Primary Violence Prevention: Taking a Deeper Look

Too often we hear that some husband has massacred his wife and children and then killed himself, with the details vividly broadcast in national headlines and news clips. One outcome of such media coverage is the marginalization of the perpetrators: These men are portrayed as unusual, psychotic, and deranged. They are depicted as different from us. We like to believe that the unusual origins of their psychoses explain how they could perform such violent acts. These events appear to be random floating blocks of ice, rather than the tip of the iceberg. Also, the fact of what happened—the ultimate violence against a woman and her children—gets lost in the spectacle of the homicide/suicide. The daily violence against women—the slappings and beatings, controlling behaviors, streams of verbal abuse, and denigration—seem disconnected from these juicy media stories. And we do not make the connection.

The heightened social awareness of violence in general does not seem to enhance our ability to go about the methodical work of screening and prevention, 2 stubborn problem areas in the current medical approach to violence against women. Despite the development of effective and validated screening instruments to detect violence against women (eg, the Woman Abuse Screening Tool [WAST], the HITS questions, and the 3-question screen),^1-3 medical professionals do not consistently conduct such screening in the family practice, pediatric, obstetrical and gynecological, and emergency sites where it has been recommended. Screening activities fall off once any dedicated research or intervention program comes to an end,⁴ and even the presence of on-site counselors to provide services to abused women does not increase the rate of screening.⁵ Formal mechanical strategies may work: Restructuring emergency department forms to require inquiry about domestic violence increases case finding.⁶ Advocates suggest that screening be incorporated into continuous quality improvement activities to maintain them on an ongoing basis.⁵ This recommendation indicates that clinicians will not do this activity unless they are being watched or there are some consequences.

Why abuse is not identified

The barriers to screening have been elucidated by a variety of investigators^7,8 and include time, skill, comfort, resources, and fear on the part of clinicians, although clinicians are more likely to attribute the lack of screening to patient characteristics than to themselves.⁹ The willingness of battered women to disclose abuse and the factors conducive to disclosure (privacy, respect, believing the woman, nonjudgmental approach, referral to resources) have also been investigated.¹⁰ However, none of this information changes what we are actually doing in clinical settings on a consistent basis.

Battering is truly a problem we do not wish to identify. Despite the screening instruments, improved knowledge base, and training, most clinicians do not seem to want to know if there’s a problem. Still, a small group of dedicated clinicians are consistently doing this work and reaping rewards.¹¹ What is different about these clinicians? Do most clinicians have difficulty with the subject because battering challenges closely held assumptions about family and men and women?¹² We need to know more about these factors if we are going to influence screening; the problem does not lie in our instruments but in ourselves.

The importance of primary prevention

The second problem—one that is ultimately more serious and has remained invisible—has to do with our failure to recognize the need for primary prevention. Zola¹³ wrote about the parable of the health care worker pulling drowning victims out of the raging river. This person was so busy resuscitating the victims that she was unable to look upstream to see why all the bodies were falling in. Family medicine has also neglected to look upstream. We are busy perfecting our tools for pulling the bodies out, even examining how we feel about doing that gruesome work, but we have been slow to march up the banks and see how we can stop the bodies from being pushed in. We seem to have gotten stuck at secondary prevention (eg, identifying teenage girls and women already in abusive relationships), and we have forgotten our professional commitment to primary prevention.

Yet the extent of violence against women sampled in the primary care and emergency room settings (which we have reason to believe involves nearly 36% to 44% of women in relationships with men during their lifetimes^14,15) reveals the serious need for primary prevention efforts. Who is talking to the parents of small children and adolescents about how wrong it is to hit girls or women or force them have sexual relations? Home visiting programs with mothers from delivery until the child reaches the age of 3 years appear to prevent use of violence by the parents and those children^16-18 but have not received wide application as a public health tool. Interventions in elementary schools to deter violent behaviors seem indicated, since gender roles of male domination and female submission are well established by first grade.¹⁹ Such programs have the potential to deter violence at the early elementary school level and decrease adolescent behavioral problems.²⁰ School-based interventions linked with community resources addressing dating violence at the middle school level are effective,²¹ and some recommend adolescence as the ideal time to address prevention of partner abuse.^22,23 Thus, despite the relative lack of long-term outcome data, it appears that community-based primary prevention programs for violence show promise,^24-29 but none of these involve physicians.

