Mid Sweden University This is a published version of a paper published in Scandinavian Journal of Public Health. Citation for the published paper: Leander, K., Berlin, M., Eriksson, A., Gillander Gådin, K., Hensing, G. et al. (2012) "Violence.: Health in Sweden: The National Public Health Report 2012. Chapter 12." Scandinavian Journal of Public Health, 40(Supplement 9): 229-254 URL: http://dx.doi.org/DOI: 10.1177/1403494812459609 Access to the published version may require subscription. Permanent link to this version: http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-18109 http://miun.diva-portal.org http://sjp.sagepub.com/ Scandinavian Journal of Public Health http://sjp.sagepub.com/content/40/9_suppl/229 The online version of this article can be found at: DOI: 10.1177/1403494812459609 2012 40: 229Scand J Public Health and Maria Danielsson Karen Leander, Marie Berlin, Annika Eriksson, Katja Gillander Gådin, Gunnel Hensing, Gunilla Krantz, Katarina Swahnberg Violence : Health in Sweden: The National Public Health Report 2012. Chapter 12 Published by: http://www.sagepublications.com can be found at:Scandinavian Journal of Public HealthAdditional services and information for http://sjp.sagepub.com/cgi/alertsEmail Alerts: http://sjp.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: What is This? - Dec 13, 2012Version of Record >> at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ http://sjp.sagepub.com/content/40/9_suppl/229 http://www.sagepublications.com http://sjp.sagepub.com/cgi/alerts http://sjp.sagepub.com/subscriptions http://www.sagepub.com/journalsReprints.nav http://www.sagepub.com/journalsPermissions.nav http://sjp.sagepub.com/content/40/9_suppl/229.full.pdf http://online.sagepub.com/site/sphelp/vorhelp.xhtml http://sjp.sagepub.com/ © 2012 the Nordic Societies of Public Health DOI: 10.1177/1403494812459609 Scandinavian Journal of Public Health, 2012; 40(Suppl 9): 229–254 Summary In Sweden and in other countries, it has become increasingly common to view violence from a public health perspective. This chapter presents a descrip- tion of interpersonal violence with an emphasis on violence in close relations, particularly in partner relationships. According to the Swedish Crime Survey 2010, approximately one in ten inhabitants was exposed to violence, threats or harassment of some kind in 2009. Young people and single mothers with small children are particularly vulnerable to violence. According to Statistics Sweden’s ULF surveys (Survey on Living Conditions) for 2004–2005, 17 per cent of men and 12 per cent of women aged 16–24 years reported having been subjected to violence or serious threats at some time in the previous 12 months. Boys and men are more frequently subjected to lethal violence and to violence resulting in hospitali- sation than girls and women. Similarly, men also make up a majority of the victims of assaults reported to the police. On the other hand, domestic violence and work-related violence more often involve women than men, and sexual violence is chiefly directed at girls and women. Most women and children who are subjected to assault are acquainted with the perpe- trator, while this only applies to a minority of male victims. Women are four to five times as likely to be killed by a partner as men. Partner assaults against women, rapes, and gross violations of a woman’s integrity account for a fifth of all reported crimes of violence (against women and men combined). Violence in partner relationships has significant consequences for physical and mental health; between 12,000 and 14,000 women seek outpatient care each year as a result of violence committed by a partner. Violence can also have serious social reper- cussions: isolation, financial difficulties, sick leave from work, unemployment, etc., and women sub- jected to this form of violence can be prevented from seeking medical or other assistance. Children are often involved. Approximately 10 per cent of all chil- dren have experienced violence in the home and 5 per cent have experienced it frequently. Many children who witness violence are also beaten themselves. In 2006, the Swedish National Board of Health and Welfare estimated the annual socioeconomic cost of violence against women to be between SEK 2.7 and 3.3 billion, SEK 38 million of which were direct medical costs. Factors affecting the risk of violence in partner relationships are related both to the social structure and individual character of the perpetrator. Trends in violence have moved in different direc- tions. Today, more people in all age groups, with the exception of the most elderly (aged 65–84), report that they have been exposed to threats or violence Violence Health in Sweden: The National Public Health Report 2012. Chapter 12. KAREN LEANDER1 †, MARIE BERLIN2, ANNIKA ERIKSSON3, KATJA GILLANDER GÅDIN4, GUNNEL HENSING5, GUNILLA KRANTZ5, KATARINA SWAHNBERG6 & MARIA DANIELSSON2 1Department of Public Health Science, Karolinska Institutet, Stockholm, Sweden, 2Swedish National Board of Health and Welfare, Stockholm, Sweden, 3National Council for Crime Prevention, Stockholm, Sweden, 4Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden, 5Department of Community Medicine and Public Health, Gothenburg University, Gothenburg, Sweden, and, 6Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden † Deceased Correspondence: Maria Danielsson, Swedish National Board of Health and Welfare, 106 30, Stockholm, Sweden. E-mail: maria.danielsson@socialstyrelsen.se 459609CCP0010.1177/1403494812459609K. Leander et al.Violence 2012 at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 230 K. Leander et al. than in the 1980s. In recent years, however, the increase has halted; there has even been a decline among young people aged 16–24. Crimes of violence reported to the police are growing in number, and the number of reports of work-related violence, for example, has more than doubled since the mid 1970s. The number of rapes reported to the police has also risen significantly in recent year, and the vic- tims are on average becoming younger. Furthermore, rape and gross violation of a woman’s integrity (com- bined) are now almost as common as robbery. This increase is probably due to a combination of greater willingness to report crimes, a lower tolerance thresh- old for violence, legislative changes and an increase in the number of violent acts committed. The rise in violence represented by crime statistics is not reflected in the proportion of people who have suffered serious physical injuries as a result of vio- lence. Over the past ten years, the number of deaths resulting from violence has declined among women and men. Hospital statistics also show that although the percentage of people receiving treatment has remained relatively stable, more people are now seeking hospital treatment following a sexual assault. Introduction Both in Sweden and internationally, it has become increasingly common to address the problem of vio- lence from a public health perspective. In the mid 1990s, the World Health Organisation (WHO) declared violence prevention and violence research, particularly in connection with women and children, a public health priority [1]. The World Report on Violence and Health was published in 2002 [2]. Among its aims was the launching of a worldwide campaign against violence. This is the first time a separate chapter of the Swedish Public Health Report has been devoted to the subject of violence. It is one way of responding to the WHO appeal for a focus on violence from a pub- lic health perspective. WHO distinguishes three main categories of vio- lence: self-directed violence, interpersonal violence and collective violence. This chapter deals with the second category, i.e. violence between individuals or groups of individuals. The emphasis is on violence in close rela- tions and, in particular, violence in partner relationships. Although violence against intimates mainly involves women and children, elderly people are also affected. It is difficult to know with any certainty how wide- spread violence is in society today. According to police statistics, only a small proportion of the popu- lation are victims of crimes of violence each year. However, one in every ten respondents in other sur- veys that question people about their exposure to violence report having been exposed to violence in the past year. Clearly many crimes of violence are not reported to the police. The number of unreported cases varies according to the type of crime, the seri- ousness of the crime and the victim’s relationship to the perpetrator. Serious crimes of violence are reported more often than minor ones, and crimes where the perpetrator is a stranger are reported more often than crimes commit- ted by an acquaintance or family member. It is believed that the number of unreported crimes is greatest in the case of sex crimes and crimes against children, although these are often serious. The National Council for Crime Prevention (BRÅ) estimates that less than half of all personal robberies, approximately a third of all cases of assault, approximately a fifth of all cases of threats and harassment and just over a sixth of all sex crimes are reported to the police [3]. This chapter begins with a review of the frequency of violence in different age groups, followed by a dis- cussion of the contexts in which violence occurs, i.e. the nature of the victims’ relationship to the perpe- trator and the types of location in which violence takes place. This is followed by a more in-depth examination of violence against family members, i.e. violence in partner relationships, violence against the elderly and honour-related violence. The chapter concludes with a presentation of trends in crime over time on the basis of existing statistics. The prevalence of violence based on various sources To gain an understanding of the characteristics and prevalence of violence, three types of sources are drawn on: statistics on crimes reported to the police, questionnaire surveys and the Swedish National Board of Health and Welfare’s Patient Registry and Cause of Death Register. For the questionnaire surveys, data are taken mainly from Statistics Sweden’s Survey on Living Conditions (ULF) and the annual Swedish Crime Survey (SCS) administered by the National Council for Crime Prevention (BRÅ). The frequency with which women and men in various age groups fall victims to violence is discussed below. Hospitalisation Boys and men are more frequently hospitalised for severe injuries following an assault than girls and women (Figure 1). Young women and men aged 15– 29 are most likely to require hospital treatment as a result of violence, and it is in this age group that we find the most substantial gender disparities. Cranial injury is common in cases of assault among people who are hospitalised. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 231 Lethal violence More men than women die as a result of violence. An annual average of 30 women, 51 men, and 4 children (0–14 years) were killed in 2004–2006 according to the Cause of Death Register. Among children and the elderly (over 75 years of age) more women than men die from violence (Figure 2). The highest percentage of men who die as a result of violence is found in the 45–59 age group while the highest proportion of women are aged 30–59. Just over half of these women were killed by their current or former partner. Thus four to five times as many women as men are victims of lethal violence in partner relationships [4]. Young people most exposed to violence and threats Approximately one in ten inhabitants was exposed to some form of violence, threats or harassment in 2006, according to Swedish Crime Survey (Table I). Threats and harassment were the most common forms of violence. It is more common for younger people than for the elderly to be subjected to violence or serious threats of violence, according to ULF studies (Figure 3). In 2004–2005, 17 per cent of men and 12 per cent of women aged 16–24 reported having been subjected to violence or serious threats at some time in the pre- vious 12 months. The reverse is true of people in 0 2 4 6 8 10 12 14 16 18 20 0–14 15–29 30–44 45–59 60–74 75+ Women MenNumber Age Figure 2. Age patterns among deaths following an assault. Number of people who died following an assault*. Women and men in various age groups, averages for 2004–2006. * ICD10 code: X85–Y09. Source: Cause of Death Register, Swedish National Board of Health and Welfare. 0 2 4 6 8 10 12 14 16 18 16–24 25–34 35–44 45–54 55–64 65–74 75–84 Women Men Age Per cent Figure 3. Age patterns among people exposed to violence or serious threats. Percentage of people who had been subjected to violence or seri- ous threats in the previous 12 months. Women and men in differ- ent age groups, 2004–2005. Source: Survey of Living Conditions (ULF), Statistics Sweden. Table I. Types of violence and threats. Percentage of people exposed to different types of violence and threats in the past 12 months. Women and men aged 16–79, 2006. Women Men All Threats 4.9 4.2 4.6 Assaults 2.0 3.0 2.5 of which serious assaults* 0.4 0.6 0.6 Sex crimes 1.3 0.3 0.8 Personal robberies 0.7 1.4 1.1 Harassment incidents 5.2 3.9 4.6 Total (any type of threat/ harassment) 10.8 10.3 10.5 *Refers to assaults serious enough to require a visit to a doctor, nurse or dentist. Source: Swedish Crime Survey (SCS), National Council for Crime Prevention (BRÅ). 0 20 40 60 80 100 120 0–14 15–29 30–44 45–59 60–74 75+ Women MenNumber per 100,000 Age Figure 1. Age patterns among hospitalised assault victims. Number per 100,000 inhabitants who were hospitalised following an assault* at some time during the year. Women and men in vari- ous age groups, averages for 2008–2010. * ICD10 code: X85–Y09. Source: Swedish National Patient Register, Swedish National Board of Health and Welfare. