My Dream for the Next Five Years: Family Violence at the Center of the National Health Agenda

1. My Dream for the Next Five Years: Family Violence at the Center of the National Health Agenda Jacquelyn C. Campbell, PhD, RN, FAAN Anna D. Wolf Chair and Professor The Johns Hopkins University School of Nursing

2. First Celebrate!! WE’VE COME A LONG, LONG WAY

3. Family Violence & Health Helfer & Kemp ‘68 – the Battered Child 1st US scholarly book on DV - Martin‘78 1970’S 1st attention to elder abuse – Rosalie Wolf Stark & Flitcraft - health care system -’79 Violence is a public health problem (Koop‘85) 1988 - Marital rape as a crime in MI(‘70 -OR) Healthy People 2000 (DHHS ‘91) 1991 - ANA resolution on DV 1992 - AMA – ’92 – Family Violence IOM reports – ’97; ‘98; ‘02; ‘07; in process JCAHO standards - 1st ED’s (‘92), now all

4. U.S. INTIMATE PARTNER HOMICIDE RATE DECLINE 1976-05 FBI (SHR, 1976-02; BJS ’05, ‘07)

5. Decline in Intimate Partner Homicide and Femicide Decline in male victimization in states where improved DV laws & services - resource availability (Browne & Williams ’98, Dugan, ‘99) Exposure reduction - increased female earnings, lower marriage rate, higher divorce rate (Dugan ’99; Smith & Brewer ’90) Gun availability decline (Wilt ‘97; Block ‘95; Kellerman ‘93, ‘97- gun increases risk X3) – Sorenson ‘06 –challenges of implementation gun removal w/OP possession prohibition – 12-13% decrease in femicide (10% overall IPH decrease)

6. U.S. INTIMATE PARTNER HOMICIDE RATES & DOMESTIC VIOLENCE SERVICES 1976-9 (Resources per 50 million - Dugan, Nagin Rosenfeld ‘03)

7. Do we believe this? NVS – as any surveillance system (e.g. BRFSS, PRAMS, DHS) undercounts prevalence of IPV But still useful for examining trends over time and associations E.G. BRFSS shows women significantly (X2) more likely to be victims of IPV than males – lifetime & past year(Breiding ‘08) So yes, we can believe this –Hurrah! NCVS survey – significant decrease in IPV – ’00 – ‘05

8. My Dream Deaths & numbers continue to decrease Fewer health care consequences & costs More recognition family violence as a driver of major health px & disparities More prevention & intervention in health care system More interdisciplinary & multi-sectorial collaboration Increased research More education of health professionals

9. Increase in research in Family Violence Significant increase in funding – NIJ, CDC, & NIJ in last 20 years BUT, proportion of funding decreased at CDC & $$ neither increased or decreased at NIH – compared to large increases in other areas Need for increased urging across NIH to councils to establish IPV and VAW as priorities – health disparities is one avenue to use across all governmental funding agencies

10. Good things happening in research!! Interdisciplinary Collaborative with advocacy organizations Combinations of qualitative & quantitative & physiological data More strength based models Increasingly including voices of those affected in research More culturally appropriate

11. Emerging areas of research with important implications for health care Physiological research on effects of Family Violence on immune system Stress response PTSD & co-morbid – PTSD & depression Implications for treatment PRAMS analysis IPV & Post Partum Depression - MMWR ’08 Activating autoimmune response – conditions like chronic pain – fibromyalgia, fibroids, STI’s also cardiovascular problems – ACE & ‘07 BRFSS data on IPV & cardiovascular

12. Emerging areas of research with important implications for health care Injury long-term outcome research – e.g. strangulation research – (Strack, McClane ’00, ‘01; Glass, Campbell ‘08 Need for immediate medical attention – coordinate protocols with first responders Implications for stroke Ongoing neurological problems Links with TBI – another emerging area Risk assessment for homicide www.dangerassessment.org

13. Emerging areas of research with important implications for health care Health Disparities AI/NA, African American & immigrant families more at risk for CAN, IPV – especially current (e.g. BRFSS ’05 – JPV ’08) To what extent does this excess risk of IPV affect health disparities such as hypertension, infant mortality, LBW, STI’s, HIV/AIDS, substance abuse, BMI – Sharps & Campbell ‘06

