Detailed Notes on Gender-Based Violence and Mental Health in US Women

Gender-Based Violence and Mental Health: A US Study

Introduction

• Gender-based violence (GBV) is a significant global health issue, encompassing physical and sexual violence against women and stalking.
• Australian studies have linked GBV to mental disorders, disability, and suicidal behavior.
• US studies have primarily focused on specific types of GBV like intimate partner violence (IPV) and their relation to certain negative health outcomes.
• There's a gap in US research concerning the broad GBV construct and its association with a wide range of mood/anxiety and substance use disorders (SUDs).

Limitations of Current US Research

• Co-occurrence of GBV types: GBV often involves multiple forms, but studies tend to focus on single types, potentially underestimating the impact of GBV overall. CDC data indicates women often experience multiple types of GBV.
• Limited timeframes: US studies often focus on GBV during specific periods (e.g., childhood or current relationships), neglecting the cumulative impact of lifetime GBV experiences, including those occurring during different developmental stages.
• Developmental period: There is a lack of knowledge on weather GBV exposure during particular developmental periods is differentially associated with risk for particular types of outcomes. For example, abuse during early childhood/adolescence was associated with reduced volume in the hippocampus( memory and implicated in PTSD risk), while abuse during late adolescence was associated with diminished frontal cortex volume (executive function and implicated in externalizing behaviors including substance abuse).
• Specific outcomes: Most studies concentrate on single outcomes like PTSD, overlooking the broader public health impact of GBV on various mood/anxiety and SUDs.

Study Aims

The study uses data from female participants in the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) to address three aims:

1. Document the prevalence of GBV and its associations with lifetime mood/anxiety and SUDs in a nationally representative US sample of women.
2. Examine associations between the level of GBV exposure (number of types and incidents) and the earliest age of first GBV exposure in relation to lifetime mood/anxiety and SUDs.
3. Examine associations between the developmental age of earliest GBV exposure and the onset of mood/anxiety and SUDs during that same age and over the lifecourse.

Methods

• Data were collected from 20,089 women who participated in wave 2 (2004–2005) of the NESARC, a face-to-face survey of non-institutionalized adults.
• The Wave 2 re-interview response rate among eligible Wave 1 participants was $86.7\%$, yielding a cumulative response rate over both waves of $70.2\%$.
• Young adults, Blacks, and Hispanics were oversampled; therefore, data were weighted to reflect the demographic characteristics of the US population based on the 2000 census.

Measures

• Gender-based violence: Exposure was assessed through 23 potentially traumatic events, including sexual assault, physical assault, and stalking.
  • Sexual assault: "ever sexually assaulted, molested, raped, or experienced unwanted sex".
  • Physical assault: "physical attacks/beating/injuries by: 1) a parent/caregiver before age 18, 2) a romantic partner, or 3) someone else".
  • Stalking: "someone followed you or kept track of your activities in a way that made you feel you were in serious danger".
• Follow-up questions gathered data on the number of times GBV occurred and the age when it first and most recently occurred.
• Three characteristics of GBV were examined:
  • Number of types of GBV (1, 2, or 3).
  • Number of occurrences of GBV (1, 2–3, 4–9, 10+ incidents).
  • Age of earliest exposure to GBV (2–10, 11–14, 15–17, 18–24, 25–34, 35–44, 45 or older).
• Mood/anxiety and substance use disorders: The Alcohol Use Disorder and Associated Disabilities Interview, Schedule IV (AUDADIS-IV) was used to assess lifetime DSM-IV disorders.
  • Eight mood/anxiety disorders: PTSD, Social Phobia, Generalized Anxiety Disorder (GAD), Depression, Panic Disorder, Bipolar Disorder, Dysthymia, and Specific Phobia.
  • Ten SUDs: alcohol, sedative, tranquilizer, opioid, amphetamine, cannabis, hallucinogen, cocaine, inhalant, and heroin.
• For respondents meeting lifetime criteria for a disorder, age of first episode onset, number of episodes, and age of most recent episode were ascertained.
• Test-retest reliability range from fair (Kappa = 0.42 for panic disorder) to excellent (Kappa = 0.84 for alcohol dependence).

Statistical Analysis

• Analyses were conducted using SAS 9.3.
• Logistic regression was used to generate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) reflecting the likelihood of specific mood/anxiety and SUDs by any GBV exposure.
• Effects of experiencing multiple types and occurrences of GBV and earliest age of GBV on meeting lifetime criteria for mood/anxiety or SUDs were examined.
• Immediate versus delayed effects of earliest GBV were examined by estimating mood/anxiety and SUD incidence at age periods subsequent to first GBV.
• Bivariate analyses were weighted, and multivariate analyses accounted for sample weight, clustering, and stratification using Taylor series linearization.

