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Domestic violence research topics.

The list of domestic violence research paper topics below will show that domestic violence takes on many forms. Through recent scientific study, it is now known that domestic violence occurs within different types of households. The purpose of creating this list is for students to have available a comprehensive, state-of-the-research, easy-to-read compilation of a wide variety of domestic violence topics and provide research paper examples on those topics.

Domestic violence research paper topics can be divided into seven categories:

• Victims of domestic violence,
• Theoretical perspectives and correlates to domestic violence,
• Cross-cultural and religious perspectives,
• Understudied areas within domestic violence research,
• Domestic violence and the law,
• Child abuse and elder abuse, and
• Special topics in domestic violence.

100+ Domestic Violence Research Topics

Victims of domestic violence.

Initial research recognized wives as victims of domestic violence. Thereafter, it was acknowledged that unmarried women were also falling victim to violence at the hands of their boyfriends. Subsequently, the term ‘‘battered women’’ became synonymous with ‘‘battered wives.’’ Legitimizing female victimization served as the catalyst in introducing other types of intimate partner violence.

• Battered Husbands
• Battered Wives
• Battered Women: Held in Captivity
• Battered Women Who Kill: An Examination
• Cohabiting Violence
• Dating Violence
• Domestic Violence in Workplace
• Intimate Partner Homicide
• Intimate Partner Violence, Forms of
• Marital Rape
• Mutual Battering
• Spousal Prostitution

Read more about victims of domestic violence .

Part 2: Research Paper Topics on

Theoretical Perspectives and Correlates to Domestic Violence

There is no single causal factor related to domestic violence. Rather, scholars have concluded that there are numerous factors that contribute to domestic violence. Feminists found that women were beaten at the hands of their partners. Drawing on feminist theory, they helped explain the relationship between patriarchy and domestic violence. Researchers have examined other theoretical perspectives such as attachment theory, exchange theory, identity theory, the cycle of violence, social learning theory, and victim-blaming theory in explaining domestic violence. However, factors exist that may not fall into a single theoretical perspective. Correlates have shown that certain factors such as pregnancy, social class, level of education, animal abuse, and substance abuse may influence the likelihood for victimization.

• Animal Abuse: The Link to Family Violence
• Assessing Risk in Domestic Violence Cases
• Attachment Theory and Domestic Violence
• Battered Woman Syndrome
• Batterer Typology
• Bullying and the Family
• Coercive Control
• Control Balance Theory and Domestic Violence
• Cycle of Violence
• Depression and Domestic Violence
• Education as a Risk Factor for Domestic Violence
• Exchange Theory
• Feminist Theory
• Identity Theory and Domestic Violence
• Intergenerational Transfer of Intimate Partner Violence
• Popular Culture and Domestic Violence
• Post-Incest Syndrome
• Pregnancy-Related Violence
• Social Class and Domestic Violence
• Social Learning Theory and Family Violence
• Stockholm Syndrome in Battered Women
• Substance Use/Abuse and Intimate Partner Violence
• The Impact of Homelessness on Family Violence
• Victim-Blaming Theory

Read more about domestic violence theories .

Part 3: Research Paper Topics on

Cross-Cultural and Religious Perspectives on Domestic Violence

It was essential to acknowledge that domestic violence crosses cultural boundaries and religious affiliations. There is no one particular society or religious group exempt from victimization. A variety of developed and developing countries were examined in understanding the prevalence of domestic violence within their societies as well as their coping strategies in handling these volatile issues. It is often misunderstood that one religious group is more tolerant of family violence than another. As Christianity, Islam, and Judaism represent the three major religions of the world, their ideologies were explored in relation to the acceptance and prevalence of domestic violence.

• Africa: Domestic Violence and the Law
• Africa: The Criminal Justice System and the Problem of Domestic Violence in West Africa
• Asian Americans and Domestic Violence: Cultural Dimensions
• Child Abuse: A Global Perspective
• Christianity and Domestic Violence
• Cross-Cultural Examination of Domestic Violence in China and Pakistan
• Cross-Cultural Examination of Domestic Violence in Latin America
• Cross-Cultural Perspectives on Domestic Violence
• Cross-Cultural Perspectives on How to Deal with Batterers
• Dating Violence among African American Couples
• Domestic Violence among Native Americans
• Domestic Violence in African American Community
• Domestic Violence in Greece
• Domestic Violence in Rural Communities
• Domestic Violence in South Africa
• Domestic Violence in Spain
• Domestic Violence in Trinidad and Tobago
• Domestic Violence within the Jewish Community
• Human Rights, Refugee Laws, and Asylum Protection for People Fleeing Domestic Violence
• Introduction to Minorities and Families in America
• Medical Neglect Related to Religion and Culture
• Multicultural Programs for Domestic Batterers
• Qur’anic Perspectives on Wife Abuse
• Religious Attitudes toward Corporal Punishment
• Rule of Thumb
• Same-Sex Domestic Violence: Comparing Venezuela and the United States
• Worldwide Sociolegal Precedents Supporting Domestic Violence from Ancient to Modern Times

Part 4: Research Paper Topics on

Understudied Areas within Domestic Violence Research

Domestic violence has typically examined traditional relationships, such as husband–wife, boyfriend–girlfriend, and parent–child. Consequently, scholars have historically ignored non-traditional relationships. In fact, certain entries have limited cross-references based on the fact that there were limited, if any, scholarly publications on that topic. Only since the 1990s have scholars admitted that violence exists among lesbians and gay males. There are other ignored populations that are addressed within this encyclopedia including violence within military and police families, violence within pseudo-family environments, and violence against women and children with disabilities.

• Caregiver Violence against People with Disabilities
• Community Response to Gay and Lesbian Domestic Violence
• Compassionate Homicide and Spousal Violence
• Domestic Violence against Women with Disabilities
• Domestic Violence by Law Enforcement Officers
• Domestic Violence within Military Families
• Factors Influencing Reporting Behavior by Male Domestic Violence Victims
• Gay and Bisexual Male Domestic Violence
• Gender Socialization and Gay Male Domestic Violence
• Inmate Mothers: Treatment and Policy Implications
• Intimate Partner Violence and Mental Retardation
• Intimate Partner Violence in Queer, Transgender, and Bisexual Communities
• Lesbian Battering
• Male Victims of Domestic Violence and Reasons They Stay with Their Abusers
• Medicalization of Domestic Violence
• Police Attitudes and Behaviors toward Gay Domestic Violence
• Pseudo-Family Abuse
• Sexual Aggression Perpetrated by Females
• Sexual Orientation and Gender Identity: The Need for Education in Servicing Victims of Trauma

Part 5: Research Paper Topics on

Domestic Violence and the Law

The Violence against Women Act (VAWA) of 1994 helped pave domestic violence concerns into legislative matters. Historically, family violence was handled through informal measures often resulting in mishandling of cases. Through VAWA, victims were given the opportunity to have their cases legally remedied. This legitimized the separation of specialized domestic and family violence courts from criminal courts. The law has recognized that victims of domestic violence deserve recognition and resolution. Law enforcement agencies may be held civilly accountable for their actions in domestic violence incidents. Mandatory arrest policies have been initiated helping reduce discretionary power of police officers. Courts have also begun to focus on the offenders of domestic violence. Currently, there are batterer intervention programs and mediation programs available for offenders within certain jurisdictions. Its goals are to reduce the rate of recidivism among batterers.

• Battered Woman Syndrome as a Legal Defense in Cases of Spousal Homicide
• Batterer Intervention Programs
• Clemency for Battered Women
• Divorce, Child Custody, and Domestic Violence
• Domestic Violence Courts
• Electronic Monitoring of Abusers
• Expert Testimony in Domestic Violence Cases
• Judicial Perspectives on Domestic Violence
• Lautenberg Law
• Legal Issues for Battered Women
• Mandatory Arrest Policies
• Mediation in Domestic Violence
• Police Civil Liability in Domestic Violence Incidents
• Police Decision-Making Factors in Domestic Violence Cases
• Police Response to Domestic Violence Incidents
• Prosecution of Child Abuse and Neglect
• Protective and Restraining Orders
• Shelter Movement
• Training Practices for Law Enforcement in Domestic Violence Cases
• Violence against Women Act

Read more about Domestic Violence Law .

Part 6: Research Paper Topics on

Child Abuse and Elder Abuse

Scholars began to address child abuse over the last third of the twentieth century. It is now recognized that child abuse falls within a wide spectrum. In the past, it was based on visible bruises and scars. Today, researchers have acknowledged that psychological abuse, where there are no visible injuries, is just as damaging as its counterpart. One of the greatest controversies in child abuse literature is that of Munchausen by Proxy. Some scholars have recognized that it is a syndrome while others would deny a syndrome exists. Regardless of the term ‘‘syndrome,’’ Munchausen by Proxy does exist and needs to be further examined. Another form of violence that needs to be further examined is elder abuse. Elder abuse literature typically focused on abuse perpetrated by children and caregivers. With increased life expectancies, it is now understood that there is greater probability for violence among elderly intimate couples. Shelters and hospitals need to better understand this unique population in order to better serve its victims.

• Assessing the Risks of Elder Abuse
• Child Abuse and Juvenile Delinquency
• Child Abuse and Neglect in the United States: An Overview
• Child Maltreatment, Interviewing Suspected Victims of
• Child Neglect
• Child Sexual Abuse
• Children Witnessing Parental Violence
• Consequences of Elder Abuse
• Elder Abuse and Neglect: Training Issues for Professionals
• Elder Abuse by Intimate Partners
• Elder Abuse Perpetrated by Adult Children
• Filicide and Children with Disabilities
• Mothers Who Kill
• Munchausen by Proxy Syndrome
• Parental Abduction
• Postpartum Depression, Psychosis, and Infanticide
• Ritual Abuse–Torture in Families
• Shaken Baby Syndrome
• Sibling Abuse

Part 7: Research Paper Topics on

Special Topics  in Domestic Violence

Within this list, there are topics that may not fit clearly into one of the aforementioned categories. Therefore, they are be listed in a separate special topics designation. Analyzing Incidents of Domestic Violence: The National Incident-Based Reporting System

• Community Response to Domestic Violence
• Conflict Tactics Scales
• Dissociation in Domestic Violence, The Role of
• Domestic Homicide in Urban Centers: New York City
• Fatality Reviews in Cases of Adult Domestic Homicide and Suicide
• Female Suicide and Domestic Violence
• Healthcare Professionals’ Roles in Identifying and Responding to Domestic Violence
• Measuring Domestic Violence
• Neurological and Physiological Impact of Abuse
• Social, Economic, and Psychological Costs of Violence
• Stages of Leaving Abusive Relationships
• The Physical and Psychological Impact of Spousal Abuse

Domestic violence remains a relatively new field of study among social scientists but it is already a popular research paper subject within college and university students. Only within the past 4 decades have scholars recognized domestic violence as a social problem. Initially, domestic violence research focused on child abuse. Thereafter, researchers focused on wife abuse and used this concept interchangeably with domestic violence. Within the past 20 years, researchers have acknowledged that other forms of violent relationships exist, including dating violence, battered males, and gay domestic violence. Moreover, academicians have recognized a subcategory within the field of criminal justice: victimology (the scientific study of victims). Throughout the United States, colleges and universities have been creating victimology courses, and even more specifically, family violence and interpersonal violence courses.

The media have informed us that domestic violence is so commonplace that the public has unfortunately grown accustomed to reading and hearing about husbands killing their wives, mothers killing their children, or parents neglecting their children. While it is understood that these offenses take place, the explanations as to what factors contributed to them remain unclear. In order to prevent future violence, it is imperative to understand its roots. There is no one causal explanation for domestic violence; however, there are numerous factors which may help explain these unjustified acts of violence. Highly publicized cases such as the O.J. Simpson and Scott Peterson trials have shown the world that alleged murderers may not resemble the deranged sociopath depicted in horror films. Rather, they can be handsome, charming, and well-liked by society. In addition, court-centered programming on television continuously publicizes cases of violence within the home informing the public that we are potentially at risk by our caregivers and other loved ones. There is the case of the au pair Elizabeth Woodward convicted of shaking and killing Matthew Eappen, the child entrusted to her care. Some of the most highly publicized cases have also focused on mothers who kill. America was stunned as it heard the cases of Susan Smith and Andrea Yates. Both women were convicted of brutally killing their own children. Many asked how loving mothers could turn into cold-blooded killers.

Browse other criminal justice research topics .

Preventing Violence Against Women and Children: Workshop Summary (2011)

Chapter: 6 papers on research in preventing violence against women and children.

6 Papers on Research in Preventing Violence Against Women and Children

The science behind preventing violence against women and children has evolved greatly over the past several decades. Several speakers offered overviews of the research and described the growing awareness of the complexities of the causes, risk factors, and adverse effects of such violence. They also explored potential intervention points that were illuminated by this discussion.

The first paper is a reprint from the World Health Organization publication Preventing Intimate Partner and Sexual Violence Against Women (WHO and LSHTM, 2010b). The full report provides an overview of the magnitude of the issue; this workshop summary includes Chapter 3 , which is an in-depth analysis of preventive interventions in low- and middle-income countries and was the basis for Claudia García-Moreno’s presentation at the workshop.

The second paper is adapted from the International Men and Gender Equality Survey (IMAGES), a multi-country study that explored men’s perspectives on gender norms and violence. The survey examined the evolving views of men on gender equality as well as whether these views affected men’s sense of well-being and their commitment to reducing violence.

The third paper, by Claire Crooks from the University of Western Ontario and the Centre for Addiction and Mental Health, provides an overview of the intergenerational transmission of violence. It also explores the ways in which violence against children can have long-term impacts as well as what considerations are valuable in designing interventions to prevent child maltreatment.

The final two papers, from Roger Fallot and Julian Ford, explore secondary and tertiary prevention of the long-term effects of violence and associated trauma by including the “trauma lens” in the provision of social services as well as through the empowerment of individuals who are exposed to violence. Trauma-informed care and psychosocial empowerment are two means by which survivors of violence can overcome potential adverse outcomes and prevent the recurrence of violence.

PREVENTING INTIMATE PARTNER AND SEXUAL VIOLENCE AGAINST WOMEN: PRIMARY PREVENTION STRATEGIES 1

Intimate partner and sexual violence are not inevitable—their levels vary over time and between places because of a variety of social, cultural, economic, and other factors. This can result in substantial differences between and within countries in the prevalence of intimate partner and sexual violence (WHO and LSHTM, 2010a). Most importantly, this variation shows that such violence can be reduced through well-designed and effective programs and policies. There are important factors related to both perpetration and victimization—such as exposure to child maltreatment, witnessing parental violence, attitudes that are accepting of violence, and the harmful use of alcohol—that can be addressed (WHO and LSHTM, 2010c).

At present, evidence on the effectiveness of primary prevention strategies for intimate partner and sexual violence is limited, with the overwhelming majority of data derived from high-income countries (HICs)—primarily the United States. Consequently, current high priorities in this field include adapting effective programs from high-income to lower-income settings; further evaluating and refining those for which evidence is emerging; and developing and testing strategies that appear to have potential, especially for use in low-resource settings, with rigorous evaluation of their effectiveness. At the same time, the dearth of evidence in all countries means that the generating of evidence and the incorporation of well-designed outcome evaluation procedures into primary prevention programs are top priorities everywhere. This will help to ensure that the efforts made in this area are founded upon a solid evidence base. Furthermore, program developers should be encouraged to explicitly base programs on existing theoretical frameworks and models of behavior change to allow underlying mechanisms to be identified and to make replication easier. Most of the evaluated strategies aimed at preventing intimate partner and sexual violence have

________________

1 Reprinted from World Health Organization and London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: World Health Organization.

targeted proximal risk factors—primarily at the individual and relationship levels of the ecological model.

The Need for Upstream Action

In the public health framework, primary prevention means reducing the number of new instances of intimate partner and sexual violence by addressing the factors that make the first-time perpetration of such violence more likely to occur. Primary prevention therefore relies on identifying the “upstream” determinants and then taking action to address these. The impact of widespread, comprehensive programs can then be measured at the population level by comparing the rates at which such violence is either experienced or perpetrated. Given the lifetime prevalence of intimate partner and sexual violence, the hundreds of millions of women worldwide in need of services would outstrip the capacity of even the best-resourced countries (WHO and LSHTM, 2010a). A problem on this scale requires a major focus on primary prevention.

Upstream actions can target risk factors across all four levels of the ecological model. To decrease intimate partner and sexual violence at the population level, it is particularly important to address the societal or outer level of the model.

Such measures include national legislation and supportive policies aimed at social and economic factors—such as income levels, poverty and economic deprivation, patterns of male and female employment, and women’s access to health care, property, education, and political participation and representation. It is sometimes even argued that programs that aim to reduce intimate partner and sexual violence against women without increasing male–female equity will ultimately not succeed in reducing violence against women. However, while many strategies involving legal and educational reform and employment opportunities are being implemented to increase gender equality, few have been assessed for their impact on intimate partner and sexual violence, making the evaluation of such strategies a priority. Any comprehensive intimate partner and sexual violence prevention strategy must address these sociocultural and economic factors through legislative and policy changes and by implementing related programs.

Creating a Climate of Non-Tolerance

Addressing risk factors at the societal level may increase the likelihood of successful and sustainable reductions of intimate partner and sexual violence. For example, when the law allows husbands to physically discipline wives, implementing a program to prevent intimate partner violence may have little impact. National legislation and supportive policies should

therefore be put in place to ensure that women have equal rights to political participation, education, work, social security, and an adequate standard of living. They should also be able to enter freely into a marriage or to leave it, to obtain financial credit, and to own and administer property. Laws and policies that discriminate against women should be changed, and any new legislation and policies should be examined for their impact upon women and men. Legislation and policies that address wider socioeconomic inequalities are likely to reduce other forms of interpersonal violence, which will in turn help to reduce intimate partner and sexual violence.

Legislation and policies that address wider socioeconomic inequalities can make a vital contribution to empowering women and improving their status in society; to creating cultural shifts by changing the norms, attitudes, and beliefs that support intimate partner and sexual violence; and to creating a climate of non-tolerance for such violence.

The human rights of girls and women need to be respected, protected, and fulfilled as part of ensuring the well-being and rights of everyone in society. As a first step toward this, governments should honor their commitments in implementing the following international legislation and human rights instruments:

• Convention on the Elimination of All Forms of Discrimination Against Women (1979);
• The Convention on the Rights of the Child (1991);
• The Declaration on the Elimination of Violence Against Women (1993);
• The Beijing Declaration and Platform for Action (1995);
• The Millennium Declaration (2000); and
• The Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women (Convention of Belem do Para, 1994).

Legislation and criminal justice systems must also be in place to deal with cases of intimate partner and sexual violence after the event. These systems should aim to help prevent further violence, facilitate recovery, and ensure access to justice—for example, through the provision of specialized police units, restraining orders, and multi-agency sexual assault response teams. Potentially, legal protection against intimate partner and sexual violence helps to reinforce non-violent social norms by sending the message that such acts will not be tolerated. Measures to criminalize abuse by intimate partners and to broaden the definition of rape have been instrumental in bringing these issues out into the open and dispelling the notion that such violence is a private family matter. In this regard, they have been very important in shifting social norms (Heise and García-Moreno, 2002; Jewkes et

al., 2002). However, the evidence surrounding the deterrent value of arrest in cases of intimate partner violence shows that it may be no more effective in reducing violence than other police responses, such as issuing warnings or citations, providing counseling, or separating couples (Fagan and Browne, 1994; Garner et al., 1995). Some studies have also shown increased abuse following arrest, particularly for unemployed men and those living in impoverished areas (Fagan and Browne, 1994; Garner et al., 1995). Protective orders can be useful, but enforcement is uneven, and there is evidence that they have little effect on men with serious criminal records (Heise and García-Moreno, 2002). In cases of rape, reforms related to the admissibility of evidence and removing the requirement for victims’ accounts to be corroborated have also been useful but are ignored in many courts throughout the world (Du Mont and Parnis, 2000; Jewkes et al., 2002).

Currently, on the whole, sufficient evidence of the deterrent effect of criminal justice system responses on intimate partner and sexual violence is still lacking (Dahlberg and Butchart, 2005). Dismantling hierarchical constructions of masculinity and femininity predicated on the control of women and eliminating the structural factors that support inequalities are likely to make a significant contribution to preventing intimate partner and sexual violence. However, these are long-term goals. Strategies aimed at achieving these long-term objectives should be complemented by measures with more immediate effects that are informed by the evidence base presented in this paper.

ASSESSING THE EVIDENCE FOR DIFFERENT PREVENTION APPROACHES

From the perspective of public health, a fundamental question is, “Do intimate partner and sexual violence prevention programs work?” That is to say, are there certain programs or strategies that are effective in preventing or reducing intimate partner and sexual violence? Effectiveness can only be demonstrated using rigorous research designs, such as randomized controlled trials or quasi-experimental designs. These typically compare the outcomes of an experimental group (which receives the program) with a control or comparison group (which is as equivalent as possible to the experimental group but which does not receive the program). One major concern is to be able to rule out alternative explanations for any observed changes in outcome in order to be confident that the changes really were due to the program and not some other factor.

Although “testimonials” are not a sound basis for evaluating the effectiveness of a program, they can provide insights into its running and on whether participants find it worthwhile. However, approaches that are based upon testimonials might expend significant resources and capacity on

programs that may be ineffective or may even make things worse (Dahlberg and Butchart, 2005). Various criteria have now been proposed to more systematically evaluate the effectiveness of different programs. The most stringent criteria involve program evaluation using experimental or quasi-experimental designs; evidence of significant preventive effects; evidence of sustained effects; and the independent replication of outcomes.

In spite of the emphasis on and visibility of efforts to promote gender equality and prevent intimate partner and sexual violence, very few of the programs reviewed in this paper meet all of these criteria, while others have not been subjected to any kind of scientific evaluation. Rigorous scientific evaluation of programs for preventing intimate partner and sexual violence are even rarer in low- and middle-income countries (LMICs). The field of intimate partner and sexual violence prevention must therefore be considered to be at its earliest stages in terms of having an established evidence base for primary prevention strategies, programs, and policies. The limited evidence base for intimate partner and sexual violence prevention has three important implications for this paper.

First, the paper extrapolates, when relevant, from the stronger evidence base for child maltreatment and youth violence prevention but clearly signals that these extrapolations remain speculative. Much, however, can be learned from the literature on youth violence and child maltreatment prevention.

Second, the paper describes those primary prevention programs that have the potential to be effective either on the grounds of theory or knowledge of risk factors—even if there is currently little or no evidence to support them or where, in certain cases, they have not yet been widely implemented. In the process, an attempt is made to draw attention to the underlying theories, principles, and mechanisms on which the programs are based. However, it is noted that a firm theoretical base and consistency with identified risk factors do not guarantee the success of a program.

Third, the paper includes programs developed in LMIC settings on condition that they have some supporting evidence (even if it is weak) or are currently in the process of being evaluated, that they appear to have potential on theoretical grounds, or that they address known risk factors. The inclusion criteria are designed on the one hand to avoid setting the bar of methodological standards too high—which would lead to the exclusion of many of the programs developed in low-resource settings on the grounds that they have no or low-quality evidence supporting them. On the other hand, setting the bar too low would run the risk of appearing to endorse programs unsupported by evidence. However, the limitations of the evidence presented are clearly spelt out and the need for rigorous outcome evaluation studies emphasized.

Although still in its early stages, there are sound reasons to believe that this field is poised to expand rapidly in coming years. Some programs have been demonstrated to be effective following rigorous outcome evaluations, evidence is beginning to emerge to support the effectiveness of many more, and suggestions for potential strategies have proliferated. Furthermore, tried and tested methods for developing effective evidence-based primary prevention programs and policies for other forms of interpersonal violence have been reported. The field of evidence-based intimate partner and sexual violence prevention now requires an open mind to promising approaches and to innovative new ideas at all stages of the life cycle.

SUMMARY TABLES OF PRIMARY PREVENTION STRATEGIES AND PROGRAMS

Table 6-1 summarizes the strength of evidence for the effectiveness of those strategies to prevent intimate partner violence and sexual violence for which some evidence is available. Strategies are grouped according to life stage. An important distinction must be drawn between a strategy and a specific program. Although specific programs may have been demonstrated to be effective, this in no way implies that all other programs categorized under the same strategy are also effective. For example, the Nurse Family Partnership, developed in the United States, is a home-visitation program that has been demonstrated to be effective in preventing child maltreatment. Nevertheless, it is the only program within the broader strategy of home visitation (which includes a multitude of different programs) that is supported by solid evidence of its effectiveness (MacMillan et al., 2009). The outcome measures of effectiveness are described in Box 6-1 .

Strategies are ranked for their effectiveness in preventing intimate partner violence and sexual violence as follows:

• Effective: strategies that include one or more programs demonstrated to be effective. Effective refers to being supported by multiple well-designed studies showing prevention of perpetration and/or experience of intimate partner and/or sexual violence.
• Emerging evidence: strategies that include one or more programs for which evidence of effectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing positive changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence.
• Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence.
• Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence.
• Ineffective: strategies that include one or more programs shown to be ineffective. Ineffective refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence.
• Probably harmful: strategies that include at least one well-designed study showing an increase in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/or sexual violence.

As shown in Table 6-1 , there is currently only one strategy for the prevention of intimate partner violence that can be classified “effective” at preventing actual violence. This is the use of school-based programs to prevent violence within dating relationships. However, only three such programs—described below—have been demonstrated to be effective, and these findings cannot be extrapolated to other school-based programs using a different approach, content, or intensity. At present, there are no correspondingly evaluated effective programs against sexual violence.

TABLE 6-1 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence for Which Some Evidence Is Available

1—Effective: strategies that include one or more programs demonstrated to be effective; effective refers to being supported by multiple well-designed studies showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence;

2—Emerging evidence of effectiveness: strategies that include one or more programs for which evidence of effectiveness is emerging; emerging evidence refers to being supported by one well-designed study showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence or studies showing positive changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence;

3—Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence;

4—Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging; emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence;

5—Ineffective: strategies that include one or more programs shown to be ineffective; ineffective refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experiencing of intimate partner and/or sexual violence;

6—Probably harmful: strategies that include at least one well-designed study showing an increase in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/or sexual violence; N/A—Not applicable.

BOX 6-1 Outcome Measures of Effectiveness

The effectiveness of a program can be evaluated in terms of three different types of outcome—each of which can be measured at different intervals after the program:

• Changes in knowledge, attitudes, and beliefs regarding intimate partner and sexual violence. This is the weakest of the three outcomes because changes in knowledge, attitudes, and beliefs do not necessarily lead to changes in violent behavior. In this respect, even successful programs in this area cannot be assumed to be effective at preventing actual intimate partner or sexual violence without further research demonstrating corresponding reductions in violent behavior.
• Reductions in the perpetration of intimate partner or sexual violence.
• Reductions in the experience of intimate partner or sexual violence.

Intimate partner violence is not a unitary construct and can take different forms, including physical, sexual, and psychological violence. Despite this, outcome evaluations generally do not examine effectiveness in relation to these different types of violence—nor are programs generally designed to address specific types of intimate partner violence in particular. It is possible that programs considered to be effective or promising may only be so for certain forms of intimate partner violence (Whitaker et al., 2007a).

Table 6-2 lists those strategies for which there is currently no evidence or very weak evidence but that appear to have potential on the grounds of theory, known risk factors, or outcome evaluations that are methodologically of lower quality; it also includes some promising strategies that are currently undergoing evaluation.

All the strategies reviewed have been organized according to the main life stages. When strategies are relevant to more than one life stage, they have been categorized under the stage at which they are most often delivered. Strategies relevant to all life stages are described last. Because of the way programs are organized, intimate partner violence is considered here to include instances of sexual violence that occur within an intimate partnership, while sexual violence is used here to refer to sexual violence occurring outside intimate partnerships (i.e., perpetrated by friends, acquaintances, or strangers). Dating violence can be considered to incorporate both possibilities because dating partners can range from being little more than acquaintances to more intimate partners. However, in Table 6-1 and Table 6-2 dating violence is classified for the sake of convenience under intimate partner violence.

TABLE 6-2 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence with Potential

During Infancy, Childhood, and Early Adolescence

Home-visitation and parent-education programs to prevent child maltreatment.

As noted in earlier sections of this document, a history of child maltreatment substantially increases the risk of an individual becoming either a perpetrator or victim of intimate partner violence and of sexual violence. It is therefore reasonable to assume that preventing child maltreatment has the potential to reduce subsequent intimate partner and sexual violence (Foshee et al., 2009). However, direct evidence of the effect of such programs on the levels of intimate partner violence is currently still lacking.

In general, however, reducing the risk of the different forms of child maltreatment reviewed in Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence (WHO and International Society for Prevention of Child Abuse and Neglect, 2006) can contribute to reducing the intergenerational transmission of violence and abuse. The most promising strategies for preventing child maltreatment in this area include home-visitation and parent-education programs (Mikton and Butchart, 2009). However, neither type of program has been evaluated for its long-term effects on the prevention of intimate partner and sexual violence among the grown-up children of parents who were involved in such programs.

Improve Maternal Mental Health

Maternal depression (which affects at least 1 in 10 new mothers) can interfere with good bonding and attachment processes. This in turn

increases the risk of persistent conduct disorders in children (a key risk factor for the later perpetration of violence) by as much as five-fold (Meltzer et al., 2003). Effective approaches for addressing maternal depression include early recognition (antenatally and postnatally) followed by peer and social support, psychological therapies, and antidepressant medication (National Collaborating Centre for Mental Health, 2007). The long-term effects on the children of mothers treated for maternal depression in terms of their later involvement in intimate partner and sexual violence have not been assessed, but the approach appears to have potential.

