GROWING ACCEPTANCE OF THE MAGNITUDE OF VIOLENCE AGAINST WOMEN AND CHILDREN

Many speakers expressed the sense that violence against women and children has become a mainstream issue over the past few decades. Claudia García-Moreno of the World Health Organization said that when she first began working in this field, she was informed that violence was not a health issue but a social problem. Currently, researchers, particularly in public health, have begun to recognize and document the magnitude of these types of violence, though many gaps remain.

Only recently has evidence demonstrated that violence has an accumulated effect, and in many cases it starts early and continues throughout the lifespan. Little data exist from low- and middle-income countries, but studies are under way, and preliminary findings show high rates of abuse. In particular, Claudia García-Moreno mentioned a study in Swaziland conducted by the Centers for Disease Control and Prevention, which found that 33 percent of girls had been victims of childhood sexual abuse. The WHO Multi-Country Study shows that between 1 and 21 percent of women in the 10 countries included in the study experienced abuse in childhood, most commonly perpetrated by a family member (García-Moreno et al., 2005). She also referred to a study by Jeff Edleson of children's exposure to violence; the study found that up to 83 percent of children had overheard episodes of intimate partner violence (Edleson et al., 2003).

Dr. García-Moreno said that in the past 10 years the amount of data on magnitude and consequences has increased significantly, although much information is still missing on different types of violence against women and children (García-Moreno et al., 2005). According to the current state of knowledge, the majority of violence perpetrated against women is done by an intimate partner, but the means and methods vary. Denise Wilson of the Auckland University of Technology mentioned statistics from New Zealand showing that 50 percent of homicides are related to family violence, and as many as 1 in 3 women in New Zealand experience some sort of lifetime physical or sexual abuse. Indigenous populations such as the Māori are at highest risk; 47 percent of women seeking safety are Māori, although this group only makes up 15 percent of the population (Wilson, 2011). Agnes Tiwari said that intimate partner violence in Hong Kong is relatively unrecognized, particularly as it tends to be emotional rather than physical abuse, which makes it difficult to determine rates of prevalence. Dr. García-Moreno added that the prevalence of other types of violence, such as female genital mutilation, does not seem to be lessening.

Finally, Dr. García-Moreno noted that in addition to the increasing body of knowledge concerning the prevalence of violence, there is also a growing body of evidence about the long-term effects, with evidence showing that consequences can continue for years after the violence itself.

GROWING ACCEPTANCE OF THE NEED FOR PREVENTION

Speakers generally felt that there was a growing recognition that prevention of violence was useful to multiple sectors in addressing health and social issues, and that this prevention included systemic changes in health systems as well as in legal systems. Claudia García-Moreno asked rhetorically why those in the health sector should care, as violence prevention efforts are often seen as competing with other interests. She felt that this state of affairs indicated the need for system-wide changes. Similarly, Roger Fallot talked about trauma-informed care as a new culture that has resulted from a systemic approach to addressing trauma that seeks to provide safety, address the potential for recurrence, and avoid replicating the violent situation. In addition, he said that a paradigm shift is needed in health service organizations and settings that would focus on supporting victims, such as an effort by health care providers to build trust with patients. Several speakers reiterated this point and said that addressing issues of violence and safety in communities and health-care systems would actually improve health-care providers' ability to provide services.

A number of speakers also spoke of the need for institutional, legal, regulatory, and policy changes to address violence. Denise Wilson described a number of pieces of legislation aimed at protecting women and children in New Zealand: the Domestic Violence Act of 1995; the Children, Youth, and Families Act in 1989; and the Care of Children Act in 2004. She also discussed the New Zealand Health Strategy of 2000, which included reduction of interpersonal violence as a goal and included family violence as a health problem.

Cheryl Thomas discussed the early stages of work performed in Central Asia in the early 1990s by a group that she led; in particular, she said, there were no provisions for domestic violence (no shelters, hotlines, or service providers, for example) and no research and no political or social will. In 1993 her group began work in Romania documenting domestic violence, which opened the door to research in the area. Through this work, she said, there has been a growing understanding that implementing laws criminalizing violence against women is essential, and many countries in Eastern Europe and Central Asia have begun to do so. In particular, Advocates for Human Rights has highlighted the importance of the role of an “order for protection.” Ms. Thomas also noted that in Morocco the work of local implementing partners, particularly women's groups, has advanced the chances for implementation of a national domestic violence law greatly.

