Violence was associated with reduced perceived state of health in the women we surveyed.
More than one fourth of women (27%) who visited the three FPCs claimed to have suffered violence at least once in their lives. Despite being close to each other and all located in the same deprived area, the proportion of women reporting domestic violence in FPC1 (42.0%) was more than twice as high as in FPC2(20.0%) or in FPC3 (16.2%). Women aged 25–34 years and 35–44 years were around 3 times more likely than women below 25 years or above 45 years of having experienced violence in their lifetime. Women from Sub-Saharan Africa had a 1.71 higher risk of violence (unadjusted OR = 1.71; 0.98–3.30); this rate was 2.3 higher among those who arrived in France less than 3 years ago than those who arrived in France more than 15 years ago (unadjusted OR = 2.30; 0.85–6.20).
Our finding that 27% of women had suffered violence, a proportion slightly higher than the 23% rate reported in a study conducted in France in 2009,16 and close to the 30% reported by the WHO. We also reported higher prevalence of violence perpetrated by a partner or ex-partner than was found by studies in other countries, ranging from 4.0% in Australia12 to 11.4% in India. But these studies only surveyed violence women suffered in the past year, while we considered lifetime history of violence. A European prevalence study found a lifetime prevalence of violence by a partner of 6.1%, which is much lower than in our result.
In our study, women aged 25–44 years were most likely to have suffered violence in their lifetime. International studies published in the past decade report that youth is an individual risk factor for suffering violence in women.,, Women under the age of 25 years are the most likely to experience violence, including sexual violence.26 Our questionnaire asked women of all ages about their lifetime history of violence so, even if the pattern of abuse of younger women holds true, older women were still more likely to have experienced violence in their lifetimes than younger women. Younger women may also more likely to minimize domestic violence, which intensifies and changes modalities over time. Older women may thus be more ready and able to identify domestic violence. We may hypothesize that young women who attend FPCs may be more likely to visit to obtain contraception or end undesired pregnancies, and may turn elsewhere if they are victims of violence. A study by Sanz-Barbero et al.,26 using the same definition of exposure to domestic violence as ours found that the prevalence of domestic violence was greater among women aged between 18 and 24 years. These discrepancies in both prevalence and risk factors illustrate the very partial knowledge we have on the subject and argue in favor of continuing observational studies in different contexts.
The association between low socio-economic level and higher risk of violence against women is often mentioned in the literature. Our results support the argument that women in vulnerable social situations are at increased risk of violence, especially related to precariousness, unemployment or job search, and immigrant status with irregular administrative status. In the major reference survey in France on violence against women ENVEFF (Enquête Nationale sur les Violences Faites aux Femmes en France), the women most exposed to violence were unemployed, retired, or working part-time. In violent relationships, the aggressor is often economically dominant and may make it difficult his partner to seek and hold a steady job. Financial independence is an obstacle to fleeing an abusive relationship. Aggressors may perceive a partner’s search for a job as a manifestation of autonomy, which could trigger domestic violence.
Immigrant status is a risk factor for violence, whether in the country of origin, during migration route, or in the country of arrival. Our study aligns with other studies of immigration and violence that have demonstrated this. Immigrant women are often dependent upon their partner (confiscation of papers, lack of economic independence) and may find it hard to seek help (language barrier, social isolation, reluctance to call the police in irregular situations). Gender inequalities, a source of reproductive violence, may also be more marked in an immigrant’s country of origin. Cultural factors affect feelings of shame, fear of stigmatization, and perceptions of violence and knowledge of the possibilities of external aid.−
Family Planning Center 1, La Maison des Femmes, is a house specifically dedicated to the management of vulnerable women or women exposed to violence. It offers care combining the health, social and judicial aspects in a single place. As FPC-1 is more than twice as likely than the 2 others, despite all being in the same deprived Paris’ conurbation, our study suggests that the "Maison des Femmes" has achieved its first objective, i.e. to be well identified by the some women of the department and neighboring departments as a preferred structure for dealing with violence.
Our finding that the women in our study reported poorer health status if they had a history of violence aligns with the results of many international studies that found abused women suffered more mental and physical health problems than women who were not victims of domestic violence. In particular, they have more anxiety disorders, sleep disorders, depression, post-traumatic stress disorder (PTSD),and a higher risk of suicide. They also have more sexual, gynecological, and obstetrical disorders.
Study limitations
Our study was limited by the small number of participants (274) so we could not make a detailed comparison of the characteristics of women from each of the three centers. The on-going AVEC-L study will increase the number of included women in order to strengthened robustness of our background results. Women may minimize or fail to identify violence in self-reports, which may lead to classification bias. Our survey did not ask women to share a chronology of violence or specify the types of violence, severity or repetition, and we did not ask them to classify their aggressors. This may explain the discrepancy as for example Sanz-Barbero et al. suggested that if younger women are more frequently exposed to intimate partner violence, these are of less severity.26 Selection bias may also be present; it is possible that women who refused to answer may have suffered more violence than by women who were willing to complete the survey. But this is unlikely because the rate of violence reported here is at least of the same magnitude than in the international literature.
This cross-sectional study does not allow us to conclude on causal links between antecedents of violence, socio-demographic characteristics and the health status perceived by the women respondents.
A cross-sectional study is not designed to identify causal links between antecedents of violence, socio-demographic characteristics, and perceived health status. A causal link between level of precariousness and surviving violence is impossible to draw from this data, and the causal connection may run in either direction or both. The amplitude of association may be the sum of an effect in both directions. Causal relationship between poor health and a history of violence is equally hard to determine. The relationship between health status and surviving violence against may be cumulative (the more traumatic episodes a woman experiences, the greater the impact on her health), adaptive (a woman's environment and experience may positively or negatively modulate the effects of violence on her health over the short and long term).
Data obtained in this study and in the on-going AVEC-L study will provide robust background evidence to assess the medical and social utility of structures specifically dedicated to the management of domestic violence like “La Maison-des-Femmes” (FPC1)