Sacks-Jones, K. (2018), "Joining the Dots: the combined burden of violence, abuse and poverty in the lives of women", Advances in Dual Diagnosis, Vol. 11 No. 1, pp. 43-46. https://doi.org/10.1108/ADD-10-2017-0019Download as .RIS
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Joining the Dots: the combined burden of violence, abuse and poverty in the lives of women
Agenda exists to campaign for the most excluded women and girls: those who struggle with the combined burden of complex and inter-related needs. There are key themes which are repeated time and time again through the lives of all of these women, but the two most ubiquitous are violence and poverty.
We have known for a long time that violence and poverty are linked in women’s lives. Agenda’s research “Joining the Dots” (McManus et al., 2016), funded by the Joseph Rowntree Foundation, outlines the strength of that link.
This report is one of the first to draw out what that combination of violence and poverty looks like for women in England. It paints a stark picture of poor mental and physical health, with higher rates of addiction to drugs and alcohol.
For “Joining the Dots”, we used data from the Adult Psychiatric Morbidity Survey (McManus et al., 2009), which gives a detailed and comprehensive picture of the lives of more than 7,000 people across England. We drew on this data to produce a typology of violence, splitting the population into four broad groups of those who have experienced:
little or no violence in their lives;
physical violence from a partner;
sexual violence as children or adults; and
extensive sexual and/or physical violence, often across the lifecourse.
Women make up the majority of those in the final three groups. We then identified women in poverty using indicators including income, fuel poverty, poor housing conditions, borrowing and being behind with utility, rent or other debt repayments.
In summary, we found that women in poverty were more than twice as likely to experience almost every kind of violence compared to those not in poverty. About 4 per cent of women – that would translate to around one million women in England – are both in poverty and have experienced the most extensive violence (that is those in the fourth category).
Poverty and violence are gendered. Across our society, it is women who disproportionately suffer them. It is unsurprising that each form of inequality reinforces the other, and breeds new forms – like higher rates of mental ill-health among women.
Poverty, abuse and mental health in women
Women and men have different needs and experiences when it comes to mental health. One in five women will have poor mental health, compared with one in eight men (Stansfield et al., 2016, p. 8). Women are more likely to suffer depression, anxiety and to self-harm, while men are at greater risk of suicide (McManus et al., 2016, p. 2).
The causes of mental ill health are different too – more than half of women who have mental health problems have experienced abuse (Scott and McManus, 2016, p. 47). That link is even more pronounced for those women who face the most severe and enduring mental health problems (Scott and McManus, 2016, pp. 13-21). Poverty also increases the risk of mental illness, with the poorest women being at greater risk than the poorest men (Elliot, 2016).
Our analysis showed that women in poverty, regardless of their experiences of violence, are three times more likely to have multiple mental disorders than those not in poverty. When violence is also brought into the equation, its impact is clear. Women living in poverty with extensive experiences of violence were at least five times more likely to have multiple mental disorders than women in poverty without experience of violence (33 per cent, compared with 6 per cent).
More than half (55 per cent) of this group met the diagnostic threshold for an anxiety or depressive disorder. This is three times higher than the rate for women in poverty but with little or no experience of violence. They had higher rates of attention deficit hyperactivity disorder, psychosis, eating disorders and borderline personality disorder. A fifth screened positive for post-traumatic stress disorder – nearly 20 times higher than for the women in poverty with little or no experience of violence (19 per cent compared with 1 per cent).
A fifth of women had thought about suicide in the previous 12 months, with more than a third making a suicide attempt. A quarter had self-harmed. These rates were several times higher than for the women in poverty with little or no experience of violence and abuse.
Despite their increased risk of mental ill health, women in poverty were less likely than those not in poverty to be in receipt of treatment or to have used health care services for a mental health reason. This indicates that there are socio-economic inequalities in treatment access, with women in poverty less likely to be able to access or receive the treatment they need.
For those who do get support, it may not always be appropriate. Research by Agenda found that women’s needs are often not taken into account by mental health services. For example only one trust out of 35 contacted by Agenda said it had a women’s mental health strategy (Agenda, 2016). Furthermore, we found that women, and particularly girls, continue to be physically restrained, often in the face-down position, in mental health units despite the risk of re-traumatisation for those with a history of abuse (Agenda, 2017). These issues highlight a clear need to prioritise women’s specific mental health needs and experiences, particularly trauma, but also other factors such as poverty and caring responsibilities that may be contributing to their poor mental health.
