A Social Challenge & Health Issue

Societies around the world face many social challenges that influence the lives and health of populations. A critical issue that greatly impacts the health of individuals is relationship violence (RV). RV has been recognized as any form of violence that happens among individuals who have some form of relationship with each other. But why would RV impact the health of people? According to the World Health Organization (WHO, 1946), health includes the physical, mental and social well-being of individuals, and it involves going beyond the absence of health ailments. To have good health is a basic human right of all individuals and everyone should have the opportunity to do so “without distinction of race, religion, political belief, economic or social condition” (World Health Organization, 1946). This basic human right is understood as a collective effort and responsibility among individuals, families, communities and government. However, health is more complex than well-being at the individual level; rather, it is interconnected between the individual and the state (community/government). WHO (1946) indicates that health is “fundamental to the attainment of peace and security” of individuals and nations. As health involves the interplay between individuals’ biological, psychological and social factors, the way people interact with each other and act within their relationships becomes critical to determine one’s health state. This is how relationship violence has become an important factor that affects people’s health.

For many years, violence in relationships was largely ignored as a public health issue; however, more and more studies have analyzed and affirmed the social determinants of health (SDOH) indicating its relevance and critical role especially in developing health promotion interventions. Therefore, RV has become a recognized public health issue, similar to the broad-sweeping impacts of a pandemic problem. RV, like a pandemic, affects people worldwide. RV is a systemic global issue that has been around for a very long time, but it was not recognized as having negative impacts until the women’s movement in the 1970s. Besides being a problem affecting nations, it is a problem with local impact and it is has been shown to be a very present issue in Canada. Estimates published by WHO indicate that globally 1 in 3 (30%) of women worldwide have been subjected to either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. Most of this violence is intimate partner violence (WHO, 2021). Worldwide, almost one third (27%) of women aged 15-49 years who have been in a relationship report that they have been subjected to some form of physical and/or sexual violence by their intimate partner (WHO, 2021). Pain (2014) affirms that “domestic violence does not receive the levels of attention and resourcing that it merits” (p. 532). He suggests that there are not enough services available to support those who experience this type of violence, which in comparison with other forms of aggression, is minimized and overlooked. The Frontier Centre for Public Policy (FCPP) that analyzes public policy in Canada and makes recommendations has links to the most current policies, Part 1 of 2: Gender-Based Violence in Canada, Part 2 of 2: The Status of Gender-Based Violence in Canada.

A more recent and critical fact related to relationship violence in the domestic environment is the realization and acceptance that intimate partner violence does not only affect women in a heterosexual relationship; men are also victims who suffer similar health consequences as women victims. To know more about intimate partner violence against men, please check the Sky News United Kingdom documentary (Male Domestic Violence Is Very REAL Measells, 2015). Besides intimate partner violence among heterosexual partners, the literature indicates that same-sex partners also experience intimate partner violence. Finneran and Stephenson (2013) show through a systematic literature review that gay males experience intimate partner violence at similar rates to heterosexual women, especially young gay males.

Additionally to issues related to intimate partner violence, people experience violence in other types of relationships such as within the family circle (i.e., parents, siblings, etc.), between neighbours and in the community, school, workplace and gangs. Among the groups of people affected are children (violence against children), women, men, older adults (City News reporting a study about elder abuse), and LGBTQ2SIA+ (lesbian, gay, bisexual, transgender, queer, two-spirited, intersex and asexual plus) (Government of Canada, 2020; City News, 2016). Unfortunately, relationship violence spares no one. It cuts across people of all ages, income status, sexuality and gender identity, ethnicity, race and geography.

Canada’s Department of Justice has modified the definition of family violence as “any form of abuse, mistreatment, or neglect that a child or adult experiences from a family member, or from someone with whom they have an intimate relationship” (Department of Justice Canada, 2017), partly in order to address these together. We use the term RV and expand this definition to include perpetrators that are known to the survivor and not just intimate partners. Therefore, RV is any form of violence (physical, emotional, financial, spiritual) that is inflicted from conception to death by someone that is known to the victim/survivor. RV includes neglect – the failure to provide care. Since RV affects so many different people, it is an issue that cannot be addressed by one organization or a government alone. It requires a response from many sectors in the community (education, housing, justice, service providers both public and private) while taking into consideration the intersectional identities of both victims/survivors and perpetrators. Since no single factor can explain RV, responses need to be tailored according to the needs within and across groups of victims based on sound research (i.e., feminist, intersectionality, health theory and others) and informed by best evidence practices.