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 232 K. Leander et al. middle age, where more women than men are affected. Among those aged 45–54, twice as many women as men had been subjected to violence or serious threats of violence. Among the elderly, more men than women had been exposed to violence. Approximately half the incidents involved physical violence while half involved threats of violence. It is mainly women who avoid going out alone in the evenings through fear of assault, robbery or some other form of molestation. In the 2007 National Institute for Public Health survey, 41 per cent of women and 9 per cent of men aged 18–84 reported that they often or sometimes avoided going out alone in the evenings. Assaults reported to the police The most common violent crime reported to the police is assault, defined in the Penal Code as an act which results in bodily injury, sickness or pain to/in another person, or which places them in a state of powerlessness. In 2007, over 82,000 crimes of assault were reported, just over half of which had been com- mitted against men or boys aged 15 or older, a third of which had been perpetrated against women or girls aged 15 or older, and the remainder of which had been committed against children under the age of 15 (Figure 4). Thus just over 60 per cent of adult victims were male and almost 40 per cent were female. In 2007, 9,600 cases of assault against children under the age of 15 were reported to the police. In the same year, statistics were be recorded separately for girls and boys for the first time. However, these data are still incomplete, although data are available on cases of assault against males and females aged 15–17 (Figure 4). Sex crimes According to the SCS, 1.3 per cent of women and 0.3 per cent of men reported having been sexually coerced, assaulted or molested in 2006 (Table I). Only 17 per cent of these sex crimes were reported to the police [3]. The most common sex crime reported to the police is sexual molestation, i.e. bodily contact of a sexual nature which is not intimate or prolonged enough to be classified as sexual intercourse. These represented almost half of all sex crimes reported in 2007. Rapes accounted for just over a third of all sex crimes. Nearly 90 per cent of these were registered as completed rapes and 10 per cent as attempted rape. In the case of completed rapes, roughly a quar- ter of the victims were under the age of 15 [5]. Just over 10 per cent of rape victims under the age of 15 were boys, whereas rape victims aged 15 or older were generally women [6]. Sexual coercion, exploi- tation etc. accounted for approximately 10 per cent of reported sex crimes, with persons under the age of 15 accounting for three-quarters of the victims of these offences. Hate crimes Hate crimes range from graffiti on the wall of some- one’s house to murder. It is the underlying motive which determines whether an offence is defined as a hate crime. There are no special codes for hate crimes in the police’s reporting system. Since 2008, how- ever, the system has included a special field for sus- pected hate crimes. A survey of hate crimes was conducted by BRÅ in 2007. In order for a crime to be considered a hate Children 0–6 yrs 2% Children 7–14 yrs 10% Girls 15–17 yrs 1% Women 18+ yrs 31% Boys 15–17 yrs 3% Men 18+ yrs 53% Figure 4. Crimes of assault reported to the police. Assaults reported to the police in 2007 (including aggravated offences) by age and gender. Percentages. Total number of reported assault offences: 82,262. Source: National Council for Crime Prevention (BRÅ) [5]. Rape 38% Sexual coercion, exploita- tion 10% Sexual molesta- tion 49% Other 3% Figure 5. Sex crimes reported to the police. Sex crimes reported to the police in 2007 by type of crime. Per- centages. Total number of reported sex crimes: 12,563. Source: National Council for Crime Prevention (BRÅ) [5]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 233 crime in the survey the perpetrator had to belong to a pre-defined majority group and the victim to a sim- ilarly pre-defined minority group. It was also essen- tial that the crime be motivated by the perpetrator’s negative attitude toward the victim’s skin colour, nationality, ethnic background, religious beliefs or sexual orientation. A hate crime motive was identi- fied in just over 3,500 crime reports. The motives were xenophobic (70 per cent of all cases), homo- phobic (20 per cent), Islamophobic (6 per cent) and anti-Semitic (2 per cent). Just over 20 per cent of hate crimes were violent offences, and approximately 35 per cent took the form of unlawful threats and/or molestation. Violent crimes were not as prominent among offences with a religious motive as among crimes based on xenophobic or homophobic motives (Figure 6). These crimes generally involved men. Approximately 80 per cent of suspected perpetrators were men, as were approximately 70 per cent of the victims. The crimes, which occurred in every possi- ble type of location, were committed in schools or in the workplace more often than in places of public entertainment [7]. In two studies (1996–1997 and 2003–2004), BRÅ asked schoolboys and schoolgirls (pupils in the 8th and 9th grades of compulsory school and the 1st and 2nd years of upper-secondary school) if they had been subjected to violence at any time during the previous 12 months because of their ethnic background. In the most recent study, which included just over 10,000 young people, 7 per cent of pupils of foreign background (born abroad with foreign-born parents) answered that they had been. The corresponding figure for pupils of Swedish background (born in Sweden with native-born par- ents) was 2 per cent. Most of the incidents had taken place during leisure time, on the street, at a disco or at a youth recreation centre. There was nothing to suggest that any appreciable change had taken place between the two studies [8]. Who commits violence and where? The available statistics provide a measure of insight into the victim’s relationship to the perpetrator. Perpetrators are predominantly men, whether the violence is directed at women or men. When the vic- tim is a woman, however, the perpetrator is more often a family member or person close to the family. Street violence and violence in the home and in the workplace According to the ULF surveys, women make up the majority (60 per cent) of victims of violence or threats of violence in the home or in connection with work, whereas 70 per cent of victims of violence in public places are men (Table II). The difference between men and women in this regard is even more marked among young people when it comes to location. Young males aged 16–24 are subjected to violence in public places (so-called street violence) three times more 0 10 20 30 40 50 60 70 Xenophobic Islamophobic Anti-Semitic Homophobic Crimes of violence*/unlawful threats/molestation Agitation against a minority group Defamation Vandalism Other crimes Per cent Crime motive Number of crimes2,489 206 118 723 Figure 6. Hate crimes. Hate crimes by motive, 2007. Percentages. *Included in hate crimes are the following categories: lethal violence, assault and violence against a public servant. Source: Klingspor, Molarin, Sporre [7]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 234 K. Leander et al. often than young females. In cases of street violence reported to the police, the majority of the perpetrators and approximately half the victims were under the influence of alcohol [9]. Young women, on the other hand, are subjected to violence and threats in the home twice as often as young men. Single women with young children constitute a particularly vulnerable group with 15 per cent of this group having been exposed to violence in the home in 2003 [10]. According to the 2005 ULF survey, violence in public places was twice as common as violence in the home. Underestimates of violence in the home tend to be larger, because the perpetrator is often acquainted with the victim and may even have been present at the interview [11]. According to the 2000–2001 ULF sur- vey, women failed to report an estimated 105,000 threats of violence or violent incidents to the police for fear of reprisals or for family reasons [12]. Table II shows the number of victims of violence or threats. It should be noted that the same person may have been subjected to several incidents of vio- lence or threats. Half of all reported incidents occurred while the victim was at work. Acquainted or unacquainted perpetrator Most of the women and children assaulted (just over 70 per cent) were acquainted with the perpetrator, compared with only slightly over 30 per cent of male assault victims. These figures are based on assaults reported to the police (Figure 7). In almost half of all reported assaults on women, the perpetrator was the victim’s current or former partner [13]. The same finding emerged from a public health survey con- ducted by Stockholm County Council: half the women exposed to violence in the previous 12 months Table II. Location and type of incident. Estimated number of people who have been subjected to violence or serious threats, by type and location of incident, and by gender (per cent). People aged 16 and over, 2005. Number of people Percentage Women Men Total Subjected to violence or serious threats 508,000 48 52 100 In the home* 106,000 60 40 100 In public place 205,000 31 69 100 In connection with work 203,000 58 42 100 Subjected to physical violence of which: 254,000 42 58 100 Violence requiring medical attention 45,000 39 61 100 *In most cases, the victim’s own home, but can also include the homes of others. Source: Survey of Living Conditions (ULF), Statistics Sweden. 60 80 100 Stranger, outdoors Acquaintance, outdoors Per cent 0 20 40 Children 0-6 yrs Children 7-14 yrs Girls 15-17 yrs Boys 15-17 yrs Women 18+ yrs Men 18+ yrs Total Acquaintance, indoors Stranger, indoors Figure 7. Relationship with the perpetrator and location of reported criminal assaults. Assault victims by group and by the victim’s relationship to the perpetrator (known and unknown to the victim) and location of assault (indoors or outdoors). Children, women, and men in various age groups, 2007. Source: National Council for Crime Prevention (BRÅ) [5]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 235 reported that the perpetrator had been their current or former partner [14]. By comparison, the same sur- vey found that approximately one in ten male victims of violence cited a partner as the perpetrator. As regards reported assaults against children aged 0–6, the perpetrator is acquainted with the victim in nine cases out of ten, and is often a parent or step- parent. In most cases these assaults occur indoors. Among children aged 7–14, assaults also tend to occur indoors and are committed by a person known to the victim, although this is somewhat less common than among victims aged 0–6. The majority of suspected perpetrators identified in these cases (approximately 60 per cent) were under the age of 15 and thus had not yet reached the age of criminal responsibility. A further 15 per cent were between the ages of 15 and 20. Almost a fifth of all women whose injuries were seri- ous enough to require hospitalisation in 2005–2007 reported having been assaulted by their partners (Figure 8). Just over a tenth had been injured as a result of sexual assault. Only a small number of men had been injured as a result of abuse by a partner or other person acquainted with the victim, and none had been hospitalised as a result of sexual assault. Approximately 98–99 per cent of those suspected of sex crimes in 2007 were men, and 20–25 per cent were between the ages of 15 and 20 [5]. Lethal violence is more common in socially mar- ginalised environments and a large proportion of the perpetrators have or have had a mental illness. A quarter of the men who killed a woman in an inti- mate relationship, committed suicide after the crime. With regard to rapes among adults (aged 15 or older) reported to the police in 2006, the victims and the perpetrators were strangers in 33 per cent and superficial acquaintances in 41 per cent of all cases. Approximately 17 per cent of all reported rapes occurred in intimate relationships, i.e. the perpetrator was either the victim’s current or former partner [16]. The remaining 9 per cent of rapes were committed by other family members or close acquaintances. Violence in close relationships The data sources cited in the introduction do not provide a complete picture of the scope of violence. Moreover, the picture is distorted because unre- ported cases are more numerous for certain violent offences than for others. Under-reporting is more prevalent in instances of violence that occur in close relationships and in private environments hidden from public view. There is also more under-reporting of crimes viewed as particularly shameful, e.g. sex crimes and child abuse. Violence in close relationships includes violence within partner relationships, against children, against the elderly, and honour-related violence. Violence in close relationships is distinguished by two features: the victim is more or less dependent on the perpetra- tor, and the violence is often recurrent, forming part of the victim’s daily life. The emphasis in this section is on violence in partner relationships, which mainly affects women and their children. Assaulted by a partner 19% Assaulted by another f amily member or an acquain- tance 4% Sexual assault 9% Women Assulted by a person who is not a f amily member or an acquaintance 68% Assaulted by a partner <1% Men Assulted by a person who is not a f amily member or an acquaintance 98% Assulted by another f amily member or an acquaintance 2% Figure 8. People admitted to inpatient treatment as a result of different types of assault. Proportion (per cent) of those admitted to inpatient treatment at some point during the year as a result of assault, by type of assault. Girls/ women and boys/men, 2005–2007. An average of 579 girls/women and 2,074 boys/men per year, received inpatient treatment as a result of assault in 2005–2007. Source: Swedish National Patient Register, Swedish National Board of Health and Welfare. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 236 K. Leander et al. Violence in partner relationships Violence in partner relationships refers here to vio- lence that occurs within a current or former relation- ship, i.e. violence committed by a current or former spouse, cohabitee, boyfriend or girlfriend, or partner in an LAT (Living Apart Together) relationship. Swedish studies of men’s violence against a female partner show that 1–3 per cent of all women have been exposed to physical violence committed by their cur- rent or former partner in the past year [14, 17]. The Swedish National Board of Health and Welfare esti- mates that at least 75,000 women in Sweden are sub- jected to some form of violence in partner relationships each year [18]. However, this figure, based on official statistics with the deficiencies they entail, is unreliable. Both Swedish and foreign studies show that women who have been subjected to violence by a male partner are often repeated victims [19]. Data on the percent- age of women subjected to partner violence should therefore be supplemented with information on how often such incidents recur in order to gain a compre- hensive picture of the scope of this problem. A national study conducted in 2001 indicates a high lifetime prevalence of violence against women [20]. Lifetime prevalence here refers to the percentage of vic- tims who have been subjected to violence at some point in their lives after the age of 15. Otherwise estimates are normally limited to a particular year. According to the study, 7 per cent of cohabiting women had been sub- jected to physical violence by their current spouse or cohabitee at some point in their lives. Among women who had previous relationships, 28 per cent had been subjected to physical violence by a former partner at some time. A study of violence in same-sex relation- ships showed that a quarter of those surveyed had been subjected to some form of psychological, sexual or physical violence in a current or previous relationship (including heterosexual relationships) [21]. A study of pregnant women in Sweden showed that nearly 3 per cent had suffered physical violence from a male partner, former partner or another rela- tive in the year preceding pregnancy, and that just over 1 per cent had been subjected to violence during or directly after pregnancy [22, 23]. These and other studies contain examples of cases where violence commenced when the woman became pregnant, and cases where ongoing violence became more severe during the pregnancy. A WHO study from 20051 showed that between 4 and 12 per cent of the women questioned were subjected to physical violence during pregnancy, and in over 90 per cent of the cases, the perpetrator was the biological father of the child [24]. International studies have shown that violence against women is a global problem [24, 25]. Sample studies among women in Canada, Finland and Norway have reported high lifetime prevalence of exposure to violence in partner relationships [26– 29]. A review of studies from several Western coun- tries has shown that 25–30 per cent of all women are subjected to violence by a partner at some point, and that 2–12 per cent are affected each year [30]. From a global perspective, the more serious forms of vio- lence against women also include human trafficking for sexual purposes, sex slavery, exploitation of labour, physical and sexual assaults against prosti- tutes, child-killings involving female victims, the abortion of female foetuses, the neglect of female children, and rapes committed in times of war [31]. Controlling or situational violence in partner relationships Violence in partner relationships can assume many forms. However, two main patterns may be distin- guished: controlling violence and situational violence [2, 32–34]. Controlling violence is serious and escalatory, involving an admixture of different forms of violence, terror, harassment and threats. The perpetrator’s behaviour is dominating and controlling. The over- whelming proportion of victims are women subjected to violence by their male partners [35]. According to the WHO report on violence and health, there is very little to indicate that women engage in violence of this kind [2]. The same applies to sexual violence by women against male partners [36], which is more often used in self-defence or in response to men’s violence. Situational violence in partner relationships is triggered by certain stressful situations in which frus- tration and anger erupt into physical aggression. In most cases the perpetrator does not feel the need to control the other person. This kind of violence is committed by both women and men. In some rela- tionships it is reciprocal or initiated by the woman [2, 34]. Controlling violence is often thought of as a pro- cess, whereas situational violence is described in terms of separate incidents. While it is probably easier to capture situational violence in public health surveys and the like, other methods also need to be used to study controlling violence, according to the WHO [2]. It has been argued that women commit violence in partner rela- tionships to the same extent as men, but these asser- tions are often based on studies that primarily capture situational violence rather than the kind of violence aimed at dominating or breaking down one’s partner [36]. Controlling violence results in physical injuries to a greater extent than other partner violence, and psychological conditions such as depression, low at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 237 self-esteem, fear (sometimes fear for one’s life), and higher levels of consumption of medical care and medication [2, 35, 37]. Consequences of partner violence Research based on clinical studies and questionnaire surveys clearly shows that violence in partner rela- tionships has a severe impact on victims’ physical and mental health, both in the short term and long term [2, 32–34]. Even long after the violence has ceased, a strong connection persists between wom- en’s ill health and their exposure to violence [24]. Studies in Sweden and other countries have shown that domestic violence is linked to suicide attempts among women [38–40]. In an Australian study, the percentage of women who reported having injured themselves, or having recently been on the point of doing so, was nine times higher among those who had been subjected to violence by their partners than among other women [41]. A questionnaire survey of women who had been in contact with the psychiatric care sector in Skåne in 2003 showed that 70 per cent had been subjected to physical, psychological or sex- ual assaults at some point in their lives, usually by an intimate and often on repeated occasions [42]. A study was conducted in the four Norrland (northern Sweden) county councils of the links between reported physical violence or threats of violence (not limited to violence in partner relationships), and reported ill health among women and men. Among women aged 30–44 who had been subjected to violence or threats, the proportion who suffered from nervousness and anxiety was many times higher than among those who had not been exposed, once social background and smoking habits had been taken into account [43]. Mental illness is more common among women than among men, but it is not known to what extent this is due to violence. According to a Norwegian study, the combination of physical and sexual violence that haunts the lives of many abused women is particularly harmful [44]. Certain specific diagnoses for which women seek medical care may be a sign that they have been sub- jected to sexual assault, both within and outside close relationships. Diagnoses often linked to sexual assault are chronic pelvic pain, other conditions involving prolonged pain, infections, post-traumatic stress dis- order (PTSD), eating disorders, self-destructive behaviour, chronic mental illness and other psychiat- ric disorders [45–48]. These health problems may be the result of violence without the connection being apparent to the woman herself or to healthcare pro- viders. Sexual assaults also frequently lead to a num- ber of gynaecological and reproductive complaints as well as to sexual problems, particularly with respect to orgasm and sexual satisfaction [49]. The authors of an Australian study estimated, on the basis of disability-adjusted life years (DALYs), that women’s burden of disease was mainly attribut- able to mental illness [50]. Seventy-three per cent of the burden of disease was attributed to issues such as depression, anxiety and suicide, while 22 per cent were attributable to harmful health behaviours, such as smoking tobacco and misuse or abuse of alcohol and illegal drugs. Less than 1 per cent were the result of physical injury. The authors also estimated that violence in partner relationships was responsible almost 8 per cent of the total burden of disease among all adult women under the age of 45 in the Australian state of Victoria, where the study was conducted. Partner violence can also entail serious social con- sequences for woman, such as isolation, difficulty in obtaining help, including healthcare [51], strained relations with employers, financial problems caused by absence from work due to illness, and unemploy- ment as a result of difficulty in maintaining normal working relationships [2]. Constant fear, restricted freedom of movement and the knowledge that the children are also being affected by the violence, can also bring about a significant deterioration in the quality of the victim’s life [52]. Each year, women in Sweden make between 12,000 and 14,000 outpatient visits to hospitals, emergency care units or primary care providers following violence in a partner relationship. Domestic violence is responsi- ble for more absences from work than street violence and work-related violence [12]. Sixteen per cent of peo- ple who had been subjected to domestic violence called in sick, compared with 6 per cent of those who had been exposed to street violence, and just below 3 per cent of those who had been subjected to violence linked to work. Although the data were not broken down by gender, they indicate that single women with children seek medical care or take sick leave as a result of vio- lence more often than other people [11]. Prolonged absence due to illness, i.e. of more than 30 days, is ten times more common among those who have been sub- jected to domestic violence than among those who have been exposed to street violence. On the other hand, street violence is responsible for more than half of all incidents of violence requiring medical treatment. In a 2006 report by the Swedish National Board of Health and Welfare, it was estimated that violence against women costs society between SEK 2.7 and 3.3 billion annually, of which direct medical care costs account for between SEK 23 and 38 million [18]. To these figures must be added costs arising in connection with sick leave and lost future productivity. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 238 K. Leander et al. Violence becomes normalised A recurring question is why so many women remain in abusive partner relationships. One theory is predi- cated on the so-called normalisation process: vio- lence is perpetuated by becoming a part of daily life, i.e. it becomes normalised and is gradually accepted by both the man and the woman [53]. The process is characterised by two important mechanisms: the woman is isolated, and the man switches between violence and warmth. By means of threats and emotional manoeuvres, the man is able to frighten the woman to the point where she adapts, then gradually isolate her from contact with her par- ents, siblings, friends and others. She is cut off from people in her surroundings who might otherwise be able to protect and help her and show her the unac- ceptability of her situation. When a man first becomes abusive he will often veer between violence and shows of warmth and consideration. He may be dev- astated after having used violence and promise that it will not happen again. This interplay helps to strengthen the man’s power; he controls the switch between good and evil. A third mechanism, accord- ing to this model, is that the dominance of the male partner is eroticised, and several violent incidents end in rape and other forms of sexual violence [46]. Women who live under such circumstances gradually lose their sense of reality and may even come to assume guilt for the man’s controlling and violent behaviour. Typical factors that trigger violence in such relationships are men’s jealousy and feelings of ownership, their expectations regarding women’s domestic duties, and the feeling of being entitled to punish ‘their’ woman for misdeeds perceived as chal- lenging their authority [54]. Some women are nonetheless able to keep a net- work of people close to them who are aware of the violence [55]. Women who eventually succeed in breaking off the relationship have often tried to do so before, and the process is marked by feelings of love, fear, hate, pity, guilt and hope. The break-up is often hastened by various ‘turning points’, for example when the woman realises that her life is at stake and/ or that her children are vulnerable, when she loses all hope for the relationship, and when outside help arrives at the right time. Violence is not limited to ongoing relationships. According to the ULF surveys, single women are subjected to violence or threats seven times as often as cohabiting women. One explanation for this is that it is both emotionally and practically easier to talk about such incidents if one does not share a home with the perpetrator. Another explanation is that separations and violence are connected – partly because a separation can lead to violence and partly because violence can be the cause of separation. Research has shown that more serious forms of vio- lence against women often take place when a rela- tionship is coming to an end. It has also been shown that homelessness among women is often the result of their having been subjected to violence in their former home [14, 35]. Another noteworthy finding of the ULF surveys is that single women with small children are the group at highest risk of violence. Approximately 15 per cent had been subjected to violence or threats in the home in 2003 [10]. Mothers living alone who lack social resources, i.e. who have a range of problems in terms of finances, education, health, employment and social networks, are exposed to recurrent vio- lence up to