Public Health Prevention of Violence Against Women: A critique of current strategies and a suggestion for future intervention – Erica Perlman - Hensen

It is not uncommon to see posters or signs in American cities advertising hotlines to report rape or other forms of violence against females. These hotlines offer much needed support to victims and raise awareness of the violence committed against women, but provide little preventative help. When hotlines and images of battered women compose the vast majority of the current public health interventions, one must ask how effective these interventions are at preventing this type of violence?

Violence against women is a term used to encompass many different types of aggression that can be directed toward women. Included in this term is intimate partner violence, such as domestic abuse, spousal and date rape, and any form of sexual violence, including rape, molestation, harassment, and even threats of these acts (1-2). More specifically, sexual violence is defined as a sexual act where consent is not obtained or freely given (3). In this paper I will use the term violence against women to specifically address violence that is perpetrated by males toward females. With the acknowledgement that other types of violent crimes exist, this is the most predominant form of violence present in our culture and will be the focus of this paper (4).

Violence against women is a significant problem in the United States. One of every six women and 20 -25% of women in college report having experienced attempted or completed rape (3). Of these rape victims, 74% said that the perpetrator was an intimate partner, family member, or acquaintance (3). Additionally, there appears to be greater sexual violence against minorities. In one study that surveyed high school students, 9.3% of African American students and 7.8% of Hispanic students reported having forced sexual intercourse, compared to the 6.9% of white students (3). In fact, intimate partner violence is the leading cause of injury to women 15 to 44 years of age. This makes intimate partner induced injuries more common than automobile accidents, muggings, and rapes from unknown perpetrators combined (5).

The effects of violence against females are devastating. For the victim it almost always results in serious physical, sexual, and/or physiological harm. Women who have been subjected to sexual violence have been shown to have a high incidence of eating disorders, depression, abuse alcohol, drug use, and are more likely to engage in risky sexual activity (3). But the effects of this type of violence do not stop at the victim; it affects family, friends, and communities of these victims as well (7). Violence against women appears to be a learned behavior. People who are frequently exposed to violence are more likely to be perpetrators as well as victims of violence against women (8). The theory that violence is learned is well documented in relation to intergenerational cycling of violence. Sons of men who beat their intimate partners are more likely to be perpetrators of violence to women and women who are daughters of victims of violence are more likely to be beaten or subjected to other forms of violence from their intimate partners later in life (8). On the social level, men’s physical and sexual violence against women is a fundamental barrier to gender equality and without amelioration of this form of violence, women will never be able to overcome the great gender divide that exists in the United States and worldwide (9).

Although there is great prevalence of violence against females in the United States and the ramifications of this abuse are immense, it has been an often-neglected public health concern (7, 10). Furthermore, the public health interventions that have been in place to address the problem of violence against females are greatly flawed in their approach and target. I will begin this paper by critiquing the current public health approach to combating violence against women. I will follow this with a personal recommendation for an intervention that would close the current gaps in public health policy pertaining to violence against women prevention.

Critique

There are three major critiques of the public health approach to dealing with violence against women. First, the majority of interventions in the United States are directed toward women and little to none toward men. Second, the interventions are directed toward individuals, often after the event has already occurred, and not whole communities or society. Third, the interventions to prevent this behavior are usually based on the threat of law enforcement, focusing on punishment of bad behavior, rather than encouraging positive behavior.

The most common public health interventions pertaining to violence against females is focused on the female victim (5). These strategies have included education, awareness, self-defense, hotlines for reporting, and crisis intervention services for survivors (7). Examples of the female focus of interventions and organizations revolving around reducing violence against females are websites such as janedoe.org and womenshealth.gov (11-12). Jane Doe Inc. is the website for the Massachusetts coalition against sexual assault and domestic violence and is considered the leading organization in Massachusetts for organizing and unifying many groups that are fighting violence against women. Yet, this site, like most other websites pertaining to this issue, is directed toward a female audience. It is constructed in pastel colors and the vast majority of pictures on the site are of women. Additionally, under recommendations to aid in prevention it states, “joining a self defense class.” Similarly, it is within the womenshealth.gov website under the U.S. department of Health and Human Services, that information regarding violence against women is found. Womenshealth.gov is the federal government’s website to distribute information about women’s health. Instead of placing violence against women as a category in the main health and human services section of the website, this aspect of health has been placed within the confines of women’s health, thus specifically targeting female viewers and not the entire population. Furthermore, this cite, like Jane Doe Inc., is constructed with pastel colors. This placement and presentation of the issue of violence against women is clearly being made to attract a female audience, within both state and federally created public health intervention websites.

