Violence Against Women as a Global Public Health Issue.

Violence against women, especially intimate partner violence, is recognized as a global public health issue due to its prevalence and global reach. This article outlines the scope of the issue, with respect to its prevalence, health outcomes, and risk factors, and identifies key milestones that led to its global recognition: methodological and data advances, acknowledgment as a criminal justice and health issue, support by the global women's movement, and the robust evidence demonstrating that intimate partner violence is preventable. Key issues for the future include recognition and consideration of intersectionality in research, improvements in the measurement of other forms of violence against women, and the need to scale up prevention efforts that have documented success. Violence against women is an urgent priority as it affects individuals, their families and surroundings, and the entire global health community.

After the gun: examining police visits and intimate partner violence following incidents involving a firearm.

Laws have been enacted to keep firearms out of the hands of abusers. In this study, we examined one such effort-removal of a firearm at the scene of intimate partner violence (IPV)-to assess the subsequent occurrence and number of IPV incidents responded to by police and subsequent risk of injury to the victim. Using the 28,977 IPV calls in one large U.S. city to which officers responded during the 2013 calendar year, we identified 220 first-time incidents in which offenders used (i.e., brandished, pistol whipped, shot) a pistol, revolver, rifle, or shotgun. Officers reported removing a firearm from 52 (24%) of the offenders. After using full propensity score matching to control for potential confounders, logistic and Poisson regressions were used to assess differences between those from whom a firearm was removed and those whose firearm was not removed. Firearm removal at the scene of an IPV incident appears to increase the likelihood of subsequent IPV reports to police and suggestive evidence that subsequent injury to the victim might increase as well. The offender shifting from threats with a firearm to physical violence and a change (an increase as well as a decrease) in victim willingness to summon police may account for the findings.

Differences Between New and Long-Standing US Gun Owners: Results From a National Survey.

OBJECTIVES: To quantify the proportion of current US gun owners who are new to owning firearms and compare new versus long-standing gun owners with respect to their firearms and firearm-related behaviors. METHODS: We performed a cross-sectional analysis of a nationally representative probability-based online survey conducted in 2015 in the United States. We defined new gun owners as current firearm owners who acquired all of their firearms within the past 5 years, but who lived in a home without a gun at some time over the past 5 years. We defined long-standing firearm owners as all other current gun owners. RESULTS: New gun owners represented 10% of all current US adult gun owners. In addition to being younger than long-standing gun owners, new gun owners were more likely to be liberal, own fewer guns, own handguns, own guns only for protection, and store guns in a safe manner. CONCLUSIONS: Gun ownership is dynamic, with approximately 1 million Americans becoming new gun owners each year. Public Health Implications. Clinical guidelines should be updated to explicitly endorse re-evaluating household firearm status at regular intervals.

New data on intimate partner violence and intimate relationships: Implications for gun laws and federal data collection.

Age at first marriage has risen substantially and birth rates are at a record low; people are spending more time in relationships that, by comparison, have fewer emotional, financial, and legal commitments. Little research has examined intimate partner violence (IPV) prevalence in current and former adult (vs. adolescent) dating relationships. Such information is relevant to federal firearms policies that are based on the nature of an intimate relationship. We examined assaultive behaviors by the type and status of the relationship - current spouse, former spouse, current boyfriend or girlfriend, and former boyfriend or girlfriend - in 31,206 IPV incidents responded to by Philadelphia police in 2013. Over 80% of the IPV incidents involved individuals in non-marital relationships. Incidents involving current boyfriends or girlfriends had the highest percentage of violent behaviors (e.g., punch, strangle). They also were more likely than current spouses to use bodily weapons (hands, fists, or feet) or non-gun weapons (knives, bats, etc.) (AOR = 1.19 and 1.43, respectively), to injure their victims (AOR = 1.37), and to be arrested (AOR = 1.46). Former unmarried partners had the highest odds of stalking their intimate (AOR = 3.37) and violating a restraining order (AOR = 2.61). Gun use was similar across relationship type. A growing portion of the population is not protected by federal policies designed to keep guns out of the hands of abusers. Current boyfriends and girlfriends are a risk to their intimates. Federal data collection practices and firearm policies merit updating to more fully take into account dating, same-sex marriage, and other partnerships.