Identify and Treat Conduct and Emotional Disorders in Children

Conduct disorders in childhood and adolescence—a precursor of antisocial personality disorder—are associated with an increased risk of experiencing and/or perpetrating intimate partner and sexual violence. Additionally, emotional disorders are associated with later depression and anxiety in adult years and can increase the risk of postnatal depression and persistent maternal depression. As outlined above, these in turn contribute to as much as a five-fold increased risk of emotional or conduct disorders in the children of mothers with poor mental health (Meltzer et al., 2003). The early identification and effective treatment of conduct and emotional disorders in childhood and adolescence could therefore be expected to reduce the occurrence of subsequent intimate partner and sexual violence.

Good evidence exists of the links between early conduct disorder and later involvement in violence as both victim and perpetrator and of the effectiveness of interventions to reduce conduct disorder and youth offending. However, despite their potential, there is at present no evidence showing that the strategy of identifying and treating conduct and emotional disorders in childhood or early adolescence leads to reductions in intimate partner and sexual violence during later adolescence and adulthood.

Interventions for Children and Adolescents Subjected to Child Maltreatment and/or Exposed to Intimate Partner Violence

Because children or adolescents who have been subjected to child maltreatment or exposed to parental violence are at increased risk of becoming the perpetrators and victims of intimate partner and sexual violence, interventions in this area are particularly important.

One meta-analysis examined 21 programs involving psychological interventions targeted at children and adolescents who had experienced child maltreatment (Skowron and Reinemann, 2005). Results suggested that psychological treatments for child maltreatment yielded improvements among participants: Some 71 percent of treated children appeared to be functioning

better than their non-treated counterparts. All of the interventions were designed to improve cognitive, emotional, and behavioral outcomes, with 11 of the studies considered to be experimental. A randomized trial of one of these programs used adolescent dating violence as an outcome and found a reduction in the experiencing and perpetration of physical and emotional abuse (Wolfe et al., 2003).

Psychological interventions for children and adolescents subjected to child maltreatment and/or exposed to intimate partner violence therefore appear to represent a strategy for the prevention of intimate partner violence supported by emerging evidence. Their effect on sexual violence remains unclear at present.

School-Based Social and Emotional Skills Development

Factors such as impulsiveness, lack of empathy, and poor social competence—which may be indicative of conduct disorder, a precursor of antisocial personality disorder—are important individual risk factors for perpetrating various forms of violence, including intimate partner and sexual violence. Cognitive-behavioral skills training programs and social development programs that address these factors in children and young adolescents are therefore promising strategies for preventing subsequent violence. These programs seek to promote pro-social behavior and to provide social and emotional skills such as problem solving, anger management, increased capacity for empathy, perspective taking, and non-violent conflict resolution. They can either be population-based or targeted at those at high risk and are typically delivered in schools. Although there is strong evidence that such programs can be effective in reducing youth violence and improving social skills, there is currently no evidence that they can reduce sexual and dating violence among adolescents and young adults or intimate partner and sexual violence later in life (Lösel and Beelmann, 2003). Nonetheless, they appear to have potential in preventing subsequent intimate partner violence and sexual violence.

School-Based Training to Help Children to Recognize and Avoid Potentially Sexually Abusive Situations

School-based programs to prevent child sexual abuse by teaching children to recognize and avoid potentially sexually abusive situations are run in many parts of the world, but evaluated examples come mainly from the United States. A recent systematic review of reviews found that although school-based programs to prevent child sexual abuse are effective at strengthening knowledge and protective behaviors against this type of abuse, evidence showing whether such programs reduce its actual

occurrence is lacking (Mikton and Butchart, 2009). Two studies that measured future experience of sexual abuse as an outcome reported mixed results (Finkelhor et al., 1995; Gibson and Leitemberg, 2000). Nonetheless, emerging evidence of their effectiveness in preventing subsequent sexual abuse victimization appears to support the use of such programs. Further research on the long-term impact on actual sexual abuse victimization is, however, required (Finkelhor, 2009).

Bullying Prevention Programs

Bullying has both immediate and long-term consequences on perpetrators and victims, including social isolation and the exacerbation of antisocial behavior that can lead to juvenile and adult crime (for perpetrators) and depression, suicidal ideation, social isolation, and low self-esteem (for victims). Some of these consequences may increase the risk of later involvement in intimate partner and/or sexual violence either as perpetrator or victim. A number of reviews have concluded that bullying prevention programs are effective in reducing bullying (Smith et al., 2004; Baldry and Farrington, 2007). A systematic review and meta-analysis of school-based programs to reduce bullying and victimization showed that, overall, school-based bullying prevention programs are effective in reducing both bullying and being bullied (Farrington and Ttofi, 2009). On average, bullying perpetration decreased by 20 to 23 percent and the experiencing of being bullied decreased by 17 to 20 percent.

Although such programs are likely to have broader potential benefits, evidence of their effect on the experiencing or perpetrating of intimate partner and/or sexual violence later in life is limited. A number of studies, however, have demonstrated an association between bullying and sexual harassment. Some sexual violence prevention programs in the United States include bullying prevention components for elementary- and middle-school-age children (Basile et al., 2009).

During Adolescence and Early Adulthood

School-based programs to prevent dating violence.

Dating violence is an early form of partner violence, occurring primarily in adolescence and early adulthood, and experienced within a “dating relationship.” Dating violence prevention programs have been the most evaluated of all intimate partner violence prevention programs, with 12 evaluations of adolescent dating violence prevention programs, including 5 randomized trials (Foshee et al., 2008). Targeted at early sexual relationships, in contexts where marriage is usually entered into from about 20

years of age, these programs have been shown to prevent dating violence and sexual violence. Furthermore, dating violence appears to be a risk factor for intimate partner violence later in life and is also associated with injuries and health-compromising behaviors, such as unsafe sex, substance abuse, and suicide attempts (Smith et al., 2003; Wolfe et al., 2009). Accordingly, the prevention of dating violence can be assumed to be preventive of intimate partner and sexual violence in later life (Foshee et al., 2009).

One dating violence prevention program that has been well evaluated using a randomized controlled design is Safe Dates. Positive effects were noted in all four published evaluations (Foshee et al., 1998, 2000, 2004, 2005). Foshee et al. (2005) examined the effects of Safe Dates in preventing or reducing perpetration and victimization over time using four waves of follow-up data. The program significantly reduced psychological, moderate physical, and sexual dating violence perpetration at all four follow-up periods. The program also significantly reduced severe physical dating abuse perpetration over time, but only for adolescents who reported no or average prior involvement in severe physical perpetration at baseline. Program effects on the experiencing of sexual dating violence over time were marginal. Safe Dates did not prevent or reduce the experiencing of psychological dating abuse. Program effects were primarily due to changes in dating violence norms, gender role norms, and awareness of community services. The program did not affect conflict-management skills. The program was found to have had a greater impact upon primary prevention as opposed to preventing re-abuse among those with a history of previous abuse (Foshee et al., 1996, 1998, 2000, 2004, 2008).

Two school-based programs for preventing dating violence in Ontario, Canada, have also been evaluated (Wolfe et al., 2003, 2009). An outcome evaluation of The Fourth R: Skills for Youth Relationships used a cluster-randomized design and found that, based on self-reported perpetration at 2.5-year follow-up, rates of physical dating violence were 7.4 percent in the program group and 9.8 percent in the control group—a difference of 2.4 percent. However, for reasons not fully understood, this decrease of self-reported perpetration was found in boys (7.1 percent in controls versus 2.7 percent in intervention students) but not in girls (12.1 percent versus 11.9 percent). The program—evaluated by sampling more than 1,700 hundred students aged 14 to 15 years from 20 public schools—was integrated into the existing health and physical education curriculum and taught in sex-segregated classes. An underlying theme of healthy, nonviolent relationship skills was woven throughout the 21 lessons, which included extensive skills development using graduated practice with peers to develop positive strategies for dealing with pressures and the resolution of conflict without abuse or violence. The cost of training and materials averaged 16 Canadian dollars per student (Wolfe et al., 2009).

The other Canadian school-based program that has been evaluated is the Youth Relationship Project (Wolfe et al., 2003). This community-based program aimed to help 14- to 16-year-olds who had been maltreated as children to develop healthy non-abusive relationships with dating partners. The program educated participants on both healthy and abusive relationships and helped them to acquire conflict resolution and communication skills. A randomized controlled trial showed that the program had been effective in reducing incidents of physical and emotional abuse and the symptoms of emotional distress over a 16-month period after the program (Wolfe et al., 2003). These three school-based programs therefore appear to be effective for the prevention of physical, sexual, and emotional violence in dating relationships in adolescents and may also help to prevent intimate partner and sexual violence among adults. However, there are a number of necessary caveats concerning dating violence prevention programs. Although high-quality evaluations of the three programs described above found reduced violence at moderately long follow-up periods, the evaluations of most other programs have been of poor quality, used short follow-up periods, and only included knowledge and attitude changes as outcomes (for which some positive effects were found). Whether changes in knowledge and attitudes lead to corresponding changes in behavior is uncertain (Whitaker et al., 2006). Moreover, further research is needed to evaluate the effectiveness of dating violence prevention programs in the longer term, when integrated with programs for the prevention of other forms of violence, and when delivered outside North America and in resource-poor settings. A particular concern that has been raised about programs such as Safe Dates is the extent to which they are culture-bound to North America and hence may be of limited value in LMICs.

School-Based Multi-Component Violence Prevention Programs

Universal multi-component programs are the most effective school-based violence prevention programs (Dusenbury et al., 1997; Adi et al., 2007; Hahn et al., 2007). Such programs are delivered to all pupils and go beyond the normal components of curriculum-based teaching to include teacher training in the management of behavior, parenting education, and peer mediation. There can also be after-school activities and/or community involvement. One systematic review estimated that, on average, universal multi-component programs reduced violence by 15 percent in schools that delivered the programs compared to those that did not (Hahn et al., 2007).

School-based multi-component violence prevention programs have mostly focused upon bullying and youth violence as outcomes. Given that the risk factors for youth violence and intimate partner and sexual violence are to some extent shared, such programs would appear to have some

potential for preventing these latter forms of violence. However, there is currently no evidence of their effectiveness in these areas.

Sexual Violence Prevention Programs for School and College Populations

In the United States, the majority of programs for the primary prevention of sexual violence by strangers, acquaintances, and non-intimate dating partners have focused on college students—though they have also increasingly been delivered to high school and middle school pupils. In settings where few go into higher education this approach has obvious limitations. Developmentally, it makes sense to educate young people in appropriate and inappropriate sexual behavior at a time when their sexual identities are forming and their attitudes to romantic partners are beginning to take shape. However, once again there is a severe paucity of evidence to confirm the effectiveness or otherwise of such programs (Schewe, 2007).

Two recent systematic reviews in the United States have evaluated the effectiveness of specific primary prevention programs in this area. The first of these included college, high-school, and middle-school populations and found that programs usually included several components (most often the challenging of rape myths, information on acquaintance and date rape, statistics on rape, and risk reduction and protective prevention skills) (Morrison et al., 2004). Of the 50 studies reviewed, 7 (14 percent) showed exclusively positive effects on knowledge and attitudes, but none used the actual experiencing or perpetration of violence as outcomes; 40 (80 percent) reported mixed effects; and 3 (6 percent) indicated no effect. The studies also had a number of serious methodological limitations that led the reviewers to conclude that the effectiveness of such programs remains unclear. These limitations included the use of knowledge and attitude as the only outcome measures, studies of higher-quality design showing poorer results, and the positive effects of the programs being found to diminish over time.

The second systematic review examined 69 education programs for college students on sexual assault and found little evidence of the effectiveness of such programs in preventing such assaults or in increasing levels of rape empathy (the cognitive–emotional recognition of a rape victim’s trauma) or awareness (Anderson and Whiston, 2005). However, the programs evaluated were found to increase factual knowledge about rape and to beneficially change attitudes toward it. The acute shortage of studies that use behavior as outcomes led the authors to conclude that more research using such outcomes was needed before definitive conclusions could be reached. The effectiveness of such programs, on the basis of these two reviews, is currently unclear. It has been found that the provision of “factual” information as part of addressing rape myths appears to have no effect on attitudes to rape or on the levels of empathy for its victims (Schewe, 2007).

Evaluation studies indicate that rape awareness and knowledge programs based on imparting such information rarely work. Similarly, educating women on effective self-defense strategies without teaching them actual self-defense skills has been found to be of questionable value and may even be potentially harmful in some contexts (Schewe, 2007). Two evaluations of programs that focused on a discussion of self-defense strategies without teaching the corresponding skills found no reduction in sexual assault risk at follow-up (Breitenbecher and Gidycz, 1998; Breitenbecher and Scarce, 2001). Rape prevention programs that use a style of personal confrontation with participants actually appear to be harmful. One study evaluating such a program found that it resulted in greater tolerance among men of the justifiability of rape (Fisher, 1986).

A number of other approaches have been tried for which there is presently very limited evidence of effectiveness. Encouraging victim empathy has been associated with both improvements and worsening of attitudes toward sexual violence and the acceptance of rape myths (Schewe, 2007). Educating women on how to avoid high-risk situations (such as hitchhiking, abusing alcohol, or becoming involved with older men) has also led to mixed results, and it too has been associated with greater acceptance of rape myths. To avoid the encouragement of victim-blaming, it is crucial that such education is delivered to female-only audiences. There have also been mixed indications of the effectiveness of programs that emphasize the negative consequences of sexual violence to men and that try to persuade them to see such sex as less rewarding than consensual sex.

Finally, several programs for preventing sexual violence have been proposed that have as yet been neither widely implemented nor evaluated. These include providing universal rape prevention education and parent education in sexual violence prevention throughout schools and workplaces, educating teachers and coaches about sexual violence and its prevention, and changing organizational practices to include activities such as mandatory training in the prevention of violence against women.

During Adulthood

Empowerment and participatory approaches to reduce gender inequality.

Empowerment is an approach that helps individuals and communities to identify their own problems and to develop, through participatory methods, the resources, skills, and confidence needed to address them. This approach emphasizes the role of individuals and communities as agents of change and prioritizes community ownership and leadership of the entire process. Comprehensive programs deal with the community as a whole or

with multiple subgroups of the population, have several components, and are designed to effect social change by creating a supportive environment for changing individual and community attitudes and behavior. Such approaches often utilize a combination of participatory rapid needs assessment, education or training, public awareness campaigns, and community action (Lankester, 1992).

Two examples of empowerment approaches for preventing intimate partner violence are the use of microfinance with gender-equality training and the Stepping Stones training package.

A number of initiatives involving microfinance have now been established to increase the economic and social power of women. These initiatives provide small loans to mobilize income-generating projects that can alleviate poverty. Stand-alone credit and rural development programs such as Grameen Bank and the Bangladesh Rural Advancement Committee target women and appear to show some promise in reducing intimate partner violence. However, the evaluation of such programs needs to take into account reports of lenders exploiting disadvantaged borrowers with very high rates of interest, which can trap people in debt and contribute to further poverty, as well as reports of increases in intimate partner violence (Kabeer, 2001; Rhyne, 2001). Disagreements over the control of newly acquired assets and earnings combined with women’s changing attitudes toward traditional gender roles, improved social support, and greater confidence in defending themselves against male authority has sometimes led to marital conflicts and violence against women perpetrated by their partners (Schuler et al., 1996). Increases in violence following participation in credit programs have also been reported elsewhere, at least in the initial stages of membership (Rahman, 1999; Ahmed, 2005). Pre-existing gender roles appear to affect the violence-related outcomes of credit programs—in communities with rigid gender roles, women’s involvement can result in increased levels of intimate partner violence not seen in communities with more flexible gender roles (Koenig et al., 2003). The outcome evaluations conducted to date of such stand-alone microfinance programs have not been as rigorous as that of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) program described in Box 6-2 .

Although microfinance programs can operate as discrete entities, IMAGE is an example of such a program that also incorporates education sessions and skills-building workshops to help change gender norms, improve communication in relationships, and empower women in other ways and has been shown to be effective at reducing intimate partner violence (Kim et al., 2009). Through education and skills building for women and engagement with boys and men and the broader community, IMAGE was effective in reducing intimate partner violence and supporting women. This was achieved without producing the type of negative effects seen in other

BOX 6-2 Intervention with Microfinance for AIDS and Gender Equity (IMAGE)

One of the most rigorously evaluated and successful microfinance and women’s empowerment programs to date has been the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in South Africa. This program targets women living in the poorest households in rural areas, and combines a microfinance program with training and skills-building sessions on preventing HIV infection, and on gender norms, cultural beliefs, communication, and intimate partner violence.

The program also encourages wider community participation to engage men and boys. It aims to improve women’s employment opportunities, increase their influence in household decisions and their ability to resolve marital conflicts, strengthen their social networks, and reduce HIV transmission.

A randomized controlled trial found that two years after completing the program, participants reported experiencing 55 percent fewer acts of violence by their intimate partners in the previous 12 months than did members of a control group. In addition, participants were more likely to disagree with statements that condone physical and sexual violence toward an intimate partner (52 percent of participants versus 36 percent of the control group).

settings where cultural shifts and other changes have taken place in the absence of efforts to engage men.

The Stepping Stones training package is another participatory approach that promotes communication and relationship skills within communities. Training sessions are run in parallel for single-sex groups of women and men. Originally designed for the prevention of HIV infection, several communities have now incorporated elements of violence prevention. The approach has been used in 40 LMICs in Africa, Asia, Europe, and Latin America. Versions of the program have now been evaluated in a number of countries (Welbourn, 2009). The most thorough evaluation to date has been a randomized controlled trial in the Eastern Cape province of South Africa, with participants aged 15 to 26 years. This study indicated that a lower proportion of men who had participated in the program committed physical or sexual intimate partner violence in the two years following the program compared with men in a control group (Jewkes et al., 2008).

Furthermore, an evaluation in Gambia compared two villages where the program was carried out with two control villages and followed participating couples over one year. It found that, compared to couples not receiving the program, communication was improved and quarrelling reduced in participating couples. In addition, participating men were found

to be more accepting of a wife’s refusal to have sex and less likely to beat her (Paine et al., 2002).

SASA! is an “activist kit” for mobilizing communities to prevent violence against women, focusing in particular on the connection between HIV/AIDS and violence against women. “Sasa” is a Kiswahili word meaning “now,” and the kit includes practical resources; activities-monitoring and assessment tools to support local activism, media, and advocacy activities; and communication and training materials. It targets community norms and traditional gender roles and aims to change knowledge, attitudes, skills, and behavior to redress the power imbalance between men and women. It was created by Raising Voices, a Uganda-based nongovernmental organization that works in the Horn of Africa and Southern Africa. The London School of Hygiene and Tropical Medicine, Raising Voices, the Kampala-based Center for Domestic Violence Prevention, and Makerere University are currently conducting a joint randomized controlled trial to evaluate the effectiveness of the approach.

Thus evidence is emerging of the effectiveness in LMICs of empowerment and participatory approaches in preventing intimate partner violence through microfinance combined with gender-equality training and through the Stepping Stones training package.

The results of the SASA! evaluation are expected to provide further evidence on the effectiveness of this type of program, which seems to have potential for reducing intimate partner violence. There is a need to replicate and scale up this type of approach. Several other participatory and community-empowerment strategies to prevent intimate partner violence may be of value, although these have seldom been implemented as primary prevention strategies or rigorously evaluated. Couples counseling focuses on violence and/or substance abuse and may be effective for couples who have not resorted to intimate partner violence but who may be at risk. Family programs to promote positive communication and healthy relationships and prevent family violence might also be effective in preventing both intimate partner and sexual violence, given the importance of family factors in their development. In Ecuador one intimate partner violence prevention program that was implemented (but not evaluated) consisted of close friends or relatives being assigned to “monitor” newlyweds and to intervene should serious conflict arise. There is also some initial evidence that social cohesion among residents increases a community’s capacity to manage crime and violence (by increasing “collective efficacy”), leading to decreases in both lethal and non-lethal intimate partner violence. Such community-level interventions can beneficially change community-level characteristics and warrant further evaluation.

Home Visitation Programs to Prevent Intimate Partner Violence

A systematic review of home visitation programs (Bilukha et al., 2005) identified only one evaluation study (Eckenrode et al., 2000) that examined the effect of home visitation on levels of intimate partner violence. No significant difference in the incidence of such violence among the program and control groups was found.

A five-year project (2007-2012) funded by U.S. Centers for Disease Control and Prevention is currently under way, which will develop, test, and evaluate a program to reduce intimate partner violence among low-income women enrolled in the Nurse Family Partnership during pregnancy and in the first two years postpartum. The Nurse Family Partnership is a nurse home visitation program of demonstrated effectiveness in reducing child maltreatment. The primary aims are to develop a model for an in-home intimate partner violence prevention program for enrolled mothers at risk of such violence, to test the feasibility and acceptability of the program, and in a randomized controlled study to compare the effectiveness of the approach to that of the Nurse Family Partnership alone.

An evaluation of the Hawaii Healthy Start Program—an early childhood home visitation program—found that when compared with a control group, the participation of mothers was associated with reduced perpetration and experiencing of intimate partner violence. The effect persisted for the first three years of a child’s life, with small decreases in both the perpetration and experiencing of maternal intimate partner violence at follow-up when the child was seven and nine years old (Bair-Merritt et al., 2010). Evidence for the effectiveness of such programs can currently thus be considered to be unclear.

U.S. Air Force Multi-Component Program to Prevent Suicide

This program was primarily aimed at reducing the rate of suicide among U.S. Air Force (USAF) personnel but was also shown to reduce “family violence,” which included both intimate partner violence and child maltreatment. The program was based upon:

• the full involvement of the USAF leadership to ensure the program had the support of the entire service;
• incorporation of suicide prevention into professional military education;
• community education and training of military personnel to identify risk factors, provide appropriate intervention, and refer individuals who were potentially at risk of suicide; and
• the creation of a multidisciplinary team consisting of mental health providers, medical providers, and chaplains who could respond to traumatic events at the community level, including suicides.

The program reduced the rate of suicide by 33 percent and the rates of severe and moderate family violence by 54 percent and 30 percent, respectively. Because of the combination of intimate partner violence and child maltreatment in the same outcome measure, it is not possible to determine the effect of the program on intimate partner violence specifically (Knox et al., 2003); hence this program is considered to have potential, rather than being supported by emerging evidence.

All Life Stages

Reduce access to and harmful use of alcohol.

Harmful use of alcohol is associated with the perpetration of intimate partner and sexual violence (WHO and LSHTM, 2010c). It can therefore be hypothesized that reducing both access to alcohol and its harmful use will lead to reductions in intimate partner and sexual violence. However, the relationship between harmful use of alcohol and violence is complex—not everyone who drinks is at equally increased risk of committing violence, and intimate partner and sexual violence can occur at high rates in cultures where alcohol use is taboo. Furthermore, there is disagreement among experts on whether or not alcohol can be considered to be a “cause” of intimate partner and sexual violence or whether it is better viewed as a moderating or contributory factor. It seems clear, however, that individual and societal beliefs that alcohol causes aggression can lead to violent behavior being expected when individuals are under the influence of alcohol and to alcohol being used to prepare for and excuse such violence. To date, research focusing on the prevention of alcohol-related intimate partner and sexual violence is scarce. There is, however, some emerging evidence suggesting that the following strategies aimed at reducing alcohol consumption may be effective in preventing intimate partner violence:

• Reducing alcohol availability: In Australia, a community intervention that included restricting the hours of sale of alcohol in one town reduced the number of domestic violence victims presenting to hospital (Douglas, 1998). In Greenland, a coupon-based alcohol rationing system implemented in the 1980s that entitled adults to alcohol equivalent to 72 beers per month saw a subsequent 58 percent reduction in the number of police call outs for domestic

quarrels (Finnish Foundation for Alcohol Studies and World Health Organization, 2003).

• Regulating alcohol prices: Increasing the price of alcohol is an effective means of reducing alcohol-related violence in general (Chaloupka et al., 2002). Although research evaluating the effectiveness of this approach in reducing intimate partner violence specifically is scarce, one study using economic modeling estimated that in the United States a 1 percent increase in the price of alcohol may decrease the probability of intimate partner violence toward women by about 5 percent (Markowitz, 2000).
• Treatment for alcohol-use disorders: In the United States, treatment for alcohol dependence among males significantly decreased husband-to-wife and wife-to-husband intimate partner violence 6 and 12 months later, suggesting that such treatment may also be an effective primary prevention measure (Stuart et al., 2003).

Intimate partner and sexual violence may also be reduced through primary prevention programs to reduce the more general harms caused by alcohol (Anderson et al., 2009). Approaches for which effectiveness is well supported by evidence include:

• Making alcohol less available: This can be achieved by introducing minimum purchase-age policies and reducing the density of alcohol retail outlets and the hours or days alcohol can be sold. Such an approach has been shown to lead to fewer alcohol-related problems, including homicide and assaults (Duailibi et al., 2007).
• Banning of alcohol advertising: Alcohol is marketed through increasingly sophisticated advertising in mainstream media; through the linking of alcohol brands to sports and cultural activities; through sponsorships and product placements; and through direct marketing via the Internet, podcasting, and mobile telephones. The strongest evidence for the link between alcohol advertising and consumption comes from longitudinal studies on the effects of various forms of alcohol marketing—including exposure to alcohol advertising in traditional media and promotion in the form of movie content and alcohol-branded merchandise—on the initiation of youth drinking and on riskier patterns of youth drinking (Anderson et al., 2009). However, evidence showing that such measures reduce intimate partner and sexual violence is currently lacking.
• Individually directed interventions to drinkers already at risk: These include screening and brief interventions. Alcohol screening and brief interventions in primary health care settings have

proven effective in reducing levels and intensity of consumption in LMICs and HICs (Finnish Foundation for Alcohol Studies and World Health Organization, 2003). However, their direct effect on alcohol-related intimate partner violence has not been measured. Evidence indicates that drinkers may reduce their consumption by as much as 20 percent following a brief intervention and that heavy drinkers who receive such an intervention are twice as likely to reduce their alcohol consumption as heavy drinkers who receive no intervention. Brief interventions include the opportune provision of advice and information in health or criminal justice settings (typically during a 5- to 10-minute period) but can also extend to several sessions of motivational interviewing or counseling (FPH, 2008; Sheehan, 2008).

School-based education on alcohol does not appear to reduce harm, but public-information and education programs (while again apparently ineffective at reducing alcohol-related harm) can increase the attention given to alcohol on public and political agendas (Anderson et al., 2009).

As with most primary prevention programs to prevent intimate partner and sexual violence, programs to reduce access to and harmful use of alcohol have mainly been conducted and evaluated in HICs, and little is known of their suitability or effectiveness outside such countries. For many LMICs, programs such as efforts to strengthen and expand the licensing of outlets could be of great value in reducing alcohol-related intimate partner and sexual violence. In many developing societies, a large proportion of alcohol production and sales currently takes place in unregulated informal markets. One study in São Paolo, Brazil, found that just 35 percent of alcohol outlets surveyed had a license of some form, and that alcohol vendors (whether licensed or not) faced few apparent restrictions on trading (Laranjeira and Hinkly, 2002). Furthermore, in many LMICs there are far fewer specialist health facilities, reducing the opportunities for alcohol treatment or screening. In such settings it may instead be beneficial to develop the role of primary health care workers or general practitioners in identifying and alleviating the harmful use of alcohol.

Although evidence for the effectiveness of measures to reduce access to and harmful use of alcohol is only beginning to emerge and high-quality studies showing their impact on intimate partner and sexual violence are still largely lacking, alcohol-related programs for the prevention of intimate partner violence and sexual violence appear promising. The strong association between alcohol and intimate partner and sexual violence suggests that primary prevention interventions to reduce the harm caused by alcohol could potentially be effective. Approaches to preventing alcohol-related intimate partner and sexual violence should also address the social acceptability of

excessive drinking as a mitigating factor in violence, while altering normative beliefs about masculinity and heavy drinking. There remains a pressing need for additional research to evaluate the effectiveness of such approaches in reducing intimate partner and sexual violence, especially in LMICs.

Change Social and Cultural Norms Related to Gender That Support Intimate Partner and Sexual Violence

Cultural and social gender norms are the rules or “expectations of behavior” that regulate the roles and relationships of men and women within a specific cultural or social group. Often unspoken, these norms define what is considered appropriate behavior, govern what is and is not acceptable, and shape the interactions between men and women. Individuals are discouraged from violating these norms through the threat of social disapproval or punishment or because of feelings of guilt and shame in contravening internalized norms of conduct. Often traditional social and cultural gender norms make women vulnerable to violence from intimate partners, place women and girls at increased risk of sexual violence, and condone or support the acceptability of violence ( Box 6-3 ).

Efforts to change social norms that support intimate partner and sexual violence are therefore a key element in the primary prevention of these

BOX 6-3 Examples of Social and Cultural Norms That Support Violence Against Women

• A man has a right to assert power over a woman and is considered socially superior. Examples: India (Mitra and Singh, 2007), Nigeria (Ilika, 2005), and Ghana (Amoakohene, 2004).
• A man has a right to physically discipline a woman for “incorrect” behavior. Examples: India (Go et al., 2003), Nigeria (Adegoke and Oladeji, 2008), and China (Liu and Chan, 1999).
• Physical violence is an acceptable way to resolve conflict in a relationship. Example: United States (Champion and Durant, 2001).
• Intimate partner violence is a “taboo” subject. Example: South Africa (Fox et al., 2007).
• Divorce is shameful. Example: Pakistan (Hussain and Khan, 2008).
• Sex is a man’s right in marriage. Example: Pakistan (Hussain and Khan, 2008).
• Sexual activity (including rape) is a marker of masculinity. Example: South Africa (Petersen et al., 2005).
• Girls are responsible for controlling a man’s sexual urges. Example: South Africa (Ilika, 2005; Petersen et al., 2005).

forms of violence. Approaches have been adopted, although rarely evaluated, throughout the world to break the silence that often surrounds intimate partner and sexual violence, to try to inform and influence social attitudes and social norms on the acceptability of violence, and to build political will to address the problem. The use of research findings for advocacy has been shown to be promising in bringing attention to, and raising awareness of, the problem and in contributing to the shaping of reforms and policies (Ellsberg et al., 1997). Currently the three main approaches for changing social and cultural norms that support intimate partner and sexual violence are social norms theory (i.e., correcting misperceptions that the use of such violence is a highly prevalent normative behavior among peers), media awareness campaigns, and working with men and boys. Often several approaches are used in one program.

