterized as not being a "clear-cut" crime such as murder. Societal pressures and norms have reinforced beliefs that rape is sometimesjustifiable, depending on the circumstances. For various reasons, about 6 in 10 rapes are never reported to the police. Unreported rapes can harm more than the victim, because if the rapists are not stopped, their violent behavior may continue. The under reporting of rape is due to a number of factors, including the pattern of "blaming the victim." Many women fear unwanted publicity from making a formal complaint, and others distrust hospital and law enforcement agencies. Feelings of shame or guilt, fear of not being believed, and fear ofreprisal or punishment if the rapist is an acquaintance or employer are other reasons why women do not report rape. Around the world, countless women in prisons and jails are at risk of rape and other forms of sexual violence. Reporting procedures in prisons are often ineffectual, and complaints are routinely ignored. To make matters worse, punishment for the crime is rare and some inmates face retaliation from the offender if a report is made.

Sexual Harassment

Sexual harassment is an illegal, violent act involving unwanted sexual attention, requests of sexual favors, or the use of sexual language or behaviors to create a hostile environment. Although sexual harassment can occur in any setting, it most commonly occurs in the workplace. Sexual harassment often involves a male harasser and a female victim. However, sexual harassment recognizes no gender boundaries—a female may harass a male, and the victim and the harasser may be the same sex. There are three types of harassment: I Gender harassment constitutes behavior that conveys a degrading or hostile attitude toward women. I Unwanted sexual attention or advances include behaviors such as staring, commenting, touching, or repeated requests for dates or sexual favors. I Sexual coercion, also referred to as quid pro quo (defined as an "equal" exchange or substitution), is the use of threats or bribery to obtain sexual favors. Any type of harassment may interfere with a woman's ability to perform her regular duties at work and often creates an intimidating or hostile working environment. Women who are at the greatest risk for sexual harassment are those in careers traditionally considered to be male occupations. Any person may initiate sexual harassment, but a harasser is most likely to be someone with more power or authority than the recipient. In addition to suffering physical and emotional victimization, the threat of economic vulnerability often leaves the victim with the feeling that she has few real options in the situation. For years, workplaces and individuals trivialized sexual harassment and refused to recognize it as a violation of rights or personal dignity. This practice sometimes persists in the present day. Harassers may rationalize their behavior or offer excuses, but these rationalizations perpetuate power disparities and further dehumanize women, As with other forms of sexual Victimization, harassment Operates as an instrument of social control. Whatever form it appears in, sexual harassment is a harmful, legally punishable offense. A Common situation involves a boss or supervisor who requires sexual services from an employee as a condition for keeping ajob or getting a promotion. Less blatant forms of workplace sexual harassment include being subjected to Obscenities or being made the target ofsexualjokes and innuendoes. However deep a harassed person's feelings of humiliation, anger, and shame, the financial consequences of not complying with sexual coercion on thejob may be devastating. Many victims, especially if they are supporting families, cannot afford to be unemployed. Also, many find it difficult to seek other work while they are employed. Thus, a person who quits or is fired as a result of sexual harassment faces the prospect of severe financial difficulties. Employers have become more sensitive to the issue of sexual harassment, in part because of court decisions that have awarded large payments to victims. Employers paid more $52 million in damages to victims of sexual harassment in 2011. It is an employer's responsibility to maintain a workplace that is free of sexual harassment by educating employees about which behaviors constitute harassment and taking appropriate measures if these behaviors occur. The US. Department of Labor Employment and Training Administration provides training guidelines for the workplace. Reported cases of sexual harassment have fallen over the past 20 years, dropping by nearly 30% from 1997 to 2011 (see Figure 14.6). While women continue to make up the vast majority of victims of harassment, the percentage of males filing claims of sexual harassment grew from 11.6% to 16.3% over the same period. Sexual harassment is not limited to the workplace. A report from the American Association of University Women found that nearly two—thirds of college students have encountered some type of sexual harassment while at college. hiore than half of female students have been subjected to sexual comments and jokes, and about 35% have experienced physical harassment by being touched or grabbed in a sexual manner. Students who are lesbian, gay, bisexual, or transgender are more than twice as likely to be harassed as heterosexual students. Only 7% of students reported the harassment. Many students actually admit to sexually harassing other students; the reason more than half gave for the harassment was "I thought it was funny." Common reactions to sexual harassment include anger, humiliation, shame, embarrassment, nervousness, irritability, and lack of motivation. Guilt is another common feeling, with a victim often questioning whether she (or he) has done something wrong to encourage the harassment. The sense of alienation and helplessness many victims of sexual harassment feel is similar to that experiential by many rape victims. Sexual harassment victims may also experience headaches, stomach pain and nausea, back and neck pain, and a variety of other stress—related ailments.

