By Michele Rountree, PHD, MSW, and Elizabeth C. Pomeroy, PHD, LCSW, ACSW
In the United States, women’s lifetime prevalence of experiencing intimate partner abuse (IPA) is between 1 in 5 and 1 in 3, meaning that over 12 million women will be physically assaulted by a partner or ex-partner during their lifetime (Raj, La Marches, Amaro, Cranston & Silverman, 2006; Cohen, Deamant, Barkan, Richardson, Young, Holman, Anasos, Cohen, & Melnick, 2000). Of all women who experience IPA, 40%-45% are forced to have sex by their intimate partners (Campbell & Soeken, 1999).
Forced sex and other coercive sexual behaviors such as verbal sexual degradation and refusal to wear a condom are related to increased risk for sexually transmitted diseases (STDs), including HIV/AIDS (Eby and Campbell, 1995). For example, women who have a history of both sexual and physical abuse are more than three times as likely to report having an STD during the abusive relationship, 5.6 times more likely to report having multiple STDs, and 5.3 times more likely to report having an STD over the past two months (Wingood & DiClemente, 2000).
As research suggests, physical and sexual violence towards women increases the likelihood of HIV transmission (El-Bassel, Gilbert, Krishman, Schilling, Gaeta, Pupura & White, 1998; Wingood, DiClemente, & Raj, 2000). HIV risk reduction strategies that are contextually relevant for this population are an important public policy priority.
In 2005, women accounted for 26% of the new HIV/AIDS diagnoses. Of these new diagnoses, 80% occurred through high-risk heterosexual contact such as unprotected anal and vaginal sex, a percentage that has increased nearly 20% in two years. Women of color are overwhelmingly affected by HIV/AIDS.
African American and Hispanic women represent less than ¼ of all U.S. women, yet they account for more than ¾ (80%) of AIDS cases in women reported to date in this country (Centers for Disease Control, 2006). Additionally, the rate of HIV/AIDS diagnoses for Hispanic women was approximately 6 times the rate for Anglo women, while the rate of diagnoses for African American women was about 24 times that of Anglo women. The high incidence of women becoming infected with HIV by male partners through unprotected anal and vaginal sex have given researchers and health policy makers a reason to turn their attention to factors such as intimate partner violence as an influence on a woman’s heightened risk for infection.
One of the most common forms of violence against women is intimate partner abuse (IPA)—also referred to as domestic violence or battering—wherein a woman is abused by her husband or intimate partner. IPA is characterized by three types of abuse: physical abuse, sexual abuse, and emotional/ psychological abuse. Approximately half (51.2%) of the women raped by an intimate and two thirds (65.5%) of the women physically assaulted by an intimate said they were victimized multiple times by the same partner (U.S. Department of Justice, 2000). The fact that women are disproportionably affected by male-perpetrated IPA indicates that gender-based violence in the United States is still a major public health issue.
Research on the intersection of IPA and HIV indicates partner violence association with increased risk for HIV infection. When comparing women who are HIV-positive and HIV-negative, Cohen, Deamont, Barkan, Richardson, Young, Homan, Anastos et al. (2000) found that past physical and/or sexual violence was strongly associated with risk-taking behaviors, such as a history of drug use, having an intimate partner at risk for HIV, having 10 or more sexual partners throughout a lifetime, participating in transactional sex in which sex is traded for money, shelter, or drugs, and being forced to have sex with an HIV-positive person. Because of the cross sectional design of this study, a directional relationship between violent experiences and HIV risk-taking behaviors cannot be established. However, regardless of whether a woman’s violent experiences shape her risk-taking behaviors (e.g., violent relationships leads to drug use and multiple sex partners) or her risk-taking behaviors shape her violent experiences (e.g., drug use and multiple sex partners lead to violent relationships), the association between sexual and physical violence and HIV risk-taking behaviors is noteworthy.
Indeed, more recent research among men who are perpetrators of IPA suggests that abusive male partners pose a greater risk of HIV infection to women than their non-abusive counterparts (Raj, Santana, La Marche, Amaro, Cranston, & Silverman, 2006).