Social norms theory assumes that people have mistaken perceptions of other people’s attitudes and behaviors. The prevalence of risk behaviors (such as heavy alcohol use or tolerance of violent behavior) is usually overestimated, while protective behaviors are normally underestimated. This affects individual behavior in two ways: (1) by increasing and justifying risk behaviors, and (2) by increasing the likelihood of an individual remaining silent about any discomfort caused by risky behaviors (thereby reinforcing social tolerance). The social norms approach seeks to rectify these misperceptions by generating a more realistic understanding of actual behavioral norms, thereby reducing risky behavior.

In the United States, the social norms approach has been applied to the problem of sexual violence among college students. Among such students, men appeared to underestimate both the importance most men and women place on sexual consent and the willingness of most men to intervene against sexual assault (Fabiano et al., 2003). Although the evidence is limited, some positive results have been reported. In one university in the United States, the A Man Respects a Woman project aimed to reduce the sexual assault of women, increase accurate perceptions of non-coercive sexual behavior norms, and reduce self-reported coercive behaviors by men. The project used a social norms marketing campaign targeting men, a theater presentation addressing socialization issues, and male peer-to-peer education. Evaluation of the campaign two years after its implementation found that men had more accurate perceptions of other men’s behavior and improved attitudes and beliefs regarding sexual abuse. For example, a decreased percentage of men believed that the average male student has sex when his partner is intoxicated; will not stop sexual activity when asked to if he is already sexually aroused; and, when wanting to touch someone sexually, tries and sees how they react. However, the percentage of men indicating that they have sex when their partner is intoxicated increased (Bruce, 2002).

Media awareness campaigns are a common approach to the primary prevention of intimate partner and sexual violence. Campaign goals might include raising public awareness (for example, about the extent of the problem, about intimate partner violence, and sexual violence as violations of women’s human rights and about men’s role in ending violence against women); providing accurate information; dispelling myths and stereotypes about intimate partner violence and sexual violence; and changing public opinion. Such campaigns have the potential to reach large numbers of people. An example of a media-awareness campaign is Soul City in South Africa. This multimedia health promotion and change project examines a variety of health and development issues, imparts information and aims to change social norms, attitudes, and practice. It is directed at individuals, communities, and the socio-political environment. One of its components aims to change the attitudes and norms that support intimate partner and sexual violence. This multi-level intervention was launched over six months and consisted of a series of television and radio broadcasts, print materials, and a helpline. In partnership with a national coalition on preventing intimate partner violence, an advocacy campaign was also directed at the national government with the aim of achieving implementation of the Domestic Violence Act of 1998. The strategy aimed for impact at multiple levels from individual knowledge, attitudes, self-efficacy, and behavior to community dialogue, shifting social norms, and the creating of an enabling legal and social environment for change. An independent evaluation of the program included national surveys before and after the intervention, focus groups, and in-depth interviews with target audience members and stakeholders at various levels. It found that the program had facilitated implementation of the Domestic Violence Act of 1998, had positively impacted on problematic social norms and beliefs (such as that intimate partner violence is a private matter), and had improved levels of knowledge of where to seek help. Attempts were also made to measure its impact on violent behavior, but there were insufficient data to determine this accurately (Usdin et al., 2005).

As the Soul City project indicates, evidence is emerging that media campaigns combined with other educational opportunities can change knowledge, attitudes, and beliefs related to intimate partner and sexual violence. Although good campaigns can increase knowledge and awareness, influence perceptions and attitudes, and foster political will for action, evidence of their effectiveness in changing behavior remains insufficient (Whitaker et al., 2007a).

Working with men and boys —There has been an increasing tendency to focus efforts to change social and cultural norms on adolescent males or younger boys using universal or targeted programs that are delivered

through a variety of mechanisms, including school-based initiatives, community mobilization, and public awareness campaigns.

Objectives typically include increasing an individual’s knowledge, changing attitudes toward gender norms and violence, and changing social norms around masculinity, power, gender, and violence. Some programs also aim to develop the capacity and confidence of boys and young men to speak up and intervene against violence, with the goal of changing the social climate in which it occurs (Katz, 2006). Failure to engage men and boys in prevention may result in the type of negative effects seen in some settings where cultural shifts and other changes have taken place in the absence of efforts to engage them ( Box 6-4 ).

BOX 6-4 Nicaraguan Backlash Shows the Need to Engage Men as Well

Since 2000, Nicaragua has pioneered a number of initiatives to protect women against domestic violence. These have included:

• a network of police stations for women (Comisaria de la Mujer) where women who have been abused can receive psychological, social, and legal support;
• a ministry for family affairs (Mi Familia), which among other responsibilities ensures that shelter is available to women and children who suffer domestic violence; and
• reform of the national reproductive health program to address gender and sexual abuse.

During the same period, civil society groups have campaigned to promote the rights of women and to empower them to oppose domestic abuse. Because of these efforts, the reported frequency of intimate partner violence and sexual violence against women has increased dramatically. The more advocacy and awareness, the more likely women will report violence against them. For example, the number of reported cases of sexual violence received by the Comisaria de la Mujer rose from 4,174 (January to June 2003) to 8,376 (January to June 2004).

Researchers at the Universidad Centro Americana and the Institute for Gender Studies say a number of factors explain this increase—growing awareness among women that the cultural traditions that foster violence are no longer acceptable under international law and the Nicaraguan Domestic Violence Law, and better reporting of cases as women are encouraged to speak out. However, as Nicaraguan women have more actively opposed male hegemony, domestic conflicts have also increased and more men have resorted to intimate partner violence. These findings suggest that responses to intimate partner violence must not focus exclusively on women, but must also target men to prevent this type of backlash (Schopper et al., 2006).

A review of programs that work with men and boys to prevent violence against women (Barker et al., 2007) included 13 primary prevention programs, 5 of which were implemented in LMICs. Four of these programs were judged by the reviewers to be “effective,” six “promising,” and three “unclear.” For example, one community outreach and mobilization campaign in Nicaragua judged to be effective was called Violence Against Women: A Disaster We Can Prevent as Men (Solórzano et al., 2000). This was aimed at men aged 20-39 years who were affected by Hurricane Mitch. The campaign’s main messages addressed men’s ability and responsibility to help prevent or reduce violence against their partners. Constructing masculinity without intimate partner violence was a group-education program aimed at men in periurban districts of Managua, Nicaragua (Welsh, 1997). The effect of the program was, however, unclear because of the weakness of the outcome evaluation.

Indeed, the methodological quality of most of the outcome evaluations was very low, and outcome measures consisted mainly of attitude changes and self-reported rates of gender-based violence, often using only small sample sizes. One campaign in New South Wales in Australia—Violence Against Women: It’s Against All the Rules—targeted 21- to 29-year-old men and aimed to influence their attitudes. Sports celebrities delivered the message that violence toward women is unacceptable and that a masculine man is not a violent man. It also sought to enhance the community’s capacity to challenge and address violence against women. A post-campaign survey indicated that the campaign achieved some positive results: 83 percent of the respondents reported that the message of the campaign was that violence against women is “not on,” and 59 percent of respondents could recall the campaign slogan. However, 91 percent of the target group reported that the issue was not one they would talk about with their peers, irrespective of the campaign.

Similarly, in the United States Men Can Stop Rape runs a public education campaign for men and boys with the message: “My strength is not for hurting.” This campaign runs in conjunction with Men of Strength (MOST) clubs—a primary prevention program that provides high-school-age young men with a structured and supportive space to learn about healthy masculinity and the redefining of male strength.

Although programs to alter cultural and social norms are among the most visible and ubiquitous of all strategies for preventing intimate partner and sexual violence, they remain one of the least evaluated. Even where evaluations have been undertaken, these have typically measured changes in attitudes and beliefs rather than in the occurrence of the violent behaviors themselves, making it difficult to draw firm conclusions on their effectiveness in actually preventing intimate partner and sexual violence. Nonetheless, some evidence is emerging to support the use of the three types of programs reviewed above in changing the social and cultural gender norms

that support intimate partner and sexual violence. However, these must now be taken to scale and more rigorously evaluated.

KEY MESSAGES

• To achieve change at the population level it is important to target societal-level factors in the primary prevention of intimate partner and sexual violence. Approaches include the enactment of legislation and the development of supporting policies that protect women, addressing discrimination against women, and helping to move the culture away from violence—thereby acting as a foundation for further prevention work.
• Currently, there are no strategies of demonstrated effectiveness for preventing sexual violence outside intimate partner or dating relationships. Only one strategy has been demonstrated to be effective in preventing intimate partner violence, namely school-based programs for adolescents to prevent violence within dating relationships—and this still needs to be assessed for use in resource-poor settings.
• Although it is too early to consider them proven, evidence is emerging of the effectiveness of several other strategies for the prevention of intimate partner and sexual violence, particularly the use of microfinance with gender equality training and of programs that promote communication and relationship skills within communities.
• Developing the evidence base for programs for the primary prevention of intimate partner and sexual violence is still very much in the early stages. But there is every reason to believe that rigorous outcome evaluations of existing programs and the development of new programs based on sound theory and known risk factors will lead to a rapid expansion in coming years.

INTERNATIONAL MEN AND GENDER EQUALITY SURVEY 2

Gary barker, juan manuel contreras, brian heilman, ajay singh, ravi verma, and marcos nascimento.

The International Men and Gender Equality Survey (IMAGES) is a comprehensive household questionnaire on men’s attitudes and practices—as well as women’s opinions and reports of men’s practices—on a wide

2 Adapted from: Barker, G., J. M. Contreras, B. Heilman, A. K. Singh, R. K. Verma, and M. Nascimento. 2011. Evolving men: Initial results from the International Men and Gender Equality Survey (IMAGES). Washington, DC: International Center for Research on Women.

variety of topics related to gender equality. From 2009 to 2010, household surveys were administered to more than 8,000 men and 3,500 women ages 18 to 59 in Brazil, Chile, Croatia, India, Mexico, and Rwanda. Topics in the questionnaire included gender-based violence, health and health-related practices, household division of labor, men’s participation in care-giving and as fathers, men’s and women’s attitudes about gender and gender-related policies, transactional sex, men’s reports of criminal behavior, and quality of life. This report focuses on the initial, comparative analysis of results from the men’s questionnaires across the six countries, with women’s reports on key variables.

Methodology

IMAGES followed standard procedures for carrying out representative household surveys in each participating city, with the exception of Rwanda, where the survey is a nationally representative household sample. The survey was carried out in one or more urban settings in each country (and rural and urban areas in Rwanda) with men and women ages 18 to 59, guided by the following parameters:

• The men’s questionnaire has approximately 250 items and took from 45 minutes to an hour to administer; the questionnaire for women is slightly shorter and took from 35 minutes to an hour to administer. The survey instruments were pretested in the participating countries, and the study protocol was approved by the institutional review board (IRB) of the International Center for Research on Women and by in-country IRBs, when such existed.
• The survey instrument was designed to be relevant for adult men and women in stable, co-habitating relationships as well as those not in a stable relationship; women and men who define themselves as heterosexual as well as men and women of different sexual orientations and practices; and women and men who have children in the household (biological or otherwise) and those who do not.
• Double-back translation of the questionnaire was carried out to ensure comparability and consistency of questions across settings. Some country-specific questions were included; some countries excluded items because of local political or cultural considerations.
• In Brazil, Chile, Mexico, and Rwanda the questionnaire was an interviewer-administered paper questionnaire. In India the questionnaire was carried out using hand-held computers, with a mixture of self-administered questions and interviewer-asked questions. In Croatia the questionnaire was self-administered (using a paper

questionnaire). Standard procedures were followed for ensuring anonymity and confidentiality.

• All research sites followed standard World Health Organization (WHO) practices for carrying out research on intimate partner violence in terms of offering referrals and information for services and special training of interviewers. Following these guidelines, men and women were not interviewed from the same household in any of the research sites.
• More sensitive questions were asked later in the questionnaire, and some key variables were included in multiple questions (to compare and thus be more informed in affirming validity). The questionnaire was pretested in all the settings prior to application.
• In all settings, male interviewers interviewed male respondents, and female interviewers interviewed female respondents, with the exception of Mexico, where some interviews with men were carried out by female interviewers (but only women interviewed women).
• Survey locations were chosen to represent different contexts in each country to achieve a mixture of major urban areas and a secondary city or cities. Within a survey location, neighborhoods or blocks were chosen based on population distributions from the most recent census data. Rural areas were included only in Rwanda and Croatia. Stratified random sampling and probability proportion to size sampling methods were used within each neighborhood or community to ensure the inclusion of adequate sample sizes by age and residence (and also socioeconomic status in the case of Chile).
• Although every participating country’s questionnaire included questions on all the themes that make up IMAGES, the questionnaire is not identical in all countries; thus data are not available from every country for every question. The questionnaire in Rwanda was the most abbreviated of the six study countries because of the much larger sample size—and thus the sheer number of interviews—required to make the study nationally representative. In those cases where Rwandan data does not appear in a table or figure in this document, that particular question was not included in the Rwandan questionnaire.

The questionnaire covers key topics in gender equality, including intimate relationships, family dynamics, and key health and social vulnerabilities for men. Based on previous research that found associations between early childhood exposure to violence and different gendered practices related to childrearing, items on childhood antecedents to particular men’s practices were included. Specific topics in the questionnaire include:

• Employment. Employment experience; unemployment and underemployment; stress and reactions associated with unemployment; reaction by spouse/partner when unemployed; income differentials between men and women; perceived gender dynamics in the workplace; work–life balance; and job satisfaction.
• Education. Educational attainment; perceived gender norms and patterns in school.
• Childhood experiences. Victimization by violence as children; witnessing of gender-based violence; gender-related attitudes perceived in family of origin; changes perceived from previous generation to the present; gender balance in work/child care in family of origin; gender patterns of childhood friendships.
• Relations at home (in current household). Marital/cohabitation status; division/participation in household chores; perceived satisfaction in family life; household decision making; time use in specific domestic chores and family care, including child care.
• Parenting and men’s relationships with their children (and with non-related children who may live in the household). Number of children; living situation of each child; time/money spent in care of each child; use of paternity/maternity leave; perceptions/attitudes toward existing parental leave in country; and child-care arrangements.
• Attitudes toward women and masculinity. Attitudes toward gender equality (using the Gender-Equitable Men [GEM] Scale and other measures); attitudes toward various gender-equality policies that may have been implemented in each country.
• Health and quality of life. Lifestyle questions (substance use, exercise, etc.); use of health services; sexual and reproductive behavior (contraceptive use, condom use); sexually transmitted infections, including HIV (past history, HIV testing); satisfaction with sexual relations; mental health issues (depression, suicide ideation); social support; use of/victimization by violence in other contexts; morbidity.
• Partner relations and spousal relations. Current relationship status/satisfaction; use of services/help-seeking in times of violence or relationship stress; relationship history.
• Relationship, gender-based violence, and transactional sex. Use of violence (physical, sexual, psychological) against partner (using WHO protocol); victimization of violence by partner (using WHO protocol); men’s use of sexual violence against non-partners; men’s self-reported purchasing of sex or paying for sex, including with underage individuals.
• Sexual behavior. Sexual experience; sexual orientation; behaviors related to sexual and reproductive health, HIV/AIDS; use of health services related to sexual and reproductive health.

Analytical Strategy

The report focuses on men’s attitudes and practices related to relationship dynamics, parenting and caregiving, health-related practices and vulnerabilities, violence (intimate partner violence and other forms), transactional sex, and attitudes toward existing gender equality policies. Women’s reports of men’s practices are included for some key variables.

The selection of questions in this initial data analysis was informed by previous research confirming the associations or impact of early childhood experiences, individually held gender-related attitudes, educational attainment, age (as a proxy of generational differences as well as developmental stage), social class (or income), and employment status and economic stress on women’s and men’s attitudes and practices in terms of their intimate relationships, their sexual practices, their use of violence, their domestic practices, and their health-seeking behaviors. Men’s knowledge of and attitudes toward key policy issues related to gender equality are also included. The report focuses on descriptive statistics and bi-variate analyses of the associations between these practices and educational levels, economic or work-related stress, gender-related attitudes, and age. In all cases where statistically significant differences are reported, these are at the p < .05 level as assessed using the Pearson’s chi-square test. As noted earlier, we also have an interest in understanding generational changes, or changes over time, in terms of men’s practices. IMAGES is not a longitudinal study; nonetheless, by comparing responses stratified by age groups we can make some inferences about generational change.

Key Findings

Work-related stress.

Work-related stress is commonplace in all survey sites. Between 34 percent and 88 percent of men in the survey sites reported feeling stress or depression because of not having enough income or enough work. Men who experienced work-related stress were more likely to report depression, suicide ideation, previous arrests, and use of violence against intimate partners.

Gender Attitudes

Men showed tremendous variation in their gender-related attitudes, with India and Rwanda showing the most inequitable attitudes. As a measure of men’s and women’s gender-related attitudes, IMAGES applied the GEM Scale. Rwandan and Indian men consistently supported the least

equitable norms among the settings studied. For example, for the statement “Changing diapers, giving kids a bath and feeding kids are the mother’s responsibility,” only 10 percent of men in Brazil agreed, whereas 61 percent in Rwanda and more than 80 percent in India agreed with the statement. Men with higher educational attainment and married men had more equitable attitudes; unmarried men had the least equitable attitudes. Homophobic attitudes were common, although they varied tremendously by context. Men who said they would be ashamed to have a gay son ranged from 43 percent of men in Brazil to a high of 92 percent in India. A slightly lower, but still high proportion of men said that being around homosexual men makes them uncomfortable, ranging from a low of 21 percent of men in Brazil to a high of 89 percent in India. Younger men and men with higher levels of education were generally less homophobic.

Relationship Dynamics and Domestic Duties

Younger men, men with more education, and men who saw their fathers do domestic work are more likely to carry out domestic duties. Nearly half of men in all the sites said they play an equal or greater role in one or more household duties—with the exception of India, where only 16 percent of men reported that they played an equal or greater role in household duties. These household or domestic duties included washing clothes, repairing the house, buying food, cleaning the house, cleaning the bathroom or toilet, preparing food, and paying the bills. The tasks that men said they play an equal or greater role in are those traditionally associated with men—namely repairing the house, paying bills, and buying groceries. Men reported higher levels of sexual and relationship satisfaction than women. Women who said their partners do more domestic work are more sexually satisfied. Men reported relatively high rates of sexual satisfaction with their current stable partners, ranging from 77 percent in Croatia to 98 percent in India. In all the countries except India, men who reported more gender-equitable attitudes were more likely to report being sexually satisfied with their current female partner. In India, Brazil, and Croatia, women who reported that their male partner plays an equal or greater role in one or more domestic duties also reported higher levels of overall relationship and sexual satisfaction.

Parenting and Involvement in Childbirth

The majority of men were neither in the delivery room nor in the hospital for the birth of their last child. In Chile, however, a dramatic generational shift is under way in men’s presence at childbirth. Younger Chilean men reported much greater rates of presence in the delivery room

for the birth of their last child than older men. This shift is largely due to a national policy, aimed at “humanizing” the birth process, which encourages women to have a male partner or other person of their choice present during birth at public maternity wards. Men are taking few days of paid or unpaid paternity leave. Among men who took leave, the average duration ranged from 3.36 to 11.49 days of paid leave and from 3.8 to 10 days of unpaid leave. Younger men and men with more education were more likely to take leave. Close to half of men with children said they are involved in some daily care-giving. Unemployed men are dramatically more likely to participate in the care of children than employed men. For men with children under age four, play is the most common daily activity in which they participate (as affirmed by women and men).

Health Practices and Vulnerabilities

Men’s rates of regular abuse of alcohol—defined as having five or more drinks in one night on a once monthly or greater basis—vary from 23 percent in India to 69 percent in Brazil and are significantly higher than women’s reported alcohol abuse in all survey sites. In most sites, younger men and men with more inequitable gender attitudes are more likely to regularly abuse alcohol. High proportions of women who reported having sought an abortion affirmed that a male partner was involved in the decision to seek an abortion (ranging from 39 percent to 92 percent). Men reported high self-esteem, with the exceptions of Croatia and India; at the same time, men showed relatively high levels of depression and suicide ideation. The rates of experiencing depression at least once in the past month ranged from 9 percent in Brazil to a high of 33 percent in Croatia. The percentages of male respondents who reported having suicidal thoughts “sometimes or often” in the past month ranged from 1 percent in Brazil and Mexico to 5 percent in Croatia.

Violence and Criminal Practices

Men reported lifetime rates of physical intimate partner violence ranging from 25 percent to 40 percent, with women reporting slightly higher rates. Factors associated with men’s use of violence were rigid gender attitudes, work stress, experiences of violence in childhood, and alcohol use. Men’s reports of perpetration of sexual violence against women and girls ranged from 6 percent to 29 percent; in India and Mexico the majority of sexual violence took place against a current or former partner. Relatively high percentages of men reported ever having participated in criminal or delinquent acts; between 6 percent and 29 percent of men reported ever having been arrested. In terms of factors associated with

men’s participation in criminal activity, men’s socioeconomic situation was the most significant. Men who owned firearms or carried out violence or criminal behavior were also more likely to report having used intimate partner violence.

Transactional Sex

Between 16 and 56 percent of men surveyed said they have paid for sex at least once. Men with lower educational attainment and less gender-equitable attitudes and men who reported less sexual satisfaction with their current partner were more likely to have paid for sex.

Knowledge and Attitudes About Policies and Laws Related to Gender Equality

Men in all the countries, with the exception of India, were generally supportive of gender equality, with 87 percent to 90 percent agreeing that “Men do not lose out when women’s rights are promoted.” Even when asked about specific policies—quotas for women in executive positions, in university enrollment, or in government—men’s support for such policies was reasonably high, with 40 percent to 74 percent of men supporting such quotas. Among themes related to gender equality, men reported the highest exposure to campaigns about gender-based violence. At the same time, across the sites, men showed negative attitudes toward laws related to gender-based violence.

Overall, IMAGES results affirm that gender equality should be promoted as a gain for women and men. Change seems to be happening as younger men and men with higher levels of education show more gender-equitable attitudes and practices. Men who reported more gender-equitable attitudes are more likely to be happy, to talk to their partners, and to have better sex lives. Women who reported that their partners participate in daily care work report higher levels of relationship and sexual satisfaction. Findings suggest that most men in most of the survey sites accept gender equality in the abstract even if they are not yet living it in their daily practices.

THE SCIENCE OF PREVENTION/ INTERRUPTING THE CYCLE OF VIOLENCE

Claire crooks, ph.d. centre for addiction and mental health, centre for prevention science and university of western ontario.

This summary describes what we know and, perhaps more importantly, what we don’t know about intervening in the cycle of violence. It encompasses both direct child abuse and exposure to domestic violence. First, the term cycle of violence is clarified, as it is a term that has been adopted into the everyday lexicon without much clarity of concept. Next is a review of some of the key findings from comprehensive review papers summarizing child abuse prevention. Finally, five gaps are identified that indicate possible future directions for research into primary prevention in this domain.

What Is the Cycle of Violence?

The cycle of violence is a phrase used to describe the observed intergenerational pattern by which many children and youth who experience direct or indirect exposure to violence later come to perpetrate violence in their own relationships. For example, children who experience child abuse and are exposed to domestic violence are at an elevated risk for perpetrating dating violence and domestic violence. Essentially, there is a continuity in their relationships such that problems with violence are evident in different ways at different times. Researchers tend to look at this cycle from different vantage points depending on their main areas of interest. Bullying researchers, for example, might note that children who bully others are more likely to perpetrate dating violence as adolescents. 3 Dating violence researchers might look at the continuity of violence between dating and adult intimate partner relationships. The investigation of direct and indirect exposure to violence has even been segmented, with child abuse researchers tending to focus on the former and domestic violence researchers tending to take on the latter. The result is a greatly segmented landscape, but one that can be pieced together to depict the cycle shown in Figure 6-1 .

3 Bullying prevention programs have been researched quite extensively and are outside the purview of this summary. Bullying/peer aggression was included in the cycle of violence figure as a reminder that children exposed to family violence have difficulties in multiple settings and often perpetrate or experience violence in relationships outside their families. A holistic approach to the impact of violence on children’s lives requires a commitment to beginning to piece together these formerly disparate areas of research.

FIGURE 6-1 Cycles of violence. SOURCE: Crooks, 2011.

It is crucial to understand that the cycle of violence is probabilistic, not determinative. That is, experiencing child abuse increases the risk for subsequently perpetrating violence in relationships, but there is significant variability in trajectories. There are a few important qualifiers for the cycle of violence idea, and they are discussed below.

Abusive Behavior Is Multiply Determined

There is no one pathway to abusive behavior. Rather, it is a final com mon pathway for a host of social, behavioral, biological, and personality risk factors. Results of a 20-year prospective study show that children’s direct and indirect exposure to violence are important risk factors for perpetration of abusive behavior (Ehrensaft et al., 2001). Furthermore, the risk for experiencing intimate partner violence as an adult (as a victim or perpetrator) increases with the number of types of abuse and additional stressors experienced as a child (Whitfield et al., 2003). At the same time, many children and youth who are abused do not become perpetrators of abuse with their own children. A review of studies suggested that approximately one-third became seriously inept, abusive, or neglectful as parents of their own children; an additional one-third remained at risk for perpetrating child abuse because of their vulnerability to social stress; while the remaining one-third were not abusive (Oliver, 1993).

Experiences of Abuse Show a Dosage Response

The Adverse Childhood Experiences (ACE) Study 4 carried out jointly by the Centers for Disease Control and Prevention and Kaiser Permanente has conclusively demonstrated a dosage effect for child maltreatment. This ongoing longitudinal study has been analyzing the relationships between multiple categories of childhood trauma and negative health and behavioral outcomes later in life. David Finkelhor’s work on poly-victimization is also instructive in identifying both the high frequency of poly-victimization and the relationship between multiple forms of abuse and poor outcomes for children (Finkelhor et al., 2009). Research with adolescents has docu mented this same relationship between multiple forms of abuse and the perpetration of violent delinquency as an adolescent, with each additional form of abuse translating to a 124 percent increase in the relative odds of engaging in violent delinquency (Crooks et al., 2007).

Co-Existing Adversities Increase the Likelihood of Negative Outcomes

Abuse affects different children differently. The ACE Study has documented the additive detrimental effects of experiences such as exposure to woman abuse, a parent with substance abuse or mental health problems, and incarceration of a parent. Low socioeconomic status can further compound difficulties for children who are experiencing child abuse. Conversely, access to protective factors (including at least one stable, nonviolent caregiver) can mitigate these impacts (Herrenkohl et al., 2008).

To summarize what we know about childhood experiences of abuse and exposure to domestic violence as a risk factor for perpetrating violence as an adolescent or adult, it is clear that childhood exposure to violence is a strong risk factor. However, there is still considerable variability among individual outcomes, and additional risk or protective factors can either exacerbate or mitigate the risk conferred by child abuse. Cumulative experiences of child abuse tend to lead to more negative outcomes, both in terms of perpetrating violence and a whole host of other negative social and physical health outcomes. The cycle of violence depicts the what of intergenerational transmission, but it does not explain the how or why. It is important to understand the cycle of violence in terms of how it works, because understanding the mechanisms underlying the intergenerational transmission of violence provides an important basis for understanding intervention opportunities.

4 Results of the study are available at http://www.cdc.gov/ace/index.htm .

How Does the Cycle of Violence Work?

At a superficial level, the intergenerational transmission of violence seems counterintuitive—if someone knows how devastating it is to be abused as a child, how can he or she turn around and do the same thing as a parent? The answer lies in understanding the impact of child abuse on a developing child and understanding how experiences of child direct and indirect exposure to violence change how an individual sees the world and others around him or her. This understanding also explains why child exposure to violence is not something that a person can just “get over.” Three particularly useful frameworks and theories for explaining the intergenerational cycle of violence are attachment, social learning theory, and trauma.

The Role of Attachment

Attachment refers to the quality of the relationship that develops between an infant and his or her primary caregiver(s) (Bowlby, 1980, 1990). Secure attachment emerges within the context of responsive caregiving. The extent to which an infant is fed when she is hungry, changed when she is wet and uncomfortable, and soothed when she is upset or afraid provides a basis for secure attachment. This first relationship becomes a template for future relationships and organizes the way an infant comes to see the world: Is it a safe and predictable place or a scary and bizarrely unpredictable one? Decades of research demonstrate that when attachment develops in a disorganized manner, an individual is at risk for ongoing difficulties in relationships with others. Child abuse and attachment are connected in a number of ways, including the development of attachment, the impacts of abuse, and the later perpetration of abuse (Bacon and Richardson, 2001). Experiences of direct and indirect child exposure to violence undermine the potential for secure attachment and provide an early experience of relationships as dangerous and unpredictable.

Although attachment is most often discussed in the context of parent–infant relationships, it continues to play an important role throughout a youth’s development. Recent longitudinal research demonstrated that youth dually exposed to direct and indirect violence (i.e., child abuse and exposure to domestic violence) were less attached to their parents in adolescence than those who experienced only direct or only indirect exposure (Sousa et al., 2011). Furthermore, attachment to parents during adolescence played an important protective role against antisocial behavior, independent of abuse status.