Reducing Risk of Rape/Sexual Assault

Society as a whole, as well as individuals of both genders, need to act together to prevent rapes and sexual assault. Women are never "at fault" when a rape occurs; women can, however, lower their risk by being careful and clearly cmmmlnicating what they are, and what they are not, comfortable with.

Stalking

Stalking is a violent behavior directed at a specific person, involving: I repeated sightings or encounters I nonconsensual communication; I written, verbal, or implied threats; or - a combination of the previous factors that would cause a reasonable person to feel afraid. Stalkers are frequently a current or former spouse, cohabitating partner, or love interest from some point in the stalked women's lives. Stalking is associated with other forms ofviolence in intimate relationships. One survey found 81% of women stalked by a current husband, former husband, or cohabitating partner were physically assaulted by that partner; 31% also were sexually abused by that partner. Although every stalking case is different, a Stalker's behavior typically becomes increasingly threatening, serious, and violent. The behavior may begin with the stalker making harassing calls, watching or following the victim, sending unwanted letters or messages, or making verbal threats. The activity generally escalates from what initially may be bothersome and annoying to the level of obsessive, dangerous, violent, and potentially fatal acts. Some stalkers may not begin with violent intentions, but still may cause harm if jealousy or anger is involved. All 50 states have passed laws to prevent stalking and punish people who engage stalking. California passed the first anti—stalking laws in 1990 in response to several high— profile cases in which the perpetrators stalked and eventually killed their victims. In each case, the victim had notified the police of the Stalker's threatening behavior, yet the police were unable to do anything legally unless the stalker acted on the threats. The California law gave law enforcement officers the right to intervene in stalking cases before the stalker acted. Since then, all states have passed similar laws. - a combination of the previous factors that would cause a reasonable person to feel afraid. Stalkers are frequently a current or former spouse, cohabitating partner, or love interest from some point in the stalked women's lives. Stalking is associated with other forms ofviolence in intimate relationships. One survey found 81% of women stalked by a current husband, former husband, or cohabitating partner were physically assaulted by that partner; 31% also were sexually abused by that partner. Although every stalking case is different, a Stalker's behavior typically becomes increasingly threatening, serious, and violent. The behavior may begin with the stalker making harassing calls, watching or following the victim, sending unwanted letters or messages, or making verbal threats. The activity generally escalates from what initially may be bothersome and annoying to the level of obsessive, dangerous, violent, and potentially fatal acts. Some stalkers may not begin with violent intentions, but still may cause harm if jealousy or anger is involved. All 50 states have passed laws to prevent stalking and punish people who engage stalking. California passed the first anti—stalking laws in 1990 in response to several high— profile cases in which the perpetrators stalked and eventually killed their victims. In each case, the victim had notified the police of the Stalker's threatening behavior, yet the police were unable to do anything legally unless the stalker acted on the threats. The California law gave law enforcement officers the right to intervene in stalking cases before the stalker acted. Since then, all states have passed similar laws. Restraining or protection orders can be issued against stalkers to protect citizens against stalking situations. A woman who believes she is being stalked should take action by recording stalking behavior, letting others know about (he stalker, and taking proper safety precautions (see Table 14.1). Stalking can also be conducted from a distance. Threatening; behavior or unwanted advances directed at another using the Internet and other forms of online communications is called cyberstalking. Cyberstalking can be conducted through email, social media sites such as Facebook, cellular phones, global positioning systems (GPS), and other technologies. The stalker may use emails, text messages, wall posts, or online comments to send obscene, threatening or unwanted messages. Online stalking often turns into offline stalking, bringing a real threat of physical harm to the victim. Law enforcement agencies estimate that cyberstalking is a factor in 20% to 40% of all stalking cases. Although current state laws encompass any type of unwanted communication with the victim, in many cases, the gap between new technologies and existing laws have created "gray areas" where stalking or stalking-like behav- iors can legally occur. Women can lower their chances of being stalked online by sharing their personal information carefully and responsibly. By adjusting their personal and account settings on sites like Facebook, women can control who has access to their posts and contact information. Safety experts generally advise women either to limit this information to the "friends" they know and trust, or to only add trusted friends and acquaintances as Facebook friends. harm to the victim. Law enforcement agencies estimate that cyberstalking is a factor in 20% to 40% of all stalking cases. Although current state laws encompass any type of unwanted communication with the victim, in many cases, the gap between new technologies and existing laws have created "gray areas" where stalking or stalking-like behav- iors can legally occur. Women can lower their chances of being stalked online by sharing their personal information carefully and responsibly. By adjusting their personal and account settings on sites like Facebook, women can control who has access to their posts and contact information. Safety experts generally advise women either to limit this information to the "friends" they know and trust, or to only add trusted friends and acquaintances as Facebook friends. Today 3:52 PM Women who mite or contribute to websites or personal blogs have a difficult choice about whether to reveal their real names. Revealing a personal name can help a woman build a reputation and readership, but it may also allow cyberstalkers to begin looking up a person's personal information, city of residence, and other information, Whether or not they use their real names, women who contribute to Websites may receive angry or romantic emails, messages, or posts. Many of these messages can be safely ignored. However, women should report any message that contains a threat (whether direct or indirect) or that feels potentially dangerous to the police or other authorities. Domestic Violence Domestic violence, also referred to as battering, occurs when a person subjects a current or former romantic partner to forceful physical, social, and psychological behavior. Battering includes five types of interpersonal violence: physical, sexual, property, psychological, and social. Physical violence includes slapping, choking, punching, kicking, pushing, and using objects as weapons. Forced sexual activity constitutes sexual violence. Property violence denotes threatened or actual destruction of property. Psychological and social forms of violence include threats of harm; physical isolation of the woman; extreme jealousy; mental degradation; and threats of harm to children, pets, or other loved ones. Battering occurs in families of all racial, economic, edupcational, and religious backgrounds. Violence in a home Women who mite or contribute to websites or personal blogs have a difficult choice about whether to reveal their real names. Revealing a personal name can help a woman build a reputation and readership, but it may also allow cyberstalkers to begin looking up a person's personal information, city of residence, and other information, Whether or not they use their real names, women who contribute to Websites may receive angry or romantic emails, messages, or posts. Many of these messages can be safely ignored. However, women should report any message that contains a threat (whether direct or indirect) or that feels potentially dangerous to the police or other authorities.