Results

• Mean age was $49.5$ (SD = $17.7$). Most respondents ($70.6\%$) were Non-Hispanic white, $11.9\%$ were African American, $10.9\%$ were Hispanic, $4.2\%$ were Asian or Pacific Islander, and $2.3\%$ were American Indians or Alaska Natives.
• Women reporting GBV were more likely to be younger [M = $45.5$ (SD = $14.6$) vs $50.8$ (SD = $18.4$); p < $0.0001$], Asian/Native Hawaiian/Pacific Islander or Hispanic, divorced, lower income, and college-educated when compared to women without GBV.
• One-quarter (n = 5284) of women reported lifetime GBV; one, two, and all three types were reported by $72.0\%$, $21.9\%$ and $6.0\%$, respectively.
• Of those with GBV, 1, 2–3, 4–9, and 10 or more incidents of GBV were reported by $33.6\%$, $22.2\%$, $15.3\%$, and $21.7\%$, respectively.
• The mean age of first GBV was $16.9$ (SD = $10.4$).
• Of the sample, $47\%$ met criteria for any mood/anxiety disorder (mean age of onset = $17.1$, SD = $14.4$), and $24.7\%$ met criteria for any SUD (mean age of onset = $21.8$, SD = $8.4$).

GBV and Lifetime Mood/Anxiety and SUDs

• Women reporting any GBV had 3.62 times the odds of a mood/anxiety disorder and 2.46 times the odds of a SUD compared to women unexposed to GBV, after adjusting for age, race, education, income, and marital status.

Level of GBV Exposure and Lifetime Mood/Anxiety and SUDs

• Those who reported more types of GBV had increased odds of mood/anxiety and SUDs, a dose–response effect.
• Similarly, exposure to more GBV incidents was associated with increasingly greater odds of mood/anxiety and SUDs, also a dose–response effect.
• Model 2 revealed that the number of GBV types was the stronger predictor of mood/anxiety and SUDs.

First GBV Exposure and Lifetime Mood/Anxiety and SUDs

• Compared to women who first experienced GBV at age 45 or older, women whose earliest GBV occurred between 2 and 10 had more than 18 times the odds of developing a lifetime mood/anxiety disorder, and women who first experienced GBV between ages 2-10 had 8.5 times the odds of a lifetime SUD.

First GBV Exposure and Onset of Mood/Anxiety and SUDs

• Earliest GBV during any age period was strongly associated with mood/anxiety disorder onset during the same period, and the magnitude of associations with disorder incidence at later periods decreased over time.
• First GBV during childhood was also associated with incident SUDs over the lifecourse.

Discussion

• One in four women reported any lifetime exposure to gender-based violence (GBV).
• Any GBV was associated with a $2.5$–$3.6$ fold elevated risk of developing a mood/anxiety or SUD.
• Number of types and number of incidents of GBV were significantly associated with mood/anxiety and SUDs, although number of types of GBV was the stronger predictor of both disorder types.
• Women who first experienced GBV between 2 and 10 had more than 18 times the odds of developing a lifetime mood/anxiety disorder.
• GBV exposure in childhood appears to have especially pernicious effects on risk for lifetime mood/anxiety and SUDs.
• Analyses also revealed strong immediate effects of first GBV at any age period on incidence of mood/anxiety and SUDs at that same age period.
• Adolescent GBV is a potent risk factor for the onset of adolescent psychopathology; preventing GBV during this period should be an important focus of mental disorder prevention efforts.
• Consistent with work suggesting that adolescence is a high-risk period for exposure to GBV and the onset of psychopathology, first GBV between 11 and 14 was associated with a more than 6-fold increase in the incidence of SUDs.

Limitations

• Age and amount of GBV exposure and age at onset of mood/anxiety and SUDs were assessed via retrospective recall, which may have introduced bias.
• Only data on age of first and most recent GBV exposure were collected.
• GBV was assessed with five screening questions about various types of GBV.
• The study did not assess all forms of psychological abuse that constitute violence against women.
• Some disorders that may be associated with GBV (e.g., obsessive-compulsive disorder, eating disorders) were not assessed.

Implications

• Preventing repeated GBV exposure and exposure to multiple types of GBV may reduce the public health burden of mood/anxiety and SUDs.
• To encourage reporting, stigma surrounding GBV exposure must be reduced and confidentiality must be protected.
• Focusing prevention on perpetrators rather than victims may yield greater reductions in GBV.
• Findings suggest that adolescence is a critical period for mental disorder prevention efforts.
• Clinicians working with violence-exposed women should assess multiple disorders and consider implementing evidence-based treatments that cut across conditions.