5 Graduate Student Journal of Psychology Fall 2024 - Vol. 23 Copyright 2024 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University Sexual and Intimate Partner Violence Against Women with Schizophrenia: A Scoping Review Intimate partner violence (IPV) is defined as any conduct occurring within an intimate relationship that inflicts physical, sexual, or psychological harm. IPV has sparked significant public health apprehension due to the growing prevalence highlighted by diverse global news outlets. It has infiltrated all societal levels, emerg- ing as the predominant manifestation of gender-based violence, leading to immediate and enduring health re- percussions for those affected. Population-based prev- alence estimates typically fail to accurately represent the problem’s magnitude due to substantial underre- porting; nonetheless, IPV still significantly contrib- utes to crime statistics in all societies (Afe et al., 2016). Indeed, as many as 38% of all murders of women are committed by intimate partners (World Health Or- ganisation [WHO], 2021). Research findings, as high- lighted by Afe et al. (2017), indicate that women, who are disproportionately impacted by sexual violence— covering non-consensual sexual activities, coercion, exploitation, harassment, or advances, irrespective of the perpetrator's relationship with the victim or the setting— and IPV are at heightened risk if they experi- ence severe mental illness (SMI). SMI is defined as in- dividuals with persistent or recurrent mental disorders significantly affecting their functioning, compared to the general population. This negatively affects wom- en’s physical, mental, sexual, and reproductive health (WHO, 2021). Thus, minimal research has been con- ducted on the sexual and IPV victimization experi- enced by women with schizophrenia, a severe mental illness characterized by hallucinations, delusions, so- cial withdrawal, diminished pleasure and motivation, cognitive deficits, and other symptoms (Darves-Bor- noz et al., 1995). As such, the objective of this re- search is to elucidate our knowledge on this topic. While IPV encompasses verbal, psychological, physi- cal, and sexual abuse, we have opted to draw a distinc- tion between IPV and sexual violence. Specifically, our discussion of IPV encompasses sexual violence per- petrated by intimate partners, whereas the section on sexual violence includes acts perpetrated by intimate partners as well as by individuals other than partners. Intimate Partner Violence Against Women Globally, 641 million women are affected by partner violence, establishing it as the most prevalent form of violence affecting women (Buchholz, 2021). During their lives, one out of three women worldwide will experience IPV (Buchholz, 2021). Adding to this distressing statistic, globally, women constitute 20 per- cent of all murder victims, and the majority of these cas- es involve killings by a partner or ex-partner (Buchholz, 2021). Characterized by any behaviour within an inti- mate relationship causing physical, sexual, or psycho- logical harm, IPV can account for physical aggression, sexual manipulation, psychological maltreatment, and controlling conduct done by a present or past partner (Afe et al., 2016). The rising media coverage of this be- haviour has raised substantial public health concerns Kellie-Anne Bélisle, Adriana Mendrek, Sarah Hepworth & Joel Montanez Psychology Department, Bishop’s University, Sherbrooke, Canada Background: Globally, 641 million women are touched by intimate partner violence (IPV), establishing it as the most prevalent form of violence affecting women. Women, who are already disproportionately affected by sexual and IPV, face an elevated risk when dealing with severe mental illnesses (SMI) compared to the general population. Schizophrenia, classified as an SMI, poses numerous obstacles that impact women’s ability to maintain employment, good health, and sustain stable relationships. Nevertheless, limited data exists on IPV against women with schizo- phrenia and its effect. Aims: The objective of this scoping review was to summarize the available literature on sexual and IPV against women with schizophrenia and underlie future avenues of research. Methods: We conducted an electronic search using keywords in the following databases: APA PsychInfo, PubMed, Scopus, Google Scholar, and Psychology and Behavioral Sciences Collection. The search yielded a total of 6,099 articles. Upon title and abstract review, 97 articles were retained for full-text reading, after which 7 articles were included in this review. Results: The available articles reveal an association between sexual violence and IPV against women with schizophrenia. Young- er women diagnosed with schizophrenia, especially those with low income or unemployed, are at a higher risk of experiencing sexual and IPV. This victimization increases the likelihood of suicide and exacerbates psychopathol- ogy. Conclusion: Research should examine care-setting interventions for women with schizophrenia, who