Violence by Strangers

Victimization rates of women are lower than those of men in all types ofviolent crimes committed by strangers, except rape and sexual assault. However, the proportion of crimes committed by strangers against women has grown over the past 20 years. These crimes include carjacking, robbery, murder, gang violence, sexual assault, and rape. In general, women are more likely to be victimized by an intimate than by a stranger, except in cases of robberies. Strangers also commit about 53% of the aggravated assaults against females. Hate crimes are a form of collective violence often committed against strangers. Hate crimes consist of arson, vandalism, assault, murder, and other offenses that are motivated by hatred or prejudice towards a person's race, religion, sexual orientation, or ethnicity. Hate crimes account for less than 1% of total reported crimes, but the damage they can cause is immense. In addition to harming their victims directly, hate crimes also affect the victims' families and communities. At heart, hate crimes are acts of terrorism— a systematic use of fear to change the way other persons behave. The number of hate crimes has fallen over the past decade. In 2009, 148,400 hate crime incidents were reported to US. law enfmcement, a 38% decline since 2003. About 40% ofvictims of hate crimes are female. Most hate crimes are committed based on a person's race or ethnicity, followed by a person's perceived association with a community or group, sexual orientation, perceived characteristics, religion, and disability (see Figure 14.5). Although violence cannot always be avoided, people can take measures to protect themselves. Women (and men) can walk with at least one other person or stick to populated, well~lit areas, especially at night, to avoid being caught alone. When alone, women should avoid isolated areas and carry a whistle or cellular phone in case of emergency. When visiting potentially dangerous areas, women can avoid carrying flashyjewelry or large sums of money. Self—defense classes can also give women the knowledge and confidence to survive or escape a violent attack. The goal of any practical self-defense class should not be to destroy an opponent, but rather to allow a person to get home safely if he or she is attacked. A good self-defense class can teach women the ways they are most likely to be attacked, as well as different responses to those attacks. Regular practice striking and grappling can give a person "muscle memory" that he or she can call upon and use quickly if needed. In addition, learning and practicing self-defense can give a person the confidence and will to use her body effectively, rather than to panic, in a dangerous situation. Women who are aware of their surroundings and use common sense can greatly reduce their risk of victimization; this does not mean, however, that women who are victimized are at fault. The circumstances and characteristics of each violent crime and each victim are unique, and it is not practical or realistic to imagine that these strategies alone could prevent all types ofviolence. Prevention is just one useful but limited tool available to women.

