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The Contribution of Intimate Partner Violence to Health Disparities for Women of Color

Phyllis W. Sharps, PhD, RN, FAAN
Jacquelyn C. Campbell, PhD, RN, FAAN


Health disparities are defined as differences in access to care, processes of health care or health outcomes. The gap between health care access and health outcomes continues between minority and non-minority populations in this country. Women of color and their children compared to non-minority families are at greater risk for health disparities, including access to care, processes of health care and health outcomes. The context of their lives, which often includes lower levels of education, higher rates of poverty, and higher vulnerability to intimate partner violence (IPV) contributes significantly to these health disparities which are manifested in decreased access to health care, shorter life expectancy, higher rates of infant mortality, greater prevalence of chronic diseases, certain cancers and infections, as well as traumatic injuries from IPV. 

Minority Women and Health Disparities

Women represent more than half of the total U.S. population and 46% of the nation’s workforce. Women continue to experience health disparities (DHHS 2001; Institute of Medicine National Research Council, 2002), compared to males, substantiating the need for attention to women’s health. There has been a shift in the biomedical paradigm to frameworks that include the social and contextual influences on health that are different for different groups of women (Mirsa, 2001). Consideration of social context seems to be particularly important for examining the health status of poor women and women of color.

“Women of color are more likely to have lower levels of education, live in poverty and in addition have less access to health care and other resources”

Woman of color suffer disproportionately from premature death, disease and disability (DHHS, 2001).  In 1998, the ethnic/racial make-up of the total population of 103.8 million women was as follows: 71% Euro-American, 13% African American, 11% Hispanics, 4% Asian/Pacific Islanders and 1% American Indian/Native Alaskan.  Since 2000, the proportion of women of color has increased dramatically, but their health status continues to lag behind white women.  Ethnic/racial background in the U.S. influences many aspects of health and well being; for example, Euro-American women’s average life expectancy is 5 years longer that that of African American women (DHHS, 2001).  Poverty, lack of education, and unemployment are more concentrated among women of color and are related to life expectancy (DHHS, 2001).  Although in absolute numbers more Euro-American women live in poverty, proportionately more African American and Hispanic women live in poverty than any other group (Mirsa, 2001).  Gaps still persist in education between men and women.  Although these gaps are decreasing and in some aspects disappearing, the greatest gains have been made among Euro-American women.  For example, more Euro-American women have a college education compared to African American women, and more African American women have less than a high school education compared Euro-American women (Mirsa, 2001). Educational levels are related to health behaviors. African American and Hispanic women, as well as low income women, are less likely to exercise on regular basis; more African American women are obese, and fewer use calcium supplements compared to Euro-American women.  Other health behaviors patterns are not consistent across ethnic/racial groups. Overall, African American and Euro-American women smoke cigarettes in the same proportions, and both smoke more than Hispanic women, although in general, women living below the poverty level smoke more. African American women use alcohol less (past year use) compared to Euro-American and Hispanics, but African American women use more illicit drugs (past year use) compared to Euro-American and Hispanic women (Mirsa, 2001).

Women of color are more likely to have lower levels of education, live in poverty, and, in addition, have less access to health care and other resources (DHHS, 2001).  This social context of their lives significantly influences their health care utilization rates, health status and health outcomes. These context variables are thought to account for much of the greater prevalence of chronic illnesses such as cardiovascular disease, lupus, certain types of cancer, diabetes, certain infections such as hepatitis, tuberculosis and AIDS among women of color (DHHS, 2001). Moreover, these contextual factors are also strongly linked to the greater severity and premature deaths related to these diseases (DHHS, 2001).  

Intimate Partner Violence Against Women and Health Consequences

Over the last decade, violence against women has received increased attention among health care researchers and practitioners (IOM NRC, 2002; Humphreys, Campbell, & Parker, B, 2001). This increased attention is related to viewing violence against women as a complex health problem instead of just a criminal or social problem (Gerlock, 1999). Violence against women is now viewed as a major public health problem that is at epidemic levels and threatens the health and well being of approximately 2 million women and their children (Plichta, 1996). IPV is defined in this article as repeated physical and sexual assault by an intimate partner within a context of coercive control (Campbell & Humphreys, 1993).

Data from two major national population-based surveys have shown that violence perpetrated by intimates i.e., spouses, ex-spouses, boyfriends and ex-boyfriends, accounted for 21-25% of the violent crime experienced by women and 2-8% of violent crime experienced by men (Moffitt, & Caspi, 1999, Tjaden & Thoennes, 2000). Recent data also indicated that the rates of non-lethal IPV are highest among women aged 16 – 24, and women residing in low-income households, (Greenfeld, Rand, Craven, African American women are disproportionately killed by abusive partners in comparison to white women, with unemployment significantly greater among those killed and the perpetrators (Campbell et al, 2003). Among African American women between the ages of 15 – 24 years, IPV is the leading cause of premature death from homicide, and injury from non-lethal causes (Rennison & Welchans, 2000).  Several population based surveys have found that IPV is significantly more common among women of color, particularly African American and Native American women, although when differences in income, education and/or employment are considered, the differences attributable to race decrease or disappear (Jones, Campbell, Schollenberger,,1999; Tjaden & Thoennes, 2000; Walton-Moss et al, 2005).  Since low income and underemployment are most common among women of color, the increase in rates of IPV experienced among them must be considered as a potential cause of disparities in health conditions shown to be associated with IPV.      

