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. [email protected]