- Email: [email protected]
Violence against women
CORRESPONDENCE
2
3
4
5
Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002; 359: 189–98. Harding SA, Boon NA, Flapan AD. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 256–57. Landolfi R, De Cristofaro R. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 257. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndrome. Circulation 2001; 104: 2767–71. Meier JJ, Gallwitz B, Schmidt WE, Nauck MA. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 257.
Violence against women
The Tendring pilot study was funded by the UK Department of Health.
*Oksana V Hoile, Gill Green, Sushil Jathanna, Tom Stewart *Tendring Primary Care Trust, Carnarvon House, Clacton-on-Sea, Essex CO15 6QD, UK; and Department of Health and Human Science, University of Essex, Colchester 1
Watts C, Zimmerman C. Violence against 12
2
3
4
5
women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36 Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner violence: findings from the national violence against women survey. Washington, DC: Office of Justice Programs, US National Institute of Justice and Center for Disease Control and Prevention, 2000. Hoile OV, Green G, Jathanna S, Stewart T. Health impact assessment of domestic violence: multi-agency pilot research project http://www.tendringpct.co.uk (accessed May 21, 2002). Ison E. Resource for health impact assessment. London: NHS Executive, 2000.
Sir—Your decision to publish the series on violence against women, especially the reports of Charlotte Watts and Cathy Zimmerman,1 and Jacquelyn Campbell,2 is welcome given this issue’s serious implications on women’s health and wellbeing. One area in which violence against women is likely to be a huge problem is the Middle East, where indirect evidence points to a striking inequality between sexes.3 As is evident on Watts and Zimmerman’s global map of research on violence against women, such behaviour in the Middle East is probably aggravated by the dearth of related information. I and colleagues have studied 412 Syrian women in Aleppo, in primary health care, to look at the spread and patterns of physical abuse and its relation to mental health.4 Current physical abuse (repeated beating of any form at least three times in past year), was reported in 23% of all, and in 26% of married women. Regular physical abuse (beating ⭓1 time 60
p<0·001 for different SRQ means and abuse rates SRQ Abuse
10
50
8
40
6
30
4
20
2
10
0
肁12 years
Proportion abused women (%)
Sir—In their contributions to the violence against women series, Charlotte Watts and Cathy Zimmerman (April 6, p 1232),1 and Jacquelyn Cambell (April 13, p 1331),2 while acknowledging intimate-partner violence as a common health-care issue, confirm domination of prevalence research. Features of interaction between abused women and agencies, and the impact intimatepartner violence has on local service providers are rarely mentioned. We believe understanding of these issues is an important area for study to promote change and reduce the impact of intimate-partner violence on health. Another rarely acknowledged issue is the association of exposure to intimatepartner violence in early life and patterns of ill health in later adulthood. Such patterns link to psychological health being profoundly affected by life circumstances, emotional strains, and family disruption. Study of violence is frequently viewed as a biased issue or a political topic. Scepticism frequently expressed by health-care professionals towards such research may be reduced by addressing the lack of sufficient evidence about any benefits of actions commonly taken to lessen or prevent the damaging effects of intimate-partner violence. We did a small-scale pilot study, in Tendring District, Essex, UK (population 137 000). To take account of the complexity of the impact intimate-partner violence has on individuals and services,3 we used a comprehensive health impact assessment4 that allows in-depth exploration of the impact on health from the introduction of policies and initiatives.5 It uses direct information from affected individuals, agencies, and community by taking into account their opinions, experience, and expectations.
We interviewed ten women with experience of intimate-partner violence in depth and sent questionnaires to all local primary-care professionals about their management of this type of violence. We also interviewed local agencies including local charities helping families with children, and a befriending-style teenage service. The agencies had no systematic response or standardised system of referral or monitoring of incidence of intimate partner violence. In a local women’s refuge, most of the residents were children. More than 30% of children referred to a local charity providing family support came from families with experience of intimatepartner violence. Some health professionals seemed to avoid asking about violence, believing it was not their remit. Victims were thus not encouraged to disclose intimate-partner violence, nor able to rely on appropriate support when they did come forward. Implementation of local healthimpact assessments could be helpful in informing local decision makers on how to gain maximum benefits of conceptual and structural changes to the way intimate-partner violence is viewed or dealt with. Meanwhile, initiatives are needed to encourage use of a broad definition of intimate-partner violence acknowledging its effect on victims and other members of the family.
