Male violence against minoritised ethnic women: exacerbating ethnic health inequity and endangering staff

Year-round action is needed to tackle the intersecting racialised and sexualised violence targeting minoritised ethnic women receiving and providing healthcare. The ways in which this violence exacerbates ethnic health inequity and endangers healthcare staff should be interrogated and acted upon by all partners working in the healthcare sector.

Introduction and context

As the UN’s 16 Days of Activism against Gender-Based Violence campaign draws to a close, we are shining a spotlight on the need for year-round action to tackle the intersecting racialised and sexualised violence targeting minoritised ethnic women receiving and providing healthcare. The pernicious ways in which this violence exacerbates ethnic health inequity and harms healthcare staff should be interrogated and acted upon by all partners working in the healthcare sector. The need for concerted, targeted action has long-been evidenced and advocated for by specialist, by and for organisations supporting minoritised ethnic women facing VAWG, such as Imkaan, its members, and countless community-led services.

Running annually from 25 November to 10 December, the annual campaign spotlights and advocates for the prevention and elimination of all forms of male violence against women and girls (VAWG). VAWG includes, but is not limited to, rape, sexual assault, sexual harassment, and domestic abuse. It has a deleterious impact on health, with the World Health Organisation recognising VAWG as a major public health problem.

We cannot tackle VAWG without centrally acknowledging the interlocking nature of gender and ethnicity, among other dimensions, in survivors’ and victims’ experience of it. The concept of structural gendered racism recognises that for minoritised ethnic women, racism and sexism coalesce and intertwine, leading to heightened risks, worse outcomes, and is a root cause of health inequity among minoritised ethnic women.

The fact that minoritised ethnic women are disproportionately affected by gender-based violence has been recognised at a national level by NHS England and law enforcement. This is tragically borne out in the ultimate, most brutal manifestation of VAWG, in which a woman is killed by a man every three days on average in the UK, and government statistics show that minoritised ethnic women are over-represented in domestic homicide rates. From March 2020 to March 2022, 22% of victims of domestic homicide were from minoritised ethnic backgrounds, despite making up 18% of the general population. This disproportionality is also reflected in research on sexual harassment, which has been most recently reported as impacting a quarter of girls and young women in England and Wales. Plan International UK’s 2021 survey of girls and young women revealed that 88% of girls with a mixed ethnic background and 82% of Black girls have experienced public sexual harassment compared to 75% of White girls.

The impact of VAWG on health 

The ways in which male violence exacerbates the health inequity experienced by women are profound and disturbing. Mortality from all causes is 44% higher in female domestic abuse survivors and victims, and they are more likely to develop serious, long term illnesses. It is estimated that between 4 and 19.5% of women attending healthcare settings in England and Wales, particularly psychiatric, obstetrics, gynaecology, and emergency departments, may have experienced domestic abuse in the preceding year.

Minoritised ethnic women face well-documented health inequity, and as previously mentioned, we know they can face heightened risks and worse outcomes as a result of male violence. Despite this, specific data on how VAWG relates to the ethnic health inequity, and how it impacts minoritised ethnic women working in healthcare, is sorely lacking. Widely driven by chronic underreporting, the reasons behind which are multifactorial, including:

  • Endemic mistrust toward providers driven by previous experiences of gendered racism while trying to access, or in receipt of, healthcare.
  • The higher likelihood of criminalisation, especially in the context of migration status and the hostile environment.
  • Documented patriarchal silencing within communities and cultural notions of honour and shame, as well as inappropriate professional responses from services driven by stereotypical notions about abuse being ‘accepted’ in certain groups.

We therefore draw reasonable conclusions on the impact of VAWG by triangulating the distinct evidence documenting the prevalence of ethnic health inequity, the impact of VAWG on women’s health, and the concentration of minoritised ethnic women in the healthcare workforce.

