Abstract
The aims of this study were to investigate the type and extent to which women with substance abuse problems have been exposed to male violence during their lifetime, and to examine possible differences between women with a residence (WR) and homeless women (HW). The total sample included 79 women (WR, n = 35; HW, n = 44; M age = 47.8 years). Of the total sample, 72 women (91%) had experienced different kinds of male violence, 88% from former partners, and 26% from male friends or acquaintances. Of the 72 women, 71% further reported “Countless occasions of violent events,” and 36% had been forced to commit criminal acts. Abused women who had been forced to commit criminal acts were significantly more frequently found to be homeless, have reported parental alcohol and/or drug problems, have witnessed domestic violence in childhood, have been victims of sexual violence, have used illicit drugs as a dominant preparation, and have injected illicit drugs. Almost half of the abused women (46%) met criteria for posttraumatic stress disorder (PTSD), where HW showed an almost 4-time higher risk (RR 3.78) than WR. In conclusion there is a particular vulnerability in women with substance abuse to male violence, which has an important impact on their health status. Thus, from a public health perspective, it is suggested that for those women who have experienced male violence, treatment protocols need to include both assessing and addressing the impact of such experience in relation to substance abuse as well as concomitant health concerns.
Keywords
Introduction
Despite growing knowledge of male violence against women with substance abuse problems, there has been relatively little research examining experience of male violence among subgroups of women with such problems. Women with these problems constitute a heterogeneous group, and different lifestyles and use of alcohol or illicit drugs might affect their exposure to male violence (Gilbert, El-Bassel, Chang, Wu, & Roy, 2012; Golder, Connell, & Sullivan, 2012). The present study examines male violence in terms of psychological, physical, and sexual violence, against women with substance abuse problems, and covers two groups of women: women with a residence (WR) and homeless women (HW). The WR received outpatient treatment for substance misuse problems.
Women With Substance Abuse Problems in Sweden
In Sweden, the female population is more than 4.7 million. Approximately 4% of the women have alcohol dependence, and nearly 11% suffer from alcohol abuse, and 1% from abuse of illicit drugs (the National Board of Health and Welfare, 2011; Statistics Sweden, 2011; the Swedish Council for Information on Alcohol and Other Drugs, 2014). The number of these women who have undergone outpatient treatment for substance misuse problems is unknown. There is no current and reliable information as to the total number of clients and patients in Sweden who have been treated for various substance misuse problems (Official Reports of the Swedish Government, 2011). Earlier assessments from 1991 and 1994 estimated the total number of persons in outpatient treatments to be 51,000 and 48,000 respectively per year, approximately one third were women (the National Board of Health, 1994, 1996; Official Reports of the Swedish Government, 2011). Outpatient treatment for substance abuse problems is twice as common as inpatient treatment in Sweden (Official Reports of the Swedish Government, 2011). Treatment in an outpatient clinic enables persons to continue working. Most patients choose outpatient treatment voluntarily, based on their own initiative.
Furthermore in Sweden, there are between 4,500 and 11,500 HW, and about 2,000 to 3,000 of them have substance abuse problems (the National Board of Health and Welfare, 2006, 2011).
Male Violence Against Women With Substance Abuse Problems
Women with substance abuse problems have an increased risk of male violence (Cunradi, Caetano, & Schafer, 2002). For example, among women seeking emergency care and reporting misuse of alcohol or illicit drugs, a connection was found between substance abuse problems and experience of Intimate Partner Violence (IPV; Gilbert et al., 2012). In a study of pregnant women in a substance abuse treatment program, 60% had experienced male violence (Martin, Kilgallen, Dee, Dawson, & Campbell, 1998). An association has been shown between substance abuse in women and experience of physical and sexual intimate violence (El-Bassel, Gilbert, & Rajah, 2003). About 32% to 45% of women in methadone treatment programs have experienced physical and sexual abuse, life-threatening or not, occurring either from stranger/acquaintances or partners/ex-partners (i.e., IPV; El-Bassel, Gilbert, Wada, Witte, & Schilling, 2000; Panchanadeswaran, El-Bassel, Gilbert, Wu, & Chang, 2008). Studies involving male violence against women with substance abuse mainly concern IPV (Cunradi et al., 2002; El-Bassel et al., 2003; El-Bassel et al., 2000; Gilbert et al., 2012; Golder et al., 2012; Panchanadeswaran et al., 2008; Schneider, Burnette, Ilgen, & Timko, 2009; Shannon, Logan, Cole, & Walker, 2008). The term IPV “describes physical, sexual, or psychological harm by a current or former partner or spouse” (Centers for Disease Control and Prevention, 2014). However, in a study of injection drug users, violence against women was perpetrated by acquaintances and sex trade clients, as well as partners (Marshall, Fairbairn, Li, Wood, & Kerr, 2008). Psychological violence against women with substance abuse problems is an understudied area.
