Jacquelyn C. Campbell
Professor and Associate Dean, Johns Hopkins University
"To Have and To Hit? Understanding and Preventing Domestic Violence"
October 9, 2002

Jacquelyn Campbell: When I talk about battery, the definition that I use is repeated physical and/or sexual assault within a context of coercive control. So we are not talking about a one time push or shove. We are talking about a pattern of behavior and we are talking about…and this is extremely important for the healthcare community…we are talking about sexual assault as well as physical assault.

Forty to forty-five percent of women who are physically abused are also being forced into sex. This has tremendous healthcare ramifications. And then there is the context of coercive control. So not only is she being hit, but she is also being emotionally abused. She is also being controlled in a number of ways including control of her access to friends, control of her access to economic resources and control of her access to the healthcare system. And even so, we know that we need to conceptualize domestic violence or battering as a risk factor for many healthcare problems rather than a disease of a diagnosis or a syndrome all by itself.

In this way we make clear that just because a woman is abused doesn’t mean that she is sick. Doesn’t mean that she ought to get a mental health diagnosis. She may have a mental health problem but it doesn’t automatically follow. However, we know now that it is a risk factor for many healthcare problems.

When we look at the research around the world, in 1993 there were only 26 population-based studies outside of Canada and the United States from 22 different countries. There was only one rural and urban comparison study from a developing country. And people like to think that it was only when people migrated to cities that things like violence would happen, that violence in the family would happen. And what they find now though, is actually in countries where the cultural norms are that it is okay to beat your wife. That occurs more often in the small villages where the whole village may go along with the notion of wife beating. And that actually in places like Papua, New Guinea in the urban areas, it is less common. But still frighteningly often.

By 1999 there was 50 population-based studies that we can learn from. And the general range around the world was between 16 and 45% of women saying that they had somewhere along the line been physically assaulted by a husband and/or partner. But it is usually a husband in the developing countries.

I am not going to spend a long time on these but this is just to give you an idea of some of the different ranges of prevalent studies in Canada, in the US, in Europe, usually the ranges are somewhere around 30%, somewhere around a third of women say they have been hit at some time during their life by an intimate partner, or ex-partner. Usually less than that in the past year demonstrating that the majority of battered women at least in industrialized countries eventually leave the abusive relationship or manage to make the violence end.

In developing countries it is harder to leave. And we see higher ranges of higher prevalence of domestic violence that women report. It does vary. And you can see in Nicaragua having one of the highest prevalences…more than fifty percent of women saying they have been assaulted by an intimate partner. I think somewhat that this is the legacy of the civil war in Nicaragua plus the strong machismo norms that are an issue in that country. In Africa, very high prevalence of domestic violence. And in Turkey, you can see has one of the highest prevalence of domestic violence. We find in the Asian countries we also have high prevalence of domestic violence particularly in India. And one recent study done by doctoral students from Hopkins in China.

Now when we do this kind of research…in order to do it better and in order to do it meaningfully, one of the things we need to pay attention to is advocacy research where we use collaborations with shelters here in this country or with NGOs, or we do special training for people that are doing interviews to make sure that they keep women safe. There is a multi-country study being done by WHO that is a comparison study that has a wonderful safety protocol that you can download from the web, from the WHO website that really has some innovative strategies. Like when interviewers going into a home, they have one interview that is about domestic violence. And then they have another interview that is general healthcare issues that they can do with another person in the home because privacy is an issue.

Doing a study specific to domestic violence seems to be a really good idea. The most persuasive studies are ones that combine qualitative and quantitative data so that the stories as well as the numbers are there. This kind of research needs to take a lifespan approach. We know that sexual assault in childhood as well as domestic violence in adulthood has serious health consequences. And we need to think about the cost of domestic violence. This makes it much more persuasive to policy makers.