Another example of the female focus of these public health interventions is the Take Back the Night campaign. The Take Back the Night Organization is one of the largest activist campaigns against sexual violence (13). Although this international organization has made great strides in raising awareness about sexual violence and in encouraging the reporting of sexual violence, it’s message, like so many other interventions, is directed toward women. It encourages women to ban together to help fight this problem and largely neglects the influence of male behavior in curbing sexual violence.

Although all of these female focused interventions are significant in their attention to the protection and empowerment of past and/or future victims, public health measures have failed to address the perpetrator. By focusing the vast majority of interventions on females, public health has made this a woman’s issue – a problem with women. Furthermore, this focus is feeding into the blaming of women and the gender inequalities that are at the root of violence against women (8). Wingood and DiClemente, in their discussion of the theory of gender and power, discuss how our culture sees women as lesser beings and are defined in relation to men instead of themselves (14). By focusing public health interventions on women, it is asking women to change their behaviors to fix the problem, versus changing men’s behaviors.

Since men are the vast majority of the source of violence against females, this approach is completely contradictory to the majority of other public health measures that focus on prevention (8). To truly fight against the origins of violence against women, preventative measures must be focused on the perpetrators and the issue should be seen as one that affects both sexes (15). This means that intervention campaigns that raise awareness and educate need to be geared to both men and women, if not more toward men. By continuing to provide interventions that are mostly focused on a female audience, not only is public health failing to address the true origins of this issue but also propagating the biased gender roles of our society.

The second critique will address the fact that most interventions to reduce violence toward women have been based at the individual level and have neglected the shaping of behavior at a societal level. Many current interventions for victims, such as hotlines, and interventions for perpetrators, such as offender treatment services and surveillance, are all based at the individual level (4, 16). Hyman et al. discuss in their article “Primary Prevention of Violence Against Women,”

[Interventions against violence toward women] include reactive interventions such as crisis management, emergency care, and criminal justice against perpetrators, rather then societal or proactive interventions. However, it is increasingly being recognized that successful interventions in reducing violence toward women in society need to be focused on primary prevention and to involve multiple levels of service providers and government (6).

As suggested by Hyman et al., there needs to be a greater focus on interventions at numerous levels of a person’s environment, from individual to society. Societal-level influences on violence against women include but are not limited to gender inequalities, religious or cultural beliefs, societal norms, and social and economic policies that “create or sustain gaps and tension between groups (16).” By addressing these societal influences, a more comprehensive approach can be created to fight violence against women.

Additionally, many feminist researchers believe that a society’s overall norm and practices of male dominance have greater significance in contributing to violence against women than learned behavior from specific individuals, such as parents (17). By neglecting social based interventions, public health is not truly addressing the underlying risk factors that create the threat of violence toward women, such as cultural norms.

Additionally, interventions that are based on shaping groups and cultural norms can be much more effective than individually based interventions. First, these group-oriented interventions can affect many individuals at the same time by targeting a group, making them more powerful (18). Second, by creating interventions that are directed at changing the perceptions of the entire community and the social norms of that community one can affect the immediate decision-making of an individual. As explained in social expectations theory, how one is socialized largely affects their perception of how they should act as well as how others should act. These perceived roles and norms largely define one’s behavior (19). Based on this theory, a person would not batter their wife because it was seen as unacceptable in their community and was not the social norm, not because they considered how this action might hurt their wife physically or mentally. This form of behavioral control can often be more powerful and long lasting. Third, by changing the norms of a society, the desired beliefs and behaviors can continue to be diffused through a society, even after the active intervention has ended (18). By not having social based interventions, public health is not addressing the issue of violence against women at its roots nor utilizing a broader, more efficient form of intervention.