Who This Book is For?

In this online “living” book, we share our experience of creating a multi-sectoral committee—Network to Eliminate Violence in Relationships (NEVR)—to address RV, with a focus on the Surrey/Delta/Langley area of British Columbia, Canada. Without any major grants or funding, this grass-roots project has provided practicum and research placements for students from various post-secondary institutions. This book can be used by any academic that wishes to work on a real world problem with students by engaging the community.

This work can be used as a textbook resource by educators in various disciplines to teach about issues related to RV. This publication is also meant to be a living document for people who work in the RV sector, all service providers, those who research and teach on RV and the general population who wants to help address the issue. This is a result of an extensive and participatory action research (PAR) approach (PAR is research determined by the community being researched and involves their participation to inform the research process). This approach was used to develop NEVR’s strategic plans (2013) that have become the “…central resource centre or database which acts as a guiding map for the committee to provide information about community resources, systems in place, and information about how to access them” (Gurm et al., 2013). Also, hopefully, this work can serve as one more stimulus, among so many others, to motivate and create change. This online resource brings together multidisciplinary and community knowledge on RV; it is what academia would call loosely a knowledge translation project.It is meant to be one local platform that provides space to bring together academics and service providers, to highlight current understandings, effective programs and organizations involved in this issue, identify the laws and policies that impact RV, and inform on the context and environment in which the relationship violence cycle takes place. Each one of the components mentioned might be useful to support the working knowledge to address RV.

A Multi-Disciplinary/Multi-Paradigm Approach to Understanding RV

We address RV across the lifespan because our NEVR members work with all age groups. In fact, having a diverse team is one of the reasons that we bring together models from different disciplines as particular theories may explain prevalence for certain groups, but they do not necessarily apply to every or any particular single individual in a given group. A multidisciplinary and multi-paradigm approach is needed to unpack and address the multiplexity of RV. For example, the feminist lens explains heterosexual relationships and the use of male power and privilege. However, this approach does not necessarily apply to all heterosexual couples because we know that females can also be perpetrators of RV. That is why we may need to draw on other rationales like Intersectionality Theory to understand, explain and intervene. We believe that practitioners need to have an understanding of the complexity of RV as background knowledge in order to ask appropriate questions to assess and understand their client which in turn will help them to refer or provide services and programs that meet the client’s particular need(s).

You will notice that this resource does not aim to provide an entire and thorough literature review; rather, it brings critical literature review pieces forward that offer an overview of understandings to help demonstrate the complexity of RV. In this book, we show the complexity and the multiple factors and their influences. As you read it, you will find the synthesis of understandings from different fields and hyperlinks to organizations, programs and prevention campaigns to help you get to the main sources of information, which serves an applied focus for the reader. Each chapter is written to be independent, in case the reader has one particular focus. 

We would like to acknowledge that RV is so complex that it is very difficult to bring together everything known because the literature is so vast and dynamic. Therefore, the chapters you will read bring a work in progress, for even our own understandings evolve as we read and discuss ideas with NEVR members and communities. We see this as a beginning to help with understanding the issue and hope that we can count on all of you to dialogue with us, to keep improving and deepening the knowledge on relationship violence in order to help create effective interventions to create a violence-free society. 

It is our sincere hope that this book will become a living resource that is continuously updated by academics, service providers, government, police, justice, health and support workers, and basically anyone that considers themselves a stakeholder. We hope you will gain an understanding of RV and how government and service organizations and community members can work with academics to leverage resources to address complex challenges. We see this resource as a beginning and not an end. If you wish to contribute please email your thoughts/comments/ideas to NEVR@kpu.ca.

Content Summaries

Chapter 2 we share the community action framework that has emerged through the Network to Eliminate Violence in Relationships Committee (NEVR) to address relationship violence. This unique action framework can be used to address many social issues. We share what NEVR has been able to accomplish since its inception.

Chapter 3 demonstrates how our community action works, and we provide a case study of NEVR. This chapter outlines the collaborative and inclusive process of NEVR. We describe the participatory action research (PAR) used to develop and maintain the committee focus and actions. Inclusion, cultural safety, and successful elements of collaboration are identified. The intersectionality and interconnections of issues of culture and other factors of RV are identified and how the NEVR committee uses principles of ways of knowing, cultural safety and humility, in order to empower clients and service providers working in the RV domain.

