Eileen Hoffman, M.D.

If

one bothered to notice, we would see that most reports about

"violence" are really stories about "violent males." That is

not to say that females aren’t violent. It is just that the male predominance is

overwhelming. Yet we speak of these events in gender-neutral language as

"school" violence, or "teen" violence, or "day

trader" violence. It is interesting to think about why a behavior so

clearly identified with one gender is spoken of without reference to that

gender. My experience has been that gender-neutral language is used to describe

a behavior when it is assumed to be the norm.

When

discussion has focused on males, it inevitably centers on the role of

testosterone in driving aggressive behavior–males have lots of it and women

don’t. If only it were that simple. Then we could measure levels and predict who

was at risk for becoming violent and have a simple therapy for it. But, the

experimental data tells us otherwise. Normal levels of testosterone are a

prerequisite for normal levels of aggression, and these normal levels span a

broad range of hormone concentrations which fail to be predictive. It turns out

that testosterone facilitates the neurochemical pathway in the brain that

underlies aggressive behavior. It’s action is "permissive." That is if

the electrical signal is flowing, the presence of testosterone will increase its

firing rate and shorten the time in between bursts of electrical activity. It is

turning up the rheostat, but the switch is already on. In fact, there is

evidence that aggressive behavior can cause an increase in testosterone levels.

The

behavioral psychologist, Robert Sapolsky, describes an interesting experiment

concerning aggression in males and females. In their natural environment in

Kenya, female spotted hyenas are bigger, more muscular, and more aggressive than

the males, and are also those who are socially dominant. Interestingly, they

happen to have more testosterone-related hormones than the males. Although

similarly large, muscular and aggressive, the females now living at the

University of California at Berkeley (having been brought there as infants) find

it difficult to establish their social dominance over the males, despite having

their usually high hormone levels. The missing factor? There is no established

social system to learn from.

Perhaps

this experiment teaches us that violence among humans is about more than just

testosterone and more than the natural instinct for boys to be boys. It is a

complex behavior that is dependent upon social context and power inequities. If

we fail to understand the interaction between gender and the cultural norms that

foster violent behavior by males, we will never be able to deal with it

effectively. How can we design effective prevention strategies to implement the

declarations made by The Centers for Disease Control and the Surgeon General

that violence is a public health issue?

Gender

is important in understanding violence in several ways. There are different

manifestations depending on the gender of the victim. Male to male violence is

public–on the street; in a barroom brawl; acting out on the job; or driving

while intoxicated. Male to female violence, in comparison, is private and occurs

at home. Four million American women are battered each year by men who are or

were intimates, injuring more women than all other forms of injury combined. The

costs of violence also vary by gender. Men are responsible for the financial

burden that violence brings to our criminal justice system. Most incarcerated

individuals are male and they account for eighty-five percent of homicides.

Women, already the major users of health care, experience many

"downstream" health issues secondary to violence. From society’s

perspective we see male "criminals" and "sick" women. But is

the criminal justice system treating a medical condition? Or is the health care

system treating a social condition? Obviously, we are seeing the same phenomenon

from two different standpoints which have a common etiology.

The

failure to identify female gender with health care costs associated with

violence is similar to the absence of male gender when discussing violent

behavior in the media. Since women rarely identify themselves to health care

providers as victims of assault, the many symptoms generated by physical or

sexual abuse are easily seen in a gender-neutral way: fatigue, insomnia,

palpitations, shortness of breath, headache, etc. Primary care physicians,

poorly trained in detecting and appropriately treating the underlying

psychosocial issues will often see these symptoms and fail to diagnose

depression, anxiety disorders, post-traumatic stress disorder, chronic pain

syndromes, sexual dysfunction, and alcohol and substance abuse let alone that

they may have been caused by violence. Commonly seen obstetrical problems are

seen just as that by obstetrians. Yet, one Cook County Hospital study showed

that 46% of maternal mortality was attributable to domestic violence. Battered

pregnant women are also at increased risk for pre-term labor, low infant birth

weight, fetal injury and fetal demise. It is somewhat easier to identify the

social etiology of medical conditions like vaginal trauma due to rape or broken

bones due to battery when delivering care in the emergency room. It is much more

difficult to look for the social context of common conditions and complaints in

the primary care practitioner’s office, especially if the trauma occurred long

ago in childhood. Most children who are sexually abused are girls, and their

abusers are usually family members or family friends who are male. Girls

surviving childhood sexual abuse are disproportionately seen among pregnant

teens, alcohol and substance abusers, those with HIV, eating disorders, women

with chronic pelvic pain, and those engaging in unsafe sex. Unplanned

pregnancies and sexually transmitted infections that lead to infertility in

girls and women engaging in unsafe sex are also major contributors to women’s

health care costs. Unique mental health issues such as dissociative disorders

and self-mutilation are seen among incest survivors.

So,

what’s the bottom line? Gender analysis is not just about women. Men have gender

too. Whether in medical care, mental health care or reproductive health care, a

gender analysis is desperately needed to start holding boys and men accountable,

as well as the cultural norms that foster these patterns of violent behavior. By

doing so, we can develop strategies to appropriately diagnose and treat (and

maybe even prevent) disorders caused by male violence and improve the health of

everyone.

Eileen

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