Finally, speakers explored the need for nuanced research into developing prevention and intervention strategies. David Wolfe pointed out that in self-reports of violence, girls state they hit as much as, if not more than, boys do, and the rationalizations they use reflect familiar language from men and boys from the 1980s (Wolfe et al., 2009). This is troublesome, he said, because the girls will often still end up the victim because the boy will often retaliate. Furthermore, the situation of girls-as-victims-only is less prevalent in adolescent abusive relationships than at the adult level, perhaps because adolescence is a training ground and teenage violence is somewhat peer-sanctioned. Thus, he surmised, interventions that address girls solely as victims miss a major piece of the growing understanding of adolescent relationships and will not be as successful.

Monique Widyono offered another example with her description of a tool called In Her Shoes, developed originally in Washington State, which allows people to “walk in the shoes” of women experiencing violence. The process allows policy makers, service providers, and others a chance to see the consequences of such violence and to diminish stereotypes or expectations of survivors of violence.

ENGAGING MEN AND BOYS

Gender equality and violence against women and children are intricately entwined, and advocates for reducing violence highlight the importance of increasing gender equality. Conversely, Kiersten Stewart discussed the reverse, describing how addressing violence can address gender inequality. James Lang said that violence is a “constitutive element of gender inequality” and that Partners for Prevention quickly became involved in engaging men and boys because they are the “gatekeepers of power” and primary prevention has to take that into account. However, Mr. Lang warned against sliding into the paternalistic language of men and boys “saving” women and girls from violence or thinking about males solely as instruments of change.

Rachel Jewkes delved deeper into the nuances of gender equity, pointing out that simply involving more females in government is not enough; relationships between men and women must be addressed as well. She demonstrated the existence of a disconnect between gender equality and a lack of violence by describing a study done in South Africa in which 90 percent of men said women should be treated equally, but 50 percent of those surveyed admitted to committing physical violence against a female partner (Gender Links and South African Medical Research Council, 2010). Dr. García-Moreno also noted that there is a growing body of information from men about their own perpetration of violence.

Dr. Jewkes explained that gender socialization is a process of learning social expectations about the goals and practices of men and women as well as about their experiences of power. Mary Ellsberg highlighted the importance of social dynamics: Boys are raised to be “tough,” and girls are raised to be pliant. Gender norms also influence the type of violence that children experience, with boys more likely to experience bullying and fights while girls are more likely to experience sexual and psychological violence and exclusion.

Thus in the process of growing up children discover that going against the dominant cultural model results in pressure, abuse, and violence. Dr. Jewkes used the example of the rape of lesbians in South Africa as a “corrective measure” to emphasize this point. Gary Barker agreed and suggested that changing gender norms should mean not only redefining the roles of men and women but also making people aware of the diversity of roles that already exist in various cultures.

Therefore, Dr. Jewkes concluded, addressing violence against women and children must include gender socialization. Various social institutions, such as schools, help define gender, but the home and family life are some of the earliest and strongest influences. If gender balances are unequal in the home or if partner violence is occurring, boys and girls are at greater risk of mimicking these models and finding themselves in abusive relationships again and again. Gary Barker reiterated this, mentioning the stress on men of being a provider, particularly during economic downturns, and suggested that perhaps early gender socialization that included alternative roles for men might reduce this stress. Dr. Jewkes, speaking for Julia Kim, said that giving women increased roles as providers does not always help, particularly if it is added to women's responsibilities for taking care of the home, because it can increase the stress on women. She noted that standards for feminine behavior in the developing context are often constructed around acquiescence to men's demands and that social structures often reward women who fit into socially acceptable roles despite the increased risk of violence they must endure.

Dr. Jewkes referred to the hegemonic masculinity theory of Raewyn Connell, which states that power is not exercised through use of force but rather through the acquiescence of the powerless. A study in South Africa found that while the vast majority of men and women believe in equality, the majority of men and a smaller majority of women believe that a woman should obey her husband. This was true across races. One of the factors contributing to this situation is a lack of exposure to other culturally appropriate ways of being a woman. Dr. Jewkes also pointed out that, according to one study, women who strongly agree that a husband has a right to beat his wife are more likely to be beaten and that women who believe that beating is a sign of affection are also more likely to be beaten (Gender Links and South African Medical Research Council, 2010).

