Violence and its impact on comprehensive health: an interview with Soledad Larrain. (Consequences of Gender Violence).

Chilean psychologist, researcher and consultant to UNICEF Soledad Larrain has dedicated much of her professional life the analysis of gender-based violence and the prevention of violence against children. In the following interview, Soledad discusses the results of a recent study on domestic violence in Chile's Metropolitan Region, which includes the national capital Santiago, and in the Araucania Region to the far south. Sponsored by the Servicio Nacional de la Mujer (SERNAM, National Women's Service), the study's research team was led by coordinator Raul Urzua and included Marcela Ferrer and Claudia Gutierrez from the Center for Public Policy Analysis of the Universidad de Chile, as well as Ms. Larrain. All the quotes in this text are taken from the preliminary version of the working paper entitled "Deteccion y Analisis de Prevalencia de Violencia Intrafamiliar" (Detection and Analysis of the Prevalence of Domestic Violence, Chile: SERNAM, 2001).

What is the relationship between physical, sexual and psychological violence and abused women's mental health?

In our recent study, we observed that physical and/or sexual violence had a great impact on the overall mental health of the victims. For example, these women present significant symptoms of anxiety, anguish, fatigue, headaches, tension and other psychosomatic symptoms. Most common, however, were symptoms of depression: far more often than women who live free from violence, victims of violence suffer from listlessness, the inability to face everyday tasks, and a marked deterioration in self-esteem. Of even greater concern is the tendency to contemplate or attempt suicide, which is seen by these women as an real alternative and sometimes the only solution to their situation.

Feelings of fatigue, irritability, insomnia and other problems have a direct impact on mental health, but do the women themselves perceive this as a consequence of the violence?

This cannot be determined within in the scope of this study. What we do observe is that the symptoms mentioned occur more often in women who suffer violence than in those who do not. However, based on my clinical experience with women who have suffered violence, they do come to realize how living in a violent environment has provoked in them a series of disorders. They realize that they are tense and filled with anguish because they are living in fear although at first they do not even make the connection.

As for suicide, we would imagine that the woman who opts for this extreme solution previously has suffered a period of depression.

Of course. She starts to develop symptoms of depression, and once she sees no way out of her problem, she may decide to commit suicide either alone or with her children. Especially when they have been victims of violence for a long time, abused women have very low self-esteem, and the process of that destruction of their self-image culminates in this type of act.

What other effects are frequent in women who suffer violence?

Again, the most common and the most worrying issue is depression. This is a high-risk problem because when these women approach the national health system requesting help, they are unlikely to mention the situation of violence. Therefore, unless the health professionals make a concerted effort to draw out what is behind the symptoms, they will probably be prescribed an antidepressant and nothing more. The basic issue, violence, remains hidden.

Also, the subject of addiction--at least to alcohol--was not perceived as significant in our study. On the other hand, there was a clearly observed tendency to consume more drugs such as tranquilizers or benzodiazepine. As I just pointed out, this is because abused women with violence-related psychosomatic symptoms who approach the National Health system for help are given tranquilizers or antidepressants to treat the symptoms, but the underlying causes are not addressed. In some way, this makes it even more difficult for the women to face their problems. When providing clinical care, you realize that they are so anxious and scared that before the aggressor is due home, they take two or three different drugs in order to anesthetize themselves so that they will not feel anything. This also prevents them from developing the ability and resources to get out of this situation.

The health services must also take responsibility for this situation. These multi-symptomatic women are usually dismissed by the system, which doesn't perceive that behind their complaints there is a hidden emotional history of violence, sometimes extending over a number of years, which prevents them from talking about their predicament. Nonetheless, there is an association between this history and their symptoms: for example, there is evidence that women who are sexually abused have many more urinary infections. However, uncovering situations of violence requires taking the time to listen and to establish a bond of trust, which rarely is achieved.

Does domestic violence occur among all social social strata?

Yes, but we have to look at each socio-economic level independently, because the violence appears in different forms. For example, psychological violence is more prevalent in the higher socio-economic levels; apparently, people with a higher level of education have a wider variety of "`tools" for the abuse. They are better prepared to use aggressive language, to belittle and humiliate their victims. In additional, there are more possibilities for control--through money, for instance--and we must not forget that one of the main objectives behind violence is control.

How does violence affect children?

Our study revealed three points worth singling out. First, approximately 70% of children are present when a violent situation occurs between the parents, and we know that the remaining 30% sense that the violence exists. This observation is particularly noteworthy in the current context of Chile: divorce does not exist, but a proposed law to introduce it has sparked concerns regarding the negative effect of separation on children. In contrast, there are virtually no opinions being voiced concerning domestic violence and the impact on 70% of children who witness their fathers beating their mothers. This experience can traumatize a child and have a disastrous effect on her or his socialization.

The second conclusion is that children of abused mothers have more physical symptoms and emotional problems than children who live in homes free from violence. They tend to have more nightmares, they are more anxious and aggressive, and they have problems with enuresis (bed-wetting). When a child who has learned to control its sphincter later starts bed-wetting again, this "secondary enuresis" reflects an emotional problem, not a neurological one. In other words, the family situation affects the child's emotional development, and this was evident in our study.