Mean SRQ score
1
0 <12 years
Illiterate
Women’s educational level
Relation between level of education, mean mental health scores, and prevalence of physical abuse in Syrian women
THE LANCET • Vol 360 • July 27, 2002 • www.thelancet.com
343
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
weekly) was reported among 3% of married women). Marriage, Islamic religion, rural residence, poor education, and mental distress were important correlates of physical abuse after adjustment for other sociodemographic characteristics. Important correlates for regular physical abuse were age difference between spouses, polygamy, smoking, and mental distress (unpublished data). Generally, women of polygamous marriages were 2·3 times more likely to report physical abuse than were those in monogamous marriages. This strong association suggests that both polygamy and physical abuse represent various manifestations of troubled marriages. A suggested ill effect from polygamy has been met with fierce resistance from medicolegal establishments in Middle Eastern societies.5 Depression and post-traumatic stress disorder are the most frequent mental health sequelae of intimatepartner violence.2 With use of the 20-item mental-health screening we self-reporting questionnaire,4 noted that physical-abuse prevalence and mean questionnaire score (low score, better mental health) were strongly related to the educational level of women (figure). Therefore, improvement of women’s education to help increase awareness and decrease tolerance of this practice should be a top-priority prevention strategy in this region. Wasim Maziak Institute of Epidemiology and Social Medicine, University of Münster, 48129 Münster, Germany (e-mail: [email protected]) 1
2
3
4
5
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36. United Nations development program: human development report. New York: Oxford University Press, 1997. Maziak W, Asfar T, Mzayek F, Fouad MF, Kilzieh N. Socio-demographic correlates of psychiatric morbidity among low-income women in Aleppo-Syria. Soc Sci Med 2002; 54: 1419–27. Maziak W. Fatal child abuse in two children of a family: the alleged role of polygamy. Ann Saudi Med 2001; 21: 356–57.
Sir—I find your approach to the topic of violence against women a monstrous folly that misses the mark. Violence and suffering have been the lot of men and women since the human race emerged from the swamps. Men have generally been the victims of torture and killing, women of beating and rape. No one likes it, except
344
presumably the perpetrators, and with the passage of time attitudes are changing and will continue to change. You are wrongly highlighting the plight of mistreated women at a time when men in developed countries are being demonised. Charlotte Watts and Cathy Zimmerman1 look at violence against women across the world. However, what is happening in Bangladesh should not be confused with what is the case in Europe and the USA, since it is culturally quite different and in many ways years behind them. You do not mention the high incidence of violence by women against men and children in Europe and the USA, and indeed the whole of the western world. Also, you neglect to include psychological abuse, which is at least as damaging as physical abuse, and perpetrated by both sexes against each other and children. I find the inclusion of an image of a fractured skull as evidence of the things your boyfriend can do to you in Jacquelyn Campbell’s report2 irrelevant and sensationalist. The numbers from the UK Metropolitan Police Force for domestic violence in 2001, include nine murders in women and four in men, and grievous bodily harm in 356 women and 246 men. Numbers for lesser degrees of violence are higher in female victims, but men are less likely to report domestic violence. I wonder how many skull fractures in either sex are accounted for in these numbers. The leaders of the radical feminist movement in the UK and elsewhere have penetrated the very core of government. I see they have also infiltrated the pages of your influential medical journal. These people are driven by envy of men and need to be reminded of what is happening in our society, in which all the imperatives of parenthood are being tossed aside to further the ambitions of women in the workplace. Donald Winnicott, the post World War II psychoanalyst, showed the essential need of an infant for the reliable presence of its own mother, holding it physically and psychologically through the early years of life, for normal emotional development.3 Others, such as John Ross and colleagues4 have shown that children need their father, and boys especially experience great deprivation without his presence in the family. It is there that our society’s very serious problems lie. As a leading medical journal, your role must include promoting understanding and healing through the publication of scientific facts. This end cannot be achieved by publishing onesided data surveys that undermine the
family unit and damage the vital role of men in its maintenance. R J Walden Bossall, 126 Bluehouse Lane, Limpsfield, Surrey RH8 0AR, UK 1
2
3
4
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36. Winnitcott DW. The maturational processes and the facilitating environment studies in the theory of emotional development. In: Sutherland JD, ed. The international psychoanalytical library. London: Hogarth Press and the Institute of Psycho-analysis, 1985. Cath SH, Gurwitt AR, Ross JM, eds. Father and child: developmental and clinical perspectives. Boston: Little, Brown and Co, 1982.