Male Violence Against HW
HW are in a particularly vulnerable position and often experience male violence; some of them face daily violence (Bourgois, Prince, & Moss, 2004; Wenzel, Leake, & Geldberg, 2001). A study of 974 HW, with or without substance abuse problems, in the United States, aged 15 to 44 years, showed that one third of the women had experienced major violence during the last year—having been kicked, beaten up, hit with an object, choked, burned, or threatened or harmed with a knife or gun—and that substance abuse problems were more common among women who experienced major violence in the past year than among those who had not (Wenzel et al., 2001). The degree of sexual assault among HW also was found to be high, up to one half of the women (Bourgois et al., 2004; Holt, Montesinos, & Christensen, 2007).
Experience of Male Violence Contributing to Mental Problems
The link between exposure to male violence and mental ill health, such as depression, posttraumatic stress disorder (PTSD), anxiety, suicide, and self-harm, is well known (for a review, see Dillon, Hussain, Loxton, & Rahman, 2013). Women with a history of IPV have a 2-3 time increased risk of meeting the criteria for PTSD as compared with women without this history (Fedovskiy, Higgins, & Paranjape, 2008; Nerøien & Schei, 2008; O’Campo et al., 2006). In the review of Dillon et al. (2013), the reported lifetime suicide attempts among women exposed to male violence ranged from 1% to 12%. Mental health problems among women with substance abuse problems and who have experienced male violence is another understudied area.
The Aim of This Study
The first aim of this study was to investigate the extent to which women with substance abuse problems have been exposed to male violence during their lifetime, as well as the relation with the perpetrator(s). The second aim was to examine possible differences in these variables, between WR and HW. Specific areas included were (a) childhood history and present life situation, (b) substance abuse and physical health problems, (c) experienced male violence, and (d) self-reported mental health problems.
Method
Study Sample
The study sample consisted of 79 women: 35 women (WR) from an outpatient treatment for women with substance abuse problems, WR, and an ordinary life, and 44 HW with substance abuse problems in contact with Social Services in Stockholm, and staying in shelters or institutions for the homeless, in training apartments or sleeping in friends’ flats.
The mean age of the 79 women was 47.6 (SD = 10.0; range = 21 to 68) years; 35 WR (M age = 48.3, SD = 10.2, range = 27 to 68 years), and 44 HW (M age = 47.0, SD = 10.0, range = 21 to 65 years). Almost all, 97%, of WR had Swedish nationality, whereas 3% had a nationality from a non-Nordic country. Among HW, 91% had Swedish nationality, and 9% had other Nordic nationalities. Among the HW, 79% had been homeless for 5 years or more. Between March 2009 and April 2010, most of the patients in an outpatient treatment for women with substance misuse problems in Stockholm, Sweden, and most of the HW with substance misuse problem in contact with an office at Social Services in Stockholm were invited by researchers, staff at the outpatient treatment, or social workers to participate in the study. In total, 143 women without serious or acute psychiatric problems received the invitation: 69 WR and 74 HW. Most of the HW had not received treatment for substance abuse problems
The criteria for inclusion were being a woman with substance abuse problems and understanding Swedish. The WR were characterized by having a residence (owned or rented) with a permanent address and a rather orderly life (contact with the labor market, family, and social network) and the HW by not having a residence (owned or rented), without a permanent address, relying on temporary housing options, and living rough on the streets or in shelters, or temporarily in institutions. Of the 143 invited women, 45 women (34 WR and 11 HW) declined participation, 10 HW did not respond, and nine HW agreed to participate but failed to come to the on-site session. The 34 WR who declined participation had an average age of 46.7 (SD = 9). Of the 30 HW who dropped out of the study, the age was known for 27 of them, with an average age of 43.5 (SD = 7) years. Although this average is younger than for the participants, it is in line with results on the population of HW with substance abuse problems in a 2000-2002 Stockholm study, reporting an average of 43 years (Finne, 2003).