are at increased risk of sexual and IPV, aiming to prevent severe harm. Implementation of preventive measures is essential for enhancing healthcare and societal transformation. Keywords: IPV, sexual violence, schizophrenia, women, victimization 6 BÉLISLE ET. AL globally. Beyond the immediate potential traumatic events, it is imperative to acknowledge the enduring short and long-term consequences faced by survivors. This underscores the urgent need for multifaceted approaches to prevention and intervention, address- ing the root causes of IPV while providing compre- hensive support for survivors to rebuild their lives. Sexual Violence Against Women According to the World Health Organization’s Multi-Country Study (MCS), the lifetime prevalence of women experiencing sexual abuse by a partner was between 6% and 59% (WHO, 2002). Sexual violence is a profound human rights violation that encom- passes any sexual activity involving coercion, sexual exploitation, harassment, or advances committed by an individual, irrespective of the relationship with the victim, and the environment (Dartnall & Jewkes, 2013; Krug et al., 2022). As perpetrators are generally men known by the victims and commonly intimate partners, it is important to acknowledge that sexual violence is pervasive in every society and frequent- ly targets women (Dartnall & Jewkes, 2013; WHO, 2002). Notably, women facing mental health challeng- es experience a higher victimization rate, reaching 53 incidents per 1000 individuals, in contrast to the gen- eral population's rate of 17 incidents per 1000 people (Van Deinse et al., 2019). Indeed, violent victimization against women with SMI was estimated at 25% greater than the general population (Van Deinse et al., 2019). Therefore, it is crucial to acquire deeper insights into the topic, given that sexual violence can lead to lasting adverse effects, worsen mental health challenges, and contribute to the emergence of concurrent disorders. Schizophrenia As of 2019, approximately 0.3 percent of the world population was reported to have schizophrenia (OWID, 2019). This disorder can disturb various fac- ets of an individual’s mental faculties such as thoughts, perception, speech, emotions, behaviour, and social functioning (Schultz et al., 2007). Symptoms may en- compass hallucinations (e.g., hearing voices), delusions (e.g., paranoia), social withdrawal, lack of pleasure, loss of motivation, cognitive deficits, and other prob- lems disrupting patients’ lives (Schultz et al., 2007). As schizophrenia affects various facets of women’s lives, many have difficulty relating and connecting to the world around them, making these women vulner- able to feelings of loneliness and isolation. Moreover, the entourage of women with schizophrenia may have difficulty understanding that their illness may compli- cate their relationships. This challenge becomes espe- cially daunting when attempting to establish intimate relationships, as these women are more vulnerable to emotional and physical victimization. Indeed, in Cher- nomas’s (2000) research, women expressed how they feared intimacy as many felt preyed upon once their psychiatric history was known. Additionally, numer- ous women shared experiences of childhood abuse, rape, and physical mistreatment, leading to a strong re- luctance and fear towards engaging in sexual intimacy (Chernomas et al., 2000). These acute stressors have been identified as factors contributing to an elevated risk of suicidal behaviours (Chernomas et al., 2000). As the lifetime prevalence of suicide in the schizo- phrenia population has been estimated to be ten times higher than in the general population, the severity of symptoms and victimization leads to a greater num- ber of suicide attempts in women with schizophre- nia (Carlborg et al., 2010; Thara & Kamath, 2015). In terms of employment, certain women opt to be homemakers, remain on disability pensions, or engage in work fields (Chernomas et al., 2000). While some express a desire to work, they are apprehensive about their ability to cope with the stress of employment. They fear the potential of falling ill and being finan- cially strained, coupled with the challenge of finding alternative employment (Chernomas et al., 2000). Moreover, many women diagnosed with schizophre- nia have encountered limiting messages regarding their ability to pursue employment or education due to their disability, underscoring their apprehension about entering the workforce (Chernomas et al., 2000). Schizophrenia has devastating effects not only on women’s emotional and cognitive health but also on their physical health. The negative impacts of antipsy- chotic medications include weight gain, amenorrhea, reduced libido, lactation, and facial hair growth (Cher- nomas et al., 2000). These side effects have a detrimen- tal impact on women’s well-being and undermine their sense of self and femininity. Furthermore, wom- en with schizophrenia have expressed a lack of suffi- cient information from health professionals regarding family