Formal and informal help-seeking associated with women's and men's experiences of intimate partner violence in Canada

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Formal and informal help-seeking associated with women's and men's experiences of intimate partner violence in Canada
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  This article appeared in a journal published by Elsevier. The attachedcopy is furnished to the author for internal non-commercial researchand education use, including for instruction at the authors institutionand sharing with colleagues.Other uses, including reproduction and distribution, or selling orlicensing copies, or posting to personal, institutional or third partywebsites are prohibited.In most cases authors are permitted to post their version of thearticle (e.g. in Word or Tex form) to their personal website orinstitutional repository. Authors requiring further informationregarding Elsevier’s archiving and manuscript policies areencouraged to visit:  Author's personal copy Formal and informal help-seeking associated with women’s and men’sexperiences of intimate partner violence in Canada q Donna L. Ansara * , Michelle J. Hindin Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe St., Baltimore, United States a r t i c l e i n f o  Article history: Available online 1 February 2010 Keywords: CanadaLatent class analysisIntimate partner violenceSpouse abuseGenderHelp-seekingService utilization a b s t r a c t While numerous studies have documented the prevalence, correlates, and consequences of intimatepartner violence (IPV); most of this research has used a criminal justice framework that has focused onacts of physical violence. However, critics argue that this narrow conceptualization of IPV belies theheterogeneity in this experience with respect to the nature of coercive control in the relationship.Moreover, they contend that the different types of abusive and controlling relationships not only havea different etiology, health consequences, and help-seeking characteristics, they also have a differentrelationship by gender. This study examined the extent to which different patterns of violence, abuse,and control were differentially associated with formal and informal help-seeking in a national Canadiansample. Data from the 2004 General Social Survey were analyzed, which included 696 women and 471men who reported physical or sexual violence by a current or ex-spouse or common-law partner. Themost commonly reported formal sources for women and men were health professionals (i.e., doctors,nurses, counselors, psychologists) and the police. For women, informal sources (i.e., family, friends,neighbors) were commonly reported across all IPV subgroups. However, the importance of almost all of the formal sources (e.g., health professionals, police, lawyers, shelters, crisis centers) increased as theseverity of the violence and control increased. Shelters and crisis centers were also reported by a notableproportion of women who experienced the most severe pattern of violence and control. For men, bothformal and informal sources were more commonly reported by those who experienced moderateviolence and control compared with those who experienced relatively less severe acts of physicalaggression. The results suggest that research that more sensitively examines people’s experiences of violence and control can help identify their health, social, and safety needs; and ultimately better informthe development of programs and services aimed at addressing these needs.   2010 Elsevier Ltd. All rights reserved. Introduction A large body of research has documented the pervasiveness anddetrimental impact of intimate partner violence (IPV) on individ-uals and communities and has increased global awareness of IPV asa significant public health problem. This research has primarilyfocused on acts physical violence, and to a lesser extent psycho-logical abuse or sexual violence. However, many researchers havechallenged this narrow conceptual and operational approach,arguing that measures that focus on the presence or absence of a single dimension (particularly physical violence) not only fails tocapture the ongoing pattern of violence, abuse, and control in therelationship, but also confounds gender differences in the experi-ence of IPV ( Johnson, 1995; Johnson & Ferraro, 2000; Stark, 2007).Moreover, they contend that there are different types of abusiveand controlling relationships that have different consequences forthose affected.One theory, proposed by Michael Johnson ( Johnson,1995, 2008; Johnson & Ferraro, 2000), distinguishes the gender symmetricpattern of ‘‘situational couple violence’’ from the gender asym-metric pattern of ‘‘intimate terrorism’’, the latter of which ishypothesized to be disproportionately perpetrated by men againstfemale partners. A related theory proposed by Evan Stark (2007)differentiates fights and assaults from an ongoing pattern of threats, intimidation, and coercive control that is primarily perpe-trated by men against women. To date, few studies have directlyexplored these distinctions, particularly using data that includesboth women and men. The current study aimed to address thisresearch gap. This paper builds on a previous analysis in which wedocumentedgenderdifferencesinthepatternsofphysicalviolence, q This research was supported by a doctoral research award from the Institute of Population and Public Health at the Canadian Institutes of Health Research. *  Corresponding author. Tel.:  þ 1 443 287 4717; fax:  þ 1 410 955 2303. E-mail address: (D.L. Ansara). