Elizabeth Reed, ScD, MPH George Washington University School of Public Health and Health Services

1. Losing the Gender in Gender-Based ViolenceThe Missteps of Research on Dating and Intimate Partner Violence Elizabeth Reed, ScD, MPH George Washington University School of Public Health and Health Services Department of Prevention and Community Health

2. Outline of Presentation • Background, including recent media attention to the issue • Discordance in the Frameworks used for understanding IPV and TDV • Girls’ experiences of IPV/TDV • Data from boys who perpetrate • Conclusions & Future Directions • Discussion

3. My background on this issue • Seeing teen dating violence and related abuses as an adolescent – and relevance of gender • Worked with girls as a counselor and ER advocate at rape crisis centers in MA and PA • Served as a public educator in high schools on issues related to teen dating violence and sexual assault • Trained in public health as a social epidemiologist • Multiple years working as a researcher in these arenas

4. Definition/Background of IPV • Intimate Partner Violence (IPV): domestic violence, dating violence, partner abuse, spousal abuse, battering • Types of abuse: Physical, sexual, emotional, psychological, verbal, economic • Historically, the majority of research and practice efforts have considered this issue a form of violence against women and rooted in gender inequities

5. Long Term Health Effects & Outcomes: Studies among Women/Girls • - Reproductive (STI’s, HIV, unwanted pregnancy, rapid • repeat pregnancies, poor pregnancy outcomes – LBW, • miscarriages, premature labor) • - Mental health problems such as depression, suicide, • eating disorders or unhealthy weight management, • lowered self-esteem • Riskier health behaviors: • Sexual risk for STI/HIV (early sexual initiation, multiple • partners, unprotected sex) • -Substance use (alcohol, illegal drugs, tobacco) • - Chronic pain • - Gastrointestinal symptoms and disorders • - Hypertension and chest pain • - Asthma Multiple recent studies

6. Findings from previous literature on boys who perpetrate IPV Factors associated with IPV in previous research: • Traditional attitudes towards gender roles (young adult men) • Cheating • Multiple partners, unprotected sex • Substance use • Exposure to abuse between parents • Family violence victimization • Other types of violence exposure/involvement Multiple recent studies

7. Adolescents Girls and Young Adult Women are at Increased Risk for IPV • Women aged 16 to 24 years experience the highest per capita rates of IPV • 1 in 5 High School Girls has experienced physical and/or sexual IPV • 1 in 10 (10%) girls report physical IPV in the past year >Important to focus on adolescents and young populations because they are the group most affected – but also because prevention is likely key Rennison et al., 2000- NIJ; Silverman et al.,2001; CDC, 2002

8. Dating Violence in the Media

9. Dating Violence in the Media • Media coverage of 19 year old popular musician Chris Brown’s attack on girlfriend and fellow young musician, Rihanna brought considerable attention to the issue of dating violence last year • A study conducted by the Boston Public Health Commission surveyed local teens and found that nearly half reported Rihanna as responsible for the incident with Chris Brown, and more than half reported that both were to blame, despite knowledge that Rihanna needed medical attention as a result of being beaten by Brown. • While this recent incident represents an unambiguous example of male perpetrated dating violence, the survey data taken from youth in Boston suggests that disturbing myths regarding this critical public health issue may still be widely supported among youth.

10. Dating Violence in the Media • Unfortunately, such misperceptions of this issue are not limited to adolescents, but are also held by a number of us working in this area. • There is continuing discord as to the basic frameworks used across studies and programs for understanding and addressing dating violence, particularly regarding the gendered basis of the problem. • It is essential that we move beyond this discord in order to improve the quality and utility of our research and programming, including educating our youth regarding the true nature of partner violence among both adolescents and adults.