Introduction

Violence has always been part of human society. Today, violence continues to affect millions of women around the world. The World Health Organization [WHO] classifies violence into three categories, based on who commits the violent act: self-directed violence, interpersonal violence, and collective violence. Self—directed violence includes suicidal behavior and self-mutilation (see It's Your Health). Chapter 12 discusses suicide in further detail. Interpersonal violence includes violence toward a child, partner, relative, or elder, as well as community violence toward an acquaintance or a stranger. Family and intimate violence—including stalking, domestic battering, child abuse, elder abuse, and rape in many cases—are major facets of the violence epidemic. Although most intimate violence qualifies as a crime, historical and cultural traditions have often condoned violence within the family setting. Violence by strangers—such as robbery, carjackings, aggravated assault, rape, and homicide—affects women when they are the victims of crime and when a partner or family member is a victim. Sexual harassment is considered a form of violence as well, because it also usually involves threats or an unjust use of power. Collective violence is violence committed against a group of people to achieve social, political, or economic objectives. It can take a variety of forms, including armed conflicts, genocide, repression, terrorism, and organized violent crime. Many acts of violence toward women evolve as a result of women's subordinate status in society. Around the world, women face collective violence through female genital mutilation, female infanticide, trafficking of women and girls for sexual exploitation, rape during war, and other acts. These forms of abuse have traditionally been associated with the developing world; however, collective violence also occurs in the United States, Canada, and Europe. From a legal perspective, most violent crime can be categorized into one offour categories: rape or sexual assault, robbery (taking something from someone through threats or force), simple assault (attacking someone and causing physical harm, or threatening to attack someone), and aggravated assault (a more extreme form of assault, often using a weapon). Figure 14.1 shows the number of Violent crimes committed against women in the United States in 2010, as well as the relationship between the victim and aggressor. Violence has mental and physical consequences for its victims, the most serious of which are long—term disability or death. Each year, more than 1.6 million people worldwide lose their lives to violence. Indeed, violence is among the leading global causes of death for people ages 15 to 44 years old. More than 2.5 million females experience some form of violence each year. On average, one in three females is abused by an intimate partner during her lifetime, and several global studies suggest that half of all women who die from homicide are killed by current or former husbands or partners. This chapter provides an , overview of violence, focusing on interpersonal violence and the issues that contribute to violence and victimization. This chapter also reviews informed decision-making criteria and ways that women can prevent or cope with violence and its consequences.

Domestic Violence During Pregnancy

Women are not immune to battering during pregnancy. Each year, as many as 335,000 pregnant women experience intimate partner violence. Battering during pregnancy is linked to an increased risk of miscarriage, premature labor, fetal distress, and low birthweight. Blunt abdominal trauma can lead to fetal death or low birthweight by provoking preterm delivery. Battering during pregnancy has numerous consequences. Women who are battered may be less likely to seek prenatal care and gain sufficient weight. They also may be more likely to engage in harmful behaviors such as smoking or alcohol use. Excessive stress and anxiety caused by being in an abusive relationship may also have physical consequences for the mother and her developing fetus.

Sources of Help

Women in abusive relationships first need to identify and acknowledge the presence of the problem. Denial, avoidance, and protection of the abusive partner often prevent or delay such acknowledgment, particularly for women who may have grown up in a dysfunctional family situation. Professional counseling and support can help a woman cope with and recover from a violent relationship. Most communities have services and facilities to support female victims of violence, including local crisis hotlines. Hotline counselors can help callers find counseling, supportive services, and emergency shelter. Shelters provide physical safety, psychological counseling, and referral services. Many local organizations have been started by women who have been battered themselves and recognize the need for sensitive and protected outreach services. Support groups allow women to share common concerns, fears, and information. For many women, the most important step in taking control of a violent situation is admitting there is a problem and reaching out for help.

