Women’s experiences with violence: A national study

Women’s Health Issues 17 (2007) 3–12

WOMEN’S EXPERIENCES WITH VIOLENCE: A NATIONAL STUDY Kathryn E. Moracco, PhDa,b,c,d*, Carol W. Runyan, PhDb,c, J. Michael Bowling, PhDb,c, and Jo Anne L. Earp, ScDc a

Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina UNC Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina d Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina b

Received 10 January 2006; accepted 16 March 2006

Background. Violence against women (VAW) is widespread and linked to negative public health and social outcomes. Research on VAW, however, has largely been limited to convenience samples and on variable definitions of violence, hindering our ability to fully characterize this important problem nationally and among subgroups of women. Methods. Using a population-based national sample of noninstitutionalized women ages >18 (n ⴝ 1,800), we conducted a telephone survey on women’s experiences with 6 types of violence, including being followed and repeatedly contacted, as well as physical and sexual assault by intimate partners and others. We calculated adult lifetime and prior year prevalence of violent experiences, examined bivariate differences in experiences among groups of women, and employed logistic regression to model the odds of adult lifetime and prior year victimization. Results. Sixty percent of the respondents experienced at least 1 form of violence since age 18; 10% reported violence in the previous year. Adult lifetime and prior-year prevalence varied widely by types of violence, and by respondents’ sociodemographic characteristics. Women under age 55, those receiving public assistance, and lesbian/bisexual women were at higher risk of experiencing violence in their adult lifetimes. Women age 18 –24 had increased risks of victimization in the previous year. Conclusions. To accurately reflect the chronic nature of partner violence, point estimates should be supplemented with adult lifetime estimates of victimization, including stalking behaviors. Ensuring adequate numbers of women from diverse backgrounds and developing measures that more completely assess the patterns and consequences of women’s experiences with violence are important next steps.

V

iolence against women (VAW) by both partners and nonpartners has serious long- and short-term physical and mental health sequelae. Physical and sexual assaults may result in fatal and nonfatal injuries, trauma-specific and generalized pain, unwanted pregnancies, sexually transmitted infections, and gynecologic problems (Brokaw et al., 2002; Coker et al., 2002; Greenfeld et al., 1998; Hathaway et al., 2000;

* Correspondence to: Beth Moracco, PhD, MPH, Pacific Institute for Research and Evaluation, 1516 East Franklin Street, Suite 200, Chapel Hill, NC 27514. E-mail: [email protected]. Copyright © 2007 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Holmes, Resnick, & Frampton, 1998; Pastore & Maguire, N.D.; Tjaden & Thoennes, 2000) Research has linked experiencing violence with gastrointestinal disorders, anxiety, depression, substance use, and suicide attempts (Bergman & Brismar, 1991; Caetano, Cunradi, Clark, & Schafer, 2000; Drossman, Talley, Leserman, Olden, & Barreiro, 1995; Holmes et al., 1998; Humphreys, Lee, Neylan, & Marmar, 2001; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kilpatrick, Resnick, & Acierno, 1997; Wyshak & Modest, 1996). Victimized women also view themselves as being less healthy, having more physical complaints and symptoms of emotional distress, and report lower levels of 1049-3867/07 $-See front matter. doi:10.1016/j.whi.2006.03.007

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physical and mental well-being than women who have not been victimized (Brokaw et al., 2002; Dickinson, deGruy, Dickinson, & Candib, 1999; Hathaway et al., 2000). As with physical and sexual assault, stalking, defined most often as repeated nonconsensual harassing or threatening behavior (U.S. Department of Justice, Violence Against Women Grants Office, 1998), has a negative impact on women’s health and well-being. A national survey revealed that in 1996 30% of women stalked during the previous year had sought counseling, and 26% had missed time from work owing to their victimization (Tjaden & Thoennes, 2000). Stalking often accompanies intimate partner violence (IPV), and is associated with threats, and often physical and sexual assault (Hall, 1998; Pathe, 1997). In addition to the impact on individual victims, VAW exacts an enormous social toll in the form of medical costs, decreased work productivity, homelessness, and an increased burden on the health, criminal justice, and human service systems. Miller, Cohen, and Wiersema (1996) estimated the tangible (property damage and loss, medical care, victims’ services, and police and fire services) and intangible costs (pain and suffering, reduced quality of life) of various crimes, and estimated that domestic violence and sexual assault resulted in $67 and $127 billion in annual losses, respectively, measured in 1993 dollars. The Centers for Disease Control and Prevention used data from the National Violence Against Women survey (NVAW) and estimated that the direct medical and mental health care services related to IPV exceeded $4.1 billion annually (National Center for Injury Prevention and Control, 2003). Despite the significance of VAW as a public health problem, our knowledge about its prevalence and patterns is limited. Currently there are no permanent national or statewide surveillance systems devoted to VAW, so prevalence estimates must be gleaned from other sources, such as the National Crime Victimization Survey (NCVS; Rennison, 2003). With the exception of the National Family Violence Surveys conducted in 1975 and 1985, and the NVAWS, conducted in 1996 (Straus, Gelles, & Smith, 1990; Straus, Hamby, Boney-McCoy & Sugarman, 1996; Tjaden & Thoennes, 2000), research has largely been limited to convenience samples, and has used variable definitions of violence, hindering our ability to fully characterize this important problem nationally and among subgroups of women. Prevalence estimates vary widely, due to differences in the types of violence included, samples considered, and methodologies employed. Although women of all ages experience violence, young women, particularly those ⬍25, have been found to be at greater risk of all types of violent victimization than older women (Coker, Smith, McKeown, & King, 2000; Straus et al., 1990; Straus et al., 1996; Tjaden & Thoennes, 2000; Verhoek-Oftedahl & Babcock, 2000).