Men with a history of IPA are much more likely to report risk taking activities such as unprotected sexual intercourse and sexual infidelity (El-Bassel, Gilbert, Fontdevila, Bilbert, Voisin, Richman, & Pitchell, 2001; Raj et al., 2006). There is also an association between IPA perpetrations and forcing unprotected sexual intercourse (Raj et al., 2006). Together, these findings suggest that women are at risk because of their partner’s behaviors more so than their own. Molina and Basinait (1998) in the study of HIV risk exposure experienced by a sample of women (n=40) residing at battered women’s shelters, found that experiences of high to extreme levels of severity of abuse were estimated for physical (42%), psychological (70%), and sexual (53%) forms of abuse. Ninety-eight percent reported that their partner never or rarely used a condom, and 50% reported that their partner had infected them with at least one form of a STD. The authors concluded “it is essential that programs serving victims of domestic abuse respond to the threatening intersection between domestic battering and HIV transmission” (p.1268). Similarly, He, McCoy, Stevens & Stark in their 1998 study found experiences of violence and threats of violence are associated with heightened risk for the sexual transmission of HIV concluded that “providers of HIV prevention need to design interventions which empower women to protect themselves from sexual transmission of HIV” (p.162).
- Culture is “a set of characteristics that includes the â€˜beliefs, practices, values, norms and behaviors that are shared by members of a group,'” (Kasturirangan, Krishnan, & Riger, 2004, p. 319).
- Cultural heritage varies across different racial and ethnic communities, shaping the worldview of people within them (Lee, Sanders Thompson, & Mechanic 2002). These differences play an important role in women’s perceptions and experiences of intimate partner violence (Ramos, Carlson & McNutt, 2004) and may attribute to different attitudes, beliefs, and knowledge levels in regards to HIV awareness and prevention.
Therefore, cultural influences are important considerations in the IPA and HIV risk of women.
- Institutionalized racism, fear of police, distrust of the legal justice system, fears of stereotyping and stigmatization, and racial/ethnic loyalty.
- Less likely to report rape than Anglo women (Lee et al., 2002). In Whyte’s study on sex, survival and risk for HIV (2006), African American women report that they engaged in unwanted sex to avoid verbal and physical assault, for fear of losing shelter or for fear of being left by their intimate partner.
- Women who participated in unwanted sex were less likely to do so safely, which indicates that coerced sex poses significant HIV risk. [how is this a barrier to African American women seeking help?]
- Whyte (2006) also found that African American women recognized their risk for HIV and worried for their personal sexual safety. Many of them had friends or family members who died of AIDS; consequently, their experience with AIDS was personal, and their fear of HIV was real. It was common for women to express that they knew or suspected that their partner was having sex outside of the relationship. Thus, they took many precautions, such as using condoms, refusing sex when possible (or at least postponing sex until raped or coerced) and regular HIV testing. [how is this a barrier? Seems more like a reason to seek help]
- Research indicates that Latinas experience disproportionately high rates of both HIV and IPA (Raj, Silverman, & Amaro, 2004). In a study involving Hispanic women, Raj et. al., (2004) found that “abused women were significantly more likely than those not abused in the past three months to report high STD/HIV perceptionâ€¦, gender-based risks including sexual control by male partnersâ€¦, and male partner risk including male infidelity” (p.519). [does not iindicate why Latina women do not seek help]
- Traditional gender roles among Hispanic immigrant populations may perpetuate woman abuse (Raj & Silverman 2002) and contribute to HIV risk. [again, how does this prevent them from seeking help?]
- The cultural context of machismo and marianismo prevent Latinas from leaving abusive relationships. Doing so would bring shame to themselves and their families.
- Fear of social consequences, economic problems, limited job skills, and a depleted sense of self-esteem are also barriers to leaving abusive relationships that result from machismo/marianismo (Moreno 2007).
- Machismo and marianismo put women at greater risk for HIV. Cultural scripts such as these may rigidly define what women may raise in her relationships such as conversations related to safe sex and partner’s sexual histories.
- Because of the nature of an honor culture, suspicion of infidelity is an acceptable reason for violence (Davila and Brackley, 1999). In a different study, Latinas who were abused reported greater incidence of refusing unwanted sex compared to negotiating condom use (Raj, Silverman, & Amaro 2004). This is most likely because abused women are put into situations “requiring assertive sexual refusal” (Raj, Silverman, & Amaro 2004, p. 527). Studies suggest that forced sexual activity is a common experience by Latinas in abusive relationships; however, many of the women do not identify their experience as rape, even if it felt like it, as marital rape is perceived as a male right (Davila and Brackley, 1999; Raj & Silverman, 2002). [again, same. This appears to explain behaviors leading to IPA]
- Non-citizen immigrant women are at increased risk for IPA because of their lack of legal rights (Raj & Silverman, 2002). Moreover, for women who are undocumented, deportation is a constant threat (Moreno 2007, Raj & Silverman 2002). This is significant when considering that, in abusive relationships, 72% of citizen and legal permanent resident spouses do not file immigration papers on their wives (Raj and Silverman 2002). [be specific and say that undocumented women do not necessarily report due to fear of deportation]
- Hispanic women are the less likely than White or African American women to contact a social service agency or friend (Lee et al., 2002).
