Kathryn E. Moracco

Femicide in North Carolina, 1991-1993: A Statewide Study of Patterns and Precursors

This population-based study describes all 586 North Carolina femicide victims age 15 and older between 1991 and 1993. We combined reviews of medical examiner records with interviews of law enforcement officers to obtain information about the events and the contexts in which the Femicides occurred. Victimization rates were highest for African American and young women. Fifty-four percent of the femicides were committed with firearms and 67% occurred at a residence. More than half the women were killed by current or former intimate partners; at least 67% of these cases were preceded by domestic violence. Nonpartner femicides often involved multiple overlapping circumstances such as criminal activity, drug-related activity, and arguments. The findings demonstrate the complexity of femicide and the need to disentangle the many contributing factors. Medical examiner data and law enforcement interviews proved complementary, but information gaps still exist, signaling possibilities for changes in data collection, as well as needs for further research.

Physical and Sexual Assault of Women With Disabilities

North Carolina women were surveyed to examine whether women’s disability status was associated with their risk of being assaulted within the past year. Women’s violence experiences were classified into three groups: no violence, physical assault only (without sexual assault), and sexual assault (with or without physical assault). Multivariable analysis revealed that women with disabilities were not significantly more likely than women without disabilities to have experienced physical assault alone within the past year (odds ratio [OR] = 1.18, 95% Confidence Interval [CI] = 0.62 to 2.27); however, women with disabilities had more than 4 times the odds of experiencing sexual assault in the past year compared to women without disabilities (OR = 4.89, 95% CI = 2.21 to 10.83).

Changes in Intimate Partner Violence During Pregnancy

Womens experiences of partner violence, both before and during pregnancy, are described using a convenience sample of women recruited from prenatal clinics. Included were an “index group” of women who told their clinicians that they had been physically abused during pregnancy, and a “comparison group” of women who told their clinicians that they had not been physically abused during pregnancy (even though later more detailed assessment found that some of these comparison women had experienced such violence). The women averaged 27 years of age, with 83% being high school graduates, 26% being married, and 66% having had previous children. The Conflict Tactics Scales 2 assessed rates of partner violence victimization of the women and their male partners, including psychological aggression, physical assault, and sexual coercion. Injuries also were assessed. Results showed that comparison men were physically assaulted at significantly higher rates than were their female partners, both before and during pregnancy (even though these victimization rates were much lower than those seen among the index couples). Index women experienced higher rates of psychological aggression, physical assault, and sexual coercion than did their male partners, and these women were significantly more likely than their male partners to be injured. Pregnancy onset was associated with significant increases in the rates of psychological aggression among both the index and comparison couples. In addition, the index women experienced a significantly increased rate of sexual violence victimization during pregnancy. However, pregnancy was not associated with significant increases in the rates of physical assault or violence-related injuries among the index or comparison couples.

Partner homicide-suicide involving female homicide victims: a population-based study in North Carolina, 1988-1992.

Homicide-suicide is a form of fatal violence in which an individual commits homicide and subsequently kills him- or herself. One hundred and sixteen homicide-suicide events involving 119 female homicide victims in North Carolina from 1988-1992 were identified through state medical examiner files. Case files were reviewed retrospectively to identify event characteristics, precursors, and typologies. In 86% of cases the perpetrator was the current or former partner of the victim. During the study period, 24% of men who killed their female partners in North Carolina subsequently committed suicide and another 3% attempted suicide but survived. Victim separation from the perpetrator was the most prevalent precursor (41%), followed by a history of domestic violence (29%). In nearly half of the cases with a history of domestic violence, the victim had previously sought protection from the perpetrator in the form of an arrest warrant, restraining order, or intervention by a law enforcement officer. Children of the victim (and/or perpetrator) witnessed the homicide-suicide, were in the immediate vicinity, found their parents’ bodies, or were killed, in 43% of cases. The prevalence of separation and domestic violence suggests several potential points of intervention, including stronger domestic violence legislation. Future research should place priority on assessing the impact of partner homicidesuicides on the families in which they occur. Such studies are essential for the informed development of preventive and therapeutic interventions for the families of both the victims and perpetrators of these fatal events. In addition, research focused on assisting men in coping with issues of control and separation is needed.