ten times as often as single women gen- erally [14, 56]. Structure of society and individual risk factors both significant Many explanations for men’s violence against women have been proposed over the years [57]. In 1994, BRÅ identified two fundamental approaches [58, 59]. The first is concerned with the question of why some men subject women to violence while others do not. The second approach, which in the view of the authors of the present report has greater validity, focuses on the significance of men’s dominance over women in society as a whole. In the background material to the 1998 legislation on a woman’s right to freedom from violence, gender inequality and sex discrimination (the Violence against Women Reform), the imbalance in power relationships between the sexes was identified as the fundamental cause of men’s violence against women [60]. An evaluation of the measures taken by govern- ment agencies to combat men’s violence against women [61] was published in 2004, and in this eval- uation, too, the explanatory models were divided into two main groups. In the first group, interpreta- tions were based on the concept of a “gender power order”, in which power is conceived as based on a “social structure where men are superior to women, and where men’s exercise of power thereby confirms a gender power hierarchy” [61]. This may be regarded as a feminist perspective. The second group was characterised by “deviance interpretations”, where violence is seen as a marginal problem and the perpetrators and victims are regarded as deviant indi- viduals. Here, explanations of violence are sought in deviant behaviours among men who perpetrate vio- lence. Attention is focused on the most deviant men, men who suffer from severe mental illness, are seri- ous criminals or substance abusers, or men from at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 239 particularly patriarchal cultures. However, the authors felt that this approach distanced violent men from others, thereby concealing the links between violence, gender and power [61]. One of their con- clusions was that government agencies principally apply the deviance model, which weakens initiatives taken to combat violence. Several attempts have also been made to combine different explanatory models. One approach has been to distinguish between the basic preconditions for vio- lence, in this case the gender power order, and trigger- ing factors such as alcohol or individual circumstances [57]. In other approaches, the feminist perspective is used as “cement” between the gender-power perspec- tive and other explanatory models [62]. The concept of “intersectionality” has also been introduced to emphasise that several social power hierarchies can influence people’s lives and living conditions simulta- neously – power orders based on gender, ethnicity, nationality, sexuality, class and skin colour [63]. At the end of the 1970s, the holistic – also known as the ecological – model was developed to explain child abuse. WHO and others have applied the model both to violence in general and to men’s violence against women (Figure 9) [2]. The model represents an attempt to combine theories and explanatory models that operate on different levels. It is based on the premise that many factors work together and that no single factor can explain either the prevalence of partner violence in different societies or different contexts, or variations in the prevalence of this vio- lence [64]. For example, violence can increase in periods of high unemployment due to individual stress, lack of social control or and reduced support to families [65]. Community norms permissive of violence also lead to violence becoming more com- mon [24]. Although it is important that society is able to help individuals, for example by protecting and supporting vulnerable women and by providing treatment to men who use violence, a structural understanding of violence makes it easier to work preventively [66]. Gender-related violence in ‘gender equal’ Sweden Sweden has often been ranked among the world’s most egalitarian societies [67]. In light of this, the question may be asked why Sweden’s successful ini- tiatives in the gender equality domain have largely failed to reduce the high levels of violence. International observers take the view that structural initiatives such as those taken in Scandinavia are needed to combat violence but that they are not suf- ficient [68]. Several studies have shown that women in the Nordic countries report that their previous relation- ships were considerably more violent than their cur- rent ones. The authors of the report Captured Queen (Slagen Dam) have interpreted these findings to mean that only after a woman has left a relation- ship and is away from the violence that she can describe her experiences. Admitting that one is liv- ing in a violent relationship is not easy, a difficulty • Norms that • Stressfull social • Inability to • Experience of IndividualStructure Society Relationship sanction men's authority over women. • Acceptance of violence as means of resolving conflicts. relations. • Relations with others whose norms legitimse violence. • Isolation of women and the family. y manage relationships. • Marital conflict. • The man takes control and makes the decisions in the family. p violence in the family during childhood and adolescence. • Lack of care during childhood and adolescence • Masculinity is associated with dominance, honor, or agression. • Rigid gender roles . • Individual-psychological factors. • Alcohol abuse. Figure 9. The holistic model. Examples of factors which increase the risk of violence in partner relationships. The model was first described by Heise [64]. The original WHO model employed the concepts ‘social’, ‘community’, ‘relationship’ and ‘individual’ [2, 18]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 240 K. Leander et al. compounded by the prevailing Swedish gender equality norms. These norms put pressure on women to interpret their ongoing relationship in terms of equality [20]. On the other hand, the find- ings can be interpreted as a sign of increased gender equality, which among other things has improved women’s opportunities to break away from violent relationships [69, 70]. The role of alcohol in partner violence Alcohol plays a complex role in partner violence. Although US studies found that the men and women involved were both sober in the majority of cases of violence against a partner [71–73], there was a risk that the violence would have been more serious if the man had been drinking alcohol [74]. Unlike men with no alcohol problems, men who had sought treatment for alcohol problems were found to be at greater risk of using violence on days when they had consumed alcohol [75]. According to the US studies, women are at considerably higher risk of being subjected to vio- lence if they live with men who have alcohol or drug problems [72]. The risk also increases in socially dis- advantaged environments, where alcohol and/or drug abuse are also more common. However, it is difficult to determine whether partner violence is a result of alcohol or drug abuse, of social marginalisation, or of a combination of the two [76, 77]. In a Swedish interview study carried out among women with alcohol or drug abuse problems, several respondents indicated that a contributing cause of their abuse was that they had been exposed to violence by a man close to them [77]. This raises the question of what is cause and what is effect in studies where a link has been found between violence and alcohol abuse. With regard to violence in partner relationships, studies have shown that alcohol plays a larger role in situational violence than in controlling violence [20, Violence against women in Sweden: a historical perspective Acceptance of men’s violence against women has varied throughout the course of history. In the 13th cen- tury, abduction – the act of taking a wife by force – was prohibited. Nevertheless, old provincial laws permit- ted married men to use “reasonable corporal punishment of wives”. However husbands were expected to observe certain limits, such as preferably not beating their wives in public, killing them, or striking them with large implements. In certain cases, women enjoyed legal protection against violence, although this was often in their capacity as men’s chattels. Early laws against rape were usually applied to protect engaged or married women from other men. It was not until the introduction of the penal code of 1864 that “corporal punishment of wives” was redefined as punishable, non-aggravated “assault in a private place”, and thereby criminalised. However, the public prosecutor could not initiate legal proceedings unless the victim herself reported the crime. This form of violence was therefore termed “accusatory crime”. It was not until the early 1980s that most cases of domestic violence and rape were prosecuted in the courts. From historically having permitted many forms of private violence, the authority to exercise violence has gradually been transferred to the state, to the military and to the police. The official view of violence against women has changed substantially in recent decades. A number of examples of legislative changes are set out below: 1965 Rape within marriage was criminalised. 1982 Violence against women, including assaults not classified as aggravated and taking place in private, became a publicly prosecutable offence. People other than the victim could also report the crime and the public prosecutor was authorised to initiate proceedings, even without the victim’s consent. 1984 Rape and other sex crimes were made publicly prosecutable offences; the definition of rape was broadened to include other acts besides intercourse, to cover homosexual assaults and to make the act gender-neutral. 1998 The crime of “gross violation of a woman’s integrity” was introduced into the Penal Code. 1999 Purchasing of sexual services was criminalised. 2003 The Restraining Orders Act was broadened to include joint homes. 2005 Sexual acts with a person in a “helpless state”, for example as a result of intoxication were made punishable as rape to a greater extent than previously. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 241 78]. For the most part, alcohol consumption appears to increase the risk that violence will be triggered and that it will have serious consequences. From a popu- lation standpoint, there are other factors that deter- mine whether or not violence will occur. If the population as a whole were to stop drinking alcohol entirely, men’s violence against women would not cease, although its prevalence would probably dimin- ish along with the number of people who suffer seri- ous injuries [79]. No studies show any clear links between alcohol and violence in relationships characterised by mod- erate alcohol consumption, but of course there is a sliding scale from moderate consumption to risk con- sumption to alcohol abuse. The fact that alcohol may be used as a means of avoiding responsibility, means that it may be accorded a more important role in partner violence than it actually has. Other drugs and medications can also heighten the risk of violence in partner relationships. Children who experience violence in the family Violence against women affects many children; according to one estimate, roughly 10 per cent of all children have experienced violence in the home and 5 per cent have experienced it frequently [20, 78]. These children are often referred to as “children who witness violence”, a somewhat questionable term. “Children who experience violence” better captures what children witness, as the psychological and emo- tional assaults to which the mother is subjected are also something that the children constantly live with [80]. Furthermore, research has shown that if a mother is beaten by her partner, her children are often beaten as well. According to one research review, this occurs in 30–60 per cent of cases, while another review estimates that 45–70 per cent of the children of mothers who are assaulted are also sub- jected to violence [81, 82]. The children of women who are subjected to vio- lence often have the same symptoms as children who are treated badly for other reasons. Some children have no symptoms at all, and age can play a role in determining whether the symptoms become visible and the way in which they manifest. Small children tend to develop physical symptoms, whereas older children often develop one or more specific symp- toms, such as eating disorders or self-harming behav- iour. Other factors are the child’s proximity to the violence, how severe it is, the frequency with which it occurs, and whether or not there are other adults who are able to protect and support the child [83]. Studies have also shown that girls and boys react in different ways: among other things girls often tend to become withdrawn while boys have a greater ten- dency to act out. Children may be affected by serious health prob- lems, such as asthma, eczema, stomach aches, diffi- culty sleeping, headaches, eating disorders, as well as prolonged mental health problems such as anxiety, self-destructive behaviour, aggression, difficulty relating to others and difficulty concentrating [84]. Other symptoms may include fears and phobias, sui- cidal behaviour, tics, bed-wetting and low self- esteem. Studies have also shown that these children often have difficulty in school, and perform more poorly in tests that measure language ability, motor function and cognitive ability. There are frequent instances of children who have lived with threats and violence in the family over long periods of time and thus suffered repeated traumas. As a result, some have developed post-traumatic stress syndrome (PTSD) [84]. As adults, these children run a greater risk of being assaulted, or of assaulting others. They also exhibit higher levels of alcohol consumption in their teenage years, and girls expose themselves to greater sexual risks [85]. Violence against children In Sweden, all corporal punishment or other abusive treatment of children is prohibited under the Children and Parents Code. In 1966, the paragraph which allowed