What underlies abuse

What would primary prevention of violence against women look like if it were conducted at office visits by family physicians? To answer this we need to examine the dynamic underlying the violence. We know that battering is not just the violence, yet we get fixated on that aspect of it. We seek explanations that have to do with violence (the media, gun control, need for skills in conflict resolution, and anger management). We neglect to consider what we also know: That battering is “a set of learned controlling behaviors and attitudes of entitlement that are culturally supported and produce a relationship of entrapment.”³⁰ Such dynamics are difficult for us to face and can be even more difficult to comprehend. Even in the absence of physical abuse the controlling behaviors are directly harmful to women; the health status of women who have been emotionally abused is measurably worse than that of nonabused women.^31,32 We must look beyond the violence to the issue of control of women by men.

We need to look at the origins behind men feeling that they have a right to control women, and we need to make a commitment to changing how we raise both girls and boys to eradicate this sense of entitlement. So far, family medicine has made no such commitment. To do so, we need to develop a set of skills to work with parents and children regarding issues of control, hitting, fighting, fighting back, and using violent tactics to get what you want. Fortunately, the clinical tools to do this work have been developed by Stringham,³³ who has incorporated questions about violence and control into every visit. He and his colleagues have found that certain screening questions for adolescents have a high predictability for subsequent violence-related injuries and can be used to stratify risk of future injury.³⁴ Using his consistent philosophy over a 20-year period he has shown thousands of families in a working class community how to raise children with self-respect and without violence.

Asking the hard questions

Questioning how a man handles himself and his sexuality with women challenges his manhood, which can be very difficult territory. We would rather talk about exercise and diet than go to the hard questions: Do you ever feel you have to hit or swear at your girlfriend? Do you ever force your wife to have sexual relations when she might not want to? Do you ever feel that you should be able to control her? Also, to whom would we pose these questions: all men, just men who we think are likely to be abusive, men who seem to fit a macho stereotype, men who drink more than we think they should, or men with a shotgun in the pickup truck? Would we ask the local physician, lawyer, or police chief when he comes in for an annual checkup? To ask these questions we need to be clear about our own values and willing to reveal them when the patient says, “Why are you asking me that, Doc?” Confronting patriarchal values does not come naturally to medicine, a field that has traditionally had women as handmaidens at home and in the office and hospital. When we work through the logical steps we can recognize and explain that male domination is not healthy for men or women. To provide violence prevention for women we will need to change health promotion with men, because women’s health depends in part on men’s healthy behaviors.³⁵

Gender-specific curriculum

To help patients change their behavior we need to connect with them as sharing similar values. How can a male family physician approach a potentially battering male patient as a reasonable equal? In what ways can we share the frustration of living with problems (economic, job, parents, kids), and yet distinguish between ourselves as not sharing the same assumptions about male privilege? Female family physicians may have more experience in working with the girlfriends and wives of batterers and have been explicit about both the joys and challenges of that particular work,¹¹ but how can a female family physician work with men who batter? Training programs need to help both male and female physicians clarify their values so that they can see how their gender and experiences will affect how they do this work. In other words, family medicine needs a gender-specific curriculum to teach the skills of working with violent men. At the same time, we need to recognize that when battering is identified one family physician cannot safely be the clinician for both the batterer and the partner.³⁶ We have much to learn about how to transition safely from being the family physician for both members of a battering relationship to being the family physician for 1 or the other.

Conclusions

Interventions for such a broad problem must take place at the level of community, school, family, and individual patient. Although we are busy incorporating screening strategies into our practices to detect battered women, it is also necessary for us to look upstream. We need long-term studies of the impact of violence prevention activities in the clinical setting. But as individual physicians we cannot wait for those results; if we are serious about primary prevention we must begin now by raising the hard questions about control and violence with boys and men. Otherwise, we will get very good at fishing the bodies out downstream but will never have any reprieve from that work.

