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Abstract

Design and methods: This research was part of the Melbourne Women's Midlife Health Project (MWMHP), an observational, longitudinal, population-based study of 438 Australian-born women conducted over nine years. In 1996, during the sixth year of the study, we asked the MWMHP participants to complete a self-administered "violence questionnaire", incorporating a modified Conflict Tactics Scale and questions on sexual abuse experienced during childhood and adult life.

Results: Of the 395 women remaining in the sixth year of follow-up of the MWMHP, 362 (92%) completed the questionnaire. Overall, 28.5% (n = 101) of the women had experienced some form of domestic violence (physical, sexual or emotional) during their lifetime; 5.5% (n = 15) of women had experienced severe physical abuse in the past year at the hands of a partner; and 11.8% (n = 42) of the women had experienced rape or attempted rape between the age of 16 and the time of our survey. Regarding abuse in childhood, 8.9% (n = 32) of women had experienced physical abuse, 42.3% (n = 152) had experienced non-contact sexual abuse, and 35.7% (n = 128) contact sexual abuse. Compared with the general-practice-based study, rates of childhood physical abuse and penetrative sexual abuse were similar, but rates of less intrusive child sexual abuse were significantly higher in our study.

Conclusions: Doctors in all areas of medicine who are dealing with middle-aged women need to be aware of the levels of violence sustained by women throughout their lives. Such experiences may have a substantial impact on women's physical and mental wellbeing.

Over the past 20 years, the high prevalence of violence against women has been exposed by rigorous research. Women's Safety Australia,¹ a large community-based survey of 6300 women undertaken by the Australian Bureau of Statistics, found that 2.6% of women who currently had partners had experienced an incident of physical violence in the previous 12-month period; 8.0% reported an incident of physical violence at some time during their current relationship; and 1.9% of women had experienced an incident of sexual violence during the 12 months prior to the survey.

Mazza and colleagues² examined the prevalence of physical, sexual and emotional violence experienced by women attending general practitioners in metropolitan Melbourne. Their study found that, of women aged 18 years and over who were in relationships, more than a quarter had been victims of physical or emotional abuse by a partner in the previous year, with one in 10 experiencing severe physical violence. In two Australian studies undertaken in hospital emergency departments,^3,4 about 19% of female attendees disclosed histories of domestic violence.

It is now recognised that domestic violence has an important influence on the morbidity and mortality of women. Increased utilisation of healthcare facilities,⁵ chronic pain (particularly pelvic pain),^6,7 functional gastrointestinal disorders,⁸ drug and alcohol dependence or misuse,^9-11 attempted suicide¹¹ and psychopathology^12-14 are all strongly associated with the experience of violence.

The aims of our study were to determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and to compare these to figures obtained in a general practice setting in a previous study.²

Methods

Questionnaire

The questionnaire incorporated the Conflict Tactics Scale,¹⁵ with the modification that respondents were asked whether the tactic had occurred never, once or more than once in the past year, and with the addition of questions on emotional abuse. Physical violence was classified as minor or severe.² Questions about sexual abuse were derived from the studies of Wyatt¹⁶ and Russell,¹⁷ both of which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as "contact" abuse (involving physical contact) or "non-contact" abuse. (For the purposes of our study, a "child" was defined as a person under 16 years of age.)

Study participants

Eligibility for the longitudinal phase of the study included women who at baseline were premenopausal, were not taking the oral contraceptive pill or hormone therapy, and had an intact uterus. Of the 779 women eligible to enter the longitudinal study, 56% (n=438) chose to do so. Volunteers for the longitudinal study were more likely than non-participants to report better self-rated health, paid employment, more than 12 years of education, having ever had a Pap smear, exercising at least once a week, and having undergone dilatation and curettage.¹⁹

In the MWMHP study, women were interviewed annually face-to-face in their own homes by trained interviewers. Information was collected on a range of variables, including sociodemographic factors, health status, lifestyle behaviours, menopausal status and hormone therapy use.

By 1996, when our study was conducted, the retention rate of MWMHP participants was 90% (n = 395). Of these women, 23 who had experienced surgical menopause were not given the violence questionnaire, and a further 10 women refused to complete the questionnaire, leaving 362 women who took part in our study.

Statistical analysis

The Statistical Package for the Social Sciences (SPSS)²⁰ was used to analyse the sample and determine the prevalence of different forms of violence reported by the women. A statistical comparison was made between the results of our study and the data (previously unpublished) for the subset of women aged 50-69 years (n = 411) from an earlier, general-practice-based study of violence² (Box 1). Ninety-five per cent approximate confidence intervals were used.

Results

At the time of completing the violence questionnaire the women were between 51 and 62 years of age (mean, 54.6; SD, 2.42). Sixty-six per cent (238/362) were in paid employment and 77% (277/362) were married or living with a partner. The median parity was 3 (range, 0-9), and 35% of the women had had more than 12 years' education.

Domestic violence

Unwanted sexual experiences with someone other than a husband or partner

Childhood abuse

Discussion

Using a longitudinal cohort study such as the MWMHP provides many benefits in a prevalence study. Principal among these is that the women surveyed have been interacting with the research staff for over six years and have therefore built up a degree of trust and comfort with these people. This may facilitate disclosure of sensitive issues such as domestic violence and sexual abuse.

A limitation of the study is that in order to obtain some comparative value with other work the questions were delivered by self-administered questionnaire, allowing no opportunity for clarification or exploration of the issues being recorded. Also, the additional questions about emotional abuse had not previously been validated.

Of interest is the fact that, despite the participants being a self-selected group of relatively well-educated and health-conscious women, there is a considerable lifetime prevalence of domestic violence among them. The fact that our community-based survey results were similar to those of the general-practice-based survey² confirms that violence affects the lives of all kinds of women and that it may be a very important contributor to concurrent morbidity occurring at the menopause.

In the area of child abuse, our data show similar levels of physical abuse and penetrative abuse but significantly greater levels of less intrusive sexual abuse than those found in the general practice sample. This is surprising given that prevalence rates of most forms of abuse are usually lower in community-based settings than in general practice.² The greater levels in our sample may reflect a cohort effect or may be owing to the long-term relationship developed over six years of follow-up that may have led to more disclosures.

Many studies have demonstrated a relationship between experience of violence and long-term morbidity. Our findings of a high prevalence of violence experienced by women over their lifetime suggest that doctors practising in all areas of medicine need to recognise and explore violence issues when considering middle-aged women's reasons for presenting with ill health.

Acknowledgement

References

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20. SPSS for Windows. Statistical package for social sciences. Version 9.0. Chicago, Ill: SPSS Inc, 1999.

Authors' details

Reprints will not be available from the authors.
Correspondence: Professor L Dennerstein, Office for Gender and Health, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Charles Connibere Building, Parkville, VIC 3050.
ldennATunimelb.edu.au

©MJA 2001
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