planning, pregnancy, parenting, or menopause, particularly in light of their mental health condition and its psychopharmacologic treatment (Chernomas et al., 2000). The lack of communication and sup- 7 VIOLENCE AGAINST WOMEN WITH SCHIZOPHRENIA port from healthcare professionals can lead women to be hesitant to discuss menstrual irregularities and sexuality as they face insufficient responses to their concerns on these matters (Chernomas et al., 2000). Women with schizophrenia constitute a vul- nerable population as their illness impacts multiple aspects of their lives, including their potential for employment, pursuit of higher education, health, and ability to establish and maintain stable relation- ships. Given that symptoms may exacerbate in the face of challenges, women with schizophrenia also exhibit a higher likelihood of suicide compared to the general population, highlighting the pressing need to improve our comprehension of women’s cir- cumstances and their vulnerability to victimization. IPV, Sexual Violence and Schizophrenia As IPV against women is highly prevalent, past lit- erature has indicated that women with SMI are at ele- vated risk of being victims of sexual and IPV (Afe et al., 2017). Across various research, the lifetime exposure to sexual and physical abuse fell between 43% and 81% for women with SMI (Kim et al., 2006). These women are more susceptible to abusive and violent relationships due to the persistent, debilitating impact of the illness and social stigmatization. Particularly, it was found by Thara & Kamath (2015), that women with schizophre- nia were severely disabled compared to women with other diagnoses. This highlights the need to intensify focus on schizophrenia, particularly considering the insufficient available data regarding the prevalence of sexual and IPV against women diagnosed with schizo- phrenia and its potential impact on their condition. Following the methodological framework pro- posed by Arksey and O’Malley (2005) and Levac et al. (2010), this scoping review seeks to describe the present literature regarding IPV and sexual violence among women with schizophrenia worldwide. Giv- en the pervasive nature of violence against women worldwide, causing harm to millions, and being es- pecially prevalent among women with SMI, it is im- perative to thoroughly investigate this phenomenon. The impact of such violence on symptoms, treatment complexities, and the overall quality of life for these women cannot be understated. Mental health pro- fessionals must be aware and diligent surrounding this issue by carefully assessing for this factor (Afe et al., 2016). By gaining a deeper understanding of the relationship between sexual violence, IPV, and wom- en with schizophrenia, more effective strategies for prevention, intervention, and support can be devel- oped. Ultimately, this examination can contribute to an enhanced comprehension of the issue, offering insights into potential avenues for future research. Methodology As a scoping review, this article is based on the methodological framework developed by Arksey and O’Malley (2005) and refined by Levac et al. (2010) following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Tricco et al., 2018). The purpose of scoping reviews is to provide a comprehensive overview of a new area of research and identify potential gaps that need to be addressed. According to recent literature, five key steps are necessary for conducting scoping reviews: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting the data; and 5) collating, summarizing, and reporting re- sults (Arksey and O’Malley, 2005; Levac et al., 2010). The main question directing this review is “What is the state of knowledge regarding sexual and intimate partner violence against women with schizophrenia?” Literature Research An electronic literature search was initiated on September 6, 2023, through the following databases: APA PsychInfo, PubMed, Scopus, Google Scholar, and Psychology and Behavioral Sciences Collection. In collaboration with an academic librarian, KAB de- veloped a search strategy using controlled vocabulary (MeSH and index terms) and keywords relevant to “sexual violence,” “intimate partner violence (IPV)” and “schizophrenia.” Continual collaboration, val- idation, and discussion followed with SH and AM. For sexual violence and intimate partner vio- lence, the terms employed for the search were: “sex- ual violence” OR “intimate partner violence” OR “intimate partner abuse” OR “sexual viol*” OR “sexual abuse” OR “sexual assault” OR “sexual co- ercion” OR “sexual harassment” OR “sex offenses” OR “acquaintance rape” OR “domestic violence” OR “victimization” OR “marital rape.” For schizo- phrenia, the terms employed were: “schizophre- nia.” The search strategy is presented in Figure 1. Study Selection After conducting the database search, all iden- tified literature was imported into Zotero reference 8 BÉLISLE ET. AL management software (v6). The search generated 6,099 articles, of which 4,459 remained after remov- ing