11. Conceptual Frameworks and Influence on Public Health Programs • Historically, the framework we have around a disease or health related issue influences the ways we develop responses • Miasma versus Germ theory • Frameworks are usually based on our observations, which can be altered by various factors (e.g. cultural beliefs, social norms, social networks, personal exposures and experiences, etc)

12. Is this a gender-based issue? Recent Research Focuses on Female Perpetration of IPV as the Same Public Health Problem • Literature on dating violence often perceives this as “kid’s play” – NOT considering it the same issue as IPV • Many studies on TDV measured boys reports of victimization as well as girls’ reports of perpetration; many reported that both the boys and girls were perpetrating violence in similar proportions – • some studies show that girls reported greater levels of perpetration compared to boys • Often these studies were using the CTS, asking about whether they were “hit or slapped” by a partner • Developed the terms “reciprocal” and “mutual” or even “bidirectional” violence to describe this phenomenon, suggesting that in such teen dating relationships, both partners are initiating the aggression • Appears likely that this framework for examining TDV (as an issue that is not based on gender) has influenced recent research on IPV

13. Is this a gender-based issue? • Gender-neutral framework appears to be US-derived and increasing among adult IPV research studies as well • Review Pub Med Studies: • Using Pub Med, in 2008, 95% (21/22) of the studies on dating violence (using dating violence as the search term) used a gender-neutral framework. • However, in 2008, 20% (18/70) of studies used a gender-neutral framework when examining adult IPV (using partner violence among a random sample of 70 studies). • A decade earlier in 1998, while the majority of studies used the term domestic violence (implying male perpetrated violence against females), among the 13 studies that used the term partner violence, only 2 used a gender neutral framework. • Among the most recent studies in 2008 that have used a gender-neutral framework, 93% of them have been US-based. Reed, Raj. Miller, & Silverman, 2010

14. Is this a gender-based issue? Arguments for a Gendered Focus 1. Prevalence Issues, e.g. Much of measured “female perpetration” has been found to be in self-defense 2. The health costs and associated consequences are greater for girls/women (e.g. pregnancy) 3. Measurements used do not really measure the specific dynamics documented as part of IPV (control, manipulation, instilling fear etc) - instead we are asking about hitting or slapping, for example 4. This type of violence has been shown to be rooted in gender inequities and related norms – this is not likely the etiology for any female-perpetrated abuse in relationships

15. 1. Prevalence Issues; e.g. Much of measured “female perpetration” has been found to be in self-defense

16. Prevalence Issues • Female perpetrated violence against intimate male partners has often been documented to be more likely as a result of self-defense or poor conflict management in relationships • With the exception of self-defense, female perpetration of violence against male partners is likely more closely related to other forms of non-gender specific unhealthy relationship behavior Stuart et al., 2006; Foshee, 1996; Molidor & Tolman, 1998; Coker, 2000; Ashley & Foshee, 2005

17. 2. The health costs and associated consequences • are greater for girls/ • women • (e.g. pregnancy)

18. Mortality and Morbidity is Greater among Girls/Women • Women and girls are more likely to be killed by male partners than any other class of individuals – a finding consistent across every study and every national context. • Women and girls are more likely to be injured than men and boys due to violence from a partner, again, across each and every study on this topic. • Large percentages of women and girls visiting emergency rooms are consistently found to be there based on violence from a male partner. WHO, Tjaden & Thoennes, & other selected studies

19. IPV and Sexual Risk for HIV/STI and Pregnancy: Findings from Women and Girls • Women and girls reporting IPV are significantly more likely to report STD, HIV, unwanted/unplanned pregnancy, rapid repeat pregnancies and abortions • Women and girls reporting IPV are significantly more likely to report: • No and Inconsistent Condom and Contraceptive Use • Fear of condom negotiation • Partner sexual infidelity • Partner STD/HIV positive or unknown status Data from multiple studies with diverse populations over the past decade

20. Associations between Past Year IPV Perpetration and Sexual Risk and Fatherhood 1Adj for age, race, income, continental US residency length, relationship length.

