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RESEARCH AND PRACTICE |
At the time of the study, Xiao Xu was with The Johns Hopkins University School of Nursing, Baltimore, Md. Fengchuan Zhu is with the Obstetrics/Gynecology Department of The First Hospital Affiliated to Fujian Medical University, China. Patricia O’Campo and Michael A. Koenig are with The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Md. Victoria Mock and Jacquelyn Campbell are with The Johns Hopkins University School of Nursing.
Correspondence: Requests for reprints should be sent to Xiao Xu, PhD, RN, Covance Health Economics and Outcomes Services, Inc, 9801 Washingtonian Blvd, 9th Floor, Gaithersburg, MD 20878 (e-mail: xiao.xu{at}covance.com).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Objectives. We estimated the prevalence of and risk factors for intimate partner violence in China.
Methods. Our cross-sectional, comparative prevalence study used a face-to-face survey of randomly selected women attending an urban outpatient gynecological clinic at a major teaching hospital in Fuzhou, China. Multiple logistic regression models were used to assess risk factors for intimate partner violence.
Results. Of the 600 women interviewed, the prevalence of lifetime intimate partner violence and violence taking place within the year before the interview was 43% and 26%, respectively. For lifetime intimate partner violence, partners who had extramarital affairs and who refused to give respondents money were the strongest independent predictors. For intimate partner violence taking place within the year before the interview, frequent quarreling was the strongest predictor.
Conclusions. Intimate partner violence is prevalent in China, with strong associations with male patriarchal values and conflict resolutions. Efforts to reduce intimate partner violence should be given high priority in health care settings where women can be reached.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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In traditional Chinese families, family structure is hierarchical, and the husband has final authority on a variety of family issues, such as financial decisions, although husbands may give the illusion of power to their spouses.17,18 Chinese women’s social and family status can be clearly depicted in the traditional Chinese aphorisms, such as "Beating is love, and scolding is intimacy." Even though China has little notion of individual privacy, violence against a woman by her husband is generally concealed and protected within the sphere of private life and, as such, is largely overlooked and ignored.19
In 1995, the US State Department estimated that at least 20% of wives in China had been abused by their husbands.20 However, in China, violence against women was not fully recognized as a social problem until after the Third World Women’s Conference in 1985.19 The few population-based studies available reported a lifetime prevalence of physical abuse of between 10% and 23%21–24 and 25% to 70% among divorced women (Z.H. Xie, "Violence against women in China," unpublished manuscript, Cambridge, Mass: Harvard University; 1992).21,22,25 No studies of abuse by intimate partners in China outside of Hong Kong have been conducted. This study was the first to consider the unique cultural traditions in the rest of China.
US studies found that women who experienced violence from an intimate partner were more likely to use health care services.26–29 Therefore, the purpose of our study was to determine the prevalence of intimate partner violence in mainland China and to investigate the associated risk factors, taking Chinese cultural traditions into consideration.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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A total of 8912 women were seen in the clinic during the 3-month data collection period; 685 of them were randomly selected to participate in the study. Of those selected, 612 women (89%) consented to participate. However, 12 of the 612 consenting women had incomplete data, so the final sample was reduced to 600 women (88%). The women in the final sample were similar in age (only comparison data were available) to those who refused to participate and the overall patient population. Most of the respondents were living in urban areas (74%), had at least a junior middle school (equivalent to grades 7–9 in the US) or higher education (78%), were married (87%), and had lived with only 1 partner in their lifetime (92%). Half of the patients had a worker position job, and three quarters earned their own income (Table 1
).
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Prevalence of violence by current or former intimate partner was assessed by timing (lifetime or past 12 months [past year]), frequency, and type (psychological or emotional, physical, and sexual abuse). WHO developed the abuse questions on the basis of a variety of other abuse assessment scales, such as the Index of Spouse Abuse and the Conflict Tactics Scale, which have strong reliability and construct validity.33,34 Physical abuse was assessed with 11 items: slapping, throwing things, pushing, and dragging were classified as less severe physical abuse behaviors, whereas hitting, kicking, beating, strangling, choking, burning, and threatening with a weapon or using a weapon (gun, knife, or object) were classified as severe.34 Sexual abuse was assessed with 3 items: using physical force to have sexual intercourse when respondent did not want to, having sexual intercourse when respondent did not want to because she was afraid of what he might do, and making the respondent do something sexually that she found unnatural or distasteful. Psychological abuse was assessed with 6 items: insult or make one feel bad, belittle or humiliate in front of other people, do things to scare the respondent on purpose, threaten to hurt the respondent, threaten to hurt someone she cares about, and abuse or mistreat the respondent.