My third critique of public health’s approach of dealing with violence against women is that the majority of interventions that exist that target males are focused on punishment and law enforcement. Many local and state governments have public service announcements aimed at preventing violence against women by threatening perpetrators or future perpetrators that violence against women is a punishable crime. One Montana public service announcement commercial begins by showing a man yelling and hitting his wife for burning his dinner followed by him eating in a jail cafeteria (20). Several Canadian public service announcement commercials created by the public health organization, Home Front, show men brutally beating and yelling at women in public and end by stating the slogan “You wouldn’t get away with it here, you shouldn’t get away with it at home (21-22).

Although these commercials are attempting to prevent future abuse and are focused on male audiences, they are not likely to be effective for several reasons. First, showing negative imagery regarding a behavior is often much less effective than encouraging positive behavior that appeals to an individual’s core values and desires (23). Second, the use of threats to curtail the individual’s behavioral freedom is likely to create reactance, a rebellion from the desired behavior (24). Psychological reactance theory is described as the increased desire for a freedom that has been threatened (25). In the case of violence against females, offenders or future offenders may reject or even be provoked by messages that remind them of the fact that violence against women may cause incarceration and thus, a loss of freedom. To a lesser degree, the offender may experience reactance simply to the fact that the intervention is identifying his behavior as bad. If these ads are creating reactance behaviors, they are not only ineffective public health interventions, but they could be actively working against the goal of the intervention by propagating this behavior.

These three critiques of the current public health approach to curtailing violence against women are neither a thorough examination of all of the public health interventions dealing with these issues nor a complete critique of the programs analyzed. These are simply three critiques of some of the most predominant forms of intervention that are present in American culture. Despite this brief overview of the topic, there are very important issues suggested by the above discussion. First, the lack of focus on males when fighting violence against women is neglecting the fact that men are the perpetrators of these acts and only perpetuates the sexism that is present in American culture by making this a women’s issue. Second, by focusing on individuals, and not the entire society, public health interventions are not being as effective as possible in changing overall cultural norms pertaining to violence against women. Third, the focus on law enforcement and punishment of males in many interventions may be causing psychological reactants, which could be furthering this unwanted behavior instead of discouraging it.

Proposed Intervention

Public health has to develop a more comprehensive approach to dealing with violence against women and return to its roots by creating preventative solutions that encourage healthy behaviors (26). To create preventative measures, the risk factors that lead to the unwanted behavior must be identified. Yet, understanding the risk factors that contribute to the threat of violence against females are largely unknown since violence against women is not biologically based, such as many other public health concerns (8).

Despite this, sociological theories of behavior can help create new interventions to aid in the prevention of future violence against women. Some past recommendations for preventative measures are early identification of individuals at risk of being victim or offender, empowerment and life skill development for women, safety and support programs, and legal policy (6, 8). Although these recommendations would likely be effective public health interventions to prevent violence against women, I will focus on the changing of social norms particularly within the male population through increased awareness and education.

My proposed intervention would increase awareness and education through a large-scale advertisement campaign. An advertisement campaign is best for reaching a large population simultaneously. Because there are few demographics and/or social characteristics that are associated with violence against women, it is most appropriate to target the entire population (8). Additionally, since the goal of the campaign is to change an entire society’s cultural norm, a far-reaching campaign that is experienced by many different groups within the society is necessary. Flood, in his article, “Engaging Men in Ending Men’s Violence Toward Women” describes the aim of preventive public health measures,

Preventions aim to lessen the likelihood of men using violence in the first place by undermining the beliefs, values, and discourses which support violence, challenging the patriarchal power relations which promote and are maintained by violence, and promoting alternative constructions of masculinity, gender and selfhood which foster non-violence and gender justice (9).

This form of prevention is key in stopping violence against women before it begins.

This campaign would be largely focused on television advertisements but would also include run/walks and other large gatherings to gain support and encourage additional awareness. It would revolve around the slogan “Be a Man.” The concept that would be propagated would be that true men are men who don’t victimize women. The advertisement commercials would star major athletes in all different sports: football, hockey, basketball, soccer, NASCAR, etc. The majority of the commercial would be of the athlete playing his sport in a very aggressive masculine light but would end with a shot of him in his sports attire standing happily with his wife or girlfriend, showing tasteful affection and saying “Join me in preventing violence against women. Be a man.” Additionally, there could be merchandise created with the slogan as well as athletes’ names to increase visibility and keep the idea of preventing violence against women very closely tied to men and their personal interests.

