The physical, psychological and social consequences of domestic violence (DV) for the victim and her family have been, and probably remain, inadequately investigated and understood. Although DV remains covert in most cases (reports to the police are estimated to represent barely 10% of all cases), our knowledge of the alarming magnitude of this problem is increasing.
Studies in different countries1-4 have revealed how serious the consequences of DV can be, and have led international organizations concerned with health care (e.g., WHO, UNO, PHO) to consider it a public health problem of the first order. Many governments have established plans to reduce DV, although this does not mean that they include this de facto problem among their political priorities.
Ensuring the availability of reliable data that reflect the context of each country with regard to the prevalence of DV and its consequences for individuals, families and society may be the best argument in support of calls for a global commitment to face this problem effectively.
Physical consequence
The effects on physical health that earlier studies have documented most clearly are as follows:
A wide variety of traumatic injuries including open wounds, burns, fractures, bruises, multiple injuries, and injuries can cause permanent sequelae or even death.
Sexual attacks lead to genitourinary problems such as sexually transmitted diseases, urinary tract infections, pelvic pain and undesired pregnancies.
Abuse during pregnancy is a health risk for the mother and the child. Violence during this period increases the risk of spontaneous abortion, low birth weight and perinatal death.
In the long term, DV leads to alterations believed to be related with prolonged stress, such as digestive tract disorders (irritable bowel syndrome, loss of appetite, vomiting, etc), headache, backache, abdominal pain, chest pain, bone and muscle pain, and unspecific physical symptoms. More recently, DV has been related to the appearance of chronic diseases such as diabetes, cardiovascular problems and somatic symptoms.5
Psychological consequences
The repercussions of DV on the victim's mental health have been widely documented in many studies.6 Problems related most clearly with DV are posttraumatic stress disorder, anxiety, depression (the indicator related most clearly with abuse), and greater risk of suicide (up to 4-fold as high as in nonabused women). Women who are victims of abuse are also at higher risk for addictive behaviors such as alcohol, illegal drug, and mood-altering drug abuse. They more frequently suffer from insomnia, somatization disorders, sexual dysfunction, and eating behavior disorders (anorexia and bulimia). In addition, victims are more likely to use violence against their own children. Victims themselves consider the psychological consequences to be more serious than physical injuries.
Another important long-term consequence is the transmission from generation to generation of DV, which perpetuates models of behavior that accept violence as an instrument of domination and submission. Children thus learn not only the role of aggressor, but also the role of victim, and are more tolerant of abusive behavior.
Social Consequences
Abused women often experience social isolation. They miss work and lose their jobs more often, and this in turn diminishes household earning capacity and socioeconomic level.
Victims of abuse consume more health care resources, and make more visits to the emergency room, to family and community health care facilities, and to mental health facilities. These facets of DV have also been widely investigated.
In Spain, few studies have been published on the repercussions of DV on mental health. The survey on DV carried out by the Instituto de la Mujer (Institute of Women's Affairs) in 2000 was one of the few studies to examine this issue.
These reasons make the study published in this issue by Raya Ortega and colleagues especially timely, being one of the first to appear in Spain that attempts to investigate the impact of DV on women´s physical and psychological health. The authors studied a population of women between 18 and 65 years of age who visited primary health care centers.
Of particular note was the high frequency of abuse, which was reported by 31.5% of the population studied. However, the real figure may well be higher as some of the exclusion criteria may have led the actual frequency to be underestimated. The figure reported by Raya Ortega and colleagues is much higher than that reported by the Instituto de la Mujer (9.4%), based on a sample of the general population of women of the same ages. However, the figure found by Raya Ortega and colleagues is consistent with the results of other studies done in primary care settings in other European countries (Richardson, 2003; Bradley, 2003). Raya Ortega and colleagues also found that in global terms, abuse was associated with poor mental health and self-perceived health. These authors also note--as other studies have reported--a higher frequency of use of mood-altering drugs and substances, and a higher frequency of chronic diseases.
Although methodological features of the study make it inappropriate to extrapolate these findings to the general population, it is clear that the findings are of considerable interest. For the first time we now have data on the frequency of abuse from a survey of women seen in primary health care centers. As the authors note in their conclusion, physical injuries are not the only proof of abuse. There are other sequelae that are less visible but perhaps much more serious, such as mental health problems or chronic illness secondary to situations of sustained violence. Primary care professionals should be on the alert to detect DV as promptly as possible and thus minimize its consequences. The results of studies such as the one by Raya Ortega and colleagues provide further arguments in support of vigilance.
Moreover, an additional positive outcome of this study in the primary care setting would be the initiation of further research on the consequences of DV. Some of the questions that merit attention in this area are as follows:
What are the long-term repercussions of DV? Although some studies have appeared, the repercussions remain poorly understood.
How do psychological problems and chronic diseases arise secondarily to DV?
How are these problems related to the duration and type of abuse?
What are the protective mechanisms and resilience factors that allow some victims to recover from abusive experiences without delayed psychological sequelae?
What repercussions does DV have on the health of other family members? What interventions should be implemented with minor children when intimate partner violence is detected? What middle- and long-term repercussions does DV have on the children? These issues are undoubtedly of considerable interest for health care, and although some studies have investigated them in other countries, they have hardly received attention in Spain.
Perhaps some of these questions will inspire other professionals to initiate further studies in this area, which has been neglected to a large extent by health care professionals in Spain. Further research in this area is necessary, as in the words of F. Bradley,7 the author of many studies on DV, research into this problem should be seen as a way to uncover and reframe this hidden stigma; research in itself is beneficial even when it is not accompanied by immediate action. Awareness of the problem is the first step toward a solution.
It is essential that domestic violence come to be understood as a health problem, and we must therefore integrate it into primary care activities, investigate the gaps in our knowledge of the problem, and obtain appropriate training to provide care and carry out research effectively.