Partner homicide in context: a population-based perspective.

The authors used a combination of medical examiner data and police interviews to develop profiles of all partner homicides that occurred in North Carolina in a single year. This methodology allowed us to investigate gender differences that might shape the context for male and female homicide perpetration and victimization. Five themes emerged: (a) The context for partner homicides is often chronic women battering, (b) leaving an abusive partner and remaining are both dangerous options, (c) protective measures for battered women are inadequate, (d) domestic violence is not necessarily private violence, and (e) alcohol and firearms often accompany homicide. These themes suggested: Partner homicides emanated almost uniformly from a history of male-perpetrated aggression; analysis of partner homicide should not be detached from the daily life created and sustained by battering; and a gender analysis of partner homicide focuses on the context of gender-based power imbalances rather than on frequency or severity of injury.

Knowledge and Attitudes About Intimate Partner Violence Among Immigrant Latinos in Rural North Carolina Baseline Information and Implications for Outreach

To create appropriate intimate partner violence (IPV) services for Latino immigrants, practitioners must be aware of their needs. We conducted interviews with 100 recent Latino immigrants in a rural North Carolina county. Overall, IPV was not perceived to be a problem; however, men and women differed in their perceptions. Men were more likely to agree with IPV myths, and both men and women felt that IPV had a detrimental impact on children. Many did not know about the local domestic violence agency, and knowledge about protective orders was limited. Outreach should emphasize the seriousness of IPV, adapt content for gender-specific audiences, and increase awareness about local resources.

Preventing Intimate Partner Violence: Screening Is Not Enough

PHYSICAL, SEXUAL, AND PSYCHOLOGICAL ABUSE OF WOMen by their intimate partners is common around the world. In response to this widespread public health problem,organizationsofhealthcareprofessionals, including the American Medical Association and the American College of Obstetricians and Gynecologists recommend that alladult femalepatientsbeaskedroutinelyaboutabuse, regardless of their presenting symptoms. However, evidence-based guides to clinical preventive services, such as the US PreventiveServicesTaskForce and theCanadianTaskForceonPreventive Health Care, have concluded that there is insufficient evidence of health benefits to abuse survivors to recommend fororagainstscreeningfor intimatepartnerviolence(IPV),primarily due to methodological weaknesses of available studies. In this issue of JAMA, MacMillan et al address this lack of evidence in the report of a trial that randomized women presenting for care in emergency departments, family practices, and obstetrics/gynecology clinics to be screened for abuse before seeing a clinician or to be seen by a clinician without being screened for abuse. It was then at the discretion of clinicians to discuss abuse (if present) or to make referrals for IPV services. To ensure a minimum standard of care for all women participating in the study, each participant, regardless of screening status, was given a printed card with names and telephone numbers of local agencies and telephone hotlines for women exposed to violence. Screening took place in primary care facilities where clinicians had received standardized training in responding to IPV. After 18 months of follow-up, the difference in recurrence of IPV for screened vs nonscreened women was not statistically significant, and a slight improvement in quality-of-life scores for the screened group was no longer statistically significant after a multiple imputation technique was used to account for loss to follow-up of study participants. Therefore, universal screening, which involves routinely asking all patients about abuse, was not found to be beneficial in this study. Universal screening should be distinguished from assessing abuse as a diagnostic test, which was not addressed in this study. Assessing abuse in women at increased risk may not only detect violence but may also lead to more accurate diagnosis and treatment of co-occurring health problems. MacMillan et al offer 2 possible interpretations for their study’s failure to demonstrate health and quality-of-life benefits of universal screening for exposure to IPV. First, the lack of demonstrated benefits may be attributable to limitations of the study methods and data. These limitations included potential errors in the measurement of violence, enrollment of women during an escalating period of violence that was likely to decrease over time even in the absence of screening (regression to the mean), unmeasured benefits to screened and unscreened women associated with being followed up by study personnel over time (Hawthorne effect), distribution of information about community resources to both screened and unscreened women (the printed card with local agencies’ information), approximately equal use of community resources by both groups, and loss to follow-up, which was 43% in the screened group and 41% in the nonscreened group. However, the authors conducted additional analyses to assess the sensitivity of their findings to these limitations, which confirmed that the most valid conclusion of their investigation was a lack of health benefits of universal screening. The authors’ alternative explanation is that the lack of efficacy of screening for IPV in this study may have been due to the lack of an evidence-based, effective intervention for IPV to accompany the screening. That is, if the clinicians had the opportunity to refer abused women to such an intervention, perhaps they would have been motivated to make more referrals. Similarly, if thestudyparticipantshadperceivedapotentialbenefit froman intervention for IPV,perhapsmorewomenwould havekept their appointmentsandremained in thestudy.Most important, if an interventionhadbeenavailable thatwaseffective in reducing violence and was acceptable to the study participants,measuredviolencesubsequenttoscreeningmighthave abated in thescreenedgroupmore thantheunscreenedgroup. Although interventions for IPV have not yet consistently been demonstrated to be effective in randomized trials, at least 3 approaches hold promise for ameliorating the deleterious effects of IPV and preventing recurrence of violence. First, the most widely used intervention for IPV survivors is referral to community resources, such as counseling, legal services, shelters, and other clinical and social services. In the United States, community-based domestic violence organizations usually serve as the hub for service provision for IPV survivors, offering direct services such as