Social Learning Theory

Social learning theory is a well-established paradigm that highlights the importance of reinforcement for promoting certain behavioral responses and inhibiting others (Bandura, 1977, 1986). Furthermore, our experi ences with behavior and reinforcement come to shape our attitudes and attributions. One of the key tenets of social learning theory is that humans learn very well from modeling, that is, from what they see others do. This modeling is not indiscriminate. Children do not copy everything around them, but they copy what they see that works. When they are exposed directly and indirectly to violence, they learn harsh but effective lessons about power and may come to see the world as made up of victims and victimizers (Dodge et al., 1994). Given such a dichotomy, they may begin to model after the victimizer to avoid further abuse. These children develop a hostile attribution bias , which is a cognitive framework for expecting the worse, even in threat-neutral situations (Fontaine, 2010). As a result, these children seem hostile and aggressive to their peers, and may be rejected by their more pro-social peers (Dodge et al., 1990). There is some evidence that exposure to family violence is a bigger contributor to later pro-violence attitudes (such as comfort with aggression, aggressive responses to shame, excitement about guns, and violence as means of preserving power) than violence experienced in the school or community (Slovak et al., 2007). In addition to underscoring the importance of what children learn, social learning theory would also draw attention to what these children do not learn, namely, egalitarian relationships, non-violent approaches to conflict resolution, and emotional regulation skills.

A third perspective that has been explored for understanding the cycle of violence is the trauma perspective. Based on his work with adolescent boys who have perpetrated lethal violence, James Garbarino has identified a process which he refers to as “hibernation of the soul” (Garbarino, 1999). Essentially, under conditions of severe, early, and chronic violence, these children may come to suppress their more humane aspects as a survival mechanism. The detachment from emotion and compassion that allows a person to survive chronic abuse is the same detachment that facilitates perpetration of severe violence without apparent remorse. Even in less extreme cases of trauma, the dysregulation of anger and arousal that develop create potent risk factors for the intergenerational transmission of violence. A significant literature has emerged to support these processes from a neurobiological perspective, which demonstrates that over-activation of the fight or flight response can result in a weak foundation for the development

of emotional regulation and self-soothing (van der Kolk and Greenberg, 1987).

In considering these three frameworks for understanding the cycle of violence—attachment, social learning, and trauma—it is evident that there are no quick fixes for breaking this cycle. Child abuse does not arise because of a lack of discipline; consequently, get-tough approaches with parents will not redress the risks. Similarly, it does not arise merely from a lack of parental support; as such, increasing support without targeting the underlying causes will not be very successful in preventing and reducing a child’s direct and indirect exposure.

What Programs Are Effective or Promising?

In efforts to prevent child abuse and exposure to domestic violence, there are a number of points for possible intervention. Prevention in other areas is often divided into universal (or primary), selective (or secondary), and indicated (or tertiary). However, an argument can be made that using this type of classification locates the abuse with the victim and pathologizes the experience of abuse. Macmillan and colleagues have proposed an alternative schema for identifying intervention points, presented in Figure 6-2 (Macmillan et al., 2009). With this approach it is clear that one can work to prevent abuse before it occurs, to prevent abuse from recurring, and to prevent impairment following abuse. Each of these targets is necessary in a comprehensive approach, and different strategies will be effective at different points.

FIGURE 6-2 Intervention to prevent child maltreatment and associated impairment. SOURCE: Macmillan et al., 2009.

Comprehensive reviews to identify what works to prevent child abuse or recurrence of child abuse follow one of two basic approaches. The first approach is to look across all previous summaries and reviews and amalgamate all of the existing evidence (Mikton and Butchart, 2009). This approach provides a somewhat bleak picture, because when studies are combined, results are generally mixed or disappointing. However, such an approach can be misleading because it includes studies that vary greatly in quality both in terms of the intervention and the research design. By contrast, the review by MacMillan and colleagues looks at high-quality programs that have shown good effects under reasonable research conditions but perhaps have yet to be replicated (Macmillan et al., 2009). Reviewing the existing studies in these two ways finds three approaches that can be considered effective or promising. Additional approaches may improve protective factors or reduce risk factors, but these three are the only ones that have been shown to prevent the occurrence or recurrence of abuse.

Home Visitation

Home visitation is the most effective child maltreatment prevention program to date (Macmillan et al., 2009). There is considerable variability in home-visiting interventions in terms of their models, service delivery, and home staffing. Two models, the Nurse-Family Partnership and the Early Start program, have been shown to be effective in reducing some indicators of child abuse. However, effects have not been uniform across other approaches to home visiting, and there are a few caveats for the success of home visiting. First, most of what we know is based on David Olds’ pioneering work, and efforts to replicate his work have had mixed success. Second, home visitation has proved to be more effective when carried out by nurses than by paraprofessionals. Third, it may be more effective with certain types of families (such as first-time mothers) than others (Macmillan et al., 2009). Finally, the presence of domestic violence may undermine the effectiveness of home visiting. In the Elmira Home Visiting study the intervention reduced reports of child maltreatment, but not for families with mothers reporting more than 28 incidents of domestic violence (Eckenrode et al., 2000).

Parent Training and Education

The results for parent training and education in general are mixed, but there are two programs that have evidence supporting their use. First, the Positive Parenting Program (Triple P) has shown promise in one study for preventing abuse, and replication is currently under way. The Triple P uses multiple levels of social learning–based programs to meet the needs of different families and offers five levels of intervention with increasing intensity

to match higher-needs families (Prinz et al., 2009). Mark Chaffin and colleagues’ work on Parent–Child Interaction Training has also been very promising in that it has been shown effective in lowering recurrence of physical child abuse (Chaffin et al., 2004). Parent–Child Interaction Training uses behavioral conditioning principles and provides immediate and detailed feedback for parents in their interactions with their children. It has been shown to both increase positive interactions and decrease recurrence of child abuse. Both of these programs warrant further investigation, particularly with larger samples of fathers, as most research has focused on mothers.

Educational Prevention of Abusive Head Trauma

The final effective strategy to date is education aimed at preventing abusive head injury (also known as shaken baby syndrome). Offered mainly through hospitals, this education offers normative information about babies’ crying, coping strategies for parents, and the impacts of shaking an infant. There is a one study to date that found that the introduction of this program lowered the rates of abusive head trauma (Dias et al., 2005). Additional trials are under way. This program appears to be a cost-effective way to reduce one specific type of child abuse.

Interventions Lacking Empirical Evidence

Consistent with the general move to positive psychology, there has been much interest in interventions that build on parents’ strengths. Many of these approaches use a mentoring or mutual support model of parents helping other parents in a way to normalize intervention and build informal support networks. The general benefits of mentoring and of encouraging strong social networks are widely accepted, but these approaches have not been found effective in the prevention of child exposure to direct or indirect violence (Macmillan et al., 2009). It is critical to recognize the distinction. A parenting program may increase parents’ satisfaction with parenting, improve their social connections, and even lead to more positive attitudes and skills, and yet it may not reduce direct child abuse or exposure to domestic violence. If a program is being espoused as a child abuse prevention program, then the research must look at child abuse outcomes and not rely on proxies or interpret the promotion of positive parenting attitudes and skills as synonymous with the prevention of abuse.

Preventing Child Exposure to Direct and Indirect Violence: The Big Picture

A review of the state of the science of child abuse prevention reveals a number of basic facts. First, there are some effective and promising

interventions, but even these have limited evidence compared to many other areas of social and medical science. Second, it obscures the picture to collapse evidence across types of intervention (e.g., with meta-analytic techniques) with no consideration for the quality or features of the program. Quality of implementation matters, training of implementers matters, and matching the intervention to the risk level of the families matters. Third, at this point there is little available evidence concerning programs that are effective for preventing emotional abuse. Finally, there have not been any trials on programs to reduce exposure to domestic violence. Community-based approaches to preventing domestic violence have not been well researched, and there are no studies evaluating strategies for preventing exposure when domestic violence is occurring. On a more hopeful note, there are many innovative interventions in varying degrees of development and evaluation. It takes a long time to reach the point where a randomized controlled trial or multi-site replication is feasible.

Gaps and Challenges

A review of the state of the research shows clearly that while we have an emerging idea of effective practice in some specific areas, there are still many gaps. Below are five gaps in research and practice.

Where Are the Dads?

Much research has focused exclusively on mothers or not included enough fathers for useful subgroup analysis. This lack of representation in research mirrors the child protection policies and practices, which tend to focus on mothers and view fathers as either dangerous or irrelevant. The reality is that men who have perpetrated violence often remain part of their children’s lives and require specific and intentional strategies to change attitudes and beliefs that support their abusive behavior, particularly when these men have also abused the children’s mothers (Scott and Crooks, 2004). Furthermore, there is a dearth of programs that both address the gendered nature of violence and address men’s abuse of their intimate partners and children concurrently. The Fathering After Violence initiative 5 for men who have been abusive to intimate partners and the Caring Dads program 6 for men who have been abusive to their partners and their children are exceptions to the rule.

5 See http://endabuse.org/section/programs/children_families/_breaking_cycle .

6 See http://www.caringdadsprogram.com .

Is Stopping the Violence Enough for Positive Child Outcomes?

When we look for successful outcomes in research, we often use the idea of recidivism or repeat violence as a sign of failure, but the corollary to that is that success is equated with no further violence. The reality is that, in the life of a child who has been victimized, just stopping the violence might not be good enough. There has been some discussion about restorative parenting and applying restorative justice models to the parent–child relationship, but we do not actually have a good sense yet about what that looks like or the implications for the child. Some work has been done in this area of child sexual abuse, but very little has been carried out that looks at father–child relationship restoration after domestic violence. There is a significant need to develop and evaluate protocols for deciding when it is safe to restore parent–child relationships post-violence and how this can be achieved with minimal risk to children.

Compartmentalization of Efforts

There have been some big strides in breaking down silos between types of abuse since the “Greenbook” was published as a model for collaboration between child protection and domestic violence sectors (Schecter and Edleson, 1999), but there is still too much compartmentalization within fields. Often researchers emphasize one type of abuse without looking at the complexities of poly-victimization or, what is even trickier, the co-occurrence of perpetration and victimization. For example, most research and programming for children exposed to domestic violence still does not inquire about the direct victimization experience of the children, particularly for abuse perpetrated by the victim parent. There are philosophical and practical reasons for these practices, but they hinder a fuller understanding and more effective response to children.

What Do Culturally Relevant Programs Look Like?

Virtually every paper or chapter ends with a plea for more culturally diverse and appropriate services, yet we have only scratched the surface in exploring what this really means. Is it merely resources translated into different languages? Is it trained therapists from the same ethnic or cultural background as the families? Is it program manuals that have different faces on them? It can be argued that we need to go much further than these superficial changes and that we have not done a good job of documenting or evaluating these processes of cultural adaptation. The challenge for cultural adaptation is further complicated when we look at implementing promising practices on a global scale, particularly in countries with less developed child protection or mental health systems.

What Is an Effective Specialized Response in the Highest Risk Cases?

Finally, for the most high-risk families, there is a complexity in terms of system involvement and information sharing that can only be addressed by collaboration across systems. Any comprehensive approach to preventing violence against children requires specialized responses that can be activated in the most high-risk cases. With the advent of domestic violence homicide review committees, a clearer picture of the risk factors for lethality to women and their children is emerging (Jaffe et al., 2003; Campbell, 2005; Jaffe and Juodis, 2006). In these cases, home visiting and parent education are not sufficient or appropriate for the degree of risk. In addition to developing clinical interventions for a wide range of families, we need to develop specialized collaborative protocols for the highest-risk cases.

In closing, although reviews that combine all interventions of a certain type tell a disheartening story, there are some bright spots in our search for effective interventions. Home visiting, parent education and training, and education approaches to abusive head trauma have all shown promise and a solid degree of evidence. The science is at the point where we know enough to know that there are no easy answers and no quick fixes. Different families need different types of support and intervention at different points in time, and we need to develop a comprehensive and coordinated system of care to ensure that no children fall between the cracks. It is a colossal task, but a vital one, because at the end of the day our children need to be safe from abuse and violence to develop to their full potential and grow into the type of adults who will contribute to a compassionate and productive society.

TRAUMA-INFORMED CARE: A VALUES-BASED CONTEXT FOR PSYCHOSOCIAL EMPOWERMENT

Roger d. fallot, ph.d. community connections.

We make a fundamental distinction between trauma-informed care and trauma-specific services (Harris and Fallot, 2001). Psychosocially empowering, trauma-specific interventions take as their primary goals ameliorating trauma-related difficulties and facilitating trauma recovery and healing. The Trauma Recovery and Empowerment Model, Seeking Safety, Trauma Affect Regulation: Guide for Education and Therapy (TARGET), the Boston Consortium Model, and Beyond Trauma, among others, are manualized approaches to helping women (and sometimes men as well) develop the skills necessary to cope more effectively with the impact of violence and abuse and to avoid revictimization (Harris, 1998; Najavits, 2002;

Covington, 2003; Ford and Russo, 2006; van Lier et al., 2009; Amaro, 2011). These interventions and many individual ones that focus primarily on post-traumatic stress disorder, such as exposure therapy, cognitive processing therapy, and other cognitive-behavioral approaches (e.g., Mueser et al., 2008), are an important component of trauma-informed care (Resick et al., 2008; Powers et al., 2010).

However, “cultures of trauma-informed care” refer to the programmatic, organizational, and community contexts that are necessary and valuable in supporting survivors and the staff who serve them. Any setting can be trauma-informed when it takes fully into account what we know about trauma, its impact, and the diverse, individualized paths to trauma recovery. In this way, not only behavioral health care settings but also primary care institutions, schools, and even correctional facilities can be trauma-informed. When an organizational culture becomes trauma-informed, it becomes more welcoming and hospitable for trauma survivors (as well as the rare individual who does not have a history of exposure to violence); it minimizes the possibility of revictimization; it indirectly facilitates healing, recovery, and empowerment; and it builds collaborations throughout the service system.

Trauma-informed care is important for a number of reasons:

• Trauma and, in particular, violent victimization are pervasive.
• The impact of trauma is broad, extending well beyond the post-traumatic stress disorders frequently perceived to be the most common outcome.
• The impact of trauma is often deep and life-shaping.
• Trauma, especially caused by interpersonal violence, is often self-perpetuating.
• Violence is even more common in the lives of those who are socially and politically vulnerable, including the poor, many racial and ethnic minorities, women and children, those diagnosed with mental health or substance abuse problems, and people who are developmentally disabled.
• Trauma affects the way people approach the human service setting, heightening fear and suspiciousness.
• The service system itself has too often been retraumatizing.

Retraumatization in the behavioral health care setting is one of the experiences that originally fueled awareness of the need for trauma-informed care (Jennings, 1998). Two types of retraumatization are noteworthy. First are the many ways in which traumagenic dynamics may be replicated in service provision. Examples include providers’ lack of interest in traumatic violence or their disbelief of individuals’ reports of violent victimization; both of these patterns may replicate earlier experiences, in which signs and

reports of violence were minimized or denied. Coercive approaches involving involuntary medication and hospitalization are still too common in many settings. And the presumption of incompetence (e.g., the inability to handle one’s own finances) may be a part of standard operating procedure in many programs, a visible reminder of the ways in which survivors’ skills are overlooked.

Second are instances of “sanctuary harm” (Robins et al., 2005). Consumers surveyed about their experiences in behavioral health care settings report violence and the fear of violence (including physical restraint and seclusion) as well as negative interactions with staff involving disrespect and humiliation. Taken as a whole, then, it is not surprising that one prominent psychiatrist has written that the past 30 years has evinced a continuing story of “destroying sanctuary” in the human services system (Bloom and Farragher, 2010).

As a counter to this destructive organizational culture, we have developed a model of trauma-informed care that builds on core values of safety, trustworthiness, choice, collaboration, and empowerment (Fallot and Harris, 2008, 2009). These values are key antidotes to the toxic effects of violence in the lives of consumers and staff members in human service delivery settings. For those who have been exposed to violence repeatedly and unpredictably, physical and emotional safety is a high priority. For those individuals affected by violence perpetrated by those who were supposed to be family or institutional caretakers, trustworthiness is a high priority. For those whose sense of voice and control has been attenuated by violent victimization, choice is a high priority. For those who have experienced the world as consistently arrayed in one-up, one-down relationships in which they have been the one down, the realistic offer to share power in a collaborative way is a high priority. And for those who have felt powerless to do anything about these other realities, empowerment is a high priority.

As a change in organizational culture, then, trauma-informed care extends far beyond any new service; it involves the physical setting, each contact, each activity, and each relationship in the organization. It extends beyond the training of clinical staff by engaging with all staff (including administrators, service staff, and support staff) and, importantly, all consumers to direct and monitor this change. Finally, trauma-informed care represents an opportunity to make these values into a routine part of the setting; it is broader than simply being “trained” in this approach.

Cultures of trauma-informed care balance trauma-specific emphases on individual empowerment and skills development with organizational emphases on safety, trustworthiness, choice, collaboration, and empowerment. This approach is consistent with other values-based approaches that have become prominent in the past two decades in behavioral health: recovery orientation, gender responsiveness, and cultural competence (Farkas et al.,

2005; Covington, 2007; Whitaker et al., 2007a). Furthermore, the core values of trauma-informed care are consistent with, and strongly supportive of, many evidence-based interventions, such as motivational interviewing, shared decision making, and psychosocial empowerment groups.

Basic shifts in both understanding and practice are fundamental in changing a traditional human service or community culture to one that is trauma-informed. Our protocol for developing a culture of trauma-informed care thus emphasizes both a paradigm shift in understanding and a thoroughly collaborative way to change practice (Harris and Fallot, 2001; Fallot and Harris, 2009). For instance, one of the key changes in understanding is establishing a “trauma first” mode of thinking about a consumer or staff member. Thus, we adopt a “trauma lens” through which other aspects of a person’s life may be viewed. Rather than asking, implicitly or explicitly, “What is wrong with you?” or “What is your problem?” we ask “What have you been through?” and “How have you tried to cope with it?” This basic change in orientation affects the organization’s view of not only consumers and staff members but also the nature of trauma itself, the services provided, and the relationship between consumer and provider. As the basic questions change, so do the approaches, from “Here is what I can do to fix you,” to “How can you and I work together to further your goals for recovery and healing?” Collaborative decision making and planning pervade trauma-informed cultures; not only are consumers’ opinions frequently sought and incorporated into individual service planning and organizational strategies, but also staff perspectives become central to administrators’ thinking as well.

In putting these ideas into practice, we address six domains of organizational culture in human service settings; three are service-level domains, and three are at the systems-level (Fallot and Harris, 2009):

Services-level changes in a culture of trauma-informed care:

• Informal service procedures and settings
• Formal service policies
• Trauma screening, assessment, service planning, and trauma-specific services

Systems-level changes in a culture of trauma-informed care:

• Administrative support for developing and sustaining this culture
• Staff training and education
• Human resources practices

As an example, let us examine our approach to informal service procedures and settings. Here we ask agency workgroups representing all constituencies (upper-level administrators, supervisors and middle management, service staff, support staff, and consumers) to review the sequence of

settings, activities, and people to whom consumers are likely to be exposed from the time of their first call to their final visit. We sometimes recommend a walk-through, in which staff literally put themselves in the place of consumers by going through the same procedures as a new consumer would in entering the agency. Once each physical setting, activity, contact, and relationship has been outlined, we ask key questions related to the core values:

• How can we ensure physical and emotional safety for consumers throughout our organization and larger system of care?
• How can we maximize trustworthiness? Make tasks clear? Maintain appropriate boundaries?
• How can we enhance consumer choice and control?
• How can we maximize collaboration and the sharing of power with consumers?
• How can we prioritize consumer empowerment and skill-building at every opportunity?

Agencies have taken this task on with enthusiasm, developing creative solutions to identified problems in these domains. For example, one residential substance abuse setting had a large sign that read “Denial stops here” over the entrance to the residential areas of its building. Deciding that this sign did not create a hospitable or emotionally safe first impression of their setting, they replaced it with a “Welcome” sign that was much more inviting. Clearer and more positive signs, more comfortable waiting rooms (with adequate space and with minimal intrusion of security staff), more positive first contacts via phone or in person, better lighting in hallways and outdoors, and more private intake procedures—among many others—are examples of the sorts of changes organizations have made in efforts to create safer and more welcoming environments.

Once this process is completed, we ask organizational workgroups to follow the same procedure, this time with a focus on the staff’s experiences of safety, trustworthiness, choice, collaboration, and empowerment. We have seen this “parallel process” with regard to trauma-related concerns played out repeatedly in a wide variety of settings. Simply put, only when staff members’ experiences of physical and emotional safety, of trustworthy relationships (with their co-workers and with supervisors and administrators), of choice in how they go about their daily work, of collaborative power-sharing with administrators and supervisors (so that staff input is weighed significantly), and of empowerment (so that staff members have the resources they need to do their jobs well) are in place is the staff able to create similar experiences for consumers.

Trauma-informed cultures of care develop over time with the collaboration and support of administrators who recognize the invaluable

perspectives of both staff and consumers. We have gathered qualitative data in support of this shift in organizational cultures. Consumers report that they feel more accepted. One woman said, for example, “Before this initiative, I had to leave an important part of myself on the doorstep to this agency; now I can bring my whole self inside.” Consumers, staff, and administrators frequently comment that the initiative fostered more collaborative relationships among them. Built on safety and trustworthiness and supported by valuing choice and empowerment, the capacity to share power meaningfully has become a hallmark of trauma-informed care.

As a values-based context strongly supportive of evidence-based trauma-specific interventions, trauma-informed organizational cultures represent a powerful source of engagement for women and their children who have been exposed to violence (Cocozza et al., 2005; Morrissey et al., 2005). (Also see the Substance Abuse and Mental Health Services Administration’s Women, Co-Occurring Disorders, and Violence Study for related discussions and findings. 7 ) To the extent that secondary and tertiary prevention of such violence relies on creating settings that are welcoming and engaging for individuals with complex histories of violent victimization, trauma-informed care is an increasingly central requirement for programs designed to assist women and children.

ENHANCING EMOTION REGULATION: A FRAMEWORK FOR PSYCHOLOGICAL EMPOWERMENT OF WOMEN AND CHILDREN EXPOSED TO VIOLENCE

Julian d. ford, ph.d. university of connecticut school of medicine.

The health care and social service professions tend to approach the question of how to assist women and children who are victims of violence by doing research on, and developing practice guidelines for, the treatment of posttraumatic stress disorder (PTSD) (Forbes et al., 2010). Extensive surveys of scientifically validated and clinically promising PTSD treatments have been compiled by the International Society for Traumatic Stress Studies, the U.S. Department of Veterans Affairs, the Clinical Resource Efficiency Support Team (part of the Northern Ireland Health Service), the American Psychiatric Association, the British National Institute for Clinical Excellence, the Institute of Medicine, and the Australian Centre for Posttraumatic Mental Health at the University of Melbourne (CREST, 2003; APA, 2004; VA, 2004; NICE, 2005; IOM, 2006; Australian Centre

7 Available at http://pathprogram.samhsa.gov/Resource/Women-Co-Occurring-Disordersand-Violence-Study-Program-Summary-21101.aspx .

for Posttraumatic Mental Health, 2007; Foa et al., 2009). These guidelines were developed to address diagnostic criteria for PTSD in the Diagnostic and Statistical Manual (APA, 1997).

Although laudable in that they have made the possible benefits of carefully developed therapies for PTSD increasingly known to professionals who treat victims of violence, this medicalized approach to helping victims recover from violence has several key limitations. First, the very terms, “victim” and “treatment” suggest a degree of passivity and deficiency that does a grave injustice to the typically extremely courageous and resilient survivors of violence. Violence temporarily disempowers those who must survive it, but even prolonged and horrific violence does not strip the survivor of the capacity to be empowered. Being viewed as broken or defective and therefore in need of corrective treatment as a result of having suffered violence adds injury (as well as insult) to injury. Although therapeutic treatments can be empowering, this is the case only to the extent that they emphasize helping the violence survivor restore or build their strengths. PTSD therapies definitely have been shown through both scientific and clinical research to empower children and adults who have experienced violence (Courtois et al., 2009; Ford and Cloitre, 2009). However, PTSD treatments tend to provide education and therapy based primarily on a view of PTSD as a breakdown of courage (i.e., avoidance of trauma reminders or memories) or deficits in arousal and anxiety management (i.e., hyperarousal, hypervigilance).

Recent research provides a basis for a paradigm shift from a pathology/deficit perspective to a framework of psychological empowerment for interventions for survivors of violence. Women and children who have been exposed to violence often suffer from aftereffects that either do not fit the criteria for PTSD or that involve symptoms and difficulties in daily living that go well beyond PTSD (Rayburn et al., 2005; Schumm et al., 2006; Ford et al., 2008, 2009, 2010, in press-b; Gill et al., 2008; Mongillo et al., 2009; Briggs-Gowan et al., 2010; Seng et al., in review). Although these sequelae might at first glance seem to be consistent with the pathology perspective (e.g., depression, panic, dissociation, addiction, oppositional–defiance, eating disorders, personality disorders, guilt, shame, complicated bereavement), in fact what they demonstrate is the extreme degree of biological, psychological, and interpersonal adaptation required to survive violence (Ford, 2005; Ford and Cloitre, 2009; Ford et al., 2009). These adaptations require substantial strength and resilience, rather than being markers for or the results of pathology or deficiencies (Herman, 1992; Courtois et al., 2009).

As a result of this paradigm shift, in the past decade an impressive array of psychological empowerment interventions has been developed for children and adults who have experienced violence and related forms of complex trauma (Courtois et al., 2009; Ford and Cloitre, 2009). As summarized

by Courtois and colleagues, psychological empowerment interventions are built upon the following two central philosophical foundations:

• Recognizing the uniqueness of the individual . The model is organized around recognition of the primacy and uniqueness of the individual and the maintenance of his/her welfare. Treatment is not one-size-fits-all; rather, each client is assessed, and treatment is planned differentially according to the specific needs of the individual. This is a phenomenological approach…. A “whole person” philosophy prevails: Although symptoms, deficits, and distress are reasons for seeking treatment and generally become the targets for intervention, the individual’s strengths, resources, resilience, personalized needs, values, and contexts are identified and reinforced.
• Personal empowerment. A strengths- and resilience-based philosophy of personal empowerment and self-determination encourages the therapist to seek to understand the individual’s unique phenomenological experience and its specific meaning and its relationship to symptoms, distress, and treatment goals. The individual has authority over the meaning and interpretation of his/her personal life history, current needs and preferences, and goals for the future. The therapist functions as an active, empathic, and responsive listener and a guide to enable the client to openly voice, examine, and therapeutically work through feelings of confusion, shame, or other emotions that have been suppressed or forbidden. The therapist seeks to create relational conditions where the client is emotionally validated and is “seen” and appreciated, to counter the invalidiation experiences typically associated with attachment trauma and subsequent victimization and to encourage emotional expression and development. The therapist strives to create conditions within the treatment that are as egalitarian as possible and that encourage collaboration with and empowerment of the client; however, the responsibilities and inherent power differences in the treatment relationship are explicitly acknowledged. The therapist seeks to use power effectively on the individual’s behalf while simultaneously encouraging the client’s development and autonomy. Importantly, the therapist conveys an openness to the client’s questioning of authority (including that of the therapist) and supports the client’s ultimate authority over his/her life, memories, and therapeutic engagement and progress. Moreover, the therapist is careful to maintain appropriate boundaries and limitations and is responsible for avoiding dual relationships and situations in which the client might be subject to pressure, coercion, or exploitation intentionally or inadvertently by the therapist. Treatment should be based in a shared plan that is systematic (not laissez-faire), utilizes effective strategies … organized around a careful assessment and a planned sequence of interventions that are hierarchically ordered and sequenced (86-87; italics in original).

A recent meta-analysis of therapy outcome studies with adult survivors of childhood sexual abuse found that cognitive behavior therapy was superior to other modalities for anxiety, depression, and other internalizing problems but not for problems more specifically related to emotion dysregulation (e.g., externalizing or interpersonal problems) (Taylor and Harvey, 2010). Thus, some violence survivors, particularly those with extensive victimization histories, may respond best to therapy focused on enhancing emotion regulation. Survivors who have severe difficulties with emotion regulation and their therapists also may prefer not to engage in trauma memory processing or to not do so until the client has acquired emotion regulation skills (Cook et al., 2004; Cloitre et al., 2010). Three manualized psychosocial intervention models that do not include trauma memory processing have been designed to enhance skills for emotion regulation, anxiety management, and interpersonal functioning. Skills Training for Emotion and Interpersonal Regulation (STAIR) has shown promise in reducing PTSD and depression symptoms and in enhancing emotion regulation with women survivors of violence (Cloitre et al., 2010). Seeking Safety has shown promise in reducing PTSD and substance use problems with girls and women (Najavits et al., 2006; Zlotnick et al., 2009). Although STAIR and Seeking Safety address emotion regulation, they emphasize becoming more assertively aware and expressive of emotions as a way to overcome excessively negative emotion states and dysfunctional avoidance of trauma memories or reminders of those memories.

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) acknowledges the extreme emotional distress (e.g., depression, anxiety, anger, guilt, shame, and grief) or emotionally numbed and shutdown feelings (e.g., dissociation) that violence survivors often suffer (Ford and Russo, 2006). However, these PTSD or trauma-related “symptoms” are currently viewed as adaptive, rather than maladaptive or dysfunctional, reactions which reflect a change in the stress response system in the body that is protective of the individual. TARGET teaches a single sequential skill set described by the mnemonic FREEDOM, designed based on research showing that emotion regulation involves recognizing, modulating, and recovering from negative emotion states as well as accessing and sustaining positive emotion states (Eisner et al., 2009; Kessler and Staudinger, 2009). Restoring affect regulation is described as requiring seven practical steps or skills denoted by FREEDOM: Focusing the mind on one thought at a time; Recognizing current triggers for emotional reactions; distinguishing dysregulated (“reactive”) versus adaptive (“main”) Emotions; Evaluations (thoughts); goal Definitions; behavioral Options; and self-statements affirming that taking responsibility for recovering from intense emotions is crucial not only to one’s own personal well-being but also to Making a positive contribution to primary relationships (e.g., as a parent) and the community.

