Abstract issues violence tion done women overwhelming
ence Hawaii, Introduction in woman to cant in under-reporting. violence multiple. physical suspect, aches, riage, psychiatric only emotional increased result children impacts of networks
Deboh UH Correspondence Honolulu, 1356
This
Acts
The
the the
any
women
Department
to
Lusltana
public
violence.
to
the
community.
woman
of
gynecological
given
muscle
of
direct this
review
of end G
and
every
impacting
Hawaii
many
and
that most
at injuries, against violence
sexual A
violence
propensity
may
development,
in
problem
Health
some
violence illness. health
Street,
our
year of
witness
most
health
with to: the
nine
linear aches, 96813
and other
Psychiatry
attempts
Violence
society
be
Review
4th women
time
assault,
home and
Violence
rape,
against
issue
overlooked
at
seconds. It all
likely
implications
jeopardized.4
are
However,
Floor
consequences has lives.
against
effects
least is
violence.3 sleep
symptoms,
as
for
women
during
most
everyday
suicide
as
begins
in
dramatically
many to
occurs
long-term
conservative, is
aggression
marriages, one
women
a
Hawaii.
For disturbances,
emphasize
against
of women whole.
a
typically
However,
their
in these whether
public
significant,
as
example, violence.
before
attempts,
in
Studies
ten
include,
psychosomatic
four
events
the
in
lifespan)-2
of
Additionally,
women
psychological
health
and
women
Hawaii. health
jobs,
have
violence increased,
perpetrated
home,
in
the
or these the Women
also due
improve
and disturbances five
in
substance
Violence
not
abuse
but
consequences challenging,
of urgency
been
the and
is, problem.
experiencing
indicate to
eating
at figures
women
they
It
This are therefore,
against the
the
lives
demonstrates
family
more of
complaints
identified
the HAWAII
violence by
sequelae
directly
workplace,
not
high against
disorders), Deborah children.
Male
abuse, equates
in
are
well-being
a
that
of
experiencing
While
in
man needs MEDICAL
women
addressing
limited
and
women
extremely
and
social
degree
represent
a the
violence
miscar
experi women signifi
known
against
among
and
to
atten
social
abuse (head often
to
As JOURNAL
that
and one
and
and
are
to, be
A.
of
an of in
a
in 232
Goebert
women herself make—where feel at only rights7 violence against studies.6 ation.8 strong abuse fear problem. have Household Violence care women available. conducted estimates. international Hawaii’s Epidemiology periodic, cultures. the is problem, l988)° and to community miological violence women
VOL abused women Violence violence
However,
This home.
Estimates
The suggest
hindered
While
extent 58,
safe
of Hawaii
prevalence
providers.
recently
dramatically SEPTEMBER
law regional
male review is
and
women most
can
Women
in In
by
attending; by in
against
Perhaps not
nor in
based
they
in
against
of
MS Hawaii that
Hawaii,
crime Unfortunately,
Hawaii, locally.
in
their It
Members).
their
However,
surveys)6
passed
threaten
the Accurately
clearly
violence
it
the violence by
provided a
frequent
standardized
also
surveys 1972
they article recognized
victim.5
are under-reporting
was
regardless
concern 1999 home
on
estimates
the partners
Home from current
women
even statistics
gross and
highlights
women
inclusion
increased.
when
early
choose
the not
This
even
poses (HRS
and lack
describes
is
or
against
the there
The type the
in
more
from
Its
declaration
until
estimating
the
about
underestimates Since
or domestic
efforts information
as and shape
when
vary this
of
of a difficulties
are Pacific affects
databases
Section it
all or
following
former
in
and worst distinct
of
serious
of are
custom,
startling
as where
data)’
1971
populations implications are
women.
article
low.f0mpc
violence
However, then, of
the from
violence
indigenous,
the
is Against
every
glaringly
are
a
only clinical
allowed
a
these
can
aspect
nations fundamental
epidemiology violence.717
problem
intimate
that home,
rates
709-906,
documented threat
they from
on
efforts
10%
from
tradition
are
is
information
There
be woman’s in is
a 12
the
against
research
accentuated
few sources
when There that
against estimating
of
walk; seen of
based major
studies
undercounted.
child
in
to
to
which
the were
deemed
and see
to immigrant violence
elimination
being
and,
male
the work;
the
the studies
are
Abuse Ii.
prevent in
compared
or
is
what
work
women,9
abuse
strategies Estimates
on
gaps
life, 13-15
last
the United abuse as health the
women
provide
sufficient religious by
efforts to
of
no
partners, indicate
female
demonstrates
what
a
local
reliably
violence
the
the choices
comparative
year
result they
first
by
even
against
that epidemiologic,
of
remain.