Early research suggested a higher rate of violence among African American women and Latinas; however, more recent studies have found no difference in the prevalence of IPV and other forms of VAW between whites and minority women, after controlling for socioeconomic factors (Coker, Smith, McKeown et al., 2000; Harwell & Spence, 2000; Hathaway et al., 2000; Straus et al., 1990; Tjaden & Thoennes, 2000; Verhoek-Oftedahl & Babcock, 2000). Previous research indicates that a history of victimization is a strong predictor of future physical and sexual assault, even after controlling for demographic variables (Acierno, Resnick, & Kilpatrick, 1997; Coker, Smith, McKeown et al., 2000; Harwell & Spence, 2000; Hathaway et al., 2000; Kilpatrick, Acierno et al., 1997). Small sample sizes have often prohibited examining subpopulations and controlling for multiple covariates of women’s experiences with violence. This study adds to our knowledge about violence in women’s lives by describing the prevalence and patterns of a variety of types of violence in a populationbased national sample of adult women. Our purposes were to 1) describe the nature of women’s experiences with violence within their adult lifetimes and during a 12-month period; 2) measure adult lifetime and prioryear prevalence of women’s experiences with violence; 3) describe how these 2 measures vary across groups of women; and 4) examine associations between selected sociodemographic variables and women’s experiences with violence. Our purpose was to better understand the prevalence and patterns of women’s experiences with violence to identify potential avenues of identification and intervention.

Methods Study Design In this research, we used qualitative and quantitative methods in a sequential, complementary manner. First, we conducted 13 focus group interviews to inform the content and suggest language for a telephone survey instrument. Then we used a random digit dial telephone interviewing procedure to provide a general probability sample of all households with telephones, including homes with unlisted numbers. We restricted eligibility to noninstitutionalized, English-speaking females at least 18 years old and living in the 48 contiguous U.S. states. Women in college or boarding school dormitories, military barracks, or other group home settings were included in the sample. If a household contained multiple eligible women, 1 was randomly selected, using a computer algorithm. Instrument Development In the focus groups, we sought to include women with a wide range of sociodemographic characteristics and experiences with violence. We also wanted to make sure

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that certain groups of women who may have had experiences with violence, including battered women, women who lived in high crime, urban areas, lesbians and older women, were included in our focus group sample. Consequently, we used purposeful sampling, employing both “intensity” (recruiting information-rich cases) and “maximum variation” (recruiting participants representing a wide range of variation on dimensions of interest) strategies to recruit participants (Patton, 2001). Homogeneity is particularly important to ensure the comfort of the participants and to facilitate lively group discussion. Thus, although we recruited focus group participants according to a variety of criteria of interest, the groups themselves were homogeneous. One hundred eleven women participated in 13 focus groups in North Carolina (n ⫽ 7 groups), Iowa (n ⫽ 2 groups), Washington state (n ⫽ 2 groups), and Maryland (n ⫽ 2 groups). We pilot tested the resulting survey instrument on a population-based sample of 143 North Carolina women, and revised the wording and format based on the results of the pilot study. We administered the survey to a national sample of 1,800 women between August and December 1997.

Telephone Interviewing (CATI) procedures. They called randomly generated numbers during weekday afternoons and evenings, and on weekends, making a total of 6 attempts before classifying a household as nonresponsive. Potential respondents were informed that their telephone numbers had been randomly generated by a computer, and they were being recruited as part of a national sample of the general adult female population for a women’s health and safety study. To ensure that respondents would not be endangered by participating in the study, we asked whether it was a safe time for them to talk, and told them they could use a code phrase (“I don’t care to contribute today, thank you”) if they needed to end the interview abruptly (e.g., if an abusive partner entered the room). Interviewers also gave toll-free numbers for the National Domestic Violence Hotline and the Rape, Incest and Abuse National Network to all study participants, regardless of whether they disclosed a history of victimization. Respondents remained anonymous and received a toll-free number they could use to call back at a safe time (for interrupted interviews) or to verify the study’s authenticity.