parents to use corporal punishment on their children as part of the child-rearing process, i.e. for educational and disciplinary purposes, was excised. An express prohibition was subsequently introduced in 1979, and Sweden thereby became the first country in the world to ban corporal punishment of children. In 2004, the Council of Europe’s parlia- mentary assembly approved a recommendation to prohibit physical violence against children in the Council’s 45 member states, and declared that cor- poral punishment of children was contrary to both the UN Convention on the Rights of the Child and the Council of Europe’s Social Charter. In 2006, the UN presented a report on violence against children recommending a total ban on the use of physical and psychological violence against children, including corporal punishment. To date, however, only a score of countries in the world have banned corporal pun- ishment of children. According to WHO estimates, some 57,000 chil- dren worldwide (0–14 years of age) died as a result of violence in 2000, and small children (0–4 years of age) were twice as likely to die as a result of violence compared with older children (5–14 years of age) [2]. In Sweden, an average of 4 children (0–14 years at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 242 K. Leander et al. of age) died each year as a result of assault in 2004– 2006 (Figure 2), and 100 children were hospitalised annually. International comparisons show that corporal punishment of children is significantly less common in Sweden than in other countries. The incidence of corporal punishment has declined in tandem with the increasingly negative attitude to corporal punish- ment of children. According to available data, approximately half of all children in the 1970s were physically punished at some point. In the 1980s, however, the proportion had dropped to about a third, and by the 1990s the figure had fallen to approximately 20 per cent. Presumably, it is mainly lighter and moderately severe forms of physical pun- ishment that are less frequent in Sweden than in other countries. More serious forms of corporal pun- ishment probably continue to occur in Sweden to the same extent as in other Nordic countries. Swedish studies from 2000 indicate that between 4 and 7 per cent of all children have at some point been struck with an object of some kind, of which 1–2 per cent have been struck frequently [86]. Younger children continue to be physically punished to a greater extent than older children and there is no evidence that the proportion of children who are punished has declined further in the 2000s [87]. Chapter 2, Children’s Health, contains an additional section on violence against children. Cases of child abuse are rarely prosecuted and few victims receive treatment for the traumas they have undergone. This is shown by a follow-up study of all the police reports of assaults on children conducted in one police district in 1986–1996 [88]. Only 25 of the 126 reports led to prosecution, although there were documented injuries in half the cases. Furthermore, only 6 of the 126 children had received professional therapy. The findings were the same in a special follow-up study conducted in Östergötland County of all reports of child abuse submitted by municipal social services committees in 2000 [89]. Of the 867 reports received, 148 resulted in a police report, of which only 20 resulted in prosecution. Violence against the elderly The scale and consequences of violence against the elderly are such that it can justly be considered a public health problem [90–92]. According to a Swedish study from 2000, an estimated 16 per cent of all elderly women and 13 per cent of all elderly men over the age of 65 had been subjected to vio- lence in some form [91]. Despite this finding, vio- lence against the elderly remains largely unresearched [93, 94]. Internationally, estimates of the proportion of elderly people who have been exposed to violence and assaults range from 1–4 per cent in Norway, Australia, Canada and the US, to 7–8 per cent in Finland [91], and as much as 20 per cent in France [95]. However, since the studies applied different definitions, a comparison of their findings, and thus of the countries concerned, has proved difficult. Violence against the elderly differs from violence in other groups of adults due to the vulnerability and state of dependency of many elderly people. In con- trast to children, whose vulnerability may somewhat resemble that of the elderly, the latter are a very het- erogeneous group in terms of their dependency and care needs. This has given rise to some disagreement concerning the kinds of incident to be subsumed under the term ‘violence against the elderly’ and whether the group should be limited to include only those elderly people who require care and attention. Narrower definitions of violence against the elderly could for example exclude neglect and substandard care, unintentional or random incidents, and inci- dents occurring outside the care context. The broader definition encompassing all forms of violence and assault committed against people over the age of 65 is usually applied in Sweden and the Nordic coun- tries [94]. Research on violence against the elderly often focuses on five different types of violence: neglect, psychological violence, physical violence, sexual violence and financial violence. A distinction is often made between violence that takes place in the home and violence which occurs in an institution. It is difficult to diagnose violence and assaults against the elderly if the latter are themselves unable or unwilling to report their experiences. Injuries among the elderly are often construed as age-related: elderly people may fall more easily due to impaired balance; their skin and skeleton become more brittle and fragile, and bruises occur more easily. An esti- mated 70 per cent of all identified cases of violence against the elderly have been reported by witnesses or caregivers [93]. In 1999, the law on mandatory reporting mistreatment within the organised health care system (Lex Sarah) was amended so that care staff are now duty bound to report irregularities and unsatisfactory conditions in the care of the elderly and functionally impaired to the relevant inspection agency (Chapter 14 of the Social Services Act) [95]. However the act only applies to unsatisfactory condi- tions in connection with professional care provision and does not cover violence in the home committed by family members. At the beginning of the 1990s, the Swedish National Board of Health and Welfare conducted a study among staff in the home care services, at care centres, emergency wards and day centres, and at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 243 among chief guardians [90]. Among other things, the study found that elderly women are exposed to vio- lence more often than elderly men. Women with physical or mental functional impairments and elderly people with few social contacts are particu- larly vulnerable. In most cases, the perpetrator was a male family member. Physical assaults and psycho- logical abuse were equally common; various forms of violence and assault often occurred at the same time. Three typical cases, or risk situations, became appar- ent: (1) assaults that occur as a result of a strained care situation; (2) long-standing family problems, for example an addicted or mentally ill child who moves in with the elderly person; and (3) prolonged, sys- tematic abuse of a woman continuing into old age. In 2000, a study was carried out among people between the age of 65 and 80 in the municipality of Umeå [91]. The findings showed no significant dif- ference in the percentages of women and men who had been exposed to violence at some time – 16 and 13 per cent respectively. On the other hand, it was found that women were subjected to more recurrent and serious violence than men. Functional impair- ment and old age also heightened the risk of violence and abuse of elderly women, but not of elderly men. In three out of four cases, the perpetrator was a man, and more than half the women had been subjected to violence by a current or former partner. Three quar- ters of the women and 40 per cent of the men who had been subjected to violence had never sought help. The women victims were worse off than their male counterparts; they had poorer health, more often suffered from psychosomatic and mental symp- toms, used more medication and were more often traumatised by earlier violence that had occurred before the age of 65. Elderly men who had been sub- jected to repeated violence drank to the point of intoxication more often than others but it is unclear whether this was a consequence or a cause of the vio- lence to which they had been subjected. Honour-related violence Honour-related threats and violence have attracted increasing attention in recent years. The term is employed both in Sweden and internationally to denote threats and violence committed in the name of ‘honour’. There is no single recognised definition of honour-related violence. However, according to a UN report, this form of violence is characterised by the fact that it is encouraged within the wider com- munity as part of a pattern of structural and institu- tionalised oppression [96]. Thus violence is used as a means of controlling individuals, particularly women and girls, in societies where the concept of honour includes the exercise of control over women’s sexual- ity [97]. This type of violence can be viewed as a con- nected series of events in which control and restrictions on freedom turn into increasingly abusive acts involving violence, assault and ultimately hon- our killings [98]. Although honour-related violence is usually directed at girls and young women, the UN, among others, points out that LGBT people and heterosexual boys and men can also end up as victims. They may of course be subjected to violence or forced into marriages themselves, but they may also be coerced into keeping watch over female rela- tives or, in the case of younger men or boys, into committing crimes on behalf of the family on the assumption that they will be given milder punish- ments due to their age [98]. It is difficult to form a picture of the scale of hon- our-related violence in Sweden, particularly since it is so difficult to define. When Sweden’s County Administrative Boards compiled all the cases of hon- our-related violence known to Swedish authorities and organisations in 2004, they found a total of 1,500–2,000 cases [99]. Girl and women victims of honour-related violence were found in all of Sweden’s counties. Schools and voluntary organisations had closest contact with these girls, followed by the social services and youth clinics. As the figures represent known cases only, they are probably a gross underestimate. Honour-related violence was the special focus of a study of the perceived freedom of upper secondary school pupils in determining their own lives [73]. A key question was whether the pupils were worried about not being able to choose their life partners themselves. Approximately 5 per cent of the girls and 3 per cent of the boys in the 2nd year of upper secondary school (aged 17) expressed such a concern. Approximately 20 per cent of these ‘worried girls’ also stated that their free- dom to make choices on issues relating to their day-to- day lives was very or fairly restricted. Approximately 60 per cent had been subjected to abusive treatment, threats and violence on at least one occasion. Nearly half the boys who were worried about not being able to choose their own life partners had also been subjected to abusive treatment, threats and/or violence. Young people of foreign background were over-represented in this group of ‘worried’ boys and girls. In 2003–2007, the government earmarked SEK 180 million for initiatives to combat honour-related violence, including preventive programmes and sup- port for sheltered housing [98]. Sheltered housing for people who had been subjected to honour-related threats and violence was examined in one follow-up study, with mixed results [100]. A third of the inter- viewees had been subjected to new threats after at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 244 K. Leander et al. seeking protection, but most felt less threatened than before. When they arrived at the shelters, many of them had health issues related to the violence they had been exposed to. One conclusion of the study was that sheltered housing and the associated inter- ventions were in most cases sufficient to prevent young people from being exposed to further violence and oppression during the year covered by the fol- low-up study. Nevertheless, their levels of mental suffering was still significant at the time of the follow- up, and it was determined that the young people needed more long-term help [101, 102]. Trends in violence This section addresses changes in the prevalence of violence over time on the basis of the statistical sources given at the beginning of this chapter. However, the number of unreported cases is considerable; moreo- ver, it is probably subject to change over time, which makes it difficult to draw definite conclusions about changes in the real prevalence of violence. Hospitalisation Significantly more men and boys than women and girls are hospitalised for injuries resulting from assaults by another person (Figure 10). The proportion of adult women (over the age of 15) hospitalised following an assault has remained relatively constant over the past 20 years. The number of hospitalisations among girls under the age of 15 has remained fairly steady at 5 per 100,000. Among men and boys, injuries from assaults requiring inpatient treatment have declined somewhat since the end of the 1980s. However, this figure has fluctuated considerably among males. Lethal violence Lethal violence has declined since the beginning of the 1990s. According to the Swedish National Board of Health and Welfare Cause of Death Register, the number of girls aged 0–14 and women aged 15+ who were killed each year as a result of “assault by another person” has been relatively constant at approximately 4 girls and 32 women since the begin- ning of the 1970s. The proportion of girls and women killed by violence has thus declined somewhat as the population has grown during the period (Figure 11). The percentage of adult men killed as a result of violence rose between 1976–1978 and 1989–1991 from 1.8 per 100,000 inhabitants to 2.3 per 100,000 inhabitants (a total of 58 and 78 male victims respec- tively). Since then, the proportion of men killed by violence has fallen to below the 1970s level. The number of boys who die as a result of assault has remained unchanged since the end of the 1970s, at roughly three boys per annum. 