There are three major components of this campaign that would make it largely successful. First, the campaign would be geared specifically for men and would play off one’s desire to be labeled as masculine. Second, the campaign would be empowering to men, showing men in a positive light and as a cohesive group banding together to help, creating group ownership of the issue. Third, because the positive message would be delivered by men to men, it would reduce the psychological reactance that is present in many of the current campaigns described previously.

To begin the discussion, I would like to address why this advertisement campaign would be specifically geared toward men. This focus is effective and significant because it enables the campaign to target the problem before it begins, and would be delivered by males. If men do not decide to end the violence themselves, women will always be victims. Thus, men must be a central part of the solution (9, 15).

This intervention will be effective toward men because of its marketing and focus on masculinity. The advertisement is mainly focused on one concept, masculinity. Masculinity is considered a core value for men (9). By redefining masculinity to include rejection of violence toward women, an association is created between the public health message and male masculinity. In this way, one can more easily sell the product of ending violence against women (23). Masculinity will be sold in this advertisement campaign by using athletes as spokesmen; as athletes are known symbols of masculinity in our culture (15). Furthermore, the vast majority of the commercial would show the athlete being strong and powerful, increasing the association of their masculinity with their message. Additionally, by showing the athlete happy with his significant other, the advertisement is also providing the promise of a healthy relationship, another basic desire for many men.

The second major component of this campaign that will make it successful is that it is being focused solely on men. Because this campaign is encouraging men to unite to deal with this issue, it is creating a type of group around the message of opposing violence against women. Michael Kaufman discusses this topic when he states,

One reason for the effectiveness of such participation [in male-focused campaigns] is that through participation, men and boys will feel a sense of “ownership” in the problem. They will feel they have a personal relationship to the issue and a stake in the process of change (15).

By creating the idea that one is an member of a group, there is increased personal enthusiasm. Additionally, with increased adopters of this belief, there is a greater likelihood that the message will become part of the social norms of that community (27).

Similar to the proposed intervention, the white ribbon campaign, an international male focused campaign against violence toward women, heightens the feeling of inclusiveness by having men and boys wear white ribbons on November 25^th to show their support. Thus, there is a specific symbol unifying the group and creating a brand for the concept (28). The white ribbon campaign in Australia has gone even further by having men “swear” that they will not contribute the problem of violence against women. They have the slogan “All Aussie men should swear (29).” This added concept not only furthers the group mentality of men and boys who have all sworn to support this issue, but it also plays off of the word “swear,” creating an element of rebellion in the message. This sense of rebellion is likely to especially appeal to adolescents who often seek rebellion and freedom from established ideas (30). In many of the same ways, the “Be a man” campaign would aim at creating ownership of the intervention and a sense of male comradery associated with it. This would help sell and propagate the message of opposing violence against females through male social networks (31).

Finally, the third major component of the success of the proposed intervention would be that it would be able to combat the physiological reactants in men that are likely produced by interventions that focus on the criminality of violence against women. This intervention would focus on the positive nature of men, showing their strength and kindness toward women. It would not depict men villains and thus would encourage involvement from males and not create a greater divide and further animosity about gender relations (24, 15). Moreover, the message would be delivered from men to men. Using peers to deliver a message has been shown to decrease reactance toward a coercive message such as this. Thus, men would no longer feel as threatened by the public health messages and would be far more likely to be persuaded by them (24).

By using sociological theories and concepts such as appealing to core values, branding, ownership, and deflecting reactants, a public health campaign can be created to effectively promote the prevention of violence against women. This advertisement campaign would not solve the problem of violence against women but it would likely be a good start in addressing the risk factors that contribute to this significant public health concern.

References

1. Kilpatrick DG. What is violence against women: Defining and measuring the problem. Journal Interpersonal Violence. 2004;19(11):1209.

2. Saltzman LE, Green YT, Marks JS, Thacker SB. Violence against women as a public health issue comments from the CDC. American Journal of Prev Medicine. 2000;19(4):325-9.

3. CDC, “Understanding Sexual Violence: Facts at a Glance,” http://www.cdc.gov/ViolencePrevention/sexualviolence/datasources.html (accessed on April 20, 2010).