Variable Definitions

Data Analyses We computed adult lifetime prevalence as the percentage of women who experienced a specific type of violence since age 18, and prior year prevalence as the percentage of women experiencing violence during the 12 months prior to the survey. We used sampling and poststratification weights,* based on 1990 census data, to correct for unequal probabilities of being

Personal experiences with violence. We used the results of the focus group to guide the content of the interview questions, including those about respondents’ experiences with violence. Respondents were queried about different types of violent experiences they may have had since age 18, including being followed by a man in a way that frightened them; repeatedly contacted by someone after telling them to stop; physically attacked by a stranger; physically assaulted by a current or former intimate partner (asked only of women who had ever been married or cohabitated with a male or female intimate partner); raped or sexually assaulted (asked as “forced to have sex and/or do sexual things”) by a stranger; and raped or sexually assaulted by someone they knew. Women who had experienced violence were asked follow-up questions about the timing and frequency of the incident(s), as well as the identity of the perpetrator for the most recent incident. Demographic variables. We measured age, ethnicity, household income, educational attainment, and urban–rural status. We also asked women whether they were married or cohabitating with an intimate partner; considered themselves to be a lesbian or bisexual; and received any type of public assistance or lived with anyone who did. We also asked how many adults and children age ⬍18 lived with them. Data Collection Trained female interviewers conducted both the pilot and the national surveys using Computer Assisted

*

To calculate weights, the respondents were categorized into subgroups by their race, census region, and age. The respondent’s race and age were questions in the survey, and their census region was obtained by matching up their state with a map of census regions. For those cases where respondents did not provide their race or age (n ⫽ 11), values were imputed. Race was defined as white versus nonwhite. Census regions are Northeast, Midwest, South, and West, as defined by the U.S. Census. Age was defined by these 5 groups: 18 –24 years old, 25–34 years old, 35– 44 years old, 45–54 years old, and ⱖ55 years old. For subgroups where the sample size was too small, age categories were collapsed. In all of these cases, the race was nonwhite. These resulted in the following changes to the subgroups: Northeast, 18 –34 years old and ⱖ35 years old; Midwest, 18 –34 years old, 35– 44 years old, and ⱖ45; and West, 18 –34 years old, 35– 44 years old, and ⱖ45 years old. This resulted in 33 subgroups for the weight calculation. First, the unadjusted weight (Whi) for the i-th respondent in the h-th adjustment cell was calculated by dividing the number of eligible women in the household in which the hi-th respondent was found by the number of phone lines reaching the household in which the hi-th respondent was found. This information was obtained from the respondent by the questions PREINTRO and H78, respectively. Then, the poststratification ratio adjustment (Ah) for the h-th cell was calculated by dividing the proportion of the female population ⱖ18 years old in the adjustment cell by the sample weighted proportion of female respondents in the adjustment cell. The 1990 United States Census was used to find the proportion of the female population ⱖ18 years old in the adjustment cell. The final adjusted weight (W*hi) is Ah multiplied by Whi.

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selected into the sample and to adjust for sampling bias. We compared our results using weighted versus unweighted data. We calculated rates of violence in the year prior to the survey by dividing the number of experiences in the 12 months before the survey by the number of women in the sample. Using the ␹2 test of homogeneity, we compared violent experiences among selected subgroups of respondents. We used logistic regression to identify demographic and experiential factors associated with adult lifetime and prior year experiences with violence, controlling for confounding among covariates. Because 215 women did not supply information about their annual household income, we excluded the income variable from regression analyses. We also omitted cases with missing data for independent and dependent variables, which resulted in sample sizes of 1,767–1,782 for models of nonpartner violence and 1,650 for the model for partner violence. For the partner violence model, we considered only women who reported ever having been married or ever cohabitating with an intimate partner. For models of violent experiences in the previous year, we combined stranger physical and sexual assault because only a small number of women reported each of these types of violence. An ␣ level of .05 was considered statistically significant for all analyses.

Results Sociodemographic Characteristics of the Study Participants We had a response rate of 73% among eligible households. All the women who began the interviews, which lasted an average of 33 minutes, completed them. As shown in Table 1, the respondents ranged in age from 18 –92 years, with a median age of 43. About one fifth (19%) described themselves as belonging to an ethnic minority group, 90% had at least a high school diploma or GED, and nearly half (45%) lived with children ⬍18 years old. The study sample was demographically comparable to that of the March 1997 Current Population Survey, with the exception that women in our sample were, on average, older and more highly educated. Therefore, we used weighted data in reporting our results. Women’s Experiences With Violence Nearly 60% of the respondents reported experiencing at least 1 form of violence listed in Table 2 since the age of 18. One in 8 (12.0%) of the respondents reported violent experiences in the previous year. Being followed, being repeatedly contacted, and being physically assaulted by a partner were the types of violence women most commonly reported experiencing both in their adult lifetimes and in the previous 12 months.