Violence Against Women and Household Ownership of Radios, Computers, and Phones in 20 Countries.

OBJECTIVES: To examine the relationship between household ownership of information and communication technologies (ICTs) and justifications for wife beating. METHODS: Women aged 15 to 49 years in 20 countries were surveyed via UNICEF's Multiple Indicator Cluster Surveys between 2006 and 2014. Multivariate logistic regressions accounted for individual-, household-, and structural-level variables. RESULTS: Household ownership of any ICT (radio, computer, fixed phone, or mobile phone but not television) was associated with increased odds of women rejecting wife beating. The largest association was with computer ownership: women in homes with a computer were more likely to reject wife beating (adjusted odds ratio [AOR] = 1.81; 97.5% confidence interval [CI] = 1.69, 1.93). Number of ICTs was important: women in households with 1, 2, 3, 4, and 5 ICTs (vs 0) were more likely to reject wife-beating justifications (AOR = 1.10 [97.5% CI = 1.03, 1.17]; AOR = 1.10 [97.5% CI = 1.03, 1.18]; AOR = 1.19 [97.5% CI = 1.11, 1.29]; AOR = 1.71 [97.5% CI = 1.54, 1.88]; and AOR = 2.85 [97.5% CI = 2.48, 3.26]; respectively). CONCLUSIONS: Independent of household wealth, country development, and other sociodemographic factors, the more ICTs in a household, the more likely that women will reject wife-beating justifications. Policymakers and program planners should consider potential implications of ICT access relating to intimate partner violence.

Assessing views about gun violence reduction policy: a look at type of violence and expected effectiveness.

OBJECTIVE: Public opinion polling about gun policy is routinely conducted and often disregarded. The purpose of this research is to explore ways in which surveys can be made more useful to policy makers, researchers, and the general public. METHODS: A stratified random sample of 1000 undergraduates at a private, urban university was recruited for an online survey about proposed gun policies. A total of 51.7% answered the questions analyzed herein. Including but going beyond typical assessments of agreement, the survey elicited respondent evaluations of the effectiveness of seven gun policies under two randomly assigned conditions: the type of gun violence (e.g., homicide, suicide, violent crime) and its magnitude. Participants were asked to estimate the effectiveness of each policy, including the possibility of making things worse. RESULTS: Participants indicated strong support for all policies and expected each to be effective with one exception - a policy designed to increase the number of guns on the scene, that is, putting armed police in schools. Persons who did not support other policies, on average, did not expect them to make things worse. Telling participants about the scope of the violence did not but the type of gun violence did affect effectiveness ratings. CONCLUSIONS: Asking about expected effectiveness of (vs. general support for) a policy might identify some optimism: Even people who don't support a policy sometimes think it will be effective. Findings suggest that surveys about the effectiveness of gun violence policies likely assess views that exclude suicide, the most common form of gun-related mortality.

SMA valiant trial: a prospective, double-blind, placebo-controlled trial of valproic acid in ambulatory adults with spinal muscular atrophy.

INTRODUCTION: An open-label trial suggested that valproic acid (VPA) improved strength in adults with spinal muscular atrophy (SMA). We report a 12-month, double-blind, cross-over study of VPA in ambulatory SMA adults. METHODS: There were 33 subjects, aged 20­55 years, included in this investigation. After baseline assessment, subjects were randomized to receive VPA (10­20 mg/kg/day) or placebo. At 6 months, patients were switched to the other group. Assessments were performed at 3, 6, and 12 months. The primary outcome was the 6-month change in maximum voluntary isometric contraction testing with pulmonary, electrophysiological, and functional secondary outcomes. RESULTS: Thirty subjects completed the study. VPA was well tolerated, and compliance was good. There was no change in primary or secondary outcomes at 6 or 12 months. CONCLUSIONS: VPA did not improve strength or function in SMA adults. The outcomes used are feasible and reliable and can be employed in future trials in SMA adults.

Self-presentation on the Web: agencies serving abused and assaulted women.

