Intimate-Partner Violence: The Need for Primary Prevention in the Community

Prevention

Vast resources have been channeled into tertiary prevention of intimate-partner violence, to the exclusion of primary prevention (Glossary). “I think it's been a real lost opportunity to perhaps prevent a health problem from materializing,” commented Lori Heise, director of Women's Health Exchange (a nonprofit research and advocacy group for international health policies and practice in Washington, D.C.). She explained that despite major strides made in recent years to address intimate-partner violence, treatment of the victims has been the primary focus. In the 1970s, advocates for women's rights, she said, played a major role in shaping the trend toward tertiary prevention because treatment for female victims presented the most urgent need; consequently, primary prevention efforts received little attention.

Health care continues to place little emphasis on addressing the batterer, although it has played an increasingly important role in tertiary and secondary prevention efforts. For example, as recently as 5 years ago, physicians seldom inquired about intimate-partner violence during routine office visits and in questionnaires, whereas now questions about domestic violence are almost commonplace. Yet, such questions are aimed almost exclusively at female patients. Health care had mostly neglected to question men to see if they were at risk for committing violence. This is only now beginning to change. In visiting more than 20 countries over 10 years for her report “Ending Violence against Women,” Heise discovered that universally—especially in the United States—male batterers and primary prevention have been ignored.

A Community Culture of Violence

Traditionally, U.S. communities did not get involved until after the violence became a law-enforcement issue. “Years ago, there was more thinking that this was a domestic dispute, and therefore, it is something that is handled within a family. But people are starting to recognize that this isn't just the victim's problem—this is a problem to society,” asserted Annmarie Kaiser, executive director of the Pennsylvania District Attorneys Association.

Heise's research showed that in many cultures, girls and boys are socialized to believe that it is not only a man's right but his responsibility to discipline his partner, sometimes physically. In her research as a member of the Defense Taskforce on Domestic Violence and author of several books, including To Have and To Hit (Chicago: Univ Illinois Pr; 1999), Jacquelyn C. Campbell, MSN, PhD, found that wife beating is almost universal. Campbell observed that most perpetrators came from cultures with an ideal of masculinity that includes ownership of one's female partner. In the United States, although male and female roles are being redefined, Campbell noted that “there is still that notion that the ideal man is very aggressive.”

Shifting the Focus from Tertiary to Primary Prevention

Harnessing all available resources strictly for treatment efforts is futile. As long as efforts do not focus on violence prevention, the cycle will continue. Kaiser said that she saw the same offenders appearing repeatedly in the court system. “Unless proper intervention occurs, you're going to have an offender again,” remarked Kaiser. “[Violence] didn't just stop with one incident unless [the perpetrator] happened to get the proper counseling.”

Some men are at high risk for the “cycle of violence,” in which male perpetrators pass the violence onto the next generation. Men at high risk for violent behavior are those who have witnessed their mother being beaten by their father or who were a victim of abuse as a child.

In To Have and To Hit, Campbell found that many cultures have primary and secondary prevention models that the United States sorely lacks, in which they enact certain mechanisms as soon as physical fighting between partners begins. For example, the women of the Garifuna ethnic group in Belize will confront a man as soon as they believe he is perpetrating violence against his wife. If they hear what sounds like physical fighting in a neighboring house, the women from the village will surround the house, beckoning the woman inside to join the women. They then confront the husband by yelling things they believe will shame him, such as “How can you do something like that? It's despicable.”

Experts say an effective primary prevention program for intimate-partner violence must take place at the community level, concentrating on public education and a zero-tolerance policy. Heise strongly urges a broader approach than merely counseling or incarcerating the perpetrators. Primary prevention must also include identifying at-risk populations. Heise applauds secondary prevention efforts, such as treatment programs for violent offenders, but suggests that another step, beyond just addressing the existing population of male abusers, is crucial. “We need to think about how to create a generation of men and boys who have totally different expectations about relationships.” She stresses that education efforts should target the general public, including young boys and girls. “We also need to focus our attention on men in the general population”—that is, those who are not abusers—“because it's the culture at large that sanctions the behavior.”