Chapter 4 we provide a definition of relationship violence and the most discussed types of violence. This chapter describes all the forms of violence, which are listed above and are included in our broad definition of relationship violence (RV) as well as a broad range of terminology used to describe RV. It highlights  how RV impacts across the life span and how different sectors/environments need to be brought together so communities can act together. It describes the collective, multidisciplinary and multi-modal action that is required to reduce the impact of RV on victims, perpetrators and our communities.

Chapter 5 presents statistics and the consequences of relationship violence. This chapter describes the scope of the issue, which is impacted by variations in reporting that leads to inconsistent data and a lack of a true understanding of the depth and scope of RV. Furthermore, information is provided on the reporting of the experiences of men and women in intimate violence, along with the impact and consequences on children/youth who experience or witness violence. Risk factors are provided and behaviour and health consequences are identified to help understand how the impact of RV can manifest in survivors.

Chapter 6 shows relationship violence models, risk factors among individuals and actions. This chapter describes the integrated model of NEVR that incorporates multiple ways of knowing in a constructivist framework. It incorporates current knowledge that is brought together into the NEVR action framework, which draws from multiple overlapping frameworks presented, recognizing the diversity of perpetrators and survivors. A comprehensive understanding of the complex web of RV needed to drive changes in laws, policies and helpful actions that can reduce the risk for all affected groups is described.

Chapter 7 provides information on the action and prevention of relationship violence (RV). It starts with the underlying principle of understanding the 16 social determinants for Canadian society in order to identify how to take a holistic approach for action and prevention in this domain. The chapter provides recommendations from NEVR and years of experience of service providers as well as a listing of programs in Canada, government resources and community-based tools available for further information and action.

Chapter 8 provides information on an important aspect of relationship violence that is often not understood or misjudged by family and community, which is to identify some of the reasons why a survivor may not report the abuse/violence. As this can be a frequent question asked by society and others, why the person did not leave abusive relationships, this chapter unpacks this further and also asks us to question, why do we not ask the more important and underpinning questions, why does the perpetrator abuse or why does society accept relationship violence? Two major theories of help-seeking – survivor theory and process model—are described to explain how survivors cope with their experiences of violence and make attempts to reduce or end the violence. The reasons why men or women stay in violent relationships are described and the overlapping experiences are identified. These reasons underpin the need to make changes at individual, family, community and institutional levels in order to reduce and end violence in intimate relationships.

Chapter 9 legislation and policy related to relationship violence in Canada are discussed. RV is articulated as a Human Rights violation and is identified as a criminal and ethical offence. This chapter identifies the links to statues and resources, including the national policies and outlines the international conventions to which Canada has made a commitment. These conventions often require Canada to report on progress made on actions and on the resolutions. Canada is part of international efforts to combat violence against women and promote the rights of children and older persons. The legislation to charge perpetrators of relationship violence is outlined through detailed information on the Criminal Code of Canada. Information related to children, youth and adults are provided, particularly situated in the legislation that impacts British Columbians.

Chapter 10 provides information on the process for a survivor to seek help and details a case example to help show the steps the survivor would go through and the range of professionals that can be involved. Further, the tasks of these professionals and what they do in their roles are articulated. As many survivors do not formally report the abuse and may turn first to family or friends for support, information is provided on how to help in this case. There are resources available for the helper, and it is important we all take a champion role to assist the survivor with appropriate information and resources in order that they can make the right choice for them. This can be to leave the partner or to stay (with a safety plan) and the steps and resources are provided. Additionally, the role of the police and court system is described so you can learn what to expect and what the survivor will go through as well as the consequences a perpetrator will face. It outlines the ability to go through an alternative dispute resolution process as many cases do not go to court and this restorative justice or mediation process provides the opportunity to repair harm, make amends and talk about the crime from multiple perspectives to create trust. It outlines why it may be helpful to include cultural perspectives and Indigenous perspectives in restorative justice processes. Many links to resources are included.

Chapter 11 provides the reader with the historical perspective of Forensic Nursing and its role in changing the healthcare response over the last five decades. The particular role development of the Forensic Nurse Examiner highlights how a change in healthcare response to the individual who has been subjected to sexual violence, has led to changed responses in RV (child maltreatment, elder maltreatment, intimate partner violence, interpersonal violence, human trafficking, death investigation and care of perpetrators of violence and trauma) is described. It predicts the future will have increased emphasis on the value of forensic nursing science and forensic science for training professionals to address RV.

Chapter 12 provides information about and links to active campaigns on relationship violence in Canada and internationally. It highlights components that may be included in a national healthy relationship campaign.

