Q&A: Burden of Proof - intimate partner violence & childhood sexual abuse

Transcript

This transcript has been lightly edited for clarity

Why is studying the health impact of intimate partner violence and child sexual abuse important?

We know that intimate partner violence and childhood sexual abuse are two of the most prevalent forms of violence against women and children across the globe. Almost one in three partnered women have been exposed to some form of intimate partner violence in their lifetime around the world. And almost 20% of girls and almost 10% of boys have experienced some form of childhood sexual abuse across the globe.

That’s what our current estimates are. So, these issues affect millions, if not billions of people, and they are really damaging, not only to the individual but to the family, to communities. And of course, here we’re focused on the health impacts, but they can have really detrimental economic impacts as well. When we think about the health impacts, we’re thinking not only about the immediate health impacts of an experience like this, a lot of injuries, but also the sort of the impacts that follow an individual over their life course in the medium and longer term.

Those sorts of medium- and longer-term impacts were really the focus of this work where we’re trying to understand when someone has been exposed to an experience like this, what happens over their life course and what does that mean, not only for them but also for generations to come?

What is the purpose of your research into intimate partner violence, child sexual abuse, and health?

The main purpose of this research was to assess all of the available literature reporting on the health impacts of two forms of violence against women and children, and those were intimate partner violence and childhood sexual abuse. Those are two very prevalent forms of violence and affect millions of women and children across the globe.

We wanted to take a look at everything that’s been reported and published and really seek to understand what exactly the health consequences of being exposed to these forms of violence are and how strong those associations are. So, we did this, and we found, not surprisingly, that there are wide-ranging mental and physical health impacts associated with both forms of violence.

And I think that finding really underscores the need to invest in violence prevention, but also in ensuring access to care and support for survivors.

I think the mental health impacts have been highlighted in the past and are maybe the health outcomes that folks write off when they think about being exposed to violence.

In this paper, we did find those mental health impacts. So, for instance, for intimate partner violence, we found a fairly strong association with major depressive disorder with our results, suggesting a 63% increased risk for folks who have been exposed to intimate partner violence. But those mental health outcomes range from not only major depressive disorder, but also to things like anxiety disorder, schizophrenia.

For childhood sexual abuse, we found that connection there. But I think something that is even equally important to highlight from our findings is that we also found physical health outcomes, which maybe haven’t been reported as strongly in the past. For childhood sexual abuse, we found an association with health outcomes like diabetes mellitus and asthma. So, we’re seeing that these health impacts are not just concentrated to mental health, but also span into physical health and affect people in many different ways.

How did the availability of data affect your research?

Another key takeaway from our analysis and this piece of research is the lack of available data that we found for intimate partner violence and childhood sexual abuse and their health impacts.

So, while we showed wide-ranging and really massive health impacts, we think that this understanding is still really limited because we didn’t find as much data as we would have liked or hoped to have found. So, to put this into context, for our most studied outcome that we found in association with intimate partner violence, we found 12 studies that met our inclusion criteria.

And those criteria are really just related to the study design and the way that they measure things that enable us to be able to use it within this work. So, like I said, we found only 12 for intimate partner violence and the most studied outcome, and for childhood sexual abuse we found 26 studies for the most studied outcome.

If we compare that to other risk factors, like smoking or high blood pressure, those risk factors have over 75 studies going into their analysis. So, I think that really shows that there are still some pretty large data gaps in this area. And to the extent that we think the data availability shows the priority level of the risk factors, I think that shows that intimate partner violence, childhood sexual abuse, and violence against women and children at large have not been prioritized as highly as maybe some other risk factors.

And so that does limit what we’re able to analyze and say about the true range and extent of the health impacts associated with these forms of violence.

Why did you study intimate partner violence and child sexual abuse together?

Intimate partner violence and childhood sexual abuse are two of the most prevalent forms of violence against women and children that we know from having measured across the world, unfortunately. So, in this paper, we focused on those two forms of violence and focused on trying to find the health impacts associated with them. They also are the two forms of violence that are studied in the Global Burden of Disease study.

This is a big epidemiological study which looks at the health burdens of many different risk factors beyond violence-related ones. But intimate partner violence and childhood sexual abuse are included in this study. So, part of the goals of this work was to improve how we understand the health impacts of those two risk factors within the context of this larger Global Burden of Disease study.

And then in the future, we hope to expand beyond those two types of exposures to other forms of violence, which might not fit into those definitions but are equally important to look at and understand what the health impacts are. And while they might seem separate, intimate partner violence and childhood sexual abuse are very interconnected issues.

They have similar risk factors, as we saw in the analysis. They have similar health outcomes associated with them, and they often occur in the same families and kind of reverberate across generations.

How would you describe the star rating system used in your study?

The star rating system was created really as a way to make the findings from our analysis as interpretable and actionable as possible. The star rating captures the strength of the association that we found. And it also can reflect the level of consistency between the studies that went into that particular analysis.

The possible ratings range from 0 to 5 stars, with five stars indicating the strongest evidence of association and zero stars indicating that we didn’t find evidence to support an association. So, for some of the risk-outcome pairs that we present in our paper, we did find one-star associations, which could be interpreted as weak evidence of an association and also can be interpreted as an evaluation of the evidence that might change should we get more data and more studies in the future.

I think with, for example, intimate partner violence and anxiety disorders, we found five studies to draw upon for that analysis. That’s a relatively low number of studies. So, there’s definitely a call for more data in that regard. And the studies that we analyzed were not all that consistent with each other. And so that leads us to a lower association, the one-star association, where we think there’s weak evidence of an association.

But that assessment might change in the future if we can get some more studies to draw upon.

Do one-star ratings diminish the impact of intimate partner violence and child sexual abuse on health conditions?

The associations and methodology of our analysis are not to say with any certainty that any individual who might have experienced violence will or will not go on to develop these health outcomes. So having a one-star association for intimate partner violence and anxiety does not mean that that is, with certainty, a not important health outcome or should not be addressed.

And for anybody who has experienced intimate partner violence and might feel that these associations are reductive, or not reflecting their experiences, that is not the aim of our analysis and not the aim of the star rating system at all. This is to say this is the evidence that we’ve found. This is what we were able to synthesize from the data. And throughout our paper, we really do make the call for more high-quality data on these topics, especially since they haven’t been studied to the extent that other risk factors for health have, so that we can understand the true extent of the health impacts and how strong each association is.

How can the availability of data for similar future studies be improved?

I think that the call for more data can be answered by funders. There needs to be investment in high-quality data collection around these areas. And what I mean by high-quality data, particularly for the purposes of an analysis like this, is data that really follows individuals over time, where we’re looking to see how experiences of violence impact folks over the course of their lives.

And that requires following people over time at multiple different time frames and, of course, that requires a larger investment, but that also yields the most high-quality epidemiological evidence. There are many challenges associated with these topics. They’re really heavily stigmatized almost everywhere, and certainly in some areas more than others. So that can make it really difficult to accurately measure who is experiencing violence.

There are all sorts of concerns about safety, about disclosing an experience of violence, and safety within one’s community, what the repercussions of disclosure could have on them and their families and their larger communities. So, it is a very challenging area to try to measure accurately. But that’s not to say that other risk factors don’t have similar challenges, and I don’t think is a reason to not measure these areas at all.

But of course, we just need to take into account how to do so in a way that really prioritizes the well-being and the safety of the respondents and folks who might be experiencing violence.