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: 0277-9536/$ – see front matter    2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.socscimed.2009.12.009 Social Science & Medicine 70 (2010) 1011–1018  Author's personal copy sexual coercion, psychological abuse, and controlling behavior ina population-based sample of Canadians using latent class analysis(Ansara & Hindin, in press). The results confirmed that althoughwomen and men were equally likely to experience relatively lesssevere and infrequent acts of physical aggression that were notembedded in a pattern of controlling behavior, only womenexperienced a severe and chronic pattern of violence and controlinvolving high levels of fear and injury. The study also identifiedintermediate patterns of violence and control for women and men.The purpose of the current study was to examine the extent towhich the different patterns of violence, abuse, and control weredifferentially associated with formal and informal help-seekingbehavior for women and men. Defining intimate partner violence ThemostcommonlyuseddefinitionofIPVwithinepidemiologicresearch focuses on the presence or absence of physical violence intherelationship.Thesestudieslargelyfollowtheframeworksetoutby the family violence or conflict theory perspective, which usesanarrowdefinitionofIPVthatisconsistentwiththelegaldefinitionof assault (Straus, 1979; Straus & Gelles, 1990; Straus, Hamby,Boney-McCoy, & Sugarman, 1996). Within community-basedsamples, these studies often find that women are either equallylikely or more likely than men to perpetrate at least one act of physical aggression against a heterosexual partner (Archer, 2000).In contrast, research using data from courts, shelters, the police,andusingalternativedefinitionssuchassevereorchronicviolence,and sexual assault find that women are disproportionately thevictims of IPV, often severe and life-threatening violence (Archer,2002; Fox & Zawitz, 2006; Mihorean, 2005; Pottie Bunge, 2002;Tjaden & Thoennes, 2000).Largely in response to this apparent contradictory evidence,some researchers have suggested that IPV may be heterogeneous,not only with respect to the nature of the violence and control, butalso in relation to women’s and men’s experiences of IPV (Holtz-worth-Munroe & Stuart, 1994; Johnson, 1995; Stark, 2007). Onetheory that has garnered significant attention was proposed byMichael Johnson ( Johnson, 1995; Johnson & Ferraro, 2000). Hecontends that while much of the violence that is captured bypopulation-based surveys reflects situational couple violence, legalor sheltersamples primarilycaptureintimateterrorism. In contrastto situational couple violence, which is hypothesized to describeaggression that is perpetrated equally by women and men and isgenerally not part of a broader pattern of coercive control in therelationship, intimate terrorism is thought to describe a chronicand severe pattern of violence, abuse, and control primarilyperpetrated by men. In a similar vein, Evan Stark (2007) describesa pattern of coercive control inwhich men use acts of intimidation,isolation,threats,andsurveillancetoentrapwomen.Whilemanyof these women experience physical or sexual violence, he suggeststhat the disproportionately negative impact of this pattern of coercive control is a consequence of the ongoing psychologicalabuse, humiliation, and persistent fear of violence and abuse asopposed to the acute effects of a physical assault.From a psychological perspective, Holtzworth-Munroe, Stuart,et al. (Holtzworth-Munroe, 2000; Holtzworth-Munroe, Meehan,Herron, Rehman, & Stuart, 2000, 2003; Holtzworth-Munroe &Stuart,1994)identifiedatypologyofabusivemennotonlybasedonthe severity of physical, sexual, and psychological abuse, but also interms of the likelihood of perpetrating violence outside the homeand the extent of psychopathology, substance use, and personalitydisorders. Three of the four subtypes–the family-only batterer, thelow-level anti-social batterer, and the generally violent and anti-social batterer–aredescribed as representing a continuum on thesecharacteristics. The family-only batterer is most similar to John-son’s situational couple violence subtype in that he is hypothesizedto perpetrate the least severe levels of violence and abuse. Thisviolence is thought to result primarily from situational factorsspecific to the relationship. In contrast, the violence perpetrated bythegenerallyviolentandanti-socialbattereristhoughttobeduetothepastexperiences andcharacteristicsof thementhemselvesandto reflect a general pattern of violence and criminal activity morebroadly. The fourth subtype, the ‘‘dysphoric-borderline batterer’’, ishypothesized to perpetrate moderate to severe levels of violenceand to be the most psychologically distressed. The violence isspecific to their relationship and these men have feelings of jeal-ousy, fear of abandonment, and insecure attachments. Thistypology suggests possible heterogeneity in the more severepatterns of IPV in terms of the underlying etiology. Women’s help-seeking and intimate partner violence Theories of abused women’s coping strategies have largelyevolved from viewing women as passive to viewing them asactively engaging in a multitude of private and public strategies tomanage, prevent, and escape the violence (Campbell, Rose, Kub, &Nedd, 1998; Gondolf & Fisher, 1988; Goodkind, Sullivan, & Bybee,2004; Goodman, Dutton, Weinfurt, & Cook, 2003; Merritt-Gray &Wuest,1995).Thisliteraturereviewdrawsontwomajortheoriesof help-seeking: survivor theory and the process model. Survivortheorywas articulated byGondolf andFisher(1988) as arebuttalto learned helplessness theory. It describes the various ways inwhichwomen actively cope with violence including repeated efforts toaccessarangeofinformal andformalsources ofhelp in response toescalating and severe levels of violence. Process models of help-seeking describe women’s efforts to reduce or end the violence orleave an abusive partner as involving a series of internal andexternalactionsratherthanasaneventthatoccursatasinglepointin time. This non-linear process involves cognitive appraisals of IPV as problematic, private attempts to manage the violence, publicattempts to access formal and informal sources of support, andleaving and returning to the abusive partner numerous times(Campbell et al., 1998; Liang, Goodman, Tummala-Narra, & Wein-traub, 2005).Initially, women may be reluctant to disclose the abuse out of fear for themselves, fear of losing their children, feelings of shame,denial, or fear of being negatively judged by others (Lutenbacher,Cohen,&Mitzel,2003;O’Campo,McDonnell,Gielen,Burke,&Chen,2002; Peckover, 2003). A qualitative analysis of battered womenfound that women’s primary objective was to find ways of achieving non-violence rather than of ending the relationship(Campbelletal.,1998).Privatestrategiesusedbywomentomanageand reduce the violence include deciding to remain in the rela-tionship while disengaging emotionally from the partner, remain-ing vigilant of the partner’s behaviorand planning todo somethingonly when the violence becomes more serious, resisting or fightingback, placating the partner, avoiding him, or actively silencingthemselves (Campbell et al.,1998; Goodman et al., 2003; O’Campoet al., 2002). For many women, certain ‘‘turning points’’ in therelationship influenced her decision to leave and/or seek helpincluding the escalation of the violence, concerns about the nega-tive effects of the violence on their children, and women’s own useof violence (Campbell et al., 1998).Informal sources of support such as family and friends are themost common sources of support sought by women experiencingIPV(Coker,Derrick,Lumpkin,Aldrich,&Oldendick,2000; DuMont,Forte, Cohen, Hyman, & Romans, 2005; Goodkind et al., 2004;Goodman et al., 2003). One prospective study found that althoughinformalsocialsupportwasassociatedwithalowerriskofre-abuse D.L. Ansara, M.J. Hindin / Social Science & Medicine 70 (2010) 1011–1018 1012  Author's personal copy among women experiencing lower levels of violence, it was notprotective for women experiencing high levels of violence(Goodman, Dutton,Vankos,& Weinfurt, 2005).With persistent andescalating violence, women are more likely to contact and useformal services and to access more diverse types of servicesincluding the criminal justice system (i.e., police, lawyers), minis-ters or clergy, shelters, crisis lines, and health professionals (Cokeret al., 2000; Duterte et al., 2008; Gondolf & Fisher,1988; Goodkindet al., 2004; Goodman et al., 2003).According to Leone, Johnson, and Cohan (2007), a limitation of this body of research is that it has primarily focused on the severeandgenderasymmetricpatternofintimateterrorismandthereforecannot be generalized to reflect help-seeking for those experi-encing situational couple violence. Using data from the ChicagoWomen’sHealthRiskStudy, Leoneet al.(2007)found nodifferencebetween these groups in the likelihood of contacting a familymember. Women in the intimate terrorism group were less likelythan those in situational couple violence group to have contacteda friend or neighbor for help in the past year, but were twice aslikely to have contacted the police or a counselor, and over threetimesaslikelytohavecontactedamedicalagency.Accordingtotheauthors, although all violence has the potential to result inpsychological and physical harm, these results highlight theincreased danger faced by women who experience intimateterrorism and underscore the need for public programs andservices to assist these women. Men’s help-seeking and intimate partner violence Research on help-seeking and IPV has focused almost entirely onwomen given that the violence they experience is, on average, moresevere and chronic compared to the violence experienced by men(Archer, 2002; Mihorean, 2005). There was therefore little infor-mation with which to characterize men’s help-seeking. Threesurveys involving women and men conductedinCanada (Mihorean,2005),the U.S. (Cokeret al.,2000),and EnglandandWales(Walby & Allen,2004)foundthatcomparedtowomen,menwerelesslikelytohave spoken with informal sources about the violence. They werealso less likely to have discussed the violence with a formal sourcesuch as the police or health professional or to have contacteda community agency. These gender differences may be due to themore severe and chronic levels of violence experienced by womenthan by men. Some research suggests that while the gender gap inhelp-seeking is apparent for less severe violence, it narrows withmore severe and chronic violence (Mihorean, 2006; Walby & Allen,2004). The lower rates of help-seeking for men may also be due tofewer services being available for men compared to women. A