Violence Prevention

Although no single theory can describe all causes of violence and abuse, the
Canters for Disease Control and Prevention recommends an ecological model as a
framework for prevention and intervention. Seeking to understand factors that shape and
create risk for the development of violence and abuse is not intended to excuse or mitigate
personal responsibility for criminal or immoral behaviours. For primary prevention,
however, it is critical to understand individual and social factors related to risk for
perpetration of violence and abuse. Macro social factors are likely related to the
development of violent behaviours. Power and control are often described as the
underpinnings of violence and abuse. The patriarchal social structure can produce a
social environment that supports male domination of women from the feminist
perspective. Poverty, lack of economic opportunity, racism, and discrimination also
support power differentials in society and are key drivers for the development of stress.
Stress appears to be related to biologic pathways potentiating increased risk for
developing maladaptive behaviours. Stress may also serve as a trigger for violent
outbursts. The media likely play a role in the shaping of social norms related to violence
and abuse and sustaining a culture of violence. Although alcohol abuse and substance
abuse are strongly associated with violence, debate exists in the literature regarding the
causal relationship between the two.

A clinically relevant issue for clinicians is the Trans generational transmission of

violence and abuse. Data strongly suggest that childhood exposures to violence and
abuse put individuals at risk for developing perpetration behaviours. Many researchers
have developed typologies to categorize perpetrators with common subtypes ranging
from perpetrators who are psychotic with antisocial personality disorders and little hope
for remediation to perpetrators of common-couples violence that occurs in the context of
bidirectional relational dysfunction. Family physicians should watch for new research and
future developments in violence prevention; in particular, they should look for findings that
can be implemented in the primary care setting. The World Health Organization defines
violence as “the intentional use of physical force or power, threatened or actual, against
oneself, against another person or against a group or community, which either results in
or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment,
or deprivation.”

Violence and abuse may be physical, sexual, or psychological. Three broad

subtypes of violence exist: self-directed, interpersonal, and collective. Self-directed
violence includes suicide and self-abuse. Interpersonal violence is violence among
individuals, including violence among related individuals in the context of a family or
extended family, and violence among unrelated individuals who may be friends,
acquaintances, or strangers. Collective violence includes social, political, and economic
violence. Self-directed, interpersonal, and collective violence are overlapping phenomena
which occur within a larger social and cultural context. Common economic, social, and
cultural risk factors influence all three. Vulnerable populations are often at increased risk
of all three forms of violence. All violence is functional, intended to dominate, punish,
control, harm, or eliminate an individual, a group, or a community. As physicians, we have
many opportunities to identify patients at risk of victimization or perpetration, and to
prevent or influence the outcomes associated with violence for our patients.

Violence occurs in the context of a broad range of human relationships.

Interpersonal violence within the family includes child abuse and neglect, sibling violence,
intimate partner violence, elder abuse and neglect, and abuse and neglect of pets and
other animals. Beyond the family context, interpersonal violence includes dating violence
(also called adolescent relationships violence), peer violence, bullying, stalking, rape,
community violence, and school violence. Collective violence is composed of many
individual acts of interpersonal violence organized within a larger social and cultural
context, and includes gang violence, hate crimes, mob behaviour, human trafficking,
sexual exploitation, and slavery. Also included within the scope of collective violence is
oppression based upon gender, race, sexual orientation, social class, national origin or
religion, and state-sponsored violence such as terrorism, genocide, war, and war-
associated rape. There is a growing body of evidence linking the many forms of violence
to adverse health effects. As family physicians, we need to understand this link and work
with our patients to minimize the negative health effects associated with violence. Since
violence and traumatic stress affect our patients and present to us as family physicians
in many different ways, it is vital that we understand them in the context of our patients’
lives. As family physicians, we all see these patients in our offices and care for them daily.
Recognizing the risk factors and asking questions about experiences with violence helps
our patients understand that violence is related to their health conditions and gives them
permission to talk about it within the context of their health. Many physicians worry about
the time it may take once this line of questioning begins, but a study, showed that when
answers to the screening questions suggest a history of abuse, it adds less than 10
minutes to the visit during which this information is uncovered. Often identifying the
experiences leads to appropriate referral for counselling or use of other resources that
help the patient. Recent clinical studies have supported the effectiveness of a two-minute
screening for early detection of abuse of pregnant women. Additional longitudinal studies
have tested a 10-minute intervention that was proved highly effective in increasing the
safety of pregnant abused women. Understanding the many presentations of violence
and its effects on our patients helps us provide better care.

Family violence affects approximately a third of family physicians’ patients. Victims

of family violence interact with the health care system twice as often as non-victims in a
typical year. Patients welcome inquiry about violence and abuse as it relates to their
health and the health of their families, as long as the inquiry is non-judgmental. In a study
performed by Burge and Schneider, nearly 97 percent of patients said they wanted their
family physician to ask them about violence, regardless of whether they had a history of
violence.26 Physicians should be equally attentive to screening for family violence in
heterosexual, gay, lesbian, bisexual, and transgender patients. In addition to the
traditional role as a secondary responder, primary care providers are ideally situated to
be agents of primary prevention. Family physicians have expertise in case management;
treating medical and mental health comorbidities associated with violence-exposed
patients; developing a referral base for subspecialty evaluation and treatment; working
from a preventive framework with longitudinal, therapeutic relationships with patients; and
addressing at-risk behaviours that tend to occur with exposures to violence and abuse.
Some presentations (anxiety, depression, and other mental health disorders; chronic pain
syndromes such as fibromyalgia and pelvic pain; and multiple somatic complaints) are
much more likely than others to be related to violence. It is important for family physicians
to be aware of the issue, and to remember to inquire about their patients’ relationships
and stressors.

Family physicians have a responsibility to assess the level of risk for the patient
and to support and empower patients in promoting harm-reduction strategies. Certain
scenarios may put patients at particularly high risk for life-threatening family violence.
These include a change in the severity and frequency of violence, drug or alcohol use,
possession of a firearm, threats of suicide or homicide, recent break up, threats or assault
with a weapon, attempted strangulation, and stalking behaviour. Physicians must know
the local and national resources available for patients affected by family violence and be
able to refer patients appropriately, especially when these warning signs are identified.
Physicians should be also familiar with local or national resources available to assist
patients in danger that are responsive to the needs of special patient populations, such
as gay, lesbian, bisexual, transgender, adolescent, elderly, or immigrant patients.
Physicians should counsel patients about the acute and long-term risks posed by
exposures to violence. The office staff and other team members in the family medicine
practice should be trained to know the clues to violence and be able to respond, as many
patients have strong relationships with other staff within a primary care office and may
disclose to staff about the violence. Asking about violence exposures may be an
intervention in and of itself, with education and patient-centred empowerment strategies
increasing the capacity of victims to avoid future exposures. Family physicians can also
use their clinical practice and office environment to educate patients about positive skills
that may reduce the risk of violence. Information on healthy relationships may help reduce
the risk of teen dating violence and adult intimate partner violence. Evidence regarding
the clinical burden of victimization and the prevalence of patients of family physicians
reporting perpetration clearly defines a role for family physicians in the recognition and
appropriate referral for treatment of perpetration as a primary prevention strategy