Table 1. Demographic Characteristics of Study Sample Study Sample Variable Age (years; n ⫽ 1,793) 18–24 25–34 35–44 45–54 55–64 65–74 ⱖ75 Median age Race/ethnicity (n ⫽ 1,796) Caucasian/white African American Biracial Multiracial Native American/American Indian Asian/Asian American Other Latina/Hispanic* Marital status (n ⫽ 1,750) Never married Married Separated/divorced Widowed Lesbian/bisexual (n ⫽ 1,793) Works outside home† Educational attainment (n ⫽ 1,800) Less than high school/GED High school diploma/GED More than high school/GED Annual household income (n ⫽ 1,534) ⬍$20,000 $20,001–$40,000 $40,001–$60,000 $60,001–$80,000 ⬎$80,000

n

%

149 348 449 315 237 185 110 43

8.3 19.4 25.0 17.6 13.2 10.3 6.1

1465 163 35 34 26 21 52 86

81.6 9.1 1.9 1.9 1.4 1.2 2.9 4.8

245 1098 232 175 42 1212

14.0 62.7 13.3 10.0 2.3 67.4

154 548 1098

8.6 30.4 61.0

379 448 370 151 186

22.8 29.2 24.1 9.8 12.12

*Hispanic/Latina respondents could be of any race. † Includes part-time and volunteer work.

For all types of violence except being followed in a way that frightened them, where strangers were the most common (80%) perpetrators, women were most often victimized by men they knew, frequently their current or former intimate partners. Three times as many women reported physical assaults by partners than assaults by strangers (23.4% versus 7.5% for adult lifetime and 2.6% versus 1.0% for pervious year), and the difference was similar for sexual assaults. Among women who reported repeated unwanted contact, current (15.9%) and former (32.9%) intimate partners were the perpetrators in nearly half of the most recent incidents, followed by strangers (20.2%), acquaintances (19.5%), coworkers (5.1%), and family members (1.6%). Almost one third (31.5%) of the women had experienced more than one type of violence (e.g., being followed and repeatedly contacted) in their lifetimes, and almost 3% had experienced multiple types of

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Table 2. Adult Lifetime and Prior Year Prevalence of Women’s Personal Experiences With Violence (n ⫽ 1,800) Prior Year Prevalence†

Adult Lifetime Prevalence*

Type of Experience Followed by a man Repeatedly contacted Physical assaulted by Intimate partner‡ or stranger Intimate partner‡ Stranger Sexually assaulted by Known person or stranger Known person Stranger Any of the above types of experience with violence

Unweighted Frequency (n)

Weighted Percentage of Women Who Have Experienced (95% CI)

Unweighted Frequency (n)

Weighted Percentage of Women Who Have Experienced (95% CI)

772 441

42.7 (40.3–44.8) 25.3 (23.3–27.4)

91 82

5.9 (4.8–7.0) 5.5 (4.4–6.5)

477 399 134

25.6 (23.7–26.4) 23.4 (21.4–25.5) 7.5 (6.3–8.7)

61 45 17

3.4 (2.7–5.1) 2.6 (1.7–3.4) 1.0 (.57–1.5)

291 248 89 1081

16.7 (15.2–17.9) 14.3 (12.7–15.9) 5.6 (4.3–6.4) 59.8 (57.5–62.0)

19 15 6 188

1.1 (.74– 1.46) .87 (.44–1.3) .36 (.08–.64) 12.0 (10.4–13.4)

*Adult lifetime prevalence ⫽ experienced since age 18. Prior year prevalence ⫽ experience during 12 months prior to the survey. ‡ Included only women who had ever been married or lived with an intimate partner (n ⫽ 1,650). †

violence in the past year. In addition, women generally experienced multiple incidents of the same type of violence, both during both their adult lifetimes and in the prior year. Thus, the number of victimizations exceeded the number of women victimized for all types of violence (data not shown). Women’s adult lifetime experiences with violence varied by their sociodemographic characteristics (Table 3). Women ⬍55, especially those 18 –34, were more likely to report having had experiences with violence than women ⱖ55. Caucasian and Asian/Asian American women appeared to be at lower adult lifetime risk of violence than African American, Hispanic, Native American, or biracial or multiracial women, although there was considerable variation among groups. Lesbians and bisexual women reported experiences in significantly higher proportions for most types of violence, with 82% having experienced some type of violence. Adult lifetime experiences with violence did not vary consistently by either income or educational attainment, although living in a household that received public assistance did appear to be associated with higher proportions of all types of violence, except being followed. The multivariate analyses for adult lifetime violence (Table 4) confirmed many of the observed bivariate relationships. The coefficients reported are the odds ratios and 95% confidence intervals for experiencing versus not experiencing specific types of adult lifetime violence. Specifically, being ⬍55 years old remained a significant risk factor for all types of violence, and living in a household that received public assistance remained significantly associated with all types of violence except being followed. Lesbians and bisexual women also reported higher levels of stranger physical and sexual violence, as well as sexual violence by

known assailants. Ethnic minority group status was not a significant risk factor for any type of violence. Being ⬍55 years old was the only variable consistently associated with victimization in the previous year, with women age 18 –24 at the highest risk of experiencing all types of violence (Table 5). Lesbian and bisexual women, and women receiving public assistance, were also more likely than other women to be sexually assaulted by a known assailant.