place
or
and
and
of and
extent
first national
Nations
Family
of
events
focused psychiatric
stating
data,
with
is
say
to as to
have
discrepant
for
when
of
consider
intervene women’s dominant incidence
a
literature
a
violence
safety abuse
estimate
as
early
express women
and spousal
women against form
women
serious and
health
epide
of
when
much
been they
that
and
she
has and that
the
do on the
as
to
of of of
estimated
largest grams
victims
women
suicide,
suicides,
1,400 lence,
physical for
identified.’ 2
single
her abusers.
were
over emotional
situations,
male
remained
almost cases.
the
the
similar
using
members,
significant by report
partners.
incident
to
ing. between
were
misdemeanor
over
mately
incidence
found
to a
beaten
abused This
studied
State
lifetime
with as
The
Additionally,
Homicides
The
Data
greater
prosecuting
be
80%
suicides
men
partner,
result
majority
time.
killed
While
referred
4,000
an
or
seemingly
in
victims
most
crime a
extent
either
of
in
escalating
majority
domestic
While
doubled,
up
that
particularly
Hawaii
7,000
of
more
from
over
Hawaii
additional
woman stated
in
accounting abuse female,
reports
other
incidents
Of estimate,
Locally,
from of
Hawaii.
relatively
by
abuse
of
percentage
or
domestic
after
the
Most
Hawaii—and
important
other
affects
it
arrests
nearly
domestic
and
statistics
those
of
In the
someone
an
of
violence
between
accurate
police
to
police
acquaintances. 23
is
the
who
cases
studies
that
preceded violence
service
attorneys’
cases
study
violence
they of
Hawaii,
provided
the
violence
usually
course
actual
primarily
directed
reveal
than
low
violence
suicide victims
are
domestic
1.3
from
women
reported
women
absolute
all
6%
they extrapolated
one
in
prosecuting
repeated
were
Additionally,
for4l%
stable,
and
records
reports
had
often
violence
figure
(63%)
precipitant
times
from of
conducted
admit
violence. 24 of
Hawaii
intimates,
in
in
of
estimate.
of
utilization
abused that
of
assault
1989
knew
in
the
non-metropolitan
increases
left
partner
a the
most
attempts
are
the
in
women
at
services against
most
forced
respondents their
offices
shelters
murdered
few
as
killed
self-defense. 27
preceded
disputes.’ 5
to
the
the
1985-1994,
women. 23 ’ 25
higher
incidents equates
neighbors
of
household. 2 °
and
the
number
of
killed
to
provide
home
attempts,
to
a
police
during someone
suicide
misdemeanor
in
female
hundred
result
lifetime. 2 ’ 3 ’
woman
home of
percentage
1992,
being
or
relationship. 26
attorneys’
The
from
men
regardless
for
conflict
by who
by
to
women
Of
discourages
records.
for
the
1994.26
by
more
in
fear
provided
in
when
for
suicide
to
the
flee
their
departments
are
risk
these,
an
by
nearly
of
of
over
is took
were Hawaii.
both
women. 1994.22 reported
killers
abused
a
suicides
attempts
is
were
nearly
women
in
have
often
29% who
of
of
Attorney
Kauai
In
spousal
killed even
a
murders
a than
they
their
This
in
of
in
partners
ten.’ 2
offices.
6,300
sequela 7.12,18
areas.’ 92 ’
place
other
history
it,
most
severity
the
of
Additionally,
of women
Victim
attempts
100
the
most
the
being had
a
domestic
of
were
personally
a
lower
is
50,000
try whether
women
themselves
one
Of
discrepancy
When
women
There
by
offenders
the
safe in
survey,
homes
precipitating
than
Abuse
by
all
HAWAII
However,
women
form
domestic
home
in
homicide. 22 felony
women
inferred
been
Fiji. 29
and
to
these,
present
General’s
likely
abuse
in
of
in
of
the
The
partners,
women. 28
third
homicides
assistance
killed
were
haven
and
flee
estimate
It
by for
a
abuse
were
Hawaii,
Hawaii
those
women
physical
MEDICAL
of
hit,
home,
murders is
woman
the
can violence
in from
may
discrepancy
is
women abuse
Attempted
were
only
men.
considered
from to
who to
frequency
of
victims
in
known
verbal
or
only
order
the in
by
violence
victim kicked
has
Hawaii’s
approxi
whereby
to
no
also
call
referred
among
87%
be women
former
report
family
Office
factor
many
JOURNAL,
police
killed
were
one’s of
over 3,000
Vio
one) 9
in
four
cases
pro 60%
their
have
were
kills
been
In
and
14%
yet
the
has
and
and
be
to
the
or
the
of
in
is an
or
a
233
VOL
abusive
co-worker
prevalent
Violence report
the
been respondents
were reported
respectively). 30
representative
place
terized
primarily
similar
during
health
ing workers),
an
involved
like
associated
ognized. 32
of ratio
1980-1989, by
murder,
3 for
only
occupational
documents
Labor
abuse,
logical
broadened
associated related
assault
as
weapon
lating tic
Work-related Statewide survive.