TARGET has been evaluated in a series of real-world effectiveness studies as a group therapy for women and men in substance abuse treatment as well as for incarcerated women, as a one-to-one therapy for low-income women with complex trauma histories and girls involved in delinquency, and as a combined group and milieu intervention for girls and boys placed in juvenile detention centers (Frisman et al., 2008, Ford et al., in press-b, in preparation; Ford and Hawke, in review). Group and milieu interventions enable participants to provide one another with peer modeling, support, and guidance as well as potentially enabling the program or community in which they take place to become “trauma informed” (Fallot and Harris, 2008). Consistent with this view, TARGET was found to enable women and men recovering from substance abuse to maintain a sense of realistic confidence and optimism (“sobriety self-efficacy”), where others who received substance abuse treatment as usual showed a marked decline in this important resilience factor (Frisman et al., 2008). The benefits to the entire setting were evident in findings from the evaluation of TARGET in youth detention centers, in which every session of TARGET received by a girl or boy was associated with a reduction in the number of behavioral incidents and punitive sanctions imposed by staff during the first two weeks of youths’ stay in the facilities (Ford and Hawke, in review). On the other hand, many girls or women who have experienced violence may prefer the privacy of a one-to-one therapy intervention, and TARGET showed evidence of helping both underserved women and girls to not only reduce their PTSD symptoms but also to increase their ability to regulate emotions (Ford et al., in press-a, in press-b).

Implications of a Psychological Empowerment Approach for Violence Survivors

To the extent that knowledge is power, providing women and children who have experienced violence with de-stigmatizing explanations of why they are struggling with persistent emotional distress and how they can draw upon their inherent personal strengths to regain their emotional balance is a very direct and essential form of psychological empowerment. Equally, if not more, important is bringing this same knowledge to the many professionals, advocates, policy makers, funders, jurists, and regulators who determine how scarce societal resources will be allocated both to prevent violence and to restore the lives and well-being of survivors of violence. If violence changes how survivors’ bodies respond to subsequent stressors (non-violent as well as violent), then traumatic stress disorders such as PTSD and its more complex variants are simply extreme versions of the out-of-balance emotional states that everyone experiences. Therefore, if recovery from the aftereffects of violence involves regaining or restoring

innate capacities for re-setting the body’s stress reaction systems—and, in so doing, regaining or restoring the innate ability to regulate emotions and maintain a generally healthy balanced emotional state despite expectable perturbations—it is essential that not only violence survivors but also the public at large (including those key determiners and providers of services) are informed about why and how emotion regulation is essential not only for survivors of violence but also on a larger scale to prevent violence. With this perspective, it becomes possible to understand not only the aftereffects of violence but also violence itself as resulting at least in part from emotion dysregulation on a broad scale (e.g., uncivil discourse in politics or extreme economic and social disparities). Knowledge and skills regarding emotion regulation are essential not just for violence survivors, but for everyone.

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Violence against women and children is a serious public health concern, with costs at multiple levels of society. Although violence is a threat to everyone, women and children are particularly susceptible to victimization because they often have fewer rights or lack appropriate means of protection. In some societies certain types of violence are deemed socially or legally acceptable, thereby contributing further to the risk to women and children. In the past decade research has documented the growing magnitude of such violence, but gaps in the data still remain. Victims of violence of any type fear stigmatization or societal condemnation and thus often hesitate to report crimes. The issue is compounded by the fact that for women and children the perpetrators are often people they know and because some countries lack laws or regulations protecting victims. Some of the data that have been collected suggest that rates of violence against women range from 15 to 71 percent in some countries and that rates of violence against children top 80 percent. These data demonstrate that violence poses a high burden on global health and that violence against women and children is common and universal.

Preventing Violence Against Women and Children focuses on these elements of the cycle as they relate to interrupting this transmission of violence. Intervention strategies include preventing violence before it starts as well as preventing recurrence, preventing adverse effects (such as trauma or the consequences of trauma), and preventing the spread of violence to the next generation or social level. Successful strategies consider the context of the violence, such as family, school, community, national, or regional settings, in order to determine the best programs.

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EDITORIAL article

Editorial: new perspectives on domestic violence: from research to intervention.

• 1 Department of Psychology, University of Turin, Turin, Italy
• 2 School of Health and Social Work, University of Hertfordshire, Hertfordshire, United Kingdom

Editorial on the Research Topic New Perspectives on Domestic Violence: from Research to Intervention

In a document dated June 16th 2017, the United States Department of Justice stated that Domestic Violence (DV) has a significant impact not only on those abused, but also on family members, friends, and on the people within the social networks of both the abuser and the victim. In this sense, children who witness DV while growing up can be severely emotionally damaged. The European Commission (DG Justice) remarked in the Daphne III Program that 1 in 4 women in EU member states have been impacted by DV, and that the impact of DV on victims includes many critical consequences: lack of self-esteem, feeling shame and guilt, difficulties in expressing negative feelings, hopelessness and helplessness, which, in turn, lead to difficulties in using good coping strategies, self-management, and mutual support networks. In 2015 the EU Agency for Fundamental Rights affirmed that violence against women can be considered as a violation of human rights and dignity. Violence against women exists in each society and it can be related to any social, economic and cultural status and impact at the economic level. It includes physical, sexual, economic, religious, and psychological abuse.

Although men experience domestic violence by women, the rate of DV among women is much higher than that of men, especially in the category of being killed due to DV.

Recent studies have shown that between 13 and 61% of women (15–49 years old) report to have been physically abused at least once by an intimate partner. Domestic Violence takes place across different age groups, genders, sexual orientations, economic, or cultural statuses. However, DV remains largely under-reported due to fear of reprisal by the perpetrator, hope that DV will stop, shame, loss of social prestige due to negative media coverage, and the sense of being trapped with nowhere to go:

Hence, it is estimated that 90% of cases of DV continue to be identified as a non-denounced violence.

The aim of this Special Issue of Frontiers of Psychology is to gather updated scientific and multidisciplinary contributions about issues linked to domestic violence, including intimate partner violence (IPV). We encouraged contributions from a variety of areas including original qualitative and quantitative articles, reviews, meta-analyses, theories, and clinical case studies on biological, psycho-social and cultural correlates, risk and protective factors, and the associated factors related to the etiology, assessment, and treatment of both victims and perpetrators of DV.

We hope that this Special Issue will stimulate a better informed debate on Domestic Violence, in relation to its psychosocial impact (in and outside home, in school, and workplace), to DV prevention and intervention strategies (within the family and in society at large), in addition to specific types of DV, and to controversial issues in this field as well.

The Special Issue comprises both theoretical reviews and original research papers. 7 research papers, 6 reviews (policy and practice review, systematic review, review and mini-review) and 1 methodological paper are included.

The first section comprises 2 systematic review and 3 original research papers focused on factors associated with Domestic Violence/Intimate Partner Violence/feminicide. Velotti et al. conducted a systematic review focused on the role of the attachment style on IPV victimization and perpetration. Several studies included failed to identify significant associations. The authors suggest to consider other variables (e.g., socioeconomic condition) that in interaction with attachment styles could explain the differences found between the studies. Considering the clinical contribution that these findings can provide to the treatment of IPV victims and perpetrators, future studies are needed. From a systematic review conducted by Gerino et al. focused on IPV in the “golden age” (old age), economic and educational conditions, younger age (55–69), membership in ethnic minorities, cognitive and physical impairment, substance abuse, cultural and social values, sexism and racism, were found as risk factors; depression emerged as risk factor and consequence of IPV. However, social support was identified as main protective factor. Also help-seeking behaviors and local/national services had a positively impact the phenomenon. Furthermore, the role of the parental communication was highlighted ( Rios-González et al. ) In that mothers encourage daughters to engage in relationship with ethical men, while removing from their representation attractive features and enhancing the double standard of viewing ethical man as unattractive vs. violent and attractive man. Fathers' communication directed toward young boys supports the dominant traditional masculinity, objectifying girls and emphasizing chauvinist values. These communicative dynamics impact males' behavior and females' choice of the partner while increasing the attraction toward violent men, and thus influencing the risk to be involved in IPV episodes.

Furthermore, factors associated with multiple IPV victimization by different partners were identified. From the study of Herrero et al. , experiencing child abuse emerged as a main predictor (“conditional partner selection process”). Similarly, adult victimization perpetrated by other than the intimate partner influences multiple IPV episodes. Moreover, this phenomenon is more frequent among younger women and those with lower income satisfaction. Length of relationship and greater psychological consequences to previous IPV are positively associated with multiple IPV episodes, while previous physical abuse is negatively related with subsequent victimization. The risk of multiple IPV episodes is reduced in countries with greater human development, suggesting the role of structural factors.

Regarding reasons of feminicide, passion motives assume the main role, followed by family problems, antisocial reasons, predatory crimes that comprise sexual component, impulsivity and mental disorders. The risk of overkilling episodes is higher when the perpetrator is known by the victim and when the murder is committed for passion reasons ( Zara and Gino ).

The second section includes papers focused on IPV/DV in particular contexts (one research paper, two reviews). Within separated couples, where conflicts are common, both men and women experience psychological aggression. However, some particularities emerged: women started to suffer of several kinds of psychological violence that was aimed to control (complicating the separation process), dehumanize and criticize them. Men report only few forms of violence experienced (likely due to the men's social position that narrows their disclosure opportunity), which mainly concern the limitation of the possibility to meet children ( Cardinali et al. ). Regarding same-sex couples ( Rollè et al. ), both similarities and differences in comparison with heterosexual couples emerged. IPV among LGB people is comparable or even higher than heterosexual episodes. Unique features present in same-sex IPV concern identification and treatment aspects, mainly due to the absence of solutions useful in addressing obstacles to help-seeking behaviors (related to fear of discrimination within LGB community), and the limitation of treatment programs tailored to the particularities of the LGB experience. Similarly, within First Nation's communities in Canada, IPV is a widespread phenomenon. However, the lack of preventing programs and the presence of intervention solutions that fail to address its cultural origins, limit the reduction of the problem and the recovery of victims. Klingspohn suggests the development of interventions capable to guarantee cultural safety and consequently to reduce discrimination and marginalization that Aboriginal people experience with mainstream health care system and which limit help-seeking behaviors.

The third section comprises two reviews and one research paper concerned with the impact of Intimate Partner and Domestic Violence. The systematic review conducted by Onwumere et al. highlighted the financial and emotional burden that violence perpetrated by psychotic patients entails for their informal carers (mainly close family relatives). Moreover, the authors identified within the studies included positive association between victimization and trauma symptoms, fear, and feeling of powerless and frustration.

Among people who suffered of Domestic Violence with a romantic or non-romantic partner who became their stalker, stalking victimization entails physical and emotive consequences for both male and female victims. Females suffered more than males of depressive and anxiety symptoms (although for both genders symptoms were minimal), while males experienced more anger. Furthermore, both genders adopted at least one “moving away” strategy in coping with stalking episodes, and the increasing of stalking behaviors determined a reduction in coping strategies use. This latter finding is likely to be due to the distress experienced ( Acquadro Maran and Varetto ).

Children abuse—which occurs often in Domestic Violence—results in emotional trauma as well as physical and psychological consequences that can negatively impact the learning opportunities. The school staff's ability to identify abuse signals and to refer to professionals constitute their main role. However, lack of skills and confidence among teachers regarding this function emerged, and further training for the school staff to increase support provided to abused children is needed ( Lloyd ).

Lastly, the fourth section includes two papers (one review and one methodological paper) that provide information on intervention and prevention programs and one research paper which contributes to the development and validation of the Willingness to Intervene in Cases of Intimate Partner Violence Against Women (WI-IPVAW) Scale. Gracia et al. The instrument demonstrated—both in the long and in its short form—high reliability and construct validity. The development of WI-IPVAW can contribute to the evaluation of the t role that can be played by people who are aware of the violence and understand attitudes toward IPV that can influence perpetrator's behavior and victim disclosure. The origin of violence within intimate relationship during adolescence calls for the development of preventive programs able to limit the phenomenon. The mini-review conducted by Santoro et al. highlighted the necessity to consider the relational structure where women are involved (history of poly-victimization re-victimization), and the domination suffered according to the gender model structured by the patriarchal context. Moreover, considering that violence can occur after separation or divorce, requires in child custody cases the evaluation of parenting and co-parenting relationship. This process can provide an opportunity to assess and treat some kind of violent behavior (Conflict-Instigated Violence, Violent Resistance, Separation-Instigated Violence). According to these consideration, Gennari et al. elaborated a model for clinical intervention (relational-intergenerational model) useful to address these issues during child custody evaluation. The model is composed of three levels aimed at understanding intergenerational exchange and identify factors that contribute to safeguard family relationship. This assessment process allows parents to reflect on information emerged during the evaluation process and activate resources useful to promote a constructive change of conflict dynamics and violent behaviors.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thanks all the authors and the reviewers who contributed to the present article collection, for their dedication to our topics and to their readiness to share their knowledge, and thus to increase the research in this field; KathWoodward, Specialty Chief Editor of Gender, Sex, and Sexuality Studies that believed in our project, and to Dr. Tommaso Trombetta for his collaboration during last year.

Keywords: domestic violence, intimate partner abuse, intimate partner violence (IPV), gender violence against women, same sex intimate partner violence, systematic review, perpetrator and victim of violence, perpetrator

Citation: Rollè L, Ramon S and Brustia P (2019) Editorial: New Perspectives on Domestic Violence: From Research to Intervention. Front. Psychol. 10:641. doi: 10.3389/fpsyg.2019.00641

Received: 25 February 2019; Accepted: 07 March 2019; Published: 28 March 2019.

Edited and reviewed by: Kath Woodward , The Open University, United Kingdom

Copyright © 2019 Rollè, Ramon and Brustia. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Luca Rollè, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 20 June 2023

A qualitative quantitative mixed methods study of domestic violence against women

• Mina Shayestefar 1 ,
• Mohadese Saffari 1 ,
• Razieh Gholamhosseinzadeh 2 ,
• Monir Nobahar 3 , 4 ,
• Majid Mirmohammadkhani 4 ,
• Seyed Hossein Shahcheragh 5 &
• Zahra Khosravi 6  

BMC Women's Health volume  23 , Article number:  322 ( 2023 ) Cite this article

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Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi’s 7-step method.

In qualitative study, seven themes were found including “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems”. In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions

Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Peer Review reports

Violence against women by husbands (physical, sexual and psychological violence) is one of the basic problems of public health and violation of women’s human rights. It is estimated that 35% of women and almost one out of every three women aged 15–49 experience physical or sexual violence by their spouse or non-spouse sexual violence in their lifetime [ 1 ]. This is a nationwide public health issue, and nearly every healthcare worker will encounter a patient who has suffered from some type of domestic or family violence. Unfortunately, different forms of family violence are often interconnected. The “cycle of abuse” frequently persists from children who witness it to their adult relationships, and ultimately to the care of the elderly [ 2 ]. This violence includes a range of physical, sexual and psychological actions, control, threats, aggression, abuse, and rape [ 3 ].

Violence against women is one of the most widespread, persistent, and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication [ 3 ]. In the United States of America, more than one in three women (35.6%) experience rape, physical violence, and intimate partner violence (IPV) during their lifetime. Compared to men, women are nearly twice as likely (13.8% vs. 24.3%) to experience severe physical violence such as choking, burns, and threats with knives or guns [ 4 ]. The higher prevalence of violence against women can be due to the situational deprivation of women in patriarchal societies [ 5 ]. The prevalence of domestic violence in Iran reported 22.9%. The maximum of prevalence estimated in Tehran and Zahedan, respectively [ 6 ]. Currently, Iran has high levels of violence against women, and the provinces with the highest rates of unemployment and poverty also have the highest levels of violence against women [ 7 ].

Domestic violence against women harms individuals, families, and society [ 8 ]. Violence against women leads to physical, sexual, psychological harm or suffering, including threats, coercion and arbitrary deprivation of their freedom in public and private life. Also, such violence is associated with harmful effects on women’s sexual reproductive health, including sexually transmitted infection such as Human Immunodeficiency Virus (HIV), abortion, unsafe childbirth, and risky sexual behaviors [ 9 ]. There are high levels of psychological, sexual and physical domestic abuse among pregnant women [ 10 ]. Also, women with postpartum depression are significantly more likely to experience domestic violence during pregnancy [ 11 ].

Prompt attention to women’s health and rights at all levels is necessary, which reduces this problem and its risk factors [ 12 ]. Because women prefer to remain silent about domestic violence and there is a need to introduce immediate prevention programs to end domestic violence [ 13 ]. violence against women, which is an important public health problem, and concerns about human rights require careful study and the application of appropriate policies [ 14 ]. Also, the efforts to change the circumstances in which women face domestic violence remain significantly insufficient [ 15 ]. Given that few clear studies on violence against women and at the same time interviews with these people regarding their life experiences are available, the authors attempted to planning this research aims to investigate the prevalence and experiences of domestic violence against women in Semnan with the research question of “What is the prevalence of domestic violence against women in Semnan, and what are their experiences of such violence?”, so that their results can be used in part of the future planning in the health system of the society.

This study is a combination of cross-sectional and phenomenology studies in order to investigate the amount of domestic violence against women and some related factors (quantitative) and their experience of this violence (qualitative) simultaneously in the Semnan city. This study has been approved by the ethics committee of Semnan University of Medical Sciences with ethic code of IR.SEMUMS.REC.1397.182. The researcher introduced herself to the research participants, explained the purpose of the study, and then obtained informed written consent. It was assured to the research units that the collected information will be anonymous and kept confidential. The participants were informed that participation in the study was entirely voluntary, so they can withdraw from the study at any time with confidence. The participants were notified that more than one interview session may be necessary. To increase the trustworthiness of the study, Guba and Lincoln’s criteria for rigor, including credibility, transferability, dependability, and confirmability [ 16 ], were applied throughout the research process. The COREQ checklist was used to assess the present study quality. The researchers used observational notes for reflexivity and it preserved in all phases of this qualitative research process.

Qualitative method

Based on the phenomenological approach and with the purposeful sampling method, nine women who had referred to the counseling units of healthcare centers in Semnan city due to domestic violence in February 2021 to March 2022 were participated in the present study. The inclusion criteria for the study included marriage, a history of visiting a health center consultant due to domestic violence, and consent to participate in the study and unwillingness to participate in the study was the exclusion criteria. Each participant invited to the study by a telephone conversation about study aims and researcher information. The interviews place selected through agreement of the participant and the researcher and a place with the least environmental disturbance. Before starting each interview, the informed consent and all of the ethical considerations, including the purpose of the research, voluntary participation, confidentiality of the information were completely explained and they were asked to sign the written consent form. The participants were interviewed by depth, semi-structured and face-to-face interviews based on the main research question. Interviews were conducted by a female health services researcher with a background in nursing (M.Sh.). Data collection was continued until the data saturation and no new data appeared. Only the participants and the researcher were present during the interviews. All interviews were recorded by a MP3 Player by permission of the participants before starting. Interviews were not repeated. No additional field notes were taken during or after the interview.

The age range of the participants was from 38 to 55 years and their average age was 40 years. The sociodemographic characteristics of the participants are summarized in table below (Table  1 ).

Five interviews in the courtyards of healthcare centers, 2 interviews in the park, and 2 interviews at the participants’ homes were conducted. The duration of the interviews varied from 45 min to one hour. The main research question was “What is your experience about domestic violence?“. According to the research progress some other questions were asked in line with the main question of the research.

The conducted interviews were analyzed by using the 7 steps Colizzi’s method [ 17 ]. In order to empathize with the participants, each interview was read several times and transcribed. Then two researchers (M.Sh. and M.N.) extracted the phrases that were directly related to the phenomenon of domestic violence against women independently and distinguished from other sentences by underlining them. Then these codes were organized into thematic clusters and the formulated concepts were sorted into specific thematic categories.

In the final stage, in order to make the data reliable, the researcher again referred to 2 participants and checked their agreement with their perceptions of the content. Also, possible important contents were discussed and clarified, and in this way, agreement and approval of the samples was obtained.

Quantitative method

The cross-sectional study was implemented from February 2021 to March 2022 with cluster sampling of married women in areas of 3 healthcare centers in Semnan city. Those participants who were married and agreed with the written and verbal informed consent about the ethical considerations were included to the study. The questionnaire was completed by the participants in paper and online form.

The instrument was the standard questionnaire of domestic violence against women by Mohseni Tabrizi et al. [ 18 ]. In the questionnaire, questions 1–10, 11–36, 37–65 and 66–71 related to sociodemographic information, types of spousal abuse (psychological, economical, physical and sexual violence), patriarchal beliefs and traditions and family upbringing and learning violence, respectively. In total, this questionnaire has 71 items.

The scoring of the questionnaire has two parts and the answers to them are based on the Likert scale. Questions 11–36 and 66–71 are answered with always [ 4 ] to never (0) and questions 37–65 with completely agree [ 4 ] to completely disagree (0). The minimum and maximum score is 0 and 300, respectively. The total score of 0–60, 61–120 and higher than 121 demonstrates low, moderate and severe domestic violence against women, respectively [ 18 ].

In the study by Tabrizi et al., to evaluate the validity and reliability of this questionnaire, researchers tried to measure the face validity of the scale by the previous research. Those items and questions which their accuracies were confirmed by social science professors and experts used in the research, finally. The total Cronbach’s alpha coefficient was 0.183, which confirmed that the reliability of the questions and items of the questionnaire is sufficient [ 18 ].

Descriptive data were reported using mean, standard deviation, frequency and percentage. Then, to measure the relationship between the variables, χ2 and Pearson tests also variance and regression analysis were performed. All analysis were performed by using SPSS version 26 and the significance level was considered as p < 0.05.

Qualitative results

According to the third step of Colaizzi’s 7-step method, the researcher attempted to conceptualize and formulate the extracted meanings. In this step, the primary codes were extracted from the important sentences related to the phenomenon of violence against women, which were marked by underlining, which are shown below as examples of this stage and coding.

The primary code of indifference to the father’s role was extracted from the following sentences. This is indifference in the role of the father in front of the children.

“Some time ago, I told him that our daughter is single-sided deaf. She has a doctor’s appointment; I have to take her to the doctor. He said that I don’t have money to give you. He doesn’t force himself to make money anyway” (p 2, 33 yrs).

“He didn’t value his own children. He didn’t think about his older children” (p 4, 54 yrs).

The primary code extracted here included lack of commitment in the role of head of the household. This is irresponsibility towards the family and meeting their needs.

“My husband was fired from work after 10 years due to disorder and laziness. Since then, he has not found a suitable job. Every time he went to work, he was fired after a month because of laziness” (p 7, 55 yrs).

“In the evening, he used to get dressed and go out, and he didn’t come back until late. Some nights, I was so afraid of being alone that I put a knife under my pillow when I slept” (p 2, 33 yrs).

A total of 246 primary codes were extracted from the interviews in the third step. In the fourth step, the researchers put the formulated concepts (primary codes) into 85 specific sub-categories.

Twenty-three categories were extracted from 85 sub-categories. In the sixth step, the concepts of the fifth step were integrated and formed seven themes (Table  2 ).

These themes included “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems” (Fig.  1 ).

Themes of domestic violence against women

Some of the statements of the participants on the theme of “ Facilitators” are listed below:

Husband’s criminal record

“He got his death sentence for drugs. But, at last it was ended for 10 years” (p 4, 54 yrs).

Inappropriate age for marriage

“At the age of thirteen, I married a boy who was 25 years old” (p 8, 25 yrs).

“My first husband obeyed her parents. I was 12–13 years old” (p 3, 32 yrs).

“I couldn’t do anything. I was humiliated” (p 1, 38 yrs).

“A bridegroom came. The mother was against. She said, I am young. My older sister is not married yet, but I was eager to get married. I don’t know, maybe my father’s house was boring for me” (p 2, 33 yrs).

“My parents used to argue badly. They blamed each other and I always wanted to run away from these arguments. I didn’t have the patience to talk to mom or dad and calm them down” (p 5, 39 yrs).

Overdependence

“My husband’s parents don’t stop interfering, but my husband doesn’t say anything because he is a student of his father. My husband is self-employed and works with his father on a truck” (p 8, 25 yrs).

“Every time I argue with my husband because of lack of money, my mother-in-law supported her son and brought him up very spoiled and lazy” (p 7, 55 yrs).

Bitter memories

“After three years, my mother married her friend with my uncle’s insistence and went to Shiraz. But, his condition was that she did not have the right to bring his daughter with her. In fact, my mother also got married out of necessity” (p 8, 25 yrs).

Some of their other statements related to “ Role failure” are mentioned below:

Lack of commitment to different roles

“I got angry several times and went to my father’s house because of my husband’s bad financial status and the fact that he doesn’t feel responsible to work and always says that he cannot find a job” (p 6, 48 yrs).

“I saw that he does not want to change in any way” (p 4, 54 yrs).

“No matter how kind I am, it does not work” (p 1, 38 yrs).

Some of their other statements regarding “ Repressors” are listed below:

Fear and silence

“My mother always forced me to continue living with my husband. Finally, my father had been poor. She all said that you didn’t listen to me when you wanted to get married, so you don’t have the right to get angry and come to me, I’m miserable enough” (p 2, 33 yrs).

“Because I suffered a lot in my first marital life. I was very humiliated. I said I would be fine with that. To be kind” (p1, 38 yrs).

“Well, I tell myself that he gets angry sometimes” (p 3, 32 yrs).

Shame from society

“I don’t want my daughter-in-law to know. She is not a relative” (p 4, 54 yrs).

Some of the statements of the participants regarding the theme of “ Efforts to preserve the family” are listed below:

Hope and trust

“I always hope in God and I am patient” (p 2, 33 yrs).

Efforts for children

“My divorce took a month. We got a divorce. I forgave my dowry and took my children instead” (p 2, 33 yrs).

Some of their other statements regarding the “ Inappropriate solving of family conflicts” are listed below:

Child-bearing thoughts

“My husband wanted to take me to a doctor to treat me. But my father-in-law refused and said that instead of doing this and spending money, marry again. Marriage in the clans was much easier than any other work” (p 8, 25 yrs).

Lack of effective communication

“I was nervous about him, but I didn’t say anything” (p 5, 39 yrs).

“Now I am satisfied with my life and thank God it is better to listen to people’s words. Now there is someone above me so that people don’t talk behind me” (p 2, 33 yrs).

Some of their other statements regarding the “ Consequences” are listed below:

Harm to children

“My eldest daughter, who was about 7–8 years old, behaved differently. Oh, I was angry. My children are mentally depressed and argue” (p 5, 39 yrs).

After divorce

“Even though I got a divorce, my mother and I came to a remote area due to the fear of what my family would say” (p 2, 33 yrs).

Social harm

“I work at a retirement center for living expenses” (p 2, 33 yrs).

“I had to go to clean the houses” (p 5, 39 yrs).

Non-acceptance in the family

“The children’s relationship with their father became bad. Because every time they saw their father sitting at home smoking, they got angry” (p 7, 55 yrs).

Emotional harm

“When I look back, I regret why I was not careful in my choice” (p 7, 55 yrs).

“I felt very bad. For being married to a man who is not bound by the family and is capricious” (p 9, 36 yrs).

Some of their other statements regarding “ Inefficient supportive systems” are listed below:

Inappropriate family support

“We didn’t have children. I was at my father’s house for about a month. After a month, when I came home, I saw that my husband had married again. I cried a lot that day. He said, God, I had to. I love you. My heart is broken, I have no one to share my words” (p 8, 25 yrs).

“My brother-in-law was like himself. His parents had also died. His sister did not listen at all” (p 4, 54 yrs).

“I didn’t have anyone and I was alone” (p 1, 38 yrs).

Inefficiency of social systems

“That day he argued with me, picked me up and threw me down some stairs in the middle of the yard. He came closer, sat on my stomach, grabbed my neck with both of his hands and wanted to strangle me. Until a long time later, I had kidney problems and my neck was bruised by her hand. Given that my aunt and her family were with us in a building, but she had no desire to testify and was afraid” (p 3, 32 yrs).

Undesired training and advice

“I told my mother, you just said no, how old I was? You never insisted on me and you didn’t listen to me that this man is not good for you” (p 9, 36 yrs).

Quantitative results

In the present study, 376 married women living in Semnan city participated in this study. The mean age of participants was 38.52 ± 10.38 years. The youngest participant was 18 and the oldest was 73 years old. The maximum age difference was 16 years. The years of marriage varied from one year to 40 years. Also, the number of children varied from no children to 7. The majority of them had 2 children (109, 29%). The sociodemographic characteristics of the participants are summarized in the table below (Table  3 ).

The frequency distribution (number and percentage) of the participants in terms of the level of violence was as follows. 89 participants (23.7%) had experienced low violence, 59 participants (15.7%) had experienced moderate violence, and 228 participants (60.6%) had experienced severe violence.

Cronbach’s alpha for the reliability of the questionnaire was 0.988. The mean and standard deviation of the total score of the questionnaire was 143.60 ± 74.70 with a range of 3-244. The relationship between the total score of the questionnaire and its fields, and some demographic variables is summarized in the table below (Table  4 ).

As shown in the table above, the variables of age, age difference and number of years of marriage have a positive and significant relationship, and the variable of number of children has a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). However, the variable of education level difference showed no significant relationship with the total score and any of the fields. Also, the highest average score is related to patriarchal beliefs compared to other fields.

The comparison of the average total scores separately according to each variable showed the significant average difference in the variables of the previous marriage history of the woman, the result of the previous marriage of the woman, the education of the woman, the education of the man, the income of the woman, the income of the man, and the physical disease of the man (p < 0.05).

In the regression model, two variables remained in the final model, indicating the relationship between the variables and violence score and the importance of these two variables. An increase in women’s education and income level both independently show a significant relationship with an increase in violence score (Table  5 ).