Conclusions and Discussion This study is one of the few national, populationbased studies to examine women’s experiences with violence, and only the second to examine stalking experiences. Our annual prevalence estimates for some types of violence were as much as 6 times higher than those of the 1997 NCVS, possibly because, even though their questions were not limited to incidents reported to law enforcement, the NCVS asks about victimization in the context of a survey about crime. Much of the violence that women experience historically has not been considered aberrant or criminal behavior (Brownmiller, 1975; Schecter, 1982) and may not have been thought of as “crimes” by NCVS respondents. In addition, our methodological strategies, such as using female interviewers, ensuring respondent anonymity, and providing a code phrase to suspend the interview, may have facilitated women’s disclosure of violent experiences. Our study was not as comprehensive or lengthy as the NVAWS, yet our findings on VAW prevalence and patterns are remarkably similar. Given the widely varying prevalence estimates for VAW, and the paucity of national population-based surveys on this

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Table 3. Women’s Adult Lifetime Experiences With Violence by Sociodemographic Characteristics* Percent Ever Experienced (Weighted)†

Characteristic

Followed

Repeatedly Contacted

Age (years) 18–24 25–34 35–44 45–54 55–64 ⱖ65 Race/ethnicity Caucasian African-American Bi-/multiracial Native American Asian Other Hispanic§ Yes No Lesbian/bisexual Yes No Public assistance Yes No Children under 18 in household Yes No Urban–rural City Suburb Medium town Small town Rural area Household income ⬍$20,000 $20,001–$40,000 $40,001–$60,000 $60,001–$80,000 ⬎$80,000 Education Less than high school/GED High school/GED More than High School/GED

p ⫽ .001 46.4 50.6 47.8 47.7 35.7 26.2 p ⫽ .32 41.6 46.1 48.2 40.8 42.8 54.7 p ⫽ .078 51.6 42.2 p ⫽ .023 58.3 42.3 p ⫽ .70 43.9 42.6 p ⫽ .065 45.4 40.8 p ⫽ .001 50.2 48.4 43.2 32.1 39.3 p ⫽ .23 41.4 45.1 43.7 50.0 46.2 p ⫽ .001 37.5 37.3 46.3

p ⫽ .0001 36.6 34.8 26.4 25.0 17.7 9.9 p ⫽ .013 24.7 25.9 42.7 36.5 7.0 30.5 p ⫽ .008 37.2 24.7 p ⫽ .008 40.9 24.7 p ⫽ .002 33.7 24.2 p ⫽ .001 30.5 21.2 p ⫽ .95 24.5 25.2 26.8 26.0 24.3 p ⫽ .18 27.4 28.2 23.3 19.9 23.2 p ⫽ .206 21.4 21.4 26.5

Physical Assault by Stranger

Physical Assault by Partner‡

Sexual Assault by Stranger

Sexual Assault by Known Person

Any Violence

p ⫽ .0001 10.1 10.1 9.9 9.3 2.5 2.1 p ⫽ .0001¶ 6.6 10.4 23.3 10.2 5.5 7.4 p ⫽ .006 16.0 7.1 p ⫽ .001 29.0 6.8 p ⫽ .001 16.0 6.3 p ⫽ .024 9.1 6.3 p ⫽ .002 9.1 9.3 10.5 4.5 4.3 p ⫽ .04 9.8 8.4 5.1 11.3 5.4 p ⫽ .32 9.1 5.8 8.0

p ⫽ .0001 23.8 27.8 29.8 28.8 18.6 11.2 p ⫽ .002 22.6 35.3 36.9 22.5 5.2 22.1 p ⫽ .28 24.8 20.9 p ⫽ .13 33.4 23.0 p ⫽ .001 41.8 20.9 p ⫽ .001 29.4 18.4 p ⫽ .04 26.5 20.2 18.4 26.9 22.6 p ⫽ .006 28.5 28.1 20.9 17.4 19.7 p ⫽ .001 37.4 22.6 22.7

p ⫽ .0001 10.5 7.5 6.1 4.1 2.3 1.3 p ⫽ .29¶ 5.2 6.6 8.2 8.9 0.0 3.6 p ⫽ .53¶ 3.1 5.4 p ⫽ .0001 22.2 4.7 p ⫽ .0001 11.7 4.4 p ⫽ .014 6.8 4.2 p ⫽ .112 6.3 5.1 7.7 4.7 2.9 p ⫽ .19 6.6 6.7 3.5 4.0 3.2 p ⫽ .65 6.5 4.7 4.8

p ⫽ .0001 21.5 19.7 17.1 13.5 6.8 5.3 p ⫽ .006¶ 13.5 17.5 38.3 23.7 0.0 12.7 p ⫽ .57 16.3 14.2 p ⫽ .0001 47.1 13.1 p ⫽ .0002 22.4 13.1 p ⫽ .020 12.6 16.4 p ⫽ .50 15.0 12.9 16.5 14.7 11.8 p ⫽ .02 17.2 17.6 12.3 11.9 8.6 p ⫽ .009 18.2 12.0 14.0

p ⫽ .0001 63.5 71.6 66.1 65.0 50.1 38.9 p ⫽ .065 58.5 62.8 75.3 66.9 51.2 73.1 p ⫽ .007 73.3 59.0 p ⫽ .0007 82.4 59.0 p ⫽ .001 69.5 58.4 p ⫽ .001 65.2 55.5 p ⫽ .013 65.5 62.7 57.0 55.9 55.9 p ⫽ .13 58.3 64.0 59.8 66.2 61.8 p ⫽ .0001 61.0 51.1 64.4

