ACSSA Forum (transcript)

Antonia Quadara:    

My name is Antonia Quadara. I'm the coordinator at the Australian Centre for the study of sexual assault which is a research centre in the Australian Institute of Family Studies. This is an awesome turnout and I know it's not just because of the brownies, I know it's because this issue that Marika's going to present and speak to us today is a really key issue – it's something that from a practice and policy perspective, people are talking about.

I know that as coordinator I have had a lot of conversations with people in policy and practice areas talking about the impacts of domestic violence and more specifically the impacts of sexual violence in domestic violence – how do we address that, how do we talk about that, how do we provide services that best fit the needs of women experiencing that. So I'm really delighted to have Marika join us - Marika's from the University of Western Australia and has recently completed a PhD. which is in the process of being published, isn't it. You've got part A…

Marika Guggisberg:

No, that's the one.

Antonia Quadara:

That's part A isn't it?

Marika Guggisberg:

That's part A, that's right.

Antonia Quadara:

Which has been some quantitative analysis - as I said I saw Marika present in November last year at a symposium on vulnerable adults and the presentation was really great and really wonderful. Marika's been doing work in this area on vulnerable individuals and particularly vulnerability or locations of vulnerability, violence, gender, substance abuse, mental health issues, for some time. I'm really pleased to have her come all the way from the West to join us and talk with her about some of her recent research findings.

Marika Guggisberg: 

Thank you. Good afternoon everybody and thank you very much Antonia for inviting me to come and present on an issue that is very close to my heart and I would like to thank you to turn up in such great numbers and showing interest in this important issue. A little bit about myself first. I have been working in the area of violence between intimate partners, violence in families for 15-20 years now. I have been working in the Heroine Program in Switzerland as a social worker, before I came here to Australia. Something that really struck me was that all the people I encountered in the facility I was working with were young adults, men and women, and all of them shared one common experience – they had been victims of sexual violence before they were heavy drug addicted living on the street and then being allegeable for participating in the Heroine program. Sexual violence is something that is very close to my heart and I thank you for turning up and showing interest in my presentation.

The topic I am talking about is titled The Complex Interplay between Women's Exposure to Intimate Partner Violence, Mental Health and Substance Use. The study was commissioned by the Western Australian Government because professionals working with women realised that there was not only a mental health issue but increasingly they saw women using all sorts of substances, also in the context of violence and being exposed to mental health problems. But there was no research around so I was asked to specifically explore this interplay of the three phenomena.

I would like to draw your attention to the book that has been published last year. It is just half - as Antonia said - the quantitative part and all the statistics that I am going to show today are found in this book. It can be ordered by morebooks.com for no shipping costs. The qualitative part is still being processed for publication but I have included some things just to give you a taste and give you a more comprehensive picture of the issue.

I would like to start by introducing you to Sarah, a young woman of approximately 30 years. Nothing in her appearance indicates her ongoing exposure to intimate partner violence and severe mental health problems. They are associated with alcohol and drug use. Sarah has been married for nine years and she has two young daughters. She reported having being subjected to violence by her husband for the whole duration of her marriage which increased in severity over the years. I am telling you my ideas why that might be.

Three years ago Sarah was diagnosed with depression and an anxiety disorder. She also suffers from sleep difficulties and frequent panic attacks. Sarah uses psychotic substances for non-medical purposes and she says that these drugs are necessary as they have a calming effect. Sarah believes that her feelings of immediate danger and constant hyper-vigilance are the consequences of intimate partner victimisation. His violence is incontrollable and often leads to an escalation where I fear for my life, she says.

She tried to seek help from the police twice, which according to her was not an effective strategy. Sarah suffers from feelings of entrapment and helplessness and she has attempted suicide previously. She feels unable to leave the relationship due to her lack of financial resources and perceived emotional dependence on her husband. Sarah hopes that he will eventually change his behaviour. This is what I am going to talk to you about today.

I would like to give you an overview of my presentation and I am aware that I don't have much time so maybe I am going to be cut short. I would like to very quickly define some concepts which is important and then give you a background on the study. I am going to talk about associated health issues – mental health and substance use and the co-occurrence of these. But then I want to move beyond the objective assessment – I  want to give women a voice with this presentation.

