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The Center for Health and Gender Equity (CHANGE) is a research and advocacy organization that seeks to integrate concern for gender equity and social justice into international health policy and practice. CHANGE staff can be reached by e-mail at change@genderhealth.org or at http://www.genderhealth.org.

Violence has been linked to many serious health problems, both immediate and long-term. These include physical health problems, such as injury, chronic pain syndromes, and gastrointestinal disorders, and a range of mental health problems, including anxiety and depression. Violence also undermines health by increasing a variety of negative behaviors, such as smoking and alcohol and drug abuse (see Figure 3).

Because most early studies on abuse and health involved women seeking medical treatment, their findings could have overstated the relationship between violence and poor health. But links between victimization and ill-health have been confirmed in recent studies among more representative groups, including random samples of women in the community and women visiting primary health care facilities.

One such study in a large health maintenance organization (HMO) in Washington state, US, found that women who experienced any type of abuse in childhood—whether physical, sexual, emotional, or neglect—had significantly poorer health than their peers. The study found that women who suffered maltreatment in childhood had more sexual and reproductive health problems, poorer physical functioning, more risky behavior, and more physical symptoms than nonabused women. Moreover, the average woman who had been abused in childhood also had more diagnoses across a wide range of health problems, including infectious diseases, mental health problems, and chronic conditions such as hypertension, diabetes, and asthma (455).

Studies among women at HMOs provide good opportunities for examining the cumulative impact of violence on women's health because HMOs generally provide for all of their members' health care—including drugs, surgeries, doctors' visits, and hospital stays (148, 260). Collectively, these HMO studies suggest three main conclusions about the health consequences of physical and sexual abuse of women:

• The influence of abuse can persist long after the abuse has stopped (148, 261).
• The more severe the abuse, the more severe its impact on women's physical and mental health (273).
• The impact of different types of abuse and multiple episodes over time appears to be cumulative (148, 260, 291, 455).