*Assessed with ␹2 test of homogeneity. † Totals may not ⫽ 100% due to rounding. ‡ Included only women who had ever been married or lived with an intimate partner (n ⫽ 1,650). ¶ More than 20% of cells had expected counts ⬍ 5. § Hispanic respondents could be of any race.

topic, consistency in findings among populationbased research is important to note, to refine our prevalence estimates, and accurately portray patterns and characteristic of subgroups, which in turn, could lead to the development of effective interventions and policies. Since the mid-1990s, the Centers for Disease Control and Prevention have sought to improve the quality of VAW data by working with researchers, practitioners,

and advocates in 5 states to standardize measures and facilitate the development and evaluation of population-based surveillance systems for IPV (Harwell & Spence, 2000; Hathaway et al., 2000; Saltzman et al., 2000; Weinbaum et al., 2001) Another strategy has been “surveillance partnerships” in which violence questions are included in ongoing surveillance systems such as the Behavioral Risk Factor Surveillance System and the Pregnancy Risk Factor Monitoring

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Table 4. Adjusted Odds Ratios and 95% Confidence Intervals for Women’s Adult Lifetime Experiences With Violence by Sociodemographic Characteristics Adjusted Odds Ratio for Victimized Versus Not Victimized in Adult Lifetime (95% CI)

Followed (n ⫽ 1,767) Age 18–34 35–54 55–64 ⬎65 (ref) Race/ethnicity African American Caucasian (ref) Otherb Hispanic Non-Hispanic (ref) Urban/rural status Urbanc Other (ref) Public assistance Yes No (ref) Education ⬍High School/GED High School/GED ⬎High School/GED (ref) Lesbian or bisexual Yes No (ref)

Repeatedly Contacted (n ⫽ 1,778)

Physical Assault by Partnera (n ⫽ 1,650)

Physical Assault Stranger (n ⫽ 1,782)

Sexual Assault by Stranger (n ⫽ 1,782)

Sexual Assault by Known Person Any Violence (n ⫽ 1,782) (n ⫽ 1,774)

2.42 (1.78–3.30) 4.54 (3.00–6.87) 2.34 (1.76–3.27) 2.95 (1.94–4.49) 1.57 (1.09–2.27) 1.76 (1.07–2.91) 1.0 1.0

2.20 (1.44–3.35) 3.69 (1.61–8.44) 6.14 (2.21–17.10) 4.03 (2.34–6.97) 2.96 (2.21–3.97) 3.54 (2.34–5.35) 4.00 (1.75–9.15) 3.82 (1.35–10.86) 3.27 (1.88–5.68) 2.81 (2.11–3.76) 1.69 (1.03–2.76) 1.03 (.34–3.13) 1.33 (.35–5.02) 1.17 (.57–2.38) 1.50 (1.06–2.11) 1.0 1.0 1.0 1.0 1.0

1.08 (.76–1.53) 1.0 1.26 (.84–1.88) 1.02 (.63–1.64) 1.0

.87 (.58–1.30) 1.0 .98 (.62–1.53) 1.46 (.88–2.41) 1.0

1.18 (.79–1.75) 1.17 (.65–2.12) 1.0 1.0 .97 (.59–1.61) 1.39 (.73–2.62) .79 (.43–1.45) 1.68 (.83–3.39) 1.0 1.0

.71 (.33–1.51) 1.0 .76 (.30–1.96) .40 (.11–1.45) 1.0

1.11 (.70–1.77) 1.0 1.03 (.60–1.80) .85 (.44–1.63) 1.0

.95 (.66–1.37) 1.0 1.14 (.74–1.75) 1.29 (.76–2.20) 1.0

1.44 (1.15–1.80) 1.0

.86 (.66–1.12) 1.0

1.11 (.85–1.46) 1.11 (.74–1.67) 1.0 1.0

1.32 (.82–2.12) 1.0

.98 (.71–1.35) 1.0

1.29 (1.02–1.63) 1.0

1.06 (.78–1.42) 1.0

1.65 (1.19–2.28) 1.0

.98 (.67–1.41) .78 (.63–.97) 1.0

.77 (.50–1.19) .96 (.75–1.24) 1.0

1.50 (.85–2.68) 1.0

1.46 (.82–2.60) 1.0

2.06 (1.49–2.84) 2.84 (1.80–4.50) 2.84 (1.66–4.88) 1.0 1.0 1.0

1.62 (1.11–2.38) 1.58 (1.15–2.18) 1.0 1.0

1.87 (1.26–2.78) 1.08 (.55–2.12) 1.29 (.99–1.69) .78 (.51–1.21) 1.0 1.0

.84 (.385–1.82) 1.14 (.70–1.87) 1.0

1.81 (1.11–2.88) 1.56 (1.06–2.25) (.73–1.38) .70 (.56–.87) 1.0 1.0

1.10 (.57–2.14) 3.97 (2.07–7.63) 3.89 (1.90–8.00) 1.0 1.0 1.0

4.19 (2.35–7.46) 2.28 (1.10–4.75) 1.0 1.0

a

Includes women who had ever been married or cohabitated with an intimate partner, n⫽1671. Includes Biracial, Multiracial, Native American, Asian, and “Other” women. c Includes women who reported living in “cities.” b