duplicates. To determine eligibility for full-text review, KAB and SH screened titles and abstracts. To be selected, studies had to meet the following inclu- sion criteria: (1) the primary theme had to be related to both sexual violence, IPV, and schizophrenia (2) articles were published in a peer-reviewed journal, (3) articles were available in English or French, (4) articles could not be systematic reviews, (5) article population had to be women (included studies that distinguished findings between sexes), (6) excluded children and (7) article population was diagnosed with schizophrenia. The authors chose to exclude children from the study due to childhood-onset schizophrenia being recog- nized as a distinct subtype of the disorder, necessitat- ing separate research. Incorporating studies involving children would primarily delve into child sexual abuse, which warrants dedicated investigation on its own. A total of 97 articles were retained for full-text review, and the final selection was agreed upon by SH and AM. Following the full-text review, sev- en articles were retained and included in the re- view. For each included article, references, authors, and “cited by” were scanned to identify additional relevant studies. The flowchart of the study selec- tion and screening process can be seen in Figure 2. Data extraction and analysis A charting form was used to facilitate team dis- cussion and approval during full-text screening and descriptive analysis. Using charting forms developed by Peters et al. (2020), Lauzon-Schnittka et al. (2022), and Arnstein et al. (2020), we extracted the following information for each article: authors, journal, year of publication, study location, the number of partici- pants, age of participants, the aim of the study, meth- odology, and important results. The extraction was done by KAB and validated by SH and AM. The results were then summarized, and narrative synthesis was employed to report the findings (Popay et al., 2006). Results The characteristics of the 7 retained articles are displayed in Table 1. Study characteristics Among the selected articles, one was published in 1995 (Darves-Bornoz et al., 1995) and one in 2006 (Kim et al., 2006). A total of 5 articles were published after 2013 (Afe et al., 2016, 2017; Khalifeh et al., 2015; Leslie et al., 2023; Yildirim et al., 2014). Two studies were conducted in Nigeria (Afe et al., 2016, 2017), one in Turkey (Yildirim et al., 2014), one in South Korea (Kim et al., 2006) and one in Canada (Leslie et al., 2023). Two studies were from Europe, includ- ing one from France (Darves-Bornoz et al., 1995) and the other from England (Khalifeh et al., 2015). The number of participants in the selected studies ranged from 70 to 1,802,645. Two articles examined female outpatients diagnosed with schizophrenia with an av- erage age of 38.3 years (Afe et al., 2016, 2017), while Kim et al. (2006) had an average age of 33.5 years. Two studies consisted of in-patients undergoing treatment (Khalifeh et al., 2015; Yildirim et al., 2014). Yildirim et al. (2014) sample consisted of female patients with an average age of 39.24 years. Khalifeh et al. (2015) randomly recruited patients with SMI (59.7% with schizophrenia) through community mental health ser- vices, with an average age of 40.8 years. Two studies had a sample of in and outpatients with schizophre- nia (Darves-Bornoz et al., 1995; Kim et al., 2006). Kim et al. (2006) had a sample with an average age of 33.5 years while Darves-Bornoz and colleagues (1995), recruited females with an average age of 34.3 years. Lastly, Leslie et al. (2023) study compared wom- en in Ontario with or without schizophrenia and who became pregnant between April 1, 2004, and March 31, 2018, with an average age of 30.6 years. Methodology The seven articles were quantitative (Afe et al., 2016, 2017; Darves-Bornoz et al., 1995; Khalifeh et al., 2015; Kim et al., 2006; Leslie et al., 2023; Yildi- rim et al., 2014). One article was surveyed through a computer-assisted face-to-face interview while also incorporating a self-completion module (Khalifeh et al., 2015). One article utilized a population-based cohort study involving the registry of administrative health and clinical data from 2004 to 2018 in On- tario, Canada (Leslie et al., 2023). Two studies em- ployed semi-structured interviews (Darves-Bornoz et al., 1995; Kim et al., 2006). Finally, Afe et al. (2016, 2017) studies employed interviews to survey wom- en. Even though these studies share the same sam- ple, they vary in terms of the assessment measures employed and the number of participants recruited. 