21. Qualitative Study with Adolescent Female Victims of IPV • Given the rising threats of HIV, more recently, research in this field has focused greatly on sexual risk for HIV • Semi-structured interviews with 65 girls ages 14-18 years recruited from victims’ programs • Participants asked to describe their relationships ---experiences of sexual risk, unwanted pregnancy, STD in the abusive relationship • Findings: • Male partners control of many aspects related to sex • Male partners refusal or sabotage of protection *Warning Graphic Content

22. Lack of Control Around Sex in IPV Relationship “…he wanted it 5 times a day, twice during the night….plus I was pregnant…And if I didn't give it to him, he'd beat the crap out of me, and then would force me to have it, and I would say no, and he would keep on just doing it, so I would lay there and just cry, and wouldn't care.”

23. Lack of Control Around Sex in IPV Relationship “I'm not gonna say he raped me... he didn't use force, but I would be like, "No," and then, next thing, he pushes me to the bedroom, and I'm like, "I don't want to do anything, " and then, we ended up doin' it, and I was cryin' like a baby, and he still did it. And then, after that... he got up, took his shower, and I just stayed there like shock... “

24. Perpetrator condom refusal linked to STD and victim-blaming “.... I told him to put a condom on, he didn't. ..I went to a clinic, and they were like, "Oh, he gave you Chlamydia." [H]e said it was me messin' around with some other guy, and that's not true, 'cause I was like, "You were the only guy I was with." And he's like, "Oh, that's you, you're messin' around," he's like, “fuck you, I thought you loved me."

25. Birth Control Sabotage leading to Pregnancy “I was on the birth control, and I was still taking it, and he ended up getting mad and flushing it down the toilet, so I ended up getting pregnant. I found out that [before this] he talked to my friends and he told them that we were starting a family. I didn't know that. I didn't want to start a family. I wanted to finish school.”

26. Research on girls’ experiences of IPV • These studies show how girls’ risks for STDs, pregnancy, etc are heightened as a result of IPV • Provides further information on the context of these relationships, the types of abuse, and evidence on how girls’ lives are affected – particularly related to pregnancy

27. 3. Measurements used do not really measure the specific dynamics documented as part of IPV (pattern of control, manipulation, instilling fear etc)Conflict Tactics Scale has been used – this is not a scale that was developed to measure intimate partner violence

28. The Context of IPV and TDV “And you can see my heart beating. You can see it through my chest. And I’m terrified but I’m not leaving . Know that I must must pass this testSo just pull the trigger …As my life flashes before my eyes, I’m wondering will I ever see another sunrise? So many won’t get the chance to say goodbye. But it’s too late too pick up the value of my life.” -Rihanna

29. Measurement of IPV • Such recent focus on female IPV perpetration may be a result of IPV measures that have often been limited to items assessing only physical violence (often including measures such as “hitting or slapping” a partner) • Such items lack specificity to capture other core elements of IPV (e.g. control, patterning of abuse, intimidation). • In future studies, IPV may need to be better distinguished by using data measures and interpretation that parallel an adopted framework - preferably a framework that considers IPV within the scope of gender-based violence.

30. 4. Male perpetrated violence against intimate partners has been shown to be rooted in gender inequities and related norms

31. The Relevance of Gender Inequities and Related Norms to IPV Perpetration • Many studies have documented that intimate partner violence is strongly related to beliefs in the inferiority of women and girls, and men’s and boys’ entitlement to control female partners via violence (e.g. WHO, Santana et al., 2006) • Country level data highlights that factors related to gender equality (e.g. civil liberties, political rights, occupation of parliamentary seats by women) are related to deaths from gender-based violence (Palma-Solis et al., 2008)

32. Traditional Masculine Gender Norms Linked to Both Risky Sex and IPV • Analysis adjusted for age, relationship length. • Analysis adjusted for age, Hispanic ethnicity. • Analysis adjusted for age, relationship length, non-English speaking. Santana et al., 2006