Children and Adolescents

More primary prevention programs are now working with children, and Campbell believes that this is an essential element of a successful primary prevention program. Educating children is an invaluable prevention effort “because it identifies a group that's at high risk and does some things very early on to mitigate that risk,” Campbell remarked.

Other prevention efforts focus on adolescent dating violence. Those programs are still scarce, however, as most resources in the area of adolescent violence are channeled into prevention of peer or gang violence. Although Campbell believes these programs are highly effective, she noted that the dynamics of violence against a partner differ from those of other types of violence. Programs need to address dating violence to be an effective primary prevention tool against intimate-partner violence, Campbell suggested. “The programs for young men should address nonviolent behavior toward girls. Many men who are violent toward their partners are not violent toward anyone else.”

Heise agrees with Campbell, stating that although many programs address violence in adolescents, they generally do not focus on violence between men and women. Heise noted that there are two distinctly different types of programs: One focuses on date violence but ignores all other types of violence, and the other focuses on gang violence but excludes date violence. Unfortunately, we fail to “look at all different kinds of violence as it touches young people's lives,” Heise remarked. She suggested that gang violence programs should include discussions about men's roles in general and their roles as partners. Heise also suggested that primary violence prevention programs should include discussions about gender issues and what defines healthy expectations in a relationship.

Heise also urged that the “conspiracy of silence” be broken. “We need to be more proactive about giving young men messages that it [violence] won't be just ‘behind closed doors,’ that violence is not tolerated against women or within families.”

Campbell's research indicates that substance abuse may be less prevalent in cases of intimate-partner abuse than is commonly believed. However, regardless of whether that can be substantiated, both problems—intimate-partner violence and substance abuse—require intervention. Campbell noted, “Just treating the substance abuse won't make the problem of violence go away.”

Campbell acknowledged that programs on intimate-partner violence in the United States are moving forward, but her optimism came with reservations. “We've made a lot of progress, and I don't want to paint a bleak picture of [the United States] as being horribly sexist, because I don't think we are. I think there's less tolerance on a nationwide level for domestic violence. Nonetheless, there is still not that neighborhood ownership. I think that many people, if they saw their neighbor with a black eye, would still not reach out to her.”

Glossary

Prevention

The levels of violence prevention—primary, secondary, and tertiary—are analogous to the levels of clinical prevention with which physicians are well acquainted.

Primary prevention: Clinicians define primary prevention as measures taken to prevent the onset of a condition, such as encouraging immunizations or promoting use of seatbelts. Primary prevention of violence is defined as broad efforts to address, inform, and educate the public about violence in order to encourage nonviolent behavior. This type of prevention does not just target at-risk populations but rather is an all-encompassing approach based on the idea that violence is a societal concern. Primary violence prevention focuses on fostering nonviolent problem solving and redefining role models through media messages, peer mediation, and elementary classroom education.

Secondary prevention: Early detection and treatment of at-risk populations characterize secondary violence prevention measures. Counseling of the perpetrator or mandatory attendance at first-time-offender programs may be involved. In secondary prevention, the focus is on intervening with the perpetrator before the violence becomes an entrenched pattern. According to Jacquelyn C. Campbell, MSN, PhD, secondary prevention should occur the first time a man pushes or shoves his partner. “If we wait until it's an entrenched pattern, then the criminal justice solution becomes the only viable solution,” she commented. However, Campbell believes that sending this type of person to a traditional intervention program for batterers is counterproductive. “He'll say, ‘I don't belong here,’ and he's probably right. Most of the people who are there are court mandated to do so, and they tend to be pretty severe batterers.” Lack of funding and difficulty in gauging quantifiable results are problems faced by batterer-prevention programs. Lori Heise, director of Women's Health Exchange in Washington, D.C., remarked, “The money that is available is on funding time cycles. There is a very strong emphasis on results. Unfortunately, the kind of long-term social change that primary prevention entails does not produce results in the 2-year timeframe that the donors require.”