Sociocultural Issues

Cultural attitudes about violence toward women may be based on how society accepts the idea of male dominance. In some cultures, both men and women believe that a man has the right to control his wife's and daughters' behaviors and that a disobedient woman should be punished. By legitimizing these behaviors, cultures perpetuate Violence against women. Women are particularly vulnerable to abuse by their partners in societies where there are marked inequalities between men and women, rigid gender roles, weak sanctions against violent behavior, and cultural norms that support a man's right to sex regardless of a woman's feelings. Violence in intimate relationships can be triggered by a woman not obeying her husband, not having food ready for him, refusing him sex, or simply being a woman. Society's tolerance of rape between intimate partners, especially married partners, is an important dimension of Violence. For years, many people believed that marriage gave men the right to have sex with their wives at any time. In these settings, if the wife refuses, the husband can force her to have sex or punish her through violent means. Tendencies to "blame the victim" influence how women and communities cope with relationship violence. Women who feel they are at fault or that they "deserved" punishment may not report a rape or other crimes. Certain factors, including a woman's style of dress, her relationship with the assailant, evidence of resistance, presence of alcohol or drugs, and location of the incident, may affect a third party's attitude toward the rape and contribute to his or her belief that the rape may actually be "excusable" or "understandable." Reported rates of rape and sexual assault vary by race and ethnicity. Native American women are significantly more likely to report rape and physical assault than were women of other backgrounds, while women of Asian and Pacific Islander descent are less likely to report rape victimization. Hispanic women are less likely than non-Hispanic women to report having been raped by strangers, but were more likely to report having beingr raped by a current or former intimate partner. Native Americans, who are victimized at rates twice as high as the national average, are more likely to experience violence from a non Native American. The explanation for these differences is unclear. These differences may be due to the fact that women of color are less likely to have social support and are more likely to be living in poverty; social, demographic, and environmental factors that keep a woman from reporting an incident; or a combination of factors.

Historical Trends

Historically, it has been socially acceptable for a husband to physically discipline his wife. The United States followed English law and allowed physical discipline of wives by their husbands until US. courts criminalized wife beating in the 20th century. Rape has been documented in American history since the arrival of the Europeans. Spanish explorers used female Native American captives for sexual services and raped Native American women whose tribes they conquered. Native American cultures, however, prohibited rape, and it had rarely occurred until the arrival of the explorers. Fears of brutal rapes by Native American men were found to be unsubstantiated during colonial-era Indian wars. Indeed, English women who had been held captive reported no such treatment. In 17th-century New England in particular, female servants were at high risk of rape and sexual harassment. During that era, an estimated one-third of rape victims were female servants, even though that group represented only 10% of the total population." Later, in the South, Where slave labor was increasineg used instead of indentured servants, African female servants and slaves found themselves victimized by white owners and overseers who viewed them as property—available for service of their sexual needs. Some historians assert that rape was used to dominate female slaves in a system that otherwise treated them as equals to male slaves.

Response to Rape/Sexual Assault

If a rape or sexual assault occurs, a woman's first concern should be finding safety and calling the police. The police will assist the victim in seeking medical attention, which is important for treating any physical injuries, testing for sexually transmitted infections (STls) and HIV/ AIDS, and collecting medical evidence for prosecution. It is important to report the assault to the police immediately, the decision about whether to prosecute the offender can be made later. A woman also should contact her local rape crisis center to inquire about counseling and support. The recovery process from rape depends on the individual and the circumstances in which the rape occurred. Victims of rape often suffer from mental health problems, gynecological issues, negative health behaviors, chronic health conditions, and higher risk for suicide. Rape also may lead to unwanted pregnancies and STIs, including HIV/AIDS. Being tested immediately after the incident for STIs may help a woman prevent long—term consequences from disease. Postexposure prophylactics, including antibiotics, emergency contraceptive pills, hepatitis B vaccination, and antiretroviral drugs, can reduced the likelihood for some sexually transmitted infections or unwanted pregnancy. Posttraumatic stress disorder (PTSD; see Chapter 12) is another common reaction to rape. At some point during their lifetimes, 32% of all rape victims develop PTSD, compared with 9% of victims of non crime-related trauma, such as car accidents. Rape trauma syndrome is another condition associated with rape victims. It is usually described as having two phases. The first phase, or acute phase, includes the immediate emotions following the event, which include shock, anger, numbness, guilt, disbelief, embarrassment, shame, feelings of being unclean, anxiety, denial, fear, self—blame, and restlessness. This phase is often characterized by significant disruption in a woman's life. The second phase of rape trauma syndrome includes attempts at reorganizing one's life and lifestyle, and learning to cope again. Victims may decide to change schools,jobs, or routes to school or work in an attempt to remove reminders of the event from their daily lives. Overwhelming feelings often develop that the victim may not directly link to the rape. Even ifa woman successfully represses her emotions about a rape, the feelings can persist, sometimes for years. Depression, guilt, and loss of self—esteem are common reactions. Other psychological problems include suicide attempts, eating disorders, substance abuse, social phobia, and other anxiety disorders. Being a victim ofrape can also affect a woman's sexual health and intimacy.

