1. ‘Abuse: The Hidden Reality’ Patterns of Violence and Abuse, Impact on Health and Well-Being Dr Jo Nurse Consultant in Public Health SE Regional Public Health Group Jo.Nurse@dh.gsi.gov.uk

2. Violence and Abuse- A hidden determinant of inequalities in Health Visible forms of violence: - Youth Violence- Assaults in Public Places - Young men, alcohol and the night time economy Invisible forms of violence: - Child Sexual Abuse - Sexual Assault - Domestic Violence

3. Patterns of Violence and Abuse, Impact on Health and Well-Being Prevalence Risk Factors Associated Health Consequences Life Course impact Reducing Harm and Prevention

4. Prevalence of Child Sexual Abuse, Sexual Assault and Domestic Violence

5. The Tip of the Iceberg

6. Prevalence of Child Sexual Abuse- UK An NSPCC, UK study a random sample of 2,869 eighteen- twenty four year olds (69% response rate), on child abuse in the UK found: 21% of young women reported experiencing child sexual abuse, (16% involved contact abuse) 11% of young men reported experiencing child sexual abuse, (7% involved contact abuse) - Sexual abuse was defined as sexual contact or non-contact, that was either under the age of 12 or non-consenting, (Cawson, 2000).

7. Child Sexual Abuse- Global Studies A meta-analysis of studies from across the world consisting of 584 articles: Females: Overall prevalence of sexual abuse was 25% (7% non- contact, 13% contact abuse, 5% involving intercourse) Males: Overall prevalence of sexual abuse was 8% (3% non- contact, 3% contact and 2% involving intercourse) Comparable studies based in High Income Countries have found the prevalence of child sexual abuse to range from 8-42% for girls and 3-25% for boys (Creighton, 2004) - Comparative Risk Assessment: Child Sexual Abuse. WHO Collaborating Centre for Evidence and Health Policy in Mental Health, St Vincent's Hospital, Sydney, Australia, May 2001

8. Children on the Child Protection Register in the SE for all categories, rate by Local Education Authority, 2004

9. Estimated number of children who may have been sexually abused in the SE Total number of children in SE for all categories on the Child Protection Register: 3,400 Nationally, there are 2,500 children on the child protection register for sexual abuse This would represent approximately 320 children in the SE who are known by the services to have been sexually abused Below the iceberg: From prevalence studies, there would be an estimated 182,000 girls (21%), and 83,600 boys (11%), in the SE who have been sexually abused. For children, we are probably only aware of approximately 1 in 800 cases of child sexual abuse.

10. Prevalence of Sexual Assault The British Crime Survery (2001) randomly selected a sample of 22,500 women and men aged 16-59 who filled out a self-completion module on sexual assault. Key findings from this study include: One in four (24%), women had experienced some form of sexual assault in their lifetime One in 20 (5%), women said they had been raped on at least one occasion during their lifetime. This represents approximately 750,000 women in England in Wales, and 125,000 in the SE of England, who have been raped. 1.5% of men had suffered a serious sexual assault at some point in their lives, with 1% reporting rape. (BCS 2001, Domestic Violence, Sexual Assault and Stalking: Findings from the 2001 British Crime Survey, Home Office Research Study 276, www.homeoffice.gov.uk/rds/index.htm Walby and Allen, 2004). www.homeoffice.gov.uk/rds/index.htm

11. Percentage of women experiencing Sexual Assault during the last year by Government Office Region BCS Walby and Allen, 2004

12. Force Number of Offences Number of No Crimes TotalNo crimes as % of total Metropolitan Police25710 0 Greater Manchester846210105620 West Midlands814207102120 West Yorkshire627416686 Hampshire46214460624 Avon & Somerset4825253410 Thames Valley4368251816 Merseyside3838446718 Essex3356940417 Northumbria3386139915 Humberside3504839812 Sussex3058639122 Nottinghamshire3035235515 Devon & Cornwall329173465 Kent286283149 Summary of top 15 areas for reported rape cases (total numbers) in England and Wales 2003-04

13. Prevalence of Domestic Violence 1 in 5 women and 1 in 10 men, had experienced at least one incident of non-sexual domestic threat or force since they were 16. 1 in 4 women and 1 in 6 men, had experienced at least one incident of non-sexual domestic threat or force, financial or emotional abuse, since the age of 16. Women were more likely to be heavily abused than men, of those experiencing abuse, 32% of women were subject to 4 or more attacks compared to 11% of men. BCS, Walby and Allen, 2004