We think we need to take a health approach as well as a human rights approach. But both strategies are very important around the world. But to establish the issue just like with Dr. Koop, to establish the issue as being a health problem brings a lot of people on board that get nervous about a human rights or women’s rights approach. So the healthcare consequences are important to include. We need to look across forms of violence against women. In many countries it is not just domestic violence that happens. It is other forms of violence against women. There are still honor killings that go on. You have heard in the news a couple of terrible cases about women being stoned, etc. And then we can use the results of these studies for policy initiatives. Every country wants to say well, it doesn’t happen here. It is not a bad health problem here. And it is only when you do a study in that country and look at the healthcare consequences that you can make your case.

They also have these studies have good publicity value. But they are very difficult to fund and it is very difficult to get anyone to want to invest in this. But as I mentioned, the WHO multi-country study is an example of a wonderful study that has been funded primarily by Scandinavian sources that will have some comparison and health data to look at.

Briefly, just to give you an overview of some of the recent work that has been done primarily in the United States establishing some of the healthcare effects. And there is a series in the Lance that I wrote the first one that looks at these healthcare effects. It is an overview. And that is actually ‘02; the years keep slipping by on me so quickly I can barely keep track of them. It just came out last spring.

But some of the very important areas that have been looked at in great depth and there is a good fleet of studies, a good solid body of evidence is around abuse during pregnancy, again Dr. Parker being part of that. And a lot of nursing research that has been a part of that. Unintended pregnancy through the PRAMS data…public health research…establishing that low birth weight…there has now been a meta analysis looking at all the studies of abuse during pregnancy and low birth weight. And establishing that it is indeed a risk factor for low birth weight.

The STD-HIV connections with domestic violence through the forced sex, no doubt, but there is also some other interesting connections have been written about, have been started to be studied. There is some good research now that was summed up by Claudia Garcia Moreno in the Lancet series. GYN symptoms in every controlled study and primary care settings, that is what we see a lot of. We see a lot of chronic pain. We used to think that was all psycho-semantic. Now we begin to realize a lot of it is due to old injuries. There is both back pain is very common with domestic violence as well as abdominal pain. Head aches. And some of that, again, is related to neurological problems not just stress related headaches. Mental health problems, depression and post-traumatic stress disorder…again another meta analysis done by Golding in 1999. A great program of research by Dr. Lesserman, a physician that has really looked at this in relationship to chronic irritable bowel syndrome. Laterno and other people have established smoking being associated. Battered women…twice as many battered women smoke as women who are not abused. And obviously that has more healthcare consequences down the line. And then women who are abused are at increased risk for homicide. And what is beginning to be established is that it is a leading cause of maternal mortality. At least in cities in the United States. And there has been studies done in Chicago, New York City, and DC that have established homicide as now the leading cause of maternal mortality in urban areas.

So what can we learn from what we know worldwide about domestic violence? First of all, wife beating occurs in 84.5% of small-scale societies. It is almost ubiquitous, while child abuse only occurs in 27% of small-scale societies. And I worked with a couple of anthropologists, Dorothy Counts and Judith Brown, on collecting some primary data from the small scale and industrialized societies around domestic violence. Trying to identify what were the preventive strategies that communities had developed on their own. What were the things that were associated with domestic violence culturally that we could learn from. And one of the things we learned is that in small scale societies around the world, people tend to differentiate wife beating which is occasional hitting of a woman that is somewhat condoned by society, and wife battering which is more like the definition that I gave you before. And that many societies recognize that occasional wife beating often happens. That is something that many couples have a problem with whether it is the stress of a young marriage, whether it is just that men are raised to be somewhat aggressive. But that is an issue. And that the cultures themselves, the communities themselves recognize that potential and took responsibility for making something happen. Mutual couple violence where both couples fight was not nearly as common. The countries that we looked at are shown by the stars on this map, which is mainly to prove to you that I can play around with PowerPoint in my spare time. But as you can see, it is fairly well distributed around the world although there are more societies in Oceania.

