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No single strategy will stop domestic violence. We must urgently invest in a sustainable health system response with an understanding of different patterns of abuse and coercive control.
The need for broader views about prevention of violence against women in Australia has been advocated for recently in the media.
I have listened to thousands of women survivors in my career as a researcher and a GP. What they have taught me is that domestic violence is not a single phenomenon with a simple solution. Domestic violence is not physical violence alone, it is a pattern of behaviours of emotional, physical and sexual abuse from their male partner that controls and instils fear. It causes major ill health for women and children in Australia. To stop domestic violence deaths requires understanding and responding to different patterns of abuse and coercive control.
If we look at patterns of deaths from domestic violence, we can see in the analyses of 199 incidents of male-perpetrated homicide by Hayley Boxall and colleagues that:
- 33% were fixated threat offenders (typically high functioning, controlling, middle-class men, with low levels of past criminal justice contact);
- 40% were persistent and disorderly offenders (of these, half were Aboriginal and/or Torres Strait Islander peoples; had complex histories of trauma and abuse, concurrent mental and physical health problems and heavy alcohol use, frequent criminal justice contact); and
- 11% were deterioration/acute stressor offenders (usually older men with chronic physical and mental health concerns, rarely had previous violence histories).
Each of these perpetrator types have different risk factors, life histories and trajectories over time, and are likely to need different evidence-based interventions. Three-quarters of these intimate partner homicide offenders had at least one emotional, mental or physical health condition during their lifetime. In addition, a deep cultural understanding of the systemic factors underlying homicides in Aboriginal and/or Torres Strait Islander peoples is necessary for prevention in this population.
A variety of interventions are needed
There is obviously a group of domestic violence perpetrators who needs judicial responses to stop severe abuse and death. For others, there needs to be a different approach to perpetrators that includes delivery of evidence-based interventions through the health system. Families where domestic violence is happening are in contact with health services and health practitioners are the often told about current domestic violence (after family and friends). Practitioners need to be upskilled to provide interventions that include motivational interviewing to change perpetrator behaviour, brief alcohol and substance use interventions for perpetrators, and mental health therapy for childhood trauma. The health system is perfectly placed to assist families and deliver these responses for healing and safety.
Survivors tell us that for some of them, safety is not always their highest priority. In a survey of over 1000 women survivors, they wanted professionals to be competent to provide emotional, practical and safety support. They wanted an ‘ally’ who can provide CARE (Choice and control, Action and advocacy, Recognition and understanding, and Emotional connection). From in-depth interviews with 30 women, survivors perceived that perpetrators needed a wake-up call and retraining, intensive therapy, and restrictions and consequences. Similarly, in the largest survey of more than 500 perpetrators in Australia, they described wanting emotional support, professional competence and practical support for relationship problems.
Addressing the underlying factors
It is urgent that, in addition to changing gender attitudes and improving the criminal justice response to domestic violence, we focus on:
- early engagement with survivors and perpetrators in the health system;
- responding to the prevalent childhood trauma in Australia through our primary care and mental health services; and
- reducing alcohol and drug use through a public health approach.
Additional to health system interventions, poverty reduction has been an underdeveloped area of prevention of domestic violence. Economic interventions in conjunction with other communication and community-based programs have been shown to be effective in reducing domestic violence. Often these programs have been tested in low–middle income countries rather than in Australia. It is urgent we look at trialling unconditional cash interventions in Australia, particularly for women who have separated from but who often return to a partner for financial reasons and because economic abuse is very prevalent in Australia.
Strategies to change gender attitudes in Australia are essential (eg, respectful relationship education in schools) but will be less impactful if children are going home to households where their fathers are role modelling abuse and violence. In Australia, this is four in ten households. Interrupting this cycle is essential if we are to provide pathways to safety and healing for women and their children.
The National Plan To End Violence Against Women And Children has pillars of early engagement, response, and recovery. Future funding needs to reflect new ways of intervening to stop domestic violence. It is time to urgently invest in a sustainable health system response to domestic violence in the community.
Professor Kelsey Hegarty is an academic GP who holds the joint chair in family violence prevention at the University of Melbourne and the Royal Women’s Hospital. She leads the Safer Families Centre of Research Excellence (see saferfamilies.org.au).
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thanks Kelsey thanks for raising the flag on new ways to look at prevention of Family violence, because what we’ve been doing hasn’t worked, as jess Hill and criminologist Professor Michael Salter have pointed out recently, https://jesshill.substack.com/p/rethinking-primary-prevention
As they discuss pointedly, ” However, even if we could engage boys and men en masse, and even if we were able to change their attitudes to gender and equality, it’s not clear that this would lead to a reduction in gendered violence. We need to consider evidence that suggests that even when gendered norms, attitudes and levels of equality are drastically improved, gendered violence remains stubbornly high.
This is known as the ‘Nordic paradox’, because in the Nordic countries that rate highest for gender equality – where women enjoy better rights, greater legal protection and more equal access to power – rates of gendered violence are, according to population surveys and other data, even higher than the EU average (Gracia & Merlo, 2016). These findings can no longer be ignored. We must grapple with the very real possibility that we could spend tens of millions more dollars pushing for greater gender equality and norms-change as our primary violence prevention strategy without actually reducing violence against women.”
They suggest ” While Australia has seen significant reductions in some kinds of crime, particularly public and street violence (typically between men), private and intimate kinds of violence – such as domestic and sexual violence – have proven more resistant to change. However, where reductions in femicide and domestic violence have occurred, contributors to prevention have been practical and material rather than cultural: particularly, gun control and alcohol prices. If we are committed to keeping women and children safe, then any and all solutions should be on the table. Solutions must be integrated into a systematic prevention response that takes advantage of every opportunity to prevent violence before it occurs. The list of targets that we present here is by no means exhaustive, but they strike us as some missing pieces to the puzzle of prevention.
1. Accountability and consequences
2. Prevention of, and recovery from, intergenerational trauma and child abuse
3. Address the socioeconomic impacts and gradients of domestic and sexual violence and coercive control
4. Address the commercial determinants of domestic and sexual violence and coercive control
If you’re interested in reducing family violence in Australia, this is worth a read in conjunction with Kelsey Hegarty’s article, IMHO