4. Wathen CN, MacMillan HL. Interventions for violence against women: Scientific review. JAMA. 2003;289(5):589.

5. Gundersen L. The national coalition against domestic violence. Office of the surgeon general; January, 1 1994. In: Gundersen L. Intimate-partner violence: The need for primary prevention in the community. Annals of Internal Medicine. 2002;136(8):637.

6. Hyman I, Guruge S, Stewart DE, Ahmad F. Primary prevention of violence against women. Women’s Health Issues. 2000;10(6):288-93.

7. CDC, “Sexual Violence: Prevention Strategies,” http://www.cdc.gov/ViolencePrevention/sexualviolence/prevention.html (accessed on April 20, 2010).

8. Jewkes R. Intimate partner violence: Causes and prevention. The Lancet. 2002;359(9315):1423-9.

9. Flood M. In: Engaging men in ending men’s violence against women. Expanding our horizons: Understanding the complexities of violence against women conference. University of Sydney; 2002. p. 18–22.

10. Rosenberg ML, O'Carroll PW, Powell KE. Let's be clear: Violence is a public health problem. JAMA. 1992;267(22):3071.

11. Jane Doe Inc., http://www.janedoe.org/index.htm (accessed on April 20, 2010).

12. Sexual Violence, http://www.womenshealth.gov/violence/ (accessed on April 20, 2010).

13. Take Back the Night, http://takebackthenight.org/index.html (accessed on April 20, 2010)

14. Wingood GM, DiClemente RJ. The theory of gender and power: A social structural theory for guiding public health interventions. In: Emerging theories in health promotion practice and research: Strategies for improving public health. 2002:313–346.

15. Kaufman M. The white ribbon campaign: Involving men and boys in ending global violence against women. In: A man's world?: changing men's practices in a globalized world. 2001:38.

16. CDC, “Sexual Violence Prevention: Beginning the Dialogue,” http://www.cdc.gov/violenceprevention/pub/SVPrevention.html (accessed on April 20, 2010).

17. Kurz D. Social science perspectives on wife abuse: Current debates and future directions. Gender and Society. 1989;3(4):489-505.

18. [1] Crosby RA. Kegler MC, DiClemente RJ. Understanding and applying theory in health promotion practice and research (Chapter 1). In Crosby RA. Kegler MC, DiClemente RJ, eds. Emerging theories in health promotion practice and research: Strategies for improving public health. San Francisco, CA John Wiley & Sons, Inc., 2002, pp. 1-15.

19. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socilization and Teories of Indirect Influence), pp 202-227. White Plains, NY: Longman Inc., 1989.

20. Montana State University, “Open Yours Eyes,” National Domestic Violence Hotline, http://www.youtube.com/watch?v=IUESbKAC5ks&feature=related (accessed on April 20, 2010).

21. Home Front: United in Breaking the Cycle of Domestic Violence, “You Spilled My Coffee,”

22. Home Front: United in Breaking the Cycle of Domestic Violence, “Boardroom,” http://www.youtube.com/watch?v=EXxUSolUcdM&feature=related (accessed on April 20, 2010).

23. Siegel M. Marketing social change: An opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. Marketing public health: Strategies to promote social change. Aspen Publishers; 2004.

24. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27(3):277-84.

25. Donnell AJ, Thomas A, Buboltz WC. Psychological reactance: Factor structure and internal consistency of the questionnaire for the measurement of psychological reactance. Journal of Social Psychology. 2001;141(5):679-87.

26. Wolfe DA, Jaffe PG. Emerging strategies in the prevention of domestic violence. The Future of Children. 1999;9(3):133-44.

27. Introduction. In: Gladwell M. The Tipping Point: How little things can make a big difference. Boston: Little Brown and Company, 2000, pp. 3-14.

28. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans, WD, Hastings G, eds Public health branding: Applying marketing for social change. Oxford University Press; 2008.

29. White Ribbon Day “Media Campaign,” http://www.whiteribbonday.org.au/Media-Campaign-42.aspx (accessed on April 20, 2010).

30. Hicks JJ. The strategy behind Florida's “truth” campaign. Tobacco Control. 2001;10(1):3.

31. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England Journal of Medicine 2008; 358:2249-2258.