May 4, 2023
Resuming debate on the inquiry of the Honourable Senator Boniface, calling the attention of the Senate to intimate partner violence, especially in rural areas across Canada, in response to the coroner’s inquest conducted in Renfrew County, Ontario.
Hon. Judith G. Seidman: Honourable senators, I rise today to speak to Senator Boniface’s inquiry calling the attention of the Senate to intimate partner violence, especially in rural areas across Canada, in response to the coroner’s inquest conducted in Renfrew County, Ontario. I thank Senator Boniface for introducing this important inquiry and for asking me to reflect specifically on the epidemiology around this particular group of women who live in rural and remote regions of Canada and are affected by intimate partner violence.
In this case, I take it to mean “from the population health vantage,” that is, the attempt to understand determinants or causation, specifically social determinants of their health outcomes. Social determinants are sometimes called the causes of the causes of health outcomes. They are very upstream from the outcomes; thus, true causation is challenging to establish.
An explanation put forward by the World Health Organization and often cited by other population health agencies explains that social determinants of health are:
. . . the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.
The Public Health Agency of Canada identifies 12 social determinants of health: income and social status; employment and working conditions; education and literacy; childhood experiences; physical environments; social supports and coping skills; healthy behaviours; access to health services; biology and genetic endowment; gender; culture; and race/racism.
As Mandana Mardare Amini writes in a 2022 report for Statistics Canada entitled Statistical Portrait of Women and Girls by the Relative Remoteness of their Communities, Series 3: Health and Well-being:
Living in a rural area remains a significant determinant of health disparities for women, both worldwide and in Canada . . . .
While rural locations themselves do not necessarily lead to poor health . . . living in a rural setting may not only limit access to health services, but also influence other socioeconomic, environmental and occupational health determinants . . . .
The report indicates that women and girls who live in very remote areas self-report the lowest perceived health, the lowest activity level, the highest proportion of women and girls without a regular health care provider, poorer mental health and significantly higher all-cause mortality and suicide-related mortality.
The report also found that suicide or intentional self-harm was a leading cause of death in very remote communities only and that health inequalities were more pronounced for Indigenous women and girls in both rural and urban areas. This 2022 Statistics Canada report indicates that the risk of poor health outcomes increases with more remote living conditions.
In Epidemiology: Principles and Methods, Brian MacMahon and Dimitrios Trichopoulos explain:
. . . the existence of an exposure-response relationship, that is, an association in which the frequency of the effect increases or decreases as the exposure to the putative cause increases, is usually thought to favour a causal relationship.
However, extensive efforts must be made to validate associations thought to be causal, and in the absence of direct experiment, the interpretation of the evidence is complex. Thus, from these Canadian statistics, we might suspect a causal relationship between the remoteness of one’s community and one’s health outcomes.
Although criminology is not my area of expertise, I note a similar trend in the data on spousal and intimate partner homicide. In the past 10 years, a higher proportion of spousal and intimate partner homicides in Canada have occurred in rural communities compared with urban areas.
In a report entitled Homicide in Canada, 2021, Jean-Denis David and Brianna Jaffray from the Canadian Centre for Justice and Community Safety Statistics found that homicides involving a spousal or intimate partner relationship between the victim and the accused accounted for 23% of homicides in rural areas, compared to 17% of homicides in urban areas. So we can suspect that there may be a relationship between intimate partner violence and residence in rural and remote areas of Canada. Unfortunately, much more data is needed.
As Eve Valera, an Associate Professor of Psychiatry at Harvard Medical School, told The Globe and Mail in December, “Women in general . . . have been understudied in lots of scientific endeavours.”
For example, the Globe article reported on work being done at the Canadian Concussion Centre in Toronto. That facility has over 100 athlete brains that scientists can study to find out more about the impact of repeated concussions, but it has only one brain of a victim of domestic violence. This is a problem.
As the article notes, researchers estimate that approximately one in eight Canadian women is likely to suffer from an unrecognized brain injury related to domestic violence, but we know little about the impact of these injuries.
In a June 2021 JAMA Network Open article entitled “Analysis of Female Enrollment and Participant Sex by Burden of Disease in US Clinical Trials Between 2000 and 2020,” Dr. Jecca Steinberg and her colleagues describe the historical under‑representation of women in clinical research:
Medical research has historically focused on male health. Female individuals were often excluded from clinical trials, supposedly to ensure homogeneity of treatment effect and reduce potential maternal-fetal liability. Sex bias persisted, even after research reported sex differences in diagnostic test results, disease progression, treatment response, drug metabolism, and surgical outcomes. Studies have associated this lack of female inclusion with suboptimal health care and adverse medical outcomes.
Steinberg and her colleagues found that female participants are still under-represented in oncology, neurology, immunology, urology, cardiology and hematology relative to their disease burden. Yet, male enrollees are under-represented compared with their disease burden in eight disease categories, including mental health and trauma research. Therefore, sex bias in clinical trials may have negative implications for both sexes.
In her speech, Senator Boniface reminded us of another inquest that happened after an intimate partner femicide in Ontario, the May-Iles inquest of 1998. Senator Boniface asked, “. . . how do we find ourselves in a similar position 24 years later?” Perhaps the answer to her question is that a lack of data and bias in the data likely contributes to this ongoing challenge.
A June 2021 study by the House of Commons Standing Committee on the Status of Women entitled Challenges faced by women living in rural, remote and northern communities in Canada found that a lack of transportation services; difficulty accessing services for women survivors of violence; a lack of reliable, affordable and adequate internet services; a lack of access to education options locally; difficulty finding stable employment; and difficulty accessing or a lack of local services, including child care, mental health and counselling services, were intersecting factors that affect the safety, economic security and well-being of women living in rural, remote and northern communities. Thus, research to better understand and investments to address health challenges for rural and remote women may also help us understand and address violence against these women.
In this regard, Canada is taking steps in the right direction. In recognition that “Geographic proximity to service centres and population centres is an important determinant of socio-economic and health outcomes,” and that, “Consequently, it is a relevant dimension in the analysis and delivery of policies and programs,” in April 2020, Statistics Canada released its Index of Remoteness dataset. This new tool has already facilitated important research, including the Statistics Canada report by Mandana Mardare Amini, which I cited earlier.
Further, the federal government has recognized that:
. . . our health system has not always understood the factors which influence the health status of women, trans women, girls, and gender-diverse communities . . .
In October of last year, it launched the National Women’s Health Research Initiative. As a first step, the Canadian Institutes of Health Research and Women and Gender Equality Canada will partner to invest in a Pan-Canadian Women’s Health Coalition. I hope that this investment will lead to tangible improvements in health research and delivery for women.
We must continue to address the historical under-representation of women in research so that we can better understand and ultimately improve outcomes for women in rural and remote communities and women in general. Women’s lives depend upon it.