33. Partner Violence in Relation to Boys’ Support of Traditional Gender Norms * cronbach alpha = 0.93 **Adjusted for living situation (live with family – yes/no) Reed, unpublished

34. Qualitative Study with Adolescent Male Perpetrators of IPV • Interviews with boys ages 14-20 years recruited from community and school programs; identified as abusive to a female partner • 24 interviews • Participants asked to describe relationship and sexual norms as well as other general aspects of their lives; we looked at the different life contexts of boys (family, peer, school, and community) • Boys in these programs who we interviewed often reported various challenges across life contexts • Maltreatment of girls was the norm in many of their social contexts – boys are not engaging in anti-social behavior; this is very pro-social *Warning Graphic Content Reed et al., 2008

35. Peer Context Issues related to girls and sex, which often included negative attitudes towards girls “…They [girls] don’t know no better… Their mind’s not strong enough to basically get over it, ‘cause like, a guy could talk to a girl, like, “You bitch, you fuckin’ ho’, this and that,” but she’s gonna like it because she’s gonna think he loves her ... Like, he could hit a female, …and she might cry? But when she go home, she’s gonna ...love you even more. …she don’t have that mind power to figure out that you’re playin’ her? …Like she’ll go for the bait, and after that, it’s do whatever you want.” Results – Qualitative Findings

36. Peer Context Issues related to girls and sex, which often included maltreatment of female sex partners “My boy had a party, and there was like a couple of girls there... we were tryin’ to DO somethin’... with ‘em, and …we just like laced the blunt... put coke in it…. I don’t think she knew about it. …her face was like purple, then... after that, I just seen her on the knees for like the whole day (chuckles), like... she was doin’ everybody. She [probably] felt like she was getting... terrorized or somethin’, like... they, …put her in slavery or somethin’.” Results – Qualitative Findings

37. More quotes on boys’ norms related to maltreatment of girls “ ...basically... just free pussy, and they could f* it however... much time they want… over and over again... until basically, they... they satisfy ‘em. [So, who are the girls...?] “... if they’re drunk, like... [for some girls] all you have to do is get ‘em drunk, and that’s basically it.” Results – Qualitative Findings

38. More quotes on boys’ norms related to maltreatment of girls – “turning girls out” “…they could brag about, “Oh, I turned on, this and that..” she might look good, she might have a big old butt and nice little figure, he could basically brag, sayin’, “Oh, I turned her out. That’s MY ‘ho.” Like that, basically.” “Yeah, we have like... we have like competitions. Like... like if... well, what we call it is ‘turnin’ a girl,’ ‘turnin’ her out.’ Like, say one of my buddies gets a girl, we’d be like, ‘Oh, bet you can’t turn her out.’ … Or, they’ll say it to me, or... it’s all like competition. ‘Oh, I bet you can’t do this and this with her.’ …When I was [living] out in [name of town], I used to do it every... every night...” Results – Qualitative Findings

39. More quotes on boys’ norms related to maltreatment of girls “He turned her around, and like he makin’ money with her? …That’s even more braggin’ rights. He could brag even more. …I think the easiest girls to like turn out? …Is a run-away. That’s the easiest whore.” Results – Qualitative Findings

40. Frameworks matter: We use frameworks to guide our research that informs our programs

41. Frameworks Matter • Gender-based violence, including male violence against intimate partners, is a public health topic shown to affect populations of women globally and became recognized as a critical public health threat and human rights issue through decades of grassroots efforts and community initiated strategies • Global consensus on the framing of partner/dating violence as gender-based (WHO and other major public health authorities) • Violence against women is seen as a clear and continuing threat to the lives and well-being of millions of women and girls worldwide