Is it clinically significant? Sir—A moment’s regret that The Lancet’s own Anodynometer did not figure among the tests of clinical significance in Sergio Erill in his May 11 Jabs and Jibes.1 “Invert the meaning by inserting a simple negative. If no sane or competent advocate for that position can be imagined then the primary statement is not worth making. Take ‘effective interaction is the key to effective pain management’. Would anyone seriously propose that ‘ineffective interaction is the key . . .’?”2 Thomas Sherwood 19 Clarendon Street, Cambridge CB1 1JU, UK 1 2
Erill S. Is it clinically significant? Lancet 2002; 359: 1708. Editorial. Guidelines for doctors in the new world. Lancet 1992; 339: 1197–98.
DEPARTMENT OF ERROR False-positive antigen test in meningitis diagnosis—In this Correspondence letter by Carles Alonso-Tarrés and colleagues (Oct 13, p 1273), the polymorphonuclear lymphocyte measurement in the second paragraph should have been 24·7⫻107/L. Nasogastric tubes in patients with dysphagia—In this Correspondence letter by Ken-Ichiro Inoue and colleagues (Jan 5, p 81), the second author’s name should have been Hirohisa Takano, and the address should have appeared as Naka Central Hospital, Naka-gun, Ibaraki 311-0134, Japan; and First Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto (e-mail: [email protected]). Suicide rates in China, 1995–99—In this Article by Michael R Phillips and colleagues (March 9, p 835), the second sentence of the third paragraph of the Results section should read: “It was the 4th most important cause of death for rural women, the 12th most important cause for urban women, the 8th most important cause for rural men, and the 14th most important cause for urban men.”
THE LANCET • Vol 360 • July 27, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
2
3
4
5
Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002; 359: 189–98. Harding SA, Boon NA, Flapan AD. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 256–57. Landolfi R, De Cristofaro R. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 257. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndrome. Circulation 2001; 104: 2767–71. Meier JJ, Gallwitz B, Schmidt WE, Nauck MA. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Lancet 2002; 360: 257.
Violence against women
The Tendring pilot study was funded by the UK Department of Health.
*Oksana V Hoile, Gill Green, Sushil Jathanna, Tom Stewart *Tendring Primary Care Trust, Carnarvon House, Clacton-on-Sea, Essex CO15 6QD, UK; and Department of Health and Human Science, University of Essex, Colchester 1
Watts C, Zimmerman C. Violence against 12
2
3
4
5
women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36 Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner violence: findings from the national violence against women survey. Washington, DC: Office of Justice Programs, US National Institute of Justice and Center for Disease Control and Prevention, 2000. Hoile OV, Green G, Jathanna S, Stewart T. Health impact assessment of domestic violence: multi-agency pilot research project http://www.tendringpct.co.uk (accessed May 21, 2002). Ison E. Resource for health impact assessment. London: NHS Executive, 2000.