- In the Hispanic culture, domestic violence is seen as a family issue. Thus, a woman’s social supports, including family, friends, and religious and community leaders often encourage her to stay in the relationship (Raj & Silverman 2002). Outside of her community, she may be hesitant to report the abuse for fear that her culture or country of origin may be criticized. Latinas who are immigrants may have little knowledge of the services available, may be unaware of laws that could protect them, and may be intimidated to approach the legal system, especially if she fears deportation (Raj & Silverman 2002).
[Why only list barriers for African American and Latina women? Are they the only ethic groups who do not report? If other groups are not listed, this section should, perhaps, be removed]
The most salient point for women in IPA situations is that they know the ideals for protecting themselves, but are required to operate in non-ideal situations. Often historically and culturally, women may not have been able to negotiate safe sex, distrust of partners, and little to no control over their daily choices. As indicated by Dunkle et al. (2004), women are becoming directly infected with HIV by their abusive partners. In a focus group of women in a domestic violence shelter, women clearly noted that the only way to protect ones’ self is to leave the relationship. This is a keen observation since most proposed HIV prevention strategies are not workable inside domestic violence situations. The Center for Disease Control (CDC) (2003) as well as others (Cabral, Pulley, Artz, Johnson & Stephens, 1999, Potts, 1994) have called for the development and wide dissemination of effective female-controlled prevention methods, stating that “more options are urgently needed for women who are unwilling or unable to negotiate condom use with a male partner” (p.2).
Recommendations [This section is clearly for service providers and not the consumer. Consider reworking this section to make it more applicable to lay persons.]
- Wider scale alternatives in finding solutions to these overlapping phenomena including a larger community awareness approach to make the problems of HIV, IPA and their intersection visible at a population level through campaigning, door to door advocating, and media advertising,
- Educate at the grass roots level such as through domestic violence shelters,
- Include men in research, prevention, and intervention,
- Increased accessibility to easier testing, condom use, service availability, reporting and law enforcement interaction,
- Use language that is understood by the specific ethnic group. Social workers should ask the client to explain what she means when using certain words. A lack of understanding of terminology could mean the difference between safety and fatality,
- HIV/AIDS and STD risk reduction interventions in domestic violence shelters and other service avenues,
- Policy wise, shelters should perhaps develop guidelines to ensure the confidentiality of client if she should self-disclose her HIV or AIDS status.
- If a women discloses having been sexually abused or having a positive status, referrals to statewide resources for HIV/AIDS counseling, testing, and treatment services should be made immediately and according to local and state laws,
- Establish counseling guidelines if a client expresses concerns about HIV infection for themselves and/or partners, and
- Social workers in shelters must be knowledgeable, culturally competent and skilled in assessing a women’s risk for intervention and linking her to referrals, resources and possible treatment.
Social workers can play a prominent role in educating colleagues and DV shelter leadership on these two intersecting public health concerns, in the reorganizing of the intake process to include a risk assessment measure for HIV, and the integrating of HIV/AIDS education and prevention programming that are contextually relevant for women in abusive relationships (e.g., negotiating strategies). Social workers can interface with HIV/AIDS agencies and service providers to advocate for integrating HIV/AIDS services, and establish coalitions that include funders, legislative and community organizations. Furthermore, a revised empowerment model that provides information to women regardless of inquiry [what does â€˜regardless of inquiry ” mean?]should be considered a major topic for discussion by the state.
- Cabral, R., Pulley, L., Artz, L., Johnson, C., Stephens, R., Macaluso, M. (1999). Women at risk of HIV and Other STDs: Who is receptive to using the female condom? The Journal of Sex Education and Therapy, 24 (1 & 2), 89-98.
- Campbell, J.C., Soeken, K.L (1999). Forced Sex and Intimate Partner Violence: Effects
- on Women’s Risk and Women’s Health. Violence Against Women, 5(9),1017-1035.
