Facets of Male Violence Against Women With Substance Abuse Problems: Women With a Residence and Homeless Women

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

substance abuse problems male violence homelessness women with a residence PTSD criminal activity public mental health

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).

Table 1.

Experience(s) of Male Violence Among 72 Women: 29 WR and 43 HW.

	All	WR	HW	p Value	RR (CI)
	n (%)	n (%)	n (%)	p Value	RR (CI)
Relation to the male perpetrator
Current partner	17 (24)	3 (10)	14 (33)	.046	3.15 [0.99, 9.99]
Former partners	63 (88)	23 (79)	40 (93)	ns	1.17 [0.96, 1.44]
Father or male relative	22 (31)	10 (34)	12 (28)	ns	0.81 [0.40, 1.62]
Male friend or acquaintance	19 (26)	2 (7)	17 (40)	.002	5.73 [1.43, 22.96]
Male official, including police	12 (17)	2 (7)	10 (23)	ns	3.37 [0.80, 14.28]
Violence from number of men
1 man in the last year	18 (25)	4 (14)	14 (33)	ns	2.36 [0.86, 6.46]
2 men or more in the last year	10 (14)	1 (3)	9 (21)	.042	—
1 man ever in life	19 (26)	14 (48)	5 (12)	.001	0.24 [0.10, 0.60]
2-4 men in life	30 (42)	14 (48)	16 (37)	ns	0.77 [0.45, 1.32]
5 men or more in life	23(32)	1 (3)	22 (51)	.000	—
Number of occasions of violence
1-20 violent events in life	9 (13)	6 (21)	3 (7)	ns	0.34 [0.09, 1.24]
21-100 violent events in life	12 (17)	8 (28)	4 (9)	ns	0.34 [0.11, 1.02]
Countless occasions of violent events	51 (71)	15 (52)	36 (84)	.007	1.62 [1.11, 2.36]
Type of violence
Psychological violence	71 (99)	28 (97)	43 (100)	ns	1.04 [0.97, 1.11]
Physical violence	65 (90)	24 (83)	41 (95)	ns	1.15 [0.96, 1.38]
Sexual violence	44 (61)	17 (59)	27 (63)	ns	1.07 [0.73, 1.57]
Forced to perform criminal acts	26 (36)	4 (14)	22 (51)	.001	3.71 [1.43, 9.65]
Mental health problems
Symptoms of posttraumatic stress reported as a result of violence	33 (46)	5 (17)	28 (65)	.000	3.78 [1.65, 8.63]
Ever received treatment for mental problems	42 (58)	23 (74)	19 (46)	.004	0.56 [0.38, 0.82]
Ever received medicines for mental problems	52 (72)	23 (79)	29 (67)	ns	0.85 [0.64, 1.12]
Has been depressed	56 (78)	26 (90)	30 (70)	ns	0.78 [0.61, 0.98]
Has had serious anxiety	58 (81)	26 (90)	32 (74)	ns	0.83 [0.67, 1.03]
Has had difficulty concentrating	53 (74)	23 (79)	30 (70)	ns	0.88 [0.67, 1.15]
Has had problem with violent behaviors	22 (31)	7 (24)	15 (35)	ns	1.45 [0.67, 3.10]
Has had thoughts of suicide	43 (60)	18 (62)	25 (58)	ns	0.94 [0.64, 1.37]
Has attempted suicide	26 (40)	11 (38)	15 (35)	ns	0.92 [049, 1.71]

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).

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).