Sir—Your decision to publish the series on violence against women, especially the reports of Charlotte Watts and Cathy Zimmerman,1 and Jacquelyn Campbell,2 is welcome given this issue’s serious implications on women’s health and wellbeing. One area in which violence against women is likely to be a huge problem is the Middle East, where indirect evidence points to a striking inequality between sexes.3 As is evident on Watts and Zimmerman’s global map of research on violence against women, such behaviour in the Middle East is probably aggravated by the dearth of related information. I and colleagues have studied 412 Syrian women in Aleppo, in primary health care, to look at the spread and patterns of physical abuse and its relation to mental health.4 Current physical abuse (repeated beating of any form at least three times in past year), was reported in 23% of all, and in 26% of married women. Regular physical abuse (beating ⭓1 time 60
p<0·001 for different SRQ means and abuse rates SRQ Abuse
10
50
8
40
6
30
4
20
2
10
0
肁12 years
Proportion abused women (%)
Sir—In their contributions to the violence against women series, Charlotte Watts and Cathy Zimmerman (April 6, p 1232),1 and Jacquelyn Cambell (April 13, p 1331),2 while acknowledging intimate-partner violence as a common health-care issue, confirm domination of prevalence research. Features of interaction between abused women and agencies, and the impact intimatepartner violence has on local service providers are rarely mentioned. We believe understanding of these issues is an important area for study to promote change and reduce the impact of intimate-partner violence on health. Another rarely acknowledged issue is the association of exposure to intimatepartner violence in early life and patterns of ill health in later adulthood. Such patterns link to psychological health being profoundly affected by life circumstances, emotional strains, and family disruption. Study of violence is frequently viewed as a biased issue or a political topic. Scepticism frequently expressed by health-care professionals towards such research may be reduced by addressing the lack of sufficient evidence about any benefits of actions commonly taken to lessen or prevent the damaging effects of intimate-partner violence. We did a small-scale pilot study, in Tendring District, Essex, UK (population 137 000). To take account of the complexity of the impact intimate-partner violence has on individuals and services,3 we used a comprehensive health impact assessment4 that allows in-depth exploration of the impact on health from the introduction of policies and initiatives.5 It uses direct information from affected individuals, agencies, and community by taking into account their opinions, experience, and expectations.
We interviewed ten women with experience of intimate-partner violence in depth and sent questionnaires to all local primary-care professionals about their management of this type of violence. We also interviewed local agencies including local charities helping families with children, and a befriending-style teenage service. The agencies had no systematic response or standardised system of referral or monitoring of incidence of intimate partner violence. In a local women’s refuge, most of the residents were children. More than 30% of children referred to a local charity providing family support came from families with experience of intimatepartner violence. Some health professionals seemed to avoid asking about violence, believing it was not their remit. Victims were thus not encouraged to disclose intimate-partner violence, nor able to rely on appropriate support when they did come forward. Implementation of local healthimpact assessments could be helpful in informing local decision makers on how to gain maximum benefits of conceptual and structural changes to the way intimate-partner violence is viewed or dealt with. Meanwhile, initiatives are needed to encourage use of a broad definition of intimate-partner violence acknowledging its effect on victims and other members of the family.
Mean SRQ score
1
0 <12 years
Illiterate
Women’s educational level
Relation between level of education, mean mental health scores, and prevalence of physical abuse in Syrian women
THE LANCET • Vol 360 • July 27, 2002 • www.thelancet.com
343
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
weekly) was reported among 3% of married women). Marriage, Islamic religion, rural residence, poor education, and mental distress were important correlates of physical abuse after adjustment for other sociodemographic characteristics. Important correlates for regular physical abuse were age difference between spouses, polygamy, smoking, and mental distress (unpublished data). Generally, women of polygamous marriages were 2·3 times more likely to report physical abuse than were those in monogamous marriages. This strong association suggests that both polygamy and physical abuse represent various manifestations of troubled marriages. A suggested ill effect from polygamy has been met with fierce resistance from medicolegal establishments in Middle Eastern societies.5 Depression and post-traumatic stress disorder are the most frequent mental health sequelae of intimatepartner violence.2 With use of the 20-item mental-health screening we self-reporting questionnaire,4 noted that physical-abuse prevalence and mean questionnaire score (low score, better mental health) were strongly related to the educational level of women (figure). Therefore, improvement of women’s education to help increase awareness and decrease tolerance of this practice should be a top-priority prevention strategy in this region. Wasim Maziak Institute of Epidemiology and Social Medicine, University of Münster, 48129 Münster, Germany (e-mail: [email protected]) 1
2
3
4
5
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36. United Nations development program: human development report. New York: Oxford University Press, 1997. Maziak W, Asfar T, Mzayek F, Fouad MF, Kilzieh N. Socio-demographic correlates of psychiatric morbidity among low-income women in Aleppo-Syria. Soc Sci Med 2002; 54: 1419–27. Maziak W. Fatal child abuse in two children of a family: the alleged role of polygamy. Ann Saudi Med 2001; 21: 356–57.