14. New Face of HIV/AIDS – HIV/VAW interface official recognition by UN ‘04 Around globe women are the fastest group contracting HIV & fastest conversion to AIDS In US – poor African American women most affected (Levenson – The Secret Epidemic) - USVI Africa – women dying most from AIDS – 3:1 ratios largest proportion – heterosexual married women – no risk factors except husbands not using condoms 3 Major studies show direct link of IPV with HIV+ status – over and above all other risk factors South Africa –Dunkle, Jewkes et. al. The Lancet 363:1415-21 ’04 Fonck, Kidula et al – Kenya – AIDS & Behavior ’05 Maman et al – Tanzania – ‘02

15. HIV/DV Connections – Etiology (Maman ’99; Garcia-Moreno ‘02) Immune system depression with stress Trauma of forced sex; anal sex Increased STD’s & untreated STD’s (Coker et.al. ’00; King et. al. ’00) Impossible to negotiate safe sex if a battering relationship (Champion ‘98 Laughon ’05) Women accused of infidelity if want to use safe sex Males have other partners unknown to women female & male – “down low” (WHO ’04) Fear of being beaten for being tested; notifying partner of positive status; Tx delay Forced sexual debut – 12.5% US –(21% <14) (Stockman ‘08)

16. Violence Prevention in Low- and Middle-Income Countries: Place on Global Agenda http://www.iom.edu/CMS/3783/48783/50755.aspx   State of science in violence prevention – US & Globally - progress, promise, & challenges IOM workshop 6/07; workshop summary 2/08 National & International participants - health, CJ public policy & economic development Identified opportunities for US government & other leaders with resources to more effectively support programming for prevention of all types of violence.  Need for integrated, science-based approach & agenda to support research, clinical practice, program development, policy analysis, & advocacy for violence prevention. HIV/AIDS intersection paper   Planning Committee: Mark Rosenberg, Chair, James Mercy, Co-Chair Sir George Alleyne, Alexander Butchart, Jacquelyn Campbell, Darnell Hawkins IOM Staff: Kimberly Scott, Senior Program Officer; Patrick Kelley, Board Director

17. Huge increase in research publications past 20 years Journals dedicated to IPV, FV or VAW – , JIPV, V & V, JFV, VAW - new APA Trauma journal, J of CAN, J of Elder Abuse As well as journals on violence – J of Aggression, J of Agg, Maltx & Abuse Other journals with substantial FV content JPM, J Women’s Health Issues, JAMA, J of Community Psychology, J of Poor & Underserved, J of Urban Health, AJPH, Need more special issues, higher impact

18. INCREASING GLOBAL ATTENTION TO VIOLENCE AGAINST WOMEN Increasing attention to problem Defined as a human rights violation by UN (1993) UN Declaration on the Elimination of VAW (1993) Recognized as related to population control (Cairo) ‘94; Special Rappateur ‘94; Beijing ‘95 WHO Violence as a PH problem -1996 WHO recognition as a health problem - ‘96 PAHO initiative; ‘97 WHO initiative - multi country study - (Garcia-Moreno, Ellsberg, Heise, Watts ‘06) World Violence & Health Report – (Krug et. al., 02) Official UN recognition of DV-HIV interface ‘04-’08

19. CAVEATS TO “WE’VE COME A LONG WAY, BABY” MARGINALIZATION: “Not in the main building” CULTURAL IMPERIALISM: Emic vs. Etic view CONTINUED GENDER DIFFERENCES ELDER ABUSE continues to be neglected MARITAL RAPE SELDOM A CRIME – except US, Canada, Europe, SA, Australia, NZ - victims pay for rape medical reports, need proof of resistance For violence against women - continued male dominance- economic & political Still reluctance to include VAW in international programs–“Safe Motherhood” “Safer Pregnancy” PEPFAR Congressional hearings-WHO study– no one came

20. Other emerging challenges – Military & Veterans Similar rates of IPV among AD military women & similar health effects (Campbell ‘04) PTSD among veterans & increased family violence (Marmar et al ‘98) IP homicide & homicide-suicide (NY Times) Similar rates of PTSD & depression overlap (O’Campo et al ‘06) Support for routine assessment but concern about mandatory reporting – recommendation from DoD Task Force - confidentiality finding – Implementation!!