The results of analysis of variance to compare the scores of each field of violence in the subgroups of the participants also showed that the experience and result of the woman’s previous marriage has a significant relationship with physical violence and tradition and family upbringing, the experience of the man’s previous marriage has a significant relationship with patriarchal belief, the education level of the woman has a significant relationship with all fields and the level of education of the man has a significant relationship with all fields except tradition and family upbringing (p < 0.05).

According to the results of both quantitative and qualitative studies, variables such as the young age of the woman and a large age difference are very important factors leading to an increase in violence. At a younger age, girls are afraid of the stigma of society and family, and being forced to remain silent can lead to an increase in domestic violence. As Gandhi et al. (2021) stated in their study in the same field, a lower marriage age leads to many vulnerabilities in women. Early marriage is a global problem associated with a wide range of health and social consequences, including violence for adolescent girls and women [ 12 ]. Also, Ahmadi et al. (2017) found similar findings, reporting a significant association among IPV and women age ≤ 40 years [ 19 ].

Two others categories of “Facilitators” in the present study were “Husband’s criminal record” and “Overdependence” which had a sub-category of “Forced cohabitation”. Ahmadi et al. (2017) reported in their population-based study in Iran that husband’s addiction and rented-householders have a significant association with IPV [ 19 ].

The patriarchal beliefs, which are rooted in the tradition and culture of society and family upbringing, scored the highest in relation to domestic violence in this study. On the other hand, in qualitative study, “Normalcy” of men’s anger and harassment of women in society is one of the “Repressors” of women to express violence. In the quantitative study, the increase in the women’s education and income level were predictors of the increase in violence. Although domestic violence is more common in some sections of society, women with a wide range of ages, different levels of education, and at different levels of society face this problem, most of which are not reported. Bukuluki et al. (2021) showed that women who agreed that it is good for a man to control his partner were more likely to experience physical violence [ 20 ].

Domestic violence leads to “Consequences” such as “Harm to children”, “Emotional harm”, “Social harm” to women and even “Non-acceptance in their own family”. Because divorce is a taboo in Iranian culture and the fear of humiliating women forces them to remain silent against domestic violence. Balsarkar (2021) stated that the fear of violence can prevent women from continuing their studies, working or exercising their political rights [ 8 ]. Also, Walker-Descarte et al. (2021) recognized domestic violence as a type of child maltreatment, and these abusive behaviors are associated with mental and physical health consequences [ 21 ].

On the other hand and based on the “Lack of effective communication” category, ignoring the role of the counselor in solving family conflicts and challenges in the life of couples in the present study was expressed by women with reasons such as lack of knowledge and family resistance to counseling. Several pathologies are needed to investigate increased domestic violence in situations such as during women’s pregnancy or infertility. Because the use of counseling for couples as a suitable solution should be considered along with their life challenges. Lin et al. (2022) stated that pregnant women were exposed to domestic violence for low birth weight in full term delivery. Spouse violence screening in the perinatal health care system should be considered important, especially for women who have had full-term low birth weight infants [ 22 ].

Also, lack of knowledge and low level of education have been found as other factors of violence in this study, which is very prominent in both qualitative and quantitative studies. Because the social systems and information about the existing laws should be followed properly in society to act as a deterrent. Psychological training and especially anger control and resilience skills during education at a younger age for girls and boys should be included in educational materials to determine the positive results in society in the long term. Manouchehri et al. (2022) stated that it seems necessary to train men about the negative impact of domestic violence on the current and future status of the family [ 23 ]. Balsarkar (2021) also stated that men and women who have not had the opportunity to question gender roles, attitudes and beliefs cannot change such things. Women who are unaware of their rights cannot claim. Governments and organizations cannot adequately address these issues without access to standards, guidelines and tools [ 8 ]. Machado et al. (2021) also stated that gender socialization reinforces gender inequalities and affects the behavior of men and women. So, highlighting this problem in different fields, especially in primary health care services, is a way to prevent IPV against women [ 24 ].

There was a sub-category of “Inefficiency of social systems” in the participants experiences. Perhaps the reason for this is due to insufficient education and knowledge, or fear of seeking help. Holmes et al. (2022) suggested the importance of ascertaining strategies to improve victims’ experiences with the court, especially when victims’ requests are not met, to increase future engagement with the system [ 25 ]. Sigurdsson (2019) revealed that despite high prevalence numbers, IPV is still a hidden and underdiagnosed problem and neither general practitioner nor our communities are as well prepared as they should be [ 26 ]. Moreira and Pinto da Costa (2021) found that while victims of domestic violence often agree with mandatory reporting, various concerns are still expressed by both victims and healthcare professionals that require further attention and resolution [ 27 ]. It appears that legal and ethical issues in this regard require comprehensive evaluation from the perspectives of victims, their families, healthcare workers, and legal experts. By doing so, better practical solutions can be found to address domestic violence, leading to a downward trend in its occurrence.

Some of the variables of violence against women have been identified and emphasized in many studies, highlighting the necessity of policymaking and social pathology in society to prevent and use operational plans to take action before their occurrence. Breaking the taboo of domestic violence and promoting divorce as a viable solution after counseling to receive objective results should be implemented seriously to minimize harm to women, children, and their families.

Limitations

Domestic violence against women is an important issue in Iranian society that women resist showing and expressing, making researchers take a long-term process of sampling in both qualitative and quantitative studies. The location of the interview and the women’s fear of their husbands finding out about their participation in this study have been other challenges of the researchers, which, of course, they attempted to minimize by fully respecting ethical considerations. Despite the researchers’ efforts, their personal and professional experiences, as well as the studies reviewed in the literature review section, may have influenced the study results.

Data Availability

Data and materials will be available upon email to the corresponding author.

Abbreviations

Intimate Partner Violence

Human Immunodeficiency Virus

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Acknowledgements

The authors of this study appreciate the Deputy for Research and Technology of Semnan University of Medical Sciences, Social Determinants of Health Research Center of Semnan University of Medical Sciences and all the participants in this study.

Research deputy of Semnan University of Medical Sciences financially supported this project.

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M.Sh. contributed to the first conception and design of this research; M.Sh., Z.Kh., M.S., R.Gh. and S.H.Sh. contributed to collect data; M.N. and M.Sh. contributed to the analysis of the qualitative data; M.M. and M.Sh. contributed to the analysis of the quantitative data; M.SH., M.N. and M.M. contributed to the interpretation of the data; M.Sh., M.S. and S.H.Sh. wrote the manuscript. M.Sh. prepared the final version of manuscript for submission. All authors reviewed the manuscript meticulously and approved it. All names of the authors were listed in the title page.

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Correspondence to Mina Shayestefar .

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This article is resulted from a research approved by the Vice Chancellor for Research of Semnan University of Medical Sciences with ethics code of IR.SEMUMS.REC.1397.182 in the Social Determinants of Health Research Center. The authors confirmed that all methods were performed in accordance with the relevant guidelines and regulations. All participants accepted the participation in the present study. The researchers introduced themselves to the research units, explained the purpose of the research to them and then all participants signed the written informed consent. The research units were assured that the collected information was anonymous. The participant was informed that participating in the study was completely voluntary so that they can safely withdraw from the study at any time and also the availability of results upon their request.

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Shayestefar, M., Saffari, M., Gholamhosseinzadeh, R. et al. A qualitative quantitative mixed methods study of domestic violence against women. BMC Women's Health 23 , 322 (2023). https://doi.org/10.1186/s12905-023-02483-0

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Domestic violence and abusive relationships: Research review

Research review of data and studies relating to intimate partner violence and abusive relationships.

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The controversy over NFL star Ray Rice and the instance of domestic violence he perpetrated, which was caught on video camera, stirred wide discussion about sports culture, domestic violence and even the psychology of victims and their complex responses to abuse . In 2015, domestic violence drew a national spotlight again when the South Carolina newspaper, the Post and Courier , won a Pulitzer Prize for its investigation of women who were abused by men and had been dying at a rate of one every 12 days.

The research on domestic violence, referred to more precisely in academic literature as “intimate partner violence” (IPV), has grown substantially over the past few decades. Although knowledge of the problem and its scope have deepened, the issue remains a major health and social problem afflicting women. In November 2014 the World Health Organization estimated that 35% of all women have experienced either intimate partner violence or sexual violence by a non-partner during their lifetimes. This figure is supported by the findings of a 2013 peer-reviewed metastudy — the most rigorous form of research analysis — published in the leading academic journal Science . That metastudy found that “in 2010, 30.0% [95% confidence interval (CI) 27.8 to 32.2%] of women aged 15 and over have experienced, during their lifetime, physical and/or sexual intimate partner violence.” The prevalence found among high-income regions in North America was 21.3%. Of course, under-reporting remains a substantial problem in this research area.

In 2010, the National Intimate Partner and Sexual Violence Survey, conducted by the U.S. Centers for Disease Control and Prevention, found that “more than 1 in 3 women (35.6%) … in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime.” That survey was subsequently updated in September 2014. The findings, based on telephone surveys with more than 12,000 people in 2011, include:

The lifetime prevalence of physical violence by an intimate partner was an estimated 31.5% among women and in the 12 months before taking the survey, an estimated 4.0% of women experienced some form of physical violence by an intimate partner. An estimated 22.3% of women experienced at least one act of severe physical violence by an intimate partner during their lifetimes. With respect to individual severe physical violence behaviors, being slammed against something was experienced by an estimated 15.4% of women, and being hit with a fist or something hard was experienced by 13.2% of women. In the 12 months before taking the survey, an estimated 2.3% of women experienced at least one form of severe physical violence by an intimate partner.

Still, the overall rates of IPV in the United States have been generally falling over the past two decades, and in 2013 the federal government reauthorized an enhanced Violence Against Women Act , adding further legal protections and broadening the groups covered to include LGBT persons and Native American women. (For research on the relatively higher violence rates among gay men, see the 2012 study “Intimate Partner Violence and Social Pressure among Gay Men in Six Countries.” )

A 2013 study published in the Journal of Marriage and Family , “Women’s Education, Marital Violence, and Divorce: A Social Exchange Perspective,” analyzes a nationally representative sample of more than 900 young U.S. women to look at factors that make females more likely to leave abusive relationships. The researchers, Derek A. Kreager, Richard B. Felson, Cody Warner and Marin R. Wenger, are all at Pennsylvania State University. They note that traditional “social exchange theory” would suggest that as women have more resources, they become less dependent on men and have more opportunities outside relationships, and therefore have more ability to divorce. The study sets out to “determine whether the relationship between a woman’s education and divorce is different in violent marriages.” The researchers also hypothesize that women who have higher levels of education are less likely to get divorced in general — prior academic work they cite supports this — but they aim to see how the introduction of intimate partner violence changes this dynamic.

The study’s findings include:

• The data provide “support for our primary hypotheses that women’s education typically protects against divorce but that this association weakens in abusive marriages. In addition, we found a similar pattern for wives’ proportional income, net of education. Together, these patterns suggest that educational and financial resources benefit women by increasing marital stability in nonabusive marriages and promoting divorce in abusive marriages.”
• Further, the “greater tendency for educated women to leave abusive marriages was substantial. For example, in highly violent marriages, women with a college degree had over a 10% greater probability of divorce in the observed time period than women without a college degree.”
• The study also finds that “women with economic resources were likely to leave unhappy marriages, regardless of whether they involve abuse. Similarly, degree-earning women were more likely than less educated women to leave violent marriages, regardless of their feelings of dissatisfaction.”

The researchers note that, across the U.S. population, more women are attaining college degrees, and given the study’s findings, this suggests “increases in women’s education should reduce rates of domestic violence. In a population with many educated women, violent marriages are likely to break up.” They caution that it is also possible “that our observed patterns reflect husbands’ perceptions and decisions. Perhaps abusive men feel threatened by successful wives, which then increases divorce risk. Nonabusive men may not feel threatened and thus stay with successful women.” On this point, more research is required.

Related research: A 2015 study titled “When War Comes Home: The Effect of Combat Service on Domestic Violence” suggests that multiple deployments and longer deployment lengths may increase the chance of family violence. A June 2014 study published in the  Journal of Interpersonal Violence , “Intimate Partner Violence Before and During Pregnancy: Related Demographic and Psychosocial Factors and Postpartum Depressive Symptoms Among Mexican American Women,”  provides a snapshot of domestic violence in a community sample of low-income Hispanic women. A March 2013 report from the U.S. Department of Justice’s Bureau of Justice Statistics, “Female Victims of Sexual Violence, 1994-2010,” provides a broad picture of such crimes across American society, examining the demographics of both victims and offenders. Regarding the issue of IPV prevention, a 2003 metastudy published in the Journal of the American Medical Association (JAMA) , “Interventions for Violence Against Women: Scientific Review,” found that “information about evidence-based approaches in the primary care setting for preventing IPV is seriously lacking…. Specifically, the effectiveness of routine primary care screening remains unclear, since screening studies have not evaluated outcomes beyond the ability of the screening test to identify abused women. Similarly, specific treatment interventions for women exposed to violence, including women’s shelters, have not been adequately evaluated.” Subsequent research continues to find problems with current techniques for screening and detection.

Tags: gender, women and work, crime, sex crimes

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John Wihbey

153 Domestic Violence Topics & Essay Examples

A domestic violence essay can deal with society, gender, family, and youth. To help you decide which aspect to research, our team provided this list of 153 topics .

📑 Aspects to Cover in a Domestic Violence Essay

🏆 best domestic violence titles & essay examples, ⭐ interesting domestic violence topics for an essay, 🎓 good research topics about domestic violence, ❓ research questions on domestic violence.

Domestic violence is a significant problem and one of the acute topics of today’s society. It affects people of all genders and sexualities.

Domestic violence involves many types of abuse, including sexual and emotional one. Essays on domestic violence can enhance students’ awareness of the issue and its causes. Our tips will be useful for those wanting to write outstanding domestic violence essays.

Start with choosing a topic for your paper. Here are some examples of domestic violence essay titles:

• Causes of domestic violence and the ways to eliminate them
• The consequences of domestic violence
• The importance of public domestic violence speech
• Ways to reduce domestic violence
• The prevalence of domestic violence in the United States (or other countries)
• The link between domestic violence and mental health problems among children

Now that you have selected one of the titles for your essay, you can start working on the paper. We have prepared some tips on the aspects you should cover in your work:

• Start with researching the issue you have selected. Analyze its causes, consequences, and effects. Remember that you should include some of the findings in the paper using in-text citations.
• Develop a domestic violence essay outline. The structure of your paper will depend on the problem you have selected. In general, there should be an introductory and a concluding paragraph, as well as three (or more) body paragraphs. Hint: Keep in mind the purpose of your essay while developing its structure.
• Present your domestic violence essay thesis clearly. The last sentence of your introductory paragraph should be the thesis statement. Here are some examples of a thesis statement:

Domestic violence has a crucial impact on children’s mental health. / Domestic violence affects women more than men.

• Present a definition of domestic violence. What actions does the term involve? Include several possible perspectives on domestic violence.
• Discuss the victims of domestic violence and the impact it has on them too. Provide statistical data, if possible.
• Help your audience to understand the issue better by discussing the consequences of domestic violence, even if it is not the primary purpose of your paper. The essay should show why it is necessary to eliminate this problem.
• You can include some relevant quotes on domestic violence to make your arguments more persuasive. Remember to use citations from relevant sources only. Such sources include peer-reviewed articles and scholarly publications. If you are not sure whether you can use a piece of literature, consult your professor to avoid possible mistakes.
• Support your claims with evidence. Ask your professor in advance about the sources you can use in your paper. Avoid utilizing Wikipedia, as this website is not reliable.
• Stick to a formal language. Although you may want to criticize domestic violence, do not use offensive terms. Your paper should look professional.
• Pay attention to the type of paper you should write. If it is an argumentative essay, discuss opposing views on domestic violence and prove that they are unreliable.
• Remember that you should include a domestic violence essay conclusion in your paper too. This section of the paper should present your main ideas and findings. Remember not to present any new information or citations in the concluding paragraph.

There are some free samples we have prepared for you, too. Check them out!

• Domestic Violence and Conflict Theory in Society The Conflict Theory explains remarkable events in history and the changing patterns of race and gender relations and also emphasizes the struggles to explain the impact of technological development on society and the changes to […]
• Domestic Violence against Women Domestic violence against women refers to “any act of gender-based violence that results in or is likely to result in physical, sexual, and mental harm or suffering to women, including threats of such acts as […]
• Domestic Violence Ethical Dilemmas in Criminal Justice Various ethical issues such as the code of silence, the mental status of the offender, and limited evidence play a vital role in challenging the discretion of police officers in arresting the DV perpetrators.
• Domestic Violence and Repeat Victimisation Theory Domestic violence is a crime which often happens because of a bad relationship between a man and woman and usually continues to be repeated until one of the parties leaves the relationship; hence victims of […]
• Ambivalence on Part of the Police in Response to Domestic Violence The police have been accused of ambivalence by their dismissive attitudes and through sexism and empathy towards perpetrators of violence against women.
• Break the Silence: Domestic Violence Case The campaign in question aimed to instruct victims of domestic violence on how to cope with the problem and where to address to get assistance.
• Behind Closed Doors: Domestic Violence The term “domestic violence” is used to denote the physical or emotional abuse that occurs in the homes. Therefore, it has contributed to the spread of domestic violence in the country.
• Domestic Violence: Qualitative & Quantitative Research This research seeks to determine the impacts of domestic violence orders in reducing the escalating cases of family brutality in most households. N1: There is a significant relationship between domestic violence orders and the occurrence […]
• Victimology and Domestic Violence In this situation there are many victims; Anne is a victim of domestic violence and the children are also victims of the same as well as the tragic death of their father.
• Theories of Domestic Violence It is important to point out that women have received the short end of the stick in regards to domestic violence. A third reason why people commit domestic violence according to the Family Violence Theory […]
• Domestic Violence in Australia: Policy Issue In this paper, DV in Australia will be regarded as a problem that requires policy decision-making, and the related terminology and theory will be used to gain insights into the reasons for the persistence of […]
• National Coalition Against Domestic Violence In addition, NCADV hopes to make the public know that the symbol of the purple ribbon represents the mission of the organization, which is to bring peace to all American households.
• Community and Domestic Violence: Elder Abuse In addition, the fact the elderly people cannot defend themselves because of the physical frailty that they encounter, they will experience most of the elderly abuse.
• Violence against Women: Domestic, National, and Global Rape as a weapon for the enemy Majority of cultures in war zones still accept and regard rape to be a weapon of war that an enemy should be punished with.
• Domestic Violence: Reason, Forms and Measures The main aim of this paper is to determine the reason behind the rapid increase of domestic violence, forms of domestic violence and measures that should be taken to reduce its effects.
• Effects of Domestic Violence on Children’s Social and Emotional Development In the case of wife-husband violence, always, one parent will be the offender and the other one the victim; in an ideal situation, a child needs the love of a both parents. When brought up […]
• Affordable, Effective Legal Assistance for Victims of Domestic Violence Legal assistance significantly increases the chances for domestic abuse victims to obtain restraining orders, divorce, and custody of their children. Helping victims of domestic violence with inexpensive legal aid is a critical step in assisting […]
• Domestic Violence: Far-Right Conspiracy Theory in Australia’s Culture Wars The phenomenon of violence is directly related to the violation of human rights and requires legal punishment for the perpetrators and support for the victims.
• Domestic Violence and Black Women’s Experiences Overall, the story’s exploration of the reality of life for an African American married woman in a patriarchal society, and the challenges faced by black women, is relevant to the broader reality of domestic violence […]
• Domestic Violence: Criminal Justice In addition, the usage of illegal substances such as bhang, cocaine, and other drugs contributes to the increasing DV in society.
• Witnessed Domestic Violence and Juvenile Detention Research The primary purpose of this study is to examine the relationship between witnessed domestic violence and juvenile detention. Research has pointed to a relationship between witnessed violence and juvenile delinquency, and this study holds that […]
• Domestic Violence Against Women in Melbourne Thus, it is possible to introduce the hypothesis that unemployment and related financial struggles determined by pandemic restrictions lead to increased rates of domestic violence against women in Melbourne.
• Intersectionality in Domestic Violence Another way an organization that serves racial minorities may address the unique needs of domestic violence victims is to offer additional educational and consultancy activities for women of color.
• Healthcare Testing of a Domestic Violence Victim Accordingly, the negative aspects of this exam include difficulties in identifying and predicting the further outcome of events and the course of side effects.
• Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
• Educational Services for Children in Domestic Violence Shelters In order to meet the objectives of the research, Chanmugam et al.needed to reach out to the representatives of emergency domestic violence shelters located in the state of Texas well-aware of the shelters’ and schools’ […]
• The Domestic Violence Arrest Laws According to the National Institute of Justice, mandatory arrest laws are the most prevalent in US states, indicating a widespread agreement on their effectiveness.
• Environmental Scan for Hart City Domestic Violence Resource Center In particular, it identifies the target population, outlines the key resources, and provides an overview of data sources for assessing key factors and trends that may affect the Resource Center in the future.
• Domestic Violence Investigation Procedure If they claim guilty, the case is proceeded to the hearing to estimate the sentencing based on the defendant’s criminal record and the scope of assault. The issue of domestic abuse in households is terrifyingly […]
• Educational Group Session on Domestic Violence This will be the first counseling activity where the counselor assists the women to appreciate the concepts of domestic violence and the ways of identifying the various kinds of violence.
• What Causes Domestic Violence? Domestic abuse, which is also known as domestic violence, is a dominance of one family member over another or the other. As a result, the probability of them becoming abusers later in life is considerably […]
• Domestic Violence and COVID-19: Literature Review The “stay safe, stay at home” mantra used by the governments and public health organizations was the opposite of safety for the victims of domestic violence.
• The Impact of COVID-19 on Domestic Violence in the US Anurudran et al.argue that the new measures taken to fight COVID-19 infections heightened the risk of domestic abuse. The pandemic paradox: The consequences of COVID 19 on domestic violence.
• Rachel Louise Snyder’s Research on Domestic Violence Language and framing play a significant role in manipulating people’s understanding of domestic violence and the nature of the problem. However, it is challenging to gather precise data on the affected people and keep track […]
• Domestic Violence Restraining Orders: Renewals and Legal Recourse Since upon the expiry of a restraining order, a victim can file a renewal petition the current task is to determine whether the original DVRO of our client has expired, the burden of obtaining a […]
• Annotated Bibliography on Domestic Violence Against Women They evaluate 134 studies from various countries that provide enough evidence of the prevalence of domestic violence against women and the adverse effects the vice has had for a decade.
• Alcoholism, Domestic Violence and Drug Abuse Kaur and Ajinkya researched to investigate the “psychological impact of adult alcoholism on spouses and children”. The work of Kaur and Ajinkya, reveals a link between chronic alcoholism and emotional problems on the spouse and […]
• Domestic Violence Counselling Program Evaluation The evaluation will be based upon the mission of the program and the objectives it states for the participants. The counselors arrange treatment for both sides of the conflict: the victims and offenders, and special […]
• Sociological Imagination: Domestic Violence and Suicide Risk Hence, considering these facts, it is necessary to put the notion of suicide risk in perspective when related to the issue of domestic violence.
• The Roles of Domestic Violence Advocates Domestic conflict advocates assist victims in getting the help needed to cope and move forward. Moreover, these advocates help the survivors in communicating to employers, family members, and lawyers.
• Domestic Violence: The Impact of Law Enforcement Home Visits As the study concludes, despite the increase in general awareness concerning domestic violence cases, it is still a significant threat to the victims and their children.
• Domestic Violence: How Is It Adressed? At this stage, when the family members of the battered women do this to them, it becomes the responsibility of the people to do something about this.
• Domestic Violence Factors Among Police Officers The objective of this research is to establish the level of domestic violence among police officers and relative the behavior to stress, divorce, police subculture, and child mistreatment.
• “The Minneapolis Domestic Violence Experiment” by Sherman and Berk The experiment conducted by the authors throws light on the three stages of the research circle. This is one of the arguments that can be advanced.
• Domestic Violence and Drug-Related Offenders in Australia The article is very informative since outlines a couple of the reasons behind the rampant increase in cases of negligence and lack of concern, especially from the government.
• An Investigation on Domestic Violence This particular experiment aimed to evaluate the nature of relationship and the magnitude of domestic violence meted on either of the partners.
• Educational Program on Domestic Violence The reason why I have chosen this as the topic for my educational program is that victims of domestic violence often feel that they do not have any rights and hence are compelled to live […]
• Supporting Female Victims of Domestic Violence and Abuse: NGO Establishment The presence of such a model continues to transform lives and make it easier for more women to support and provide basic education to their children.
• Family and Domestic Violence: Enhancing Protective Factors Current partner Previous partner Percentage of children When children are exposed to violence, they encounter numerous difficulties in their various levels of development.
• Domestic Violence in Women’s Experiences Worldwide Despite the fact the author of the article discusses a controversial problem of domestic violence against women based on the data from recent researches and focusing on such causes for violence as the problematic economic […]
• Parenting in Battered Women: The Effects of Domestic Violence In this study, ‘Parenting in Battered Women: The Effects of Domestic Violence on Women and their Children,’ Alytia A. It is commendable that at this stage in stating the problem the journalists seek to conclude […]
• Domestic Violence Types and Causes This is acknowledged by the law in most countries of the world as one of the most brutal symbols of inequality.
• Alcohol and Domestic Violence in Day-To-Day Social Life My paper will have a comprehensive literature review that will seek to analyze the above topic in order to assist the reader understand the alcohol contributions in the domestic and social violence in our society.
• Power and Control: Domestic Violence in America The abusive spouse wants to feel powerful and in control of the family so he, usually the abusive spouse is the man, beats his wife and children to assert his superiority.
• Domestic or Intimate Partner Violence Intervention Purpose of the study: The safety promoting behavior of the abused women is to be increased using a telephone intervention. They were allocated to either of the groups by virtue of the week of enrolment […]
• Substance Abuse and Domestic Violence: Comprehensive Discussion Substance abuse refers to the misuse of a drug or any other chemical resulting in its dependence, leading to harmful mental and physical effects to the individual and the wellbeing of the society.
• Environmental Trends and Conditions: Domestic Violence in the Workplace Despite the fact that on average the literacy rate and the rate of civilization in the world have been increasing in the past few decades, the statistics for domestic violence have been increasing on an […]
• Domestic Violence in the Organizations Despite the fact that on average the literacy rate and the rate of civilization in the world has been increasing in the past few decades, the statistics for domestic violence have been increasing on an […]
• Domestic Violence and Honor Killing Analysis Justice and gender equality are important aspects of the totality of mankind that measure social and economic development in the world. The cultural justification is to maintain the dignity and seniority framework of the family.
• Facts About Domestic Violence All aspects of the society – which starts from the smallest unit, that is the family, to the church and even to the government sectors are all keen on finding solutions on how to eliminate, […]
• Domestic Violence in Marriage and Family While there are enormous reports of intimate partner homicides, murders, rapes, and assaults, it is important to note that victims of all this violence find it very difficult to explain the matter and incidents to […]
• One-Group Posttest-Only Design in the Context of Domestic Violence Problem This application must unveil the risks and their solutions by researching the variables and the threats to the validity of the research.
• Domestic Violence as a Social Issue It is one of the main factors which stimulate the study’s conduction, and among the rest, one can also mention the number of unexplored violence questions yet to be answered.
• Reflections on Domestic Violence in the Case of Dr. Mile Crawford Nevertheless, the only way out of this situation is to escape and seek help from the legal system. From a personal standpoint, to help her would be the right thing to do.
• Gender Studies: Combating Domestic Violence The purpose of this paper is to provide a detailed description of domestic violence, as well as the development of an action plan that can help in this situation.
• Domestic Violence Funding and Impact on Society The number of domestic violence cases in the US, both reported and unreported, is significant. The recent decision of Trump’s administration to reduce the expenses for domestic violence victims from $480,000,000 to $40,000,000 in the […]
• Campaign against Domestic Violence: Program Plan In addition, men who used to witness aggressive behavior at home or in the family as children, or learned about it from stories, are two times more disposed to practice violence against their partners than […]
• Domestic Violence and Bullying in Schools It also states the major variables related to bullying in schools. They will confirm that social-economic status, gender, and race can contribute to bullying in schools.
• Domestic Violence Within the US Military In most of the recorded domestic violence cases, females are mostly the victims of the dispute while the males are the aggressors of the violence.
• Reporting Decisions in Child Maltreatment: A Mixed Methodology Approach The present research aims to address both the general population and social workers to examine the overall attitudes to the reporting of child maltreatment.
• Domestic Violence in Australia: Budget Allocation and Victim Support On the other hand, the allocation of financial resources with the focus on awareness campaigns has also led to a lack of financial support for centres that provide the frontline services to victims of domestic […]
• Domestic Violence and Social Interventions In conclusion, social learning theory supports the idea that children have a high likelihood of learning and simulating domestic violence through experiences at home.
• Domestic Violence and Child’s Brain Development The video “First Impressions: Exposure to Violence and a Child’s Developing Brain” answers some questions of the dependence of exposure to domestic violence and the development of brain structures of children. At the beginning of […]
• Local Domestic Violence Victim Resources in Kent The focus of this paper is to document the local domestic violence victim resources found within a community in Kent County, Delaware, and also to discuss the importance of these resources to the community.
• The Impact of Domestic Violence Laws: Social Norms and Legal Consequences I also suppose that some of these people may start lifting their voices against the law, paying particular attention to the idea that it is theoretically allowable that the law can punish people for other […]
• Domestic Violence Abuse: Laws in Maryland The Peace and Protective Orders-Burden of Proof regulation in Maryland and the Violence against Women Act are some of the laws that have been created to deal with domestic violence.
• Nondiscriminatory Education Against Domestic Violence The recent event that prompted the proposed advocacy is the criticism of a banner that depicts a man as the victim of abuse.
• Domestic Violence in International Criminal Justice The United Nations organization is deeply concerned with the high level of violence experienced by women in the family, the number of women killed, and the latency of sexual violence.
• Project Reset and the Domestic Violence Court The majority of the decisions in courts are aimed to mitigate the effects of the strict criminal justice system of the United States.
• Same-Sex Domestic Violence Problem Domestic violence in gay or lesbian relationships is a serious matter since the rates of domestic violence in such relationships are almost equivalent to domestic violence in heterosexual relationships. There are a number of misconceptions […]
• Domestic, Dating and Sexual Violence Dating violence is the sexual or physical violence in a relationship which includes verbal and emotional violence. The rate of sexual violence in other nations like Japan and Ethiopia, range from 15 to 71 percent.
• Anger Management Counseling and Treatment of Domestic Violence by the Capital Area Michigan Works These aspects include: the problem that the program intends to solve, the results produced by the program, the activities of the program, and the resources that are used to achieve the overall goal.
• Understanding Women’s Responses to Domestic Violence The author’s research orientation is a mix of interpretive, positivism and critical science – interpretive in informing social workers or practitioners on how to enhance their effectiveness as they deal with cases related to violence […]
• Poverty and Domestic Violence It is based on this that in the next section, I have utilized my educational experience in order to create a method to address the issue of domestic violence from the perspective of a social […]
• Evaluation of the Partnership Against Domestic Violence According to the official mission statement of the organization, PADV is aimed at improving the overall wellbeing of families all over the world and helping those that suffer from domestic violence The organization’s primary goal […]
• Cross-Cultural Aspects of Domestic Violence This is one of the limitations that should be taken account. This is one of the problems that should not be overlooked.
• Domestic Violence in the Lives of Women She gives particular focus on the social and traditional aspects of the community that heavily contribute to the eruption and sustenance of violence against women in households. In the part 1 of the book, Renzetti […]
• Financial Planning and Management for Domestic Violence Victims Acquisition of resources used in criminal justice require financial resources hence the need to manage the same so as to provide the best machines and equipments.
• Effects of Domestic Violence on Children Development In cases where children are exposed to such violence, then they become emotionally troubled: In the above, case them the dependent variable is children emotions while the independent variable is domestic violence: Emotions = f […]
• Evaluation of Anger Management Counseling and Treatment of Domestic Violence by the Capital Area Michigan Works These aspects include: the problem that the program intends to solve, the results produced by the program, the activities of the program, and the resources that are used to achieve the overall goal.
• Knowledge and Attitudes of Nurses Regarding Domestic Violence and Their Effect on the Identification of Battered Women In conducting this research, the authors sought the consent of the prospective participants where the purpose of the study was explained to participants and confidentiality of information to be collected was reassured.
• Domestic Violence Dangers Mount With Economic, Seasonal Pressures These variables are believed to be able to prompt the family to explore the experiences and meanings of stress and stress management.
• Impact of the Economic Status on Domestic Violence This article investigates the possible factors that may help in explaining the status of women who are homeless and their capacity to experience domestic violence.
• Dominance and “Power Plays” in Relationships to Assist Clients to Leave Domestic Violence According to psychologists, the problem of domestic violence is based on the fact that one partner needs to be in control of the other.
• Social Marketing Campaign on Domestic Violence In this marketing campaign strategy the focus would be centered on violence against women, as a form of domestic violence that is currently experience in many countries across the globe.
• Art Therapy With Women Who Have Suffered Domestic Violence One of the most significant benefits of art therapy is the fact the patients get to understand and interpret their own situations which puts them in a better position to creatively participate in own healing […]
• Collaborative Crisis Intervention at a Domestic Violence Shelter The first visit is meant to collect the information that the professional in domestic violence deem crucial concerning the precipitating incidence and history of violence.
• Domestic Violence Exposure in Colombian Adolescents In this topic, the authors intend to discover the extent of association of drug abuse to domestic violence exposure, violent and prosocial behavior among adolescents.
• Domestic Violence and Social Initiatives in Solving the Problem The absence of the correct social programs at schools and the lack of desire of government and police to pay more attention to the prevention of the problem while it is not too late are […]
• Domestic Violence in the African American Community Previous research has suggested this due to the many causes and effects that are experienced by the members and especially the male members of the African American community.
• Domestic Violence: Predicting and Solutions There are several factors which predict the state of domestic violence in the future and this will help in preventing domestic violence.
• Domestic Violence: Signs of Abuse and Abusive Relationships The unprecedented rejuvenation of such a vile act, prompted the formation of factions within society, that are sensitive to the plight of women, and fight for the cognizance of their rights in society.
• Domestic Violence against South Asian Women Again, this strategy is premised on the idea that domestic violence can be explained by the financial dependence of women in these communities.
• The Effects of Domestic Violence According to statistics and research provided in the handout, women are at a higher risk of being victims of domestic violence.
• Effect of Domestic Violence on Children This is done with the aim of ensuring that the child is disciplined and is meant as a legitimate punishment. Most of our children have been neglected and this has contributed to the increase in […]
• Domestic Violence and Elderly Abuse- A Policy Statement Though this figure has been changing with the change in the method of survey that was conducted and the nature of samples that were taken during the research process, it is widely accepted fact that […]
• Domestic Violence as a Social and Public Health Problem The article, authored by Lisa Simpson Strange, discusses the extent of domestic violence especially in women and the dangers it exposes the victims to, insisting that severe actions should be taken against those who commit […]
• Guilty until Proven Otherwise: Domestic Violence Cases The presumption of the guilt of a man in domestic violence cases is further proven by the decision of the court in which the man is required to post a bond despite the fact that […]
• Community and Domestic Violence; Gang Violence Solitude, peer pressure, need to belong, esteem, and the excitement of the odds of arrest entice adolescents to join these youth gangs.
• Fighting Domestic Violence in Pocatello, Idaho Having realized the need to involve the family unit in dealing with this vice, Walmart has organized a sensitization program that will involve the education of whole family to increase awareness on the issue. The […]
• What Is the Purpose of Studying Domestic Violence?
• What Does Theory Explain Domestic Violence?
• What Is the Difference Between IPV and Domestic Violence?
• What Age Group Does Domestic Violence Affect Most?
• When Domestic Violence Becomes the Norm?
• How Are Domestic Violence Problems Solved in American and Other Cultures?
• What Are the 3 Phases in the Domestic Violence Cycle?
• How Can Domestic Violence Be Explained?
• How Many Deaths Are Caused by Domestic Violence?
• When Was Domestic Violence First Defined?
• How Is a Domestic Violence Prevention?
• How Race, Class, and Gender Influences Domestic Violence?
• Why Do Victims of Abuse Sometimes Stay Silent?
• How Does Domestic Violence Affect the Brain?
• Is Mental Illness Often Associated With Domestic Violence?
• How Does Domestic Violence Affect a Person Emotionally?
• How Does Domestic Violence Affect Children’s Cognitive Development?
• Why Should Employers Pay Attention to Domestic Violence?
• What Are the Causes of Domestic Violence?
• What Country Has the Highest Rate of Domestic Violence?
• How Does Domestic Violence Affect the Lives of Its Victims?
• What Are the Possible Causes and Signs of Domestic Violence?
• How Does Socioeconomic Status Affect Domestic Violence?
• How Does the Australian Criminal Justice System Respond to Domestic Violence?
• How Does Culture Affect Domestic Violence in the UK?
• What Is the Psychology of an Abuser?
• What Is Police Doing About Domestic Violence?
• How Does the Government Define Domestic Violence?
• What Profession Has the Highest Rate of Domestic Violence?
• What Percent of Domestic Violence Is Alcohol-Related?
• Family Relationships Research Ideas
• Alcohol Abuse Paper Topics
• Drug Abuse Research Topics
• Child Welfare Essay Ideas
• Childhood Essay Topics
• Sexual Abuse Essay Titles
• Divorce Research Ideas
• Gender Stereotypes Essay Titles
• Chicago (A-D)
• Chicago (N-B)