Finally, I am connecting the dots and I am presenting you with a hypothetical, theoretical model that I developed as a result of this study and I am more than interested in your thoughts and your comments. Please have a look at that and give me feedback. I will finish this presentation with some concluding remarks.

Lets start with defining the concepts: Sexual violence is a very difficult issue to define and we know that also from the criminal law. Different terms are used in the literature. Sexual violence, sexual assault, rape, sexual abuse – what exactly do we mean? There is a whole range of behaviours included in the strategies by which sexual activity is obtained against the wishes and the will of somebody else.

It is important for me to tell you that my definition of sexual assault or sexual violence - I called it - is forced or demanded sexual activity against the will of the woman. No coercion was involved in this definition. The numbers that you see are really talking about forced sexual activity or demanded sexual activity, maybe under threat of physical violence. The intimate partner in my study was a person who is a current or former partner in an intimate relationship with somebody else regardless whether they were living together or apart at the time, and whether they shared children.

As a background of the study – as I said – it was commissioned by the Western Australian Government and it was supported by certain universities and a women's health centre where I also obtained access to women. All women who were already clients of either a government service or a non-government service which was a women's health centre, where they were eligible to participate if they were 18 years of age and if they were not accompanied by a man at the time of appearing. That was important because I wanted to protect women who may be in an abusive relationship. For example, women attended a service to obtain financial assistance or went to the GP for a check up or they participated in a working group.

Somebody working at these facilities invited the women while they were waiting in the waiting room to complete a questionnaire which was absolutely anonymous, no identifying data were required. Tick boxes and answer 96 questions about the experience of violence by an intimate partner, mental health problems and substance use issues. I also asked about illegal substances and that's the reason why it was really important to have the questionnaire completely anonymous. I also invited each and every participant to be interviewed after the completion of the questionnaire at the last page – asking them to provide contact information if they experienced, in their opinion, all three forms of the phenomena I was interested in – violence, mental health problems and substance use issues at the very time. Then they could provide me with a mobile phone number or an email address and I would contact them and set up an interview for qualitative in-depth interviews.

The data were collected between 2007 and 2008. As I said, the aim of the study was to find out what exactly is going on, how are these issues connected to each other - the exposure to intimate partner violence, mental health problems and alcohol and added drug use. I used standardized questionnaires for the study. There were four sections, demographic questions - I can't go into that during my presentation here but you'll find all the information in my book. 47 items asked about intimate partner violence, the violence assessment index and the controlling behaviour index developed by Dobash and Dobash. Mental health questions and alcohol and other drug use questions, I used the audit and questions from the National Drug Strategy Household Survey.

As you can see here with some of the findings, intimate partner violence victimisation is not mutually exclusive. 70.5 percent of the women in my study experienced at least one form of violence in the past six months prior to the study. Controlling behaviour was the most single form of victimisation with the prevalence of 15 percent. However, a formal test of significance for independence on distributions revealed a highly significant association. Under the assumption of independence I would have expected to find less than 23 women to experience sexual violence, physical violence and controlling behaviour at the same time – which you can see here in the middle. 24 percent experienced this with 55 women.

Similarly, under the assumption of independence I expected to find 24 or 25 women in the category outside of the Venn diagram not experiencing any form of violence, but there were actually 67. So, that led me to the conclusion that I have to build some categories where I compare different combinations of violence. This is what I did – comparison group one is the women in the middle of the Venn diagram experiencing sexual violence in additional to physical violence and in addition to controlling behaviour.

Group two: Were the women experiencing physical violence and controlling behaviour at the same time but there was no sexual violence involved. Group three: Were the women experiencing no physical forms of violence and group four: the reference group, those not experiencing any form of violence at all.

Let me move to associated health issues. I would like to show you some statistics around the co-occurrence of different forms of mental health problems and the co-occurrence of different forms of substance use issues. These are also called homotypic co morbidity because they are within one specific category. Co-occurring anxiety and depression was experienced by women in category one - those had experienced sexual violence is 73 percent. That is in stark contrast to the number of the other categories, 26 percent in group two, 15 percent in group three and 10 percent in group four.