Sir—I find your approach to the topic of violence against women a monstrous folly that misses the mark. Violence and suffering have been the lot of men and women since the human race emerged from the swamps. Men have generally been the victims of torture and killing, women of beating and rape. No one likes it, except
344
presumably the perpetrators, and with the passage of time attitudes are changing and will continue to change. You are wrongly highlighting the plight of mistreated women at a time when men in developed countries are being demonised. Charlotte Watts and Cathy Zimmerman1 look at violence against women across the world. However, what is happening in Bangladesh should not be confused with what is the case in Europe and the USA, since it is culturally quite different and in many ways years behind them. You do not mention the high incidence of violence by women against men and children in Europe and the USA, and indeed the whole of the western world. Also, you neglect to include psychological abuse, which is at least as damaging as physical abuse, and perpetrated by both sexes against each other and children. I find the inclusion of an image of a fractured skull as evidence of the things your boyfriend can do to you in Jacquelyn Campbell’s report2 irrelevant and sensationalist. The numbers from the UK Metropolitan Police Force for domestic violence in 2001, include nine murders in women and four in men, and grievous bodily harm in 356 women and 246 men. Numbers for lesser degrees of violence are higher in female victims, but men are less likely to report domestic violence. I wonder how many skull fractures in either sex are accounted for in these numbers. The leaders of the radical feminist movement in the UK and elsewhere have penetrated the very core of government. I see they have also infiltrated the pages of your influential medical journal. These people are driven by envy of men and need to be reminded of what is happening in our society, in which all the imperatives of parenthood are being tossed aside to further the ambitions of women in the workplace. Donald Winnicott, the post World War II psychoanalyst, showed the essential need of an infant for the reliable presence of its own mother, holding it physically and psychologically through the early years of life, for normal emotional development.3 Others, such as John Ross and colleagues4 have shown that children need their father, and boys especially experience great deprivation without his presence in the family. It is there that our society’s very serious problems lie. As a leading medical journal, your role must include promoting understanding and healing through the publication of scientific facts. This end cannot be achieved by publishing onesided data surveys that undermine the
family unit and damage the vital role of men in its maintenance. R J Walden Bossall, 126 Bluehouse Lane, Limpsfield, Surrey RH8 0AR, UK 1
2
3
4
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359: 1232–37. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331–36. Winnitcott DW. The maturational processes and the facilitating environment studies in the theory of emotional development. In: Sutherland JD, ed. The international psychoanalytical library. London: Hogarth Press and the Institute of Psycho-analysis, 1985. Cath SH, Gurwitt AR, Ross JM, eds. Father and child: developmental and clinical perspectives. Boston: Little, Brown and Co, 1982.
Is it clinically significant? Sir—A moment’s regret that The Lancet’s own Anodynometer did not figure among the tests of clinical significance in Sergio Erill in his May 11 Jabs and Jibes.1 “Invert the meaning by inserting a simple negative. If no sane or competent advocate for that position can be imagined then the primary statement is not worth making. Take ‘effective interaction is the key to effective pain management’. Would anyone seriously propose that ‘ineffective interaction is the key . . .’?”2 Thomas Sherwood 19 Clarendon Street, Cambridge CB1 1JU, UK 1 2
Erill S. Is it clinically significant? Lancet 2002; 359: 1708. Editorial. Guidelines for doctors in the new world. Lancet 1992; 339: 1197–98.
DEPARTMENT OF ERROR False-positive antigen test in meningitis diagnosis—In this Correspondence letter by Carles Alonso-Tarrés and colleagues (Oct 13, p 1273), the polymorphonuclear lymphocyte measurement in the second paragraph should have been 24·7⫻107/L. Nasogastric tubes in patients with dysphagia—In this Correspondence letter by Ken-Ichiro Inoue and colleagues (Jan 5, p 81), the second author’s name should have been Hirohisa Takano, and the address should have appeared as Naka Central Hospital, Naka-gun, Ibaraki 311-0134, Japan; and First Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto (e-mail: [email protected]). Suicide rates in China, 1995–99—In this Article by Michael R Phillips and colleagues (March 9, p 835), the second sentence of the third paragraph of the Results section should read: “It was the 4th most important cause of death for rural women, the 12th most important cause for urban women, the 8th most important cause for rural men, and the 14th most important cause for urban men.”
THE LANCET • Vol 360 • July 27, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.