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Cross-cultural perspectives on intimate partner violence

Addressing intimate partner violence through an ecological model and viewing it as a matter of public health can improve identification, treatment, and prevention.

James E. Anderson, PA-C; Mufiyda Abraham, PA-C; Diane Michelle Bruessow, RPA-C; Robert David Coleman, MPAS, PA-C; Kelly C. McCarthy, BS; Trisha Harris-Odimgbe, MS, PA-C; Cindy K. Tong, MS, PA-C

The authors are members and associates of the AAPA Committee on Diversity. Contact James Anderson, chair, at jeandrsn@u.washington.edu.

The personal and societal consequences of intimate partner violence (IPV) are staggering. More than $5 billion is spent annually in medical, legal, and other related costs,¹ and this does not count the massive personal toll of pain, suffering, and degradation experienced by victims of IPV. This type of violence is the leading cause of injuries to US women 15 to 44 years old; 30% of all murdered women are IPV victims, as compared to 3% of all men murdered. Approximately 1 in 3 female trauma victims, 1 in 6 pregnant women, and 1 in 10 primary care clinic visitors have experienced IPV.² There are significant consequences as well for the children and family who witness the violence and who are at increased risk for the psychosocial problems related to such experiences.²

This article reviews IPV data and research related to specific racial and cultural groups, while placing the issue in a wider public health perspective. Our purpose is to provide clinicians with broad understanding and increased sensitivity to the cultural, socioeconomic, and public health milieu of IPV, offering specific tools they can use to assess and reduce this problem. The review finds literature rich in specific examination of cultural settings of IPV. Although we find that specific features related to race and ethnicity impact IPV, we also find that race and culture—unlike socioeconomic status—are not predictors of IPV.

THE “CITIZEN PA” MODEL

Clinicians commonly define clinical activity narrowly, often focusing on examination skills, face-to-face encounters with patients, and the application of diagnostic and prescriptive tools. PA education, with a notable competency-based history, may further heighten the PA’s intensified attention to the microtherapeutic level.

This review attempts to wrap “bigger picture” framing of IPV around existing assessment and treatment guidelines, underscoring the possible benefit of expanding the “Citizen PA” role. Improving patient health stands as the ultimate goal of clinical efforts. Placing specific diagnostic and treatment tools within a larger societal understanding of violence and cultural diversity, while moving advocacy for patients beyond the examination room into broader policy arenas, may provide additional and direct health benefits to patients when added to insightful examination and assessment skills.

DEFINITIONS

Variable definitions Whereas domestic violence describes an array of violence taking place in a domestic setting, the term intimate partner violence more specifically describes the relationship context of such violence. The CDC defines IPV as “violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend,” while a US Department of Justice (DOJ) report notes other ongoing areas of controversy related to IPV definitions, including the issue of whether to limit the definition of IPV to acts carried out with the intention of causing physical pain or injury to another person.^3,4 Although such a narrowing of the IPV definition might allow a more tangible focal point for study, the DOJ report describes the problems of such a narrowing:

Although this approach presents a narrow definition of intimate partner violence that can be readily operationalized, it ignores the myriad behaviors that persons may use to control, intimidate, and otherwise dominate another person in the context of an intimate relationship. These behaviors may include acts such as verbal abuse, imprisonment, humiliation, stalking, and denial of access to financial resources, shelter, or services.⁴

It’s about control Definition-based discrepancies indicate the need for providers working with diverse and politically marginalized groups to consider big-picture forces that may impact certain groups, rather than attempting to master the elusive characteristics of the groups themselves. Although contemporary writing and research continue to refine societal understanding of this issue, Bell notes that earlier work provides what continues to be one of the most descriptive and insightful views of IPV:

One of the most cogent theories argues that, to gain power and control over their partners and families, perpetrators of domestic violence use a complex matrix of practices that includes intimidation; emotional abuse; isolation; minimizing; denying and blaming; economic abuse; coercion and threats; manipulation of children; exertions of male privilege; sexual abuse; and physical abuse. This power and control thesis represents a significant advancement over previous theories that represented domestic assault as a syndrome brought on by the masochistic orientation of female victims.”⁵