Measurements
The following questionnaires were included in this study:
A Swedish version of the WHO Questionnaire of Male Violence Against Women (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005; Nyberg, Taft, & Krantz, 2013; World Health Organization, 2005) was used, consisting of 22 questions covering areas such as experience of men’s physical violence (seven items), psychological violence (11 items), sexual abuse (four items), and number and incidence of assault in relation to each man during the last 12 month (from 0 times to >5 times). For experienced violence earlier in life, the alternative answer was only “yes” and “no.” An additional question was included by the authors of this study: “Have you ever been forced to commit criminal acts?” Additional questionnaire areas, formulated by the authors for this study, concerned domestic violence, awareness of or witnessed between adults during childhood, relation to male perpetrator (partner, father, acquaintance, etc.), whether the violence was reported to the police, whether the report resulted in prosecution, any help/support they received and from whom, and experienced satisfaction with this help/support.
Addiction Severity Index (ASI; the National Board of Health and Welfare, 2007; based on McLelland, Cacciola, Alterman, Rikoon, & Carise, 2006), an objective face-to-face structured interview instrument consisting of 161 items, was used for information about self-rated substance abuse problems (drug/alcohol use, including drunkenness, use of illicit drugs, past 30 days and lifetime use), physical and psychological health, family situation, marital status, children, and experience of the justice system. In this study, each domain is calculated 0 and 1 (1 = yes).
Impact of Event Scale–Revised (IES-R; Weiss, 2004; Weiss, & Marmer, 1997) was used to measure the subjective response to traumatic events and symptoms of posttraumatic stress. In this study, it was used in connection to the reported experience of male violence. The questionnaire contains 22 questions (about intrusive thoughts, nightmares, intrusive feelings and imagery, dissociative-like re-experiencing, numbing of responsiveness, avoidance of feelings, situations, and ideas, anger, irritability, hyper vigilance, concentration difficulties), with a scale of 0 to 4 (0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely). The cut-off level for meeting criteria for PTSD was 33 out of 88 points (for further information, see Birath Scheffel, Beijer, DeMarinis, & af Klinteberg, 2013).
Procedure
The WHO Questionnaire of Male Violence Against Women and IES-R were completed by the participants in the presence of one of the researchers/authors, to address any questions raised. Regarding the ASI Questionnaire, the participants were interviewed by researchers/authors who filled in the form. The questionnaire completion process took place at an outpatient clinic specialized for women with alcohol dependence problems, social service offices, or shelters/institutions for homeless people.
Ethics
The study was approved by the Stockholm Regional Ethics Committee (No 2009/2144-31/5).
Data Analyses
Chi-square tests were conducted and Fisher’s exact test was used (p < .05) to analyze the relationships between all WR and HW concerning childhood history, present life situation, substance abuse problems, and physical health problems, and between those among the WR and HW who have been exposed to male violence concerning relation to the male perpetrators, number of violence from men, number of occasions of violence, type of violence, and mental health problems. To analyze the risk between WR and HW in these subjects, relative risk/risk ratio (RR) with confidence interval (CI) was used, as RR can be used even in small data samples by comparing frequencies in crosstab statistics in SPSS 19.
Results
Most of the women with substance misuse problems, 72 of the 79 (91.1%), had experienced physical, psychological, and/or sexual violence from men—83% of WR and 98% of the HW—where HW had a higher risk than WR of exposure to male violence (RR = 1.18, 95% CI = [1.01, 1.38], not shown in table).
Characteristics of Women With Experience/No Experience of Male Violence
Only seven of the 79 women (six WR and one HW) had not experienced any physical or psychological male violence. All seven had completed college or university studies, which was not the case for the 72 abused women, where only half of them (51%) had completed education at the same level (p = .16, RR = 1.95; 1.55-2.44, not shown in table). Moreover, the women who had not experienced male violence had lived to a higher degree with their parents up to age 16 (71% vs. 39%), were cohabiting or married (86% vs. 22%), and had work (71% vs. 39%). Fewer in the group of women who had not experienced violence had been drinking alcohol before age 15 (29% vs. 61%), had received medication for physical problems (14% vs. 47%), and had experience of anxiety (57% vs. 81%) or suicidal ideation (14% vs. 54%).