The International Men and Gender Equality Survey (IMAGES) described by Dr. Barker found that men report knowing about laws addressing gender-based violence but express sometimes contradicting views on such laws. One consensus among interviewees across countries was the feeling that the laws increase a sense of being observed or scrutinized, which Dr. Barker described as not only a symptom of the gender power balance being upset but also an indication that additional education might be needed to explain how these laws are protective and not punitive. Claire Crooks also expressed a concern about lack of services for men at risk of perpetrating violence aimed at preventing either violence or the recurrence of violence; most efforts are punitive instead of preventive.

To explain why some men experience similar risk factors but do not perpetrate violence, Dr. Barker showed responses from IMAGES suggesting that men are sensitive to positive cultural and social norms, including the influence of a respected elder, reflection on past abuse (as victim or perpetrator), and exposure to community spaces that promote non-violence.

Interventions that take into account these sensitivities often include involving men in the care of family. Dr. Crooks said that it is important not to assume that a program that works with mothers will work with fathers and that more effort should be put into designing programs that include men more actively.

Agnes Tiwari agreed, citing her work in including men in prevention efforts as active participants rather than as passive partners. In her Hong Kong study, men were included in a prenatal education intervention in which the discussion around parenting skills was used as an entry point to discussing couple relationships. This was more effective because the cultural barrier to discussing romantic relationship skills could be overcome. In particular, it was effective in reaching men and discussing both partner and father roles in a way that didn't seem “therapeutic.”

INTERSECTION WITH OTHER INEQUITIES

Recent research in the field of violence prevention shows that violence does not occur in a vacuum; instead, it is highly co-occurring with certain factors such as poverty, food insecurity, the presence of infectious and chronic diseases, and lack of education. Addressing violence prevention in a comprehensive way requires looking at these other issues as well. Dr. Butler-Jones remarked that “poverty is a constellation” and can entail a lack not only of economic resources but also of relationships as well. Having stability, shelter, and adequate food means the difference between average health and good health, all of which affect resiliency.

Thus investing in preventing violence against women and children is not just about ending violence and promoting gender equality. As Dr. Ellsberg said, “We cannot hope to make significant progress in achieving the ambitious goals of ending poverty and hunger, achieving universal primary education, improving maternal and child health, and combating AIDS and other infectious diseases unless we are able to end violence against women and children.” Brigid McCaw also said that it is important to identify co-morbidities and inequities (poverty, substance abuse, and so forth) because they may be more likely to bring the victim to the attention of the provider than the violence itself. For example, as Claudia García-Moreno pointed out, children experiencing violence at home often have difficulties, such as behavior problems, at school, and understanding this link can lead service providers to the violence even if no report is ever made.

These intersections are bi-directional: The increased risk of violence creates a suspicion of legal and medical authorities, while unstable social conditions can lead to an increased incidence of violence. Dr. Ellsberg pointed out, for example, that poverty and lack of access to health care prevent parents from accessing resources for addressing parenting and coping skills. Furthermore, those who fear the stigma of HIV and its associated violence—of which women are most at risk—fail to seek screening and care. Roger Fallot said that while violence increases the risk of homelessness, incarceration, and substance abuse problems, those outcomes in turn place people at risk of continued violence.

The context in which violence can occur is a major factor affecting the risk and severity of violence. Dr. Amaro suggested it might be useful to look further upstream at issues such as environmental factors and structural violence, a topic that had been touched upon by an earlier audience member who suggested that violence prevention efforts need to be incorporated into social studies curriculum in schools. Dr. Crooks said that the more types of violence a person experiences, the worse the outcome will be in terms of both future perpetration and health and psychosocial outcomes. Poverty and racism increase both the likelihood and the severity of violence and also affect the impacts of violence. Denise Wilson underscored this point by bringing up the example of the Māori, who live in the most deprived neighborhoods in urban centers of New Zealand and who still experience barriers to access to health care and social services system because of racial discrimination. The Māori are disproportionately victims of violence, and they account for 50 percent of women and children in shelters. Dr. Wilson also described how the Māori culture has seen huge shifts over the past several decades, with the loss of traditional social structures that previously supported women's equality. Not all women have the same rights, Dr. Wyatt said, and ethnic and racial differences play a large role in who is exposed to or victimized by violence.

Promundo's IMAGES study shows that one major factor in predicting violence is whether men report feeling economic stress (as opposed to reporting of actual income), which is related to the social norms of men's traditional roles as providers. Dr. Jewkes referred to a study from South Africa in which women who report higher food insecurity report less equitable views of gender and men who report lower food security report higher rates of violence against a partner. A similar outcome was found in a study in India, which found that 49 percent of women who did not own property reported violence, as compared with 7 percent of women who did own property. In general, a lower ability to mobilize resources is correlated with a higher acceptance of violence, greater likelihood of being a victim or perpetrator, and lower likelihood of leaving a violent situation. This greater risk of violence leads to a continued cycle of violence in which victims find themselves re-victimized and sometimes become perpetrators themselves.