Many other related studies confirm that a history of violence is clearly a risk factor for a person's future life. Women who are victims of conjugal violence were more often abused, including sexually, by their fathers than women who do not endure domestic violence. Additionally, women victims of violence are more likely to have had mothers who were also abused. We consider this a very significant point.

Does this phenomenon also occur in other countries?

Yes, around the world. It also reflected in other studies we have conducted in Chile, and it is once more strongly evident in this particular study. It is also evident that the aggressor is more likely to have been abused as a child and that his father is more likely to have beaten his mother. This is the transgenerational transmission of violence, the process of socialization that has legitimized the use of violence within the family.

Two other UNICEF studies on child abuse have shown similar results. They have also shown that abused children tend to justify their parents' use of violence. For instance, when these children are asked, "Do you think that there are occasions when a parent is justified in beating a child?" The abused children answer yes; they justify the actions of their father or mother and do not question their conduct. These types of responses show a marked socialization of violence and explain how a child who has suffered the pains of abuse can become an abuser in adulthood. Thus, it is clear that prevention is the best way to deal with this issue. If we want to prevent violence against women, we must work with the children as well as the women who are victims of abuse in order to prevent the repetition of certain behavior.

What role can the health care systems play in the prevention of violence against women?

I think that the health care system should concentrate on early detection as well as prevention. In the case of pregnant women, they should focus on the couple in order to strengthen the bond between partners, especially with mothers in high-risk situations. In pregnancy, there are certain conditions that increase the risk of child abuse, including unwanted pregnancies, pregnancy resulting from rape, adolescent pregnancy, pregnancy resulting from contraceptive failure, and so on. In cases in which there is no mother/father/child relationship, the health care worker must try to strengthen the woman's relationship with her family. This is vital for the prevention of violence. But how does one create a more parent-friendly system when so few hospitals allow fathers to be present at childbirth?

How are abused women treated when they go to health care centers?

The SERNAM study established that a significant number of women go to health care centers to receive treatment for their injuries, but more than 30% of these do not tell the health care provider the reason for their injuries.

And the health care workers do not ask.

And they should, if only to administer the correct treatment. A nurse could do this rather than the doctor. For example, in Mexico all hospital personnel, from the receptionists on up, undergo training on handling different crises. When an abused woman arrives they are prepared to administer first aid and to direct her towards further treatment within the hospital. She is also encouraged to follow up her treatment with help from a social worker or another specialist.

Immediate treatment and counseling is key to tackling the problem from the beginning. It is very different if a woman receives this help only after enduring ten or more years of abuse.

In other words, the earlier the problem is detected, the better the chances of improving the relationship or ending it?

There are two important points here: as time goes by, the damage is so great that the possibility of healing the relationship progressively decreases. When a woman has been abused, put down and insulted for ten or more years, usually the only thing she wants is a complete break. After years of abuse, she is filled with hopelessness, and her self-esteem can only be repaired through a great effort. On the other hand, if this situation is detected and stopped immediately, the woman may look upon it as a dramatic, painful episode which she has managed to overcome, either by reconstructing the relationship or ending it. If the abuse goes on for many years, it is no longer an episode; it is her life story and far more difficult to overcome.

Nevertheless, if the health system treats the abused woman but doesn't follow up on her case, her treatment is interrupted, which is also detrimental.

Yes, this is a serious problem, and in fact, there is no follow-up on these cases in Chile's health care system. Despite the tremendous impact on women and children's physical and mental health, there is no national program of treatment for victims of domestic violence. While there are some programs at the municipal level--centers set up by SERNAM and some self-help groups established by women's NGOs--these efforts can only begin to address a problem of this magnitude.

However, all sectors, even the users of the health care system itself, are demanding that mental health concerns be made a priority in the public health system. Of all the services offered, mental health care is most in demand, specifically for depression and stress problems related to living conditions where violence appears to be a significant factor.

I also have heard that women who live in a violent environment are more prone to heart ailments.

There is no evidence of this in Chile, but studies worldwide have suggested it. There is a lot of work to be done on how we register and record domestic violence. For instance, many cases of female suicides have not been attributed to their real cause. The registrations of many injuries are not associated with domestic violence either. And if even these extreme consequences have not been recorded as caused by violence, it is all the more difficult to confirm the association of violence with heart ailments.

In other countries, there is data associating violence with cancer as a consequence of its psycho-emotional impact over a long period of time. If we look at it in terms of post-traumatic stress disorder, we find that stress is the body's reaction to environmental situations that alter the normal equilibrium. When the situation is temporary, equilibrium presumably will be re-established. But in cases of domestic violence this alteration can last for years.

What do you suggest as a solution for this public health problem?

An interdisciplinary and intersectoral approach is necessary since many areas with different responsibilities are involved. Education is all-important in prevention as well as in fostering equality in relationships. However, the health sector plays a key role in prevention and couple counseling as well as in early detection and intervention. This is the national health system's responsibility since a nation's primary health objective should be to maintain high levels of well-being among its citizens.

Half of all women in Chile experience some degree of physical, sexual and/ or psychological violence. It is incomprehensible that there is no national program to deal with this problem. It is unacceptable that the hospitals are not recognizing the evident signs of violence among multi-symptomatic women. It is also unacceptable that there is no center for information and orientation, where requests for help could be received.