Global Issues

In 2005, the World Health Organization conducted a study of more than 24,000 women in 10 countries from different geographical areas, cultures, and rural and ur in settings. This landmark study allowed researchers, for the first time, to estimate the frequency and predominant forms of Violence against women around the world. The study found that violence against women exists in every culture and every setting, but the frequency of thatviolence varies sharply. Violence against women was typically, but not always, more common in rural settings and the developing world. Among other findings, the study found that: I The proportion of women who had ever suffered physical violence from an intimate partner ranged from 13% in urban Japan to 61% in rural Peru. I The proportion of women who had ever experienced sexual violence from an intimate partner ranged from 6% in urbanJapan and Montenegro to 59% in rural Ethiopia. I More than 75% of women in urban parts of Serbia, Namibia, Japan, and Brazil said that violence against women was never justified, while fewer than 25% of women in rural Peru, Ethiopia, and Bangladesh thought the same. I In two—thirds ofinterview settings, at least 5% ofwomen reported that their first sexual encounter was forced. Rates of forced first sexual encounters were highest in Bangladesh, rural Peru, rural Ethiopia, and Tanzania. Partner violence can and does lead to death. In many countries, about half of female murder victims were killed by a husband or a boyfriend, often during an ongoing abusive relationship. These deaths may sometimes be concealed as accidents. For example, some deaths of women in India that were recorded as "accidental burns" may actually be murders where women were doused with kerosene and set on fire. Even in healthcare settings, tens of thousands of women each year are subjected to sexual violence, including sexual harassment by providers, genital mutilation, forced gynecological exams, and obligatory inspections of virginity. Rape is also used as a documented weapon of war. Before the country split into North and South Sudan in 2011, civil war raged in Sudan from 1983 to 2005. During this time, Janjaweed militias from the North systematically used rape as tools of intimidation (by scaring individuals and villages into submission), destruction (by harming and killing thousands of women), and genocide (by redUCing the proportion of the ethnic tribes that existed in southern Sudan)" During the Bosnia—Herzegovina conflict from 1992 to 1995, soldiers raped between 10,000 and 60,000 women. In Southeast Asia, hundreds of thousands of children are involved in the sex trade, and poverty in those countries continually drives more boys and girls into this arena. Although the demand is driven mostly by local clients, sex tourism (travel for the purposes of finding a sex partner) continues to grow and fuel the market in countries such as Thailand, Cambodia, and Vietnam. In Cambodia, almost all of the girls in prostitution are the main providers for their families. Children as young as age 12 from poor families are sold by parents or agents into the sex trade. Elder abuse also occurs around the world. In some countries, rapid socioeconomic change weakens family networks that once supported older generations. Twenty years after the collapse of the Soviet Union, thousands of elderly men and women from Russia and other former Soviet republics have been left to fend for themselves with only minimal stipends from the government, resulting in numerous cases of elder neglect.

Dealing Effectively with Harassment

Individuals who have been sexually harassed have several options. First, the victim should recognize that criminal charges can be filed against the perpetrator. If the coercion falls short of attempted rape or assault, it is often wise to confront the person responsible for the harassment. The confrontation should be stated in clear terms, and the specific behaviors should be identified as sexual harassment. The victim should make it clear that the behavior is unwelcome, will not be tolerated, and that, if it continues, charges will be filed through appropriate channels. Some victims carefully document what has occurred and provide a written confrontation rather than undertake a verbal discussion. Others may choose to seek out the assistance of their human resources department if the sexual harassment occurs within a work setting. If the behavior does not stop, the next step is to discuss it with the supervisor of the person responsible for the harassment. It is often helpful to talk to other employees—many times there is more than one victim. Discussing the matter with other employees provides peer support and pressure: for the behavior to stop. Official complaints can be with local or state Human Rights Commissions or Employment Practice Agencies. If legal action is necessary, victims can file lawsuits federal courts under the Civil Rights Act. Lawsuits can It be filed under city or state laws prohibiting employment discrimination. A person who has been the victim of sexual harassment is more likely to receive a favorable court ruling if attempts were made to resolve the problem Within the organization before taking the issue to court.