The Influence of Stigma and Discrimination on Female Sex Workers’ Access to HIV Services in St. Petersburg, Russia

Stigma associated with HIV and risk behaviors is known to be a barrier to health care access for many populations. Less is known about female sex workers (FSW) in Russia, a population that is especially vulnerable to HIV-infection, and yet hard-to-reach for service providers. We administered a questionnaire to 139 FSW to better understand how stigma and discrimination influence HIV service utilization. Logistic regression analysis indicated that HIV-related stigma is negatively associated with uptake of HIV testing, while sex work-related stigma is positively associated with HIV testing. HIV-positive FSW are more likely than HIV-negative FSW to experience discrimination in health care settings. While decreasing societal stigma should be a long-term goal, programs that foster inclusion of marginalized populations in Russian health care settings are urgently needed.

Relationships Among Alcohol Outlet Density, Alcohol use, and Intimate Partner Violence Victimization Among Young Women in the United States

Greater access to alcohol has been widely found to be associated with many negative outcomes including violence perpetration. This study examines the relationship between alcohol outlet density, alcohol use, and intimate partner violence (IPV) victimization among young women in the United States. A direct association between alcohol outlet density in one’s neighborhood and the likelihood of IPV victimization was examined. Data were from Wave III of the National Longitudinal Study of Adolescent Health (Add Health), which followed a nationally representative sample of adolescents into adulthood. Participants were young adult females age 18 to 26 at Wave III. Of the 4,571 female respondents who reported a current heterosexual relationship and had IPV data, 13.2% reported having been the victim of physical violence only and 6.5% experienced sexual only or physical and sexual violence in the relationship during the past year. In the regression models tested, there was no significant direct association between neighborhood alcohol outlet density and IPV victimization nor was there an association between outlet density and drinking behaviors, thus eliminating the possibility of an indirect association. Results of fully adjusted models indicate females who drank heavily, whether infrequently or frequently, were at significant risk for experiencing sexual only IPV or sexual and physical IPV. Asians and Native Americans were at significantly greater odds of experiencing sexual only or sexual and physical IPV compared with non-Hispanic Whites, while non-Hispanic Blacks were at significantly greater odds for physical only IPV. We conclude that a continuous measure of alcohol outlet density was not associated with IPV in models controlling for individual and other neighborhood characteristics. Young women who drink heavily, whether infrequently or frequently, have greater odds of experiencing sexual only or sexual and physical compared to abstainers. Similar to previous study findings, young women living with or married to their partner were at far greater risk of experiencing physical only and/or sexual only or sexual and physical IPV. The study adds to the growing body of literature that examines how community characteristics such as outlet density influence the likelihood of IPV.

Future directions for violence against women and reproductive health: science, prevention, and action.

Despite the recognition that violence may be associated with serious consequences for womens reproductive health, the understanding of the relationship between the two remains limited, as does our understanding of the most effective role for reproductive health care providers and services. This paper briefly summarizes the history of the nexus of public health, health care, and violence against women in the United States. In addition, we present some considerations for future directions for research, health care practice, and policy that will advance the understanding of the complex relationship between violence and reproductive health.