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Domestic violence affects millions of Americans and people around the world. It creates unsafe homes, toxic relationships, and can severely harm the victims who endure the violence. Whether you are interested in learning more about this topic, finding help and resources for yourself or your friends, or conducting academic research, this guide will point you to interesting and relevant sources.

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If you're just starting to learn about domestic violence, try these resources to find out what it involves, who's affected, and what's happening around the country and the world.

• CQ Researcher: Domestic Violence Provides in-depth article on many high-interest topics, with historical and current information, and resources to continue your research.
• VAWNet (National Resource Center on Domestic Violence) Large collection of reports on almost every facet of violence against women, including a section on international issues.
• Maine Coalition against Sexual Assault (MECASA) Provides training for service providers that deal with sexual assault cases in the state of Maine. Research page has large list of research topics and statistics.

• Google News: Domestic Violence
• MedLine Plus: Domestic Violence Hosted by the National Library of Medicine, a roundup of the latest news, reports and articles.
• World Health Organization: Violence against Women Information and reports by WHO on various topics.
• US Department of Justice: Violence against Women: Reports to Congress Statistical and analytic reports submitted to Congress from this office.
• CDC: Sexual Violence The CDC has many reports, statistics, and analysis of various forms of sexual and domestic violence.
• UMaine Title IX Student Services
• University of Maine Counseling Center
• Rape Response Services Provides hotlines, help groups, and advocacy for Piscataquis and Penobscot county in Maine.
• Partners for Peace Located in Maine, Partners for Peace provides shelter for women and children, a hotline, advocacy and legal services.
• DomesticShelters.org Find available shelters and help anywhere in the nation.
• National Domestic Violence Hotline Offers hotline and advocacy services.
• Maine Coalition to End Domestic Violence (MCEDV) Offers hotline, advocacy and training as well as a wealth of information on how to recognize and end domestic violence (including elder abuse and teen dating violence).

• Domestic Violence and Elder Abuse
• Intimate Partner Violence: Understanding Factors that Impact Survivors

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Domestic violence describes abuse perpetrated by one partner against another in the context of an interpersonal relationship. Domestic violence can be committed by current or former partners. The alternate term intimate partner violence has gained favor in the twenty-first century, as it expands the definition to include relationships between couples who are not married or cohabiting. Family violence further extends the scope of the issue to consider cases in which other immediate family members are victimized by violent or abusive behavior.

The prevalence of domestic and intimate partner violence is difficult to determine, as these forms of violence often remain unreported. For example, according to the US Department of Justice's Office for Victims of Crime, reports of intimate partner violence...  ( Opposing Viewpoints )

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55 Media Violence Essay Topics

🏆 best essay topics on media violence, 🎓 most interesting media violence research titles, 💡 simple media violence essay ideas.

• Does Media Violence Cause Violent Behavior?
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• Graphic Violence on Social Media and Its Impact on Young Adults
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• The Effects of Media Violence Exposure and Dark Personality Traits
• A Sociological Perspective on Television Violence and Aggression
• The Effects of Media Violence on Anxiety in Emerging Adults
• Long-Term Effects of Repeated Exposure to Media Violence in Childhood
• Desensitizing Effects of Violent Media on Helping Others
• Aggression and Popular Media: From Violence in Entertainment Media to News Coverage of Violence
• The Impact of Mass Media Violence on Homicides in the US
• Media Violence and Judgments of Offensiveness: A Quantitative and Qualitative Analysis
• Examining Media Violence Effects on Cooperative Behavior
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• The Relationship Between Exposure to Media Violence and School Bullying
• Examining the Immediate Effects of Media Violence on Behavior
• Direct and Indirect Relationship Between Media Violence Exposure and Cyberbullying Perpetration
• The Mediating Role of Sympathy in the Relationship Between Media Violence and Adolescents’ Social Behaviors
• The Evolution of Scientific Skepticism in the Media Violence Debate
• Media Violence in Inducing Neural Changes During Emotional Face Processing
• Catharsis and Media Violence: A Conceptual Analysis
• Examining Exposure to Graphic Media Violence Through a Theory of Vivid Media Violence
• Media Violence and Adolescents’ ADHD-Related Behaviors: A Genetic Susceptibility Perspective
• Types of Media Violence and Degree of Acceptance in Under‐18s
• The Effects of a Media Literacy Program on Critical Attitudes Toward Media Violence
• Investigating How Media Violence Causes Antisocial Behavior
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• The Interplay of Media Violence Effects and Behaviorally Disordered Individuals
• Violent Video Games as the Newest Media Violence Hazard
• Aggression‐Consistent, ‐Inconsistent, and ‐Irrelevant Priming Effects on Selective Exposure to Media Violence

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Domestic violence against women in India: A systematic review of a decade of quantitative studies

Ameeta kalokhe.

a Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA

b Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA

Carlos del Rio

Kristin dunkle.

c Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA, USA

Rob Stephenson

d Center for Sexuality and Health Disparities, University of Michigan School of Public Health and School of Nursing, Ann Arbor, MI, USA

Nicholas Metheny

Anuradha paranjape.

e General Internal Medicine, Temple University School of Medicine, Philadelphia, PA, USA

Seema Sahay

f Department of Social and Behavioral Sciences, National AIDS Research Institute, Pune, India

Associated Data

Domestic violence (DV) is prevalent among women in India and has been associated with poor mental and physical health. We performed a systematic review of 137 quantitative studies published in the prior decade that directly evaluated the DV experiences of Indian women to summarise the breadth of recent work and identify gaps in the literature. Among studies surveying at least two forms of abuse, a median 41% of women reported experiencing DV during their lifetime and 30% in the past year. We noted substantial inter-study variance in DV prevalence estimates, attributable in part to different study populations and settings, but also to a lack of standardisation, validation, and cultural adaptation of DV survey instruments. There was paucity of studies evaluating the DV experiences of women over age 50, residing in live-in relationships, same-sex relationships, tribal villages, and of women from the northern regions of India. Additionally, our review highlighted a gap in research evaluating the impact of DV on physical health. We conclude with a research agenda calling for additional qualitative and longitudinal quantitative studies to explore the DV correlates proposed by this quantitative literature to inform the development of a culturally tailored DV scale and prevention strategies.

Introduction

Domestic violence (DV), defined by the Protection of Women from Domestic Violence Act 2005 as physical, sexual, verbal, emotional, and economic abuse against women by a partner or family member residing in a joint family, plagues the lives of many women in India. National statistics that utilise a modified version of the Conflict Tactics Scale (CTS) to measure the prevalence of lifetime physical, sexual, and/or emotional DV estimate that 40% of women experience abuse at the hands of a partner ( Yoshikawa, Agrawal, Poudel, & Jimba, 2012 ). Data from a recent systematic review by the World Health Organization (WHO) provides similar regional estimates and suggests that women in South-East Asia (defined as India, Maldives, Sri Lanka, Thailand, Bangladesh, and Timor-Leste) are at a higher likelihood for experiencing partner abuse during their lifetime than women from Europe, the Western Pacific, and potentially the Americas ( WHO, 2013 ).

Among the different proposed causes for the high DV frequency in India are deep-rooted male patriarchal roles ( Visaria, 2000 ) and long-standing cultural norms that propagate the view of women as subordinates throughout their lifespan ( Fernandez, 1997 ; Gundappa & Rathod, 2012 ). Even before a child is born, many families have a clear preference for male children, which may result in their preferential care, and worse, sex-selective abortions, female infanticide and abandonment of the girl-child ( Gundappa & Rathod, 2012 ). During childhood, less importance is given to the education of female children; further, early marriage as occurs in 45% of young, married women, according to 2005–2006 National Family Health Survey (NFHS-3) data ( Raj, Saggurti, Balaiah, & Silverman, 2009 ), may also heighten susceptibility to DV ( Ackerson, Kawachi, Barbeau, & Subramanian, 2008 ; Raj, Saggurti, Lawrence, Balaiah, & Silverman, 2010 ; Santhya et al., 2010 ; Speizer & Pearson, 2011 ). In reproductive years, mothers pregnant with and/or those who give birth to only female children may be more susceptible to abuse ( Mahapatro, Gupta, Gupta, & Kundu, 2011 ) and financial, medical, and nutritional neglect. Later in life, culturally bred views of dishonour associated with widowhood may also influence susceptibility to DV by other family members ( Saravanan, 2000 ).

In addition to being prevalent in India, DV has also been linked to numerous deleterious health behaviours and poor mental and physical health. These includes tobacco use ( Ackerson, Kawachi, Barbeau, & Subramanian, 2007 ), lack of contraceptive and condom use ( Stephenson, Koenig, Acharya, & Roy, 2008 ), diminished utilisation of health care ( Sudha & Morrison, 2011 ; Sudha, Morrison, & Zhu, 2007 ), higher frequencies of depression, post-traumatic stress disorder (PTSD), and attempted suicide ( Chandra, Satyanarayana, & Carey, 2009 ; Chowdhury, Brahma, Banerjee, & Biswas, 2009 ; Maselko & Patel, 2008 ; Shahmanesh, Wayal, Cowan, et al., 2009 ; Shidhaye & Patel, 2010 ; Verma et al., 2006 ), sexually transmitted infections (STI) ( Chowdhary & Patel, 2008 ; Sudha & Morrison, 2011 ; Weiss et al., 2008 ), HIV( Gupta et al., 2008 ; Silverman, Decker, Saggurti, Balaiah, & Raj, 2008 ), asthma ( Subramanian, Ackerson, Subramanyam, & Wright, 2007 ), anaemia ( Ackerson & Subramanian, 2008 ), and chronic fatigue ( Patel et al., 2005 ). Furthermore, maternal intimate partner violence (IPV) experiences have been associated with more terminated, unintended pregnancies ( Begum, Dwivedi, Pandey, & Mittal, 2010 ; Yoshikawa et al., 2012 ), less breastfeeding ( Shroff et al., 2011 ), perinatal care ( Koski, Stephenson, & Koenig, 2011 ), and poor child outcomes ( Ackerson & Subramanian, 2009 ). These negative health repercussions and high DV frequency speak to the need for the development of effective DV prevention and management strategies. And, the development of effective DV interventions first requires valid measures of occurrence and an in-depth understanding of its epidemiology.

While many aspects of DV are similar across cultures, recent qualitative studies describe how some aspects of the DV experienced by women in India may be unique. These studies highlight the role of non-partner DV perpetrators for those living in both nuclear and joint-families ( Fernandez, 1997 ; Kaur & Garg, 2010 ; Raj et al., 2011 ). (These families are patrilineal where male descendants live with their wives, offspring, parents, and unmarried sisters.) They discuss the high frequency and near normalisation of control, psychological abuse, neglect, and isolation, the occurrence of DV to women at both extremes of age (young and old), dowry harassments, control over reproductive choices and family planning, and demonstrate the use of different tools to inflict abuse (i.e. kerosene burning, stones, and broomsticks as opposed to gun and knife violence more commonly seen in industrialised nations) ( Bunting, 2005 ; Go et al., 2003 ; Hampton, 2010 ; Jutla & Heimbach, 2004 ; Kaur & Garg, 2010 ; Kermode et al., 2007 ; Kumar & Kanth, 2004 ; Peck, 2012 ; Rastogi & Therly, 2006 ; Sharma, Harish, Gupta, & Singh, 2005 ; Stephenson et al., 2008 ; Wilson-Williams, Stephenson, Juvekar, & Andes, 2008 ).

This paper presents a systematic review of the quantitative studies conducted over the past decade that estimate and assess DV experienced by women in India, and evaluates their scope and capacity to measure the DV themes highlighted by recent qualitative studies. It aims to examine the distribution of the prevalence estimates provided by the recent literature of DV occurrence in India, improve understanding of the factors that may affect these prevalence estimates, and identify gaps in current studies. This enhanced knowledge will help inform future research including new interventions for the prevention and management of DV in India.

We utilised PubMed, OVID, Cochrane Reviews, PsycINFO, and CINAHL as search engines to identify articles published between 1 April 2004 and 1 January 2015 that focused on the DV experiences of women in India ( Figure 1 ). Our specific search terms included ‘domestic violence’, ‘intimate partner violence’, ‘spouse abuse’, ‘partner violence’, ‘gender-based violence’, ‘sexual violence’, ‘physical violence’, ‘wife battering’, ‘wife beating’, ‘domestic abuse’, ‘violence’, and ‘India’. We first removed duplicate articles and then filtered the articles based on our inclusion criteria: quantitative studies evaluating original data that had been published in English and directly surveyed the DV experiences of women. While we recognise that in cultures where DV is commonplace the reporting of DV perpetration by men may be as high as the frequency of experiencing DV reported by women ( Koenig, Stephenson, Ahmed, Jejeebhoy, & Campbell, 2006 ), we restricted our eligibility criteria to studies directly surveying women about their DV experiences to reduce further inter-study variation and allow for more accurate cross-study comparisons. We excluded reviews, case reports, meta-analyses, and qualitative studies. A single author (ASK or NM) reviewed each individual article to determine whether it met inclusion criteria. If questions arose regarding its inclusion into the review, they were discussed with a second author (SS) until concordance was reached regarding whether or not the paper was to be included.

Adapted PRISMA Flow Diagram demonstrating study selection methodologies and filter results.

Note: An initial PubMed search of articles published between 1 April 2004 and 1 January 2015 focusing on the DV experiences of women in India is depicted. This figure illustrates the search terms, search engines, applied inclusion and exclusion filters, the process by which articles were chosen to be included in the study, and the results of the selection process.

We collected data from each study regarding study population; study setting; use of a validated scale; forms of, perpetrators of, and time frame during which DV was measured; whether an attempt was made to measure severity of DV; whether potential DV correlates were evaluated; and whether DV prevalence was estimated. We subcategorised the forms of violence into physical, sexual, psychological, control, and neglect based on descriptions of questions provided in the studies. Emotional and verbal forms of abuse were classified as psychological abuse and deprivation was classified as neglect. If the study asked participants about agency or autonomy, this was noted in the summary tables. In publications where information about the DV assessment tool and its validation was not provided, we contacted the authors for more information. If authors reported having conducted formative fieldwork to generate questions, pre-tested the items, and/or conducted some assessment of the measurement tool’s expert or face validity, we reported the validation as ‘limited’. If we did not hear back from the authors, we stated the data were ‘not reported’.

Article yield of systematic search

Our initial search of DV articles published in PubMed, OVID, Cochrane Reviews, PsycINFO, and CINAHL between 1 April 2004 and 1 January 2015 yielded 3843 articles ( Figure 1 ). We identified 628 articles using search terms ‘domestic violence’ and ‘India’, 283 articles using ‘intimate partner violence’ and ‘India’, 98 articles using ‘spouse abuse’ and ‘India’, 221 articles using ‘partner violence and India’, 54 articles using ‘gender-based violence’ and ‘India’, 199 articles using ‘sexual violence’ and ‘India’, 120 articles using ‘physical violence’ and ‘India’, 1 article using ‘wife battering’ and ‘India’, 51 articles using ‘wife beating’ and ‘India’, 10 articles using ‘domestic abuse’ and ‘India’, and 2022 articles using ‘violence’ and ‘India’. Of the 3843 articles, 3705 articles were removed because they (1) were duplicated in the search, (2) focused on extraneous topics, (3) lacked Indian context, (4) were not based on original quantitative data, or (5) were based on study data that were not directly obtained through surveying women about their personal DV experiences. Thus, the selection criteria yielded a total of 137 studies examining the DV experiences of women in India: 14 international studies (see Table 1 in supplementary material ), 50 multi-state India studies (see Table 2 in supplementary material ), and 73 single-state India studies (see Table 3 in supplementary material ).

The scope and breadth of recent studies: study populations

Collectively, the reviewed studies provide information on the DV experienced by young and middle-aged women in traditional heterosexual marriages from both urban and rural environments, joint and nuclear families, across Indian states ( Figure 2 ). Among the studies specifying age limits, the vast majority (88% or 92/104) evaluated DV experienced by women age 15–50, with only 11% (11/104) of studies surveying DV suffered by women above age 50 and 1% (1/104) evaluating DV experienced by young adolescents (wed before age 15). Only one study assessed DV experienced by women in HIV discordant. No studies surveyed DV in non-traditional relationships, such as same-sex relationships or live-in relationships. Less than one-third (29% or 40/137) collected data differentiating DV experienced by women in joint versus nuclear families. Thirty-seven per cent (51/137) evaluated domestic abuse suffered by women living in urban settings, 18% (24/137) in rural, and the remainder (44% or 60/137) in both rural and urban environments. Only one examined DV experienced by women residing in tribes. Twenty-three per cent (32/137) and 3% (4/137) utilised a nationally representative and sub-nationally representative study population, respectively. Southern Indian states were by far the most surveyed in the literature (Maharashtra 66 studies, Tamil Nadu 59 studies, and Karnataka 51 studies) and Northern Indian states the least (Uttaranchal, Sikkim, Punjab, Haryana, Chhattisgarh, and Assam each with 33 studies).

A summary of the distribution of recent Indian DV literature by region, state, surveyed perpetrator, and family type.

Note: (a) demonstrates the distribution of studies by rural versus urban region, (b) by state, (c) by the perpetrator surveyed, and (d) whether the survey collected data differentiating DV in joint versus nuclear family households.

Prevalence of DV in India

Collectively, the reviewed studies demonstrate that DV occurs among Indian women with high frequency but there is substantial variation in the reported prevalence estimates across all forms of DV ( Figure 3 ). For example, the median and range of lifetime estimates of psychological abuse was 22% (range 2–99%), physical abuse was 29% (2–99%), sexual abuse was 12% (0–75%), and multiple forms of DV was 41% (18–75%). The outliers at the upper extremes were contributed by a study of in low-income slum communities with high prevalence of substance abuse( Solomon et al., 2009 ) and a second study conducted in a tertiary care centre where surveys were self-administered and thus participants may have felt increased comfort in reporting DV( Sharma & Vatsa, 2011 ). The median and range of past-year estimates of psychological abuse was 22% (11–48%), physical abuse was 22% (9–90%), sexual abuse was 7% (0–50%), and multiple forms of DV was 30% (4–56%). The outlier of 90% for physical abuse was contributed by a study of women whose husbands were alcoholics in treatment ( Stanley, 2012 ). As expected, higher DV prevalence was noted when multiple forms of DV were assessed. Of all forms of DV, physical abuse was measured most frequently, with psychological abuse, sexual abuse, and control or neglect receiving substantially less attention. Further statistical analysis beyond these descriptive statistics was not conducted due to the large inter-study heterogeneity of designs and populations limiting comparability across studies.

A summary of the lifetime and past 12-month prevalence estimates of the various forms of DV as documented by each individual study.

Note: Circles, squares, upright triangles, and inverted triangles represent prevalence estimates of psychological, physical, sexual, and multiple forms of DV, respectively, as provided by each individual study. While medians and ranges are provided, further analysis was not carried out due to the limited homogeneity between studies impeding accurate comparison.

The scope and breadth of recent studies: study design

The past decade of quantitative India DV research has included a breadth of large regional and international studies as well as smaller scale, single-state studies. However, the capacity to draw causal inferences from this literature has been limited by the nearly exclusive use of cross-sectional design. The country and regional-level studies utilised larger, often nationally or sub-nationally representative samples (average sample size: 25,857 women, range: 111–124,385), to provide inter-country or regional epidemiologic comparisons. The single-state studies tended to use smaller sample sizes (average: 1109 women, range: 30–9639) to provide a more in-depth evaluation of DV experienced in a particular population of women.

The vast majority of all reviewed studies utilised cross-sectional design, with only 12% (17/137) using a prospective design to draw causal inferences. Six of these 13 utilised the NFHS-2 and four-year follow-up data from the rural regions of four states to evaluate the effect of DV on mental health disorders ( Shidhaye & Patel, 2010 ), a woman’s adoption of contraception, occurrence of unwanted pregnancy ( Stephenson et al., 2008 ), uptake of prenatal care ( Koski et al., 2011 ), early childhood mortality ( Koenig et al., 2010 ), functional autonomy and reproduction ( Bourey, Stephenson, & Hindin, 2013 ), and contraceptive adoption ( Stephenson, Jadhav, & Hindin, 2013 ), while one used the data to evaluate the effect of autonomy on experience of physical violence ( Nongrum, Thomas, Lionel, & Jacob, 2014 ; Sabarwal, Santhya, & Jejeebhoy, 2014 ). Only one study employed a case-control study to evaluate the link between DV and child mortality ( Varghese, Prasad, & Jacob, 2013 ) and another utilised a randomised control design to evaluate the effect of a mixed individual and group women’s behavioural intervention in reducing DV and marital conflict over time ( Saggurti et al., 2014 ). The remainder of prospective studies evaluated the causal association between DV and incident STIs and/or attempted suicide ( Chowdhary & Patel, 2008 ; Maselko & Patel, 2008 ; Weiss et al., 2008 ), DV and maternal and neonatal health outcomes ( Nongrum et al., 2014 ), the effect of the type of interviewing (face-to-face versus audio computer-assisted self-interviews) on DV reporting ( Rathod, Minnis, Subbiah, & Krishnan, 2011 ), trends in DV occurrence over time ( Simister & Mehta, 2010 ), and the effect of change in a woman or her spouse’s employment status on her experience of DV ( Krishnan et al., 2010 ).

The scope and breadth of recent studies: DV measures

Only 61% (84/137) of studies reported use of a validated scale or made attempts to validate the instrument they ultimately used. When use of a validated instrument was reported, most (82% or 69/84) had been developed for the cultural context of North America and Europe (i.e. modified CTS, Abuse Assessment Screen, Index of Spouse Abuse, Woman Abuse Screening Tool, Partner Violence Screen, Composite Abuse Scale, and Sexual Experience Scale). In fact, only 15 of the studies reporting use of a validated questionnaire adapted or developed their instrument to the Indian context by surveying themes raised by the prior qualitative literature (i.e. use of belts, sticks, and burning to inflict physical abuse, restricting return to natal family home, not allowing natal family to visit marital home). As expected, these studies reported higher frequencies of DV. In personal communication, some authors who chose not to use validated, widely used DV scales (i.e. CTS) stated they did so because of space limitations and inadequacy of existing tools for measuring DV in the Indian cultural context.