Informed Decision Making

Knowing the facts about violence can lead to a certain level of paranoia and anger, both unhealthy conditions. Identifying the factors that contribute to violence and working to eliminate them are much more constructive reactions to potential or perceived threats of violence. The stereotype that men should be aggressive and that women should be passive, compliant, and pleasing to others continues to exist and influences people's behavior. When people—whether male or female—buy into these stereotypes, it sets the stage for problems. For example, women who have been socialized to be passive may not think that they have a right to express their opinions openly and freely. Men who have been socialized to live up to a macho image may think that they need to "score" with women or control women to be "real" men. They may expect women to go along with their need to prove themselves or believe that a woman means "yes" when she says "no." To address these stereotypes, a woman must take several steps: ' Recognize the inherent limitations in any stereotype I Be open in discussing values with respect to relationships and sexuality " Decide for herself and be explicit about when she will or will not have sex ' Understand that coercion and violence are never acceptable or deserved within a relationship I Avoid situations Where inebriation by one or both parties makes open and clear communication difficult Some women find talking openly about relationships and sexuality difficult. Instead of using clear communication, they rely on assumptions, hints, innuendoes, and considerable hope that their partner understands. Unfortunately, such indirect communication is highly unreliable. Expectations and values about relationships and sexuality should be explicitly expressed. Communication is bidirectional: In a relation- ship, each person must carefully listen to the other person and confirm what has or has not been said. Finally, "no" means "no."

Child Abuse and Neglect

Legally, child abuse or neglect, often referred to as maltreatment, consists of any act, or failure to act, that causes serious harm, or that creates an imminent risk of harm, to a child. Child maltreatment includes physical, emotional, and sexual abuse, as well as neglect (failure to provide for a child's basic physical, educational, medical, or emotional needs). In 2010, 695,000 children were reported as victims of abuse and neglect. This number is likely an underestimate, since many cases go unreported. Of these children, 51% were girls and 49% were boys. More than 80% of these children were maltreated by one or both parents, most commonly the female parent; women represented nearly 60% of all perpetrators of such violence. Women are more likely than men to commit neglect, but men are more likely to commit sexual abuse. Neglect is the most common type of child maltreatment, followed by physical abuse, sexual abuse, emotional abuse, and medical neglect (Figure 14.3). Many abused children suffer more than one type of maltreatment. Younger children are most likely to be abused or neglected (Figure 14.4). Common reasons for child abuse and neglect include substance abuse by one or both of the parents, poverty or other economic strain, parental capacity and skill, and other incidents involving domestic abuse. Children who experience abuse or neglect often develop behavioral and psychological problems, relationship problems, low self-esteem, depression, suicidal behavior, alcohol and substance abuse, sexual dysfunction, and sexual risk—taking later in life. About 1,500 children die from abuse and neglect in the United States each year; about 80% of children who die as a result of abuse are younger than 4 years old. Substance abuse is a often major problem in families with suspected child maltreatment. Although children from all socioeconomic levels suffer from abuse and neglect, children from families with annual incomes of less than $15,000 are more than 25 times more likely than children from families with annual incomes of $30,000 or more to suffer abuse or neglect. Many problems associated with poverty contribute to child maltreatment, including more transient residence, poorer education, and higher rates of substance abuse and emotional disorders. Moreover, fami- lies at the lower\socioeconomic levels have less adequate socral support systems to assist parents in their Childcare responsibilities. Abuse and battering tend to perpetuate themselves in cycles. Almost all abusive parents were themselves abused or neglected as children, and battered children often grow up to become battering adults. Child abuse is frequently a symptom of family violence. One large study revealed that women who had both witnessed violence between their parents and been victims of parental abuse themselves were twice as likely to abuse their partner or children than were women who had been exposed to only one or the other type of violence. Women appeared to be most strongly influenced by their mother's behavior. With every witnessed incident in which the woman's mother had attacked her father, there was an increased likelihood that the woman would: I abuse her child; I abuse her partner; or I become the victim of her current partner. Several psychological traits are associated with child abusers: I Immaturity and dependency I A sense of personal incompetence I Difficulty in seeking pleasure and finding satisfaction as an adult I Social isolation I A reluctance to admit the problem and seek help I fear of spoiling children I a strong belief in the value of punishment I Unreasonable and age-inappropriate expectations of children I Low personal self—esteem Any combination of these traits results in an inability to cope and problem—solve effectively when a problem or crisis evolves. In such cases, the outcome may ultimately be abuse.

Media Influences

Media access through television, movies, video and computer games, and the Internet is a major influence in the lives of Americans, especially for children and adolescents. Media can be a powerful tool for positive learning and entertainment, but can also pose a threat to emotional and physical safety. Violence and sex on television and in other media are important, often unrecognized, influences on children and adolescent health and behavior. Research is conflicting as to whether exposure to violent media actually causes violent behavior. However, exposure to violent television, movies, and video games does appear to desensitize children and adolescents, or make them more accepting, towards violent behavior. Exposure to violent media also creates a "mean world effect," causing people to believe the world is a more violent, cruel place than it actually is.