System. Recent findings from these efforts should provide needed guidance (Durant, Colley Gilbert, Saltzman, & Johnson, 2000; Harwell & Spence, 2000; Hathaway et al., 2000; Saltzman et al., 2000; Vest, Catlin, Chen, & Brownson, 2002). Being followed by a man in a way that frightened them and being repeatedly contacted, behaviors that fit within most definitions of stalking, were experiences noted by the largest percentage of respondents. The NVAWS, which defined stalking as behavior(s) that occurred on ⱖ2 occasions and resulted in reports of feeling frightened or fearing bodily harm, reported that 8.1% of American women had been stalked in their adult lifetimes and 1% had been stalked in the previous 12 months (Hall, 1998; Tjaden & Thoennes, 2000). However, stalking is neither typically defined as “violence,” nor assessed in crime or victimization surveys. As both the NVAW survey and this study indicate, stalking is an important component of women’s overall experiences with violence. Future research should explore the contexts and consequences of stalking in greater detail. Because of the serious health consequences of IPV against women, in the past decade there has been a

call for health care facilities to develop and implement IPV “screening” protocols for female patients has been endorsed by many public health and health care professional associations (American College of Emergency Physicians, 1994; American College of Nurse Midwives, 1995; American Medical Association, 1992, 1995; American Nurses Association, 1991). Despite these recommendations, surveys of health care providers in both acute and primary care settings indicate that fewer than half regularly ask their female patients about IPV, and even fewer ask about other types of violence (Feldhaus, Houry, & Kaminsky, 2000; Friedman, Samet, Roberts, Hudlin, & Hans, 1992; Hamberger, Ambuel, Marbella, & Donze, 1998; Thompson et al., 2000). Currently no “gold standard” screening instrument exists, and there has been only limited evaluation of health care-based identification and referral protocols for victims of violence (Chalk, King, & National Research Council Committee on the Assessment of Family Violence Interventions, 1998; Cohn, Salmon, & Stobo, 2002; Ramsay, Richardson, Carter, Davidson, & Feder, 2002; Wathen & MacMillan, 2003). Thus, although encounters with health care providers may provide excellent opportunities to identify vic-

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Table 5. Adjusted Odds Ratios and 95% Confidence Intervals for Women’s Victimization Experiences in Prior Year by Sociodemographic Characteristics Adjusted Odds Ratio for Victimized vs. Not Victimized in Prior Year (95% CI)

Type of Violence Followed Repeatedly contacted Stranger physical or sexual violence Physical violence by partner储 Sexual assault by known person** Any violence

Age 18–24*

Age 25–54†

34.19 (13.2–88.4) 5.24 (2.04–13.4) 47.8 (11.05–206.8) 16.23 (3.95–66.70) 34.84 (4.36–278.5)

NS

11.29 (1.39–91.8)

9.75 (1.36–69.8)

NA

32.33 (16.1–65.0)

NA

7.14 (3.65–14.0)

Minority‡

Urban¶

.89 (.48–1.37) 1.47 (.94–2.30) NS NS NS

NS

Public Assistance§ .53 (.22–1.25) NS NS

.90 (.39–2.06) 1.56 (.75–3.25) 1.27 (.45–3.25) 1.34 (.41–4.38)

Less than High School/ GED

2.68 (1.01–7.16) 1.12 (.44–2.85) NS NS NS

NS

.59 (.20–1.75)

4.02 (1.36–11.86)

.59 (.16–2.16) 7.26 (2.10–25.12) 1.82 (.34–9.64)

1.02 (.71–1.48) 1.13 (.80–1.59)

.91 (.55–1.48)

Lesbian or Bisexual

.96 (.56–1.65)

9.12 (2.77–30.0)

1.90 (.99–3.63)

*Referent⫽⬎55. † Referent⫽⬎55. ‡ African American, Asian, Biracial, Multiracial, Hispanic, Native American, and “Other” women. ¶ Women who reported living in “cities.” § Women who lived in households receiving public assistance. 储 Includes only women who had ever been married or cohabitated with an intimate partner (n ⫽ 1,650). **All of the women who had been sexually assaulted by someone they knew in the previous 12 months were ⬍55.