	All 79	72 Women With Experience of Male Violence
	All	All	WR	HW	p	RR (CI)
	n (%)	n (%)	n (%)	n (%)	p	RR (CI)
Childhood history
Grew up with both parents to age 16	42 (53)	37 (51)	20 (69)	17 (40)	.018	0.41 [0.21, 0.80]
Domestic violence during childhood	25 (32)	23 (32)	5 (17)	18 (42)	.039	2.43 [1.02, 5.81]
Saw domestic violence	17 (27)	15 (21)	4 (14)	11 (26)	ns	1.86 [0.65, 5.26]
Parental alcohol and/or drug problems (mother and/or father)	52 (66)	48 (67)	14 (48)	34 (79)	.010	1.64 [1.10, 2.46]
Mental health problems in mother and/or father	25 (32)	23 (32)	12 (41)	11 (26)	ns	0.62 [0.32, 1.21]
Only completed/not completed primary school	35 (44)	35 (49)	3 (10)	32 (74)	.000	7.19 [2.43, 21.30]
College/university degree	20 (25)	16 (22)	13 (45)	3 (7)	.049	0.16 [0.04, 0.50]
Present life situation
Civil status/single	57 (72)	56 (78)	20 (69)	36 (84)	ns	1.21 [0.92, 1.60]
Has children	58 (73)	56 (78)	27 (93)	29 (67)	.011	0.72 [0.58, 0.91]
Employed	33 (42)	28 (39)	25 (86)	3 (7)	.000	0.08 [0.03, 0.24]
Ever been prosecuted for crimes	47 (59)	47 (65)	9 (31)	38 (88)	.000	2.85 [1.64, 4.95]
Substance abuse problems
Drank alcohol/tested drugs before age 15	46 (58)	44 (61)	12 (41)	32 (74)	.007	1.80 [1.13, 2.87]
Alcohol as the dominant drug	45 (57)	38 (52)	28 (97)	10 (23)	.000	0.24 [0.14, 0.42]
Illicit drugs as the dominant drug^a	34 (43)	34 (47)	1 (3)	33 (77)	—	—
Has ever injected illicit drugs	34 (43)	34 (47)	2 (7)	32 (74)	.000	10.79 [2.8, 41.6]
Has been forced to attend treatment^b	13 (16)	13 (18)	0	13 (30)	—	—
Physical health problems
Prolonged physical damage/illness	54 (68)	50 (69)	14 (48)	36 (84)	.002	1.73 [1.16, 2.56]
Received medication for physical problems	35 (44)	34 (47)	14 (48)	20 (47)	ns	0.96 [0.59, 1.58]
Hepatitis C virus infection	33 (42)	33 (46)	2 (7)	31 (72)	.000	10.45 [2.7, 40.3]
HIV	8 (10)	8 (11)	0	8 (19)	—	—

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).

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).

	Forced	Not Experiencing	p	RR (CI)
	n (%)	n (%)	p	RR (CI)
Childhood history
Saw domestic violence	9 (35)	6 (13)	.039	2.65 [1.06, 6.62]
Parental alcohol and/or drug problems (mother and/or father)	22 (85)	26 (57)	.019	1.50 [1.11, 2.20]
Mental health problems in mother and/or father	10 (38)	13 (28)	ns	1.36 [0.70, 2.66]
Criminality by mother or father	5 (19)	5 (11)	ns	1.77 [0.56, 5.55]
Only completed/not completed primary school	15 (58)	20 (43)	ns	1.33 [0.83, 2.11]
Substance abuse problems
Drank alcohol/tested drugs before age 15	22 (85)	22 (48)	.002	1.77 [1.26, 2.49]
Ever injected illicit drugs	18 (69)	16 (35)	.007	1.99 [1.24, 3.19]
Illicit drug as a dominant preparation	17 (65)	17 (37)	.028	1.77 [1.11, 2.83]
Number and type of violence from men
Countless occasions of violent events	25 (96)	26 (57)	.000	1.70 [1.31, 2.22]
Sexual violence	20 (77)	24 (52)	.040	1.47 [1.04, 2.09]
Criminal activity
Ever been prosecuted for crime	21 (81)	26 (57)	.043	1.43 [1.04, 1.96]
Health problems
Prolonged physical damage/illness	21 (81)	29 (63)	ns	1.28 [0.99, 1.71]
Hepatitis C virus infection	19 (73)	14 (30)	.001	2.40 [1.46, 3.94]
HIV	4 (15)	4 (9)	ns	1.77 [0.48, 6.49]
Ever received medicines for mental problems	19 (73)	33 (72)	ns	1.01 [0.76, 1.37]
Has attempted suicide	10 (38)	16 (35)	ns	1.11 [0.59, 2.07]
Meeting criteria for posttraumatic stress disorder	15 (58)	18 (39)	ns	1.47 [0.91, 2.40]

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.).

Author Biographies

Ulla Beijer is PhD in medicine, BSW, assistant professor at the Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden, and research leader at the unit of Research and Development in Sörmland, Sweden. Beijer has conducted research on gender, physical- and mental health and mortality among homeless, family psychosocial characteristics, and male violence against women with substance abuse problems including post-traumatic stress disorder symptoms. She has published thirty-five different publications; books, reports, articles, chapters, and is reviewer for ten international peer-reviewed journals.