0 10 20 30 40 50 60 70 80 1987 93 99 05 0–14 years Number per 100,000 Women 2010 0 10 20 30 40 50 60 70 80 1987 93 99 05 15+ years Number per 100,000 Men 2010 Figure 10. Hospitalisation as a result of assault in 1987–2010. Number of people per 100,000 inhabitants who received inpatient hospital treatment following an assault* at some time during the year. Girls and boys aged 0–14, and women and men aged 15+, 1987–2010**. * ICD10 code: X85–Y09. ** In 1997 there was a change in the classification. Corrections have been made for lapses in the reporting of external causes of injury in the Swedish National Patient Register on the assumption that the lapse was uniformly distributed across all injury diagnoses. Source: Swedish National Patient Register, Swedish National Board of Health and Welfare. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 245 Approximately 16 women die each year as a result of violence in a partner relationship. Approximately three men per year are also killed by a partner. Thus women are killed by a partner four to five times as often as men [103]. The number of women in Sweden killed by a partner has declined since the 1970s, when it stood at around 23 per year. According to BRÅ, this can be explained in part by social changes, increased protection for women and by the fact that women have become more financially independent. Number of young people subjected to violence and threats no longer on the increase Statistics Sweden’s ULF surveys have shown that peo- ple in all age groups are more frequently exposed to threats or violence today than in the 1980s, with the exception of elderly people aged 65–84 (Figure 12). In recent years, however, this trend has halted, and among the youngest adults (16–24 years) the number of people exposed to threats and violence has actually declined. Statistics Sweden’s interview survey also enables observers to determine where people have been sub- jected to violence or serious threats (Figure 13). Among women, violence or serious threats at work have shown the highest increase and are now more common than violence or threats at home or in a public place. The level of violence in the home rose among women at the beginning of the 1990s but remained stable thereafter. The prevalence of vio- lence in public places has stayed relatively constant. Public places figure most prominently in men’s reported experiences of violence or serious threats. Violence in public places is also referred to as street violence. While the percentage of people subjected to violence in 2005 stood at the same level as in the early 1980s, this proportion has both risen and fallen in the interim. Violence and serious threats at work are less common among men than among women. Increasing numbers of assaults reported to the police The number of police reports of assault has risen sig- nificantly since the 1980s (Figure 14) [104]. In 2007, 300 crimes of assault per 100,000 women aged 15 or older were reported to the police, compared to 100 in 1981. The number of assaults reported by men in the same period increased from almost 200 to 500 per 100,000 men. Although cases of assault reported to the police are less common among children than adults, the former have also increased in number. In 1981, 2 cases of assault per 100,000 children aged 0–6 were reported to the police. By 2007, the figure had risen to 17. In the 7–14 age group, the number of cases per 100,000 rose from 9 to 88 over the same period. Assaults against younger and older children are usually committed indoors, generally by an acquaintance. This is also the category of reported assaults that seen the biggest increase, with a ten- fold rise between 1981 and 2007 (Figure 15). 0 1 2 3 1976 80 84 88 92 96 2000 04 08 0–14 years Number per 100,000 Women 0 1 2 3 1976 80 84 88 92 96 2000 04 08 15+ years Number per 100,000 Men Figure 11. Cases of death resulting from assault in 1976–2007. Number of people per 100,000 inhabitants who died as a result of assault*. Girls and boys aged 0–14, and women and men aged 15+, for the period 1976–2007**. * ICD10 code: X85–Y09. **Three-years moving average. Source: Cause of Death Register, Swedish National Board of Health and Welfare. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 246 K. Leander et al. More sex crimes reported to the police A growing number of sex crimes are also being reported to the police (Figure 16), mainly sexual molestation and rapes. In 2005, the definition of rape was broadened to include cases in which the “victim is in a powerless state”, due for example to drunkenness or unconsciousness. Such incidents previously often came under the heading of sexual coercion or exploitation and the number of crimes registered under these other categories has therefore decreased since the law was changed. The rise in the number of rapes was accompanied by a change in the structure of reported crimes, according to a study by BRÅ of reported rapes of people aged 15 or over in the period 1995–2006 [16]. The victims were on average younger than the perpetrators, and the age gap increased during the period under study. While the median age of the perpetrators fell from 32 to 30, the median age of the 0 5 10 15 20 25 1979 1984 1989 1994 1999 2004 16–24 25–44 Number per 100,000 Women 0 5 10 15 20 25 1979 1984 1989 1994 1999 2004 45–64 65–84 years Number per 100,000 Men Figure 12. People in various age groups exposed to violence or serious threats, 1979–2005. Proportion (per cent) of people who were subjected to violence or serious threats in the previous 12 months. Women and men in various age groups, 1979–2005*. * Three-year moving averages. Source: Survey of Living Conditions (ULF), Statistics Sweden. 0 1 2 3 4 5 6 7 1982/83 1990/91 1998/99 In their own or in another person’s home Per cent Women 04/05 0 1 2 3 4 5 6 7 1982/83 1990/91 1998/99 Public place In the workplace Per cent Men 04/05 Figure 13. Violence or serious threats by location. Proportion of people who had been exposed to violence or serious threats in the home, in public places or at work in the previous 12 months. Women and men aged 16–84, 1982/1983–2004/2005. Source: Survey of Living Conditions (ULF), Statistics Sweden. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 247 victims dropped from 27 to 24. The increase recorded in recent years has mainly been in the number of rapes involving lower levels of violence. In 2006, however, violence was used against the victim in at least 56 per cent of the cases studied, and vic- tims had documented injuries in 32 per cent of the cases. Rapes involving multiple perpetrators increased sig- nificantly between the years 1995 and 2006, from an estimated 100 plus to around 550 cases per year (Figure 17) [16]. In 2006, these incidents accounted for 18 per cent of all reported rapes against persons aged 15 or over. The number of rapes occurring in places of public entertainment has also risen significantly. BRÅ believes that this trend is partly due to the fact that more people are reporting rapes owing to lower public tolerance of sexual abuse, and partly to changes in the “opportunity structure”: people have access to more entertainment venues, drink more alcohol and use the internet to a greater extent than previously. 0 20 40 60 80 100 120 1981 85 89 93 97 01 05 2009 0–6 yrs 7–14 yrs Number per 100,000 Children 0 100 200 300 400 500 600 1981 85 89 93 97 01 05 2009 Women 15+ yrs Men 15+ yrs Number per 100,000 Adults Figure 14. Crimes of assault reported to the police in 1981–2009. Number of cases of assault (including aggravated assault) per 100,000 reported to the police in 1981–2009 by age and gender. Note dif- ferent axis scales for children and adults. Source: National Council for Crime Prevention (BRÅ). 0 5 10 15 20 25 1980 85 90 95 2000 05 2010 Acquaintance, indoors Acquaintance, outdoors Children 0–6 years Number per 100,000 0 10 20 30 40 50 60 1980 85 90 95 2000 05 2010 Non-acquaintance, indoors Non-acquaintance, outdoors Children 7-14 years Number per 100,000 Figure 15. Child abuse cases reported to the police, 1981–2009. Number of cases of assault (including aggravated assault) per 100,000, in which the perpetrator was known/not known to the victim, and the assault occurred indoors/outdoors. Children aged 0–6* and 7–14, 1981–2009. Note different axis scales for younger and older children. *Among children aged 0-6 years, fewer than 1 per 100 000 were not acquainted with the perpetrator (not shown in the figure). Source: National Council for Crime Prevention (BRÅ) [5]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 248 K. Leander et al. The number of reported rapes of children under the age of 15 has also increased significantly, from 100 reports in 1975 to close to 2000 reports in 2009, an increase from 1 per 100,000 to 20 per 100,000 children (Figure 18). In 2007, child rape accounted for 27 per cent of all completed rapes. However, the definition of rape as it applies to chil- dren under the age of 15 has been expanded consider- ably during the period, most recently in 2005. Until 2005, rape against both children and adults was defined identically by the same section of the Penal Code. 0 20 40 60 80 1975 80 85 90 95 2000 05 2010 Rape, incl. aggravated Sexual coercion, exploitation, etc Sexual molestation (not incl. exposure) Exposure Other sex crimes Number per 100,000 Figure 16. Sex crimes reported to the police. Number of sex crimes reported to the police per 100,000, by type of crime, 1975–2009. Source: National Council for Crime Prevention (BRÅ) [5]. 0 100 200 300 400 500 600 Stranger- rape Multiple perpe- trators Enterta- inment- related In close relation- ships 1995 2000 2004 2006 Number Figure 17. Types of rape. Estimated number* of reported rapes of people aged 15 years or over, by type and year, 1995, 2000, 2004, and 2006. * From a review of a sample of police reports. Source: Hradilova Selin, 2008 [16]. 0 5 10 15 20 25 30 35 40 1975 1980 1985 1990 1995 2000 2005 2010 Of children under 15 Of people 15+ Number per 100,000 Figure 18. Completed rapes reported to the police. Number of completed rapes of children under the age of 15 and of people 15 years or older reported to the police, per 100,000, 1975–2009. Source: National Council for Crime Prevention (BRÅ) [5]. 0 5 10 15 20 25 30 1975 1980 1985 1990 1995 2000 2005 2010 Against policemen Against security guards Against another person Number per 100,000 Figure 19. Reported incidents of violence against public servants. Number of cases of violence against a public servant reported to the police per 100,000 inhabitants, by type of public servant and year, 1975–2009. Source: National Council for Crime Prevention (BRÅ). at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 249 However, the new sex crime legislation that came into effect in 2005 introduced a new offence “rape of a child”, whereby any act of sexual intercourse or equiva- lent with a child under the age of 15, including oral sex and penetration with fingers or other objects, is defined as rape, irrespective of any other circumstances such as the presence or absence of threats or force, the condi- tion of the victim (powerless or otherwise), or whom the sexual act was initiated by. The increase in the number of registered rapes against children under the age of 15 has been particularly marked since the new legislation came into force. In 2007, rapes of children represented 34 per cent of all completed rapes. Increase in workplace violence With regard to threats and violence at work, consid- erable variation exists among occupational groups. The Swedish Work Environment Authority estimates that approximately 14 per cent of the working age population, i.e. more than half a million people each year, are exposed to violence or threats in the work- place [105]. Most of those affected today are women, who account for nearly three-quarters of all reported cases. According to Statistics Sweden’s ULF surveys, women have been more exposed than men in this respect since the beginning of the 1990s. However, violence and threats at work have become more com- mon among both women and men [12]. Approximately 4,600 cases of violence against a public servant were reported in 2007, i.e. double the number reported in the mid-1970s. Reported crimes of violence against the police have declined since the 1980s, with the exception of a temporary upturn during disturbances in connection with the EU sum- mit in Gothenburg in 2001. In other occupational groups, the number of reported offences has increased. Has crime actually increased? The total number of violent offences reported to the police per 100,000 inhabitants has quadrupled since 1975 (Figure 20). As the sex of the victim is not recorded for all categories of violent crime included in the statistics, Figure 20 shows the overall trend in violent crime for women and men (and children). Almost 80 per cent of reported violent offences involve assault. In 2009, 930 cases of assault were reported per 100,000 inhabitants, compared with 260 cases per 100,000 inhabitants in 1975. However, assault is not the only type of violent crime which has increased since 1975 (Figure 21). The crime “gross violation of a woman’s integrity” was introduced into the Penal Code in 1998. It refers 400 600 800 1,000 1,200 Number per 100,000 0 200 1975 85 95 2005 Robbery, incl. aggravated Violence against public servant Gross violation of integrity Gross violation of a woman’s integrity Rape, incl. aggravated Assault, incl. aggravated Figure 20. Violent crimes reported to the police. Number of violent crimes* reported to the police per 100,000 inhabitants, by type of crime, 1975–2009. *Reported cases of attempted murder and lethal violence is are few in number and are not shown here. Source: National Council for Crime Prevention (BRÅ) [5]. 