- Centers for Disease Control and Prevention. (2003). HIV/AIDS among US women: Minority and young women at continuing risk, 1-3. Retrieved October 31, 2003, from http://www.cdc.gov/hiv/pubs/facts/women.htm
- Centers for Disease Control and Prevention. (2006). HIV/AIDS among US women: Minority and young women at continuing risk, 1-3. Retrieved October 31, 2003, from http://www.cdc.gov/hiv/pubs/facts/women.htm
- Cohen M. C, Deamant, S., Barkan, J. , Richardson, Young, Y., Holman, S., Anastos, K.
- Cohen, Melnick, J. (2000). Domestic Violence and Childhood Sexual Abuse in
- HIV-Infected Women and Women at Risk for HIV. American Journal of Public Health, 90(4), 560-565.
- Davila, Y.R. & Brackely, M. A. (1999). Mexican and Mexican American women in a battered women’s shelter: barriers to condom negotiation for HIV/AIDS prevention, Issues in Mental Health Nursing, 20(4), 333-355.
- Dunkle, K., Jewkes, R., Brown, H., Gray, G., McIntyre, J., Sioban, D., Harlow, S. (2004,
- May). Gender-Based Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa. The Lancet, 363(9419), 1415-1421.
- Eby, K.K., Campbell, J.C., Sullivan, C.M., & Davidson, W.S. (1995). Health effects of experiences of sexual violence for women with abusive partners. Healthcare for Women International, 16(6), 563-576.
- El-Bassel, N., Fontdevila, J., Gilbert, L., Voisin, D., Richman, B., Pitchell, P. (2001). HIV risks of men in methadone maintenance treatment programs who abuse their intimate partners: A forgotten issue. Journal of Substance Abuse, 13, 1-15.
- El-Bassel N., Gilbert, L. Wu, E., Go, H.& Jennifer Hill (2005). HIV and
- Intimate Partner Violence Among Methadone-Maintained Women in New York City. Social Science & Medicine. 2005, 61 (1), 171-183.
- He, H., McCoy, H., Stevens, S. J., & Stark, M. (1998). Violence and HIV sexual risk behaviors among female sex partners of male drug users. Women and Health, 27(1-2), 161-175.
- Kasturangan, A., Sandhya, K., & Riger, S. (2004). The Impact of Culture and Minority Status on Women’s Experience of Domestic Violence. Trauma Violence and Abuse, 5(4) 318-332.
- Lee, R.K., Sanders Thompson, V.L., Mechanic, M.B. (2002).
- Intimate Partner Violence and Women of Color: A call for Innovations. American Journal of Public Health, 92(4), 530-534.
- Molina, L.D., Basinait-Smith, C. (1998). Revisiting the intersection between domestic abuse and HIV risk, American Journal of Public Health, 88(8), 1267-1268.
- Moreno, Claudia L (2007). The Relationship Between Culture, Gender, Structural Factors, Abuse, Trauma and HIV/AIDS for Latinas. Qualitative Health Research, 17(3), 340-352.
- Raj, A., Silverman, J. (2002). Violence Against Immigrant Women. Violence Against Women, 8(3), 367-398.
- Raj. A., Silverman, G., Amaro, H. (2004). Abused women report greater male partner risk and gender based risk for HIV: Findings from a community based study with Hispanic women. AIDS Care, 16(4), 519-529.
- Raj, M. Santana, C., La Marche, A., Amaro, H., Cranston, K., Silverman, J.G. (2006). Perpetration of Intimate Partner Violence Associated with Sexual Risk Behaviors Among Young Adult Men. American Journal of Public Health, 96(10), 1873-1878.
- Ramos, Blanca M., Bonnie E. Carlson, & Louise-Anne McNutt (2004, June). Lifetime Abuse, Mental Health, and African American Women. Journal of Family Violence, 19(3), 153- 164.
- U.S. Department of Justice. Extent, nature, and consequences of intimate partner violence: Findings from the national violence against women survey, July 2000.
- Whyte, James IV (2006). Sexual Assertiveness in Low-income African American Women: Unwanted sex, survival, and HIV Risk. Journal-l of Community Health Nursing. 23(4) 235-244.
- Wingood, G., DiClemente, R., & Raj, A. (2000). Adverse consequences of intimate partner abuse among women in non-urban domestic violence shelters, American Journal of Preventive Medicine, 19(4): 270-275.