The context of violence also affects the severity of the outcomes. Julian Ford and Claudia García-Moreno paid particular attention to the concept of toxic stress and how continual exposure to violence both directly and indirectly creates a climate of chronic stress, which has been shown to have fundamental effects on cell growth in the brain. This is of particular importance for children, whose brain development can be significantly altered, resulting in secondary outcomes throughout their lives. Exposure to chronic stress affects language and communication ability and places an individual at increased risk of substance abuse. The development of trauma as a long-term outcome also has a complex relationship with violence, putting victims at additional risk of re-victimization as well as at risk of other adverse health outcomes. Dr. Amaro mentioned the high rates of co-occurrence of alcohol- and drug-related disorders with trauma and post-traumatic stress disorder (PTSD). Often the alcohol- and drug-related issues are methods of self-medicating that are used to deal with trauma, but such use intensifies the symptoms of PTSD, creating a cycle.

In the Boston Consortium study discussed by Dr. Amaro, an integrated system was created to address trauma and substance abuse issues in women. This included treatment for the trauma (psychotherapy and skills building) as well as substance abuse treatment, both clinical and residential. The intervention involved careful attention to gender and racial linguistic usage because the population was primarily African-American and Latina women, and it paid close attention to addressing the roles of women in society and their relationship to violence. The intervention also included components to address integration with other services being provided, because many of the women involved had other issues, such as the loss of custody of children or a lack of economic empowerment.

Cris Sullivan applied her community advocacy model to discuss how empowering women has a strong effect on whether abuse recurs and on how capable women are of escaping the cycle of violence. She found in her intervention that providing an advocate who would support the woman with skills transfer and assistance empowered her to take control of her life.

PREVENTION THROUGH PROMOTION

The speakers also agreed on the importance of primary prevention and on moving even further upstream to address the environment in which violence occurs. Researchers felt that promoting resilience and protective factors provides individuals with skills to deal with the conflict and instability that breeds violence. Addressing many of the issues mentioned previously, such as gender equality and co-morbidities and the chronic stress on children, would be cost-effective and successful in the prevention of violence against women and children. Speakers felt that mitigating the climate of violence through social and legal programs often results in the greatest success.

Some of these legal interventions would involve laws and regulations that strengthen the rights of women and children, such as the international and country-level policies mentioned by Cheryl Thomas and Kiersten Stewart. Katrina Baum of the National Institute of Justice described the paradigm shift that occurs when including criminal justice in prevention, citing a case of a police chief referring to a stalking unit as a “homicide prevention unit,” and Gary Barker noted that there is good evidence that community policing can play a role in preventing violence.

Prevention can also be addressed in programs that strengthen individual skills and family coping mechanisms. Bryan Samuels of the Administration on Children, Youth, and Families referred to research undertaken to inform program decision making that showed three important protective factors: “young people who have the ability to self regulate, young people who choose a particular way of coping with adversity, and young people who have a level of self efficacy that leads them to the belief that they can avoid the bad things that are going on around them, and that they have got a skill set or a method for doing so.” Dr. Fallot talked about G-TRIM (Loving Life), in which girls were given a space to talk about trauma, anger, and how to move forward.

David Wolfe said that prevention is cheaper and easier than treatment and noted that the Fourth R is designed around the promotion of healthy relationships in adolescence. Learning to relate starts early, and adolescents are curious and experimental, pushing at boundaries and becoming more exposed to risk factors. The Fourth R addresses management of these risk factors, strengthening the skills needed to make responsible choices and teaching students to balance “pro-abuse” messages with healthy messages. An important component of the program is involving youth in their own empowerment, particularly having older youth demonstrate the skills learned through the program in videos or other activities. One major outcome of the program is that boys who experienced maltreatment outside of school were less likely to engage in dating violence after this intervention. Risk factors are most noticeable at the middle school level, so addressing troubling relationships then makes sense. However, it could potentially be more effective to begin earlier with general information on the skills needed to build healthy relationships.