Two-thirds of studies (64% or 87/137) assessed two or fewer forms of DV. Of all forms of DV, physical abuse was evaluated most frequently (96% or 131/137), followed by sexual abuse (58% or 79/137), psychological abuse (44% or 60/137), neglect and control (4% or 7/137). Only 11% (15/137) of studies evaluated DV perpetrated by non-partner family members. For these studies evaluating DV perpetrated by partners and non-partner family members, available estimates of lifetime sexual and psychological abuse were always higher than the median prevalence estimates of reviewed studies; available estimates of lifetime physical abuse were often, but not universally, higher. Only 20% (109/137) attempted to evaluate different levels of DV severity. While many (43% or 59/137) studies evaluated lifetime violence, a considerable number assessed recent DV (42% or 58/137 past-12 month DV, 5% or 7/137 past-6 month DV, 4% or 5/137 past-3 month DV, and 4% or 6/137 the time period of current or research partnerships). Additionally, 10% (14/137) evaluated DV occurrence during pregnancy or the peri-partum period.

The scope and breadth of recent studies: measured outcomes

Figure 4 provides a framework for synthesising the potential DV correlates measured to date. It demonstrates that the focus of the quantitative literature has largely been on the mental health and gynecologic consequences of DV but has only begun to evaluate repercussions on physical health and health behaviour. Twelve per cent (16/137) of the studies evaluated one or multiple mental health disorder as outcomes of DV, including PTSD, depression, and suicide, but not anxiety. The literature provided a comprehensive evaluation of the association between DV and gynaecologic health including sexual (15% or 21/137) and maternal health (8% or 11/137). However, only six studies were dedicated to evaluating physical health outcomes (oral health, nutrition, chronic fatigue, asthma, direct injury, and blindness during pregnancy). And while 17 studies were dedicated to evaluating the association between DV and uptake of health behaviours, 11 of the 15 were focused on behaviours related to sexual and maternal health. Thus, the association between health behaviours like the woman’s substance abuse and adherence to medical and clinical care remains largely understudied, as does the link between DV and physical health outcomes such as cardiovascular and gastrointestinal disease, chronic pain syndromes (including migraines), and urinary tract infections.

A framework for conceptualising the reviewed studies.

Note: The proposed framework provides structure for interpreting and synthesising the prior decade’s quantitative research evaluating the domestic violence experienced by women in India.

The past 10 years have been an incredible period of growth in DV research in India and South Asia. Our systematic review contributes to the growing body of evidence by providing an important summary of the epidemiologic studies during this critical period and draws attention to the magnitude and severity of the ongoing epidemic in India. Comprehensively, the reviewed literature estimates that 4 in 10 Indian women (when surveyed about multiple forms of abuse) report experiencing DV in their lifetime and 3 in 10 report experiencing DV in the past year. This is concordant with the WHO lifetime estimate of 37.7% (95% CI: 30.9%43.1%) in South-East Asia (defined as India, Maldives, Sri Lanka, Thailand, Bangladesh, and Timor-Leste) and is higher than the regional estimates provided by the WHO for the Europe, the Western Pacific, and potentially the Americas. In addition to highlighting the high frequency of occurrence, the studies in this review emphasise the toll DV takes on the lives of many Indian women through its impact on mental, physical, sexual, and reproductive health.

Perhaps the most striking finding of our review was the large inter-study variance in DV prevalence estimates ( Figure 3 ). While this variability speaks to the capacity of the India literature to capture the breadth of DV experiences in different populations and settings, it also underscores the need for standardising aspects of study design in the investigator’s control to make effective inter-study and cross-population comparisons. Standardisation of the instruments used to measure DV should be a priority. To optimise the yield of such an instrument in capturing the DV experiences of Indian women, it should build upon currently available, well-validated instruments, but also be culturally tailored. Thus, it should account for the culturally prominent forms of DV identified by the Indian qualitative literature and social media, survey abuse inflicted by non-partner perpetrators, survey multiple forms abuse (i.e. physical, sexual, psychological, and control), and ideally, include a measure of DV severity (i.e. based on frequency of affirmative responses, frequency of abuse, or resultant injury). Our review demonstrates that current studies fall short, with only 61% reporting use of validated questions (rarely developed or adapted to Indian culture), 11% surveying DV perpetrated by non-partner family members, 64% assessing more than two different forms of abuse, and 20% evaluating level of DV severity. Our review also suggests that when questions assessing DV are culturally adapted and validated, evaluate multiple forms of abuse, and survey abusive behaviours by non-partner family members in addition to partners, reporting of DV increases.

While our search yielded many well-designed cross-sectional studies providing insight into the epidemiology of DV in India (i.e. patterns of occurrence, socio-demographic, and health correlates), it also revealed many gaps and thus, a potential research agenda. Future qualitative studies are needed to examine the link between DV and correlates identified by the cross-sectional literature, to inform the development of future prevention strategies, and to enhance delivery of DV supportive services by examining survivor preferences and needs. Additional longitudinal quantitative studies are also needed to better understand predictors of DV and to explore the direction of causality between DV and the physical health associations identified in the reviewed studies. They are also needed to assess the link between DV and other physical health outcomes like injury, cardiovascular disease, irritable bowel syndrome, immune effects, and psychosomatic syndromes as well as non-sexual health behaviours such as substance abuse and medication adherence. This is particularly paramount in India, where physical injury and cardiovascular disease together account for over a quarter of disability-adjusted life years lost ( National Commission on Macroeconomics and Health, 2005 ).

Additionally, our review also exposed gaps in the current understanding of DV in some populations and regions of India. For example, most studies focused on women of age 15–50. Only 11 reported on the DV experiences of women over 50, a stage where frailty, financial and physical dependence, and culturally engendered shame and disgrace associated with widowhood may heighten their risk of experiencing DV, neglect, and control by various family members ( Solotaroff & Pande, 2014 ). And, while 43% of Indian women aged 20–24 marry before the age of 18, we encountered few studies evaluating DV experienced by pre-adolescents or young adolescents married as children ( UNICEF, 2014 ). An additional gap is in evaluating the DV experiences of women engaging in live-in relationships as opposed to marital relationships, divorced or widowed women, women involved in same-sex relationships, and in HIV serodiscordant and concordant relationships, settings in which social and family support systems are already weakened ( Kohli et al., 2012 ). Next, beyond the national and multi-state data sets, there is little representation of the northern states of India (i.e. Uttaranchal, Sikkim, Punjab, Haryana, Chhattisgarh, and Assam) and of women residing in tribal villages ( Sethuraman, Lansdown, & Sullivan, 2006 ). The vast cultural, religious, and socio-economic inter-regional differences in India highlight the need for more in-depth study of the DV experiences of women in these areas.

The high prevalence of DV and its association with deleterious behaviours and poor health outcomes further speak to the need for multi-faceted, culturally tailored preventive strategies that target potential victims and perpetrators of violence. The recent Five Year Strategic Plan (2011–2016) released by the Ministry of Women and Child Development discusses a plan to pilot ‘one-stop crisis centres for women’ survivors of violence, which would include medical, legal, law enforcement, counselling, and shelter support for themselves and their children. The significant differences in women’s empowerment and DV experience by region and population within India ( Kishor & Gupta, 2004 ) underscore the need to culturally- and regionally tailor the screening and support services provided at such centres. For example, in resource-limited states where sexual forms of DV predominate, priority should be given to the allocation of health-care providers to evaluate, document, and treat associated injuries and/or transmitted diseases. In settings where financial control and neglect are common, legal, financial, and educational empowerment may need to be given precedence.

Our review is not without limitations. First, our analysis relied solely on data directly provided in the publications. We did not further contact the authors if information was not provided. Second, a single author (ASK or NM) reviewed the individual papers for inclusion into the review, which may have introduced a selection bias. We tried to limit this bias through discussion of the papers in which eligibility was not clear-cut with a second author (SS) until agreement about the inclusion status was reached. Next, we included studies whose main intent was to evaluate the DV experiences of Indian women as well as studies whose main aim may not have been related to DV at all, but included DV as a covariate in the analysis. Thus, many of the studies that solely included DV as a covariate may not have had the intent or resources to fully examine the DV experience. While this may be viewed as a limitation, our goal was not to critically evaluate each individual study, but to comprehensively review the information currently provided in the Indian DV literature. Lastly, inclusion of multiple studies that utilise the same data set (e.g. NFHS) may have skewed the overall median estimate of DV prevalence and the remainder of our analysis. We felt, however, that the substantial differences in DV assessment (e.g. measurement time frames, forms of DV assessed, whether DV severity was assessed, and measured health correlates) between these studies legitimised their need to be included as separate entities in the review.

In conclusion, our literature review underscores the need for further studies within India evaluating the DV experiences of older women, women in same-sex relationships, and live-in relationships, extending the assessment of DV perpetrated by individuals besides intimate partners and spouses, and assessing the multiple forms and levels of abuse. It further stresses the necessity for the development and validation (in multiple regions and study populations within India) of a culturally tailored DV scale and interventions geared towards the prevention and management of DV.

Supplementary Material

Tables and table references, acknowledgments.

This work was supported by the US Department of Health and Human Services, National Institutes of Health, Fogarty International Center [grant number 1 R25 TW009337-01 K01 TW009664].

Supplemental data for this article can be accessed at http://dx.doi.org/10.1080/17441692.2015.1119293

Disclosure statement

No potential conflict of interest was reported by the authors.

Ameeta Kalokhe , http://orcid.org/0000-0002-3556-1786

Seema Sahay , http://orcid.org/0000-0001-6064-827X

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Violence Research Paper

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The term violence is used to describe animal and human behavior that threatens to cause or causes severe harm to a target. Most animal studies emphasize variations in aggression and use the concept of extreme aggression (rather than violence) to denote the most serious and injurious behavior. In studying human behavior, violence and aggression are frequently used as synonyms, with violence marked by an extra degree of excessiveness. In some cases, the choice of the term ‘‘aggression’’ or ‘‘violence’’ is a matter or preference or convention. For example, aggression is most commonly used to describe young children’s behavior while such behavior in adolescents is called youth violence. Violence tends to be the preferred term for describing classes of behavior or phenomenon (e.g., domestic violence, media violence, sports violence) without specific reference to the degree of severity involved.

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Different authorities have been extremely variable in their willingness to include a range of actions under the heading of violence. Indeed, there has been much controversy about the term and just what actions should be covered. Some have offered more limited definitions based on constraints such as intentionality, legality, and nature of targets. Each limitation provides a more specific definition with associated advantages and disadvantages. For instance, many definitions of both aggression and violence specify that harm be intentional. Accidentally causing serious injury generally is not considered an act of violence in both common discourse and legal proceedings. However, specifying intentionality poses measurement challenges because violence can no longer be judged by merely observing a behavior; rather, the mental state of the person must be assessed or inferred.

Limiting the definition of violence to ‘‘illegal behaviors’’ that cause harm or injury is consistent with legal guidelines. Such a definition is useful from a policy and control perspective because it covers actions generally considered as violent, including forcible rape, armed robbery, aggravated assault, gang violence, and homicide. A problem with this definition is that the same behavior may be judged illegal or legitimate depending on specific cultural and historical conditions. From this perspective, a behavior would only be considered violent if there were official sanctions against it.

Some definitions of violence include only behavior that is designed to harm others (or animate beings). This focus emphasizes the antisocial and immoral nature of violence as an act against others and society. It is consistent with most contemporary criminal definitions of violence. However, it excludes the self as a target of harm and injury, which is inconsistent with public health definitions of violence that generally include harm to self. Other definitions construe the target even more broadly, extending it to include inanimate objects (e.g., destruction of property).

Classification

Violence is not one behavioral pattern but several. The multifaceted and complex nature of violence has led to a number of proposed guidelines and classification schemes for studying its component parts. Behavioral scientists have worked to develop classifications by grouping together meaningful categories of violence that share common characteristics related to etiology and function. One approach has been to classify violence according to the underlying motivation of the aggressor. A frequently used distinction is between hostile and instrumental motivation. In hostile violence, the major goal is to inflict harm or injury. In other words, hurting is an end in itself. In instrumental violence, actions may cause harm but are not motivated by the desire to cause harm per se. Rather, they are motivated by goals such as taking resources from others. In both cases, this distinction depends on the individual’s intent, not on the act itself.

Although not conceptually clean, this distinction has proved useful. Certain types of violence such as armed robbery, murder-for-hire, and terrorism generally are well planned, goaldirected, instrumental actions. Offenders are acting to maximize their benefits and minimize their costs. Many prominent models of criminal behavior emphasize the rational choice component of crime (e.g., Cornish and Clarke). This type of planned behavior is distinguished from more impulsive and hostile violent actions often characterized by loss of control, irrationality, and rage. Such impulsive violent behaviors are frequently labeled emotional violence and are linked with emotions such as anger and fear. Biological models of violence have identified distinct neural patterns that characterize each type of violence. For example, the ‘‘low-arousal’’ aggressor more likely to commit instrumental violence is underreactive and responds sluggishly to stressors. In contrast, the ‘‘high-arousal’’ aggressor who is more prone to hostile violence tends to be hypervigiliant and easily frustrated (Niehoff).

Another distinction between classes of violence that bears some similarity to the hostile/ instrumental classification is the difference between defensive and offensive violence. This distinction has been fundamental to animal studies of aggression, with defensive and offensive aggression linked to stimulation of different areas of the brain. In humans, instrumental aggression is roughly analogous to predatory aggression although it is limited to intraspecies behavior. In other words, when humans kill animals for food it is generally not considered offensive violence in the same sense as killing a rival gang member. Similarly, emotional or hostile aggression in humans could be considered the analogue of defensive aggression in response to a threat or perceived threat. Studies of children have found differences in propensity for proactive aggression and reactive aggression, although some children score high on both types of aggression (Dodge and Coie). This work provides some empirical support for distinguishing between offensive violence that is unprovoked and defensive violence that is a reaction to another’s provocation.

Clearly, different classification schemes serve different purposes. In everyday usage, violence is often divided into distinct classes based on criteria useful for description, dialogue, and public policy. Violence can be grouped into categories based on variables such as the agents of violence (e.g., gangs, youth, collective groups), the victims of violence (e.g., women, children, minority groups), the relationship between aggressor and victim (e.g., interpersonal, nonrelated), perceived causality (e.g., psychopathological, situational, learned), and type of harm (e.g., physical, psychological, sexual). These criteria are frequently combined to examine particular forms of violence, such as psychological abuse of women in intimate relationships, youth sexual violence, instrumental collective violence, and so on.

Some efforts have focused on developing classification systems that can guide prevention, intervention, and control efforts. Tolan and Guerra describe four types of youth violence: situational, relationship, predatory, and psychopathological. This is not an exclusive classification proposed to cover all types of violence, but rather provides some conceptual organization for structuring efforts to prevent or reduce violence. Each distinct type of violence is associated with different causal mechanisms and warrants a different type of intervention. For example, relationship violence is influenced more by anger and conflict than predatory acts of violence such as armed robbery of a stranger. Consequently, biochemical interventions that block anger arousal or conflict-resolution training programs that teach anger management skills may have some influence on relationship violence but much less influence on predatory violence.

The Causes of Violence

As historical and cross-cultural records demonstrate, our evolutionary history is laced with examples of violence. Indeed, paleontological data reveal a rather continuous stream of human violence dating back thousands of years. It is clear that violence is not restricted to early historical periods or particular cultural groups. Despite recent concerns in the United States and elsewhere over spiraling violence rates, available data suggest that there is actually less violence now than in ancient times. From an evolutionary perspective, human violence may represent a context-sensitive solution to particular problems of social living that may ebb and flow in accordance with changing conditions. In reviewing these adaptive functions, Buss and Shackelford describe seven problems for which violence may have evolved as a solution: (1) co-opting the resources of others; (2) defending against attack; (3) inflicting costs on same-sex rivals; (4) negotiating status and power hierarchies; (5) deterring rivals from future aggression; (6) deterring males from sexual infidelity; and (7) reducing resources expended on genetically unrelated children.

Against a backdrop of adaptive violence, there are still many other factors that play a role in the ontogeny of violence and help explain variations in violence across individuals and social groups. In most cases, a number of different factors converge to increase the likelihood of violent behavior. These factors can be divided into roughly three groups: (1) innate factors; (2) socialization factors; and (3) situational factors.

Innate Factors

Early efforts to unveil differences between violent and nonviolent individuals began with attempts to assign precise neural locations to a range of behaviors including violence. Known as phrenology , this approach assigned high priority to the innate and presumably defective aspects of individual makeup. The idea that behaviors are linked to physical characteristics also drove some of the first criminological efforts to understand the etiology of violence. Perhaps the most well-known work is that of nineteenth-century Italian criminal anthropologist Cesare Lombroso, who popularized the notion that violent individuals possessed distinct physical features indicative of primitive or inferior development, known as atavisms .

A concern over physical features gave way to the far more powerful influence of genetics. Although there was much resistance toward biology-as-destiny approaches, more and more geneticists were taking over the reigns of biology. However, much of the early writing on the genetic underpinnings of violence failed to pinpoint the precise causal mechanisms. The lack of a genetic road map did not unravel efforts to search for the innate determinants of aggression. Support for the idea that aggression was hardwired from birth came from a number of different encampments.

Beginning in the early part of the twentieth century, ethologists saw aggression and violence as a response to the call of internal mechanisms or instincts . This emphasis found good company in the Freudian psychoanalysts. They saw aggression as derived from an inborn tendency to destroy. Like all instincts, it builds up over time and must ultimately be discharged in either acceptable or unacceptable ways. This pressure is made worse by frustration. The idea that aggression and violence are linked to frustration had a significant impact on the field and was followed by models emphasizing the frustrationaggression connection (Dollard et al.). Although still grounded in a drive model of behavior, this work also provided evidence that violence can be learned. Still, innate drive theories persisted and were later popularized by the writings of Konrad Lorenz. According to Lorenz, aggression was not simply a response to an instinct but was itself an innate driving force, notable for both its spontaneity and centrality to species preservation.

But drive theories found themselves caught up in an empty vessel. There was little evidence to indicate that aggressive energy builds up until it is released. Further, while the notion of drive or instinct may have some descriptive utility, it offered little in the way of specifying the precise internal mechanisms that underlie violence and ran the risk of engendering a pessimistic attitude about prevention. Fortunately, scientific advances in understanding neuranatomy, brain chemistry, and genetic transmission allowed for increasingly greater precision in understanding the biology of violence, leading us farther from the notion of violence as inevitable instinct. The role of key areas of the brain in regulating emotion and behavior is now well established. Violence has also been associated with some kinds of brain damage from birth trauma, tumors, or head injury. However, rather than acting alone, the biological and social environments seem to exert reciprocal influences.

For example, threat perceptions involve neurotransmitters that partially determine an individual’s sensitivity to environmental stimuli— some more reactive, others less so. But environmental exposure to violence, danger, or abuse during the early years can quickly overload the brain’s alarm system, creating adolescents who are hypervigilant to stress and overreact to environmental cues (Pynoos, Steinberg, and Ornitz). Hypervigilance to threats may also explain some of the inconclusive findings linking testosterone and aggression. It appears that testosterone is linked to specific types of aggression, notably the tendency to ‘‘fight back’’ in a more defensive or reactive fashion related to heightened threat perception rather than the tendency to start fights or engage in offensive aggression (Olweus, Mattson, and Low).

Socialization Factors

Not only does the social environment serve as a trigger for biological development, it also provides a context for learning appropriate behaviors. Whatever propensity for violence is written on an individual’s biological birth certificate, it is clearly molded and shaped through interactions with others. There is a sizable body of evidence showing that early socialization across multiple contexts accounts for much of the individual differences in later violent behavior.

Different mechanisms have been implicated in the learning of violence. Early theories stressed the importance of reinforcement. A young child wants a toy, but his playmate will not relinquish it. The boy pushes and grabs the toy and the playmate relents. Aggression works. If followed by reinforcement, both mild aggression and serious violence are likely to increase. Such reinforcement is not limited to tangible objects; it can include outcomes such as attention, status, and advantageous positioning in the peer status hierarchy, similar to some of the adaptive functions of aggression discussed previously.

In addition to the role of reinforcement, early formulations of social learning theory emphasized the role of observational learning (Bandura). Individuals who see others use and obtain rewards for violence, especially others whom they admire, are more likely to imitate them and behave violently under similar circumstances. As a psychological mechanism, modeling can also explain variation in violence levels across different social groups and cultures. As violence becomes more legitimate in a social group, it is more likely that members will conform to these emerging group norms. Some observers have described a ‘‘code of violence’’ that characterizes the behavior of many inner-city males. Status is associated with willingness to use violence, and children emulate the toughness and violence of older male role models.

Much of the concern about the links between exposure to media to violence and aggression derives from social learning theory. Research with children has clearly demonstrated a correlation with exposure to media violence and aggressive behavior. Children who watch more violent movies and television are more likely to engage in similar behaviors both as children and adults. Long-term exposure to media violence fosters later violence through several mechanisms. In addition to teaching aggressive attitudes and behaviors, it also seems to desensitize viewers to violence, making it more acceptable. People who watch a lot of televised violence also show exaggerated fears of violence, perhaps making them more hypervigilant and susceptible to reactive outbursts.

The media is but one socialization context that can promote the learning of violence. Research has shown that both parents and peers can be a powerful force in shaping children’s behavior. Lack of attention to children’s behavior and inconsistent parental discipline and monitoring of activities have been consistently related to the development of aggressive and violent behavior patterns. Extremely harsh and abusive parenting has also been linked to later aggression. Stated simply, ‘‘violence begets violence.’’ Equally important is the failure of positive encouragement for prosocial and nonviolent behaviors. Many parents ignore children’s efforts at solving conflicts peacefully or managing frustration. Oversights such as these may inadvertently teach children that aggressive acts alone are worthy of notice.

Peers also exert an influence from an early age, but seem to become most important during adolescence. Perhaps one of the most robust findings in the delinquency literature is that antisocial and violent peers tend to gravitate toward one another. Delinquents associate with each other and this association stimulates greater delinquency. Nowhere is this more apparent than in the actions of gangs. Not only is violent behavior accepted, it is required. Members must be ‘‘jumped in’’ via violent victimization; the same procedure is followed for those who want to leave the gang.

The environment also operates to influence the learning of violence. Some studies of environmental influences have focused on the effects of poverty and disadvantage. Poverty itself does not cause violence. Rather, being poor affects one’s life experiences in several ways conducive to violence. Individuals living in poor neighborhoods have few resources and supports for healthy development and are more likely to experience multiple stressors. In some neighborhoods, there are few legitimate routes to financial success and social status, which may also engender feelings of relative deprivation in contrast to middle-class society. Those who have little also have little to lose. Thus, low social and economic status may contribute to heightened risk-taking behavior, an idea that finds some support in psychological studies showing that artificially lowering an individual’s self-esteem gives rise to higher levels of risky or rule-breaking behavior.

In urban settings, poverty often produces situational factors, such as overcrowding, that are linked to violence. Indeed, the highest rates of violence typically are found among the urban poor (Dahlberg). Drive-by shootings and random violence have come to characterize some of the most distressed, inner-city communities. As violence increases and neighborhoods become more dangerous, the use of force may be seen as normal and even necessary for self-protection. A subculture of violence can emerge wherein violence is legitimized as an acceptable behavior within certain groups. The idea that degree of violence is related to the prevailing social norms about its acceptability can also shed light on cross-cultural differences. Countries where violence is considered non-normative such as Japan have low homicide rates; countries where violence has become almost a way of life such as El Salvador and Guatemala have homicide rates over one hundred times higher (Buvinic, Morrison, and Shifter).

These different contextual factors can serve as a training ground for violence via their influence on children’s learning. However, beyond a focus on how individuals learn violent behavior through socialization, recent efforts have highlighted the importance of cognitive processes that help shape and control behavior—what might be called the software of the brain. Studies have shown that more aggressive and violent individuals have different ways of processing information and thinking about social situations. They tend to interpret ambiguous cues as hostile, think of fewer nonviolent options, and believe that aggression is more acceptable (Crick and Dodge). Once these cognitions crystallize during socialization, they are more resistant to change.

Situational Factors

Both innate factors and socialization experiences mold an individual’s propensity to violence. But this is not the whole story. It appears that situational catalysts can also lead to violence and increase the seriousness of such behavior. Almost any aversive situation can provoke violence. Frustrating situations are linked to heightened aggression, although frustration does not always produce aggression and is certainly not the only instigating mechanism. Other aversive experiences such as pain, foul odors, smoke, loud noises, crowding, and heat portend heightened aggressiveness, even when such behavior cannot reduce or eliminate the aversive stimulation (Berkowitz).

The influence of pain on violent behavior has been widely studied. Pain-instigated aggression is often cited as one of the clearest examples of aversively generated aggression. Further, the likelihood of overt aggression increases as the pain becomes greater and the ability to avoid it decreases. However, it is not necessarily the pain, per se, that causes aggression. Indeed, investigations of people suffering from intense pain have documented higher levels of anger and hostility and speculate that subsequent aggression may be due to the agitated negative affect that accompanies pain rather than the pain itself. Along these lines, any type of aversive experience that results in heightened negative affect should increase the likelihood of subsequent aggression.

Alcohol has also been shown to promote violence. In studies of alcohol and domestic violence, alcohol use typically is implicated in more than half of all incidents. Similarly, both homicide victims and perpetrators are likely to have elevated blood alcohol levels. Although a relation has been established, the precise mechanisms by which alcohol increases violence are unclear. It is likely that these effects are related to its impact on how an individual evaluates social situations and decides on an appropriate response. For example, some alcohol-violence studies suggest that ingestion of alcohol makes normal social interactions extremely difficult, heightening the likelihood of a range of inappropriate responses including violence.

Situational cues that suggest violence are also likely to increase violence by priming violencerelated thoughts, feelings, and behaviors. Street fights engender more violence because they cue violent responses in observers. The presence of guns can also make violence more likely to occur when they are associated with an aggressive meaning and positive outcomes. For instance, the presence of a hunting rifle will not promote hostile and violent behavior in those who disapprove of aggression toward others. It is not just the weapon but the meaning and anticipated consequences of its use that promote violence. Even the picture of a gun or weapon in a room can increase the chance of an aggressive act. This effect is of particular concern because guns make violence more deadly. For example, the rise in murders of juveniles in the United States during the late 1980s and early 1990s was entirely firearm-related. Firearms are now the leading cause of death among children and youth in many places (Snyder and Sickmund).

Even nonviolent individuals can turn violent when they are part of a violent crowd. Group violence seems to make individuals feel less personally responsible for their behavior, acting in ways they would never do alone. Violence becomes an act of the group with no one person being held responsible. In some groups, violence emerges as a necessary strategy for defense against enemies—as seen in gang warfare, terrorist organizations, and political violence. At the other end of the spectrum, isolation also breeds violence. Different mechanisms to account for the influence of isolation have been proposed. These range from psychological changes akin to delusions of grandeur to disturbances in the balance of neurochemical pathways critical to the control of emotional and stressful responses.

Prevention and Control of Violence

Although history attests to the ubiquitousness of violence, it is also true that individuals have available and use a wide array of inhibitory or alternate behavioral strategies. Although aggression and violence may be ever present, they are not inevitable. The longevity of a social group, society, or nation hinges, in part, on the peaceful resolution of conflicts and other social problems. Escalating or unacceptably high rates of violence can serve as a call to action to mobilize the forces of prevention and control.

Just as there is no single cause of violence, there is no single solution. Rather, different types of violence are associated with different causal processes and warrant different responses. A reasoned approach to prevention and control hinges on sorting out these multiple influences as they impact the developing individual over time and across contexts. The control of violence requires a confluence of synchronized efforts that address innate, socialization, and situational contributions to violence, for all individuals as well as for those who display more extreme problems. New research on the biology of violence provides a credible starting point that looks at individual development as it both influences and is influenced by the environment. If this development proceeds on a course that minimizes violent behavior, it results in a nervous system that is in tune with the demands of the outside world, is able to integrate emotional and representational data, and is not hypersensitive to perceived threat. Environmental factors that compromise this development, such as exposure to lead, head trauma, and abuse provide a viable beginning for prevention. The fact that brain development occurs at a rapid pace during the first years of life suggests that these factors must be addressed at an early age. Not only should efforts focus on prevention of trauma, but healthy developmental supports are needed. Healthy Start and Nurse–Home Visitation programs are examples of programs that can address these issues.

To the extent that violent actions are learned, a range of prevention and control responses can interrupt this learning process. First in line are strategies to reduce the perceived or actual positive consequences of violence. These may involve changing peer group and parent norms, providing nonviolent and positive means to achieve desired goals such as status and money, and training parents and other socialization agents to reward cooperative and prosocial behaviors. Under some conditions, punishment can also reduce aggression. A child who is sent to his room after hitting his brother should be less likely to hit his brother the next day. A child who is severely spanked for hitting his brother may suppress his aggression in the days to come while also learning that violence is a good way to solve problems. Prison is unfortunately one of the best schools for violence known to society. Inmates are held in isolation, under crowded conditions, socializing only with other violent or antisocial peers, with treatment for accompanying mental health or addiction problems the exception rather than the rule. Prisons also come into play far too late in the game, when brain patterns and cognitions are well formed.

Another prevention prescription would focus on reducing the myriad of opportunities to model violent acts as a result of a continuous exposure to glorified violence in television, movies, and video games, as well as ‘‘sports’’ activities such as extreme fighting. Observing violence can increase individual attitudes and beliefs that such behavior is acceptable. In addition to reducing such modeling opportunities, research suggests that cognitive-behavioral interventions can also shift thinking patterns toward more reflective and less automatically aggressive thoughts.

The notion that human violence is innate or inevitable precludes effective prevention and control. In contrast, if we understand violence as an optional strategy that can be increased or decreased through a variety of mechanisms, opportunities for prevention and control abound. Individuals are biologically and socially capable of peaceful coexistence—a clear and powerful antidote to violence.

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