Too often we hear that some husband has massacred his wife and children and then killed himself, with the details vividly broadcast in national headlines and news clips. One outcome of such media coverage is the marginalization of the perpetrators: These men are portrayed as unusual, psychotic, and deranged. They are depicted as different from us. We like to believe that the unusual origins of their psychoses explain how they could perform such violent acts. These events appear to be random floating blocks of ice, rather than the tip of the iceberg. Also, the fact of what happened—the ultimate violence against a woman and her children—gets lost in the spectacle of the homicide/suicide. The daily violence against women—the slappings and beatings, controlling behaviors, streams of verbal abuse, and denigration—seem disconnected from these juicy media stories. And we do not make the connection.

The heightened social awareness of violence in general does not seem to enhance our ability to go about the methodical work of screening and prevention, 2 stubborn problem areas in the current medical approach to violence against women. Despite the development of effective and validated screening instruments to detect violence against women (eg, the Woman Abuse Screening Tool [WAST], the HITS questions, and the 3-question screen),^1-3 medical professionals do not consistently conduct such screening in the family practice, pediatric, obstetrical and gynecological, and emergency sites where it has been recommended. Screening activities fall off once any dedicated research or intervention program comes to an end,⁴ and even the presence of on-site counselors to provide services to abused women does not increase the rate of screening.⁵ Formal mechanical strategies may work: Restructuring emergency department forms to require inquiry about domestic violence increases case finding.⁶ Advocates suggest that screening be incorporated into continuous quality improvement activities to maintain them on an ongoing basis.⁵ This recommendation indicates that clinicians will not do this activity unless they are being watched or there are some consequences.

Why abuse is not identified

The barriers to screening have been elucidated by a variety of investigators^7,8 and include time, skill, comfort, resources, and fear on the part of clinicians, although clinicians are more likely to attribute the lack of screening to patient characteristics than to themselves.⁹ The willingness of battered women to disclose abuse and the factors conducive to disclosure (privacy, respect, believing the woman, nonjudgmental approach, referral to resources) have also been investigated.¹⁰ However, none of this information changes what we are actually doing in clinical settings on a consistent basis.

Battering is truly a problem we do not wish to identify. Despite the screening instruments, improved knowledge base, and training, most clinicians do not seem to want to know if there’s a problem. Still, a small group of dedicated clinicians are consistently doing this work and reaping rewards.¹¹ What is different about these clinicians? Do most clinicians have difficulty with the subject because battering challenges closely held assumptions about family and men and women?¹² We need to know more about these factors if we are going to influence screening; the problem does not lie in our instruments but in ourselves.

The importance of primary prevention

The second problem—one that is ultimately more serious and has remained invisible—has to do with our failure to recognize the need for primary prevention. Zola¹³ wrote about the parable of the health care worker pulling drowning victims out of the raging river. This person was so busy resuscitating the victims that she was unable to look upstream to see why all the bodies were falling in. Family medicine has also neglected to look upstream. We are busy perfecting our tools for pulling the bodies out, even examining how we feel about doing that gruesome work, but we have been slow to march up the banks and see how we can stop the bodies from being pushed in. We seem to have gotten stuck at secondary prevention (eg, identifying teenage girls and women already in abusive relationships), and we have forgotten our professional commitment to primary prevention.

Yet the extent of violence against women sampled in the primary care and emergency room settings (which we have reason to believe involves nearly 36% to 44% of women in relationships with men during their lifetimes^14,15) reveals the serious need for primary prevention efforts. Who is talking to the parents of small children and adolescents about how wrong it is to hit girls or women or force them have sexual relations? Home visiting programs with mothers from delivery until the child reaches the age of 3 years appear to prevent use of violence by the parents and those children^16-18 but have not received wide application as a public health tool. Interventions in elementary schools to deter violent behaviors seem indicated, since gender roles of male domination and female submission are well established by first grade.¹⁹ Such programs have the potential to deter violence at the early elementary school level and decrease adolescent behavioral problems.²⁰ School-based interventions linked with community resources addressing dating violence at the middle school level are effective,²¹ and some recommend adolescence as the ideal time to address prevention of partner abuse.^22,23 Thus, despite the relative lack of long-term outcome data, it appears that community-based primary prevention programs for violence show promise,^24-29 but none of these involve physicians.