Chapter 13 provides information on the empirical evidence surrounding the development and implementation of risk assessments for survivors (adults, older adults and children). The research on why it is important to understand risk is identified. Information on risk assessment tools used in Canada including how local police/RCMP can respond is provided. It notes that there is increased risk due to: mental illness, history of complaints by the victim, violation of no-contact order, and continued contact with the offender. It highlights that assessing risk is important to the safety of the survivor and the children, and the use of these tools can aid the professional in their response.

Chapter 14 explains how there may be different actions that can be taken to reduce the acceptance of relationship violence based on different theories. It explains how the process of change occurs and suggestions on how to create healthy relationships. It provides steps of how to make personal change and steps to consider in community change.

Chapter 15 focuses on relationship violence against women, commonly called IPV.  It explains the many theories that have been presented over the years to explain relationship violence, including psychological, psychopathological, sociological, structural, and others. It describes the socio-environmental model that draws on them all as well as the cycle of abuse and the power and control wheel. It reviews the risk factors and lists actions.

Chapter 16 provides information about relationship violence involving children (child abuse and neglect or mistreatment), and the consequences of experiencing this type of trauma early in life and preventive actions. It reviews literature that indicates correlations between RV among children and impacts on children’s brain development and bio-psycho-social development from the time of conception throughout their life span. As well, systematic reviews that identify resilience factors in preventing or reducing adverse effects are provided. It lists effective prevention programs include parenting programs that strengthen the family unit and minimize harm to the child through education to the parent(s)/caregiver(s) through the introduction of alternative punishment strategies and parental self‐management.

Chapter 17 summarizes relationship violence among older adults, risk factors for relationship violence and actions against it. In Canada and around the world, elder abuse is increasing and older adults have their own unique set of vulnerabilities in these situations. Elder abuse is recognized as a public health and pervasive social issue and how often relatives, friends and caregivers are the perpetrators of elder abuse. Risk factors and protective factors are identified in this chapter. Resources on how to recognize elder abuse, how to help and supports available are provided.

Chapter 18 provides literature on relationship violence against men, the most discussed types of relationship violence among this population and their risk factors. It highlights large scale studies that indicate the most prevalent type of RV experienced by men is psychological and physical violence. It lists barriers to seeking help such as fear of disclosure, the challenge to masculinity, commitment to relationship, diminished confidence/despondency that inhibits action and invisibility/perception of services. It discusses how male survivors may experience distress and secondary victimization when professionals and services are not prepared to provide support to this population group. It points out that access to support services among male victims of intimate partner violence is typically considerably lower than services for women. It states that if RV against males is not acknowledged or treated, it can result in alcohol and drug abuse, family violence, suicide and social dysfunction.

Chapter 19 discusses information on the experiences of Indigenous peoples in relationship violence. While traditionally among Indigenous communities, women were valued and held leadership roles, now there is violence against women in these communities. With the arrival of colonizers, over time, Indigenous communities got disconnected from their culture and this history is an important context for understanding relationship violence. While this group has commonalities with other groups, there are specific differences and these are discussed. It provides the higher rates of RV that exist in the Canadian Indigenous population. The statistics highlight the importance of paying attention to the impact of relationship violence amongst different groups and populations and this will impact practitioner knowledge development and needed policy changes to end relationship violence in Indigenous groups. As well, risk factors, a list of initiatives, programs and resources to end violence and national inquiries are provided to inform our perspectives and advocacy to eliminate relationship violence. It states in order for programs for Indigenous peoples to be helpful, culturally appropriate and safe practices that build on Indigenous knowledge and experiences, and are informed by Indigenous practitioners and elders need to be developed. Connection to traditional beliefs and restoring connections to Indigenous identity, spirit and spirituality are encouraged through the research. The chapter notes the disconnect between how written policies are not always enacted, change takes generations and how everyone has a role in advocacy and supporting culturally appropriate and safe policies and practices.