21. Other emerging challenges IPV amongst our own Health Care System Based IPV programs need to provide services to employees - Training for our own EAP & HR, Occupational Health Services & student wellness programs

23. Prevalence of IPV current or former intimate partner Physically, sexually assaulted, threats of either or stalked (CDC definition ’99) past 12 months n= 52 2.4% 1-5 years ago n=119 5.5% 6-10 years ago n=124 5.7% >10 years ago n=295 13.6% Lifetime n=542 25% Emotionally abused or sexually harassed Past 12 months n= 52 2.3% 1-5 years ago n=127 5.8% 6-10 years ago n=108 5.0% >10 years ago n=207 9.5% Lifetime n=470 21.6%

24. Prevalence of Childhood Abuse

25. Multivariate Analysis Low levels of DV at work BUT harassment relatively common – just not recognized as WPV IPV (lifetime & current) significant predictor of physical & psychological health outcomes along with childhood trauma (especially CSA), taking care of elders & WPV CSA & IPV significant predictors of WPV Demonstrates need to look at cumulative trauma and other family stressors in HR health care professional programs

26. What have we accomplished – in research & practice We have increased exponentially services for abused women – shelters – in health care systems & criminal justice systems One stop shops – Family Justice Centers – some but not all include health/forensic services – more need to But not enough We have shown that shelters “work” But not enough research on what works

27. What have we accomplished – in research & practice We have increased routine assessment for IPV in health care settings (especially prenatal care & ED) & we know how But not enough routine assessment & sometimes not done well – need for system change (Campbell, Coben et al ‘02) And not yet the clinical trials demonstrating that IPV assessment & intervention in health care system works – Although trials are on the way & Kaiser West is the gold standard model

28. What have we accomplished – in research & practice We have some good prevention models Dating violence – “Safe Dates”, “Fourth R” & “Arts Based Dating Violence Prevention” Nurse Home Visitation – Olds Model – Nurse Family Partnership – to prevent CAN & testing strategies for IPV But not nearly enough – e.g. Hawaii Healthy Start

29. What have we accomplished – in research & practice Increased education Family Violence in health care But often a charismatic leader model – as soon as the passionate person leaves the program disintegrates Need to train health care professional researchers T32 – pre and post doctoral training – few in violence - need more

30. What have we accomplished – in research & practice We have shown that batterer intervention programs work for some men But not all perpetrators – need more tailored interventions – that take into account childhood trauma Need to remember this is what many women want Including interventions for violent women

31. What have we accomplished – in research & practice We have started to pay attention to needs of indigenous families & families of color & immigrant families experiencing violence But not enough We have good collaborations of researchers & practitioners But not enough

32. What have we accomplished – research & practice & policy We have gotten much smarter in federal policy Many friends and departments & programs in federal infrastructure for research & program More stable funding for research and program But there has been & will be resistance - – often two steps forward and one step back

33. Research Supporting Policy “CONSTITUENCIES OF THE POOR AND POWERLESS MUST PROVE THEIR CASE FOR CHANGE

34. Legislative Change VAWA Acts I, II – ‘95, ‘00 VAWA ‘05 – Health Care Provisions International VAWA – introduced in ’07 – will be re-introduced in ‘09 DoD DV Task Force – ’00 – ’03 PTSD & Veterans’ Compensation IOM Report – ‘07 Policy Change in VA care Legislation pending

35. Changing Norms - Getting Men Involved Globally (“Masculinities” - Abrahams) “White Ribbon Campaign”-Canada HIV testing & counseling programs for men – Tanzania - Maman Teaching recruits in the military – “Tough Guise” Jackson Katz Prisoner re-entry programs – Oliver Williams “Soul City” & “Stepping Stones” (Jewkes) & Sonke Gender Justice – Dean Peacock – South Africa Promundo – Brazil – Gary Barker

37. Change Has ComeCelebrate & Build On the AccomplishmentsMeet the ChallengesKeep up the Good Work!! – Make my Dreams Come True!