The National Violence Against Women Survey (Tjaden & Thoennes, 2000) also reported that an intimate injured 41% of women compared to 19% of men, and that most received some type of medical treatment.  Immediate traumatic injuries included broken bones, lacerations, facial trauma, tendon and ligament injuries and pain. Women of color are overrepresented in emergency departments and in injury data bases.  In addition to the immediate traumatic injuries women receive from IPV, there are significant consequences to their physical and mental health.  Empirical findings from several studies (Campbell et al, 2002; Coker et al, 2002, 2004) and comprehensive reviews of health consequences of IPV (Campbell 2002, Nauman, Langford, Torres,, 1999; Sharps & Campbell 1999; Humphreys, Campbell, & Parker 2001) describe a variety of health outcomes.  Battered women compared to non-battered women use more primary care and mental health services, spend more days in bed due to illness and are more likely to describe their health as fair or poor.  Chronic physical conditions for which IPV is a significant risk factor include gastrointestinal disorders (loss of appetite, eating disorders), neurological problems (fainting or passing out, severe headaches, vision and hearing problems) urinary tract and other infections, and shortness of breath (Campbell 2002; Nauman, Langford, Torres,, 1999; Sharps & Campbell, 1999).

Among female IPV survivors, 40-45% are forced into sex by male intimate partners (Campbell & Soeken, 1999).  Forced sex is associated with acute and chronic reproductive health problems, including increased pelvic inflammatory disease, increased risk of sexually transmitted diseases, including HIV/AIDS, vaginal and anal tearing, dysmenorrhea, sexual dysfunction and pelvic pain (Campbell 2002, Nauman, Langford, Torres,,1999). From 3-19% of pregnant women are battered with associated adverse outcomes for both mothers and infants (Campbell, Garcia-Moreno & Sharps, 2003). Maternal consequences include traumatic injury, increased miscarriage, increased unintended or mistimed pregnancy, poor weight gain, increased risk for sexually transmitted and urinary tract infections, increased substance use including cigarette smoking and late entry into prenatal care. Neonatal and infant consequences include fetal injury, low birth weight, preterm delivery and substance exposure (Nauman, Langford, Torres, et. al., 1999, Sharps & Campbell, 1999).  Poor maternal child outcomes of pregnancy are also more common among women of color, yet the possible connections specifically with IPV in contributing to these health disparities are seldom considered separately.

Female IPV survivors suffer increased mental health problems, accounting for much of the increased health care costs from IPV (Wisner, Gilmer, Saltzman,, 1999). Depression is the primary response of battered women to IPV (Campbell, Kub, Belknap, et. al., 1996). Other mental health problems for women survivors of IPV include posttraumatic stress disorders (PTSD), increased substance use including alcohol, illegal drugs and cigarettes (Sharps & Campbell 1999; Campbell & Soeken, 1999; Sharps, Campbell, & Campbell, et. al., 2001).  Again, women of color are more likely to experience PTSD, smoke and to use illegal drugs than are Anglo women, but the relative contribution of IPV to these health disparities are usually not specifically identified.

“Among African American women between the ages of 15 to 24 years, IPV is the leading cause of premature death from homicide and injury from non lethal causes.”

Although most studies of IPV suggest that poor women and women of color, especially African American women, are more at risk for IPV, injuries from IPV, and the physical and mental health effects of IPV (Tjaden & Thoennes, 2000; Plichta, 1996), the specific effects of IPV on the health of African American women have seldom been studied specifically.  The few investigations that have been conducted (e.g. Schollenberger, Campbell, Sharps, et. al., 2003; Sharps, Campbell, & Campbell, et. al., 2001;  Price, 1996; Torres, Campbell, Campbell, et. al., 2002; Jones, Campbell, Schollenberger, et. al.,1999) are a beginning effort. IPV health effects specific to African American women included higher rates of hypertension and higher rates of emergency department use for IPV injuries in abused African American women compared to Euro-Americans, and more low birth weight infants among abused African American women than white and Latina (Price, 1996; Jones, Campbell, Schollenberger,,1999).  Campbell (Campbell, & Soeken, 1999) has also examined depression and IPV in a diverse sample and found that for African American women IPV was a significant predictor of depression and the depressive effects of IPV lasted long after the IPV ended. More research is needed to identify the health needs of African American and other minority ethnic female survivors of IPV.