What underlies abuse

What would primary prevention of violence against women look like if it were conducted at office visits by family physicians? To answer this we need to examine the dynamic underlying the violence. We know that battering is not just the violence, yet we get fixated on that aspect of it. We seek explanations that have to do with violence (the media, gun control, need for skills in conflict resolution, and anger management). We neglect to consider what we also know: That battering is “a set of learned controlling behaviors and attitudes of entitlement that are culturally supported and produce a relationship of entrapment.”³⁰ Such dynamics are difficult for us to face and can be even more difficult to comprehend. Even in the absence of physical abuse the controlling behaviors are directly harmful to women; the health status of women who have been emotionally abused is measurably worse than that of nonabused women.^31,32 We must look beyond the violence to the issue of control of women by men.

We need to look at the origins behind men feeling that they have a right to control women, and we need to make a commitment to changing how we raise both girls and boys to eradicate this sense of entitlement. So far, family medicine has made no such commitment. To do so, we need to develop a set of skills to work with parents and children regarding issues of control, hitting, fighting, fighting back, and using violent tactics to get what you want. Fortunately, the clinical tools to do this work have been developed by Stringham,³³ who has incorporated questions about violence and control into every visit. He and his colleagues have found that certain screening questions for adolescents have a high predictability for subsequent violence-related injuries and can be used to stratify risk of future injury.³⁴ Using his consistent philosophy over a 20-year period he has shown thousands of families in a working class community how to raise children with self-respect and without violence.

Asking the hard questions

Questioning how a man handles himself and his sexuality with women challenges his manhood, which can be very difficult territory. We would rather talk about exercise and diet than go to the hard questions: Do you ever feel you have to hit or swear at your girlfriend? Do you ever force your wife to have sexual relations when she might not want to? Do you ever feel that you should be able to control her? Also, to whom would we pose these questions: all men, just men who we think are likely to be abusive, men who seem to fit a macho stereotype, men who drink more than we think they should, or men with a shotgun in the pickup truck? Would we ask the local physician, lawyer, or police chief when he comes in for an annual checkup? To ask these questions we need to be clear about our own values and willing to reveal them when the patient says, “Why are you asking me that, Doc?” Confronting patriarchal values does not come naturally to medicine, a field that has traditionally had women as handmaidens at home and in the office and hospital. When we work through the logical steps we can recognize and explain that male domination is not healthy for men or women. To provide violence prevention for women we will need to change health promotion with men, because women’s health depends in part on men’s healthy behaviors.³⁵

Gender-specific curriculum

To help patients change their behavior we need to connect with them as sharing similar values. How can a male family physician approach a potentially battering male patient as a reasonable equal? In what ways can we share the frustration of living with problems (economic, job, parents, kids), and yet distinguish between ourselves as not sharing the same assumptions about male privilege? Female family physicians may have more experience in working with the girlfriends and wives of batterers and have been explicit about both the joys and challenges of that particular work,¹¹ but how can a female family physician work with men who batter? Training programs need to help both male and female physicians clarify their values so that they can see how their gender and experiences will affect how they do this work. In other words, family medicine needs a gender-specific curriculum to teach the skills of working with violent men. At the same time, we need to recognize that when battering is identified one family physician cannot safely be the clinician for both the batterer and the partner.³⁶ We have much to learn about how to transition safely from being the family physician for both members of a battering relationship to being the family physician for 1 or the other.

Conclusions

Interventions for such a broad problem must take place at the level of community, school, family, and individual patient. Although we are busy incorporating screening strategies into our practices to detect battered women, it is also necessary for us to look upstream. We need long-term studies of the impact of violence prevention activities in the clinical setting. But as individual physicians we cannot wait for those results; if we are serious about primary prevention we must begin now by raising the hard questions about control and violence with boys and men. Otherwise, we will get very good at fishing the bodies out downstream but will never have any reprieve from that work.