Chapter 20 provides information about relationship violence against LGBQT2SIA+ (youth, adults and older adults), rates within this group and services available. Forms of abuse specific to LGBTQ2SIA+ communities include a perpetrator: questioning their partner’s sexual or gender identity and right to be in the LGBTQ2SIA+ community; using transphobic, biphobic or homophobic slurs; controlling their partner’s expression of their gender or sexual identity; forcing personal displays of affection (PDAs) in non-safe spaces;  forcing PDAs in public to ‘out’ their partner; withholding hormones from their transgender partner; using their partner’s identity as ammunition in child custody cases; threatening to ‘out’ their partner to children, family, employers, friends; engaging in financial abuse through identity theft; isolating their partner from the LGBTQ2SIA+ community; reinforcing internalized trans/bi/homophobia; and forcing them to have sex in ways that do not match their identity. The chapter includes how RV among youth is a public health concern and illustrates how critical it is that schools, educators, youth service providers, and mental health practitioners educate and support diverse youth regarding healthy romantic relationships. Also, how LGBTQ2SIA+ elders lived through decades of outright discrimination and persecution and these experiences have taken a toll on their mental health is mentioned. It highlights that lack of research and data on RV in LGBTQ2SIA+ communities has resulted in programs that offer limited benefits and support or even further marginalize victims within LGBTQ2SIA+ communities.

Chapter 21 is a summary of relationship violence among immigrants and refugees, risk factors and programs available to this population. While the act of migration itself does not cause RV, some specific factors that may increase the risk of abuse are discussed. These may include post-migration strain and stigma, the stress associated with migration, geographic and social isolation, changes in socioeconomic status, power imbalances between partners; change in social networks and supports, loss of culture, family structures, and community leaders, economic insecurity resulting from non-recognition of professional/educational credentials, changes in gender roles and responsibilities, and unresolved pre-migration trauma. Some protective factors such as the history of religious practices (e.g., Buddhist beliefs) have been identified and resources listed.

Chapter 22 provides a discussion about relationship violence in the workplace, the risks of RV, symptoms and impacts, and legislation available to protect workers. It describes how relationship violence at home can carry into the workplace. RV in the workplace has been described as any type of abuse, threat, intimidation or assault that occurs in a place of employment with the most common forms mentioned as physical, sexual, emotional, spiritual and financial. Research on workers experiencing harassment in the workplace, surrounding legislation and initiatives to end workplace violence are identified.

Chapter 23 summarizes some of the RV incidents on Canadian post-secondary campuses that lead some Canadian provinces including BC to create legislation that directed post-secondary institutions in the province to create sexual assault policies. Good policy needs to include RV against all employees and address the violence that occurs to students even when they are not on campus. As well, there needs to be clear procedures that are easy to communicate, a definition of consent, and support for survivors. A legislative framework that can be used on campuses is provided along with links to resources.

Chapter 24 describes how to care for the caregiver. This is an important aspect of all of the work done by service providers. Our intent is not to review the myriad ways to prevent compassion fatigue (CF) but to offer a few insights from the literature on definitions and effective interventions. Since we know that CF can occur, it is best to take action to prevent CF in the first place.

Chapter 25 is a broad philosophical understanding that underpins our knowledge. The chapter provides examples of some collaborations in Canada and future direction for work on addressing RV to create a violence-free society.

References

City News. (2016, June 2). New study gives a shocking snapshot of elder abuse in Canada. [Video]. Toronto City News. https://toronto.citynews.ca/2016/05/26/new-study-gives-shocking-snapshot-of-elder-abuse-in-canada/

Department of Justice Canada. (2017). Family violence. https://www.justice.gc.ca/eng/cj-jp/fv-vf/index.html

Finneran, C., & Stephenson, R. (2013). Intimate partner violence among men who have sex with men: A systematic review. Trauma, Violence, & Abuse, 14, 168185. doi:10.1177/1524838012470034

Government of Canada. (2020). Ending violence against children and youth. https://www.international.gc.ca/world-monde/issues_development-enjeux_developpement/human_rights-droits_homme/ending_violence-fin_violences.aspx?lang=eng

Gurm, B., Thandi, G., Early, S., Majedi, M., Menon, P., Cheema, M., & KPU Nursing Students. (2013). Understanding violence against women in relationships from multiple perspectives. https://www.kpu.ca/sites/default/files/NEVR/Understanding%20Abuse%20from%20Multiple%20Perspectives%20final%20report%20%20Dec%206%20%202013_0.pdf

Measells, D. (2015, November 29). Male domestic violence is very real. [Video]. YouTube. https://www.youtube.com/watch?v=5rCV8W7J-to

Pain, R. (2014). Everyday terrorism connecting domestic violence and global terrorism. Progress in Human Geography, 38(4), 531-550.

World Health Organization. (1946). Constitution of the World Health Organization. https://www.who.int/about/who-we-are/constitution  

World Health Organization. (2017). Violence against women. https://www.who.int/en/news-room/fact-sheets/detail/violence-against-women

World Health Organization. (2021). Violence against women. WHO. https://www.who.int/news-room/fact-sheets/detail/violence-against-women