Experience of Male Violence—Comparison Between WR and HW Groups
When comparing the WR and HW groups concerning experience of male violence, results indicated a more severe position for the HW group participants. As presented in Table 1, HW had a 3 time higher risk compared with WR, to having experienced violence from a current partner, and almost a 6 time higher risk to having experienced violence from a male friend or acquaintance. Furthermore, 51% of HW had experienced “violence from five men or more in life,” compared with only 3% of WR. Although 48% of WR had experienced violence only from “1 man ever in life,” the figure here was only 12% of HW. There was a significant difference between the groups in occasions of violence, where 84% of the assaulted HW and 52% of WR had experienced “countless occasions of violent events.” Furthermore, there was also a highly significant difference between the groups concerning being “forced to commit criminal acts,” where HW displayed almost a 4 time higher risk compared with the WR. There were no significant differences between the two groups of women in having experienced male psychological, physical, and/or sexual violence (see Table 1).
Experience(s) of Male Violence Among 72 Women: 29 WR and 43 HW.
Note. Results of chi-square, Fisher’s exact test, between WR and HW, significance level, and RR with CI. WR = women with a residence; HW = homeless women; RR = relative risk; CI = confidence interval.
Mental Health Problems in WR and HW With Experience of Male Violence
Regarding the women’s experience of “posttraumatic stress reported as a result of violence,” there was a significant difference between the groups in that the HW showed almost a 4 time higher risk compared with WR. The groups also significantly differed concerning “ever received treatment for mental problems,” where more WR (74%) than HW (46%) had received such treatment. Finally, there were no significant differences between the two groups concerning other mental health issues (received medical treatment for mental problems, been depressed, had serious anxiety, difficulties to concentrate, had problems with violent behaviors, and thoughts of suicide and attempted suicide; Table 1).
Childhood History and Present Life Situation in WR and HW With Experience of Male Violence
There were significant differences between WR and HW in some history of childhood variables, as presented in Table 2, and in present life situation, where the WR were raised in more stable circumstances compared with the HW. For example, of the two thirds (67%) of the women who had experienced parental substance abuse problems, it was significantly more likely to have occurred among HW (RR 1.64) than among WR. The HW were also more than twice as likely to have been aware of domestic violence between adults during their childhood. However, there was no difference between groups concerning having witnessed such domestic violence in childhood. Furthermore, HW had nearly three times higher risk (RR 2.85) of being criminally prosecuted (Table 2).
Childhood History, Present Life Situation, and Substance Abuse and Physical Health Problems, Frequencies (n), and Percentages (%) of All 79 Women With Substance Misuse (35 WR and 44 HW), and of Those 72 Women Who Experienced Male Violence (29 WR and 43 HW).
Note. Results of chi-square, Fisher’s exact test, between HW and WR, significance level, and RR with 95% CI. WR = women with a residence; HW = homeless women; RR = relative risk; CI = confidence interval.
The number of participants in one of the groups is <2.
Treated according to the law The Care of Drug and Alcohol Abusers Act (the National Board of Institutional Care, 2007).
Substance Abuse and Physical Health Problems in WR and HW With Experience of Male Violence
Regarding substance abuse problems among the women with experience of male violence, there were significant differences between the groups in “alcohol consumption and/or tested illicit drugs before the age of 15 yrs,” and “ever having injected illicit drugs,” where HW displayed a higher risk, and only HW had “ever been forced to treatment” according to The Care of Drug and Alcohol Abusers Act.
Significantly more WR, however, reported “use of alcohol as the dominant drug” (see Table 2). There were no significant differences between women with alcohol as a dominant drug and women with illicit drugs as a dominant drug concerning perpetrator, with the exception of violence from “male friends or acquaintance” where women with illicit drugs had a higher risk (RR = 1.36, 95% CI = [1.01, 1.84], not shown in table).
Regarding reported physical health problems, results revealed that HW had a significantly higher risk of “prolonged physical damage/illness,” and almost 75% of them reported having Hepatitis C virus infection (HCV), significantly differing from WR. Furthermore, one sixth of the HW reported having HIV, whereas none did of the WR (Table 2). However, there was no significant difference between the two groups of women concerning “received medication for physical problems” (Table 2).