14. Percentage women and men experiencing non- sexual domestic violence in the last year by Government Office Region BCS Walby and Allen, 2004

15. Risk Factors for Child Sexual Abuse, Sexual Assault and Domestic Violence

16. Risk Factors for CSA Victims: Females are at greater risk of abuse compared to males (ratio of approximately 3:1) The highest risk age group is between 5- 14 years 33% had more than one abuser and 60% were repeatedly abused, (Singh, 1996). Families experiencing increased arguments and physical violence between other family members (Silverman AB, 1996). Comparative Risk Assessment: Child Sexual Abuse. WHO Collaborating Centre for Evidence and Health Policy in Mental Health, St Vincent's Hospital, Sydney, Australia, May 2001 Perpetrators: Male- 90% of abusers Older- majority are young men, also includes adolescents A study in Switzerland found a third of abusers came from the same peer group. The majority (two thirds) of abusers are known to the child or adolescent. Step father, other family member, acquaintance of the family, or father Females more likely to be abused by a family member (20%), compared to males (6%) (Halperin et al, 1996; Krug, 2002).

17. Risk Factors for Sexual Assault Overlap between Domestic Violence and Sexual Assault- 50% rape and sexual assault by partner or ex-partner, 18% by stranger. Increased risk of repeat victimisation – small minority suffer heavy and multiple abuse BCS Walby and Allen, 2004

18. Percentage women experiencing Sexual Assault by age in the last year BCS Walby and Allen, 2004

19. Percentage experiencing Domestic Violence by age and sex in the last year BCS Walby and Allen, 2004

20. Young Age: Sexual Relationship Violence in Adolescents and Young People Age: A recent UK study on teen abuse, found that 16% of teenage girls have been hit by a boyfriend, and 6% were forced to have sex by a boyfriend. Regional variations existed, with 80% of teenagers in the South, believing hitting a boyfriend of girlfriend was acceptable, (NSPCC, 2005). Influence of parenting styles on 10-12 year old boys found that either perceived laxness of monitoring by parents or overly harsh parenting practices predicted later perpetration of dating violence when followed up at ages 16-17. (Lavoie, 2002)

21. Sexual assault- drugs, alcohol and violence 6 % were drugged in some way 17% were incapable of consent due to alcohol 8% were unconscious or asleep 29% reported some other form of force or intimidation, (BCS, Walby and Allen, 2004) One study found 58% of men imprisoned for rape had drunk alcohol within 6 hrs preceding the assault, whilst 37% were considered to be alcohol dependent. The strongest risk factor for experiencing dating violence for adolescent females was a previous history of forced sex (OR 2.9 p<0.0001) (Kreiter, 1999). Longitudinal study of 16-20 year olds, found that boys who engaged in peer violence was a significant predictor of sexual aggression or dating violence at one year follow-up, (Ozer, 2004).

22. Risk Factors for Sexual Assault and Domestic Violence (BCS Walby and Allen, 2004) Sexual Assault Young age, female, previous abuse Low income (OR1.8) Unemployed (OR 1.8) Social Gradient: unclear Ethnicity: 30% less for Asian vs white or Black Housing: Private Rented (OR 3.1) Being Single Inner city: 3.0% vs 1.2% rural area Domestic Violence Young age, female, previous abuse Low income (OR 3.4 for women, 1.6 for men) Unemployed (OR 1.6 women, 1.2 for men) Social Gradient: 1.5 times higher for lower classes vs higher. Ethnicity: No difference for women, 4x higher for white, 2.6 x for black men vs Asian men Housing: Social rented (OR 3.3) Being single (OR 3.7) or seperated (OR 7.3) Inner city (OR 2.1) Being Pregnant

23. Domestic Violence and Alcohol Abuse Strong link between alcohol consumption and intimate partner violence with 32% of perpetrators reported as being under the influence at time of assault. Alcohol abuse has been found to be 2-7 times higher for perpetrators of intimate partner abuse than for other offenders.