Christina Scheffel Birath is PhD and licenced psychologist at Stockholm Centre for Dependency Disorders in Stockholm County Council and connected to Karolinska Institutet, Stockholm, Sweden. She has conducted research on women with substance use disorder and their children from a gender- and psychological perspective in terms of behavior, personality and psychological treatment methods. She has focused her work on motivational interviewing, relapse prevention and prolonged exposure to post-traumatic stress disorder (PTSD).

Valerie DeMarinis, Professor of Psychology of Religion and Cultural Psychology and Director of the Health Research area of the IMPACT Research Programme, Uppsala University; from 2015 Guest professor in Public Mental Health, Institution for Public Health, Umeå Medical School, Sweden; and from 2014 also Professor in Public Mental Health at Innlandet Hospital Trust and National Research Centre for Dual Diagnosis, Norway. Research areas: palliative care, addiction studies, transcultural psychiatry, public mental health, and migration, over 60 scholarly articles and chapters. She coordinates a Scandinavian task force in public mental health promotion.

Britt af Klinteberg, Professor of Psychology, Stockholm University/Karolinska Institutet, a member of the Swedish Government’s advisory board on Alcohol, Narcotics, Doping and Tobacco, since 2008. Her research focus is on dysfunctional impulse control, hyperactive behavior, attention and cognition as important intervening factors in the development of psychosocial disturbances, such as antisocial behavior, drug abuse and violence. She has published more than eighty scientific articles and chapters; is reviewer for a number of international journals.

References

af Klinteberg

Almquist

Beijer

Rydelius

P.-A.

(2011). Family psychosocial characteristics influencing criminal behaviour and mortality—Possible mediating factors: A longitudinal study of male and female subjects in the Stockholm Birth Cohort. BMC Public Health, 11, Article 756. doi:10.1186/1471-2458-11-756

Beijer

Andréasson

(2009). Physical diseases among homeless people: Gender differences and comparisons with the general populations. Scandinavian Journal of Public Health, 37, 93-100.

Beijer

Wolf

Fazel

(2012). Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: A systematic review and meta-analysis. Lancet Infectious Diseases, 12, 859-870.

Birath

S. C.

Beijer

DeMarinis

af Klinteberg

(2013). Women with substance abuse problems exposed to men’s violence—A public mental health challenge. Journal of Addiction Research & Therapy, 4, 149 doi:10.4172/2155-6105.1000149

Birath

S. C.

Beijer

DeMarinis

af Klinteberg

(2014). Barn till våldsutsatta kvinnor med missbruksproblem [Children of women with substance use problems exposed to violence]. Retrieved from http://www.folkhalsomyndigheten.se/documents/livsvillkor-levnadsvanor/barn-unga/stod-barn-familjer-missbruk/rapport-barn-till-valdsutsatta-kvinnor.pdf

Birath

S. C.

DeMarinis

af Klinteberg

(2010). Moods and expectancies of female alcohol drinking—An exploratory study. Scandinavian Journal of Caring Sciences, 24, 472-481. doi:10.1111/j.1471-6712.2009.00737.x

Bourgois

Prince

Moss

(2004). The everyday violence of hepatitis C among young women who inject drugs in San Francisco. Human Organization, 63, 253-264.

Centers for Disease Control and Prevention. (2014). Injury prevention & control: Division of violence prevention. Retrieved from http://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html

Clark

H. W.

Power

A. K.

(2005). Women, co-occurring disorders, and violence study: A case for trauma-informed care. Journal of Substance Abuse Treatment, 28, 145-146.

10.

Cunradi

B. C.

Caetano

Schafer

(2002). Alcohol-related problems, drug use, and male intimate partner violence severity among US couples. Alcoholism: Clinical & Experimental Research, 26, 493-500.

11.

Dillon

Hussain

Loxton

Rahman

(2013). Mental and physical health and intimate partner violence against women: A review of the literature. International Journal of Family Medicine, 2013, 1-15. Retrieved from https://dx-doi-org.web.bisu.edu.cn/10.1155/2013/313909

12.

Downs

W. R.

Capshew

Rindels

(2004). Relationships between adult women’s Alcohol problems and their childhood experiences of parental violence and psychological aggression. Journal of Studies on Alcohol, 65, 336-344.

13.

Dube

S. R.

Anda

R. F.

Felitti

V. J.

Edwards

V. J.

Williamson

D. F.

(2002). Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: Implications for health and social services. Violence and Victims, 17, 3-17.

14.