For each type of abuse, lifetime abuse was defined as the experience of 1 or more acts at any time from a current or former male intimate partner. Abuse taking place within the previous year (past year abuse) was defined as acts taking place within the past 12 months before the interview. Intimate partner violence was defined as physical or sexual violence, or both; the definition was similar to that set forth by the Centers for Disease Control and Prevention.35 Internal reliability (Cronbach 
coefficient) was 0.84 for the intimate partner violence items and 0.76 for the psychological abuse items.36
Risk factors were examined for intimate partner violence separately for the previous year and lifetime in the following areas of risk: (1) demographic, (2) behavioral, and (3) socioeconomic and cultural. Table 1
shows a detailed description and response for each demographic variable. Behavioral factors are listed in Table 2, and Table 3 includes a detailed description and response for each socioeconomic and cultural risk factor variable.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Among those who reported physical abuse in the previous year, 70% experienced less severe violence only. Among the less severe physical violence items, the most frequently occurring forms were "push/shove," "drag," and "slap" in 27%, 20%, and 13%, respectively, of the sample at least once during their lifetime and 14%, 12%, and 5%, respectively, in the previous year. For severe physical violence, the most frequently occurring acts were "hit with fist," "kick," and "choke" in 8%, 6%, and 6%, respectively, of the sample at least once during their lifetime and 4%, 3%, and 2%, respectively, in the previous year. Among the 3 sexual abuse items, the most frequently occurring was forced sex, with 14% of the women having been forced by their partners to have sexual intercourse in their lifetime and 10% in the previous year.
Risk Factors
Tables 1, 2, and 3 present the descriptive statistics as well as the univariate logistic regression results of the demographic, behavioral, and socioeconomic and cultural factors.
Demographic risk factors.
Among the 7 demographic risk factors that were significant(P < .05) for lifetime intimate partner violence, respondents who grew up in rural areas (regardless of whether they migrated or stayed), who had 2 or more live-in partners, and who had an unemployed partner had the highest odds ratios (ORs = 2.06, 3.09, and 2.63, respectively). Partners who had higher education and were in managerial or supervisory positions and respondents who earned their own income and who had longer length of stay in the current region were significant (P < .05) protective factors (ORs = 0.88, 0.40, 0.67, and 0.98, respectively). Similar demographic risk and protective factors were found for the past year intimate partner violence, except for the number of live-in partners and the respondents’ income status, but these factors failed to reach significance (Table 1).
After we controlled for other factors with the multiple logistic regression models, only 2 factors remained significant for intimate partner violence: having had 2 or more live-in partners (OR = 3.08) and having partners who were in managerial or supervisory positions (OR = 0.40). Having partners who were in managerial or supervisory positions (OR = 0.35) and having grown up in a rural area (regardless of whether the respondent migrated or remained in the same area) (ORs = 2.00, 2.13) remained significant (P < .02) for past year intimate partner violence (Table 4).
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). In particular, intimate partner violence was most likely to happen if the partners had extramarital affairs with other women (13%) (ORs = 5.55 and 3.17 for lifetime and past year intimate partner violence, respectively) and if the respondents quarreled frequently (47%) with their partners (ORs = 3.67 and 3.39 for lifetime and past year intimate partner violence, respectively). Also, partners who used illegal drugs were significantly more likely to abuse their spouses physically, sexually, or both in their lifetime (OR = 6.59).
After we controlled for other factors, partners having extramarital affairs and frequent quarreling between respondents and partners remained significant for both lifetime intimate partner violence (ORs = 3.00 and 2.76, respectively) and past year intimate partner violence (ORs = 2.45 and 3.18, respectively). In addition, partners who got drunk in the previous year also significantly predicted lifetime intimate partner violence (OR = 2.15) (Table 4).
Socioeconomic and cultural risk factors.