PREVALENCE

Race and culture are not reliable predictors of IPV. Smith, Conradi, and Bent-Goodley all describe the overriding importance of socioeconomic status as a predictor of IPV, unlike race and other cultural features.^2,6,7 Although the literature provides conflicting data on the prevalence of IPV based on race and other minority status, IPV does not appear to be more prevalent in specific racial or cultural groups. In fact, an American Psychological Association (APA) curriculum describes the very assertion of increased prevalence in certain races as a result of broader racial discrimination, calling it “fundamental attribution error.”⁸ This describes the process of asserting that IPV rates are higher in minority communities, magnifying behavior of individuals and attributing that behavior to an entire group, ultimately impacting the way data are collected and interpreted.⁸ Additionally, the APA curriculum notes the tendency to elevate race over socioeconomic status in analyzing IPV, noting: “Statistics on the prevalence of relationship violence in the ethnic minority community are unreliable…. To the extent that African-American families earn less than their white counterparts, the difference in domestic violence can be accounted for by [socioeconomic status] and not ethnicity.”⁸

Even with this apparent lack of increased prevalence of IPV in minority communities, the literature clearly exposes culture-specific characteristics related to IPV. With these characteristics comes the accompanying need to acknowledge the role of ethnicity in order to provide quality services to patients of all cultures.²

The links between IPV and other types of violence relate to the interaction between individual factors and the broader social, political, economic, and cultural contexts. This suggests that addressing known cultural risk factors across the broader societal context may contribute to decreases in more than one type of violence. Hampton provides one such understanding of IPV in cross-cultural settings through a three-variable model. The structural context describes social conditions that impact access to opportunities and quality of life. Hampton asserts that intergenerational exposure to oppression increases the likelihood of IPV. The cultural context describes the adopting of masculine gender roles rooted in violence and control as a response to repeated exposure to racial oppression, whereas the situational context describes particular settings, interpersonal dynamics, and encounter specifics.⁹

HEALTH DISPARITIES, CULTURE, AND IPV

Mastering all cultures is futile Rather than attempting to master all the elusive characteristics of cultural groups, leaders in the cultural competency field recommend instead that providers consider systemic forces as noted in the World Health Organization (WHO) ecological model of violence.^10,11 Coleman writes about the “myth” of cultural competence, the acceptance of a “not knowing” position, and the need to learn from our patients about their needs, avoiding the stereotyping that may result from focusing on group characteristics.¹² Further, challenging our own assumptions about a patient’s identity, beliefs, and behaviors may be a key element in improving IPV prevention. Green and Burgess have written key papers on the role of implicit bias in clinical decision making. Kimberg also notes the benefits of acknowledging the heterogeneity within all cultures.¹³ Their work has significant implications for IPV prevention, particularly in the area of assessing the prevalence and negative impact of racial stereotyping on levels of care.^10-13

Cross-culturally grounded interventions The literature does reveal a broad concurrence on the need for developing IPV prevention models that are cross-culturally grounded and account for bias related to race, ethnicity, gender, or sexual orientation and identity; immigrant status; religious affiliation; and socioeconomic, disability, and HIV status.⁵ Marginalized communities have repeatedly identified negative experiences with medical staff related to prejudicial attitudes, potentially preventing timely care of IPV.²

PAs should note that although much of the literature appears to view “culture” as a barrier to care, culture must not be viewed exclusively as a risk factor. Cultural strengths can be optimized in clinical settings to effectively identify and address IPV.² Connection with community, in particular with a homogeneous community, has a protective effect. Cultural identities are grounds on which to engage patients.²

CATEGORIZATION OF VIOLENCE

The typology illustrated in Figure 1 proposed by the WHO divides violence into categories according to characteristics of those committing the violent act.¹⁴ Creating a useful framework for examining the “complex patterns of violence in the everyday lives of individuals, families, and communities,” it captures the nature, relevance of setting, and perpetrator- victim relationships that often frame individual and collective violence.¹⁴

The WHO categorization divides violence into four major types. Each of these—physical, sexual, psychological, or involving deprivation or neglect—occur within the personal and collective realms and subcategories described in Figure 1.¹⁴

The American Psychological Association’s IPV curriculum also places IPV within the broader context of all violence, emphasizing the need to address violence of all types in order to reduce instances of IPV.⁸ Subsequently, efforts to reduce IPV must also focus on reducing other forms of violence as well.⁸

CAUSES, CULTURE, AND BARRIERS TO CARE

Like many other health problems, the prevalence of IPV and other types of violence among certain populations cannot be explained by any single factor. Also, all types of violence are not distributed evenly across population groups or settings.