thirdexplanation is that these differences may be a consequence of internalized gender norms of masculinity that may decrease thelikelihood that men will seek help for any health-related issue,particularly in response to violence by a female partner.Despite the lower rates of help-seeking for men, studies havedocumented a notable proportion who report disclosing theviolence to someone. In one Canadian survey, 44% of men reportedtalkingtoafamilymemberabouttheviolence,41%reportedtalkingto a friend or neighbor, and 12% reported talking to a doctor ornurse(Mihorean,2005).Asmallproportionofmen(3%)alsosoughtassistance from a men’s center or support group. In another studybased in the U.S. that involved 190 men who called the DomesticAbuse Helpline for Men over an approximately two-year period,many of the callers described severe levels of violence, control, andstalking perpetrated by their female partner (Hines, Brown, &Dunning, 2007). There is clearly a need for more research on men’sexperiences of IPV and consequent help-seeking behavior to morefully understand the gendered nature of this issue. Current study This study examined the patterns of formal and informal help-seeking associated with different experiences of violence, abuse,and control for women and men. The sources of informal supportthat were examined include family, friends or neighbors, and co-workers. The sources of formal support reflect a wide range of support services and community programs, some of which aredesigned specifically to address IPV, including health professionals,the police, lawyers, priests or ministers, community or familycenters, women’s and men’s centers or support groups, shelters,crisis centers, and victim services. Research documenting differ-ences in help-seeking for different patterns of IPV could not onlycontribute to a better understanding of the nature of women’s andmen’s experiences of IPV, but could potentially better identify thehealth, social, and service needs for those experiencing differentpatterns of violence, abuse, and control. Methods Data and sample Data from Statistics Canada’s 2004 General Social Survey (GSS)on Victimization were used, which is a geographically stratifiedcross-sectional telephone survey of 23,766 non-institutionalizedwomen and men 15 years of age and over living in the ten prov-inces. One eligible person in the household was interviewed ineither English or French via computer assisted telephone inter-viewing (CATI). The overall response rate for the survey was 74.5%(Statistics Canada, 2005).This analysis includes respondents who reported a current orex-spouse or common-law partner as these respondents wereadministered the modules on IPV. Only respondents who reportedphysical or sexual violence were included in the analysis sincethose who did not report any violence were not asked the help-seeking questions ( n ¼ 1231).Those who reported being gay, lesbian, or bisexual wereexcluded ( n ¼ 36) as were those who did not respond to the help-seeking questions ( n  ¼  22). Six influential observations were alsoexcluded based on a previous analysis in which we defined thelatent class models (i.e., the patterns of IPV) for men and women(Ansara & Hindin, in press). The final analytic sample included 696women and 471 men. This study was not conditional on humansubjects approval. Instruments and measuresIntimate partner violence and abuse The survey included a range of questions assessing various actsof violence, psychological abuse, and controlling behavior. Theseitems were used to define the latent class models. The descriptivestatistics for these items are provided as a supplementary table inAnsara and Hindin (in press).The emotional and financial abuse module included sevenbinary items (i.e., yes/no). For those reporting about a currentpartner, the items were worded in the present tense. For thosereporting about an ex-partner, the items were worded in the pasttense. Respondents were asked if their partner perpetrated any of the following acts:1) tries (tried) to limit your contact with family or friends2) puts (put) you down or calls (called) you names to make youfeel bad D.L. Ansara, M.J. Hindin / Social Science & Medicine 70 (2010) 1011–1018  1013  Author's personal copy 3) is (was) jealous and doesn’t (didn’t) want you to talk to othermen/women4) demands (demanded) to know who you are (were) with andwhere you are (were) at all times5) harms (harmed) or threatens (threatened) to harm someoneclose to you6) damages (damaged) or destroys (destroyed) your possessionsor property7) prevents(prevented)you fromknowing aboutorhavingaccessto the family income, even if you ask (asked)The physical and sexual violence module included a modifiedversionof theConflictTactics Scales(Straus,1979).Theseitemsalsohad a binary response format. Respondents were asked if theirpartner perpetrated any of the following acts in the previous fiveyears:1) threatened to hit you with his/her fist or anything else thatcould have hurt you2) thrown anything at you that could have hurt you3) pushed, grabbed, or shoved you in a way that could have hurtyou4) slapped you5) kicked you, bit you, or hit you with his/her fist6) hit you with something that could have hurt you7) beat you8) choked you9) used or threatened to use a gun or knife on you10) forced you into any unwanted sexual activity, by threateningyou, holding you down, or hurting you in some way Formal and informal help-seeking  