A woman was at higher risk for intimate partner violence if she had refused jobs because of her partner, the partner took money away from her, or the partner refused to give her money (ORs = 2.43–9.78 for both lifetime and past year intimate partner violence). Notably, partners who refused to give money were almost 10 times more likely to abuse the respondents than were those who gave money. Joint management of money with the partner was protective for lifetime intimate partner violence (OR = 0.65) (Table 3).
In terms of domestic authority, attitudes, and cultural beliefs, respondents who believed the following were more likely to experience intimate partner violence: (1) it is important for a man to show his wife or partner who is the boss, (2) it is a wife’s obligation to have sexual intercourse with her husband even if she does not feel like it, (3) there are good reasons to beat a wife, and (4) it is a wife’s obligation to satisfy her husband sexually. Respondents who believed that family problems should be discussed only with people in the family were only three-fifths as likely to experience intimate partner violence (OR = 0.62). Respondents who communicated less with their partners also were more likely to be abused (ORs = 1.25 and 1.21 for lifetime and past year intimate partner violence, respectively). Also, for every increase in the respondents’ experience of controlling behaviors from their partners, the chance of their being abused increased (Table 3).
After we controlled for other factors, the cultural belief in the wife’s obligation to have sexual intercourse with her husband remained significant for lifetime intimate partner violence (OR = 1.61), and the cultural belief that there are good reasons to beat a wife remained significant for both lifetime (OR = 1.49) and past year (OR = 1.29) intimate partner violence. Privacy norms that dictate that family problems should be discussed only in the family remained protective (OR = 0.55) against both lifetime and past year intimate partner violence.
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DISCUSSION |
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These prevalence figures are comparable to or even higher than data gathered in US health care settings, where rates of lifetime intimate partner violence range from 30% to 39%,28,38–44 and rates of past year intimate partner violence range from 6% to 23%.14,26,28,29,40–42,45 A similar gynecological clinic study in 5 Nordic countries showed that Chinese women had much higher past year physical (16% vs 4%) and sexual abuse (12% vs 1%) prevalence rates than did the Nordic sample, whereas lifetime physical (38% vs 48%) and sexual abuse (21% vs 24%) prevalence rates were lower.46 These figures are much higher than prior population-based estimates in China19,21–23,47 and Chinese American samples, which ranged from 12% to 26% (M. R. Yoshioka, PhD, J. DiNoia, PhD, "Attitudes toward marital violence among Chinese and Cambodian adults," unpublished manuscript, New York, NY: Columbia University; 2000),48 but lower than the prevalence in Chinese divorce cases (30%–80%), as would be expected (Z. H. Xie, "Violence against women in China," unpublished manuscript, Cambridge, Mass: Harvard University; 1992).25,49 These higher rates in health care studies than in population-based studies in China are consistent with findings in the United States.43
Demographic Risk Factors
Relatively young age, poverty, being divorced or separated, and prior victimization have been found across studies as characteristics of women that are associated with an increased risk for (rather than sequelae of) intimate partner violence.29,43,50 Surprisingly, age was not associated with even past year intimate partner violence in this investigation in contrast to what has been found in many US studies.3,8,14,24,29,43 Reasons for this difference should be explored in future studies on Chinese populations. In this study, only 1.3% of the women were divorced or separated; thus, this subgroup might have been too small to detect an increased risk for intimate partner violence.
Consistent with Heise’s analysis,51 after all other socioeconomic and cultural factors were controlled, the partner’s unemployment was not significant in predicting intimate partner violence in this study. However, having partners who had a managerial or supervisory position was a protective factor for women being abused.
In contrast to expectations, infertility or having given birth to only female children was not associated with intimate partner violence in the current study. This finding contradicted the researcher’s earlier finding from qualitative interviews of 30 women from the same clinic (unpublished data available from the authors). Further investigation of this association in future studies is warranted.
Behavioral Risk Factors
Although studies in the United States have found illegal drug use to be significantly related to intimate partner violence,14 only 0.3% of our respondents and 1.0% of their partners used illegal drugs. Even so, partner’s illegal drug use was related to lifetime intimate partner violence.