El-Bassel

Gilbert

Rajah

(2003). The relationship between drug abuse and sexual performance among women on methadone: Heightening the risk of sexual intimate violence and HIV. Addictive Behaviors, 28, 1385-1403. doi:10.1016/S0306-4603(02)00266-6

15.

El-Bassel

Gilbert

Wada

Witte

Schilling

(2000). Drug abuse and partner violence among women in methadone treatment. Journal of Family Violence, 15, 209-225.

16.

Engstrom

El-Bassel

Gilbert

(2012). Childhood sexual abuse characteristics, intimate partner violence exposure, and psychological distress among women in methadone treatment. Journal of Substance Abuse Treatment, 43, 366-376.

17.

Epele

M. E.

(2002). Gender, violence and HIV: Women’s survival in the streets. Culture, Medicine, and Psychiatry, 26, 33-54.

18.

Fedovskiy

Higgins

Paranjape

(2008). Intimate partner violence: How does it impact major depressive disorder and post traumatic stress disorder among immigrant Latinas? Journal of Immigrant and Minority Health, 10, 45-51.

19.

Finne

(2003). Statistik över socialtjänstens kontakter med missbrukare, hemlösa och psykiskt störda i Stockholm år 2001 [Statistics of social services contact with people with substance abuse problems, homeless, and people with mental disorders in Stockholm 2001] (FoU-Rapport 2003:6). Stockholm, Sweden: Socialtjänstförvaltningen [Social Services].

20.

Garcia-Moreno

Jansen

Ellsberg

Heise

Watts

(2005). WHO multi-country study on women’s health and domestic violence against women. Geneva, Switzerland: World health Organization. Retrieved from http://www.who.int/gender/violence/who_multicountry_study/Introduction-Chapter1-Chapter2.pdf

21.

Gilbert

El-Bassel

Chang

Roy

(2012). Substance use and partner violence among urban women seeking emergency care. Psychology of Addictive Behaviors, 26, 226-235.

22.

Golder

Connell

C. M.

Sullivan

T. P.

(2012). Psychological distress and substance use among community-recruited women currently victimized by intimate partners: A latent class analysis and examination of between-class differences. Violence Against Women, 18, 934-957.

23.

Holmberg

Smirthwaite

Nilsson

(2005). Mäns våld mot missbrukande kvinnor: ett kvinnofridsbrott bland andra [Male violence against women with substance abuse problems: A crime against women]. Stockholm, Sweden: Mobilisering mot narkotika.

24.

Holt

R. L.

Montesinos

Christensen

R. C.

(2007). Physical and sexual abuse history in women seeking treatment at a psychiatric clinic for the homeless. Journal of Psychiatric Practice, 13, 58-60.

25.

Lim

S. S.

Vos

Flaxman

A. D.

Danaei

Shibuya

Adair-Rohani

Ezzati

(2012). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380, 2224-2260.

26.

Marshall

Fairbairn

Wood

Kerr

(2008). Physical violence among a prospective cohort of injections drug users: A gender-focused approach. Drug and Alcohol Dependence, 97, 237-247.

27.

Martin

S. L.

Kilgallen

Dee

D. L.

Dawson

Campbell

(1998). Women in a prenatal care/substance abuse treatment program: Links between domestic violence and mental health. Maternal and Child Health Journal, 2, 85-94.

28.

McLelland

A. T.

Cacciola

J. C.

Alterman

A. I.

Rikoon

S. H.

Carise

(2006). The Addiction Severity Index at 25: Origins, contributions and transitions. American Journal on Addictions, 15, 113-124.

29.

The National Board of Health. (1994). Öppenvård för alkoholmissbrukare [Outpatient treatment for persons with alcohol misuse]. Stockholm, Sweden: Socialstyrelsen.

30.

The National Board of Health. (1996). Kursändring i missbrukarvården – mot öppnare former [Course change in substance abuse treatment—Towards more open forms]. Stockholm, Sweden: Socialstyrelsen.

31.

The National Board of Health and Welfare. (2006). Hemlöshet i Sverige 2005 [Homeless in Sweden 2005]. Stockholm, Sweden: Socialstyrelsen.

32.

The National Board of Health and Welfare. (2007). ASI Grund, mars 2007 [ASI base, March 2007]. Stockholm, Sweden: Socialstyrelsen.

33.

The National Board of Health and Welfare. (2011). Missbruk, Kunskapen, Vården [The substance abuse, knowledge, care]. Stockholm, Sweden: Elanders Sveriges AB.