I put in a trend line for you just for emphasis. A logistic regression revealed that women in group one when compared to those in group four were 23 times more likely to report co-occurring anxiety and depression. Looking at the reporting of co-occurring anxiety, depression with symptoms of PTSD, I found that 31 percent of women with sexual violence experienced that, compared to eight and nine percent in groups four and three, and 13 percent in group two. The regression analysis again demonstrated that women with sexual violence experienced this form of homotypic co morbidity at a factor of six I should say, compared to group four – they were six times more likely - the odds increased by six if they experienced sexual violence.

Looking at potential alcohol dependence and nicotine dependence you see a similar trend. 35 percent of women with sexual violence reported co-occurring potential alcohol dependence and cigarette smoking versus eight percent in group two. Only one woman in group three and two women in group four reported this substance use issue – again with the likelihood of six with the factor of the regression analysis.

Looking at alcohol dependence and illicit drug use you see a similar trend – 27 percent of women with sexual violence compared to 13 percent with women also experiencing physical violence and controlling behaviour. The same as women in category one, but there is no sexual violence involved. Two women in the other two categories fell also there. Heterotypical mobility is when different categories are involved. I looked at co-occurring single and multiple mental health and substance use problems of the different categories.

Alcohol dependence and anxiety was experienced by 44 percent of women in group one compared to 18 percent in group two and six percent in group three. Those not experiencing any form of intimate partner violence here in the past six months there was one woman who also reported this form of heterotypical mobility. I ran a regression analysis between group one and two and found out that women with sexual violence experiences were four times more likely to report co-occurring anxiety and potential alcohol dependence.

Examining depression and potential alcohol dependence the trend is the same. 40 percent of women in group one versus eight percent of women in group two. Two women in group three and one person in group one, one of 67 also experienced depression and potential alcohol dependence with no violence at all. The regression analysis here between group one and two demonstrates that women with sexual violence were eight times more likely to report depression and co-occurring alcohol dependence. Then we move into complex co morbidity looking at anxiety and depression associated with potential alcohol dependence and nicotine dependence. The other categories fall away. 14 out of the 55 women or one in four in group one reported this form of complex co morbidity and there was one person in group two. If we look at anxiety and depression and PTSD associated with alcohol and nicotine dependence we find only women in group one. 13 percent, seven out of the 55 reported this form of complex co morbidity and none in the other group.

So to summarise, there is a very clear pattern that emerged with a remarkable consistency. Women with sexual violence victimisation reported statistically significant increased risks of mental health problems and substance use issues in various combinations. They were really much more likely than those with no sexual violence to experience co morbidity. I would like to move beyond the objective assessment. As I said - I believe it is very important to note that the experience of harm, the experience of risk – being in danger is subjective - it can't be objectively explored.

So to understand the effects of victimisation I believe it is necessary to move beyond the statistics. Women and men always - or very often say that they regulate stress with using different sorts of substances. Now I would like to give some voice to the women I interviewed. I was very surprised to find that many women want to discuss their victimisation and mental health and substance use issues with me. At the beginning I was worried that maybe there will be a handful of people wanting to identify themselves and talk to me about their issues and I was overwhelmed with the responses. I was not always able to accommodate the women because it is very difficult sometimes to get hold to somebody. At times the interview had to be rescheduled five times before I was able to meet with the woman - and we met in very different areas. Some invited me to their homes when they were separated, others felt more comfortable in a public library or they came to the University where I worked and some they wanted to meet at public places – at the beach.

There was one woman – she called herself smiley face. She didn't want me to give her name – that was not really necessary. She said I call myself smiley face because I want to be able to smile again – I can't smile. We met at the beach and she told me her story while we had a little picnic. Another woman wanted to meet me at the pub and I can tell you it was quite difficult for me to find this specific pub in Free Mantle. I don't know the locations there and I felt a little bit strange walking into a pub at 4 o'clock in the afternoon. I got some very strange looks, particularly because I was just there waiting half an hour and then I left again because the woman didn't show up.

There was one woman - she wanted to meet at a street corner in Free Mantle. She was aboriginal. She didn't want me to record the interview but she was very interested in telling me important information – but she was always looking around making sure that she could just disappear in the crowd when she felt unsafe – and that was fine with me. What I did is systematically analyse the interview data using [unclear] phenomenological analysis approach, having themes that then built into meaning units and then just boiled down to the essence - which you can see here is fear and anger. These are the things that I would like to explore to you a little more today.