Alcohol and Drug Influences

Substance use and abuse are consistently associated with all forms of relationship violence. It is unclear whether a direct cause-and—effect relationship exists between the use ofdrugs or alcohol and violence, or whether this situation involves two overlapping social epidemics. Violence in a home may cause depression and lower self—esteem, possibly leading to an increased use of alcohol abuse. Conversely, conflicts in interpersonal relationships may arise as a consequence of substance use and abuse and lead to violent behavior. Data from the National Crime Victim Survey, an ongoing nationally representative survey on crime, highlight the strong association between interpersonal violence and substance use. Among victims able to tell whether there was substance use by the perpetrator, 30% reported alcohol use by the offender at the time of the crime. Two—thirds of victims who suffered violence by a current or former partner reported alcohol use by the oflfender. Alcohol can play a significant role in violence. For example, 62% of Native American victims report an Offender who was under the influence of alcohol, compared to 42% for the national average.

Legal Dimensions

The number of violent crimes by intimate partners against females has significantly decreased over the past 20 years. This decrease has been attributed to the Violence Against Women Act (VAWA) of 1994, which includes these provisions: I Making it a crime to cross state lines to continue to abuse a spouse or partner I Creating tough new penalties for sex offenders I Prohibiting anyone facing a restraining order for domestic abuse from possessing a firearm I Providing a substantial commitment of federal resources for police, prosecutors, and prevention service initiatives in cases involving sexual violence or domestic abuse I Requiring sexual offenders to pay restitution to their Vlctlms I Requiring states to pay for rape examinations I Providing funds for federal victim—witness counselors I Extending rape shield laws to protect crime victims from abusive inquiries into their private conduct l Requiring that released ofienders report to local enforcement authorities

Domestic Violence Woman with Disabilities

Women with disabilities are about as likely as other women to experience physical, sexual, or emotional abuse at some point in their lives. Women with disabilities, however, were more likely to report multiple perpetrators, longer duration of abuse, and more intense experiences of abuse. Disabled women are most likely to be abused by an intimate partner, followed by a family member, a personal care attendant, a stranger, or a healthcare provider. The abuse often begins subtly, as the abuser tries to determine how much violence will remain unnoticed. Abuse may take the form of psychological, physical, or financial abuse, or it may involve neglect by withholding care, medication, or mobility devices. Many people with disabilities are especially vulnerable to victimization because of their real or perceived inability to fight, flee, or to tell anyone about the abuse. Many battered women's shelters may be inaccessible or lack attendant care or personnel trained in working with women with disabilities; a woman, therefore, may find herself trapped in an abusive situation. Consequently, healthcare practitioners should find ways to conduct at least part of their visit with a woman with disabilities in private. This opportunity allows a woman to answer questions and confide in her practitioner without a caretaker or family member being present.

Costs of Victimization

adolescent health and behavior. Research is conflicting as to whether exposure to violent media actually causes violent behavior. However, exposure to violent television, movies, and video games does appear to desensitize children and adolescents, or make them more accepting, towards violent behavior. Exposure to violent media also creates a "mean world effect," causing people to believe the world is a more violent, cruel place than it actually is. Costs of Victimization Violent crime directly causes financial losses, such as healthcare costs for treating any physical and mental injuries, as well as lost wages for missed workdays. The annual health-related costs of rape, physical assault, stalking, and homicide by intimate partners are more than $5.8 billion. Victims of intimate partner violence lose nearly 8 million days of work as a result of violence. Other costs may include stolen property in burglaries and expenses for repairing or replacing damaged property. Police services, fire services, and state victims' services that deal with Violent crime impose a financial burden on society as well. Each year, federal, state, and local governments in the United States spend about $228 billion and employ 2.5 million people for police protections, corrections, and judicial and legal activities. But Violence causes much more than just financial losses. Intangible losses, such as long-term pain and suffering and reduced quality of life, are more diflicult to quantify but no less real. Studies show a significant relationship between intimate partner Violence and chronic pain, headaches, vaginal infections and bleeding, digestive problems, depression, low self-esteem, and substance abuse. All of these findings lead to higher direct medical costs and consequently more losses for the Victim. Many studies have found that the intangible loss of quality of life exceeds the tangible losses for Victims of all crimes.