9 VIOLENCE AGAINST WOMEN WITH SCHIZOPHRENIA Prevalence of Intimate Partner Violence Among Women with Schizophrenia In four articles, the authors aimed to explore IPV among women with schizophrenia (Afe et al., 2016, 2017; Khalifeh et al., 2015; Leslie et al., 2023). The four studies reported a higher prevalence of IPV among women with schizophrenia than women without this diagnosis. Afe et al.'s (2016) aim was to study the various patterns of IPV against women with schizophrenia and its association with psychopatholo- gy. The results indicated that 75% of the participants experienced at least one occurrence of IPV (Afe et al., 2016). Afe et al. (2017) investigated socio-demograph- ic and other attributes of partners of women with schizophrenia in Nigeria. They reported that 73% of the participants experienced IPV at least once which is much higher than the prevalence of non-mentally ill women found at 40% in Nigeria (Afe et al., 2017). Khalifeh et al. (2015) assess and compare the prevalence and consequences of domestic and sexu- al violence among individuals with SMI, with 59.7% of the participants diagnosed with schizophrenia, and the general population. Their research found that women with SMI reported higher domestic vi- olence (69%) compared to the control group (33%) (Khalifeh et al., 2015). The SMI population also had a higher rate of sexual violence (10%) compared to the control group (2%) (Khalifeh et al., 2015). Last- ly, Leslie et al. (2023), aimed to assess and compare the risk of interpersonal violence necessitating an emergency department (ED) visit during pregnan- cy or within one year postpartum among women with and without schizophrenia. They found a high- er risk of ED visits for interpersonal violence among women with schizophrenia (4%) compared to wom- en without schizophrenia (0.4%) (Leslie et al., 2023). Prevalence of sexual violence among women with schizophrenia In three studies, the authors examined sexual vi- olence committed against women with schizophrenia (Darves-Bornoz et al., 1995; Kim et al., 2006; Yildirim et al., 2014). All three studies indicated that women with schizophrenia have a high prevalence of sexual abuse. In Kim et al.'s (2006) article, the aim was to present findings on the prevalence of sexual abuse in female patients attending a mental hospital for schizo- phrenia in South Korea. They found that 37% of the study’s population had a history of sexual abuse where 29.7% were abused by a family member, 32.4% by an unrelated perpetrator and 60% by a stranger (Kim et al., 2006). In Darves-Bornoz et al. (1995), the aim was to study women with schizophrenia and bipolar dis- order in relation to sexual victimization. It was discov- ered that the prevalence of rape was found to be 23% among women with schizophrenia, in contrast to the general population rate of 7% or 8% (Darves-Bornoz et al., 1995). In this research, the perpetrators of sexual violence were family members (Darves-Bornoz et al., 1995). Lastly, Yildirim et al. (2014), aimed to explore the effect of adulthood trauma such as sexual harass- ment and sexual abuse experienced by patients with schizophrenia who did not have a history of child abuse. They found that 24.3% of patients had experienced sexual abuse during their adulthood whereas 14.3% were abused by a stranger and 10% by someone they knew (Yildirim et al., 2014). For sexual harassment, 28.6% were sexually harassed (Yildirim et al., 2014). These three studies focused on sexual abuse not committed within an intimate relationship. Nonethe- less, three articles which focused on IPV also assessed sexual assaults committed towards schizophrenic women. Khalifeh et al. (2015), found in their popu- lation that 61% of women experience sexual assault compared to 21% of women without schizophrenia. In both Afe et al.'s (2016, 2017) studies, the authors reported that 24% of the sample was sexually assaulted. IPV & Sexual Violence Association with Symp- tomology Out of the seven articles, four found an associa- tion between IPV, sexual violence and higher psycho- pathology (Afe et al., 2016, Darves-Bornoz et al., 1995; Kim et al., 2006; Yildirim et al., 2014), while Afe et al. (2017) revealed that patients who do not adhere to treatment and experience symptom improvement are more likely to become victims of IPV. Afe et al. (2016) found that participants who reported sexual, verbal, and physical IPV indicated higher psychopathology (e.g., worsened psychiatric symptoms). Higher psy- chopathology was also associated with a decrease in physical health, such as “injuries, gynecological prob- lems, depression of immunity and possibly untimely death” (Afe et al., 2016, p. 8). Kim et al. (2006), identi- fied higher psychopathology scores within the abused population indicating increased distress in somatiza- tion, obsessive-compulsive behaviours, depression, and anxiety, while also indicating greater dissociative 10 BÉLISLE ET. AL expression. Yildirim et al. (2014), reported higher psy- chopathology such as anxiety, aggression, hallucina- tions, and delayed gratification among patients who experienced sexual abuse. Darves-Bornoz et al. (1995) also stated a relationship between the occurrence of rape and the increased chronicity of the disorder. Last- ly, regarding treatment adherence, Afe et al. (2017) noted a counterintuitive finding suggesting that ir- regular medication use increases the odds of IPV and individuals with a shorter duration of illness are more