0 20 40 60 80 100 120 1975 80 85 90 95 2000 05 10 Rape, incl. aggravated Gross violation of a woman’s integrity Gross violation of integrity Violence against public servant Robbery, incl. aggravated Lethal violence Attempted murder Number per 100,000 Figure 21. Violent crimes, excluding assault, reported to the police. Number of violent crimes, excluding assault, reported to the police per 100,000 inhabitants, by type of crime, 1975–2009. Source: National Council for Crime Prevention (BRÅ) [5]. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 250 K. Leander et al. to repeated or systematic violations of women’s integ- rity, including assault, threats, unlawful coercion, deprivation of liberty, domestic trespass, and sexual coercion, where the perpetrator is a man with whom the woman has, or has had, an intimate relationship. The number of reported crimes classified in this way has nearly tripled since 1999; in 2009 about thirty cases per 100,000 inhabitants were reported to the police. The closely related crime category “gross violation of integrity” can be applied to similar forms of violence in other types of relationships, for exam- ple when the victim is a man, a child or other close relative. Fourteen such cases per 100,000 inhabitants were reported in 2007. In the same year, rapes and violations of a woman’s integrity together accounted for 9 per cent of all violent crimes reported to the police (irrespective of the victim’s gender). This can be compared with the crime of robbery, which also accounted for 9 per cent. Violence and threats of violence have thus become more common both according to the crime statistics and what people have reported in various surveys. However, it is by no means certain that the significant rise in the number of police reports and growing evi- dence from interview surveys necessarily add up to a correspondingly large rise in the actual number of violent incidents. The willingness to report incidents may have been due to diminished public tolerance of violent crimes. Since the number of unreported cases is large, trends are significantly affected by how many crimes are detected and how many are reported. BRÅ has conducted a series of special studies of crime trends, taking account of changes over time in people’s willingness to report different types of crime. BRÅ concluded on the basis of these studies that street violence, i.e. offences defined as “assault out- doors, where the victim and the perpetrator are not acquainted with each other”, have increased since the beginning of the 1980s [106]. The increase in the number of rapes may be partly due to the fact that the legal definition of rape has been gradually broadened. The most recent amendment to the law, enacted in April 2005, was followed by a very considerable increase in the number of recorded cases. Although the increase is probably due in part to this broader definition and to greater willingness to report crimes, BRÅ notes that an increase in the actual num- ber of rape offences is also likely [16]. Crime statistics show a marked increase in violence in society. However, this is not reflected in the statis- tics on the proportion of people who have suffered serious physical injuries as a result of violence. In the past ten years, the number of deaths from violence has declined among women and men, and hospital statis- tics show that the proportion of girls, boys and women receiving treatment has remained relatively unchanged, although it has risen among men. On the other hand, a study of inpatients in Stockholm County showed that 67 per cent more people sought treat- ment as a result of sexual assaults in 2004 compared with 1997 [107]. The statistics do not provide a com- plete picture of violence in intimate relationships; this type of violence is probably considerably more wide- spread than the statistics indicate. According to the WHO, violence in intimate relationships is a public health problem. This also applies to Sweden. Notes 1. The study interviewed approximately 24,000 women in Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia, Montenegro, Thailand and Tanzania. Acknowledgments The authors wish to acknowledge the help of Lars-Age Johansson and Charlotte Björkenstam. They also wish to acknowledge the help of David Shannon at The Swedish National Council for Crime Prevention (Brå). Funding This research received no specific grant from any funding agency in the public, commercial, or not-for- profit sectors. References [1] World Health Assembly. Prevention of violence: A public health priority. WHA49.25. Geneva; 1996 [cited 10–24– 2008]; Available from: http://www.who.int/violence_injury_ prevention/resources/publications/en/WHA4925_eng.pdf. [2] Krug, EG, Dahlberg, LL, Mercy, JA, Zwi, AB and Lozano, R, ed. World report on violence and health. Geneva: World Health Organisation; 2002. [3] Töyrä A, Wigerholt J and Eriksson K. Nationella trygghet- sundersökningen 2007. Om utsatthet, trygghet och förtro- ende [National Crime Survey 2007. On Vulnerability, Safety and Confidence]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention), 2008. BRÅ-rapport 2008:3. [4] Rying M. Utveckling av dödligt våld mot kvinnor i nära rela- tioner [Trends in Lethal Violence Against Women in Intimate Relationships]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention), 2007. BRÅ-rapport 2007:6. [5] BRÅ (The Swedish National Council for Crime Prevention). / Statistik / Anmälda brott [Statistics / Reported Crimes]. [database]; 2008 [updated 03–19–2008; cited 01–09–2009]; Available from: http://www.bra.se/extra/pod/?action=pod_ show&id=2&module_instance=21. [6] Grevholm E, Nilsson L and Carlstedt M. Våldtäkt – En kartläggning av polisanmälda våldtäkter [Rape – A Survey of Rapes Reported to the Police]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention)), 2005. BRÅ-rapport 2005:7. [7] Klingspor K, Molarin A and Sporre T. Hatbrott 2007. En sammanställning av anmälningar med främlingsfient- liga, islamofobiska, antisemitiska och homofobiska motiv [Hate Crimes in 2007. A Compilation of Reports Involving Crimes with Xenophobic, Islamophobic, Anti-Semitic and at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 251 Homophobic Motives]. BRÅ (The Swedish National Coun- cil for Crime Prevention), 2008. BRÅ-rapport 2004:16. [8] Ring J and Morgentau S. Intolerans. Antisemitiska, homofo- biska, islamofobiska och invandrarfientliga tendenser bland unga [Intolerance. Anti-Semitic, Homophobic, Islamopho- bic and Anti-Immigrant Tendencies Among Young People]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention) & Forum för levande historia, 2004. [9] BRÅ (The Swedish National Council for Crime Preven- tion). Apropå 1– 2006 / Den som dricker mycket riskerar begå brott [Apropos of 1– 2006 / The Person Who Drinks A Lot Risks Committing Crimes]. [homepage]; 2006 [cited 01–09–2009]; Available from: http://www.bra.se/extra/ pod/?action=pod_show&id=706&module_instance=12. [10] Häll L. Ökat hot mot kvinnor [Increased Threats Against Women]. Välfärd. 2004 (3). [11] Häll L. Offer för våld och hotelser bland kvinnor och män 1980–2003 (föredrag Almedalsveckan 2004) [Female and Male Victims of Violence and Threats, 1980–2003 (paper presented at the Almedalsveckan [conference] 2004)]. Stockholm: SCB (Statistics Sweden), 2004. [12] Häll L. Offer för våld och egendomsbrott 1978–2002 [Vic- tims of Violence and Property Crimes, 1978–2002]. Stock- holm: SCB (Statistics Sweden), 2004. Levnadsförhållanden Rapport:104. [13] Leander K. Synligt folkhälsoproblem som vi har svårt att se. Läkartidningen [A Visible Public Health Problem Which We Have a Hard Time Seeing]. 2008; 105(7):454–456. [14] Leander K. Mäns våld mot kvinnor. Ett folkhälsoproblem [Men’s Violence Against Women. A Public Health Prob- lem]. Stockholm: Stockholm läns landsting, Centrum för folkhälsa, 2007. [15] Peterson L and Rying M. Dödligt våld [Lethal Violence]. In: Dolmén L, ed. Brottsutvecklingen i Sverige 2001–2003 [Crime Trends in Sweden, 2001–2003]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention), 2004:3. [16] Hradilova Selin K. Våldtäkt mot personer 15 år eller äldre: Utvecklingen under åren 1995–2006 [Rapes Committed Against People 15 Years or Older: Trends in 1995–2006]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention), 2008. BRÅ-rapport 2008:13. [17] Nilsson L. Våld mot kvinnor i nära relationer. En kartläggn- ing [Violence Against Women in Intimate Relationships. A Survey]. Stockholm: BRÅ (The Swedish National Council for Crime Prevention), 2002. 14. [18] Socialstyrelsen (Swedish National Board on Health and Welfare). Kostnader för våld mot kvinnor. En samhällseko- nomisk analys [The Costs of Violence Against Women. A Socioeconomic Analysis]. Stockholm: Socialtjänstavdelnin- gen, 2006. [19] Carlstedt M. Upprepad viktimisering : en studie av utsat- thet för brott i Sverige [Repeated Victimization: A Study of Exposure to Crime in Sweden]. Stockholm: Univ., Krimi- nologiska institutionen; 2001. [20] Lundgren E, Heimer G, Westerstrand J and Kalliokoski A- M. Slagen dam. Mäns våld mot kvinnor i jämställda Sverige – en omfångsundersökning [Battered Lady. Men’s Violence Against Women in Equal Opportunity Sweden – A Scope Sur- vey]. Umeå: Brottsoffermyndigheten (Crime Victim Compen- sation and Support Authority). Uppsala University, 2001. [21] Holmberg C, Stjernqvist U and Sörensen E. Våldsamt lika och olika: om våld i samkönade parrelationer [Violently Equal and Unequal: On Violence in Same-Sex Relation- ships]. Stockholm: Stockholms universitet, Centrum för genusstudier, 2005. Skriftserie från Centrum för kvinnofor- skning vid Stockholms universitet nr 36. [22] Stenson K. Men’s Violence against Women – a Challenge in Antenatal Care. [Licentiate thesis]. Uppsala: Uppsala University, Dept. of Women’s and Children’s Health, Obstretrics and Gynecology; 2004. [23] Edin KE. Perspectives of intimate partner violence, focus- ing on the period of pregnancy. [PhD thesis]. Umeå: Umeå universitet, Institutionen för Folkhälsa och klinisk medicin, avdelning för Epidemiologi och folkhälsovetenskap; 2006. [24] García-Moreno C, Jansen HAFM, Ellsberg M, Heise L and Watts C. WHO Multi-country study on women’s health and domestic violence against women. Initial results on preva- lence, health outcomes and women’s responses. Geneva: World Health Organisation, 2005. [25] Stanko E. The day to count: Reflections on a methodology to raise awareness about the impact of domestic violence in the UK. Criminal Justice. 2001; 1(2):215–226. [26] Heiskanen M and Piispa M. Faith, Hope, Battering. A Survey of Men’s Violence against Women in Finland. Hel- sinki: Statistics Finland, Council for Equality, 1998. Justice 1998:12. [27] Statistics Canada. Violence Against Women Survey – High- lights. The Daily, Statistics Canada. Thursday, November 18, 1993. [28] Neroien AI and Schei B. Partner violence and health: results from the first national study on violence against women in Norway. Scand J Public Health. Mar 2008; 36(2):161–168. [29] Piispa M, Heiskanen M, Kääriäinen J and Siren R. Violence against Women in Finland. Helsinki: National Research Institute of Legal Policy, The European Institute for Crime Prevention and Control, affiliated with the United Nations (HEUNI), 2006. Publication No. 225; Publication Series No.51. [30] Wathen CN and MacMillan HL. Interventions for vio- lence against women. Scientific Review. JAMA. 2003; 289(5):589–599. [31] Watts C and Zimmerman C. Violence against women: global scope and magnitude. Lancet. 2002; 359(6):1232– 1237. [32] Johnson MP. Gender symmetry and asymmetry in domes- tic violence. Violence Against Women. 2006; 12(11):1003– 1018. [33] Johnson MP and Ferraro KJ. Research on domestic violence in the 1990s: Making distinctions. J Marriage Fam. 2000; 62:948–963. [34] Archer J. Sex differences in aggression between heterosexual partners: a meta-analytic review. Psychological Bulletin. Sep 2000; 126(5):651–680. [35] Stark E. Coercive Control. How Men Entrap Women in Personal Life. Oxford, New York: Oxford University Press; 2007. [36] Dobash RE and Dobash RP. Women’s violence to men in intimate relationships. British Journal of Criminology. 2004; 44(3):324–349. [37] Plichta SB. Intimate partner violence and physical health consequences: policy and practice implications. J Interpers Violence. Nov 2004; 19(11):1296–1323. [38] Leander K. Övergrepp mot kvinnor – vad kan göras? [Assaults Against Women – What Can Be Done?]. Stock- holms läns kvinnohälsorapport, kapitel 4. Rapport från Yrkesmedicinska enheten 1997:5. Sundbyberg: Socialmedi- cin Kronan, 1997. [39] Bergman B and Brismar B. Suicide attempts by battered wives. Acta Psychiatr Scand. 1991; 83:380–384. [40] Stark E and Flitcraft A. Killing the beast within: woman battering and female suicidality. Int J Health Serv. 1995; 25(1):43–64. [41] Fisher C, Hunt L, Adamsam R and Thurston WE. “Health’s a difficult beast”: the interrelationships between domestic violence, women’s health and the health sec- tor. An Australian case study. Soc Sci Med. Oct 2007; 65(8):1742–1750. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 252 K. Leander et al. [42] Bengtsson-Tops A. Vi är många. Övergrepp mot kvinnor som använder psykiatrin. En omfångsstudie [There Are A Lot of Us. Assaults Against Women Who Use Psychiatry. A Scope Study]. Malmö: Malmö högskola och Riksförbundet för social och mental hälsa, 2004. [43] Danielsson I, Olofsson N and Gillander Gådin K. Vål- dets följder – en fråga om folkhälsa. Starkt samband mel- lan våld/hot och ohälsa hos både kvinnor och män [The Consequences of Violence – A Question of Public Health. A Strong Link Between Violence/Threats and Ill Health in Both Women and Men]. Läkartidningen. 2005; 102 (12–13). [44] Eberhard-Gran M, Schei B and Eskild A. Somatic symp- toms and diseases are more common in women exposed to violence. J Gen Intern Med. Dec 2007; 22(12):1668–1673. [45] Wijma B, Heimer G and Wijma K. Kan patienten ha utsatts för våld? Skall man ställa frågan – och i så fall hur? [Was the Patient Subjected to Violence? Should One Ask the Question – And, If So, How?] Läkartidningen. 