Women fear for their safety and the safety of their children. They fear of being killed – they are concerned for their children. The women talk to me about walking on eggshells – these are their words – and how they use self-medication to moderate this fear. How they try to control the situation, how they use different forms of resistance and agencies not feeling so helpless. How they use retaliation which then of course blurs the victim offender relationship. There are a number of women that end up in our prisons.

I want to start by talking about Laura. She is an Aboriginal woman – one of the three that I was able to interview. She tells about her fear of being killed with the following words – he used to throw a machete against me and once almost chopped my left hand with it. A few weeks ago he tried to strangle me with his bare hands. This woman showed up to the interview with her eight year old daughter and a research assistant was taking care of her while we met at a shopping centre and then sat down at a bench and talked to each other. Jane, a Caucasian woman said I said that I am leaving you, I am not taking this anymore. He jumped out of the bed, grabbing me by the head, got me down to the floor and twisted my head around screaming I kill you, I kill you, you whore. He did this until my eight year old and my two year old came in. I thought he was going to kill me. The kids were crying and really scared. As soon as he let me go I went to call to the police.

Emma is also a Caucasian woman. She has four children and she is very afraid. She said at times I had to call the police to save my life - this happened many times. From there I was sent to a women's shelter but feared that my partner would hunt me down. He made me so scared of him and I thought he knew every move I made. I had many unsuccessful escapes. He sometimes sensed that I was going to run away again. I learnt to handle it – she was talking about the violence. While measuring each time the severity that maybe it will be this time he is going to kill me, or how many times I wished he did so because then I would not have to face another moment of how great he is and how small and worthless I am. I cannot run. I have to stay here and be strong for my children. I never know - today I am alive - I have to stay strong for my children and I'll do whatever keeps me alive. Whatever keeps her alive is to stay together with her children and letting him breach the violence restraining order – because she told me that if he wants to come in he is going to come in. If I don't let him he just smashes the door and then I have to pay for the repair.

Concern for the children was a huge issue among the women I interviewed. [Unclear] are women who experienced huge violence. A woman who had two of her children in care at the time of the interview said, with me becoming pregnant it became worse – the bashing got heavier and the things he'd done got worse. What I didn't write here was that her partner used to rape her anally while holding a gun at the back of her head. Adela said - of course these names are pseudo names – he hit me to the ground and into the stomach. There was lots of name calling going on. He said that the baby was sucking all the life out of me. He was never excited about my pregnancy – he was angry that I was pregnant - I think. He wanted a baby but life would certainly have been easier if he didn't have the complication of me being pregnant.

Children are also endangered while the women – their mothers are victimised. Adela said he had been on the computer for 48 hours. I cannot remember the conversation but he came behind me and choked me before he threw me forward. I landed very closely to where my son was sitting in a highchair. I obviously said something to him that made him angry. I was crying, sitting on the couch, my two year old son in my arms and he put a knife to my throat screaming that it was all me – I was the cause of these actions and it was my fault that he was doing that to me. I am holding my son close to my heart and holding my hands protectively over his ears. I thought he is going to kill me but suddenly he went to have a shower.

Cara said – he first wanted me to be pregnant and then changed his mind. He said we could not afford a baby and wanted me to have an abortion. He ran off with my two year old daughter, said he would take her out for a day to give me a day off. I remember going to the cinema that day – not suspicious at all. After looking for them for a long time I was absolutely terrified. He phoned me shortly after saying he was in New South Wales and I would never see her again – the daughter, that is. I thought he was going to kill them both.

A little bit of background to Cara's story: She was one of two women not exactly the stereotypical victim. Women not only from low socio-economic areas but also well known in the society can fall victims. Cara was the wife of a well respected and well known GP. What he did because of his status he told the police that his wife is a nutcase. When she went to the police and said he had abducted her 22 month old daughter, the police would not believe her. It took considerable effort to get the police involved. She went over to New South Wales looking for her daughter absolutely terrified. Many of the women, when they told me their stories they cried – they were very emotional because of the fear they experienced and everything that went on even after years and years they told me their stories. She was able to find her daughter and her husband and they were safe but it was very, very difficult. The police didn't come up very well here.