Using an ecological model Because violence is a multifaceted problem with cultural and environmental roots, it must be confronted on several different levels at once. Along with the typology described above, the WHO developed an ecological model to examine violence, serving both to represent levels of risk and to describe points of intervention for each level.¹⁴ First applied in the 1970s to address child abuse and youth violence, this attempt to understand and reduce violence has been used recently as a tool to examine IPV.¹⁴

Exploring the relationship between individual and contextual factors, the ecological model considers violence as the product of the multiple levels of influence on behavior, while highlighting obstacles and barriers to care.¹⁴ This is illustrated in Figure 2.

Individual level The individual level of the ecological model seeks to identify the personal history factors that individuals bring to their behavior. This level of the ecological model focuses on the characteristics of the individual that increase the likelihood of being a victim or a perpetrator of violence. For example, patients may not disclose IPV for fear of being “looked down upon” by clinicians,¹⁵ concerns about disclosure to their family and friends, worry about ensuing negative encounters with law enforcement authorities should they disclose, and trepidation about being suspected of perpetrating violence if their IPV is known to authorities.¹⁵

Bent-Goodley describes related individual barriers such as “help-seeking,” where members of some cultures may be more likely to turn to informal service providers initially, thereby delaying their presentation to licensed clinicians.² Stigma is also described as barrier for women who may have the perception that IPV does not happen in their culture. This may be reinforced by public health messages and campaigns primarily featuring white women. Internalizing messages of shame and secrecy and the perception that abuse is related to inferior socioeconomic class may decrease the likelihood that the victims of IPV will openly discuss their experiences.^2,15

Relationship level The second level of the WHO ecological model explores how relationships with peers, intimate partners, and family members can increase the risk for both victimization by and perpetration of violence. Family members are often bound tightly together in ongoing relationships. These strong relationship bonds may make separation in the face of abuse more difficult, increasing the likelihood that victims may suffer repeated and sustained abuse.¹⁴ Increased relationship isolation may be magnified in some cultural settings, further increasing the likelihood and frequency of IPV in those settings.¹⁶

Community level The third level of the ecological model examines the community in which social relationships are embedded, such as schools, workplaces, kinship networks, and neighborhoods. This community-level examination seeks to identify the characteristics of these settings that are associated with both increased victimization and perpetration of violence.¹⁴

For example, factors impacting Hispanic patients without documentation of citizenship include the fear of deportation for themselves or their attacker. Such fear may reduce the likelihood of their entering the medical and legal systems voluntarily.¹⁶ Fear of legal punishment related to citizenship status is not limited to Hispanic women and may pose an obstacle to care for all immigrants. Legal concerns may also affect transgender patients, users of illegal drugs, or any patient facing fear of negative consequences related to exposure to the legal and medical system.

IPV within same-sex relationships may entail unique dynamics related to homophobic bias. West noted that “homophobic control” can be an additional IPV weapon, in which the victims are threatened with, or punished by, “outing” to friends, family, and coworkers.¹⁷

Race is often used as a proxy for actual systemic causes of disease, and Michalski offers a framework for examining this community impact on IPV with significant relevance to populations experiencing isolation, marginalization, exclusion, and discrimination. This framework cites social isolation, inequality, lack of participation in the lives of others, centralization of authority, and exposure to violence as predictors of IPV. These factors may be magnified among some communities and populations, creating unique risk factors for IPV among these groups.¹⁸ Examining and integrating these community features into clinical understanding moves away from the inaccurate use of race, known now to be an unscientific concept, as an obstacle to broader systemic examinations of the role of community on IPV and other issues.