likely to experience sexual, physical and verbal IPV. Suicide Among the seven articles, five studies discussed the risk of suicide when victimized (Afe et al., 2016, 2017; Darves-Bornoz et al., 1995; Khalifeh et al., 2015; Kim et al., 2006). Kim et al. (2006), discovered a higher risk of suicidal attempts among abused patients compared to non-abused patients. Darves-Bornoz et al. (1995) found that victimization of women with schizophrenia was associated with an elevated risk of suicidal attempts. Afe et al. (2016) claimed that victimization increased the rates of suicide risks while Afe et al. (2017) empha- sized how abuse within SMI like schizophrenia raises the incidence of suicide. Lastly, Khalifeh et al. (2015), revealed that half of the women in their sample who were coping with SMI and had encountered sexual as- sault went on to report instances of attempted suicide. Age Of the seven selected articles, five discussed the relationship between age and victimization. Afe et al. (2016), found that the younger group had higher chanc- es of reporting IPV than the general population. Afe et al. (2017), similarly showed a higher prevalence of IPV reports within adults younger than 40 years old. Yildi- rim et al. (2014) discovered that patients who had expe- rienced sexual abuse were notably younger compared to those who did not report a history of sexual abuse. Leslie et al. (2023) indicated that younger mothers had a higher risk for an ED visit for interpersonal violence. Lastly, Darves-Bornoz et al. (1995) found that women with schizophrenia were more at risk of being raped during the end of adolescence and early adulthood. Unemployment/ Low Income Five studies assessed victimization and its as- sociation with unemployment/low income. Afe et al. (2016) found higher rates of IPV, more precisely verbal abuse among unemployed women. Afe et al. (2017) also found that participants’ unemployment status was linked with higher chances of experienc- ing IPV. Indeed, women who were unemployed and had low or no income were found to have increased odds of experiencing physical, verbal and sexual abuse from their partners (Afe et al., 2017). Darves-Bornoz et al. (1995), also expressed how low income had an important role in sexual victimization. Leslie et al. (2023), found in their sample that women who expe- rienced interpersonal violence were residing in low- er-income neighbourhoods and were also more likely to have an ED visit for interpersonal violence. Last- ly, Khalifeh et al. (2015), indicated that within their population who experienced domestic and sexual violence, 80% of the participants were unemployed. Discussion The objective of this scoping review was to analyze the existing peer-reviewed literature on sexual and IPV against women with schizophrenia to summarize the current state of knowledge on this subject and high- light future research avenues. As shown through the seven selected studies in this scoping review, a strong association was found between sexual violence, IPV, and women with schizophrenia. Across four studies, it was observed that women diagnosed with schizophre- nia demonstrated a significantly higher prevalence of experiencing IPV compared to women without this diagnosis (Afe et al., 2016, 2017; Khalifeh et al., 2015; Leslie et al., 2023). In Leslie et al.'s (2023) study, wom- en with schizophrenia were ten times more likely to experience IPV when pregnant. In contrast, research by Afe et al. (2017) and Khalifeh et al. (2015) showed that women with schizophrenia were twice as likely to experience IPV. The findings from the three remaining studies pointed toward a heightened prevalence of sex- ual abuse of approximately 28% among women diag- nosed with schizophrenia (Darves-Bornoz et al., 1995; Kim et al., 2006; Yildirim et al., 2014). This highlights how women with schizophrenia are more likely to be victims of sexual and IPV. Yet, this issue is rarely discussed by mental health professionals and physi- cians creating a lack of awareness (Afe et al., 2017). Through the seven articles, various themes arose describing the risk factors and effect of victimization upon women with schizophrenia. Regarding symp- tomology, four articles found a relationship between IPV, sexual violence, and elevated psychopathology (Afe et al., 2016, Darves-Bornoz et al., 1995; Kim et 11 VIOLENCE AGAINST WOMEN WITH SCHIZOPHRENIA al., 2006; Yildirim et al., 2014). Studies have identified that instances of abuse and victimization contribute to heightened psychiatric symptoms in women. This is manifested through increased levels of depression, anxiety, dissociative expression, and hallucinations (Darves-Bornoz et al., 1995; Kim et al., 2006; Yildirim et al., 2014). The amplification of symptoms can be attributed to women’s response to victimization and having limited resources in a society that stigmatizes them (Chernomas et al., 2000). Furthermore, women not only face heightened psychiatric symptoms but also encounter physical health issues. Given that indi- viduals with