VAWG exacerbates the health inequity experienced by minoritised ethnic women

The stark ethnic inequity in maternal mortality rates reported by MBRRACE-UK, in which Black women are up to three times and Asian women up to twice as likely to die during or one year proceeding pregnancy compared to White women, rightly elicit outrage. Viewing these appalling figures through the lenses of gendered racism and VAWG make for profoundly troubling reading. MBRRACE-UK have also reported that the 12% of the women who died during or one year proceeding pregnancy in the UK in 2020-22 were at severe and multiple disadvantage, with domestic abuse a main element, underscoring the heightened risks that pregnant minoritised ethnic women face. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists has named domestic abuse a ‘maternal health issue.’ It has been reported that as much as 30% of domestic abuse starts in pregnancy, that 40 to 60% of women experiencing domestic abuse are abused during pregnancy, and that abuse is more likely escalate in frequency and severity during pregnancy and the first year after birth.

We also know that significant ethnic inequity exists in access to, and experience and outcomes of, mental healthcare and support. Minoritised ethnic women experience mental ill health at higher rates than White women, with the Agenda Alliance evidencing that 29% of Black and mixed-race women, and 24% of Asian women have a mental health problem, compared to 21% of White women. Viewed through the lenses of gendered racism and VAWG, these figures take on a further concerning significance. A 2024 survey by the Royal College of Psychiatrists found that psychiatrists across the UK, informed by their experience of treating patients, believe that violence and abuse is a leading cause of mental ill health among women and girls. When asked to name the top three issues contributing to women’s poor mental health, almost six out of 10 (59%) psychiatrists identified violence and abuse. This is borne out in research, with domestic abuse evidenced as a significant risk factor for women and children, and the fact that women in mental health services are six times more likely to experience domestic violence.

VAWG endangers minoritised ethnic women in the healthcare workforce  

The most recent NHS staff survey revealed that discrimination against healthcare workers in England from members of the public has reached its highest level in five years. For the first time, the survey asked NHS staff if they had experienced sexual harassment while at work, with the results revealing 58,000, or 1 in 9, of the roughly 670,000-strong workforce had experienced sexual harassment from patients, patients’ relatives, or other members of the public in 2023.

These significant, unacceptable findings have troubling implications for a workforce that employs high numbers of minoritised ethnic women. Minoritised ethnic women are overrepresented in the healthcare workforce. Almost three-quarters (74%) of NHS staff in England are women, and 31% are from an minoritised ethnic background. These rates vary by role; for example, the proportion of women ranges from nearly 100% of midwives, 89% of nurses, and 46% of doctors, and the proportion of minoritised ethnic staff ranges from 54% of doctors and 39% of nursing staff.

With nurses most likely to be both minoritised ethnic and women, it is troubling to see that 60% of nurses surveyed by UNISON and Nursing Times reported experiencing sexual harassment. The Trades Union Congress’ recent, dedicated research on Black women’s experience of sexual harassment in the workplace, it is reported that the concentration of Black women in industries such as the health sector, leads to higher rates of exposure to gendered racism.

The sexualised violence and abuse women face from fellow staff is also a major concern. The aforementioned NHS staff survey revealed that 25,000 staff experienced sexual harassment from colleagues. The Working Party of Sexual Misconduct in Surgery and partners have found that two-thirds of women surgeons reported being sexually harassed, and a third had been sexually assaulted, by male colleagues in the past five years. An investigation by the BMJ and the Guardian into every hospital trust in England revealed that they reported just 902 incidents of abuse against staff by colleagues. This figure has been described as implausibly low, reflecting a lack of confidence in reporting mechanisms and fear of reprisals.

A call to action

This piece provides a brief snapshot of how intersecting racialised and sexualised violence targeting minoritised ethnic women permeates the healthcare system. It entrenches and exacerbates ethnic health inequity and endangers staff.

Minoritised ethnic women using healthcare services, and those providing them, face a heightened risk of being targeted. Should they overcome the prohibitively high barriers to reporting gendered racism, they face a higher likelihood of being subject to punitive consequences, or even criminalised.

Healthcare services can be trusted spaces. The Domestic Abuse Commissioner has found that more domestic abuse survivors and victims told health organisations first of their domestic abuse experience, ahead of the police. And while only one in five survivors and victims will call the police, 80% will seek help from health services. Despite this, they risk failing minoritised ethnic women survivors and victims by failing to act and make appropriate interventions.

We cannot truly tackle ethnic health inequity without accounting for the impact of VAWG. It is the responsibility of all of us working across the healthcare system, from national decisionmakers to practitioners on the ground.