Characteristics of WR and HW With Experience of Male Violence—Having Been Forced to Commit Criminal Acts
Among WR and HW, 36% of the women who had been exposed to male violence also had been “forced to commit criminal acts.” Results indicated a 4 time higher risk of HW than WR (see Table 1). This subgroup of women who had been forced to commit criminal acts, was significantly more often found to be homeless, had witnessed domestic violence during childhood, had experienced parental alcohol and/or drug problems, had consumed alcohol or tested illicit drugs before age 15, had used illicit drugs as a dominant preparation, and had injected illicit drugs (Table 3). Furthermore, the subgroup members were more likely to have experienced countless occasions of violent events, sexual violence, prosecution for crime (mostly drug crimes and property crimes, not shown in table), and HCV (Table 3).
Frequencies (n) and Percentages (%) for Characteristics of Women With Substance Misuse Problems, Having Been Forced to Commit Criminal Activities (n = 26) or Not Experiencing This (n = 46).
Note. Results of chi-square, Fisher’s exact test, significance level, and RR with 95% CI. WR = women with a residence; HW = homeless women; RR = relative risk; CI = confidence interval.
Discussion
This is one of the few studies that examine male violence against women with substance misuse problems, and the only one that includes WR and a rather orderly life (WR), and HW. We found that the majority of the total study population had experienced male violence.
Differences and Similarities Between WR and HW
Among the women who experienced male violence, there were, as expected, major differences between WR and HW in childhood history, including schooling, present life situation, substance abuse problems, and prolonged physical ill health. Among HW, the proportion of illicit drug users was high, and therefore, the high rates of HCV and HIV among the HW was not unexpected, as HW in Sweden had high rates of these diseases (Beijer & Andréasson, 2009). A review and systematic meta-analysis also indicated that the prevalence of HIV, Hepatitis C, and other infectious diseases are high among HW and men globally, diseases that can be related to drug abuse (Beijer, Wolf, & Fazel, 2012).
The similarities between the two groups of women were mainly witnessing domestic violence during childhood, having parents with mental health problems, having been exposed to male violence, and having taken medication for physical problems. To have witnessed domestic violence in childhood was connected with substance abuse problems later in life (Dube, Anda, Felitti, Edwards, & Williamson, 2002). In an early study of drug abuse and partner violence among women in methadone treatment, those who experienced IPV had a more frequent history of childhood victimization, and having witnessed their mother being abused (El-Bassel et al., 2000). Furthermore, having a parent with mental health problems was reported to be related to alcohol or illicit drug problems later in life for women (af Klinteberg, Almquist, Beijer, & Rydelius, 2011). Physical diseases have been well documented as common among persons with substance abuse problems (Lim et al., 2012).
Experience of Male Violence
The proportion of women victims of male violence was higher in the present study compared with other international studies (e.g., Martin et al., 1998), however not as compared with a Swedish study of 103 women with severe substance misuse problems, where 92% of them had experienced violence in adulthood (Holmberg, Smirthwaite, & Nilsson, 2005). That study covered women in treatment for substance abuse problems, and HW, in line with the present study, which may explain the high level of experienced male violence. The most common perpetrator was a former partner, and one third had experienced different kinds of violence from a father or male relative, mainly during childhood. Other studies also showed a link between experiences of abuse in childhood and alcohol or drug problems in adulthood among women (Birath Scheffel, DeMarinis, & af Klinteberg, 2010; Downs, Capshew, & Rindels, 2004; Rydelius, 1997; Spak, Spak, & Allebeck, 1997).
We found no differences in dominant preparation use in relation to violence by different perpetrators, with the exception of the women using illicit drugs and experiencing violence from a male friend or acquaintance. More HW than WR have illicit drugs as the dominant preparation. The women using illicit drugs were more exposed to violence from male acquaintances, which is consistent with the findings from the Marshall et al. (2008) study.
Forced to Commit Criminal Acts
The fact that women with substance abuse problems, in the present study, reported that they had been forced by men to commit criminal acts is something rarely documented. Although the most vulnerable to this ill treatment were HW, there were also some WR who reported this experience. A new finding in this study is that women who had been forced to commit criminal acts, compared with those who had not, also had a higher risk of being sexually assaulted. This finding might be of use as an indication of special treatment and care needs for these women. An addicted HW lives in a hazardous environment where she can encounter different types of male violence, which makes her particularly vulnerable and threatens her mental and physical health (Bourgois et al., 2004; Epele, 2002). Furthermore, the women who had been forced to commit crimes obviously had a higher risk of being criminally prosecuted. The number of crimes they had been forced to commit is however not known, but could be the subject of further research.