tims of violence, research examining the most effective screening methods, interventions, and referral protocols is sorely needed. As confirmed in this study, the number and proportion of women who report violence during their adult lifetimes is considerable, yet the National Criminal Victimization Survey, and most past research, inquire only about events during the previous 12-month period. Numerous studies suggest that the effects of violent victimization are profound and enduring (Coker, Smith, Bethea, King, & McKeown, 2000; Drossman et al., 1995; Kilpatrick, Resnick et al., 1997; Norris & Kaniasty, 1997). Therefore, longitudinal research that details the “natural history” of violent experiences, including the contexts in which they occur and the nature and duration of their impact, will provide an empirical basis for a fuller understanding of the scope and long-term impact of VAW. We found that women ⬍35 years old were significantly more likely to report experiencing violence in their adult lifetimes and within the past year than women ⱖ35. Although a higher proportion of young women might be expected to report violent experiences in the previous year than older women, the finding that adult lifetime prevalence was also higher for women 18 –34 may reflect the influence of experiences unique to women in different age groups (cohort effect), recall bias, or a reluctance to disclose past violent experiences among older women. We found that women who live in households that receive some form of public assistance were more likely to report adult lifetime experience with all types

of violence and sexual assault by a known perpetrator (most often a current or former partner) in the previous year, even after controlling for covariates. Because they have fewer resources, perhaps women who receive public assistance are potentially less able to leave violent relationships, quit abusive work situations, or move to safer neighborhoods. In multivariate analyses, the differences in victimization between white and minority women was not significant. However, bivariate analyses revealed considerable variation among women of different ethnic backgrounds. The uniformly low rates among Asian women we found are consistent with findings from the NVAWS and the National Criminal Victimization Survey. These results are particularly intriguing, given that in our study over half the Asian women were under age 25, and hence theoretically at higher risk. Some researchers have suggested that traditional cultural values in Asian communities may discourage women from disclosing violent acts, especially those committed by partners (Bui & Merry, 1999; Ho, 1990; Tjaden & Thoennes, 2000; Yoshihama, 1999). However, the small number of both Asian women and their personal experiences with violence in the study sample limit our ability to examine this finding further. Also consistent with the NVAWS are our findings that higher proportions of biracial or multiracial women reported experiencing all types of violence, and that more Native American women reported physical and sexual assault by strangers and sexual assault by a known person (Tjaden & Thoennes, 2000). Again,

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sample size precluded more in-depth analyses of these groups’ experiences. Lesbians and bisexual women reported high levels of violence, and sexual orientation remained a risk factor for some types of adult lifetime victimization after controlling for covariates. However, these groups’ small numbers in our sample, and our inability to establish the temporal sequence of women’s violent experiences necessitates cautious interpretation. Currently, little is known about unique victimization risk factors for lesbians and bisexual women. This area is ripe for future research, including information about whether these women are the targets of antigay violence. Study Limitations Although our survey allowed us to examine women’s experiences with violence in some depth, our study’s generalizability is limited by several factors. First, our sample was restricted to English-speaking adult women who lived in homes with telephones. However, we used poststratification weights to adjust for sampling bias and any unequal probability of being selected into the sample. In addition, the cross-sectional nature of the survey limited our ability to discern the temporal relationships among variables; for example, whether receiving public assistance put women at higher risk of violence, or whether experiencing violence preceded women’s needing public assistance. Our measures of violence were limited; we did not ask about all forms of violence (e.g., child abuse, elder abuse by a caregiver), nor were our variables explicitly behaviorally defined. Thus, we have likely underestimated women’s experiences. We also relied on women’s self-reports of violent experiences, which may have been subject to recall bias. Conclusion and Implications To devise appropriate prevention and intervention strategies, a clear understanding of the patterns, context, chronology, and consequences of VAW is necessary. Future studies should rely on longitudinal designs, ensure that adequate numbers of women from diverse ethnic backgrounds are included, and collect information on stalking behaviors.

Acknowledgments The authors thank Thomas B. Cole, Brenda DeVellis, and Sandra L. Martin for their assistance reviewing drafts of the manuscript, and Lisa Dulli and Michele Decker for their help in editing and preparing the manuscript for publication. Supported by grants from the National Center for Injury Prevention and Control (R49/CCR4105-01 and R49CCR402444-04-13).

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Author Descriptions Kathryn E. Moracco, PhD, is a Research Scientist at the Chapel Hill Center of the Pacific Institute for Research and Evaluation (PIRE) and Adjunct Assistant Professor in the Departments of Maternal and Child Health and Health Behavior and Health Education at the UNC Chapel Hill. Her research and advocacy interests include the effects of violence on women’s physical and mental health and participatory evaluation of community-based violence and substance abuse prevention programs. Dr. Moracco was working at the UNC Injury Prevention Research Center when she conducted this research. Carol W. Runyan, PhD, is a Professor in the Departments of Health Behavior and Health Education and Pediatrics and is Director of the University of North Carolina Injury Prevention Research Center. She has broad interests in injury and violence, with focus on the foundations for policy. J. Michael Bowling, PhD, is a research methodologist and sampling statistician who designs and implements quantitative evaluations of public health interventions directed towards intentional and unintentional injury and cancer prevention. Jo Anne L. Earp, ScD, is a Professor in the Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill. She is a medical sociologist whose research focuses on the role of social and attitudinal factors in explaining variation in health behaviors.