24. Health outcomes and risk behaviours associated with Child Sexual Abuse, Sexual Assault and Domestic Violence

25. Health risk behaviours associated with abuse during childhood and adolescence Smoking (OR 2.5) Binge Drinking (OR 1.7) Substance misuse (Cocaine: OR 3.4) Multiple sexual partners (OR 3.3) First intercourse below age 15 (OR 2.4) Not using a condom (OR 2.0) Further risk of sexual assault Poor Health related Quality of Life scores (OR 1.7) Sleep difficulties School absenteeism

26. Health outcomes associated with abuse during childhood and adolescence (Anteghini M et al, 2001; Kenney JW, 1997; Johnson PJ, 2002; Krug, 2002 Kreiter, 1999; Silverman, 2001; Coker AL, 2000; Roberts TA, 2003; Covington, 2000)). Attempted suicide: (OR 8.6) Depression and mental health problems Bulimia (OR 3.7) Pregnancy (OR 3.9) Increased violence during pregnancy (OR 1.9), with an increase in pre-term delivery (OR 3.5) Sexually Transmitted Infections Excess in physical health problems, (e.g., irritable bowel syndrome, gynaecological problems, heart disease and cancers)

27. Health related outcomes of abuse for young men Victim: Victim of dating violence associated with attempted suicide (OR 2.3) Experiencing abuse associated with antisocial and violent behaviour Perpetrator: Number of times of getting someone pregnant (OR 1.7) Poor health related quality of life scores (OR 2.3) Perpetration of dating violence associated with suicide attempts (OR 1.5)

28. Health Consequences Sexual Assault - Adults Women who had been subject to serious sexual assault (including rape), since the age of 16: 52% had suffered depression (x 2 higher rate) 5% had attempted suicide 4% had become pregnant as a result of the rape Stopped trusting people (38%) and go out less often (15%) (BCS, Walby and Allen, 2004).

29. Health Consequences associated with Domestic Violence ever since age of 16 (BCS, Walby and Allen, 2004). Females: 48% minor injury 26% moderate injury 8% severe injury 37% mental or emotional problem Males: 35% minor injury 15% moderate injury 2% severe injury 10% mental or emotional problems

30. Health Consequences associated with Domestic Violence Chronic physical health problems eg irritable bowel syndrome, backache and headaches, (Campbell 2002). Reproductive health: increased rates of unintended pregnancies, terminations (Gazmararian et al 2000), and low birth weight babies (OR 1.4, 95% CI 1.1-1.8) (Murphy et al 2001). Sexual health: lower rates of contraceptive use, higher rates of sexually transmitted infections, (Garcia-Moreno and Watts C, 2000).

31. Health Consequences associated with Domestic Violence Mental health: higher rates of depression, anxiety, self- harm and suicide (Campbell 2002). Depressed women 6 times more likely to have experienced severe combined abuse than non- depressed women, (OR: 5.8, CI: 2.8-12.0), (Hegarty, 2004). Health of children increase in short & long-term anti- social behaviour, (missing school, getting into fights, and cruelty to animals); mental health problems: depression, anxiety, substance misuse & suicidality, (Shipway, 2004; McFarlane, 2003; Roberts, 2003).

32. Life-course risk of further abuse Any history of previous sexual abuse at whatever age, but especially between 14-18 years, increased the risk of sexual assault in late adolescence and early adulthood compared to non- abused students. Risk of repeat assault increased according to the degree of severity of the initial assault. (Humphrey JA, 2000). Longitudinal study of US female college students found a previous history of physical assault in adolescent dating relationships, increased the risk of further physical assault during their first year at college, (RR: 2.96). After four years at college, any history of physical assault in a dating relationship, increased the risk of further physical assault and sexual assault, (Smith, 2003).

33. Determinants of Childhood Health Inequalities Uncovering the Hidden Life-course Impact of Child Sexual Abuse on Health Inequalities ADOLESCENCEADOLESCENCE ADULTHOODADULTHOOD CHILD SEXUAL ABUSE Prevalence: Females: 22% Males: 11% Socio- Economic Gender Female> Male Disability Power Inequalities Ethnicity Age: Power Inequalities Increased Mental Health Problems: Depression Self Harm Suicide Increased Health Risk Behaviours: Smoking & Alcohol Obesity Increased Sexual Relationship Violence Increased STIs Teen-Pregnancy Abusers: Poor MH & Alcohol Misuse Increased Health Risk Behaviours: Smoking Substance Misuse Obesity Increased Mental Health Problems: Depression Self Harm Suicide Abusers: Increased Suicide/ Poor QoL Increased Intimate Partner Violence Increased STIs Poor Preg. Outcomes Chronic Gynae Problems Poor Long-term Health Outcomes: CHD & Cancer Chronic Diseases Nurse J, 2004

34. Seeking Help and Reducing Harm

35. Disclosing abuse 34% of women and 62% of men had never told anybody about their experience of Domestic Violence prior to the survey Most likely to tell friends or family, followed by the police. Those suffering the worst abuse were more likely to tell someone Sexual assault (and CSA) even less likely to have told anyone. Police came to know about 15% of rapes in females over 16. (BCS, Walby and Allen, 2004).