Respondents who reported at least one act of physical or sexualviolence were questioned about their formal and informal help-seeking. For informal sources, respondents were asked ‘‘Other thanto the police, did you ever talk to anyone about these/this inci-dent(s), such as’’: a family member, friend or neighbor, or co-worker.Forformalsources,respondentswereaskediftheyspoketoa doctor or nurse; lawyer; and minister, priest, clergy or anotherspiritual advisor. Respondents were also asked ‘‘During the past 5years, did you ever contact or use any of the following services forhelp because of the violence, such as’’: crisis center or crisis line,counselor or psychologist, community center or family center,shelter or transition house, women’s center, men’s center or men’ssupport group, senior’s center, and victim services or victimwitness assistance programs. Victim services include assistance orprograms provided by the criminal justice system including thepolice, courts, and corrections, as well as community-basedprograms for victims of violence. This analysis excludes senior’scenters as no respondent reported having used this service. Statistical analysis Latent class analysis (LCA) was conducted using Mplus version5.1 (Muthe´n & Muthe´n, 1998–2007). Latent class analysis isdescribed as the categorical analogue to factor analysis (FA).Whereas FA assumes that the underlying latent construct iscontinuous (i.e., people vary along a continuum), LCA assumesthatitis categorical(i.e., thatsubgroups exist)(Muthe´n&Muthe´n,2000). Latent class analysis is used to identify a set of mutuallyexclusive subgroups or classes based on the patterns of responsesto the observed categorical variables (Goodman, 2002). Since theobjective of our srcinal study was to identify different patterns of IPV, LCA was chosen as the analytic method. Two types of parameters are estimated with LCA: latent class probabilities andconditional probabilities. Latent class probabilities describe theproportion of the population that fall within each class of thelatent variable. Conditional probabilities describe the probabilityof reporting the items given that an individual is in a particularclass. These conditional probabilities describe the nature of theclasses.A detailed description of the methods that were used to identifythe latent class models for women and men can be found else-where (Ansara & Hindin, in press). To examine help-seeking acrossthe IPV classes, the latent class models for the entire sample(including those who did not report any violence) were re-runusing the auxiliary variable function in Mplus. This procedureestimates the proportion of individuals in the classes who reporteach of the help-seeking items by randomly assigning individualsto ‘‘pseudo-classes’’ based on their posterior probability of classmembership. It also tests for mean (i.e., proportion) differencesacross the classes using Wald chi-square tests. An overall chi-square test is provided to test for differences across the classes aswell as bivariate chi-square tests of each class against every otherclass. For this analysis, only the bivariate tests for the classesinvolving physical or sexual violence are presented since respon-dents who did not report any physical or sexual violence were notasked the help-seeking questions. Results Violence-related classes for women and men The IPV classes involving physical or sexual violence for womenand men are presented in Table 1. For women, three violenceclasses were found. The ‘‘Physical aggression’’ class is the leastchronic and severe and generally does not involve acts of coercivecontrol. In contrast, the ‘‘Severe violence, control, verbal abuse’’class is the most chronic and severe and involves acts of control,intimidation, and threats of violence. The ‘‘Physical aggression,control,verbal abuse’’classrepresentsanintermediatepatternthatis characterized by the least severe acts of physical aggression aswell as acts of control and verbal abuse. Based on our previousanalysis (Ansara & Hindin, in press), women in the severe violenceclasswerealsothemostlikelytoreportfearingthattheirlifewasindanger, having been injured, having to take time off or stay in bedas a result of the violence, and partner alcohol use during theincident(s).For men, two violence classes were found. The physicalaggression class is less chronic and less severe than the moderateviolenceandcontrolclass.Meninthemoderateviolenceclasswerealsomorelikelythanthoseinthephysicalaggressionclasstoreportfearing that their life was in danger, having been injured, having totake time off or stay in bed, and partner alcohol use during theincident(s).The ‘‘Physical aggression’’ classes for women and men werecomparable in terms of the frequency and the nature of theaggression. However, the impact was greater for women based onthe violence-related characteristics. The moderate violence classfor men was comparable to the intermediate physical aggressionclass for women with respect to nearly all of the violence-relatedcharacteristics. Help-seeking and intimate partner violence This analysis describes the proportion of respondents withineach of the IPV classes who reported having spoken with someoneabouttheviolence orhaving usedthe variousservicesor programs.It should be noted that many of these estimates have wide D.L. Ansara, M.J. Hindin / Social Science & Medicine 70 (2010) 1011–1018 1014
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