OBJECTIVES: We examined the content and usability of the Web sites of agencies serving women victims of violence. METHODS: We entered the names of a systematic 10% sample of 3774 agencies listed in 2 national directories into a search engine. We took (in April 2012) and analyzed screenshots of the 261 resulting home pages and the readability of 193 home and first-level pages. RESULTS: Victims (94%) and donors (68%) were the primary intended audiences. About one half used social media and one third provided cues to action. Almost all (96.4%) of the Web pages were rated "fairly difficult" to "very confusing" to read, and 81.4% required more than a ninth-grade education to understand. CONCLUSIONS: The service and marketing functions were met fairly well by the agency home pages, but usability (particularly readability and offer of a mobile version) and efforts to increase user safety could be improved. Internet technologies are an essential platform for public health. They are particularly useful for reaching people with stigmatized health conditions because of the anonymity allowed. The one third of agencies that lack a Web site will not reach the substantial portion of the population that uses the Internet to find health information and other resources.

A systematic review of the epidemiology of nonfatal strangulation, a human rights and health concern.

We reviewed the literature on the epidemiology of nonfatal strangulation (also, albeit incorrectly, called choking) by an intimate partner. We searched 6 electronic databases to identify cross-sectional, primary research studies from 1960 to 2014 that reported national prevalence estimates of nonfatal strangulation by an intimate partner among community-residing adults. Of 7260 identified references, 23 articles based on 11 self-reported surveys in 9 countries met the inclusion criteria. The percentage of women who reported ever having been strangled by an intimate partner ranged from 3.0% to 9.7%; past-year prevalence ranged from 0.4% to 2.4%, with 1.0% being typical. Although many epidemiological surveys inquire about strangulation, evidence regarding its prevalence is scarce. Modifying or adding a question to ongoing national surveys, particularly the Demographic and Health Surveys, would remedy the lack of data for low- and middle-income countries. In addition, when questions about strangulation are asked, findings should be reported rather than only combined with other questions to form broader categories (e.g., severe violence). Such action is merited because of the multiple negative short- and long-term sequelae of strangulation.

Current considerations about the elderly and firearms.

In the United States, more than 17 million people aged 65 years or older own a firearm. They have the highest rate of suicide by a firearm, and recent data suggest that a disproportionate number apply to carry a concealed weapon. At least one new handgun has been designed and marketed for older people. Memory, thinking, and judgment as well as physical and behavioral competence issues related to an elderly person's safe operation of a motor vehicle apply to firearms, too. Gun availability can pose a particular risk to those with dementia and to their caretakers. The elderly constitute a substantial and rapidly growing population and market segment for whom the public health implications of firearm production, promotion, access, ownership, and use merit consideration.

"I didn't know I could turn colors": Health problems and health care experiences of women strangled by an intimate partner.

Strangulation is a unique and particularly pernicious form of intimate partner violence. To increase the relatively little that is known about strangulation survivors, focus groups and interviews were conducted as part of a practice-research engagement with a domestic violence shelter. All of the participants had been strangled and, among them, almost all were strangled multiple times. The loss of consciousness was common. Participants associated "choking" with use of body parts and "strangling" with use of objects. Although some minimized the assault, most considered strangulation to be serious and reported a variety of medical conditions following the assault. Few sought medical care. Of those who did, few disclosed the assault, or were asked about strangulation, which commonly resulted in misdirected treatment. Implications for improving detection and treatment are discussed.

Gender disparities in injury mortality: consistent, persistent, and larger than you'd think.

OBJECTIVES: The purpose of this study is to update knowledge about gender differences in injury mortality. METHODS: Data were drawn from the Web-based Injury Query System, which contains US injury mortality data from 1981 to 2007. Male-to-female rate ratios in injury mortality are calculated for key variables, and age and ethnic group comparisons are made. RESULTS: Boys and men were more likely than girls and women to die of injury. From 1981 to 2007, the male-to-female age-adjusted rate ratio decreased by 20% to 2.15 for unintentional injury and increased by 11% to 3.91 for violence-related injury. Excess male mortality existed in manner of death, cause of death, and within ethnic and age groups. Additionally, with rare exception, the gender disparity was greater than ethnic and age disparities in unintentional and violence-related injury mortality. CONCLUSIONS: Gender disparities in injury mortality are consistent and persistent. Gender patterns in injury mortality do not follow typical social justice analyses of health, in that men are at greater risk. Lifestyle and behavioral risks as well as masculine socialization merit consideration.