36. Seeking Help More likely to seek help (police or medical) if repeated attacks, more serious injuries, if older, on lower incomes, and if they’ve told someone else. 30% women, 14% of men sought medical help following domestic violence resulting in injuries Only 29% of women suffering a serious sexual assault sought medical help 27% with serious medical injuries sought no medical attention Of those who sought medical help, 65% did so with their GP, 35% at A & E, and 10% with mental health services (BCS, Walby and Allen, 2004).

37. Reducing Harm 94% of women were asked about the cause of injury by GP or in A & E, and 74% said they disclosed the abuse 79% of women who told someone about their experience of domestic violence in the last year found that person or service was able to help Treatment was offered in 36% of women who disclosed abuse 13-15% of female and male perpetrators were offered either counselling, therapy, treatment for alcohol abuse or a DV programme

38. Preventing Child Sexual Abuse, Sexual Assault and Domestic Violence

39. Violence Prevention Framework ADOLESCENCEADOLESCENCE ADULTHOODADULTHOOD CHILDHOODCHILDHOOD Societal And Community Interventions Legislation -Alcohol -Inequalities Partnerships CDRPs Alter Environment Community Awareness Campaigns Information Help Lines Prevention Focus Primary Secondary Tertiary Home Visitation Programmes/ Parent Skill Training School Based Child Bullying & Abuse Prevention Social Development Training & Pre-School Enrichment School Based Skills and Education Positive Relationships & Communication Protective Skills & Abuse Awareness Conflict resolution skills Anti-Bullying programmes Seeking Help & Peer Support Educational enrichment Links with Health Promotion: Substance Abuse & Alcohol Sexual Health Enhance Adult Skills: Opportunities with Ante-natal classes: -Conflict resolution -Communication -Protection Ecological Model Societal Community Relationship Individual Child Protection Procedures Identification & early Treatment Of Abusers Containment & Restriction Of Abusers Treatment & Management Of Abusers -Alcohol Protection & Containment Identify high Risk Groups For Abusing to intervene early Early Identification ofAbused for: Therapy/ support Protective skills Family Therapy Mentoring Early Identification of Abused: Safety skills and procedures Support & manage related issues Therapy and preventive skills Referral to support agencies Child & Family Therapy

40. Effective approaches for prevention targeted at children Home Visitation Programmes- (eg Sure Start) fifteen year follow-up study found reduction in child abuse Sexual abuse prevention training in early childhood whilst at school. For college women studied: 8% had subsequently experienced sexual abuse, compared to 16% of those who had no training as a child

41. Effective approaches for prevention targeted at Adolescents & Young People School Based Education Programmes: Developing ‘positive relationships’ and how to seek help- found reduced rates of perpetration and experience of dating violence after 4 year follow-up 2-3 hour brief interventions on protective skills for young women- reduce the rate of subsequent sexual assault by 50% Targeting high risk groups of young people with additional interventions is also effective at reducing further sexual assault

42. Effective approaches for prevention targeted at Adults Referring to Support and Advocacy services for women leaving violent relationships is effective in reducing further abuse Alcohol abuse treatment services for male perpetrators of domestic violence are effective for reducing further perpetration of abuse- (whilst there is mixed evidence on the evidence of perpetrator programmes) Working in Partnership via CDRPs to reduce populations of alcohol consumption potentially will have an impact on reducing all alcohol related violent crime

43. Victims of Violence & Abuse Prevention Programme- VVAPP CSA, Domestic Abuse & Sexual Assault Childhood & adult victims & perpetrators Research- Mapping, Literature review, Delphi consultation, Expert groups- to inform future action. Improve service responses – SARCs; routine enquiry in ANC & training for pilot MH services. Prevention: working with DH, HO & DfES to develop joined up approach to earlier prevention at national & regional levels.

44. For more details about the presentation and on prevention please contact Dr Jo Nurse Consultant in Public Health SE Regional Public Health Group Jo.Nurse@dh.gsi.gov.uk