Too often we hear that some husband has massacred his wife and children and then killed himself, with the details vividly broadcast in national headlines and news clips. One outcome of such media coverage is the marginalization of the perpetrators: These men are portrayed as unusual, psychotic, and deranged. They are depicted as different from us. We like to believe that the unusual origins of their psychoses explain how they could perform such violent acts. These events appear to be random floating blocks of ice, rather than the tip of the iceberg. Also, the fact of what happened—the ultimate violence against a woman and her children—gets lost in the spectacle of the homicide/suicide. The daily violence against women—the slappings and beatings, controlling behaviors, streams of verbal abuse, and denigration—seem disconnected from these juicy media stories. And we do not make the connection.

The heightened social awareness of violence in general does not seem to enhance our ability to go about the methodical work of screening and prevention, 2 stubborn problem areas in the current medical approach to violence against women. Despite the development of effective and validated screening instruments to detect violence against women (eg, the Woman Abuse Screening Tool [WAST], the HITS questions, and the 3-question screen),^1-3 medical professionals do not consistently conduct such screening in the family practice, pediatric, obstetrical and gynecological, and emergency sites where it has been recommended. Screening activities fall off once any dedicated research or intervention program comes to an end,⁴ and even the presence of on-site counselors to provide services to abused women does not increase the rate of screening.⁵ Formal mechanical strategies may work: Restructuring emergency department forms to require inquiry about domestic violence increases case finding.⁶ Advocates suggest that screening be incorporated into continuous quality improvement activities to maintain them on an ongoing basis.⁵ This recommendation indicates that clinicians will not do this activity unless they are being watched or there are some consequences.

Why abuse is not identified

The barriers to screening have been elucidated by a variety of investigators^7,8 and include time, skill, comfort, resources, and fear on the part of clinicians, although clinicians are more likely to attribute the lack of screening to patient characteristics than to themselves.⁹ The willingness of battered women to disclose abuse and the factors conducive to disclosure (privacy, respect, believing the woman, nonjudgmental approach, referral to resources) have also been investigated.¹⁰ However, none of this information changes what we are actually doing in clinical settings on a consistent basis.

Battering is truly a problem we do not wish to identify. Despite the screening instruments, improved knowledge base, and training, most clinicians do not seem to want to know if there’s a problem. Still, a small group of dedicated clinicians are consistently doing this work and reaping rewards.¹¹ What is different about these clinicians? Do most clinicians have difficulty with the subject because battering challenges closely held assumptions about family and men and women?¹² We need to know more about these factors if we are going to influence screening; the problem does not lie in our instruments but in ourselves.

The importance of primary prevention

The second problem—one that is ultimately more serious and has remained invisible—has to do with our failure to recognize the need for primary prevention. Zola¹³ wrote about the parable of the health care worker pulling drowning victims out of the raging river. This person was so busy resuscitating the victims that she was unable to look upstream to see why all the bodies were falling in. Family medicine has also neglected to look upstream. We are busy perfecting our tools for pulling the bodies out, even examining how we feel about doing that gruesome work, but we have been slow to march up the banks and see how we can stop the bodies from being pushed in. We seem to have gotten stuck at secondary prevention (eg, identifying teenage girls and women already in abusive relationships), and we have forgotten our professional commitment to primary prevention.

Yet the extent of violence against women sampled in the primary care and emergency room settings (which we have reason to believe involves nearly 36% to 44% of women in relationships with men during their lifetimes^14,15) reveals the serious need for primary prevention efforts. Who is talking to the parents of small children and adolescents about how wrong it is to hit girls or women or force them have sexual relations? Home visiting programs with mothers from delivery until the child reaches the age of 3 years appear to prevent use of violence by the parents and those children^16-18 but have not received wide application as a public health tool. Interventions in elementary schools to deter violent behaviors seem indicated, since gender roles of male domination and female submission are well established by first grade.¹⁹ Such programs have the potential to deter violence at the early elementary school level and decrease adolescent behavioral problems.²⁰ School-based interventions linked with community resources addressing dating violence at the middle school level are effective,²¹ and some recommend adolescence as the ideal time to address prevention of partner abuse.^22,23 Thus, despite the relative lack of long-term outcome data, it appears that community-based primary prevention programs for violence show promise,^24-29 but none of these involve physicians.