Judy Langford discussed Strengthening Families, which targets all families, not just those at risk, and aims to increase resilience and promote strengths. To easily reach out to families, the program is carried out at locations that they are likely to frequent. Strengthening Families is designed to support five essential protective factors that were identified through research and evaluation of successful programs. The first is parental resilience, which aids a parent's ability to maintain healthy relationships and handle individual and parenting challenges. The second is social connections and the ability to create a social network to prevent the damage caused by isolation as a result of or a precursor to susceptibility to violence. The third is knowledge of parenting and child development, which encompasses not only “official” information from parenting guides but also the unofficial information gleaned from family networks and cultural sources. The fourth is concrete support in times of need, both the basic needs required to maintain a stable household, such as economic stability, and access to services in crisis. The fifth protective factor is social and emotional development of children, because children with developmental delays and cognitive disabilities are more vulnerable to maltreatment than those with normal development. The importance of this work, Ms. Langford said, is highlighted by the number of states that expressed interest in learning about this framework, which in turn resulted in a number of interdisciplinary approaches being created and used in these states. Strengthening Families has been adopted by national and international nongovernmental organizations, parent groups, administrators, and state child welfare agencies as a means to reduce violence and improve family relationships.

Gary Barker discussed an intervention strategy, Program H, designed to promote alternative masculine identities of non-violent or less violent men and directed at both men and women. The program ran a campaign including radio spots, TV ads, community theatre, and other media that highlighted positive aspects of masculinity. In Brazil the campaign resulted in attitude change; in India, it resulted in lower reported rates of gender-based violence. Preliminary data in the Balkans are being assessed, but one major obstacle to success there was the ingrained violence in all-male schools, a more difficult cultural context to overcome. A second intervention, Program M, is looking at changing these attitudes within schools, not only among students, but also among teachers as transmitters of these norms.

In the Intervention with Microfinance for AIDS and Gender Equity study in South Africa, which was conducted by Julia Kim and described by Rachel Jewkes, researchers sought to identify whether microfinance programs with added gender training elements resulted in women feeling more empowered and in men and women reporting fewer violent events. Women reported feeling more empowered collectively. There were also increases in food security and household assets and a reduction in loan defaults. The program also saw a 55 percent reduction in intimate partner violence two years after the intervention, through shifts in attitudes, including greater negotiating status of women, the ability of women to leave abusive relationships, and fewer conflicts over finances. In a comparison group without the gender training, there was no reduction in violence.

Finally, several speakers addressed the importance of education, given that higher levels of education correlate to low violence. Dr. Barker referred to cases in which the dropout rates for girls and boys in secondary school are high, suggesting that while the focus is mostly on girls, consideration should be given to addressing the issue with boys in order to keep them in school, which in turn would increase earning potential, reduce economic stress, and expose the boys to more positive gender role socialization.

KEY MESSAGES

The stigma of violence against women and children is diminishing, revealing important cultural and contextual elements that could be addressed. This paradigm shift involves increasing the evidence base, implementing programs that move further upstream and address contextual factors, and engaging men and boys, traditionally seen as perpetrators, as part of the solution. As well, as the violence prevention community produces further research and evidence of successful programs, the pervasive nature of violence, and its relationship to other health and social inequities, continues to be illuminated.

REFERENCES

• Edleson JL, Mbilinyi LF, Beeman SK, Hagemeister AK. How children are involved in adult domestic violence: Results from a four-city telephone survey. Journal of Interpersonal Violence. 2003;18(1):18–32.
• Ellsberg M H, Jansen AFM, Heise L, Watts CH C, Garcia-Moreno, Hlth WMSW. Intimate partner violence and women's physical and mental health in the WHO Multi-country Study on Women's Health and Domestic Violence: An observational study. Lancet. 2008;371(9619):1165–1172. [PubMed: 18395577]
• García-Moreno C, Watts C, Ellsberg M, Heise L, Jansen HAFM. WHO Multi-country Study on Women's Health and Domestic Violence against Women. Geneva, Switzerland: World Health Organization; 2005.
• Gender Links and South African Medical Research Council. The war at home: Preliminary findings of the Gauteng Gender Violence Prevalence Study. Johannesburg, South Africa: Gender Links; 2010.
• Wilson D. New Zealand's efforts to prevent violence against women. Washington, DC: 2011. (Paper presented at IOM Workshop on Preventing Violence Against Women and Children).
• Wolfe DA, Crooks CV, Jaffe P, Chiodo D, Hughes R, Ellis W, Stitt L, Donner A. A school-based program to prevent adolescent dating violence: A cluster randomized trial. Archives of Pediatric Adolescent Medicine. 2009;163(8):692–699. [PubMed: 19652099]