The Endemic Amid the Pandemic: Seeking Help for Violence Against Women in the Initial Phases of COVID-19.

During the first months of the COVID-19 pandemic, governments instituted a series of measures to control the spread of the virus. The measures were widely believed to increase women's risk of violent victimization, most of which is by an intimate partner. We examined help-seeking during this period in a large U.S. city and used an interrupted time series analysis to assess the effects of three government interventions on domestic violence and sexual assault hotline calls and on "911" calls regarding domestic violence, assault, and rape. Declaration of an emergency appeared to reduce victim calls to the rape crisis hotline and the few "911" calls about rape. School closure was associated with a reduction in "911" calls about assault and rape and victim calls to the domestic violence hotline. Implementation of stay-at-home orders was associated with a gradual increase in domestic violence hotline calls. Although "911" calls regarding assault fell by nearly half, calls to police for domestic violence were unchanged. In sum, there was a decrease in help-seeking for sexual assault and assault in general but not for domestic violence during the initial phases of the COVID-19 outbreak. The analysis underscores the importance of distinguishing between the violence itself, calls to police, and calls to helplines when claims are made about changes over time in violence against women. The opportunities and constraints for each can differ widely under usual circumstances, circumstances that were altered by public health interventions related to the pandemic.

Police response to violence and conflict between parents and their minor children.

PURPOSE: This study examines the nature of all domestic violence incidents involving parents and their minor children to which police in Philadelphia responded during the 2013 calendar year. METHOD: We use a retrospective design to explore the nature and outcome of parent-child incidents to which police are summoned. Incidents that officers determined met the state statute definition of child abuse are not included. RESULTS: Of 54,456 domestic violence incidents in the city of Philadelphia in 2013, 2,361 involved a verbal incident or physical altercation between a minor child and at least one parent. Most reports (83.3%) identified the child as the offender and were for verbal incidents (89.6%), suggesting police were called to resolve conflict in the home. When a child was the offender, boys were the most common offenders and mothers the most common victims. When a parent was the offender, mothers were the most common offenders and daughters the most common victims. Parent-offender incidents were far fewer (16.7%) but more likely than child-offender incidents to involve physical violence (AOR=6.19) and to result in arrest (AOR=3.67). CONCLUSIONS: Parent-child incidents that are not child abuse constitute about 20% of all domestic violence incidents to which police are summoned. Parent-child incidents are an under-researched and perhaps under-served issue. We know of few resources beyond law enforcement for on-the-scene crisis intervention and, as such, officers appear to serve as mediators in these mostly verbal disagreements. The appropriateness and cost of such intervention merits investigation and discussion.

Stability of Oxandrolone in Medium-Chain Triglyceride Oil and Pharmacokinetics Following Buccal Administration of the Extemporaneous Formulation in Neonates and Adults.

OBJECTIVES: Growth failure following surgical palliation of complex congenital heart defects (CHDs) is a prognosticator of poor outcomes. Many strategies for improving weight gain have been implemented in this population, with limited success. We recently described the potential of the anabolic steroid oxandrolone to improve weight gain following surgical repair of CHD when administered via a medium-chain triglyceride (MCT) oil suspension to the buccal mucosa. The current study evaluates the stability of oxandrolone in the MCT oil formulation, as well as the pharmacokinetics of oxandrolone when administered via buccal mucosa in both neonates and adults. METHODS: Stability was assessed by long-term storage of the preparation 1) at ambient conditions and 2) under photodegradative conditions for 3 days. Neonatal pharmacokinetic parameters were determined in a cohort of neonates following surgical CHD repair, whereas adult pharmacokinetics parameters were collected as part of a prospective study to evaluate the relative bioavailability of the oxandrolone in MCT oil formulation. RESULTS: We found that oxandrolone was stable in the MCT oil formulation for at least 1 month, although exposure to light hastened drug degradation. Both neonatal and adult oxandrolone pharmacokinetics were variable; however, oxandrolone in MCT oil was relatively well absorbed through the buccal mucosa (mean bioavailability = 62.5%). CONCLUSIONS: These data suggest that the variability in oxandrolone exposures is inherent to the drug, and not the formulation or route of administration. Combined, these data support further study of this novel oxandrolone in MCT oil formulation and its impact on growth following complex surgical repair of CHD in neonates.