What underlies abuse

What would primary prevention of violence against women look like if it were conducted at office visits by family physicians? To answer this we need to examine the dynamic underlying the violence. We know that battering is not just the violence, yet we get fixated on that aspect of it. We seek explanations that have to do with violence (the media, gun control, need for skills in conflict resolution, and anger management). We neglect to consider what we also know: That battering is “a set of learned controlling behaviors and attitudes of entitlement that are culturally supported and produce a relationship of entrapment.”³⁰ Such dynamics are difficult for us to face and can be even more difficult to comprehend. Even in the absence of physical abuse the controlling behaviors are directly harmful to women; the health status of women who have been emotionally abused is measurably worse than that of nonabused women.^31,32 We must look beyond the violence to the issue of control of women by men.

We need to look at the origins behind men feeling that they have a right to control women, and we need to make a commitment to changing how we raise both girls and boys to eradicate this sense of entitlement. So far, family medicine has made no such commitment. To do so, we need to develop a set of skills to work with parents and children regarding issues of control, hitting, fighting, fighting back, and using violent tactics to get what you want. Fortunately, the clinical tools to do this work have been developed by Stringham,³³ who has incorporated questions about violence and control into every visit. He and his colleagues have found that certain screening questions for adolescents have a high predictability for subsequent violence-related injuries and can be used to stratify risk of future injury.³⁴ Using his consistent philosophy over a 20-year period he has shown thousands of families in a working class community how to raise children with self-respect and without violence.

Asking the hard questions

Questioning how a man handles himself and his sexuality with women challenges his manhood, which can be very difficult territory. We would rather talk about exercise and diet than go to the hard questions: Do you ever feel you have to hit or swear at your girlfriend? Do you ever force your wife to have sexual relations when she might not want to? Do you ever feel that you should be able to control her? Also, to whom would we pose these questions: all men, just men who we think are likely to be abusive, men who seem to fit a macho stereotype, men who drink more than we think they should, or men with a shotgun in the pickup truck? Would we ask the local physician, lawyer, or police chief when he comes in for an annual checkup? To ask these questions we need to be clear about our own values and willing to reveal them when the patient says, “Why are you asking me that, Doc?” Confronting patriarchal values does not come naturally to medicine, a field that has traditionally had women as handmaidens at home and in the office and hospital. When we work through the logical steps we can recognize and explain that male domination is not healthy for men or women. To provide violence prevention for women we will need to change health promotion with men, because women’s health depends in part on men’s healthy behaviors.³⁵

Gender-specific curriculum

To help patients change their behavior we need to connect with them as sharing similar values. How can a male family physician approach a potentially battering male patient as a reasonable equal? In what ways can we share the frustration of living with problems (economic, job, parents, kids), and yet distinguish between ourselves as not sharing the same assumptions about male privilege? Female family physicians may have more experience in working with the girlfriends and wives of batterers and have been explicit about both the joys and challenges of that particular work,¹¹ but how can a female family physician work with men who batter? Training programs need to help both male and female physicians clarify their values so that they can see how their gender and experiences will affect how they do this work. In other words, family medicine needs a gender-specific curriculum to teach the skills of working with violent men. At the same time, we need to recognize that when battering is identified one family physician cannot safely be the clinician for both the batterer and the partner.³⁶ We have much to learn about how to transition safely from being the family physician for both members of a battering relationship to being the family physician for 1 or the other.

Conclusions

Interventions for such a broad problem must take place at the level of community, school, family, and individual patient. Although we are busy incorporating screening strategies into our practices to detect battered women, it is also necessary for us to look upstream. We need long-term studies of the impact of violence prevention activities in the clinical setting. But as individual physicians we cannot wait for those results; if we are serious about primary prevention we must begin now by raising the hard questions about control and violence with boys and men. Otherwise, we will get very good at fishing the bodies out downstream but will never have any reprieve from that work.