Societal level The fourth and final level of the ecological model examines the larger societal forces that influence rates of violence in all settings, including IPV. Included are factors creating a climate in which violence is seen as acceptable or inevitable, those that reduce inhibitions against violence, and those that create and sustain gaps between different segments of society or tensions between different groups. Bell’s power and control thesis, noted earlier in this article, represents a significant advancement over previous, victim-focused theories in explaining this societal impact.⁵

Other powerful societal factors that may contribute to violence in general (and IPV in particular) include institutional, educational, economic, and social policies that maintain high levels of economic or social inequality between groups in society, creating an institutionalized level of discrimination. Some examples include narrowly defined state laws that exclude victims of IPV who are lesbian, gay, bisexual, or transgender by defining IPV only as violence between members of the opposite sex or as violence occurring between spouses, former spouses, or family members who are related. Waltermaurer cites data noting the connection between perceived discrimination and IPV, noting that women who experienced discrimination are more likely to experience IPV.¹⁹

CULTURE-RELEVANT INTERVENTIONS

Assessment tools are well described elsewhere, most recently in Terebelo’s 2006 review.²⁰ Standardized instruments such as Campbell’s Danger Assessment tool and Kimberg’s Quick Screening tool facilitate cross-cultural assessment of IPV risk.^21,22 Kimberg’s one page screening/assessment/intervention tool (available at www.leapsf.org/PDF/onepagesummary.pdf) also serves as a helpful and concise set of competencies for clinicians.²²

Offer consistent displays of support Approaching the patient who has experienced IPV in a sensitive and cautious manner is essential in cross-cultural settings. Providing consistent messages of support to the patient includes having contact information for local resources available, offering assistance with a safety plan and advocacy, and arranging proper follow-up.²³ Another online resource that provides cultural context for working across ethnic differences is the University of Washington’s Ethnomed project, available at http://ethnomed.org.²⁴

Create culturally sensitive, community-based interventions Bell cites four goals in developmental psychotherapy for African-Americans, and these goals have particular utility to developing culturally sensitive IPV interventions for broader populations: 1. Identify and dispel racial myths within the clinician; 2. Acknowledge the significance of race; 3. Develop sensitivity to the patient’s needs and desires; 4. Adjust for the unique expectations of the multicultural patient.⁵

Hampton proposes the initiation of community-based interventions aimed at the developing attitudes of young men about gender stereotypes and relationships.⁹ One such effort is Coaching Boys to Men, a program of the National Family Violence Prevention Fund aimed at working with young boys through athletic coaches to learn healthy views toward women, anger, and violence.²⁵

Build a systems change approach Kaiser Permanente’s “systems change” approach includes a comprehensive set of interventions, including chart prompts, restroom signs, examination room posters, and the ability to self-refer to IPV services through the Kaiser system. Such comprehensive and systemic changes are uniquely suited to “closed” organizations such as Kaiser, while still offering utility to a broader set of clinical settings.²³

Develop network models The development of a network model is also identified in recent literature as a way to provide culturally competent care for IPV. This model realistically acknowledges the inability of all programs to have the expertise and capacity to tailor services to the wider range of racial, ethnic, and cultural populations in need of service. It focuses instead on the coordination between agencies, clinicians, providers, and institutions, creating a network able to respond to unique cultural needs and built on the premise that such an effort is necessary to sustain efforts to meet the needs of unique populations.¹⁶

CONCLUSION

Clinicians must look both at and beyond culture when considering IPV. Although culture may play a role in how certain populations view and process IPV, socioeconomic status remains a far stronger predictor of IPV.^2,6,7 Clinicians working in cross-cultural settings can facilitate IPV prevention by broadly defining culture and maintaining a patient-centered focus, with the acknowledgement that no culture is homogenous and that broad cultural assumptions often undermine the provision of quality care.

Recognizing that IPV exists within a broad typology of violence, addressing IPV through an ecological model, emphasizing root problems that are shared among patients of diverse cultures, and viewing IPV as an urgent matter of public health can create a context of improved identification, treatment, and prevention.¹ Where there is violence, there is intimate partner violence.

Clinicians may benefit from identifying site-specific barriers to care, utilizing assessment tools and competencies, recognizing both the value and limitations of broadened understanding of cultural characteristics, and establishing action plans that acknowledge socioeconomic and cultural barriers to IPV care. Attentive application of existing assessment and treatment guidelines may be augmented by broader efforts on the part of clinicians and professional organizations to address policy and the public framing of IPV, both individually and collectively. Noting that complex health problems seldom can be effectively and completely addressed exclusively in the confines of the examination room, clinicians may bring direct benefit to the health of patients by adding the broader policy advocacy outlined in the WHO ecological model to more traditionally defined clinical duties. JAAPA

Acknowledgement: The authors wish to thank librarian Ellen Howard, MLS, from the University of Washington School of Medicine, who assisted them greatly with their literature search.

REFERENCES

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