Keeping guns out of the hands of abusers: handgun purchases and restraining orders.

Persons under certain domestic violence restraining orders are prohibited by federal law from purchasing and possessing a firearm. We used administrative data from California to link 794426 restraining orders with 1388724 handgun purchase applications. We found that restrained persons were not a less law-abiding group in general, but they appeared to be repeatedly or serially abusive to intimate partners, and their handgun purchase rates were highest after their restraining orders expired.

Mental health and firearms in community-based surveys: implications for suicide prevention.

Suicide rates are higher among those who own a handgun and among those who [corrected] live in a household with a hand gun. This article examines the association between [corrected] gun ownership and mental health, another risk factor for suicide. Data from the General Social Survey, a series of surveys of U.S. adults, are analyzed to compare general emotional and mental health, sadness and depression, functional mental health, and mental health help seeking among gun owners, persons who do not own but live in a household with a gun, and those who do not own a gun. After taking into account a few basic demographic characteristics associated with both variables, there appears to be no association between mental health and gun ownership. Nor is there any association between mental health and living in a household with a firearm. Findings suggest that the high risk of suicide among those who own or live in a household with a gun is not related to poor mental health. Implications for prevention are discussed.

Nonfatal Gun Use in Intimate Partner Violence: A Systematic Review of the Literature.

Guns figure prominently in the homicide of women by an intimate partner. Less is known, however, about their nonfatal use against an intimate partner. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched eight electronic databases and identified 10 original research articles that reported the prevalence of the nonfatal use of firearms against an intimate partner. Results indicate that (1) there is relatively little research on the subject of intimate partners' nonfatal gun use against women. (2) The number of U.S. women alive today who have had an intimate partner use a gun against them is substantial: About 4.5 million have had an intimate partner threaten them with a gun and nearly 1 million have been shot or shot at by an intimate partner. Whether nonfatal gun use is limited to the extreme form of abuse (battering) or whether it occurs in the context of situational violence remains to be seen. Regardless, when it comes to the likely psychological impact, it may be a distinction without a difference; because guns can be lethal quickly and with relatively little effort, displaying or threatening with a gun can create a context known as coercive control, which facilitates chronic and escalating abuse. Implications for policy, practice, and research are discussed, all of which include expanding an implicit focus on homicide to include an intimate partner's nonfatal use of a gun.

Intervention on behalf of children exposed to intimate partner violence: assessment of support in a diverse community-based sample.

OBJECTIVE: The aim of this study is to assess community-based support for intervening on behalf of children exposed to intimate partner violence (IPV) and to determine what contextual and respondent characteristics are associated with that support. METHOD: An experimental vignette design was used in a random-digit-dial survey of six ethnic groups in California. For each respondent (n=3679), seven vignettes about IPV were generated using randomized categories of victim and assailant characteristics (i.e., gender and sexual orientation, age, ethnicity, nativity, occupational status, and relationship status) and situational characteristics (i.e., motivation, weapon use, type of abuse, alcohol use, frequency of the incident, and child present). All vignettes analyzed for this manuscript (n=6556) mentioned that "there was a child in the other room" during the incident. RESULTS: In 70% of the IPV scenarios, respondents supported intervention on behalf of the child. Support was lowest when the IPV was purely psychological in nature (62-63%), higher when it involved threats, coercion, or limited physical abuse (68-71%), and highest when it involved severe physical abuse (76-81%). The odds of supporting intervention also were elevated when a weapon was involved, when the IPV occurred multiple times, and when the IPV involved gay men. Men and Vietnamese Americans had the lowest odds of favoring intervention. CONCLUSIONS: Public opinion assessed in this survey is aligned with that of professionals who believe that the potential impact of IPV on children should not be ignored and who have suggested that criteria should be developed to guide a graded intervention response for such cases.