The numbers of women dying from HIV/AIDS and the large racial disparities in morbidity and mortality in this disease warrant particular attention to the IPV/HIV-AIDS interface. The harsh reality of the new face of the HIV/AIDS epidemic is that women all around the world are being infected in the largest proportions, and that in Africa, they are the majority of those infected, and the majority of those dying. It is well documented in the United States that women of color are those who are the most affected by this particular health disparity. The intersections of HIV/AIDS and IPV are increasingly being recognized and definitively documented with persuasive and rigorous research (e.g. Dunkle, 2004; Gielen, O’Campo et. al., 1997; Greenwood, Relf et. al., 2002; Maman, Campbell et. al., 2000; Maman, Mbwambo, Campbell et. al., 2002; Relf, 2001; Whetten et al, 2006; Wingood, 2001; Wingood & DiClemente, 1997; Wyatt et. al., 2002). Since women of color are most frequently the victims of sexual violence by intimate partners as well as others, they are most often affected by this intersection and it is for them that the issues are most critical.
The important interfaces of HIV and violence can be summarized as follows: 1) epidemiological studies showing significant overlap in prevalence (Greenwood, Relf, Huang et. al, 2002); 2) studies showing IPV as a risk factor for HIV among women and men (e.g. Dunkle, Jewkes, Brown et. al., 2004; Greenwood, Relf, Huang et. al, 2002); 3) studies showing violent victimization increasing HIV risk behaviors, including IV drug use (e.g. Abdool, 2001; Choi et. al., 1998; Gilbert, El-Bassel, Rajah et. al., 2002; Wyatt, Myers, Williams et. al., 2002); 4) emerging research showing immune system alteration from violence victimization in women (Woods et. al., 2005), 5) studies showing violence or fear of violence impeding or as a consequence of HIV testing (Gielen, McDonnell, Burke, & O'Campo, 2000; Maman et. al., 2001; Maman et. al., 2002); 6) studies showing partner violence as a risk factor for STD’s, which increases the rate of transmission of HIV (Thompson, Potter, Sanderson & Maibach, 2002); 7) data indicating that abusive men are more likely to have other sexual partners unknown to their wives (Garcia-Moreno & Watts, 2000); and 8) studies showing the difficulties of negotiating safe sex behavior for abused partners (Davila & Brackley, 1999; Wingood & Clemente, 1997). In addition, there are hypothesized but as yet untested relationships between increased HIV transmission and IPV through intimate partner forced sex, known as a frequent form of intimate partner violence (Campbell & Soeken, 1999; Maman, Campbell, Sweat, & Gielen, 2000). Forced vaginal sex may cause trauma which increases the chance of transmission. In addition, abused women report forced anal sex as a frequent form of forced sex in violent intimate relationships, and anal sex is known to increase HIV transmission because of the same direct to blood transmission.

Current emphasis on increasing antiretroviral medication (ART) availability and vaccine development to combat HIV/AIDS must continue and be supported. Violence can also be related to differential access to care for women by contributing to a delay in obtaining treatment if there is a fear of violence in the relationship. Prevention efforts must also continue, and issues of interpersonal violence need to be addressed throughout the spectrum of initiatives that will continue to be needed for many years (regardless of vaccine development): primary prevention, testing, medication adherence, and transmission reduction. Some prevention and intervention programs are beginning to include content on violence (e.g. Wingood, Clemente et al, 2006); however, evidence supporting these interventions is as yet limited, and few interventions systematically address the issue. The forced first sex that is the sexual initiation for so many girls around the world, especially in Africa (20-30% of all women), but also in the United States, where 25% of sexually active young (< 14 yo) adolescents state that their first sexual encounter was forced, must be acknowledged and addressed (Jewkes, Levin, Mbananga, & Bradshaw, 2002; Heise, Ellsberg & Gottemoeller, 1999). This reality illustrates the futility of an abstinence-only approach.


In the United States and all around the world, there are glaring disparities in the health of women of color in comparison to white women. This reality is well recognized as is the reality of intimate partner violence for large proportion of women. Yet these two intersecting issues are seldom considered together in spite of the documentation of more IPV among women of color and IPV as a risk factor for many conditions where health disparities are well documented. More research is needed to further unravel these connections, for instance, to determine if the health disparities are related to differential causation specific to IPV, lack of access to care for poor and minority ethnic women and/or differential lack of health care system recognition of violence, or differential rates in obtaining treatment because of the controlling behavior of abusive partners. Until these issues are determined, the culturally appropriate strategies and type of setting for health care system interventions for abused women will remain undetermined. As health care system interventions for domestic violence are developed and tested, it is imperative that they be tested specifically among different racial, ethnic and cultural groups or we may contribute to widening health disparities for abused women of color rather than narrowing the gaps.


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