34.

The National Board of Institutional Care. (2007). Socialstyrelsens allmänna råd; Tillämpning av lagen (1988:870) om vård av missbrukare i visa fall [The care of drug and alcohol abusers act] (SOSFS 1997:6). Västerås, Sweden: Edita Västra Aros.

35.

Nerøien

I. A.

Schei

(2008). Partner violence and health: Results from the first national study on violence against women in Norway. Scandinavian Journal of Public Health, 36, 161-168.

36.

Nyberg

Taft

Krantz

(2013). Psychometric properties of the WHO violence against women instrument in a female population-based sample in Sweden: A cross-sectional survey. BMJ Open, 3. Retrieved from http://bmjopen.bmj.com/content/3/5/e002053.short

37.

O’Campo

Kub

Woods

Garza

Jones

S. A.

Gielen

C. A.

. . . Campbell

(2006). Depression, PTSD, and comorbidity related to intimate partner violence in civilian and military women. Brief Treatment and Crisis Intervention, 6, 99-110.

38.

Official Reports of the Swedish Government. (2011) . Missbruksutredningens slutbetänkande [Substance misuse commission’s final report]. Stockholm, Sweden.

39.

Panchanadeswaran

El-Bassel

Gilbert

Chang

(2008). An examination of the perceived social support levels of women in methadone maintenance treatment programs who experience various forms of intimate partner violence. Women’s Health Issues, 18, 35-43.

40.

Pirard

Sharon

Kang

S. K.

Angarita

G. A.

Gastfriend

D. R.

(2005). Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes. Drug and Alcohol Dependence, 78, 57-64.

41.

Rosen

C. S.

Ouimette

P. C.

Sheik

J. I.

Gregg

J. A.

Moos

R. H.

(2002). Physical and sexual abuse history and addiction treatment outcomes. Journal of Studies on Alcohol, 63, 683-687.

42.

Rydelius

P.-A.

(1997). Annotation: Are children of alcoholics a clinical concern for child and adolescent psychiatrists of today? Journal of Child Psychology and Psychiatry and Allied Disciplines, 38, 615-624.

43.

Schäfer

Verthein

Oechsler

Deneke

Riedel-Heller

Martens

(2009). What are the needs of alcohol dependent patients with a history of sexual violence? A case-register study in a metropolitan region. Drug and Alcohol Dependence, 105, 118-125.

44.

Schneider

Burnette

M. L.

Ilgen

M. A.

Timko

(2009). Prevalence and correlates of intimate partner violence victimization among men and women entering substance use disorder treatment. Violence and Victims, 24, 744-756.

45.

Shannon

Logan

T. K.

Cole

Walker

(2008). An examination of women’s alcohol use and partner victimization experiences among women with protective orders. Substance Use & Misuse, 43, 1110-1128.

46.

Spak

Allebeck

(1997). Factors in childhood and youth predicting alcohol dependence and abuse in Swedish women: Findings from a general population study. Alcohol and Alcoholism, 32, 267-274.

47.

Statistics Sweden. (2011). Befolkningsstatistik 2011 [Statistic of the population 2011]. Örebro: Official Statistics of Sweden.

48.

The Swedish Council for Information on Alcohol and Other Drugs [CAN]. (2014). Drogutvecklingen i Sverige 2014 [Drug trends in Sweden 2014]. Stockholm, Sweden: CAN.

49.

Wahlbeck

(2011). European mental health policy should target everybody. European Journal of Public Health, 21, 551-553.

50.

Weiss

D. S.

(2004). The Impact of Event Scale–Revised. In Wilson

J. P.

Keane

M. T.

(Eds.), Assessing psychological trauma and PTSD (2nd ed., pp. 168-189). New York, NY: Guilford Press.

51.

Weiss

D. S.

Marmer

C. R.

(1997). The Impact of Event Scale–Revised. In Wilson

J. P.

Keane

T. M.

(Eds.), Assessing psychological trauma and PTSD: A handbook for practitioners (pp. 399-411). New York, NY: Guilford Press.

52.

Wenzel

S. L.

Leake

B. D.

Geldberg

(2001). Risk factors for major violence among homeless women. Journal of Interpersonal Violence, 16, 739-752.

53.

World Health Organization. (2005). WHO multi-country study on women’s health and life experiences: Questionnaire. Geneva, Switzerland: Department of Gender Women and Health, World Health Organization.