schizophrenia confront a notably shorter life expectancy than the general population, with ap- proximately 90% of deaths attributed to physical ill- nesses, it becomes apparent that sexual and IPV play a role as contributing factors to the deterioration of health (Chernomas et al., 2000). This form of violence can result in injuries, gynecological problems, and com- promised immune function, thereby intensifying the overall health challenges experienced by these women (Chernomas et al., 2000; Seeman, 2018). Conversely, Afe et al. (2017) demonstrated that individuals who do not comply with treatment and show symptom improvement are at a higher risk of IPV. This counter- intuitive finding suggests the need to further explore the repercussions of victimization on symptomology. Among the seven articles analyzed, five studies (Afe et al., 2016, 2017; Darves-Bornoz et al., 1995; Khalifeh et al., 2015; Kim et al., 2006) investigated the relationship between victimization and the risk of suicide. In each instance, there was a uniform obser- vation of an increased risk of suicide. Given that sui- cide is more prevalent in women with schizophrenia compared to the general population (Seeman, 2018), research indicates that suicidal behaviour increases during acute social crises. Crucial predictive factors for suicide in women with schizophrenia include a history of sexual abuse, IPV, and the loss of children (Carl- borg et al., 2010). These traumatic events also have re- percussions on women’s psychiatric symptoms, with depression and hopelessness identified as significant contributing risk factors to suicide (Carlborg et al., 2010). In schizophrenia, the risk factors for suicide ap- pear to be less associated with typical core symptoms of psychosis, such as delusions and hallucinations, and more linked to depressive symptoms, including agitation, hopelessness, and feelings of worthless- ness (Carlborg et al., 2010). Consequently, as suicide risk is already high among people with schizophre- nia, victimization exacerbates their situation, leading to an even higher likelihood of committing suicide. Additionally, an increased likelihood of experienc- ing sexual and IPV during younger years was found in five studies (Afe et al., 2016, 2017; Darves-Bornoz et al., 1995; Leslie et al., 2023; Yildirim et al., 2014). The vulnerability of younger women with schizophrenia may stem from the decline in social skills and cognition linked to the chronicity of the illness (Afe et al., 2017). Younger women also tend to be more dependent on their partner, increasing their risk of IPV, especially among women with SMI (Afe et al., 2017). Regard- ing employment, unemployed or low-income women with schizophrenia were more likely to be victims of sexual and IPV (Afe et al., 2016, 2017; Darves-Bornoz et al., 1995; Khalifeh et al., 2015; Leslie et al., 2023). As the study of Afe et al. (2017) pointed out, individuals with schizophrenia are more likely to have a lower so- cioeconomic status due to the debilitating effect of the illness on their cognition, social skills, and ability to be productive. Moreover, barriers still exist regarding em- ployment and the improvement of the socioeconomic status of people with schizophrenia due to the ongoing stigma and discrimination (Afe et al., 2017). Thus, this becomes even more difficult for women with schizo- phrenia as gender barriers exist (e.g., men having better economic opportunities, more education, and more employment opportunities) (Afe et al., 2017). Given that employment offers substantial support, contrib- utes to a dignified existence, and fosters financial in- dependence, it is noteworthy that many women with schizophrenia lack jobs or sufficient income (Afe et al., 2017). Consequently, these women face an increased likelihood of experiencing violence, primarily attribut- able to their socioeconomic status and lower income in comparison to the general population (Afe et al., 2017). These results suggest that younger women diag- nosed with schizophrenia, particularly those with low income and/or unemployed status, face an elevated risk of becoming victims of sexual and IPV. This victimiza- tion, in turn, amplifies the risk of suicide and height- ened psychopathology. The findings also suggest that IPV worsens the progression of schizophrenia, leading to an increase in symptoms and a higher risk of suicide. These findings underscore the need to enhance interventions that could better support women with 12 schizophrenia experiencing sexual violence and IPV. Certainly, mental health professionals should rou- tinely inquire about IPV among women with schizo- phrenia to identify potential victims. By making both direct and indirect inquiries about IPV, clinicians can better detect IPV and develop comprehensive thera- py plans that include social interventions to support women with schizophrenia. Additionally, clinicians need to be aware of the elevated prevalence of sexual and physical abuse in this population. They should thoroughly evaluate psychosocial, familial, and