2002; 99(20):2260–2264. [46] Risberg G. Sexualiserat våld i sociokulturellt perspektiv. Varför går du inte? Fel fråga till offer [Sexualised Violence in a Sociocultural Perspective. Why Don’t You Leave? The Wrong Question for Victims]. Läkartidningen. Dec 14 1994; 91(50):4772–4774. [47] Dahl S. Rape – A Hazard to Health. Trögstad, Norge: Scan- dinavian University Press; 1993. [48] Risberg G. Sexualiserat våld som hälsoproblem [Sexual- ised Violence as a Public Health Problem]. Läkartidningen. 1994; 91(50):4770–4771. [49] Öberg K. On conditions of Swedish women’s sexual well- being. An epidemiological approach. Uppsala: Uppsala Uni- versity, Department of Neuroscience; 2005. [50] Vos T, Astbury J, Piers LS, Magnus A, Heenan M, Stanley L, et al. Measuring the impact of intimate partner violence on the health of women in Victoria, Australia. Bull World Health Organ. Sep 2006; 84(9):739–744. [51] McCloskey LA, Williams CM, Lichter E, Gerber M, Ganz ML and Sege R. Abused women disclose partner interfer- ence with health care: an unrecognised form of battering. J Gen Intern Med. Aug 2007; 22(8):1067–1072. [52] Wittenberg E, Joshi M, Thomas KA and McCloskey LA. Measuring the effect of intimate partner violence on health- related quality of life: a qualitative focus group study. Health Qual Life Outcomes. 2007; 5:67. [53] Lundgren E. Våldets normaliseringsprocess [Violence’s Normalisation Process]. Stockholm: Riksorganisationen för kvinnojourer och tjejjourer i Sverige (ROKS), 2004. [54] Dobash RE and Dobash RP. Women, Violence and Social Change. London & New York: Routledge; 1992. [55] Holmberg C and Enander V. Varför går hon? Om misshand- lade kvinnors uppbrottsprocesser [Why Is She Leaving? On the Breaking-up Process Among Abused Women]. Ystad: Kabusa böcker; 2004. [56] Estrada F and Nilsson A. Exposure to threatening and vio- lent behaviour among single mothers. British Journal of Criminology. 2004; 44(2):168–187. [57] Steen A-L. Mäns våld mot kvinnor – ett diskursivt slagfält : reflektioner kring kunskapsläget [Men’s Violence Against Women – A Discursive Battleground – Reflections Con- cerning the State Of Knowledge]. Göteborg: Göteborgs universitet, Sociologiska institutionen, 2003. Forskning- srapport 131. [58] Leander K and Danielsson M. Violence against women In: Östlin P, Danielsson M, Diderichsen F, Härenstam A, Lind- berg G, editors. Gender Inequalities in Health A Swedish Perspective. Boston: Harvard University Press. 2001. [59] Wiklund G. Våld mot kvinnor i nära relationer [Violence Against Women in Intimate Relationships]. Stockholm: BRÅ (The Swedish National Council for Crime Preven- tion), 1994. BRÅ-PM 1994:4. [60] Arbetsmarknadsdepartementet. Kvinnofrid [The Integ- rity of a Woman’s Person]. Stockholm: 1997. Regeringens proposition. Prop. 1997/ 98:55. [61] Integrations- och jämställdhetsdepartementet. Slag i luften. En utredning om myndigheter, mansvåld och makt [Strik- ing at Air. A Report on the Authorities, Male Violence and Power]. Stockholm: Fritzes; 2004. Betänkande från Utred- ningen om kvinnofridsuppdragen. SOU 2004:121. [62] McPhail BA, Busch NB, Kulkarni S and Rice G. An inte- grative feminist model: the evolving feminist perspective on intimate partner violence. Violence Against Women. Aug 2007; 13(8):817–841. [63] Integrations- och jämställdhetsdepartementet (Minister for Integration and Gender Equality). Makt att forma samhäl- let och sitt eget liv – jämställdhetspolitiken mot nya mål [The Power to Shape Society and One’s Own Life – Equal Opportunity Policies Towards New Goals]. Stockholm: Fritzes; 2005. Slutbetänkande från Jämställdhetspolitiska utredningen N 2004:07. SOU 2005:66. [64] Heise L. Violence against women: An Integrated, Ecologi- cal Framework. Violence Against Women. 1998; 4 (no. 3, June):262–290. [65] Bourgois P. In search of masculinity – violence, respect and sexuality among Puerto Rican crack dealers. Br J Criminol. 1996; 36:412–427. [66] Integrations- och jämställdhetsdepartementet (Minister for Integration and Gender Equality). Handlingsplan för att bekämpa mäns våld mot kvinnor, hedersrelatierat våld och förtryck samt våld i samkönade relationer [A Plan of Action for Combating Men’s Violence Against Women, Honor- related Violence and Repression, As Well As Violence in Same-Sex Relationships]. Stockholm: 2007. Regeringens skriv- else 2007/08:39. [67] SocialWatch. Gender Equity Index 2008. http://wwwsocial- watchorg/en/portadahtm. 2008. [68] Ertürk Y. Report of the Special Rapporteur on violence against women, its causes and consequences – Mission to Sweden. United Nations, General Assembly, Human Rights Council; 200715 March 2006. Available from: http://www2. ohchr.org/english/issues/women/rapporteur/annual.htm. [69] Garcia-Moreno C, Heise L, Jansen HA, Ellsberg M and Watts C. Public health. Violence against women. Science. Nov 25 2005; 310(5752):1282–1283. [70] Kyvsgaard B and Snare A. Vold mod kvinder. En- eller fler dimensionel? [Violence Against Women. One or Sev- eral Dimensions?] In: von Hofer H, Nilsson A, ed. Brott i välfärden: om brottslighet, utsatthet och kriminalpolitik [Crime in the Welfare Society. On Criminality, Vulnerabil- ity and Crime Policy]. Stockholm: Stockholms universitet, Kriminologiska institutionen; 2007. Festskrift till Henrik Tham. Rapport 2007:1. [71] Quigley BM and Leonard KE. Alcohol and the continuation of early marital aggression. Alcohol Clin Exp Res. Jul 2000; 24(7):1003–1010. [72] Cunradi CB, Caetano R and Schafer J. Alcohol-related problems, drug use, and male intimate partner violence severity among US couples. Alcohol Clin Exp Res. 2002; 26(4):493–500. [73] Testa M, Quigley BM and Leonard KE. Does Alcohol Make a Difference? Within-Participants Comparison of Incidents of Partner Violence. J Interpers Violence. 2003; 18(7):735–743. [74] Leonard KE and Quigley BM. Drinking and marital aggres- sion in newlyweds: an event-based analysis of drinking and the occurrence of husband marital aggression. J Stud Alco- hol. Jul 1999; 60(4):537–545. [75] Farley M and Patsalides BM. Physical symptoms, posttrau- matic stress disorder, and healthcare utilization of women at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ Violence 253 with and without childhood physical and sexual abuse. Psy- chol Rep. 2001; 89(3):595–606. [76] Lown EA, Schmidt LA and Wiley J. Interpersonal violence among women seeking welfare: unraveling lives. Am J Pub- lic Health. 2006; 96(8):1409–1415. [77] Holmberg C, Smirthwaite G and Nilsson A. Mäns våld mot missbrukande kvinnor – ett kvinnofridsbrott bland andra [Men’s Violence Against Addicted Women – A Crime Involving the Violation of a Woman’s Integrity, Among Other Things]. Mobilisering mot narkotika. Narkotikapoli- tisk samordning, 2005. 8. [78] Stenson K, Claesson I and Heimer GM, Uppsala univer- sitet, Rikskvinnocentrum, Akademiska sjukhuset (Uppsala). Våldutsatta kvinnors hälsa och livssituation : en longitudi- nell deskriptiv studie [The Health and Life Circumstances of Women Who Are Exposed to Violence: A Longitudinal, Descriptive Study]. Uppsala: Uppsala universitet: Aka- demiska sjukhuset : Rikskvinnocentrum (RKC), 2006. Rik- skvinnocentrums rapportserie 2006:1. [79] Hammarström A and Hensing G. Folkhälsofrågor i ett genus- perspektiv – Arbetsmarknad, maskuliniteter, medikalisering och könsrelaterat våld [Public Health Issues in a Gender Per- spective – The Labor Market, Masculinities, Medicalization and Sex-Related Violence]. Östersund: 2008. R 2008:8. [80] Graham-Bermann S. The impact of women abuse on children. Social development: research and theoretical perspectives. In: G Holden, R Geffner and E Jouriles ed. Children exposed to marital violence; Theory, research and applied issues. Wash- ington: American Psychological Association; 1998. [81] Edleson JL. The overlap between child maltreatment and woman battering. Violence Against Women. 1999; 5(2):134– 154. [82] Fantuzzo JW and Mohr WK. Prevalence and effects of child exposure to domestic violence. Future Child. Winter 1999; 9(3):21–32. [83] Groves BM. Mental health services for children who wit- ness domestic violence. Future Child. Winter 1999; 9(3):122–132. [84] Socialstyrelsen (Swedish National Board on Health and Welfare). När mamma blir slagen: att hjälpa barn som levt med våld i familjen [When Mom Is Being Beaten: Helping Children Who Have Lived with Domestic Violence]. Stock- holm: 2005. Status report. [85] Blair-Merritt. Physical health outcomes of childhood expo- sure to intimate partner violence: a systematic review. Pedi- atrics. 1997; 117(2):278–290. [86] SOU 2001:18. Barn och misshandel. En rapport om kroppslig bestraffning och annan misshandel i Sverige i slutet av 1900-talet. Rapport från kommittén mot barn- misshandel [Children and Abuse. A Report on Corporal Punishment and Other Abuse in Sweden at the End of the 20th Century. Report from the Committee Against Child Abuse]. Socialdepartementet (Ministry of Health and Wel- fare). Stockholm: 2001. [87] Allmänna barnhuset. Våld mot barn 2006–2007. En natio- nell kartläggning [Violence Against Children, 2006–2007. A National Survey]. Stockholm: 2007. [88] Lindell C. Child physical abuse. Reports and interventions. Linköping University Dissertations No. 879 [PhD thesis]. Linköping: Linköping universitet, Institutionen för mole- kylär och klinisk medicin; 2005. [89] Socialstyrelsen (Swedish National Board on Health and Wel- fare). Barnmisshandel – Att förebygga och åtgärda [Child Abuse – Preventing and Taking Steps]. Stockholm: 2001. SOU 2001:72. [90] Socialstyrelsen (Swedish National Board on Health and Welfare). Övergrepp mot äldre – ser vi toppen av ett isberg? [Assaults Against the Elderly – Are We Seeing the Tip of an Iceberg?]. Stockholm: 1994. SoS-rapport 1994:1. [91] Eriksson H. Ofrid? Våld mot äldre kvinnor och män – en omfångsundersökning i Umeå kommun [Violence against a Person’s Integrity? Violence Against Elderly Women and Men – A Scope Study in the Municipality of Umeå]. Umeå: Brottsoffermyndigheten, 2001. [92] Hydle, I, ed. Overgrep mot eldre [Assaults Against the Elderly]. Copenhagen; 1994. Nordiska Ministerrådet. Nord 1994:2 [93] Erlingsson C. Elder abuse explored through a prism of per- ceptions: Perspectives of potential witnesses [PhD thesis]. Umeå: Umeå Universitet, Medicinska Fakulteten; 2007. [94] Jönsson H. Övergrepp mot äldre i två perspektiv [Assaults Against the Elderly from Two Perspectives]. Socialvetens- kaplig tidskrift. 2004; 3–4. [95] Nationellt råd för kvinnofrid. Han var väl inte alltid så snäll. Våld mot äldre kvinnor [He Was Not Always So Nice. Vio- lence Against Elderly Women]. Stockholm: 2002. Skrift. [96] General Assembly of United Nations. In-depth study on all forms of violence against women. Report of the Secretary- General. Sixty-first session. Item 60 (1) on preliminary list. Advancement of Women. A/61/122/Add.1. 2006 [cited 01–16– 2008]; Available from: http://daccessdds.un.org/doc/UNDOC/ GEN/N06/419/74/PDF/N0641974.pdf?OpenElement. [97] Johnsson-Latham G. Patriarkalt våld som hot mot män- sklig säkerhet – en karläggning av åtgärder mot patriarkalt våld och förtryck, särskilt i hederns namn, mot kvinnor och homo- och bisexuella samt transpersoner [Patriar- chal Violence As a Threat to Human Security – A Survey of Measures Taken Against Patriarchal Violence and the Repression (Especially in the Name of Honor) of Women, Homosexuals and Bisexuals, and Trans People]. Stock- holm: Regeringskansliet, 2006. [98] Länsstyrelsen i Stockholms län (Stockholm County Administrative Board ). Personalens möte med utsatta flickor – arbete mot hedersrelaterat våld [Staff Encounters with Girls Who Have Been Exposed to Violence – Initia- tives Against Honor-Related Violence]. Stockholm: 2006. Rapport 2006:25. [99] Länsstyrelsen i Stockholms län (Stockholm County Admin- istrative Board ). Nationell rapport om skyddat boende mm [A National Report on Shelters, etc.]. Stockholm: 2004. Rapport 2004:16. [100] Socialstyrelsen (Swedish National Board on Health and Welfare). Frihet och ansvar. En uppföljning av skyddade boenden för personer som hotas av hetersrelaterat våld [Freedom and Responsibility. A Follow-up Study of Shel- ters for People Who Are Subjected to Honor-Related Vio- lence]. IMS, ed.; 2007. [101] Länsstyrelsen i Östergötland(Östergötland County Administrative Board ). Behovet av insatser mot s.k. hedersrelaterat våld i landet – bedömning för 2007 [The Need for Initiatives Against So-called Honor- related Violence in Sweden – Assessment for 2007]. 2007. Rapport 2006:28. [102] Hanberger A, Wikström E and Ghazinour M. Hur fungerar skyddat boende? [How Do Shelters Work?]. Umeå: Umeå universitet, Centrum för utvärderingsforskning, 2007. Del- rapport 2 från den nationella utvärderingen av regeringens insatser mot hedersrelaterat våld. [103] Rying M. Utveckling av dödligt våld mot kvinnor i nära relationer [Trends in Deadly Violence Against Women in Intimate Relationships]. Stockholm: Brottsförebyggande rådet, 2007. Rapport 2007:6. [104] Brottsförebyggande rådet (BRÅ) (The Swedish National Council for Crime Prevention). Brottsutvecklingen i Sverige fram till år 2007 [Crime Trends in Sweden up to 2007]. Stockholm; 2008 [cited 02–10–2009]; Available from: http://www.bra.se/extra/faq/?module_instance=2&action_ question_show.478.0.=1. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/ 254 K. Leander et al. [105] Arbetsmiljöverket (Swedish Work Environment Authority). Våld och hot om våld (OH) [Violence and Threats of Violence (OH)]. 2007 [cited]; Available from: www.av.se/ teman/valdochhot/statistik. [106] Kühlhorn E. Misshandel [Assault and Battery]. In: Dolmén L, ed. Brottsutvecklingen i Sverige 2001–2003 [Crimes Trends in Sweden, 2001–2003]. Stockholm: Brottsförebyggande rådet (The Swedish National Council for Crime Prevention); 2004. BRÅ rapport 2004:3. [107] Kühlhorn E and Grevholm E. Det grova våldet i sjukvårds- data. En metodstudie [Aggravated Violence As Presented in Medical Care Data. A Methodological Study]. Stock- holm: Brottsförebyggande rådet (The Swedish National Council for Crime Prevention) (BRÅ), 2007. 13. at Mittuniversitetet on December 28, 2012sjp.sagepub.comDownloaded from http://sjp.sagepub.com/