Poverty, abuse and substance misuse in women
As with mental health, women’s experiences of substance misuse are different to men’s. Women facing addiction are more likely start using drugs because they are in a relationship with a man who is using. Men’s addictions on the other hand, are more likely to start misusing substances with their peers (e.g. Merz, 2014).
More than half of women in prison have used heroin, crack or cocaine shortly before entering prison and drug addiction is often linked to prostitution. Of the approximately 80,000 women involved in street prostitution, as many as 95 per cent are addicted to heroin or crack (Gilchrist, n.d.).
Our analysis for Joining the Dots showed that a quarter of women in poverty who had experienced extensive violence had a problematic pattern of alcohol consumption (28 per cent, compared with 16 per cent of women just in poverty), and 8 per cent showed signs of drug dependence (compared with 3 per cent).
Women who misuse substances usually have particularly complex needs and often have a worse quality of life than men (National Treatment Agency for Substance Misuse, 2010). These higher rates may reflect the use of substances as a coping mechanism to deal with their experiences of violence and trauma, as well as poverty.
Yet, getting help for substance misuse can be difficult for many women. Substance misuse services are often dominated by men. For women who have experiences of abuse, and who are struggling mentally, physically and financially, they can be, at the very least, intimidating and at their worst, dangerous. Many women who are mothers are also afraid to present at drugs services, because of fears about social services’ involvement with their children.
Because women are a minority in these sorts of services, there is a perceived lack of need, meaning policy makers, commissioners and service providers are not thinking sufficiently about women. As a result, services are designed by default for men, with women finding their needs overlooked again and again.
The findings of “Joining the Dots” are a clear reminder that offering women support for individual problems like mental health and substance misuse in isolation is not effective. These issues are complex and intertwined. Women in poverty have fewer resources and can find it harder to escape the perpetrators of violence, while experiencing abuse is often a factor in women’s substance misuse, poor mental health and poverty.
Women who have experienced high levels of violence live with unresolved trauma and may experience mental health problems as well as misusing substances to cope, each exacerbating the other. A study by the Royal College of Psychiatrists (Banerjee et al., 2002) suggested that up to a half of women with dual diagnosis have experienced sexual abuse.
Women who are facing both poor mental health and misuse substances can find it even more difficult to identify and access help. They may be passed from a mental health service to an addiction service and back again, never quite meeting the criteria for each and never quite able to address the challenges they face.
Tackling the inequalities highlighted in “Joining the Dots” must start at the very top. We are calling for a cross-government approach to improving life chances for women who face the most extensive abuse, poverty and disadvantage. We need leadership and strategic thinking to break the links between these issues.
It is also essential that services exist to provide the needed help. At the moment, we have some world-class specialist support in this country, but the services which provide it are few and far between and often struggle for funding. Central and local government must make sure that specialist services providing holistic support are adequately funded and properly commissioned everywhere.
With this, the option of women-only support is also important. Women who have faced violence at the hands of men often need a woman-only environment to feel safe enough to start addressing their mental health needs and addiction. Support also needs to be trauma-informed, underpinned by an understanding of women’s lives, particularly their histories of abuse, and how being a woman inevitably shapes their experience.
And we have got to start recognising these women. We hear stories time and time again from women about the missed opportunities for support, with professionals unable to see the trauma that lay at the root of their problems. “Routine enquiry” (asking women and girls whether they have experienced violence and abuse) needs to become standard practice across a range of health and support services and be accompanied by proper support for those who disclose past or present experiences of abuse. That way we will stop missing the opportunities we have got to reach out to women.
If we want to ensure that women’s life chances are not narrowed by gender, that girls born today would not face the limitations and closing off of opportunities caused by the combination of poverty and abuse, and the impact it can have on their physical and mental health, we have got to start joining these dots.
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About the author
Katharine Sacks-Jones is the inaugural Director of Agenda. She brings 15 years’ experience working across policy, campaigns, public affairs and parliament. She is an expert in social policy and has a track record of influencing the policy, political and media agendas and bringing about policy change for marginalised groups including securing new primary legislation to protect private tenants whose landlords are repossessed; funding for homelessness services and programmes; and the prevention of specific benefit cuts. Katharine currently sits on the Advisory Board for Female Offenders and is the Co-chair of the Women’s Mental Health Task Force at the Department of Health. Before joining Agenda, Katharine led the Policy & Campaigns team at Crisis. She has written for the Guardian, Telegraph, Huffington Post and New Statesman as well as sector and specialist publications.