42. Frameworks Matter • The gender-neutral approach is not grounded in community or grassroots efforts to address a public health issue • Academic production of a public health problem • Became more popular after TDV research initiated that considered this issue “kids play” rather than a form of IPV • While men and women can be in abusive intimate relationships, we cannot ignore the relevance of gender power imbalances and how these play a role in intimate relationships between genders as well as how this has affected women on a global level throughout history

43. Frameworks Matter • Globally, and within every country, populations of men have not been threatened by this issue in the same way that we have observed among populations of women throughout history • Abuse in relationships of any kind is wrong and, while all forms of violence may be rooted in issues related to power and control, we need to distinguish violence rooted in long-standing oppression and inequities from other forms of violence and abuse

44. Conclusion • Abuse and unhealthy behaviors can exist across a number of different types of relationships • Certainly, abuse in intimate relationships is of particular concern • Like other types of violence rooted in inequities, male violence against women/girls needs to be addressed using a framework that is gender-based • We should not ignore that the majority of male perpetrated violence against intimate partners is likely rooted in gender-based inequities and related norms disfavoring women

45. Social environment supportive of maltreatment of women/girls, including exposure to violence against women (e.g. domestic violence between parents) MALE PERPETRATED VIOLENCE AGAINST FEMALE PARTNERS Environmental exposures (e.g. trouble in school, family disruptions, economic burdens, community disorganization, exposure to contexts supportive of violence, context of substance use, racial discrimination) Beliefs around inferiority of women/girls; embrace traditional gender norms Women’s/girls’ exposure to or victimization from male perpetrated partner violence or other forms of violence against women GENDER-BASED INEQUITIES Women’s/girls’ reports of self-defense • UNSTUDIED ETIOLOGY • Environmental exposures? • Other power and control issues not • related to gender? • Does not appear to be a population level • concern related to gender FEMALE PERPETRATED VIOLENCE/ABUSE AGAINST MALE PARTNERS

46. Gender-based Framework: Need for Understanding how Structures Play a role in IPV perpetration • Existing studies have often pointed to individual characteristics of males, (e.g. substance use behaviors) • Perpetrating IPV is not something that occurs evenly among all boys, but rather, it affects certain groups of boys more • Using a gender-based framework for looking at IPV, we need to consider the gendered power imbalances within societies, communities, and families that affect how men and boys engage with women and girls as intimate partners. • We need to address this issue in a way that considers factors much bigger than individual decisions and behaviors.

47. A Gender-Based Framework: Summary • Important to recognize that if we accept a framework that is gender-based, then we need prevention efforts that seek to change some of these problematic gender norms • Structural change – rather than blaming boys for perpetration or girls as victims; e.g. boys who perpetrate are often acting in ways that are parallel with their exposures and social norms • Many gender norms that promote male dominance and control are also bad for the health and well-being of boys/men; e.g. linked to greater sexual risk taking, substance and tobacco use, unintentional injury, deaths related to suicide, injuries and homicides related to non-partner specific violence • Health interventions are needed that address the structural influences related to such gender norms to reduce the multitude of health threats to boys and men as well as to decrease associated violence against women throughout the globe • Interventions are needed to reach both boys and girls

48. Implications • If we fail to understand the gendered nature and basis of dating and partner violence, we will, without doubt, fail in attempts to develop programs, policies, and educational campaigns to address this highly prevalent and debilitating public health threat. • Progress in this arena is vitally important, particularly among young populations • 1) to prevent such violence from becoming a pattern of behavior into adulthood among boys and young men • 2) to reduce the impact of gender-based violence across the lifecourse among women and girls.

49. Acknowledgements • Elizabeth Miller, University of California, Davis • Anita Raj, Boston University School of Public Health • Jay Silverman, Harvard School of Public Health

50. Discussion • What do you think about the media attention and the response from Boston youth related to the Chris Brown and Rihanna incident? Have you heard similar remarks regarding this incident or other incidents? Have you heard other comments specific to the gendered nature of this topic? • How has your thinking on this topic been informed by your work and related exposures?