Tertiary prevention: Tertiary prevention includes treatment interventions that take place after the violence has occurred. Tertiary prevention is “damage control,” and it includes the provision of counseling and other health care services to the victims. Tertiary prevention aimed at perpetrators ranges from counseling and offender programs to correction and punishment, possibly in the form of arrest and incarceration.

Domestic vs. Intimate-Partner Violence

Because the term domestic violence has begun to include the abuse of children, siblings, and elders, the U.S. Centers for Disease Control and Prevention prefers the more precise term intimate-partner violence, which it defines as actual or threatened physical or sexual, or psychological or emotional abuse by a spouse, ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend, or date. Intimate-partner violence may include date rape, domestic abuse, spouse abuse, and battery.

Although the term intimate-partner violence refers to abuse by or to a man or woman, for purposes of this article, the term implies female victims and male perpetrators. According to the Report to the Nation on Crime and Justice, Bureau of Justice Statistics, in 1983, 95% of all intimate-partner violence was perpetrated against women by men. Only about 5% of intimate-partner violence is committed against U.S. men [U.S. Dept. of Justice. Violence Against Women. NCJ-145325. January 1994]).

Specific Programs

Efforts to prevent violence are in their infancy, but they are beginning to grow rapidly.

The Family Violence Prevention Fund (FVPF) [http://www.fvpf.org], which began in San Francisco as an emergency department–based program to help abused women, is an example of an agency that focuses on prevention at all levels—primary, secondary, and tertiary. It is a national nonprofit organization whose mission is to promote education and public policy reform. It is dedicated to ending intimate-partner violence by changing the social norms that allow it to thrive. The FVPF campaign “There's No Excuse for Domestic Violence” is a case in point. This media campaign against violence takes a different approach: The intended audience of the campaign is neither the victims nor the perpetrators but, instead, the friends, coworkers, and families “who perpetuate the violence with their silence.”

The National Advisory Council on Violence against Women is turning its attention to prevention efforts. The Council, established in 1995, recently issued a report entitled “Ending Violence Against Women—An Agenda for the Nation” (available at http://www.4woman.gov/violence/nations.htm), which addresses supporting victims of violence and preventing violence. The focus is on ending social norms that condone violence against women. The Agenda coordinates widespread efforts among key participants, including victim's advocates; the military; community leaders; organized sports; the health care, welfare, and justice systems; the media; faith communities; colleges and universities; businesses; and children's advocates. The Agenda advocates increasing the support for prevention efforts with children, including lessons about gender roles that encourage or perpetuate violence toward women.

The National Center for Injury Prevention and Control, a subagency of the National Centers for Disease Control and Prevention, started the “Family and Intimate Violence Prevention Program,” which is leading efforts on community-based primary prevention programs (http://www.cdc.gov/ncipc/dvp/fivp/fivp.htm). The agency is involved mainly with surveillance, research, evaluation, communication, and training. The program also funds various programs focusing on all levels of prevention. For example, the program funded four multifaceted community-based projects for 5 years starting in 1994, including Milwaukee Women's Center, Inc., and Men Stopping Violence, Inc., in Georgia. It also sponsored six community-response projects, three of which were designed for rural and Native-American communities to develop a community-coordinated response to intimate-partner violence. The National Crime Prevention Council (http://www.ncpc.org) advocates several primary prevention programs that focus on violence in teen dating relationships. The school-based programs use trained youth to perform duties such as answering hotlines and counseling peers. One such school-based program is the “Boston Dating Violence Intervention Project,” which teaches boys and girls not to accept violence in their earliest relationships. The children are taught how to manage conflict, recognize abusive behavior, and communicate respectfully.