Violence, Gender and Health

Eileen Hoffman, M.D.

If one bothered to notice, we would see that most reports about "violence" are really stories about "violent males." That is not to say that females aren't violent. It is just that the male predominance is overwhelming. Yet we speak of these events in gender-neutral language as "school" violence, or "teen" violence, or "day trader" violence. It is interesting to think about why a behavior so clearly identified with one gender is spoken of without reference to that gender. My experience has been that gender-neutral language is used to describe a behavior when it is assumed to be the norm.

When discussion has focused on males, it inevitably centers on the role of testosterone in driving aggressive behavior--males have lots of it and women don't. If only it were that simple. Then we could measure levels and predict who was at risk for becoming violent and have a simple therapy for it. But, the experimental data tells us otherwise. Normal levels of testosterone are a prerequisite for normal levels of aggression, and these normal levels span a broad range of hormone concentrations which fail to be predictive. It turns out that testosterone facilitates the neurochemical pathway in the brain that underlies aggressive behavior. It's action is "permissive." That is if the electrical signal is flowing, the presence of testosterone will increase its firing rate and shorten the time in between bursts of electrical activity. It is turning up the rheostat, but the switch is already on. In fact, there is evidence that aggressive behavior can cause an increase in testosterone levels.

The behavioral psychologist, Robert Sapolsky, describes an interesting experiment concerning aggression in males and females. In their natural environment in Kenya, female spotted hyenas are bigger, more muscular, and more aggressive than the males, and are also those who are socially dominant. Interestingly, they happen to have more testosterone-related hormones than the males. Although similarly large, muscular and aggressive, the females now living at the University of California at Berkeley (having been brought there as infants) find it difficult to establish their social dominance over the males, despite having their usually high hormone levels. The missing factor? There is no established social system to learn from.

Perhaps this experiment teaches us that violence among humans is about more than just testosterone and more than the natural instinct for boys to be boys. It is a complex behavior that is dependent upon social context and power inequities. If we fail to understand the interaction between gender and the cultural norms that foster violent behavior by males, we will never be able to deal with it effectively. How can we design effective prevention strategies to implement the declarations made by The Centers for Disease Control and the Surgeon General that violence is a public health issue?

Gender is important in understanding violence in several ways. There are different manifestations depending on the gender of the victim. Male to male violence is public--on the street; in a barroom brawl; acting out on the job; or driving while intoxicated. Male to female violence, in comparison, is private and occurs at home. Four million American women are battered each year by men who are or were intimates, injuring more women than all other forms of injury combined. The costs of violence also vary by gender. Men are responsible for the financial burden that violence brings to our criminal justice system. Most incarcerated individuals are male and they account for eighty-five percent of homicides. Women, already the major users of health care, experience many "downstream" health issues secondary to violence. From society's perspective we see male "criminals" and "sick" women. But is the criminal justice system treating a medical condition? Or is the health care system treating a social condition? Obviously, we are seeing the same phenomenon from two different standpoints which have a common etiology.

The failure to identify female gender with health care costs associated with violence is similar to the absence of male gender when discussing violent behavior in the media. Since women rarely identify themselves to health care providers as victims of assault, the many symptoms generated by physical or sexual abuse are easily seen in a gender-neutral way: fatigue, insomnia, palpitations, shortness of breath, headache, etc. Primary care physicians, poorly trained in detecting and appropriately treating the underlying psychosocial issues will often see these symptoms and fail to diagnose depression, anxiety disorders, post-traumatic stress disorder, chronic pain syndromes, sexual dysfunction, and alcohol and substance abuse let alone that they may have been caused by violence. Commonly seen obstetrical problems are seen just as that by obstetrians. Yet, one Cook County Hospital study showed that 46% of maternal mortality was attributable to domestic violence. Battered pregnant women are also at increased risk for pre-term labor, low infant birth weight, fetal injury and fetal demise. It is somewhat easier to identify the social etiology of medical conditions like vaginal trauma due to rape or broken bones due to battery when delivering care in the emergency room. It is much more difficult to look for the social context of common conditions and complaints in the primary care practitioner's office, especially if the trauma occurred long ago in childhood. Most children who are sexually abused are girls, and their abusers are usually family members or family friends who are male. Girls surviving childhood sexual abuse are disproportionately seen among pregnant teens, alcohol and substance abusers, those with HIV, eating disorders, women with chronic pelvic pain, and those engaging in unsafe sex. Unplanned pregnancies and sexually transmitted infections that lead to infertility in girls and women engaging in unsafe sex are also major contributors to women's health care costs. Unique mental health issues such as dissociative disorders and self-mutilation are seen among incest survivors.

So, what's the bottom line? Gender analysis is not just about women. Men have gender too. Whether in medical care, mental health care or reproductive health care, a gender analysis is desperately needed to start holding boys and men accountable, as well as the cultural norms that foster these patterns of violent behavior. By doing so, we can develop strategies to appropriately diagnose and treat (and maybe even prevent) disorders caused by male violence and improve the health of everyone.

Eileen Hoffman, M.D. American College of Women's Health Physicians Dr. EHoffman@aol.com