Mental Health
The degree of reported mental health problems was high among these women exposed to male violence. This is in line with evidence that patients in treatment for substance abuse problems with a history of experienced violence have poorer outcomes than patients with no history of experienced violence (Pirard, Sharon, Kang, Angarita, & Gastfriend, 2005; Rosen, Ouimette, Sheik, Gregg, & Moos, 2002). We therefore suggest that they have more complex treatment needs compared with other groups with substance abuse, which has also been highlighted in earlier research (Clark, & Power, 2005; Schäfer et al., 2009). Nearly half of the women (46%) in this study had met criteria for PTSD. The majority of women attributed their posttraumatic symptoms to their experience of male violence. The findings here can be related to a study of 753 women in methadone treatment, where those with a lifetime exposure to intimate partner violence had the highest risk of having PTSD (Engstrom, El-Bassel, & Gilbert, 2012). The HW had an almost 4 time higher risk of PTSD compared with WR, which might be explained, at least in part, by their precarious living situation and resulting exclusion from ordinary social life. At the time of the on-site session, fewer WR were living with a partner who had assaulted them, and all the WR were currently in regular treatment for their substance abuse problems. In contrast, many of the HW were still living together with partners (in the homelessness situation) who had assaulted them, and the majority of the HW had no ongoing treatment for alcohol or drug problems.
Methodological Considerations
Even if, to our knowledge, this is the first study in Sweden examining male violence against these two groups of women with substance abuse problems (WR and HW), there are drawbacks that have to be mentioned. First, the rather small sample size and the relatively high drop-out rate limit the generalization of the results. Furthermore, the potential for memories to be limited and biased, mainly regarding reports about violent situations and childhood experiences, should be considered. The subjects in focus are, however, difficult to reach for this kind of study. Another drawback is that we did not have access to detailed psychiatric diagnostic information. In the light of the importance of cultural-context analysis for research, it is worth noting that our Swedish experience results might not extend to other cultures or ethnic groups. However, despite these limitations and notation, the study results might, if cautiously interpreted, give some broadened knowledge and inspire future exploration of the psychological situation and mental health status for these women, as well as similarities and differences between those two groups of women in the society.
Conclusion
The study results suggest that women with substance abuse problems, both WR and HW, are exposed to an alarming degree of male violence. This places special demands on society for early detection of risk of and exposure to violence, and for meeting the needs of these populations with supporting interventions. The present data highlight that male violence against women seriously affects these women psychologically. It is noteworthy, that experienced male violence was reported to be associated with symptoms of PTSD by these women. Thus, it is suggested that such experiences are to be considered in all different forms of treatment facilities for women with substance abuse problems, as well as in other societal services that meet women with these problems. The women in the current study are burdened with substance abuse problems and difficult life situations in that they, to a high degree, experienced male violence, a multi-faceted violence including the forcing of women to commit criminal acts. Considering the psychological, social, physical, and cyclical (inter-generational) consequences for those who had such experiences, as well as for society, framing this topic as a public health concern certainly can and should be further investigated (Birath Scheffel, Beijer, DeMarinis, & af Klinteberg, 2014). Such an investigation would be most fruitfully undertaken by the evidence-based strategy whereby mental health is understood as an integral component of public health, and that it has a significant impact on individual countries and their human, social, and economic capital (Wahlbeck, 2011). The particular vulnerability of women with substance abuse to male violence has an impact not only on the human, social, and economic capital of the women themselves but also on society at large.
Footnotes
Acknowledgements
Special thanks are given to all the women who participated in the study, sharing their thoughts, feelings, behaviors, and experiences. We are further grateful to Associate Professor Marlene Stenbacka for valuable comments on the initial planning of the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by grants from the Crime Victim Compensation and Support Authority (Dnr: 03663/2009, to B.a.K.); the Kempe–Carlgrenska Foundation (Dnr 2013, to B.a.K.); the Swedish National Institute of Public Health (Dnr: VERK 2013/502, to B.a.K.); Uppsala University IMPACT research program grant, Wellbeing and Health area (to V.D.); and Uppsala University post-doctoral research grant (to C.S.B.).