And what we found is that almost every of those societies except for one had at least occasional wife beating. And I always love it except for one, because at least that means that all men do not beat their wives. That there are some cultures where it is completely not done. So that is always very hopeful to me because I personally love men and I have some really important ones in my life. And I like to know that. But that wife battering was much less common. And that doesn’t quite show up as well as it should but as you can see in many societies it was much less common and in some societies, although there was occasional wife beating, there was no battering going on.

Mutual violence seemed to have a totally different pattern that didn’t have anything to do with anything. It was a totally different patterns when women were violent that had it’s own factors that went along with it. So we said, what is happening? What…when we look at the societies where there is high level of battering, what can we identify that is common. What we found was that there were high levels of historic and current norms of male ownership of women. Men in those societies said things like I wouldn’t let my woman do this. Or my woman, or my wife do that. There was strong machismo norms and although that is a Latino term, it is something that you see in all kinds of cultures around the world where there is extreme male sexual jealousy and ideals of male toughness and violence.

There is other forms of violence against women in those societies. And we also find that there is heavy divorce restrictions. We also find that associated with homicide in this country. That divorce restrictions although we think that might a good thing for people to stay married, if it is a violent relationship, it is not a good thing for women.

Low levels of battering were where there were community level sanctions against it. Where the community said we don’t allow battering to happen. Where there was sanctuary for battered women…and the first edition of this book was called sanctions and sanctuary, it is my very favorite title in the world and when we did a second addition, the original publishers insisted on keeping the title. So we had to name the second one, to have and to hit. But sanctions and sanctuary is so important for providing safety to women. And sanctuary in this country is shelters and in developing countries it is other kinds of forms of sanctuary. There were female workgroups or other solidarity groups for women. And women had significant power outside of the home. And in some places it was financial and in some places it was magical power in some places it was political.

Now you would think that there would be a nice linear relationship between women’s status and wife beating. But when we look around the world, there is not. It is more of a curva-linear relationship. And in places where men have all the power, where the society says women have less power than men and we will enforce it…think of the Taliban in Afghanistan, the society enforced a low status of women. In those societies individual men don’t have to hit their women so much. The culture, the society will take care of it. They will take care of keeping them subservient.

Where there is high status for women, there is less wife beating. And we see that in some of the Scandinavian countries. It is where the status of women is in flux that we see the highest levels of wife beating. It is where people are unsure, where individual couples aren’t sure how they should organize their home.

I want to briefly take you on a little travel tour to Belize. It is a small country in Central America. It used to be British Honduras. It is known for it’s reefs and dieting. But it also has a very interesting both cultural and historic background. Belize is made up of three primarily…primarily three ethnic groups. One is the Creole people. They are descendants from slaves of the British. They are the ones that when Belize got it’s independence the British said, you guys are…will be the most educated. You will get the government, you will have the power. As I said, there is a history of slavery. This is the group where women are the most often beaten. The other main cultural group are the Mayans. The official language in Belize is English but the Mayan women are not encouraged to learn English. This often happens with immigrant couples in the United States. One way to keep a woman isolated is for her not to learn English. And oftentimes that is interpreted as it is in Belize that the Mayan women are the keepers of the Mayan culture and therefore don’t need to learn English and probably would be better off not learning English because it would get in the way of their culture. So I didn’t get to actually talk to any Mayan women. In the Mayan culture, women are very subservient. Machismo is very strong. And supposedly there is not much wife beating. As I said, I don’t have any real informants from Mayan women, so don’t know for sure but that is what people said. The third major cultural group are the Garifuna. That is pronounced a couple of different ways but that is what my people…my key informants in Belize told me you are supposed to pronounce it. The Garifuna are descended from a slave ship that wrecked off the coast of Belize on an island and the people intermarried with the indigenous people that were on those islands. They were never enslaved. That is an important part of their heritage, that they will talk about. They live in small villages on the coast. Mainly make their living by fishing. And amongst the Garifuna, this is one of these societies where there is occasional wife beating but not much battering. What happens is when the village hears the sounds of a couple fighting and they hear noises that makes them worry that it might become violent, all of the women go and surround the house. And they call to the young man and they say, aren’t you shamed, what is wrong with you, why would you do that kind of thing, we hear you yelling and saying ugly things to your wife, don’t you dare let that happen. And they make it clear to that young man that battering is not allowed. And they have community level sanctions against domestic violence.