In this study, a significantly higher number of abusive partners had extramarital affairs, and such affairs significantly predicted their wives being physically or sexually abused or both in their lifetime and in the previous year. An earlier study in Shanghai found that "allegations of extramarital affairs" or "third person problems" was the most frequent reason given by respondents for being beaten by their partners (32%).52
Besides extramarital affairs, frequent quarreling significantly predicted both lifetime and past year intimate partner violence. A significantly greater number of women who experienced intimate partner violence had sometimes or often quarreled with their partners, compared with the women who did not experience intimate partner violence (65% vs 33%, P < .001). This finding is consistent with numerous prior studies that reported that marital conflict was highly predictive of wife assault, even after other variables were controlled.12,50,53–55
Socioeconomic and Cultural Factors
Multiple studies have found that certain characteristics of male partners are associated with intimate partner violence.13,18,56 The evidence on status inconsistency (a woman having a higher educational, occupational, or income level than her partner) has had mixed support in recent research in the United States,43 and it was not found to be a significant risk factor in this investigation of Chinese women, similar to other international findings.57 The partner’s financial control was a particularly important aspect of controlling behaviors in this study. The findings of this study supported Levinson’s small-scale societies study,58 in which he found that wife beating is most frequent in societies in which men control wealth, especially the fruits of family labor. Gallin59 also reported that women in Taiwan were beaten if they did not give their private money to their husbands for activities such as drinking and gambling.
Both respondents’ and partners’ beliefs that there are good reasons to beat a wife predicted both lifetime intimate partner violence and intimate partner violence occurring within the previous year. In this sample, all women, regardless of whether they are a victim of intimate partner violence, had a relatively high approval and tolerance of the phenomenon of wife beating. Thirty-six percent of the women agreed that if a man found out that his wife was unfaithful, it was acceptable for him to beat her (47% of the women who had experienced intimate partner violence agreed, and 29% of the women who had not experienced intimate partner violence agreed). Heise and colleagues60 also reported similar rates of agreement among women in Singapore (33%) and women in rural Nicaragua (32%). Much higher levels of agreement with this question were reported in a study from Israel (71%), and relatively lower percentages were found in studies from Brazil, Chile, Colombia, El Salvador, and Venezuela (ranging from 5% to 19%), which indicates varying cultural influences.60
Most women in this study agreed that it was acceptable for a married woman to refuse to have sexual intercourse with her husband if she did not want to, if he was drunk, if she was sick, or if he mistreated her. This attitude is a marked improvement over the traditional cultural values that required a woman to be obedient to her husband always, especially in terms of sexuality. Even so, significantly more women who had experienced intimate partner violence than those who had not disagreed with the premise that a woman could refuse to have sexual intercourse with her husband if she did not want to. The fact that those women who had experienced intimate partner violence expressed views consistent with more traditional values was shown throughout this research.
It was surprising that a belief in not discussing family problems with outsiders was protective against both lifetime and past year intimate partner violence in both the adjusted and the bivariate analysis. Although this question tried to address social isolation as a risk factor for intimate partner violence, women may have misunderstood the intent of the question. They may have thought that they were endorsing support of family communication, which could be expected to be protective against intimate partner violence.
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Conclusions |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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The risk factors that predict intimate partner violence must be viewed within the Chinese cultural context. With current reform initiatives and the development of a "socialist market economy" in China, women are supposed to "hold up half of the sky," which is economic and political independence. However, the women treated in the clinic were not as supportive of gender equality, at least in terms of marital relationships, as the new Chinese constitution prescribes. Women still adhere to the norms of a male-dominant culture to some degree. Their belief in that traditional culture and the likelihood of abuse were strongly associated. Either the partner may be influencing the woman to accept more traditional beliefs, or the woman may tell herself that his dominance must be appropriate. Also, the reform has resulted in 30% of these women being unemployed, which has increased their financial dependency on the partner and thus put them at further risk for being abused. Thus, one of the main problems for contemporary Chinese society is providing for women what was promised: "half of the sky." Without both kinds of independence, freedom and equality for Chinese women are unlikely.
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Acknowledgments |
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Our special thanks to Dr Claudia Garcia-Moreno at the World Health Organization (WHO), Geneva, Switzerland, for providing permission for use of the WHO’s copyright of the Multicountry Study on Women’s Health and Life Experiences Questionnaire in this study.
Human Participant Protection
This study was approved by the institutional review boards of The Johns Hopkins Medical Institute and The First Hospital Affiliated to Fujian Medical University.
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Footnotes |
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Accepted for publication February 3, 2004.
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References |
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