clinical histories collectively (Kim et al., 2006). Studies have shown that clinicians can identify IPV risk and ad- dress relationship dynamics, socioeconomic challeng- es, and pharmacological therapy effectively by giving proper attention to women's socio-demographic back- ground, economic circumstances, and partners (Afe et al., 2017). Hence, the integration of regular violence screening and the establishment of a robust therapeu- tic rapport with clients offers health professionals a vi- tal opportunity for intervention to prevent severe phys- ical, psychological, and social harm to these women. This review also denotes how the selected articles assessed women in the same age range (between 30 and 40 years old) indicating scarce data for sexual and IPV among women with schizophrenia in younger and el- derly populations. As a result, it is recommended that forthcoming studies take into account diverse popu- lations, sexual diversity, and gender while adopting a non-binary perspective. Lastly, the selected studies, published between 1995 and 2023, with a majority published after 2013 (n=5), suggest a recent emergence of reporting sexual and IPV incidences against women with schizophrenia. While most studies were cross-sec- tional, there is a need for qualitative and mixed-method studies to fully understand the experience of women with schizophrenia to prevent and protect them from sexual and IPV. Overall, this scoping review reveals that more studies are needed to improve our knowledge of sexual and IPV against women with schizophrenia. Study Limitations This scoping review has some limitations to consider. To begin, only peer-reviewed articles pub- lished in scientific journals were included in this re- view, excluding grey literature. The authors decided to exclude grey literature to prioritize the most rig- orous reviewed and established research. This helps in providing a clearer picture of the current state of knowledge by ensuring the quality and reliability of the articles. Thus, this limited our ability to identify potential research and advance our understanding. Moreover, the study selection criteria restricted this review to English and French, which prevented stud- ies in other languages from being considered. Fur- thermore, this research constrained its focus to adult women, omitting post-pubertal schizophrenia in chil- dren and young adolescents. Lastly, the chosen articles lacked clear distinctions between sex and gender, with a majority frequently remaining ambiguous about whether they were addressing gender, sex, or both. As such, studies in other languages, the inclusion of grey literature, and the inclusion of a broader popu- lation could provide further insight into this subject. Conclusion The aim of this scoping review was to identify and synthesize literature on sexual and IPV against women with schizophrenia. The studies included in this review revealed a higher prevalence of sexual abuse and IPV among women with schizophrenia relative to the general population. The findings indicate that younger women diagnosed with schizophrenia, es- pecially those with low income and/or unemployed status, are at an increased risk of experiencing sexual and IPV. This victimization, subsequently, raises the likelihood of suicide and heightened psychopathol- ogy. These results underscore the necessity of foster- ing interdisciplinary collaboration among health- care professionals, social workers, and policymakers to effectively tackle IPV against women diagnosed with schizophrenia. While the retained articles for this review were small, there is a need for further in- vestigation. Future research should explore current care setting interventions to prevent severe physical, psychological, and social harm, while also examining the impact of victimization on symptomatology as current results are mixed. Additional research should also explore childhood-onset psychosis and its asso- ciation with sexual and intimate partner violence. References Afe, T. O., Emedoh, T. C., Ogunsemi, O., & Adeg- bohun, A. A. (2016). Intimate partner violence, psychopathology and the women with schizo- phrenia in an outpatient clinic South-South, Ni- geria. BMC Psychiatry, 16(1), 197. https://doi. org/10.1186/s12888-016-0898-2 BÉLISLE ET. 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WHO multi-country study on women's health and do- mestic violence against women (No. WHO/FCH/ GWH/02.2). World Health Organization. Yildirim, M., Yildirim, E. A., Kaser, M., Guduk, M., Fistikci, N., Cinar, O., & Yuksel, S. (2014). The relationship between adulthood traumatic experi- ences and psychotic symptoms in female patients with schizophrenia. Comprehensive Psychiatry, 55(8), 1847–1854. https://doi.org/10.1016/j. comppsych.2014.08.049 BÉLISLE ET. AL 15 VIOLENCE AGAINST WOMEN WITH SCHIZOPHRENIA Figure 1 Summary of the search strategy 16 BÉLISLE ET. AL Figure 2 Flowchart of study selection and screening process 17 VIOLENCE AGAINST WOMEN WITH SCHIZOPHRENIA Table 1 18 BÉLISLE ET. AL Table 1 (cont.)