Women
to
A
Sexual
58,
The
Homicides
violence
assault
Violence
the
workplace,
women
beating,
considerable workers
violence
workplace
1.
SEPTEMBER
threatened
no
6%
are
of
being
prevalence
and
this
violence,
impact
by
Among
behavior. 23 harassment
is
violence
to
difference occupational
being harm.
and
accounting
perpetrated
Against
of
including
when
lost
assault
health
rate
Questionnaires
with
support
isolation required
in
period. 35
Domestic
social with
occupations
with
(9.9 all
with
to
While
at
victims
63
reported
sexual
is
compensation
homicide
injury
time
Hawaii
are
1999
that
work,
of
and
people
afraid sample
include
cases
Violence
workers
the
women,
women
in
pervasive
versus
homicides,
physical Although
and
frequently
local
work
Data
in
nearly has
proportion
services.
a
Women
of
the
and
from
cost
few
had
in
the
major
highest
guns,
and
A of
from
death
by
The
assault
for
social much
by
physical
been
of
of
Violence
data
fear death killed
past being
activities. 30
harassment from
are
1997
of
workplace
0.8
forms
increased
becoming
of
co-workers
work-related studies
twice
OSHA
any
accessed
were
the that
40%.
reported
work
identified
occupations
assault,
the
knives,
600
cause
rate
were
narrowly
for
work
in and
per
reporting
five
increasingly
of in
services,
with
assault
leading
rates
at
crime
the
a
assault
and/or
harassed
claims
of
occurs
public
the
which
that assaults, violence
of
more
for
the
civilian
nationwide occurred
work
100,000
threats
Survey.’ 9
years
threats completed
have
of
standards,
majority
place
more
aggression
Community
men
layoffs
low
their
household
is
a
has
of
services
than
death workplace.
victim
Recently,
rates
victim
and
the defined
cause
for
are
or
than
verbal
and
remains
and
from
men
at
to
while
sexual
documented
of
levels
not
than
is
between
homicide
in
workers
against
and findings
abusive
threat
men.
workers),
females. 3 ’
lowest
to
supervisors
sexual
the
the
other
12
Respondents
among
at
coworkers.
among
the
in
the
(51
study been
of
1.7
death
and
women. 3334
survey
Washington
by
one
times
harassment
on
around
there abuse
risk
the
to
of
Hawaii
incidents
assault
workplace
object,
such
non-fatal
Harassment
the
unreported
last that
versus
times
311
women
13%
the include
intentional
for
well
assault type
group
behavior
men
organization.
shows
by
are
workers.
Historically,
in
are
those
definition
from
higher
the
job.
are produces
12 victims
using as
While and
homicide
the
the non-fatal
reported
consistent.
studied.
of the
(37%
were
more
far
and
26
and
Department
male
verbal
months,
harmony
reported
no
were
work in
victims violence
only
employed
Department
assaults
violent that
in Women
While
the
per
outweighed
than
state
State
and
and workplace. vehicles.