So lessons to bring home. Those community level sanctions are extremely important. Way around the world in Oceania, the Nagavisi…there is a different kind of tradition but somewhat similar where when a young man hits his wife for the first time…and again it is a small village and people always know…he is sent home to his family to be fixed. And he can’t come back until he learns to act better. (clapping) Again, a community level sanction.

There are some other traditions in small villages in Oceania. Another one where again, when sounds of fighting are heard, the people of the village…in this village it is both men and women, the people of the village go and surround. And they call the young woman and they say come out Mary. Come out and join us. We don’t want this to happen anymore. Just leave him alone. And you come out with us and we’ll go and do some other things.

So again it is the community that is decided. And oftentimes it is women helping women. But it is also oftentimes the entire community that enforces these norms. One of the things that we see is that non-violence becomes a part of attaining manhood rather than attaining manhood meaning you get tough and you are strong and you can be aggressive, but attaining manhood means you become non-violent. One of the things my son who is now 28 always complains about is he says, my Mom taught me that not only would I never dare to hit a woman, but I am also personally responsible for all of my friends never hitting a woman. And I think that is how we have to raise our sons. A real man would never hit his partner.

Early interventions in the healthcare system, in the community and in Head Start, home visitation programs in our schools, extended families or compadres in the mountains in the Andes and Ecuador…each couple when they get married is assigned a compadre. Now that is fairly common amongst Hispanic peoples but in these villages in Ecuador the primary purpose of that compadre is to make sure there is no violence in that home. And should there be any violence amongst that couple, that older person in the community would be shamed.

So there are different strategies the people use. But they provide sanctuary for women should they be beaten and they also…and what we can learn from that is providing sanctuary in the healthcare system. And you have a wonderful display here in the hospital about the domestic violence program here. Some wonderful pamphlets, safety planning pamphlets, ways to assess for domestic violence with your patients…those of you that are healthcare providers, managed care discharge planning, substance abuse treatment, mental health settings, school health, all of these are places where we can intervene, where we can find women after the first push or shove like in those villages. And we can provide them with information and we can get them good interventions.

The other thing we can do as neighbors and friends is do a woman to woman, person to person approach. Say something to a woman…if you ever see a woman with a black eye…guess what, she probably got hit by a husband or boyfriend. Say something to her. Are you okay? Is there anything I can do? Reach out to her. When you are talking to women who are abused, appeal to her concerns about here children. Remind her it is not good for kids to be in homes where there is domestic violence. Put it in safety language. Don’t say you ought to leave him. Say let’s talk about ways you can keep you and the children safe. That is the same kind of language you can use if you are a healthcare provider. Tell her you are concerned about her. Tell her that you are there for her no matter what even if she tells you today she wants to leave him and next week she decides she doesn’t. That is okay, you are still there for her.

There is a national domestic violence hotline. 1 800 799 SAFE. They have speakers in every language. They have ways to address every part of this issue.

But getting men involved. That is what we realize that we really need to do. And I am just so pleased to see so many men in this audience and that is fabulous. The Family Violence Prevention Fund…and you can get their information from the web…has a new campaign on getting fathers and men to take a minute and teach our sons…all of our sons…prevention programs in schools and sports, the white ribbon campaign in Canada is very important…Jeffrey Katz is working with the military with marines in terms of teaching about domestic violence when they are first recruited. There is a wonderful soul city campaign in South Africa that involves men. So what we are talking about is a community approach. What we are talking about is all of us working together. What we are talking about is making sure that our neighbors know that it is not okay to hit your wife and particularly that our sons know that lesson. Thanks.