The role of alcohol and other drug use. Madeline and other Aboriginal women said there are a lot of problems with drinking – a lot of girls drink and do drugs. You know many, many of them do. I asked why? She said to be able to take it all. You go to work, earn your money and then when there is payday he wants your money to buy drugs. If you refuse to give him money he bashes you. So what do you do? It's always the same. So what do you do? You also drink and take drugs - it's always the worst when payday comes.

Jane said I used to binge drink when I was in my early teens. I had an abusive dad and he used to be violent to my mum too. So I went through the whole binge drink phase after I left home and I was 17, 18. I kind of grew out of it, I didn't drink for years and years. It has only been in the last probably four years that I have started drinking again. I wouldn't say that I always use that as a way to cope now but I would say that there are times where I would drink sort of to numb myself. I know that's not the answer. So there is the issue of using alcohol and other drugs to cope but then things can happen and they can get out of hand.

Mandy said I did not want to be defenceless and thought that by punching back I would get to stop him but he usually hit even more. So I learnt to take what he dish out – no matter how I tried to punch back he just got angrier and then he would hit harder because I did not just take the bashing. I never had broken bones or things like that – of course I had lots of bruises from my neck down, occasionally on my face but because bruises could be covered up he purposefully avoided to bash me so that people could see it.

Ashley said, I retaliate when I get angry – definitely – I have been pushed to the limit and actually did a bit of jail time. I've been pushed that I picked the knife up and I actually threw it at my partner of 13 years. Because of that moment I ended up in prison. Actually I learnt a lot when I was in prison about domestic violence – I did some courses. But you can only take so much over the period of time and if you push too much that you are so lashing out you will end up hurting that person that's coming at you. It's either his way or no way, sometimes it's even a very trivial issue that gets us into an argument. That incident happened when she was intoxicated. She happened to stand in the kitchen and there happened to be a knife.

Here is my model. This is a hypothetical model and I know it needs to be tested. I invite you to think about it and give me your ideas. Intimate partner violence occurs in different forms and more importantly in different combinations. There are no mutual categories that we can say somebody experiences only physical violence or only sexual violence. Some people do but most of them experience physical violence and sexual violence and controlling behaviour at the same time. If a woman tells you she is physically abused she might very well also be a victim of sexual violence.

Mental health problems are a consequence that literature has very well established. Alcohol, tobacco and added drug use is something that occurs very often but we don't' hear much about it because women fear that their children are going to be taken away if somebody knows - but they have to cope. The women in my study told me that they use alcohol, nicotine and other illicit substances to feel good, to be able to sleep, to reduce their anxiety and their fear and just to get through the day. But what happens by being intoxicated is that there is a dis-inhibition that very often takes place. Women would not as readily – maybe – engage in violence themselves and feel I exercise my right and I engage in violence then as well – if they were not intoxicated. I don't say they shouldn't and the men are allowed to use substances but it just complicates the issue and then the violence gets more easily out of hand – maybe. The violence can become lethal and over time we can see that there is an escalation in severity.

I would like to finish by giving Mandy the last word: She said family support is most important. Not only the person going through the issues but the whole family – you see my mother got hit by my dad so badly and even my grandmother was bashed. My mum saw her own mother abused and I got bashed too. My mother got heavy depression and even though she left my dad she still suffers a lot. It would be important to go somewhere to talk about it and know you don't need to be ashamed of it or maybe in fear that the children are going to be taken away. So I conclude by suggesting that we should place the focus of attention on breaking the cycle of violence and assisting those who are caught up in the violence. This requires correcting a number of existing misconceptions and this maybe also requires to look beyond the individual person.

There are women victimised, there are children victimised, there are men victimised, there are women perpetrators, there are men perpetrators. There are children trying to assist the mother and go against the partner of the woman.  So there is this interconnection between violence, the offenders, the victims, mental health problems on all sides, substance use issues and then there can be an explosion and we have a deadly end which really can be avoided. Thank you.

Antonia Quadara:    

Thanks very much Marika. Thanks for a very powerful presentation.

-- end --