a
and
women
the
was
the
identified
and
However,
published
of
likely to
random,
injuries,
has
100,000 use
physical
charac
psycho
19%
place
having
threats,
the
domes
overall
at
Utiliz threats female
events
unrec
work
that
more
86%,
there
work- in
were
from
10%
esca
been
and only
and
such
Un
that
had
of
rate
to
of
the
in
in
of
is
is a of the Attorney General indicates that the average crime victim in cologist or pediatrician. These findings suggest that women are not this state is female, under age 45, and living on 36Oahu. This annual only willing to seek help for abuse but frequently do seek help for survey found that 10.1 % of women in Hawaii, or nearly 50,000 abuse. The onus is placed on the provider to ask personal questions. women, reported being victims of violent crimes. Sixty-six percent However, the role of the provider represents only one of many of these violent attacks were committed by a person well-known to barriers to help seeking behaviors for abuse. them and 25% by strangers or casual acquaintances. (The remaining There are many reasons women do not report their experiences to 17% is committed by a family member and constitutes violence in police or health care 38providers. Victims of violence are stigma the home.) Less than 1% of women were assaulted with a weapon tized, thus, by acknowledging their status, they incur some level of and 2.1% of women had been beaten. Women were more likely than devaluation. Qualitative research on women that are abused has men to be beaten (60.0% versus 40.0%). found that women are often reluctant to identify themselves because Two percent of women were forced to have sex in the last 36year. they feel ashamed. Additionally, female victims of violence are In fact, rape and sexual assault are the only violent crimes in Hawaii seen as instigators4 or even participants in crime unless strong that have increased over the past few years. Rape is considered by resistance’ in the form of serious physical injury can be demon the FBI to be the second most serious crime, following murder. Only strated. The two leading problems with the system reported by 37.5% of those arrested for rape were convicted for felony sex female victims surveyed in Hawaii were “people made me feel like 37offenses. The majority of assaults that lead to an arrest take place it was my fault” and “people made me feel like they didn’t believe between victims and alleged offenders who are either acquaintances 9me”.’ The social consequences of help seeking may be one reason or members of the same family. Generally, these assaults occur in that women are also likely to refrain from mentioning the cause of private residences (59.7%), although not necessarily the victim’s their 42injuries. home (32.1%). Approximately 90% of victims were female. These The reporting behavior of victims has a number of important findings are similar to other research that reports more than 90% of health implications. Women who do not report violence may not be adult rape victims are women and 78% of child sexual abuse notifiedaboutnor qualify forpublic-supported health 43care. Women involves 38girls. that present with multiple injuries to health care providers and are A University of Hawaii study found that one out of every three not identified as victims of violence may fail to receive appropriate female students identified themselves as having been victims of treatment for the nonphysical effects of these 42events. Psychologi sexual or attempted sexual 23assault. Thirty-five percent of males cal abuse is likely to be much more prevalent and less likely to be responding to different survey at the University of Hawaii admitted identified. Additionally, public funding for services is based on to committing acts which are legally classified as sexual assault. The incidence estimates from reporting. There are numerous examples Honolulu Police Department reported the majority of calls regard that demonstrate an incongruence between reporting and need for ing sexual assault on Oahu come from the University 39area. A services. For example, funding for shelter in Hawaii are based on similar study of college women in New Zealand found that 25% had incidence estimates using police and survey data. However, Hawaii been victims of rape or attempted rape.° has insufficient shelter 9space.’ As-new shelters open or existing shelters expand, they soon fill to maximum capacity. Health Care Interventions There is a proliferation of literature on recommendations for Utilization of services by women who are victims of violence improving detection and screening of violence against women, appears to be high. Given the breadth and magnitude of health providing training protocols and instruments.’ examples see 17. 49, 54 effects, it is not surprising that between 22% and 54% of all visits McCleer and Anwar found that, after staff training and the introduc to the hospital emergency departments are estimated to be made by tion of an identification protocol, the percentage of women identi victims of emotional or physical 4547abuse. A recent study among fied as being battered in the emergency department increased nearly women seeking routine care in a Native American health care six-fold from 5.6% to 30%. Yet the implementation of hospital and facility found similar 48rates. While women seek help for as few as medical protocol for victims of domestic and sexual violence in one in five assaults, between 40% and 80% of all victims of violence Hawaii are inconsistent at 56best. Few personnel are appropriately are likely to turn to health workers for assistance at some 249stage.’ trained and available to properly interact with victims in need of ° In a national study, 68% of women who experienced’ severe medical care or to conduct forensic exams. This is particularly true violence had sought help at least 51once. In a more recent study, for the neighbor islands. Additionally, protocols have primarily Hutchinson and Hirschel found that 98% of abused women inter been developed for emergency departments. In the Kauai study, viewed had sought help from formal sources and 65% seeking some 59% of women reported they would seek help from an agency if kind of social 52assistance. beaten or sexually abused but only four percent of injured women Yet only 5% of all battered women who seek medical care are reported seeking treatment in the emergency department after such 2338identified. Rodriquez and colleagues conducted a qualitative an 29incident. All providers need to be prepared to interact with study of abused Latina and Asian women examining barriers to patients that have been victims of 497violence. discussing’ abuse with health care 53providers. Several participants discussed the difficulty of disclosing abuse and asking for help, Conclusion particularly where providers did not bring up the topic. Participants Violence against women is endemic. Acts of violence are every expressed a desire and expectation for providers to initiate discus day events in the lives of women, impacting all women whether or sions about abuse. Participants also indicated that they would be not they directly experience violence. Violence against women is more willing to get help from their primary care physician, gyne occurring in the home, at the workplace and in the community. This
HAWAIIMEDICALJOURNAL, VOL58, SEPTEMBER 1999 234 25. 24. 23. 21. 22. 20. 19. 17. 16. 18. 15. 14. 13. 12. 9. 11. 10. 7. 6. 8. 5. 4. 3. 2.
1.
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